Cesarean Section Rate In China Research Articles

Promotion of Pre-natal Education Courses Is Associated With Reducing the Rates of Caesarean Section: A Case-Control Study.

Objective: The number of women having a caesarean section has significantly increased worldwide, in particular in China. Maternal requestion makes a moderate contribution to this increased rate in China. Reducing the caesarean section rate is now becoming a big challenge to midwives and obstetricians as well as health policymakers in China. Our recent survey found that pre-natal education course had some positive effects on the reduction of caesarean section on maternal request. However, pre-natal education course is relatively new in China. In this study, we investigated whether pre-natal education course influences delivery mode in the largest tertiary women's hospital in China.Methods: In this retrospective study, during the study period, 644 pregnant women attended a pre-natal education course and 4,134 pregnant women did not. Data on maternal age, parity, gravida, delivery mode, delivery weeks, birthweight, gestational age at attending pre-natal education course and maternal body mass index before pregnancy were collected and analysed.Results: The numbers of women who attempted vaginal delivery were significantly higher in women who attended a pre-natal education course, compared to women who did not (87 vs. 60%). In addition, the rate of caesarean section on maternal request was 23% in women who attended a pre-natal education course.Conclusion: Attendance of a pre-natal education course influences the mode of delivery and reduces the unnecessary caesarean section in China. Our findings suggest that the promotion of pre-natal education courses is important to reduce the higher caesarean section rate in China, by midwives or obstetricians or health policy-makers as part of China's strategy.

Obstetricians\u2019 perspectives on trial of labor after cesarean (TOLAC) under the two-child policy in China: a cross-sectional study

BackgroundAs the birth policy has been adjusted from one-child-one-couple to universal two-child-one-couple in China, there is an increasing number of women undergoing a second pregnancy after a previous cesarean section (CS). Undertaking an elective repeat CS (ERCS) has been taken for granted and has thus become a major contributor to the increasing CS rate in China. Promoting trial of labor after CS (TOLAC) can reduce the CS rate without compromising delivery outcomes. This study aimed to investigate Chinese obstetricians’ perspectives regarding TOLAC, and the factors associated with their decision-making regarding recommending TOLAC to pregnant women with a history of CS under the two-child policy.MethodsA cross-sectional survey was carried out between May and July 2018. Binary logistic regression was used to determine the factors associated with the obstetricians’ intention to recommend TOLAC to pregnant women with a history of CS. The independent variables included sociodemographic factors and perceptions regarding TOLAC (selection criteria for TOLAC, basis underlying the selection criteria for TOLAC, and perceived challenges regarding promoting TOLAC).ResultsA total of 426 obstetricians were surveyed, with a response rate of ≥83%. The results showed that 31.0% of the obstetricians had no intention to recommend TOLAC to pregnant women with a history of CS. Their decisions were associated with the perceived lack of confidence regarding undergoing TOLAC among pregnant women with a history of CS and their families (odds ratio [OR] = 2.31; 95% CI: 1.38–1.38); obstetricians’ uncertainty about the safety of TOLAC for pregnant women with a history of CS (OR = 0.49; 95% CI: 0.27–0.96), and worries about medical lawsuits due to adverse delivery outcomes (OR = 0.14; 95% CI: 0.07–0.31). The main reported challenges regarding performing TOLAC were lack of clear guidelines for predicting or avoiding the risks associated with TOLAC (83.4%), obstetricians’ uncertainty about the safety of TOLAC for women with a history of CS (81.2%), pregnant women’s unwillingness to accept the risks associated with TOLAC (81.0%) or demand for ERCS (80.7%), and the perceived lack of confidence (77.5%) or understanding (69.7%) regarding undergoing TOLAC among pregnant women and their families.ConclusionA proportion of Chinese obstetricians did not intend to recommend TOLAC to pregnant women with a history of CS. This phenomenon was closely associated with obstetricians’ concerns about TOLAC safety and perceived attitudes of the pregnant women and their families regarding TOLAC. Effective measures are needed to help obstetricians predict and reduce the risks associated with TOLAC, clearly specify the indications for TOLAC, improve labor management, and popularize TOLAC in China. Additionally, public health education on TOLAC is necessary to improve the understanding of TOLAC among pregnant women with a history of CS and their families, and to improve their interactions with their obstetricians regarding shared decision making.

Factors affecting failed trial of labor and countermeasures: A retrospective analysis.

