Sustainable Development of China’s Maternity Insurance System in the Context of Population Policy Changes: Using a Grounded Theory Approach

Abstract

Background: Declining birth rates have become a challenge for many countries around the world. This study aimed to analyze the influencing factors of the sustainable development of the maternity insurance system and find ways to promote higher birth rates. Methods: We used four multi-stakeholder workshops and in-depth interviews to bring together three groups of people: maternity insurance system developers, implementers, and researchers. Then, we analyzed the factors influencing the sustainability of the maternity insurance system using grounded theory. Results: In this study, the most powerful and effective intervention measures for China in the short term include the policy of merging national health insurance with maternity insurance and a dynamic payment rate policy. In the long term, expanding the coverage of the maternity insurance system and improving the management level of the maternity insurance fund are effective intervention measures. Conclusion: This study subdivides the factors influencing the sustainable development of the maternity insurance system, which has certain theoretical significance and can be used as the theoretical basis for quantitative and empirical research model construction in the future.

1. Introduction

Declining birth rates have become a challenge for many countries around the world as economies develop [1,2,3,4]. Some studies suggest that efforts to increase birth rates should be made in terms of fertility attitudes, fertility behaviors, family policies, and assisted reproductive technologies [5,6,7,8]. However, the maternity insurance system (abbreviated as MIS) is also important to improving birth rates, as the system itself ensures gender equality, and the payment provided during childbirth reduces the financial stress on mothers during pregnancy [9,10,11]. In China, MIS has become an important source of income for women during their pregnancy. An unsustainable MIS may reduce women’s willingness to have children. For the sustainability of the MIS, it is necessary to make the MIS compatible with socio-economic development and maintain fund balance [12,13].

The number of births in China has been rapidly declining. A drop of 40% in the number of newborns has been observed, from 17.86 million in 2016 to 10.62 million in 2021 (National Bureau of Statistics, 2021). China abolished the existing one-child population and family planning policy in 2015. This was replaced with a comprehensive two-child policy [14]. Although the actual population growth remained lower than expected, the comprehensive two-child policy has been effective in increasing the number of births. According to a recent study [12], the current comprehensive two-child policy in China has already led to the unsustainability of the maternity insurance fund. This is a phenomenon worth examining, as a deficit in the maternity insurance system is likely to change the trend of increasing birth rates among insured people. Therefore, ensuring the sustainability of the maternity insurance system is a prerequisite for recent population policy reforms aimed at improving birth rates.

The MIS in China is one of the five social insurance systems designed to support the citizens. The rest are basic medical insurance, pension insurance, unemployment insurance, and work-related injury insurance [15]. China’s MIS can be divided into three stages since its establishment. First, the period of unrestricted childbirth from 1952 to 1977: since the early 1950s, China has consistently promoted new policies and programs to ensure a high maternal survival rate in accordance with global best practices. Some of these notable interventions include The Instructions on the Implementation of the System of Public Medical Care for Staff Members of the People’s Governments at Various Levels, Political Parties, Mass Organizations, and Public Institutions Attached to them. This policy was promulgated in 1952 and was followed by another policy called The Notice Concerning the Provisions on the Maternity Leave of Female Staff Members, which was promulgated in 1955 [15]. These policies mainly supported the population policy of encouraging childbirth and expanding the size of the population [16]. Second, the strict family planning phase from 1978 to 2014: the strict family planning phase in China began in the late 1970s and ended in 2014, with the main policy regime being the one-child policy. In 1994, China’s Labor Department started The Trial Measures on Maternity Insurance for Enterprise Staff and Workers to help working mothers obtain decent and affordable healthcare and livelihood before, during, and after childbirth [17,18]. Third, the period of family planning relaxation from 2015 to the present: After having abolished the family planning policy in 2015, China has implemented the “one-child policy”, and soon after that transitioned to the “comprehensive two children policy”. With the new policy, the government also abolished incentives for late parenthood and late marriage [19]. Recently, China is planning to merge national health insurance with maternity insurance [12]. These reforms aim to increase the risk resilience of the maternity insurance fund. China started a pilot reform to merge national health insurance with maternity insurance in individual cities in 2018. However, this policy has not been scaled up to the whole country thus far [17]. It is worth noting that Jiangsu Province is located in mid-east of China and one of the most economically prosperous provinces in China. Its proximity to Shanghai and large coastline make it an economically strategic area in China. Maternity insurance began in Jiangsu much earlier than in many other provinces; it is considered one of the most effective social insurance schemes in China and has become a reference point for other provinces [20]. Figure 1 shows the number of births per year in China and the three distinct phases of the demographic policy (National Bureau of Statistics, 2021).

