Preplanned Studies: The Distribution of Pregnant Women with Different Pregnancy Risks — 4 Cities, China, 2019

In October 2015, China’s One-Child Policy was replaced by a universal Two-Child Policy; following the policy change, multiparous births exceeded primiparous births nationwide (1). From July 2016 to December 2017, the monthly mean percentage of being multipara and being of advanced maternal age (aged 35 years and over) increased by 9.1% and 5.8%, respectively, and this increase was also seen in at-risk pregnant women (2). The comprehensive high-risk score method for pregnant women was used to screen pregnancy risks, but the screening results were untargeted and disorganized (3). In order to prevent adverse pregnancy outcomes and ensure the safety of mothers and infants, the National Health Commission (NHC) of China in 2017 proposed implementing the “Five-Color Management” for women during pregnancy and 42-days postpartum based on different pregnancy risk levels (4). Compared with the traditional comprehensive high-risk score method, the “Five-Color Management” for pregnant women is to screen, assess, classify, and manage pregnancy risks from a thematic perspective (5). We conducted this study based on surveillance projects from 4 cities (Beijing, Chengdu, Shenzhen, and Wuhan) in China from 2014 to 2019. This study aims to analyze the implementation of the “Five-Color Management” in 2019 in the 4 cities. The results showed that the proportions of “Yellow and above” pregnancy risk ranged from 54.5% to 65.0% and ranged from 7.4% to 16.3% for “Orange and above” pregnancy risk. Among women with “Orange and above” pregnancy risk, most of them gave birth in public tertiary institutions (71.8%–79.4%).

The data were collected from the surveillance project that was founded by the China-World Health Organization Biennial Collaborative Projects entitled “Surveillance of high-risk maternal health services and management” (2018–2019). The surveillance project was implemented by the National Center for Women and Children’s Health of China CDC, and its details were described in our previous publications (6-7). Briefly, three cities including Chengdu, Wuhan, and Shenzhen were selected for the surveillance from the western, central, and eastern regions of China, respectively. These cities were selected based on their geographical location, and the existing city-wide unified reporting system for maternal and child health (MCH) covering the whole city. Furthermore, these criteria were used to select two districts (Haidian District and Chaoyang District) in Beijing to represent the northern region of China. The surveillance covered all medical institutions providing childbirth services in the 4 cities, including general hospitals, maternal and children’s healthcare hospitals, specialized hospitals, community health centers/township hospitals, and private hospitals. In 2019, a total of 325 medical institutions were covered in the surveillance.

According to national regulations, the “Five-Color Management” requires that pregnant women be classified into five colors levels — green, yellow, orange, red, and purple — according to their basic conditions and pregnancy complications (4-5). “Green” indicates normal pregnancy; “Yellow” indicates general risk and that pregnancy complications are mild and stable; “Orange” indicates medium risk and that pregnancy complications pose a threat to mother and infant safety; “Red” indicates high risk and that pregnant women suffer from serious pregnancy complications, continued pregnancy may endanger the life of mother and infant; and “Purple“ indicates that the pregnant women have infectious diseases such as viral hepatitis, syphilis, HIV/AIDS, tuberculosis, serious infectious pneumonia, or a specific viral infection (H1N7, Zika, etc.). Except for the combination of “Purple” and other color levels, pregnant women will be managed according to their “color level” with the highest pregnancy risks. “Yellow and above” was classified as high-risk pregnancy, and “Orange or above” was classified as key groups of high-risk pregnancy. In the 4 cities, the MCH information system covered the whole city, and individual antenatal care and delivery information for all pregnant women were recorded in the system. Due to the adjustment of the MCH information system, the analysis of the “Five-Color Management” only covered pregnant women from July 1 to December 31, 2019 in Wuhan, while in the other 3 cities included all pregnant women during 2019.

Among 625,305 pregnant women in the 4 cities, the proportions of being multipara and of advanced maternal age were 47.4% and 13.3%, respectively. The proportion of being of advanced maternal age in multipara (21.8%) was higher than that in primipara (5.7%). (Table 1)

In the 4 cities, the proportion of “Yellow” pregnancy risk was between 48.1% and 62.1%, and the proportion of “Orange” and “Red” pregnancy risk was the highest in Beijing (14.5%) and the lowest in Wuhan (6.3%). The proportion of “Yellow and above” pregnancy risk (high-risk pregnancy) ranged from 54.5% to 71.4%, and “Orange and above” pregnancy risk (the key groups of high-risk pregnancy) ranged from 7.4% to 16.3%. (Table 2)

In the 4 cities, the proportion of pregnant women giving birth in public tertiary institutions was between 65.9% to 76.9%, and the proportion giving birth in public secondary institutions or other institutions were between 11.2% to 18.6%. More than 82.0% of pregnant women with “Yellow” risk gave birth in public secondary or above institutions, and 71.8% to 79.4% of pregnant women with “Orange and above” risk gave birth in public tertiary institutions. However, more than 20% of pregnant women that had “Orange and above” risk gave birth in public secondary and below institutions. (Table 3)