【摘要】：一、研究背景 近二十年來,我國孕產(chǎn)婦和兒童的生存狀況有了明顯的改善,己基本達(dá)到了聯(lián)合國制定的千年發(fā)展目標(biāo)4和5。然而孕產(chǎn)婦與兒童的生存與健康仍面臨著兩個(gè)巨大的挑戰(zhàn)。一是既往我國的婦幼衛(wèi)生體系中缺乏整合和連續(xù)性,使婦幼衛(wèi)生服務(wù)的成本——效益沒有得到最大化。二是孕產(chǎn)婦和兒童生存整體的改善掩蓋了地區(qū)和人群間的差異。既往研究已經(jīng)明確整合若干孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施可以有效降低孕產(chǎn)婦和兒童死亡。而要連續(xù)、有效地改善孕產(chǎn)婦和兒童生存與健康,彌合不同地區(qū)和人群之間的差異,就需要綜合反映保健連續(xù)性的孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施覆蓋率指標(biāo),并對(duì)干預(yù)措施覆蓋率在不同地區(qū)和不同人群的差異進(jìn)行分析,既有利于衛(wèi)生服務(wù)資源的合理導(dǎo)向與配置,又可以明確需要重點(diǎn)干預(yù)的人群并制定相應(yīng)的干預(yù)策略。 近年來國內(nèi)外對(duì)于婦幼衛(wèi)生健康公平性的研究熱度遞增。在發(fā)展中國家的研究中發(fā)現(xiàn)社會(huì)經(jīng)濟(jì)狀況好的家庭孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施覆蓋率普遍優(yōu)于社會(huì)經(jīng)濟(jì)狀況差的家庭,城市地區(qū)、受教育程度高、和非少數(shù)民族的婦幼衛(wèi)生服務(wù)利用程度更好。我國的研究也有類似的發(fā)現(xiàn),在農(nóng)村地區(qū)、貧困家庭孕產(chǎn)婦保健的利用程度較差。 然而現(xiàn)有的文獻(xiàn)中均在以下幾點(diǎn)局限性：1)尚沒有體現(xiàn)保健連續(xù)性的孕產(chǎn)婦和兒童干預(yù)措施指標(biāo)體系。2)孕產(chǎn)婦產(chǎn)前保健和產(chǎn)后保健的公平性研究結(jié)論不一致,有待于進(jìn)一步驗(yàn)證和分析。且尚未發(fā)現(xiàn)針對(duì)兒童衛(wèi)生服務(wù)(如免疫接種、常見病管理)公平性的研究。3)個(gè)體水平衛(wèi)生服務(wù)公平性的研究和對(duì)公平性影響因素進(jìn)行探索的研究甚少。 因此本研究通過選擇綜合評(píng)價(jià)孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施覆蓋率的指標(biāo),并應(yīng)用不公平的測(cè)度方法描述我國地區(qū)和個(gè)體(不同家庭社會(huì)經(jīng)濟(jì)狀況)兩個(gè)層面孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施的現(xiàn)狀和不公平程度,并探討其影響因素。 二、研究方法 本研究數(shù)據(jù)來源于2008年開展的第四次國家衛(wèi)生服務(wù)調(diào)查的家庭健康詢問調(diào)查部分,共計(jì)調(diào)查了全國31個(gè)省、自治區(qū)、直轄市共56456戶家庭。由經(jīng)過培訓(xùn)的衛(wèi)生工作者使用結(jié)構(gòu)式問卷進(jìn)行詢問。本研究中僅采用家庭健康詢問調(diào)查部分的家庭一般情況、家庭成員健康詢問調(diào)查、15-49歲已婚育齡婦女情況和5歲以下兒童情況四個(gè)部分的數(shù)據(jù)。分析產(chǎn)前、產(chǎn)時(shí)和產(chǎn)后孕產(chǎn)婦干預(yù)措施以及早開奶時(shí),分析的樣本量為7414名母親——兒童對(duì)。而在分析兒童喂養(yǎng)(除早開奶外)、免疫接種和兒童腹瀉時(shí),總分析的樣本量為9639名5歲以下兒童。 通過回顧目前國際上通用的孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施覆蓋率指標(biāo)體系和國內(nèi)的指標(biāo)體系,最終選擇了11項(xiàng)孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施覆蓋率作為分析的核心指標(biāo)。