BACKGROUNDVaginal delivery is the ideal mode of delivery for the termination of a pregnancy. However, the cesarean section rate in China is much higher than the published by the World Health Organization in the Lancet in 2010.AIMTo retrospectively analyze the factors related to failed trial of labor and the clinical indications for cesarean section conversion, explore how to promote the trial of labor success rate, and determine the feasibility of reducing the rate of conversion to cesarean section.METHODSA retrospective analysis was performed on 9240 maternal women who met vaginal delivery conditions and required a trial of labor from January 2016 to December 2018 at our hospital. Among them, 8164 pregnant women who had a successful trial of labor were used as a control group, and 1076 pregnant women who had a failed trial of labor and converted to an emergency cesarean section were used as an observation group. The patients’ clinical data during hospitalization were collected for comparative analysis, the related factors of the failed trial of labor were discussed, and reasonable prevention and resolution strategies were proposed to increase the success rate of trial of labor.RESULTSThe analysis revealed that advanced age (≥ 35 years old), macrosomia (≥ 4000 g), delayed pregnancy (≥ 41 wk), use of uterine contraction drugs, primipara, and fever during labor were associated with conversion to an emergency cesarean section in the failed trial of labor. Multivariate regression analysis showed that age, gestational age, primipara, use of uterine contraction drugs, fever during birth, and newborn weight led to a higher probability of conversion to an emergency cesarean section in the failed trial of labor. The analysis indicated that the following clinical indications were associated with the conversion to cesarean section in the failed trial of labor: Fetal distress (44.3%), social factors (12.8%), malpresentation (face presentation, persistent occipitoposterior position, and persistent occipitotransverse position) (9.4%), and cephalopelvic disproportion (8.9%).CONCLUSIONThe conversion to emergency cesarean section in failed trial of labor is affected by many factors. Medical staff should take appropriate preventive measures for the main factors, increase the trial of labor success rate, improve the quality of delivery, ensure the safety of mother and child during the perinatal period, and improve the relationship between doctors and patients.

Factors associated with Chinese pregnant women's preference for a cesarean section based on the theory of planned behaviour.

Cesarean delivery on maternal request is one of the important public health issues in China. Our study aimed to apply the theory of planned behaviour to comprehensively determine the factors regarding pregnant women's preference for cesarean section and to provide references for establishing measures to reduce cesarean delivery on maternal request. This cross-sectional analysis was conducted in four women's and children's hospitals in China from May to June 2018. Eligible women arriving for routine antenatal visits at these hospitals were recruited to answer a structured questionnaire. A total of 1853 pregnant women consented to participate in the investigation, with a response rate of 88.75%. Finally, 1677 pregnant women (984 nulliparae and 693 multiparae) were involved in the analysis. Descriptive statistics and logistic regression analyses were used. Of the study participants, 20.39% preferred cesarean section. For both nulliparae and multiparae, those who had lower scores of attitudes towards vaginal delivery, lower scores of childbirth self-efficacy and higher scores of subjective norms were more likely to prefer cesarean section. Pregnant women's birth preferences were significantly associated with their attitudes towards the delivery mode, childbirth self-efficacy and subjective norms, which is consistent with the theory of planned behaviour. Interventions to reduce cesarean delivery on maternal request can be developed based on the theory of planned behaviour.

Using healthcare failure mode and effect analysis as a method of vaginal birth after caesarean section management

Aims and objectivesThis research was conducted to explore the effectiveness of employing the healthcare failure mode and effect analysis method in the management of trial of labour after caesarean, with the aims of increasing vaginal birth after caesarean section rate and reducing potential risks that might cause severe complications.BackgroundPreviously high caesarean section rate in China and the “two children” policy leads to the situation where multiparas are faced with the choice of another caesarean or trial of labour after caesarean. Despite evidences showing the benefits of vaginal birth after caesarean, obstetricians and midwives in China tend to be conservative due to limited experience and insufficient clinical routines. Thus, its management needs further optimisation in order to make the practice safe and sound.DesignA prospective quality improvement programme using the healthcare failure mode and effect analysis.MethodsWith the structured methodology of healthcare failure mode and effect analysis, we determined core processes of antepartum and intrapartum management, conducted risk priority numbers and devised remedial protocols for failure modes with high risks. The programme was then implemented as a clinical routine under the agreement of the institutional review board and vaginal birth after caesarean success rates were compared before and after the quality improvement programme, both descriptively and statistically. Standards for Quality Improvement Reporting Excellence 2.0 checklist was chosen on reporting the study process.ResultsSeventy failure modes in seven core processes were identified in the management process, with 14 redressed for actions. The 1‐year follow‐up trial of labour after caesarean and vaginal birth after caesarean rate was increased compared with the previous 3 years, with a vaginal birth after caesarean rate of 86.36%, whereas the incidence of uterine rupture was not compromised.ConclusionsThe application of healthcare failure mode and effect analysis can not only promote trial of labour after caesarean and vaginal birth after caesarean rate, but also maintaining a low risk of uterine rupture.Relevance to clinical practiceThis modified vaginal birth after caesarean management protocol has been shown effective in increasing its successful rate, which can be continued for further comparison of severe complications to the previous practice.