A review of the literature reveals that the sustainability of social insurance systems, including MIS and national health insurance, in fact mainly depends on the balance of the fund. The balance between funding and payment is driven by a myriad of factors [21]. Specifically, the level of socio-economic development, bank interest rates, population mobility status, taxation, child-care services, education preferences, and housing price regulation indirectly influence it [22], while payment method, compensation policy, the contribution rate, and the number of insured people are the direct factors that have greater impacts and higher frequency [23,24,25].

At present, there are few studies on the sustainable development of the maternity insurance system, mainly focusing on the impact of population policies on the MIS [12,15]. Some researchers have focused on the maternity allowance, operation of the maternity insurance fund, and reform of MIS [13,26,27,28]. Little research has comprehensively and systematically summarized the factors influencing the sustainability of MIS. To address the limitations of prior studies, this study aimed to identify influencing factors of the sustainable development of the MIS, and investigate their mechanisms. This may help to ensure that the MIS is scientifically and rationally reformed and reaches a sustainable state, thus supporting the shift in population policy and ultimately promoting higher birth rates. This study will provide scientific evidence to facilitate the current MIS reform to achieve suitability, with the ultimate goal of improving birth rates.

2. Methods

2.1. Study Design

This study was conducted using the framework of Strauss and Corbin’s grounded theory [29]. This theory comprises a systematic inductive methodology that builds theories through the analysis and summary of data. The factors that guarantee the sustainability of maternity insurance have not yet been fully reviewed, and the factors influencing the sustainability of maternity insurance are complex and interrelated. It is difficult to study such in-depth direct and indirect factors through traditional hypothesis testing [30]. Therefore, in this respect, grounded theory is suitable for analyzing the present study’s data and deriving new and in-depth insights.

2.2. Case Selection and Data Acquisition

This study used purposive sampling to collect relevant information from multiple authoritative sources. Purposive sampling was chosen because it allows for the selection of people or events that are capable of providing the most relevant and rich information for in-depth research [31]. From 2015 to 2020, We used 4 multi-stakeholder workshops and in-depth interviews to bring together three groups of people: maternity insurance system developers, implementers, and researchers. In total, 24 participants or interviewees were carefully selected, the main sources of which included professors and scholars in social security research at some of the top universities in Jiangsu Province, including: relevant experts from the Jiangsu Provincial Health Insurance Bureau and Jiangsu Provincial Health Insurance Settlement Centre; relevant experts from the Human Resources and Social Security Bureau and Health Insurance Bureau of each city in Jiangsu Province.

Thereafter, the data were analyzed using the framework of grounded theory. The three-step coding process of grounded theory was performed via initial, axial, and theoretical coding, and the study’s conclusions were drawn by organizing the results according to this coding method [29]. In contrast to formulaic calculations and quantitative models, qualitative research explores and expands on the research question during the research process to help inscribe and derive the essence of the research question. As information becomes saturated, the final theoretical results will be refined. This paper used NVivo 12.0 and EXCEL software to analyze data to investigate factors influencing the sustainability of the maternity insurance system through a grounded theory approach [30,32].

2.3. Ethical Considerations

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Jiangsu University. Informed consent was obtained from all subjects involved in the study. The researchers also explained to the participants that the interviews would be recorded, the recorded and transcribed data would be used only for research purposes, and the anonymity of the research participants was guaranteed.

3. Results

21% of the 24 participants or interviewees were policy developers from relevant provincial government agencies, 33% of them were researchers from top universities in Jiangsu Province, and 46% of them were policy implementers from relevant government agencies in every cities in Jiangsu Province. More than 70% participants or interviewees were over 40 years old; they had extensive work or research experience.

Table 1. Interviewee characteristics.