通過加權(quán)計(jì)算描述我國孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施覆蓋率的現(xiàn)狀和地區(qū)差異、采用絕對(duì)差值和相對(duì)比值來定量分析地區(qū)差異的大小,并輔以地理分布圖來直觀呈現(xiàn)各省的分布。以家庭人均年生活消費(fèi)性支出作為劃分人群社會(huì)經(jīng)濟(jì)狀況的依據(jù),并采用健康不公平絕對(duì)和相對(duì)指標(biāo)(集中指數(shù))來測(cè)度孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施的覆蓋率的公平性,通過(Q1-Q2)/(Q5-Q4)和圖示計(jì)算不公平的類型。 三、研究結(jié)果 (一)孕產(chǎn)婦與兒童衛(wèi)生干預(yù)措施覆蓋率的現(xiàn)狀 至少進(jìn)行一次產(chǎn)前保健和住院分娩的覆蓋率最高,分別為94.65%和89.55%。兒童期輔食添加、免疫接種和腹瀉的口服補(bǔ)液治療的覆蓋率分別為72.45%、80.38%和73.96%。至少進(jìn)行1次產(chǎn)后訪視的覆蓋率為53.94%。產(chǎn)前保健的質(zhì)量指標(biāo)的兩項(xiàng)指標(biāo)(滿足產(chǎn)前檢查基本質(zhì)量和產(chǎn)前保健至少5次且滿足產(chǎn)前檢查基本質(zhì)量)的覆蓋率為62.01%和39.08%。早開奶和純母乳喂養(yǎng)6個(gè)月的比例均低于40%。 (二)孕產(chǎn)婦與兒童衛(wèi)生干預(yù)措施覆蓋率的地區(qū)差異 通過地區(qū)和分省分析,孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施最低的仍然多集中在西部省份,如云南、青海、貴州、新疆、西藏等省份。盡管大多數(shù)孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施在城鄉(xiāng)之間未見顯著的差別,然而Ⅳ類農(nóng)村地區(qū)產(chǎn)前保健和住院分娩最低。此外,與至少進(jìn)行過一次產(chǎn)前保健的高覆蓋率(95%)相比,至少進(jìn)行過4次或5次產(chǎn)前保健以及滿足產(chǎn)前檢查基本質(zhì)量的比例則僅為66%、52%和62%,而產(chǎn)前保健至少5次且滿足產(chǎn)前保健基本質(zhì)量的比例更低(39.08%)。 (三)孕產(chǎn)婦與兒童衛(wèi)生干預(yù)措施覆蓋率的公平性 無論其整體覆蓋率的高低,產(chǎn)前、產(chǎn)時(shí)和產(chǎn)后保健的集中指數(shù)均大于0,提示存在著隨家庭社會(huì)經(jīng)濟(jì)狀況升高而覆蓋率增加的趨勢(shì),即親富人(pro-rich)現(xiàn)象,且不同指標(biāo)之間的不公平程度也存在差異。最富裕與最貧困人群產(chǎn)前保健至少5次且滿足產(chǎn)前檢查基本質(zhì)量覆蓋率的絕對(duì)差值達(dá)到了57%,最富裕人群的覆蓋率是最貧困人群的3.94倍。住院分娩在最貧困與最富裕人群覆蓋率的差距較小(差值為12%,比值為1.15)。產(chǎn)后訪視整體的覆蓋率低,而最富裕與最貧困人群之間的覆蓋率也存在著差距(差值為25%,比值為1.58)。嬰幼兒喂養(yǎng)中僅發(fā)現(xiàn)純母乳喂養(yǎng)6個(gè)月存在不公平的現(xiàn)象(集中指數(shù)=-0.93,P0.0001),其覆蓋率隨著家庭社會(huì)經(jīng)濟(jì)狀況的上升而下降,即“親窮人”。對(duì)于免疫接種和兒童腹瀉的管理,本研究沒有發(fā)現(xiàn)顯著的不公平現(xiàn)象。 對(duì)于不公平類型的分析發(fā)現(xiàn),整體覆蓋率高(≥90%)的干預(yù)措施(如至少進(jìn)行一次產(chǎn)前保健、住院分娩),其不公平的類型為bottom型,提示家庭社會(huì)經(jīng)濟(jì)狀況最差的20%的人群干預(yù)措施的覆蓋率明顯落后于其他等級(jí)。