Principal findings
Based on URBMI data, this study provides an estimate of changes in inpatient admission rates and associated costs of infants between 0 and 6 months old after the universal two-child policy was implemented in China. The study yielded three main findings. First, inpatient admission rates were 24.9 and 29.8% for infants within 1 month and 6 months old, respectively. In comparison with 2015, inpatient rates increased among infants in both age groups, with larger increases observed among male infants. Second, compared with 2015, in 2017, there was an increase in inpatient admissions rates overall and for both infectious and noninfectious diseases. The leading five causes of hospitalization were jaundice, pneumonia, preterm birth or small size for gestational age, bronchitis, and neonatal aspiration syndrome. Inpatient admission rates were higher in 2017 than in 2015 for jaundice, pneumonia, lower for bronchitis, but not for preterm birth/small size for gestational age or neonatal aspiration syndrome. Third, the average cost per admission was RMB 8412.3 ($1320.61), with 53.0% percent paid out of pocket, and 76.2% of hospital stays took place in tertiary hospitals. There was no increase in spending per visit overall except for jaundice.
This study adds to our understanding of how the universal two-child policy affects infant inpatient outcomes in China. First, it provides an assessment of inpatient outcomes for infants up to 6 months of age. Second, it captures all types of infant hospitalizations and presents leading causes of hospitalization, providing a more completed understanding of infants’ healthcare utilization. Prior literature has examined only a limited number of infant health complications or diseases [
5,
9]. Our results are consistent with the two major studies on this topic [
5,
9]. More specifically, Li et al. [
5] found an increase in maternal age but no increase in preterm births following the universal two-child policy, while Zhang et al. [
9] found an increase in women with advanced maternal age and an increase in birth defects. The null result in preterm births is puzzling. Li et al. [
5] did not provide a discussion on why there was no increase in preterm births despite the increase in advanced maternal age. It is possible that the universal two-child policy is associated with an increase in miscarriage or stillbirths or preterm that have resulted in neonatal death, and thus they do not show up in our sample. A dataset that covers information on miscarriage, stillbirths, and neonatal death is needed to examine this issue further. Examining infant hospitalization trends and understanding why infants are hospitalized before and after the universal two-child policy is critical to inform clinical practices and health policies governing the allocation of hospital resources. As there is an urgent shortage of pediatricians in China, to better meet the increasing healthcare needs of this cohort of children, an increased supply of pediatricians, continuous professional training and retention programs, and structural reforms to the pediatric care system are needed [
9].
Consistent with previous studies [
14,
15], we found that male infants were at a higher risk of being hospitalized and that the increase in inpatient admission rates was higher among males than among females. One explanation for these differences is biological: male infants are more vulnerable to illness, especially at a younger age [
16]. Alternatively, possibly because of the old age security motive [
17,
18], as well as patriarchal and son-preference culture in China [
19], families are more likely to take male infants to hospitals [
20]. Also, because mothers who gave birth following the universal two-child policy were older [
5], and were more likely to give birth to male children as their second child [
21], male children born after the two-child policy may be less healthy than male children born before the two-child policy. Thus, special attention should be paid to understanding and addressing gender differences in children’s health.
We find that the cost of an inpatient admission is not high in China. The average inpatient admission cost is RMB 8412.3 ($1320.61)—significantly lower than in the United States or other developed countries [
22]. The average out-of-pocket cost is RMB 4458.5 ($699.92), which is not a catastrophic cost for most patients in China. The average annual household income in 2015 is RMB 31194.8 ($4897.14), and households’ total consumption expenditure net of food in 2015 is RMB 6359.7 ($998.38) in China [
23]. The average hospitalization cost across all diseases is lower than the threshold for catastrophic health expenditures, defined as out-of-pocket payments amounting to greater than 40% of a household’s total consumption expenditures net of food [
24,
25].
However, our findings are consistent with previous literature showing that the proportion of out-of-pocket costs for children is relatively high compared with that for adults [
7]. Literature has shown that the share of costs paid out-of-pocket for all healthcare services is 28.8% in national data [
26], whereas the share paid out-of-pocket for infants in our sample was 53.0%. Because the individuals in our sample are covered by URBMI, these differential out-of-pocket rates may be due to higher demand for services or drugs not included in the essential benefits package [
7]. To reduce the burden posed by out-of-pocket healthcare costs, regulation and oversight of the efficient use of services should be implemented by the government. In addition, more research is needed to understand why hospitalization for infants results in a higher proportion of services or drugs that fall outside of the essential benefits package, as compared with adults. If these services or drugs are essential in treating infants, the depth and breadth of coverage need to be increased for infants to ensure financial protection for families.
