Factors affecting the frequency and contents of routine antenatal care in remote rural China in 2009-2016: An observational study.

OBJECTIVE: We assessed factors associated with the frequency and contents of antenatal care (ANC) in remote rural China, including the province of residence and individual-level factors. DESIGN: Survey-based cross-sectional study. SETTING: Five provinces in remote rural China: Guizhou, Hunan, Jilin, Ningxia and Shaanxi. SAMPLE: A cohort of 3918 women with a live birth in 2009-2016. METHODS: Poisson regression. MAIN OUTCOME MEASURES: ANC frequency: five or more visits, starting in the first trimester. ANC contents: coverage of six care components and overuse of ultrasound. RESULTS: Three-quarters (72.9%) of women had five or more ANC visits, starting in the first trimester; 68.8% received all six care components and 94.5% had three or more ultrasounds. Only 30.9% of women sought ANC from township hospitals, paying between $3.80 and $25.80 per visit. ANC frequency and contents were associated with the socio-economic characteristics of the women, but provincial effects were much greater, even after adjusting for individual factors. Women living in Guizhou and Ningxia, the two poorest provinces, with high proportions of ethnic minorities, were particularly underserved. Compared with women in Shaanxi, women in Guizhou were 33% (adjusted RR 0.67, 95% CI 0.61-0.74) less likely to receive five or more ANC visits, starting in the first trimester; women in Ningxia were 17% less likely (adjusted RR 0.83, 95% CI 0.76-0.90) to receive all six care components. CONCLUSIONS: The province of residence was a stronger predictor of ANC frequency and contents than the individual characteristics of women in China, suggesting that strengthening the decentralised system of the financing and organisation of ANC at the province level is crucial for achieving success. Future efforts are warranted to engage subregional administrations. TWEETABLE ABSTRACT: The province of residence was a stronger predictor of ANC frequency and contents than the individual characteristics of women.