Risk for Cesarean section in women of advanced maternal age under the changed reproductive policy in China: A cohort study in a tertiary hospital in southwestern China.

To describe changed epidemiological features of advanced maternal age (AMA) and to examine the effect of AMA on the risk for Cesarean section (CS) in a Chinese pregnant population. This retrospective single-center cohort study investigated the changes of epidemiological features of AMA parturients with respect to the revised reproductive policy in China in 43 702 singleton deliveries with live birth at ≥28 weeks managed from January 2005 to December 2016. We also evaluated the pregnancy outcomes in different age groups and risk factors of CS with multivariate analysis. In this 12-year study period, the average maternal age increased from 28.5 to 30.2 years, and the proportion of AMA raised from 6.5% to 17.2%. AMA was significantly associated with increased risk of adverse pregnancy outcomes, and after adjustment for confounding factors, AMA remained a significant independent risk factor for CS. Furthermore, the effect of AMA in nulliparous women on the risk of CS was more significant than in multiparous women, while the history of previous CS (adjusted odds ratio 39.85) and interdelivery interval ≥10 years (adjusted odds ratio 1.52) also increased the risk of CS in multiparous women. AMA increased the risk of a number of adverse pregnancy outcomes, and was independently associated with increased risk for CS. The increasing number of AMA parturients with risk factors is likely to increase CS rate in China in the near future, thus it is imperative to reduce the rate of primary CS as a matter of policy.

Predicting the success of vaginal birth after caesarean delivery: a retrospective cohort study in China

ObjectivesTo develop a nomogram to predict the likelihood of vaginal birth after caesarean section (VBAC) among women after a previous caesarean section (CS).DesignA retrospective cohort study.SettingTwo secondary hospitals in Guangdong...

Chinese obstetricians’ attitudes, beliefs, and clinical practices related to cesarean delivery on maternal request.

BackgroundObstetricians’ beliefs, attitudes, and clinical practices related to cesarean delivery on maternal request appears particularly important in the context of high cesarean section rate. However, few relative studies have been conducted. AimTo examine Chinese obstetricians’ attitudes, beliefs, and clinical practices with regard to cesarean delivery on maternal request, and to explore influencing factors associated with their practices of cesarean delivery on maternal request. MethodsA cross-sectional design was used. Self-administered anonymous questionnaires were distributed to eligible obstetricians at the Congress of the Shanxi Society of Gynecology and Obstetrics as well as the Congress of the Hainan Society of Gynecology and Obstetrics. The overall response rate was 526/649 (81.05%). Multivariate logistic regression models were used to examine independent effects on obstetrician’s clinical practices related to cesarean delivery on maternal request. FindingsObstetricians who agreed with pregnant women’s decision to choose cesarean section directly and believed the benefits of this procedure outweigh the risks had higher odds of performing cesarean delivery on maternal request. In addition, measures to decrease cesarean section at hospitals were associated with reduced likelihood to perform cesarean delivery on maternal request. ConclusionsThe present study showed a strong correlation between obstetricians’ attitudes, beliefs, as well as interventions to decrease cesarean section at hospitals and their clinical practices of cesarean delivery on maternal request. Measures to enhance the training of obstetricians and reduce CS at hospitals are essential to decrease the overall cesarean section rate in China.

Effects of two-child policy on cesarean section rate in China: analysis under Robson Ten-Group Classification