There is evidence that spending is on the rise for jaundice after the universal two-child policy. Spending on the hospitalization cost of jaundice can increase due to an increase in the severity of diseases. Alternatively, as parents may have son preference due to old age security motive [
17,
18], with a larger increase in jaundice for male infants (the associated coefficient is 0.027 in males versus 0.017 in females), spending on average may have increased because more male infants are hospitalized for jaundice. The increases in spending, as well as increases in the rate of inpatient care, add to economic burdens for families and for social health insurance. Thus, it is important to look for ways to contain costs.
In our analyses, we found that 76.2% of inpatient visits took place in tertiary hospitals. Even though China intends to build an integrated healthcare system, the system remains to be fragmented, and patients often bypass lower-tier hospitals, and tend to prefer tertiary hospitals because they are perceived to have higher quality [
27]. This imbalance creates overwhelming demand at the tertiary level, with a single physician typically responsible for 80 to 100 visits per day in some tertiary children’s hospitals, while lower-level hospitals may be underutilized [
28]. Because of the congestion, families with children often have to wait in long lines in seeking for care, and physicians can pay less attention to each case, causing tension between patients and physicians [
29]. In addition, as dictated by the price schedule designed by the Ministry of Health, tertiary hospitals are more expensive than non-tertiary hospitals [
30]. Thus, one important way to contain costs and reduce congestion in large hospitals is to strengthen the capacity of non-tertiary hospitals to treat infants.
Policy implications
Understanding the hospitalization trends of infants is important for healthcare resource allocation and requires specific policies to aid the early diagnosis and treatment of preventable diseases. The increasing demand coupled with the acute shortage of pediatricians calls for an improvement in the quantity and quality of pediatric education and the workforce system. In addition, as male infants have a higher rate of inpatient admissions, special attention should be paid to understanding and addressing gender differences in children’s health.
While the rate of catastrophic cost is not high, the proportion of the out-of-pocket cost is higher than adults. In addition, there is an increase in spending on certain illnesses. Also, the rate of attending tertiary children’s hospitals is high. Thus, it is important to provide better financial protection for infants by increasing the depth and breadth of healthcare coverage while at the same time to strengthen the capacity of non-tertiary hospitals to treat infants to achieve the goal of containing costs and reducing congestion in large hospitals.
This paper also has important public policy implications in the era of the three-child policy. China announced in August 2021 that all couples are allowed to have up to three children. This policy has targeted parents who already have two children. If it is successful in encouraging families with two children to have a third, the likelihood of mothers being of advanced maternal age would be even higher as all these mothers have already given births to two children. With the well-established link between advanced maternal age and infant health problems [
7,
8], it is possible that there would further increase in the hospitalization of infants post three-child policy. Thus, the healthcare system should monitor the health status of this cohort proactively, and adopt changes in response to the change in infant health.
Limitations
Our findings should be cautiously interpreted due to several limitations. First, as there is no appropriate control group, we cannot rule out possible confounding factors and therefore cannot establish causality. There may be changes in the structure of the population of women of childbearing age even in absence of the universal two-child policy, thus biasing the result of our study. For example, the younger generation of women may be delaying the age of births regardless of population policy. Second, in our analyses, we compared healthcare utilization for infants born in 2015 versus those born in 2017. Because the universal two-child policy was announced in October 2015, births after June 2016 (9 months after the announcement of the universal two-child policy) are usually considered to fall in the range of the post-period. It is possible that the mothers who are successful in getting pregnant right after the announcement of the universal two-child period are younger, healthier, or have more resources, and our results may be different if we include this group of women. Because we do not have information on monthly births, we cannot answer this question empirically. Thus, the interpretation of the paper may be limited to the healthcare utilization of the cohort born in 2017. Second, our study is limited to the utilization of URBMI. If patients do not apply for health insurance or do not use health insurance, their hospitalizations do not appear in our dataset. However, because of the nontrivial cost associated with hospitalization and families’ ability to apply and use health insurance retroactively, the likelihood of hospitalization without health insurance for infants who are qualified for health insurance may be low. Third, inaccuracy and incompleteness of patients’ medical information may affect the accuracy of our analysis. Fourth, we do not have information on infant death, so our results are conditional on living infants. We also lack data on outpatient visits, so we cannot provide an estimate of total medical costs. Lastly, the study only uses data from one metropolitan city, and results from other regions of China are likely to differ.