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Neonatal mortality as a sentinel indicator for health system performance: a 33-year analysis of China's maternal and child health policies.

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Title: Neonatal mortality as a sentinel indicator for health system performance: a 33-year analysis of China's maternal and child health policies.
Authors: Rao Z; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Yin D; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Xu Y; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Qing Z; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., An W; Department of Maternal, Child and Adolescent Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Yin Z; Department of Maternal, Child and Adolescent Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Lu Y; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Li J; The Second Clinical Medical School of Shandong University, Jinan, China., Li D; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Cheng K; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Li S; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China., Yuan C; The Second Clinical Medical College, Guangdong Medical University, Dongguan, China., Dai Q; Department of Health, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Source: Journal of global health [J Glob Health] 2026 May 22; Vol. 16, pp. 04173. Date of Electronic Publication: 2026 May 22.
Publication Type: Journal Article
Language: English
Journal Info: Publisher: International Society of Global Health Country of Publication: Scotland NLM ID: 101578780 Publication Model: Electronic Cited Medium: Internet ISSN: 2047-2986 (Electronic) Linking ISSN: 20472978 NLM ISO Abbreviation: J Glob Health Subsets: MEDLINE
Imprint Name(s): Publication: <2019>-: Edinburgh : International Society of Global Health
Original Publication: Edinburgh : Edinburgh University Global Health Society, 2011-
MeSH Terms: Infant Mortality*/trends , Health Policy*, China/epidemiology ; Maternal Mortality/trends ; Humans ; Infant, Newborn ; Infant ; Female ; Longitudinal Studies ; Pregnancy ; Child, Preschool
Abstract: Background: This study aims to research short-term disequilibrium adjustments and long-term cointegration relationships among the maternal mortality ratio (MMR), under-five mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR), while evaluating the contributions of pivotal health policies and service coverage.
Methods: Using nationally representative longitudinal data (1991-2023), this study applied Joinpoint regression model to identify trend inflection points and calculate average annual percent change (AAPC), Pearson correlation analysis to assess inter-indicator associations, and vector error correction model framework to analyse cointegration and short-term dynamics after establishing stationarity and causality.
Results: All mortality indicators exhibited significant decreasing trends (AAPCMMR = -4.92%, AAPCU5MR = -6.79%, AAPCIMR = -7.19%, AAPCNMR = -7.40%), with inflection points aligning with major policy implementations. Strong positive correlations were observed among all indicators (ρ≥0.980). The vector error correction model revealed three cointegrating vectors, confirming long-term equilibrium relationships. The NMR demonstrated faster error correction speed (error-correction term = -0.89, P = 0.030) and was identified as the Granger cause of MMR, U5MR, and IMR (P < 0.05). Policy analyses revealed that New Rural Cooperative Medical Scheme expansion significantly reduced NMR (α = -0.26, P = 0.006), whereas hospital delivery rate exhibited a counterintuitive short-term positive association with NMR (α = 0.05, P = 0.013). The Reducing Maternal Mortality and Eliminating Neonatal Tetanus project significantly reduced IMR (α = -0.25, P = 0.014), outperforming isolated neonatal visits.
Conclusions: The NMR serves as a pivotal sentinel indicator for China's maternal and child health system performance, with Granger-causal precedence over other metrics. Phased health policies, particularly New Rural Cooperative Medical Scheme and Reducing Maternal Mortality and Eliminating Neonatal Tetanus project, accelerated mortality reductions through distinct mechanistic pathways, despite short-term trade-offs. These findings provide a transferable policy blueprint for low- and middle-income countries to accelerate progress towards Sustainable Development Goal 3.2 through equity-oriented reforms.
(Copyright © 2026 by the Journal of Global Health. All rights reserved.)
Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.
Entry Date(s): Date Created: 20260522 Date Completed: 20260717 Latest Revision: 20260717
Update Code: 20260717
DOI: 10.7189/jogh.16.04173
PMID: 42170693
Database: MEDLINE
Description
ISSN:2047-2986
DOI:10.7189/jogh.16.04173