To cope with these challenges, based on the previous evidence and country experience, the National Health Commission implemented a package of nationwide strategies in April 2016. These are called the Five Strategies for Maternal and Newborn Safety (FSMNS). They involve taking into account the natural progress of cases that ended in death, from low-risk pregnancy to high-risk pregnancy to critical pregnancy to death. The FSMNS consists of five components: (1) pregnancy risk screening and assessment strategy, (2) case-by-case management strategy for high-risk pregnancies, (3) referral and treatment strategy for critically ill pregnant women and newborns, (4) reporting strategy for maternal deaths and (5) accountability strategy (box 1).18 19 Among the five strategies, screening for and assessment of high-risk pregnancies is the foundation of high-quality perinatal healthcare. All the pregnant women are screened and assessed by medical workers using uniform standards and procedures, all of whom have undergone unified training (figure 5). After risk assessment and classification, medical records of women are labelled with green (low risk), yellow (moderate risk), orange (high risk), red (highest risk) or purple (infectious disease) for tailored management. Pregnant women with different risk levels are transferred to designated medical institutions at different levels for further perinatal care and delivery (figure 5). Case-by-case management is implemented on pregnancies at higher level of risk (labelled with orange, red, and purple).
Box 1Key points in the Five Strategies for Maternal and Newborn Safety
Pregnancy risk screening and assessment
Risk screening for pregnant women is carried out during the first visit to a healthcare facility. The secondary or tertiary healthcare facilities use midwifery services to conduct pregnancy risk assessments and classify pregnancy risk according to risk severity. Medical records are labelled with five colours of ‘green (low risk), yellow (moderate risk), orange (high risk), red (highest risk), and purple (infectious disease)’ to facilitate classification and management. Pregnant women labelled with yellow, orange, red, and purple are instructed to seek maternal health services and hospital delivery at secondary or tertiary health facilities.
Case-by-case management of high-risk pregnancies
Pregnant women with different risk levels are transferred to different types of maternal and child health (MCH) institutions for perinatal care and delivery. Women at greater risk (orange, red and purple) are considered a key population and sent for case-by-case management to foster whole-process management, dynamic supervision and centralised treatment and to facilitate the screening, registration, reporting, management and treatment of every high-risk pregnant women.
Critically ill pregnant women and newborn referral and treatment
A nationwide network of critically ill pregnant women and a newborn referral and treatment system has been established. A multidisciplinary maternal and neonatal critical care expert group has been established in each county. Maternal and neonatal critical care centres are responsible for critical care in designated areas, and they keep the green channel (express referral networks) open for critical illness referrals.
Reporting maternal deaths
Statistical tables of orange and red labelled cases have been established to guide the effective management and treatment of high-risk pregnant women. China launched a direct reporting system for individual maternal deaths for the first time on 1 October 2017. Within two hours of a maternal death, health facilities are required to report each case to the designated county-level maternal and child healthcare institutions. After checking the situation, designated personnel located at the county-level maternal and child healthcare institution should report detailed information of the death case using the national annual online reporting information system for maternal and child health before the 10th day of each month. After a review of maternal deaths, rectification measures should be implemented by related health facilities.
Accountability
Areas that have achieved outstanding progress in the reduction of the maternal mortality ratio (MMR) should summarise and promote these effective experiences in a timely manner and be praised by the National Health Commission. For areas with increasing MMR trends, a group of experts should be assigned to provide training to a targeted guidance in a timely manner. For areas that have not implemented the required measures to reduce the MMR, the National Health Commission will issue criticism by circulating a notice. If a hospital sees maternal deaths continuously, the director of the related hospital will be held accountable.