Trends in maternal mortality in China and Hainan Province: an analysis based on GBD 2023 and Hainan surveillance data

To examine long-term trends in maternal mortality ratio (MMR) in China (1990-2023) and Hainan Province (2003-2023), characterize age-specific and cause-specific patterns, and assess the impact of major policy events on MMR trends.

Data were obtained from the Global Burden of Disease Study 2023 and Hainan provincial maternal mortality surveillance records. Joinpoint regression was used to identify segmented trends and estimate annual percent change (APC). Log-linear regression was used to estimate the overall estimated annual percent change (EAPC). National data were used for age- and cause-specific analyses. Interrupted time series analysis assessed temporal associations of the 2009 healthcare reform, the 2016 universal two-child policy, and the 2020 COVID-19 pandemic with national MMR trends.

From 1990 to 2023, China's MMR decreased from 121.9 to 10.7 per 100,000 live births, a 91.3% decline, with an EAPC of -9.06% (95% CI: -9.79 to -8.32). In Hainan Province, MMR decreased from 47.5 to 8.9 per 100,000 live births during 2003-2023, an 81.4% decline, with an EAPC of -7.39% (95% CI: -9.06 to -5.72). Three national joinpoints were identified in 2004, 2013, and 2018, indicating a slow decline, rapid decline, slower decline, and stabilization during 2018-2023. No significant joinpoint was detected in Hainan Province. MMR decreased significantly across all age groups but remained relatively high among women aged 40-49 years. Mortality due to postpartum hemorrhage and hypertensive disorders of pregnancy declined markedly. Indirect maternal mortality also decreased but remained relatively high in the later period. After the 2016 policy, both the level and trend terms of MMR increased significantly. After the COVID-19 pandemic, the level term was not significant, whereas the trend term increased significantly.

MMR declined substantially in China from 1990 to 2023 and showed a sustained decline in Hainan Province, with a markedly narrowed provincial-national gap. Older pregnant women remain a key high-risk group, and postpartum hemorrhage and hypertensive disorders of pregnancy remain major prevention priorities. After the universal two-child policy, both the level and trend terms of MMR increased significantly. After the COVID-19 pandemic, the MMR trend term also increased significantly.