A systematic review of the profile and density of the maternal and child health workforce in China

Maternal and child mortality levels have fallen substantially in China since the Liberation in 1949. China’s maternal mortality ratio was estimated to be around 1500 deaths per 100 000 live births in 1950 [1], dropping to 17.8 in 2019[2]. The under-five mortality rate dropped from 210.7 to 7.8 deaths per 1000 live births over the same period [1, 2]. Investment in health systems has no doubt accelerated the progress in reducing maternal and child mortality [3, 4]. Key to this success has been the training and deployment of maternal and child health (MCH) workers, which are seen as the cornerstone of successful MCH programmes [5]. Understanding who they are, and how many (per unit of population), is critical to the planning of such services.

Defining what constitutes an “MCH worker”, and what their qualifications should be, remains a challenge internationally as well as in China. A joint report issued by the World Health Organization (WHO) and the United Nations Population Fund, defined sexual, reproductive, maternal, newborn and adolescent health workers as those including but not limited to “midwives, nurses, nurse-midwives, general practitioners, specialist doctors (such as obstetrician/gynaecologist, neonatologists, paediatricians), auxiliary staff, community health workers, and support workers (including traditional birth attendants)” [6]. The joint report did not define the health workers by cadre, and advised national workforce assessments to categorize health workers according to the cadre titles used in their own country. However, the full complexity and dynamics of the MCH workforce within each country is difficult to capture. So far, most of the research in this area has focused on the definition and measurement of particular cadres of MCH workers, e.g. midwives or paediatricians, not the entire workforce [7‐12]. The WHO, for example, has recently updated its definition of a skilled birth attendant [13], but that definition does not necessarily help with human resource planning, since the criteria used are not well aligned with in-country training or qualification systems.

In China, there is no consensus on what constitutes an MCH worker. The health system allows extensive variation in education, roles and responsibilities between health workers, and definitions vary over time and between geographical locations [14]. Terms such as “obstetrician” or “paediatrician” are used loosely, and there is no standard definition. To our knowledge, there has not been a comprehensive assessment of the profile of MCH workers in China.

Education level, health-related discipline and certification are most commonly used to understand the profile of health workers in China [14‐16]. Education levels generally move from primary or middle school to high school or secondary technical school, junior college, Bachelor’s degree, Master’s degree, and Doctoral degree [14]. The length of medical training varies between different disciplines, ranging from three to eight years. The tracking of health-related disciplines is also important, because China’s educational reforms in 1998 redesigned medical training from the former Soviet model, which was based on empirical clinical training to a Western model, where categorizations are based on disciplines from the natural sciences [15]. Certification, and in particular the “MCH care certificate” (Muying baojian jishu hegezheng, thereafter referred to as certification), is critical in allowing MCH workers to perform certain duties. All MCH workers who are directly involved in prenatal diagnosis, delivery care and termination of pregnancy need to be certified by law to be allowed to perform these tasks [17]. To be eligible for a certificate, applicants need to have graduated from secondary technical schools or higher education and hold a valid medical doctor, nurse/midwife, or medical technician license. Candidates are certified by county-level or higher-level health authorities after passing a theoretical and skill examination, which is regulated by National Health and Family Planning Commission (previously the Ministry of Health).

The density of health workers is widely used as an indicator of health systems inputs [18, 19]. The Chinese government uses the “density of doctors per 1000 population” as a performance indicator, but there is very little information on the density of MCH workers. Work within the MCH field has suggested that the total population may not accurately reflect the obstetric or paediatric needs of a population. Maternal health worker density, for example, should be expressed over total number of births, while child health worker density should be counted per number of children [20‐22]. This is particularly relevant for China since fertility rates are low [23]. Using births as the reference population, the World Health Report 2005 suggested a minimum requirement of 20 midwives or 3 doctors (at least part time) per 3600 births per year to ensure essential maternal and newborn care [24].

The lack of information on the profile and density of MCH workers in China greatly restricts evidence-informed policy making to address potential workforce issues. The aim of this study is to systematically review the literature reporting on the profile and density of MCH workers in mainland China.

The aim of the review was to describe the profile and density of MCH workers in China and to help understand how the MCH workforce development contributes to China’s achievement in MCH. The study has three main findings. First, only two-thirds of obstetricians and paediatricians had a bachelor or higher degree. This proportion was lower in primary-level facilities (28%). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% in any health facility and 1% in primary care facilities). Second, the proportions of MCH workers who held a certificate—a rigorous system introduced by the Chinese Government to regulate who can perform MCH tasks—ranged from 32% (47 of 149 obstetric nurses) to 95% (41 out of 43 midwives) in primary care facilities. Third, the average density of obstetricians was 9.0 (7.9–10.2) per 1000 births and that of obstetric nurses 16.0 (14.8–17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births).

Obstetricians, paediatricians and other MCH worker cadres were much less educated at the primary level than at the tertiary level. That is partly because most medical school graduates in China compete to join large hospitals, where their salaries, working conditions and career opportunities are superior to those offered by primary-level health facilities [78]. The mobility rate of experienced and qualified health workers in primary-level health facilities is high [79]. The lower capacity of MCH workers at the primary level is also seen in other low- and -middle-income countries (LMICs). China’s strategy has been to achieve widespread deployment of the workforce first and then to upgrade the skills of the providers to improve the standard of care gradually. Such strategy contributed to the higher density of obstetricians and obstetric nurses as compared to the international benchmark. Similar strategies are also seen in the expansion of the insurance schemes, where universal health insurance coverage is achieved first and an improvement of the benefit package follows [80].

