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China has been declared free of one of the world’s major causes of preventable death of mothers and newborns. Following a maternal and neonatal tetanus (MNT) elimination validation exercise carried out last month, theWorld Health Organization (WHO) formally declared that China has eliminated MNT on 30 October 2012.
The validation exercise was carried out by 103 monitoring teams that conducted cluster surveys in Hechi Prefecture of Guangxi Province and Jiangmen Prefecture of Guangdong Province – chosen because of their high proportion of rural poor and migrant worker populations, who have limited access to clean delivery practices. The survey teams visited 45,088 households and investigated 2,306 live births and found zero cases of MNT.
WHO considers elimination of MNT to be achieved when there is less than one case of neonatal tetanus per one thousand live births in every district. If neonatal tetanus is eliminated, maternal tetanus elimination is assumed. The validation was coordinated by the Ministry of Health with support of the United Nations Children’s Fund (UNICEF) and WHO and now confirms that all prefectures in China have less than one case of the disease per one thousand live births.
China now joins the 161 countries that have eliminated neonatal tetanus.
Tetanus is a painful and often fatal disease that affects mothers and newborn babies. It causes muscle stiffness and spasms, sometimes called “lockjaw.” In newborns and mothers it is generally caused by unclean delivery conditions and umbilical stump infections.
Neonatal tetanus can be prevented by hygienic childbirth, careful handling of the umbilical cord during and after childbirth or maternal vaccination with tetanus toxoid vaccine.
“We are extremely happy that WHO has validated China’s elimination of maternal and neonatal tetanus, one of the world’s major preventable causes of maternal and infant death,” said Gillian Mellsop, UNICEF Representative for China. “With this announcement a major step toward the global goal of MNT elimination has been taken. We congratulate China and its Ministry of Health for this noteworthy achievement for children.”
China’s success in eliminating MNT is also noteworthy because it is due primarily to significant increases in its hospital delivery rate, especially in remote rural counties. Other countries working on MNT elimination have placed emphasis on scaling up tetanus toxoid immunization efforts. China does not have a policy of immunizing pregnant mothers with tetanus toxoid.
The commitment to global elimination of maternal and neonatal tetanus was launched by World Health Assembly in 1989. By 2010, it was estimated that worldwide MNT deaths had been reduced by more than 90 per cent.
“UNICEF has been working with the Ministry of Health for more than thirty years now on improving maternal and child health. In recent decades the Ministry of Health has put special emphasis on safe motherhood, or keeping mothers and babies safe and healthy during pregnancy and childbirth,” said Dr Robert Scherpbier, UNICEF Chief of Health and Nutrition. “China’s elimination of MNT is a wonderful story because, while most of the world is also immunizing pregnant mothers to fight this terrible disease, China has done it the “hard way” so to speak, by massive investment and attention on improving hospital delivery rates and rural maternal and child health outcomes more broadly.”
Historically, hospital delivery was quite low in China, especially in poor rural districts. Prior to 1995 China’s rural hospital delivery rate was below 25 per cent, and in some of the poorest counties it barely reached 10 per cent.
In 1999, UNICEF helped launch the safe motherhood initiative in 40 of the poorest counties in China, in cooperation with the Ministry of Health and the National Working Committee for Children and Women (NWCCW). The aim was to encourage women to deliver their babies in hospital instead of at home for increased access to hygienic delivery conditions and potentially life-saving care.
The safe motherhood approach as implemented by the Government of China emphasizes community health education, small subsidies for hospital delivery, provision of clean childbirth kits to rural health facilities, improved obstetric care infrastructure at county and township hospitals, capacity building for rural health workers and midwives and establishing the “fast channel” referral mechanism for pregnant women near birth.
Between 2000 and 2009 the safe motherhood strategy modeled by UNICEF consistently demonstrated improved maternal and child health outcomes and increased hospital delivery rates in the counties where they were piloted.
Based on this extensive body of evidence accumulated, the Government of China funded and progressively expanded the safe motherhood strategy to all central and western rural counties in China, with the subsidized hospital delivery policy extended to all 2,297 rural counties in China. China’s hospital delivery rate is now above 96 per cent in most rural areas.
“In addition to bringing about a substantial reduction in maternal and newborn mortality, China’s hospital delivery policy has now also led to the elimination of maternal and newborn tetanus as a public health problem,” observed Dr. Robert Scherpbier of UNICEF. “
“The microorganism causing tetanus is a spore forming organism that is present everywhere in the environment and can survive under harsh conditions. So while tetanus has been eliminated as a public health problem, due to the resilience of the bacterium, it can reemerge if these successful public health policies are relaxed,” he added.
“Thus it is important to sustain these enormous achievements and ensure almost universal hospital delivery rates are sustained, and improved wherever possible.”