Delivery settings and caesarean section rates in China

OBJECTIVE: To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China. METHODS: We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables. FINDINGS: Institutional births increased from 53.5% in 1993-1994 to 82.2% in 2001-2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4-11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001). CONCLUSION: The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and women's demand for the procedure.     

Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries

Caesarean section rates have risen dramatically in several developing countries, especially in Latin America and South Asia. This raises a range of concerns about the use of caesarean section for non-emergency cases, not least the progressive shift of resources to non-essential medical interventions in resource-poor settings and additional health risks to mothers and newborns following a caesarean section. There are only a few studies that have systematically examined the factors influencing the recent increase in caesarean rates. In particular, it is not clear whether high elective caesarean rates are driven by medical, institutional or individual and family decisions. Where a woman's decisions predominate her interaction with peers and significant others have an impact on her caesarean section choices. Using random intercept logistic regression analyses, this paper analyses the institutional, socio-economic and community factors that influence caesarean section in six countries: Bangladesh, Colombia, Dominican Republic, Egypt, Morocco and Vietnam. The analyses, based on data from over 20,000 births, show that women of higher socio-economic background, who had better access to antenatal services are the most likely to undergo a caesarean section. Women who exchange reproductive health information with friends and family are less likely to experience a caesarean section than their counterparts. The study concludes that there is a need to pursue community-based approaches for curbing rising caesarean section rates in resource-poor settings.     

The significance of increasing caesarean section rates

Obstetric intervention has been the subject of much recent criticism from both the medical profession and consumer groups who point to increasing caesarean section rates and question their justification. This article examines the indications for caesarean section and assesses the relative benefits and disadvantages.     

Socioeconomic inequalities in hospital births in China between 1988 and 2008

Objective

To assess trends in hospital births in China during 1988–2008 in an effort to determine if efforts to overcome financial barriers to giving birth in hospital have reduced the access gap between the rich and the poor.

Methods

Cross-sectional data obtained from four National Health Service Surveys were used to determine trends in hospital births during 1988–2008. Crude and adjusted annual rates were calculated by means of Poisson regression and were used to define trends across socioeconomic regions and households in different income quintiles.

Findings

In 2008 women throughout China were giving birth in hospital almost universally except in region IV, the most remote rural region, where the percentage of hospital births was only 60.8. Hospital births in this region had increased steadily before 2002, but after that year the upward trend slowed down. During 1988–2001 the average yearly increase had been 21%, but in 2002–2008 it dropped to 10% (P = 0.0031). Inequalities between socioeconomic regions were greater than among individual households belonging to different income strata. By 2008 the difference between low- and high-income households in the proportion of hospital births had become very small (96.1% and 87.7% of high- and low-income households, respectively, gave birth in hospital that year).

Conclusion

Most Chinese women now give birth in hospital, but the poorest rural region is still lagging behind. A more active and comprehensive approach will be needed to increase hospital births in these remote, hard-to-reach populations.     

Delivery-related complications and determinants of caesarean section rates in India

Caesarean section rates have been increasing worldwide, raising the question of the appropriateness of the selection of cases for the procedure. This paper examines the levels and correlates of delivery-related complications and caesarean section deliveries in 18 selected states of India in terms of specific maternal and institutional factors, using data from the National Family Health Surveys, 1992-93. Goa (15.3%) and Kerala (13.7%) were the two states with relatively higher caesarean section rates. There is reason to believe that current rates are part of a rising trend. This cannot be attributed entirely to the rise in institutional deliveries alone because of the strong association between caesarean sections and private sector institutions. Apart from the fact that the states of Kerala and Goa have relatively high caesarean section rates, in Andhra Pradesh, Bihar, Gujarat, Karnataka, Punjab and Uttar Pradesh the risk of undergoing caesarean section in private sector institutions is four or more times that in the public sector. It is possible that this extremely useful surgical procedure is being misused for profit purposes in the private sector in several states. There is therefore a need to examine this phenomenon using data disaggregated by the nature of caesarean sections, i.e. whether it was an elective or an emergency caesarean section along with the reasons for the choice.     

Health consequences of the increasing caesarean section rates

Caesarean section (C-section) rates are rising in many middle- and high-income countries, with the justification that higher rates of C-section are associated with better outcomes. A review of 79 studies comparing outcomes of elective caesarean sections with vaginal deliveries, including both observational studies and randomized trials, suggests that caesarean sections may have substantially greater risks than vaginal deliveries. In this issue of Epidemiology, Leung and colleagues present data from Hong Kong on morbidity in offspring related to C-section. Such studies are needed to widen the scope of possible health outcomes related to elective C-sections, including such endpoints as maternal satisfaction and women's relationship with their child. Testing of interventions to reduce unnecessary C-sections is also needed, with strategies to enhance the role of women in the process of their obstetric care.     