Interviewee	Type	Title	Source	Gender	Age
1	researcher	Professor	University	M	40’s
2	researcher	Professor	University	M	40’s
3	researcher	Professor	University	M	30’s
4	researcher	Professor	University	M	50’s
5	implementer	Section Chief	HRSSB of city Z	M	30’s
6	developer	Division Director	HISC of J Province	M	40’s
7	developer	Deputy Division Director	HISC of J Province	F	30’s
8	researcher	Professor	University	M	30’s
9	researcher	Professor	University	M	40’s
10	implementer	Section Chief	HRSSB of city N	M	40’s
11	developer	Consultant	HIB of J Province	M	60’s
12	implementer	Section Chief	HISC of city N2	M	30’s
13	implementer	Section Chief	HRSSB of city H	M	40’s
14	implementer	Section Chief	HIB of city H	M	30’s
15	implementer	Section Chief	HIB of city W	M	30’s
16	implementer	Section Chief	HIB of city C	M	40’s
17	implementer	Section Chief	HIB of city S	F	40’s
18	developer	Division Director	HIB of J Province	M	50’s
19	developer	Section Chief	HIB of J Province	M	40’s
20	researcher	Professor	University	F	40’s
21	researcher	Professor	University	M	50’s
22	implementer	Section Chief	HISC of city N2	M	40’s
23	implementer	Section Chief	HIB of city X	M	40’s
24	implementer	Deputy Division Director	HRSSB of city Z	M	40’s

Note: HRSSB (Human Resources and Social Security Bureau), HISC (Health Insurance Settlement Centre), HIB (Health Insurance Bureau).

shows the characteristics of all interviewees in the study.

3.1. Initial Coding

Table 2. Initial coding list.

No.	Type	Interview Content Codes
1	Researcher from University	A1 The sustainability of the fund can be judged by the current balance and accumulated balance of the maternity insurance fund; A2 The per capita income of local employees affects the revenue of the fund; A3 The dynamic adjustment of the policy of the unified fund can ensure its dynamic adaptability; A4 The per capita insurance cost expenditure should be in line with the level of local GDP per capita; A5 The reaction of the public to the reform and changes of the maternity insurance system, and degree of support; A6 The response of medical institutions in the face of the reform and changes in the MIS; A7 The degree of implementation of the reform and changes in the MIS by insurance administrators and executive implementers; A8 The degree of awareness, attitude, understanding and support for the maternity policy; A9 Changes in contribution rates should be commensurate with the actual situation.
...	...	...
24	Implementer from Human resources and Social Security Bureau in city Z	A140 City Z is currently operating in a state of overspending in the maternity insurance coordination fund; A141 City Z has a large budget balance in the individual account of the health insurance fund due to the pilot health insurance policy; A142 City Z needs to scientifically adjust the account structure and cap line if maternity insurance and health insurance are to be implemented together; A143 Although the state has introduced the two-child policy, individual willingness to have children cannot be ignored; A144 The strategy for regulating housing prices and the level of housing prices also affects the willingness to have children.

Note: Due to the length of Table 2, the full version will be included as an annex at the end of the paper (Appendix A. Full Initial Coding List).

shows 144 initial codes that were derived from workshop and interview data. Although they may not represent the concepts in the strictest sense, they are characterized by the preservation of the originality of the data collected and are the cornerstone of the axial and theoretical coding below. It can be found that the two insurance policies being combined, contribution rate, contribution base, and level of entitlement per capita were frequently mentioned by participants, with all these frequencies being more than 10. There are also some other initial coding results mentioned with frequencies between 6 and 10, such as the comprehensive two-child policy, fund management, maternity insurance fund expenditure items, and the number of insured persons.

3.2. Axial Coding

Through the analysis of the initial codes, the conceptual content of the various concepts in the initial codes was refined, considered, analyzed, and compared. Twenty-nine categories were extracted from policy, social environment, economy, management, population, education, and other dimensions for the purpose of this essential study. Based on the relationships of the 29 sub-categories, seven main categories were derived during axial coding. By counting the frequency of various initial codes, the proportions of seven main categories could be determined: institutional change (20.13%), funding of the maternity insurance fund (20.13%), expenditure from the maternity insurance fund (16.67%), operation of the maternity insurance fund (15.28%), level of maternity insurance coverage (11.81%), health insurance fund performance (11.11%), and willingness to have children (4.86%). The concepts and contents of all the axial codes point to the theme of this study—the factors influencing the sustainable development of MIS. The relationship between the seven main categories and the content corresponding to each is shown in

Table 3. Axial coding results.