而覆蓋率低(39%-70%)的干預(yù)措施(如至少進(jìn)行過5次產(chǎn)前保健、孕早期進(jìn)行產(chǎn)前保健、有質(zhì)量的產(chǎn)前保健、至少進(jìn)行過4次產(chǎn)前保健且有質(zhì)量的產(chǎn)前保健以及至少進(jìn)行過5次產(chǎn)前保健且有質(zhì)量的產(chǎn)前保健),其不公平的類型為top型,即家庭社會(huì)經(jīng)濟(jì)狀況最好的20%的人群干預(yù)措施的覆蓋率明顯優(yōu)于其他等級(jí)。 (四)不公平的影響因素 家庭人均年生活消費(fèi)性支出在產(chǎn)前保健和產(chǎn)后保健不公平中所占比重最大(47.05%-118.8%)。反映產(chǎn)前保健質(zhì)量的有效覆蓋率指標(biāo)中,母親職業(yè)和東中西部地區(qū)對(duì)不公平的貢獻(xiàn)率則分別為0.1845-0.2029和0.1212-0.1264。至少進(jìn)行一次產(chǎn)后保健“親富人”貢獻(xiàn)大的影響因素也包括東中西部地區(qū)(貢獻(xiàn)率為0.1540)和母親職業(yè)(貢獻(xiàn)率為0.1474)。住院分娩不公平的影響因素分別是母親教育程度(貢獻(xiàn)率為0.3690)、家庭人均年生活消費(fèi)性支出(貢獻(xiàn)率為0.2401)和母親產(chǎn)次(貢獻(xiàn)率為0.1768)。 四、結(jié)論 我國孕產(chǎn)婦和兒童衛(wèi)生服務(wù)存在發(fā)展不平衡。產(chǎn)前、產(chǎn)時(shí)保健和兒童期的免疫接種均已達(dá)到了較高的覆蓋率,然而產(chǎn)后保健、嬰幼兒喂養(yǎng)的覆蓋率則較低。孕產(chǎn)婦和兒童保健干預(yù)措施最低的仍然多集中在西部省份和Ⅳ類農(nóng)村地區(qū),提示西部和偏遠(yuǎn)落后的農(nóng)村地區(qū)仍然是沒有得到孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施的有效覆蓋,是未來婦幼衛(wèi)生工作的重點(diǎn)。此外,盡管產(chǎn)前保健的粗干預(yù)措施覆蓋率高,但是產(chǎn)前保健質(zhì)量較差且地區(qū)差異大。可見即使醫(yī)療衛(wèi)生服務(wù)達(dá)到了較高的利用,如不加強(qiáng)醫(yī)療衛(wèi)生機(jī)構(gòu)的服務(wù)質(zhì)量、提高衛(wèi)生工作者的技能和服務(wù)水平,孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施仍未全面惠及目標(biāo)人群,有效改善孕產(chǎn)婦和兒童的生存與健康。無論整體覆蓋率的高低,產(chǎn)前、產(chǎn)時(shí)和產(chǎn)后保健均存在著隨家庭社會(huì)經(jīng)濟(jì)狀況升高而覆蓋率增加的趨勢(shì),即親富人(pro-rich)現(xiàn)象。但干預(yù)措施的不公平類型不盡相同。不公平類型的研究也有助于了解干預(yù)措施實(shí)施過程不公平產(chǎn)生的規(guī)律與趨勢(shì),從而采取不同的策略盡量彌合不公平。 家庭人均年生活消費(fèi)性支出在產(chǎn)前和產(chǎn)后保健不公平中所占比重最大,說明影響產(chǎn)前和產(chǎn)后保健不公平的主要因素是家庭對(duì)于孕期和產(chǎn)后相關(guān)醫(yī)療衛(wèi)生保健服務(wù)的購買力。反映產(chǎn)前保健質(zhì)量的有效覆蓋率指標(biāo)中,母親職業(yè)和東中西部地區(qū)對(duì)不公平的貢獻(xiàn),說明母親職業(yè)和中西部地區(qū)對(duì)孕期相關(guān)醫(yī)療衛(wèi)生服務(wù)利用的不公平也有一定的影響。消除健康不公平既可以采用重點(diǎn)人群的直接干預(yù),也可以實(shí)施惠及全體居民的全面覆蓋策略。無論何種策略的實(shí)施,都需要建立婦幼衛(wèi)生公平性的監(jiān)測(cè)和評(píng)估系統(tǒng),對(duì)孕產(chǎn)婦和兒童衛(wèi)生干預(yù)措施的公平性及影響因素進(jìn)行持續(xù)的監(jiān)測(cè),明確重點(diǎn)人群并建立追蹤機(jī)制,為促進(jìn)衛(wèi)生服務(wù)的公平利用提供理論依據(jù)和證據(jù)支持。
[Abstract]:First, the research background.