中山市民众医院4年中剖宫产率升高原因分析

目的 通过对中山市民众医院2007至2010年剖宫产指征进行分析,探讨降低剖宫产率的措施.方法 采取回顾性分析的方法,对中山市民众医院4年来的1 476例剖宫产病例临床资料进行分析.结果 在4年中,剖宫产率逐渐上升,由2007年的26.61%上升到2010年的37.48%(χ2＝45.48,P<0.01);剖宫产的主要指征为瘢痕子宫、头盆不称、胎儿窘迫、社会因素等.结论 医务人员应做好宣传指导工作,积极推广无痛分娩,严格掌握剖宫产指征,控制剖宫产率,提高产科质量.     

Trends in caesarean section rates at a maternity hospital in Mumbai, India

The steady rise in caesarean section rates is an emerging area of concern in mother-child healthcare and a matter of international attention, since the trend is no longer confined to western industrialized countries. Crude and caesarean section-related perinatal mortality and case-fatality rates may well serve as public-health indicators. Monitoring time-trends in caesarean section rates has been considered a useful approach in the recognition of this rapidly-changing health policy and in estimating the magnitude of this problem. The study examined the observed time-trends in caesarean section rates in relation to perinatal mortality rates and maternal case-fatality rates in a hospital setting in Mumbai, India, using 1957-1998 data on retrospective cohort. Both overall rates and those specific to type of delivery were assessed. During 1957-1998, the caesarean section rates in the Nowrosjee Wadia Maternity Hospital (NWMH) increased from 1.9% to 16%, with the most significant rise over the past decade. The perinatal mortality rate showed a significant reduction from 69 per 1,000 in 1957 to 36 per 1,000 in 1992 and remained steady in the 1990s despite the higher caesarean section rates. The caesarean section rate in the NWMH rose by almost 10-fold during 1957-1998. No improvement in perinatal outcome was observed beyond a caesarean section rate of 10%, but the perinatal mortality rate in caesarean births increased significantly due to a more liberal use of caesarean sections in preterm deliveries and those that yielded low-birth-weight babies.     

Quality and equality in obstetric care: racial and ethnic differences in caesarean section delivery rates

We sought to examine racial/ethnic differences in deliveries by caesarean section (CS) over time, particularly among women at low risk for this procedure. To do so, we conducted a retrospective cohort study at the University of California, San Francisco, a tertiary care academic centre. Births occurring between 1980 and 2001 were included in the analyses. Women with multiple gestations, fetuses in other than the cephalic presentation or with other known contraindications to vaginal birth were excluded. A total of 28 493 African American, Asian, Latina and White women were studied. Risk-adjusted models were created to explore differences in CS risk by race/ethnicity. We also performed analyses of subgroups of women at relatively low risk of CS, and explored changes in observed disparities over time.
The overall CS rate was 15.8%. The absolute rate was highest among Latinas (16.7%) and lowest among Asians (14.7%). After adjustment for known risk factors, African American women had a 1.48 times greater odds of having a CS than did White women [95% confidence interval (CI) 1.31, 1.68], and Latina women had a 1.19 times greater odds [95% CI 1.05, 1.34]. Stepwise adjustment for confounders showed that this variation is not entirely explained by known risk factors. These differences exist even for women at low risk of CS, and have persisted over time. We conclude that racial and ethnic disparities in CS delivery exist, even among women presumed to be at lower risk of CS; rates have not improved with time. Disparities in risk-adjusted CS should be considered as a quality metric for obstetric care, whether at the national, state, hospital or provider level.     

剖宫产产妇产前剖宫产偏好及原因分析

目的 了解剖宫产产妇产前剖宫产偏好率、偏好原因、分娩并发症知识水平及影响因素。方法 研究者于2014年4~6月在北京某三甲妇产专科医院调查门诊产检的孕妇,采用自行设计的问卷收集资料。调查一般人口学信息、孕产史、分娩方式偏好原因及分娩并发症知识等。结果 共调查192名剖宫产产妇,其中70人产前偏好剖宫产。偏好剖宫产的主要理由为减少胎儿宫内窒息的危险,偏好阴道产的主要理由为阴道产是自然过程、阴道产后恢复更快、阴道产婴儿更健康。多因素结果显示,在所有孕妇中孕次>1次者（OR_adjusted=2.8,95% CI：1.5~5.3）、判断要选用何种分娩方式时只选一种信息源者（OR_adjusted=2.5,95% CI：1.0~5.9）、认为医生无权决定自己的分娩方式者（OR_adjusted=2.2,95% CI：1.0~4.8）报告更偏好剖宫产。在初产妇中高龄孕妇（OR_adjusted=3.4,95% CI：1.5~7.7）、认为医生无权决定自己的分娩方式者（OR_adjusted=2.1,95% CI：1.1~6.0）更偏好剖宫产。结论 本研究中调查对象剖宫产偏好率高达36.5%,将来有必要针对产前偏好剖宫产者进行干预以降低实际剖宫产率。     

