Uptake of maternal care and childhood immunization among ethnic minority and Han populations in Sichuan province: A study based on the 2003, 2008 and 2013 health service surveys

Background: China has made remarkable progress in maternal and child health (MCH) over the last thirty years, but socio-economic inequalities persist. Ethnicity has become an important determinant of poor MCH outcomes, but little rigorous analytical work has been done in this area. To understand the socio-economic factors that explain ethnic variation in uptake of MCH care, we report the findings from an analysis in Sichuan province. Methods: We linked data from the 2003, 2008 and 2013 National Health Service Surveys in Sichuan Province. The ethnic disparities in uptake of maternal care (completing 5 antenatal visits, giving birth in hospital and receiving a caesarean section) and childhood immunization (Bacillus Calmette Guerin (BCG), three doses of diphtheria (DPT) and measles immunization) were examined by geographical (Han district/county vs. ethnic minority county) and individual-based (Han women/children vs. ethnic minority women/children) comparisons. We also examined variation by distance to township and county hospitals, women's education, parity and age using weighted multilevel Poisson regressions with random intercept at district/county level. Results: Ethnic inequalities in maternal care were marked, both at the geographical (district/county) and the individual level. The % of births in hospital was 90.7% among women in Han districts, compared to 83.3% among women living in Han counties (crude RR 0.93; 95% CI 0.75-1.15), 53.8% among Han women living in ethnic minority counties (crude RR 0.57; 95% CI 0.36-0.93), and 13.5% among ethnic minority women living in ethnic minority counties (crude RR 0.18; 95% CI 0.06-0.57). Adjusting the analysis for survey year, education, parity and distance to county level hospital weakened the association between geographical/individual ethnicity and uptake of maternity care, but associations remained remarkably strong. Coverage of childhood immunization was much higher than uptake of maternity care, and inequalities by ethnicity were much less pronounced. Conclusion: Lessons can be learned from China's successful immunization programme to further reduce inequalities in access to maternity care among ethnic minority populations in remote areas. Bringing the services closer to the women's homes and strengthening health promotion from the township to the village level may encourage more women to seek antenatal care and give birth in hospital