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To the Editor: From 1990 to 2021, the disease burden of pregnant women in China has changed significantly. China is facing challenges in addressing the complex factors affecting the well-being of pregnant women. Socioeconomic disparities, regional variations in healthcare infrastructure, and gaps in the quality of care remain significant barriers to achieving optimal health outcomes for vulnerable populations.[1,2] Economic development has brought new health challenges, highlighting the need to update data in China to improve health equity. Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, our study assesses the maternal disease burden in 2021 and updates national trends from 1990 to 2021. The trend of disease burden indicators was analyzed by the annual percent change (APC), average annual percent change (AAPC), and estimated annual percentage change (EAPC); the trend of disease burden indicators after 2021 was predicted in the Bayesian age-period-cohort analysis. Our study helps to identify gaps in maternal disorders across Chinese provinces and guides the creation of targeted measures, which is crucial for developing effective public health services for maternal health in China. Comparison of maternal disorder disease burden in China with globality: In 2021, the age-standardized mortality rate (ASMR) of maternal disorders in China was 0.24 per 100,000 population, lower than ASMR in other regions in the world: 4.87 in the globality, 1.38 in Southeast Asia, East Asia, and Oceania, 4.54 in South Asia, and 0.34 in high-income countries, per 100,000 population. Except for sub-Saharan Africa, the decline in maternal disorder deaths and disability-adjusted life-years (DALYs) worldwide was driven by the epidemiological change contribution. Both epidemiological and population aging trends for maternal disorders have declined globally, with the most significant decrease observed in China [Supplementary Figure 1, https://links.lww.com/CM9/C798]. Since 2013, the Chinese government has adopted the Belt and Road Initiative to connect the Asia–Pacific Economic Area with the European Economic Area. The initiative will also provide a platform for China to strengthen its global health strategy further, especially in terms of policy cooperation with other parts of the world on maternal health. China and provincial maternal disorders diseases burden in 2021: In 2021, maternal disorders caused 1.51 (95% uncertainty interval [UI]: 1.07 to 2.08) thousand female deaths and 124.64 (95%UI: 95.53 to 161.79) thousand DALYs person-years in China; the age-standardized maternal mortality rate (MMR) per 100,000 live births was 14.09 (95%UI: 9.92 to 19.52), and the age-standardized DALYs rate (ASDR) was 20.54 (95%UI: 15.64 to 26.63) per 100,000 population. The highest age-standardized MMR of maternal disorders per 100,000 live births was seen in Xizang (61.39 [95%UI: 39.32 to 92.91]), and 13 provinces such as Qinghai (36.17 [95%UI: 21.55 to 60.70]), Xinjiang (31.42 [95%UI: 17.75 to 50.44]), Yunnan (26.72 [95%UI: 14.79 to 45.74]) have the higher rate than the national average (14.09 [95%UI: 9.92 to 19.52]), while the MMR of each maternal disease subtype in Heilongjiang, Hong Kong, Jiangsu, and Liaoning is relatively low [Figure 1]. Xizang also had the highest ASDR per 100,000 (97.60 [95%UI: 65.43 to 143.23]), with 14 provinces above average (20.53 [95%UI: 15.73 to 26.67] per 100,000) [Supplementary Figure 2, https://links.lww.com/CM9/C798]. Among the subtypes, the highest age-standardized MMR per 100,000 live births were all indirect maternal deaths. The main cause of maternal death in 27 provinces was also indirect maternal deaths [Figure 1]. The results of ASDR were shown in Supplementary Figure 2, https://links.lww.com/CM9/C798. We also compared the prevalence, incidence, and mortality rates of each maternal disorder subtype across provinces in 2021. Based on ASMR rankings, Xizang had the highest burden nationwide, with leading prevalence, incidence, and mortality rates. Yunnan, Guangdong, and Guangxi also exhibited relatively high prevalence and incidence of maternal disorders [Supplementary Figure 3, https://links.lww.com/CM9/C798]. Hotspot analysis identified Xinjiang, Xizang, and Qinghai as 99% confidence hotspots for both age-standardized MMR and ASDR of maternal disease, and the cold spot values of age-standardized MMR were concentrated in the southern region; ASDR cold point values were concentrated along the eastern region. The age-standardized MMR in Xinjiang, Xizang, and Qinghai showed a high–high cluster and in Jilin and southern regions, it exhibited a low–low cluster, and no outliers were observed. ASDR has a high–high in Xinjiang, Xizang, and Qinghai; a low–low in eastern coastal areas and northeast areas; and a high–low outlier in Anhui and Shanxi [Supplementary Figure 4, https://links.lww.com/CM9/C798].Figure 1: Age-standardized MMR (per 100,000 live births) of maternal disorder and its subtypes at the provincial level. HIV/AIDS: Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome; MMR: Maternal mortality rate.China and provincial maternal disorders diseases burden trends: As for the maternal disorders, the age-standardized MMR per 100,000 live births decreased from 68.00 (95%UI: 46.34 to 92.69) in 1990 to 14.09 (95%UI: 9.92 to 19.52) in 2021, AAPC was −4.94 (95% Confidence Interval [CI]: −5.29 to −4.59); ASDR per 100,000 population declined from 148.86 (95%UI: 103.78 to 199.21) in 1990 to 20.53 (95%UI: 15.73 to 26.67) in 2021, AAPC was −6.14 (95%CI: −6.51 to −5.76). From 1990 to 2021, the province with the biggest change in age-standardized MMR per 100,000 live births of maternal disorders was Hunan (−7.99 [95%CI: −7.26 to −8.72]); in ASDR per 100,000 population, also was Hunan (95%CI: −7.65 [−7.24 to −8.06]). In the EAPC results of maternal disorder subtypes, the biggest change of age-standardized MMR in 21 provinces was maternal sepsis and other maternal infections; the biggest change of ASDR in 26 provinces was maternal hemorrhage. The distribution of heatmaps in EAPC results by provinces shows that the MMR for each maternal disorder subtype in Hunan has decreased; however, Tianjin, Jilin, and Liaoning were the provinces with a smaller decline. The ASDR in Guizhou has decreased obviously; however, Tianjin was the city with the smallest decline [Supplementary Figure 5, https://links.lww.com/CM9/C798]. By calculating the APC of each subtype age-standardized MMR and ASDR, it was found that three diseases, indirect maternal deaths, maternal hypertensive disorders, and other direct maternal disorders, had the most significant decline during 2010–2015, and maternal hemorrhage had a significant decline during 2010–2014 [Supplementary Figure 6, https://links.lww.com/CM9/C798]. Obstetricians must attend to the complex spectrum of gynecological and gynecological diseases during gestation. Multifaceted interventions have contributed to the reduction in maternal mortality associated with these conditions.[3] Since 1994, China has implemented a three-stage national poverty alleviation plan (1994–2000, 2001–2010, and 2011–2020), gradually incorporating women, children, and other vulnerable groups into the healthcare system, especially in rural and remote area. The differences between regions are gradually narrowing. Effects of age on MMR and ASDR: In 2021, the MMR per 100,000 live births was lower among those aged 20–34 and highest at 50–54 years, the indirect maternal deaths were the leading cause in every age group; The DALYs rate per 100,000 population was higher in the 20–34 age group and lowest at 10–14 years, with indirect maternal deaths remaining the leading cause in all but the 25–29 years group [Supplementary Figure 7, https://links.lww.com/CM9/C798]. By calculating APC, the age-standardized MMR and ASDR of all age groups showed an overall downward trend from 1990 to 2021, with the most significant decline in age groups 20–24 years old and 25–29 years old from 2010 to 2015, and the most significant decline in women over 30 years old from 2003 to 2007 [Supplementary Figure 3, https://links.lww.com/CM9/C798]. Projections suggest a continued decline in MMR and ASMR of pregnant women in China from 2022 to 2040 . The MMR decreased to 32.05 per 100,000 live births in 2040; the ASMR declined from 2.30 per 100,000 population in 2021 to 0.03 per 100,000 population in 2040. By 2030, China’s MMR aims to decrease to 12.0 per 100,000 live births.[4] To achieve the goals of the Healthy China strategy on schedule, continued efforts are necessary in maternal and child safety management. We found that in 2021, the ASMR, ASDR, and MMR of China was lower than that of global regional average separately. Maternal and newborn disease burden indicators in China show a declining trend nationally and provincially. Our study reveals that from 1990 to 2021, the disease burden of pregnant and postpartum women in China has decreased continuously. Key findings indicate that maternal hemorrhage and indirect maternal causes are the leading subtypes of maternal disorders. MMR remains persistently higher in Western regions compared with Eastern regions in China. China has made remarkable progress in maternal and neonatal health, significantly reducing the disease burden among pregnant women. Maternal disease burden has significantly decreased due to improvements in antenatal care, skilled birth attendance, and timely access to emergency obstetric services. However, despite these achievements, disparities in the supply of medical resources persist between different provinces and regions in China. To further reduce maternal and newborn mortality, it is essential to continue focusing on maternal and child health. Crucial measures include preventing obstetric hemorrhage, improving the quality of obstetric and newborn care, and strengthening the medical security system to ensure equitable access to quality services across all regions. Funding This study was funded by the High-Level Public Health Specialized Talents Project of the Beijing Municipal Health Commission (No. 2024-3-028). Conflicts of interest None.