Main-Category	Sub-Category	Frequency	The Connotation of Initial Coding	Dimension
Institutional change 20.13%	Comprehensive two-child policy	7	After the implementation of the comprehensive two-child policy, the number of births covered by the maternity insurance fund increased and the cost of expenditure from the fund increased	Policy
	Two insurance policies combined	13	To avoid overwhelming the maternity insurance fund after the implementation of the comprehensive two-child policy, the state proposes to merge maternity insurance with medical insurance	Policy
	Dynamic Contribution Rate Policy	4	Dynamic adjustment of contribution rates can effectively hedge against the collapse of maternity insurance funds	Policy
	Drug price reform	1	The price reform in public hospitals has led to a decrease in the price of drugs and an increase in the cost of treatment items, resulting in an increase in maternity insurance expenses	Policy
	Reforming the level of integration	2	The sustainable development of the maternity insurance fund should be based on the concept of sharing, and the trend is to increase the level of coordination in the future	Policy
	Social crisis	2	Social crises such as declining births and aging populations contribute to changes in population policies and thus influence changes in MIS	Social environment
Operation of the Maternity Insurance Fund 15.28%	Cumulative balance	7	The higher the accumulated balance, the more sustainable the maternity insurance fund will be	Economy
	Risk margin situation	2	Risk margin will be used when the fund falls short of its revenue and expenditure	Economy
	Fund Management	8	Improving the management of maternity insurance funds can improve the efficiency of fund operations	Management
	Deficit situation	5	Current deficits will ring alarm bells, cumulative deficits herald fund collapse	Economy
Funding of the maternity insurance fund 20.13%	Contribution rate	13	Contribution rates are determined by national policy and are a very direct and important factor affecting the revenue of maternity insurance funds	Economy
	Contribution base	12	The average contribution base of the maternity insurance fund should have been the average social wage, the size of which is positively related to the revenue of the social insurance fund	Economy
	Gross regional product (GDP)	4	Gross regional product corresponds to the general economic environment of the region and affects people’s income	Economy
Expenditure from the maternity insurance fund 16.67%	Level of entitlement per capita	13	Level of total annual maternity insurance fund expenditure apportioned to each individual	Economy
	Maternity insurance fund expenditure items	9	The expenditure of the maternity insurance fund mainly covers prenatal check-ups, one-off nutrition benefits, maternity allowances, cesarean sections, treatment of complications, hospital deliveries, family planning operations, etc. The more items there are, the more likely it is that the expenditure will increase	Economy
	Number of beneficiaries	2	The higher the number of people entitled to maternity insurance benefits, the greater the expenditure of the maternity insurance fund and vice versa	Population
Level of maternity insurance coverage 11.81%	Number of insured persons	9	The number of participants is an important factor affecting the revenue of the social insurance fund, and to a certain extent, it has a positive relationship with the revenue of the social insurance fund, i.e., the greater the number of participants, the greater the revenue of the social insurance fund	Population
	Population movements	3	Mobile population as a potential insured population	Population
	Coverage	5	Expanding coverage can boost maternity insurance fund revenue	Population
Willingness to have children 4.86%	Fertility Policy Awareness	2	A high level of awareness can increase willingness to have children	Policy
	Bank Rate	1	Boosting or reducing income affects willingness to have children	Economy
	Personal tax deductions	1	Boosting or reducing income is associated with financial stress	Economy
	Childcare services	1	A good package of childcare services can reduce the pressure on people who have children	Education Services
	Education offers	1	Excellent education policies can reduce the pressure on people who give birth	Education Services
	House price control	1	Reasonable house prices allow people with children to put their worries aside	Economy
Health insurance fund performance 11.11%	Funding levels	5	If the two insurances are combined, the higher the level of funding of the health insurance fund the higher the sustainability of the fund, which in turn affects the sustainability of the maternity insurance fund	Economy
	Expenditure profile	5	A reasonable level of expenditure is conducive to the sustainability of the health insurance fund, which in turn affects the sustainability of the maternity insurance fund	Economy
	Fund pool cumulative holdings	4	The accumulated pool of the medical insurance fund is much larger than the maternity insurance fund, and if combined, could improve the sustainability of the maternity insurance fund	Economy
	Population insured	2	The higher the coverage of the insured population, the higher the revenue of the health insurance fund	Population

.

3.3. Theoretical Coding

Through in-depth mining analysis of the seven main categories obtained from the axial coding and their corresponding categories, as well as a continuous comparative analysis with the initial coding and the original data, a theoretical coding of the factors influencing the sustainability of the MIS was developed. The relationship between the seven main-categories and the content corresponding to each is shown in Figure 2. In this Figure, the main categories are systematically and theoretically linked, and the findings are logically condensed, and then are constructed into a theoretical framework.

3.3.1. Institutional Change—Sustainable Development of MIS

Institutional changes directly affect the sustainable development of the MIS.

First, due to social crises such as population aging and low birth rates, the national government has adjusted its population policy and the comprehensive two-child policy has replaced the one-child policy.