Although the education level of MCH workers is variable, China achieved near-universal access to childbirth in health facilities with low maternal mortality and neonatal mortality as a result [3, 81]. Childbirth is now concentrated in well-staffed hospitals at secondary and tertiary levels, whereas primary-level facilities focus on antenatal care and screening of high-risk pregnancies [3]. Concentrating births in large facilities facilitates an efficient and effective midwifery and obstetric skill mix, with providers being highly trained and equipped to ensure safe birth. The government no longer allows caesarean sections to be provided at township hospitals, where maternal health workers now focus on home visits, birth preparedness, and postpartum follow-up. In addition, accredited obstetricians from tertiary facilities regularly visit secondary or primary-level facilities to provide in-service training and supervision [3]. Evidence from other countries has shown that some MCH tasks do not require advanced skills and health workers with no advanced training can perform well provided that they get supervision from higher-level facilities [82]. Another example is immunization, which is not a complex intervention. Although primary-level facilities are poorly staffed for highly medicalized services, immunization is offered largely at primary care level. In rural areas, immunization is actively promoted by village doctors, who only have basic levels of education.

Certification of MCH workers is an important strategy to ensure that particular tasks are only performed by those skilled and equipped to do so [83, 84]. We found that not all MCH workers held a valid certificate. The finding does not necessarily imply that this is a failure of certification mechanism. Health facilities are required to comply with the regulations relating to certification of MCH workers. But there is a lack of information on the degree of compliance of health facilities with the regulations. It could be partly due to the fact that limited resources have been put in place to enforce the certification law. Although rare evidence exists, this problem might also occur in private hospitals, which are often less regulated.

Our study has found that for density of MCH workers, the population denominator has been used more often than birth denominator. The weighted average density of MCH doctors reported in our study (11.9 per 100 000 population) was similar to that in Sweden and France in 2012—12.1 and 12.3, respectively [85]. However, fertility in these countries is higher than in China, so comparisons may not be valid. We echo Gabrysch and colleagues’ recommendations about the need to enhance discriminatory power of density indicators and measure density of different cadres of MCH workers according to specific demographic profile, for example, define density of obstetricians using per births instead of per population [20].

Through the analysis of MCH worker ratio, we found a larger maternal health workforce than child health workforce, and more nurses than doctors. Although no gold standard exists for the ratio of maternal to child health workers, the shortage of child health workers in China has been a long concern. Paediatrics is not a popular choice for medical students due to the heavy workload, low salary compared with other medical professions and intense doctor–patient relationships [86]. The revealed deficit in the availability of child health workers needs to be addressed through implementing targeted human resource policies, such as through the salary and bonus systems or improved working conditions. Compared with the optimal 2:1 nurse-to-doctor ratio as recommended by WHO [19], the nurse-to-doctor ratio in MCH area was less than optimal. China has a long history of having a low nurse-to-doctor ratio. The nurse-to-doctor ratio was estimated around 1:10 in the early 1950s (WHO, 2015) [87]. The situation was reversed with an estimated nurse-to-doctor ratio of 1.1:1 in 2019 [88]. China still needs to step up its training of nurses to perform the MCH services.

In the era of SDGs, many countries address MCH workforce challenges through task-shifting and creating cadres capable of providing antenatal care, intrapartum care, postpartum care and paediatric care [89]. It is necessary to look at the MCH workforce as a whole in-country systems to complement to the measurement of particular cadres of MCH workers. While the presented MCH workforce analysis was confined to mainland China, the analysis we have done is likely to apply to many LMICs which do not apply international training standards, e.g. Vietnam, Myanmar and Zambia [90]. As countries try to address MCH workforce gaps, reliable and up-to-date information on the profile and density of MCH workers is urgently needed for evidence-based policy making. This calls for improved methods in future primary data collection, including clear definitions of MCH workers and robust measurement of MCH workforce density.

Our study has several limitations. First, we found no studies reporting on the private sectors, where the profile of MCH workers may be different from those working in the public sector. Second, we only focused on the length of education without analysing the content of training, so we did not assess the skills of the MCH workers. Third, we did not separate the data by year for the meta-analysis because that would result in too few studies for each cadre and each subgroup. Given that 94% of the included studies were done after 1990 and health workforce usually takes a decade or a generation to develop [91], the difference in time period was unlikely to change the results. Fourth, there were relatively too few studies contributing to each subgroup (less than 10 studies). Subgroup proportions need to be interpreted with uncertainty. Fifth, there could be some mis-reporting given the methods used to report on MCH workers. Last, the quality of the included studies needs careful scrutiny, because there is unclear and high risk of bias in almost all studies.

The high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as “obstetricians” or “paediatrician” have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision. In a global context, particularly in the area of maternal and newborn health, many countries are pushing for degree-level qualification of skilled health professionals. China’s experience in training and optimizing the roles of less educated MCH workers can be further explored as a strategic option for poor-resourced settings.