In the past 20 years, the living conditions of pregnant women and children in China have improved significantly, and have basically reached the Millennium Development Goals 4 and 5 set by the United Nations. However, the survival and health of pregnant women and children are still facing two great challenges. First, the lack of integration and continuity in China's maternal and child health system has made maternal and child health clothing. The cost-effectiveness of services is not maximized. Second, the overall improvement in maternal and child survival masks regional and population differences. Previous studies have clearly integrated a number of maternal and child health interventions that can effectively reduce maternal and child mortality. Health, bridging the differences between different regions and populations, we need to comprehensively reflect the continuity of maternal and child health care interventions coverage indicators, and the coverage of interventions in different regions and different groups of differences in analysis, not only conducive to the rational direction and allocation of health services resources, but also can be clear about the need for heavy Point out intervening crowd and formulate corresponding intervention strategy.
In recent years, there has been an increasing research interest in the equity of maternal and child health both at home and abroad. In developing countries, studies have found that the coverage of maternal and child health interventions in families with good socio-economic conditions is generally better than that in families with poor socio-economic conditions, urban areas, highly educated, and maternal and child health services in non-ethnic minorities. The utilization of maternal health care in poor families is poor in rural areas.
However, the existing literature has the following limitations: 1) There is no indicator system of maternal and child intervention measures reflecting the continuity of health care. 2) The conclusion of the study on the equity of prenatal and postnatal health care is inconsistent and needs further validation and analysis. Research on fairness of health services at individual level and factors affecting fairness are few.
In this study, the coverage rate of maternal and child health interventions was evaluated by selecting indicators and unfair measures were used to describe the status quo and unfairness of maternal and child health interventions at different levels in China.
Two, research methods.
The data of this study were collected from 56 456 households in 31 provinces, autonomous regions and municipalities directly under the Central Government in 2008. The trained health workers used structured questionnaires to ask questions. Data were collected from 4,414 mothers and children aged 15-49 and under 5 years. The sample size was 7,414 mothers and children for prenatal, intrapartum and postpartum interventions and early breast-feeding. For children with diarrhea, the total sample size was 9639 children under 5 years of age.
By reviewing the current international and domestic indicators of maternal and child health interventions coverage, 11 maternal and child health interventions coverage rates were selected as the core indicators for analysis. The absolute difference and relative ratio were used to quantitatively analyze the regional differences, and the geographical distribution map was used to visually show the distribution of the provinces. The per capita annual living expenditure was used as the basis for dividing the social and economic conditions of the population, and the absolute and relative indexes of health inequality (concentration index) were used to measure the pregnant and lying-in women. Equity in coverage of maternal and child health interventions was calculated by (Q1-Q2) / (Q5-Q4) and charts.
Three, research findings
(1) the current situation of maternal and child health intervention measures
The coverage rates of at least one prenatal care and hospital delivery were 94.65% and 89.55%, respectively. The coverage rates of supplementary food, immunization and oral rehydration for diarrhea in childhood were 72.45%, 80.38% and 73.96%, respectively. The coverage rates of at least one postnatal visit were 53.94%. The coverage rates of basic quality of antenatal examination and antenatal care at least 5 times and meeting the basic quality of antenatal examination were 62.01% and 39.08%, respectively.