Second, because of the increase in the number of newborns after the implementation of the comprehensive two-child policy, the expenditure of the MIS became higher than the revenue. The sustainability of the MIS was undermined.

Third, the national government reformed the MIS by adjusting contribution rates and expanding coverage to restore the sustainability of the MIS.

3.3.2. Operation of the Maternity Insurance Fund—Sustainable Development of MIS

The operating status of the maternity insurance fund directly affects the sustainability of the MIS.

First, the higher the balance of the maternity insurance fund, the longer it will be able to maintain a sustainable state.

Second, improving the management of the maternity insurance fund increases the efficiency of the fund’s operation, which is beneficial to the sustainable development of the MIS.

3.3.3. Financing of Maternity Insurance Funds—Sustainable Development of MIS

The financing of the maternity insurance fund directly affects the sustainability of the MIS.

First, the higher the contribution rate of the MIS, the more revenue the maternity insurance fund will generate. A moderate adjustment of the contribution rate will help the sustainable development of the MIS.

Second, the higher the GDP, the higher the contribution base, and the contribution base is positively related to the revenue of the maternity insurance fund.

3.3.4. Expenditure of the Maternity Insurance Fund—Sustainable Development of the MIS

The expenditure of the maternity insurance fund directly affects the sustainability of the MIS.

First, if the expenditure of the maternity insurance fund is higher than the revenue, it will reduce the balance of the maternity insurance fund.

Second, the higher the per capita expenditure of the maternity insurance fund, the higher the total expenditure.

Third, the greater the variety of items of expenditure in the MIS, the higher the total expenditure.

Fourth, the higher the number of beneficiaries of the MIS, the higher the expenditure of the maternity insurance fund.

3.3.5. Level of MIS Coverage—Sustainable Development of MIS

The level of coverage of the MIS directly affects the sustainability of the MIS. The wider the coverage of the MIS and the more insured people there are, the more resilient the maternity insurance fund will be.

3.3.6. Willingness to Have Children—Sustainable Development of MIS

People’s willingness to have children indirectly affects the sustainability of the MIS.

First, when people’s willingness to have children increases, the number of births increases, the number of beneficiaries of MIS increases, and the expenditure of the maternity insurance fund increases.

Second, for the government, increasing the willingness to have children requires policy, economic, educational interventions, and so on.

3.3.7. National Health Insurance Fund Operation—Sustainable Development of MIS

If the MIS is merged with the national health insurance system, the operation of the national health insurance fund will be the indirect factor influencing the sustainability of the MIS.

First, if the two insurance systems are merged, the higher the level of financing of the national health insurance fund, and the more sustainable it will be. Indirectly, the sustainability of the maternity insurance fund will be affected.

Second, a reasonable level of expenditure is conducive to the sustainability of the national health insurance fund and indirectly affects the sustainability of the MIS.

Third, the fund balance of the national health insurance is much higher than the maternity insurance fund, which indirectly increases the sustainability of the MIS.

Fourth, the wider the coverage of the national health insurance system and the more people insured, the higher the revenue of its fund, which indirectly increases the sustainability of the MIS.

4. Discussion and Conclusions

This qualitative research adopts the grounded theory method to develop a substantive theory that helps to comprehensively understand and explain the factors influencing the sustainable development of China’s maternity insurance system and how they interact, under the background of population policy changes. The research results include seven core categories, five direct effects (institutional change, fund operation status, revenue of the fund, expenditure of the fund, level of insurance coverage), and two indirect effects (the willingness to have children, health insurance fund performance).

In this study, institutional change is considered to be the core direct determinant of the sustainable development of the MIS. The influencing mechanism can be simply described as the following process. First, social crisis, such as the aging of the population and the continuous decrease in the birth rate, has led to the adjustment of population policy, namely the introduction of a comprehensive two-child policy. Second, after the implementation of the policy, the birth population and the number of pregnant women enjoying benefits increased, destroying sustainability of the MIS. The increase in constant revenue and expenditure of maternity insurance has led to the unsustainability of the MIS. Finally, the national government found this unsustainable, so it reformed and changed the MIS by adjusting the payment rate, merging the two insurances, expanding the coverage, and other measures, so as to keep it sustainable and adapt to the current population policy, large population environment, and economic environment, so as to solve the crisis.

