Abstract
BackgroundThe cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China.Methods and findingsThis intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010–September 2014 and October 2014–December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period.A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067, p < 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: −0.09 [95% CI −0.16 to −0.02] between Stage 1 and baseline, p = 0.014; −0.11 [95% CI −0.20 to −0.02] between Stage 1 and Stage 2, p = 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (Z = −4.368, p < 0.001) and PMR (Z = −13.142, p < 0.001) declined by stage over the intervention period.One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed.ConclusionsApparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was most evident among nulliparous women who delivered term singletons. Despite some limitations for causal inference, Guangzhou’s experience in controlling the CS rate by implementing composite interventions with public health education and perinatal healthcare service improvement could have implications for other similar areas with high rates of CS.
Highlights
Cesarean section (CS), essential and lifesaving with the correct indication, is largely unnecessary in nonemergency conditions, leading to greater financial costs relative to vaginal delivery, without proven benefit, and increasing risks for maternal morbidity and mortality [1,2,3,4,5,6,7,8]
The primary outcome was the cesarean section (CS) rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS)
The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages
Summary
Cesarean section (CS), essential and lifesaving with the correct indication, is largely unnecessary in nonemergency conditions, leading to greater financial costs relative to vaginal delivery, without proven benefit, and increasing risks for maternal morbidity and mortality [1,2,3,4,5,6,7,8]. A statement issued in 2016 further strengthened WHO’s position, with evidence suggesting that population-level CS rates higher than 10% are not associated with reduced maternal and neonatal mortality [15]. The rate of cesarean delivery has been rising sharply in the last two decades worldwide [16,17]. A nationwide study covering 2,865 counties in China reported that the overall annual CS rate rose from 28.8% in 2008 to 34.9% in 2014 [18]. In Guangzhou, the third largest city in China with a population of 14 million and 300,000 annual births, the CS rate was about 40% between 2001 and 2010, far higher than the national average and the level recommended by WHO. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China
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