Reducing maternal mortality in China in the era of the two-child policy

Reducing maternal mortality ratio (MMR) is of great concern worldwide. After the implementation of the two-child policy in 2013, the number of live births and the proportion of high-risk pregnancies both increased, and these bring new challenges to the reduction of MMR. China implemented a package of nationwide strategies in April 2016, the Five Strategies for Maternal and Newborn Safety (FSMNS). 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. To better implement the FSMNS, China formulated a unified pregnancy risk screening form. After risk assessment and classification, medical records of all the pregnant women are labelled with green (low risk), yellow (moderate risk), orange (high risk), red (highest risk) or purple (infectious disease) for tailored management. By the implementation of FSMNS, China has already kept the MMR stable and cause it to enter a controlled decline. MMR in China has declined by 21.1%, from 23.2 per 100 000 live births in 2013 to 18.3 per 100 000 live births in 2018. The country's challenges and experience in reducing the MMR could provide useful lessons for other countries.