(two) regional differences in maternal and child health interventions coverage
By regional and provincial analysis, the lowest level of maternal and child health interventions is still concentrated in Western provinces, such as Yunnan, Qinghai, Guizhou, Xinjiang and Tibet. In addition, compared with the high coverage rate (95%) with at least one antenatal care, only 66%, 52% and 62% had at least four or five antenatal care and met the basic quality of antenatal care, while the proportion with at least five antenatal care and met the basic quality of antenatal care was lower (39.08%).
(three) fairness of maternal and child health interventions coverage
Regardless of the overall coverage, the prenatal, intrapartum and postpartum health care concentration index is greater than 0, suggesting that there is a trend of increasing coverage with the increase of family socio-economic conditions, that is, pro-rich phenomenon, and the degree of inequity between different indicators also varies. The richest and poorest groups have at least five prenatal care. The absolute difference between the coverage of basic quality of antenatal care reached 57%, and the coverage of the richest was 3.94 times that of the poorest. There was also a gap in coverage rate (25% difference, 1.58 ratio). Only 6 months of exclusive breastfeeding was found to be unfair (concentration index = - 0.93, P 0.0001), and the coverage rate declined with the rise of family socio-economic conditions, i.e.'pro-poor'. Significant inequalities.
An analysis of unfair types found that interventions with high overall coverage (> 90%) such as at least one antenatal care, hospital delivery, and the unfair type was bottom, suggesting that the coverage of interventions in the 20% of the population with the worst socio-economic status in the family lagged significantly behind other levels, while interventions with low coverage (> 39% - 70%). Measures (e.g. at least five prenatal care, early prenatal care, quality prenatal care, at least four prenatal care and quality prenatal care, and at least five prenatal care and quality prenatal care) are of the top type, i.e. 20% of the population with the best socio-economic status in the family. The coverage of intervention measures is obviously better than that of other grades.
(four) factors affecting inequity
Per capita annual expenditure on household living accounts for the largest proportion of unfair prenatal and postnatal care (47.05% - 118.8%). The influencing factors of the "rich" contribution included the east, middle and west regions (contribution rate 0.1540) and the mother's occupation (contribution rate 0.1474). The unfair factors of in-hospital delivery were maternal education level (contribution rate 0.3690), family per capita annual consumption expenditure (contribution rate 0.2401) and maternal parity (contribution rate 0.1768).
Four. Conclusion
Prenatal health care and childhood immunization coverage have reached a high level, but postnatal health care and infant feeding coverage are low. The lowest maternal and child health interventions are still concentrated in western provinces and rural areas of type IV, suggesting that Western and remote rural areas are still not effectively covered by maternal and child health interventions, which is the focus of future maternal and child health work. In addition, although the coverage rate of crude interventions in antenatal care is high, the quality of antenatal care is poor and the regional differences are great. It can be seen that even if medical and health services have reached a high level. Utilization, such as not strengthening the service quality of medical and health institutions, improving the skills and service level of health workers, maternal and child health interventions have not yet fully benefited the target population, effectively improving the survival and health of pregnant women and children. Pro-rich phenomena will increase with the increase of economic conditions, but the unfair types of intervention are not the same. The study of unfair types will also help to understand the law and trend of unfairness in the implementation process of interventions, so as to adopt different strategies to bridge the unfairness as far as possible.
The annual per capita living expenditure of the family accounts for the largest proportion of prenatal and postnatal health care inequities, indicating that the main factor affecting prenatal and postnatal health care inequities is the family's purchasing power for prenatal and postnatal related health care services. The contribution of ministries and regions to unfairness shows that the mother's occupation and the middle and western regions also have a certain impact on the unfairness of medical and health service utilization during pregnancy. Establish the monitoring and evaluation system of maternal and child health equity, continuously monitor the equity of maternal and child health interventions and influencing factors, identify key groups and establish a tracking mechanism to provide theoretical basis and evidence support for promoting the fair use of health services.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2013
【分類號(hào)】：R172

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