Do caesarean section rates ‘catch-up’? Evidence from 14 European countries

This study investigated the catch up effect of Caesarean Section (CS) birth rates across 14 European countries during 1980–2009 for the first time. The panel stationary test incorporating multiple structural breaks and cross-sectional dependence was used to provide reliable evidence for the existence of the catch up effect of CS birth rates. Our results suggested that the CS birth rates in 14 European countries have mostly exhibited signs of convergence through a steady upward trend from 1980 to 2009. Policymakers in low CS birth rate countries should be cautioned concerning the negative impact of the increase of CS births.     

剖宫产分娩对男女童青春期发育影响的队列研究

探讨在控制青春期发育遗传背景后,剖宫产分娩方式对男女童青春期发育的前瞻性影响,为选择有利于青春期发育正常进程的分娩方式提供参考依据.方法 采用整群抽样方法于2016年在安徽省蚌埠市2所小学招募一至三年级学生997名,建立儿童青春期发育队列.采用父母问卷调查收集儿童分娩方式、出生体重、胎龄、早期喂养方式、家庭经济状况和父母文化程度等信息,每年评估儿童身高、体重和青春期发育(女童乳房发育Tanner分期和男童睾丸容积).基于青春期相关17个单核苷酸多态性(SNP)位点计算青春期发育多基因遗传风险评分(PRS).采用Kaplan-Meier生存分析探讨剖宫产分娩与男女童青春期发育的关联.结果 调查对象基线年龄为(8.01±0.84)岁,体质量指数(BMI)为(17.96±2.96) kg/m2.男女童剖宫产比例分别为43.30%和32.47%.基线和随访结束,剖宫产女童乳房发育启动检出率(39.89%,95.21%)高于自然分娩组女童(4.39%,68.48%)(x2值分别为118.65,51.42,P值均<0.01).控制PRS、年龄、BMI、早期喂养方式等因素发现,剖宫产与女童乳房发育启动年龄提前有关(风险比HR=1.98,95%CI=1.67~2.34,P<0.01).结论 剖宫产分娩可能增加女童乳房发育提前风险.需要更多研究证实自然分娩或为儿童青春期发育提前的预防途径之一.     

Promoting normal birth and reducing caesarean section rates: An evaluation of the Rapid Improvement Programme

This paper evaluates the impact of the 2008 Rapid Improvement Programme that aimed at promoting normal birth and reducing caesarean section rates in the English National Health Service. Using Hospital Episode Statistics maternity records for the period 2001–2013, a panel data analysis was performed to determine whether the implementation of the programme reduced caesarean sections rates in participating hospitals. The results obtained using either the unadjusted sample of hospitals or a trimmed sample determined by a propensity score matching approach indicate that the impact of the programme was small. More specifically there were 2.3 to 3.4 fewer caesarean deliveries in participating hospitals, on average, during the postprogramme period offering a limited scope for cost reduction. This result mainly comes from the reduction in the number of emergency caesareans as no significant effect was uncovered for planned caesarean deliveries.     

Fee exemption for caesarean section in Morocco

Financial barriers are an important obstacle for access to emergency obstetric care and a contributing factor to too slow a reduction in the level of maternal mortality. In Morocco, in 2009, a fee exemption policy for delivery and caesarean section was implemented in public maternity hospitals. As in most countries where a fee exemption policy has been implemented, fee exemption is considered synonym to free care. However, other direct costs may subsist. The objective of this study was to get an estimate of the actual cost of caesarean sections from the patients' perspective.     

剖宫产术护理中的临床护理路径

目的探讨临床护理路径在剖宫产术护理中的应用效果。方法根据制定的临床护理路径对试验组进行整体护理,完成各项检查、治疗护理和健康教育。结果试验组对制定的临床护理路径满意度达到98％,明显高于对照组的满意度（80％）。结论实施临床护理路径后,病患满意度明显提高,并提高了护士的积极性和工作效率。