A comprehensive approach is needed to tackle a complicated problem.

Abstract

A World Health Organization survey stunned the world in 2010: China has a caesarean rate of nearly 50%, the highest reported worldwide (Lumbiganon et al. Lancet 2010;375:490–9). This finding has drawn much attention, often with suspicion and incomprehension. Various sources of data and empirical evidence support this astonishing result (Zhang et al. Obstet Gynecol 2008;111:1077–82). Furthermore, whereas the caesarean rate in urban settings may have plateaued or even declined slightly in recent years, the rate in rural areas (now over 30%) may still be rising. In this issue of BJOG, Hellerstein et al. provided more statistics and shed light on the possible causes of the high caesarean rate in China. The list of potential causes is long but several important characteristics suggest that the root of the problems may lie in deficiencies in the healthcare system and inadequacy in patient education. In China, the caesarean rate increases linearly with individual education and income levels, both in rural and urban areas (Feng et al. Bull World Health Organ 2012;90:30–9). The rate is not influenced by health insurance status, i.e. women are willing to pay out of their own pockets to have a caesarean delivery. The high demand for caesarean birth is not just a side effect of the one-child policy, but is also frequently driven by misinformed beliefs and perceptions. The latter reflects inadequate patient education regarding the risks and benefits of caesarean section. Professional advice on the choice of vaginal over caesarean birth, on the other hand, are hampered by medico-legal concerns, financial interest, and the extremely busy schedules of care providers. In fact, China is in dire shortage of adequately trained obstetricians. Among the 190 000 obstetrics/gynaecology (ob/gyn) doctors in China, only 20% have a medical bachelor or higher degree (http://www.china-obgyn.net/gxm/flash/cogasurvey/player.html). If we consider the ob/gyn with a university education in China equivalent to the ob/gyn in the UK, China and England & Wales have similar numbers of ob/gyn per 100 000 population and births per ob/gyn doctor. The number of nurses and midwives in China is a fraction of that in UK, however. The overwhelming volume of deliveries performed by Chinese doctors, particularly in urban hospitals, coupled with only one birth per woman, offers little incentive for doctors to promote vaginal births. Nonetheless, the caesarean rate in China may be at a turning point. With the recent loosening of China family planning policy, a second birth is allowed for some women. This may encourage these women to try for a vaginal first birth. Policy measures such as changing the payment structure for caesarean versus vaginal births may help to decrease the caesarean rate. Training more doctors and midwives can alleviate the shortage of obstetric staff. China has an effective family planning and primary maternity care system. Accurate health information on caesarean and vaginal births can be disseminated through this structured channel (Brown Semin Perinatol 2012;36:403–6). In addition to conducive health policies, the involvement of professional organisations to establish evidence-based guidelines on the management of labour and to provide appropriate training and continuing education for doctors and nurses is critical for tackling the skyrocketing caesarean rate. A comprehensive intervention approach may lower the rate of caesareans performed in China over time. The author has no conflicts of interest to declare.