For China, the most important influencing factor in the category of institutional change currently is the comprehensive two-child policy, which was formally proposed at the Fifth Plenary Session of the 18th CPC Central Committee as a new population policy of the Chinese government to address social crises such as aging populations and declining birth populations. After the comprehensive two-child policy was launched, the number of births increased, alleviating, to some extent, the social crisis of the declining birth population and aging population structure in China. However, after the comprehensive two-child policy was introduced, the number of pregnant women enjoying benefits under the MIS increased, and the constant revenue and expenditure of the MIS increased, which may lead to the unsustainability of the MIS, becoming an important factor triggering the change of the MIS. This observation is consistent with the earlier work of Antwi and colleagues, who indicated that the maternity insurance fund balance in Guangxi Zhuang Autonomous Region China also began accumulating escalating levels of deficits in 2019. Although this is not the first time that the maternity insurance scheme in these two regions has experienced a decline in fund balance, it is believed that the comprehensive two-child policy program implemented across China in 2015 has contributed to the deficit accumulation of the maternity insurance fund [14,15].

In this study, the most powerful and effective intervention measures for China in the short term include the policy of merging national health insurance with maternity insurance and the dynamic payment rate policy. In the long term, expanding the coverage of the MIS and improving the management level of maternity insurance fund are effective intervention measures. Specifically, under the background of two-child policy implementation, merely the MIS alone cannot support it; combining the MIS together with the central government, the enterprises, and institutions is big policy direction aimed at reduced pressure and burden; increasing the contribution rate to ensure sustainable operation of the implementation of birth insurance fund may be more difficult. Therefore, according to international experience, the combination of maternity insurance and medical insurance is relatively easy to achieve at this stage. From an objective perspective, the accumulated balance of China’s urban medical insurance fund is 47 times that of the maternity insurance fund. The combination of the two insurance types can drive the MIS, which is on the edge of deficit, out of the dilemma and achieve sustainable development. Additionally, the index, such as the pay rate, should be adjusted according to the actual operation of the maternity insurance fund to establish a dynamic financing mechanism. This is in line with Huang’s view, who points out that China’s maternity insurance contribution rates should range between 0.5 and 1%. Therefore, employers can choose to contribute at any rate on their own, but not lower than 0.5%, and it is highly feasible to implement a dynamic payment rate policy [33].

In this study, the willingness to have children is the more important one among the indirect influences. For China, increasing the willingness to have children requires policy, economic, and educational interventions, as well as others. In the short term, as the family planning policy is deeply rooted in people’s minds; people will have a process of understanding and reacting after the country decides to relax the family planning policy. The continuous publicity of the new population policy is conducive to improving the insured people’s understanding and awareness of the details of the relaxed family planning policy, so that it is reasonable and legal to have a second child. This is in line with Eroglu and colleagues, who argue that cultural norms and values significantly affect birth rates [5]. Specific measures of fertility incentives and family policies include baby bonuses, family allowances, maternal, paternal, and parental leave [34]. In the long term, tax policy reform, housing price regulation, childcare services, and education system reform need to be promoted. These potential interventions are supported by previous empirical studies. For example, this is supported by some research in which the analysis of the data from the China Household Finance Survey between 2013 and 2017 demonstrated an approximately 0.94% decrease in the probability of having a child under two, with a 1% increase in housing prices [35]. Taxes and education also have a strong impact on the willingness to have children [36].

The final results of this study are condensed into a model of the factors influencing the sustainability of MIS, which is in fact a theoretical framework that can guide development of a quantitative model to simulate the reality of the operation of maternity insurance, providing implications to its reform and adjustments. Previous studies on the sustainability of maternity funds have mostly used structural equations and actuarial models, but there is a lack of a general model that encompasses all factors in the operation of maternity insurance. For example, Antwi and colleagues only calculated the effect of maternity insurance fund revenue and expenditure factors on maternity insurance in Jiangsu Province and Guangxi Autonomous Region before and after the comprehensive two-child policy [15].

This study has two limitations. First, the study analyzed a single case of China’s maternity insurance system, and the participants of workshops and in-depth interviews were mainly from Jiangsu province, thus, the results may not be generalizable to other countries. Second, we applied grounded theory to this exploratory study, which has determined a comprehensive list of influencing factors; however, their relationships have not been quantified. Our future research will seek to further define the relationship between the sustainable development of the maternity insurance system and population policy adjustment on the basis of quantitative analysis. The opinions of couples of childbearing ages on the MIS will also be collected through interviews, so that these questions, such as what the contribution rate should be set at for a sustainable maternity insurance system, can be answered through modeling or simulation.