Objective To investigate the changes in cesarean section rate(CSR) after the announcement of universal two-child policy using the Robson Ten-Group Classification. Methods A retrospective study was conducted to analyze 9 734 deliveries in the First Affiliated Hospital of Soochow University from January 2013 to August 2016. All deliveries were classified by the Robson Ten-Group Classification System and divided into three subgroups including phase 1(delivered between January 2013 and November 2013, the period before the selective two-child policy was implemented), phase 3( delivered between October 2015 and August 2016, the period after the universal two-child policy was implemented) and phase 2 (delivered between December 2013 and September 2015, the transition period from selective two-child policy to the universal two-child policy). Changes in CSR were analyzed by Chi-square test and Logistic regression. Results The cesarean section deliveries in Group 2b (singleton, cephalic presentation, primipara, ≥37 gestational weeks, cesarean section before labor) and group 5 (singleton, cephalic presentation, multipara with at least one cesarean section history, ≥37 gestational weeks) accounted for 52.78% (2 062/3 907) of the total cesarean section deliveries. The overall CSR decreased in phase 3 than in phase 1 [34.29% (654/1 907) vs 43.71% (1 112/2 544), χ2=40.376, P=0.000], and the most remarkable decline was found in group 2b [5.35% (102/1 907) vs 14.27% (363/2 544), χ2=92.700, P=0.000]. Compared with phase 1, in all deliveries, the constituent ratio of deliveries of groups 1 and 2 (singleton, cephalic presentation, primipara, ≥37 gestational weeks) was decreased in phase 3 [50.24% (958/1 907) vs 60.34% (1 535/2 544), χ2=45.145, P=0.000], while that in groups 3 and 4 (singleton, cephalic presentation, multipara, ≥37 gestational weeks, no cesarean section history) [21.66% (413/1 907) vs 16.71% (425/2 544), χ2=17.483, P=0.000] as well as in group 5 [14.47% (276/1 907) vs 9.28% (236/2 544), χ2=28.910, P=0.000] were increased. In group 5, the rate of vaginal birth after cesarean in phase 3 was higher than that in phase 1 [17.39% (48/276) vs 2.54% (6/236), χ2=29.732, P=0.000]. Conclusions The proportion of multiparae significantly increases, while the overall CSR significantly decreases after the implementation of universal two-child policy in China. Gravidas in groups 2b (singleton, cephalic presentation, primipara, ≥37 gestational weeks, cesarean section before labor) and 5 (singelon, cephalic presentation, multipara with at least one cesarean section history, ≥37 gestational weeks) are the most important target population in attempting to reduce CSR in China. Key words: Cesarean section; Logistic models; Population surveillance

VBAC should be encouraged as a means to reduce the caesarean section rate in China: FOR: VBAC reduces not only the caesarean section rate but also other associated issues.

VBAC should be encouraged as a means to reduce the caesarean section rate in China: FOR: VBAC reduces not only the caesarean section rate but also other associated issues.

VBAC should be encouraged as a means to reduce the caesarean section rate in China: AGAINST: This strategy won't work!

VBAC should be encouraged as a means to reduce the caesarean section rate in China: AGAINST: This strategy won't work!

Commentary: China's changing health system: Implications for sexual and reproductive health

Commentary: China's changing health system: Implications for sexual and reproductive health

An analysis of the indications for cesarean section in a teaching hospital in China

ObjectivesCesarean delivery rates have increased remarkably worldwide. The indications for this increase are not fully understood and there may be regional, ethnic or health system differences in quoted indications which may explain, at least in part, the observed changes. In 2008 China was cited as having one of the highest rates of cesarean delivery in the world, but there was no accurate information about the indications for the high rate. This study sought to provide some information about the high cesarean section rate in China. Study designData on all births in a university teaching hospital in northern China serving a general obstetric population, excluding premature births, were collected from the hospital database from January 2009 to September 2012. All indications on the mode of delivery were analyzed for live births. ResultsThere were 5267 births and the cesarean delivery rate was 41.4% in the study period. There was no significant trend in the cesarean delivery rate from 2009 to 2012. Fetal indications contributed most to the rate. More than 50% of all cesarean deliveries were due to nuchal cord, previous cesarean delivery, fetal distress and malpresentation. The rate of cesarean delivery on maternal request was 9.07%. Smaller contributions to the indications for cesarean delivery came from cephalopelvic disproportion, preeclampsia, prolonged labor, uterine rupture and other obstetric conditions. ConclusionThe data show increased fetal or maternal risk assessments are the main indications for cesarean delivery rather than cesarean delivery on maternal request in China.

Caesarean Section Rates, Australia 1986: Variations at State and Small Area Level

The first national study of Caesarean section rates was made possible by combining 1986 data from hospital morbidity collections and medicare claims. Rates per 100 births, based on the area of usual residence of the mother, were calculated for statistical local areas, which were aggregated to statistical subdivisions, statistical divisions and States. The rate for mainland Australia was 16.9% (Tasmania could not be included). Variations in rates were of the order of one and a half- to two-fold. The highest rates were found in Canberra and central Brisbane (26.3% and 25.4% respectively). The rates for Northern Territory, South Australia, and Queensland were higher than those for other States. There were few consistent patterns in the variations. Generally rates were highest in the State capital cities and for insured women. This suggests an association with the supply of obstetricians and with demand factors such as the expectations of obstetricians and consumers.