Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
BMC Pregnancy and Childbirth
Published in: BMC Pregnancy and Childbirth 1/2017

Open Access 01-12-2017 | Research article

Large reductions in cesarean delivery rates in China: a qualitative study on delivery decision-making in the era of the two-child policy

Authors: Eileen Wang, Therese Hesketh

Published in: BMC Pregnancy and Childbirth | Issue 1/2017

Login to get access

Abstract

Background

In 2010, China’s cesarean delivery (CD) rates increased to one of the highest in the world, a significant proportion of which were without medical indication. However, recent studies have indicated some declines, coinciding with national and local efforts to promote vaginal birth, as well as the relaxation of the one-child policy. Considering these trends, we aimed to qualitatively explore attitudes towards childbirth and experiences of delivery decision-making among women and physicians.

Methods

Semi-structured interviews were conducted with 45 postpartum women and 7 healthcare providers at one county-level and one provincial-level maternity hospital in Zhejiang Province. We also collected routine data from 2007 to 2016 and observed doctor-patient interactions and hospital facilities as context for the interviews. Interviews were recorded, translated and transcribed into English, and then analyzed using a framework approach.

Results

From 2007 to 2016, cesarean delivery rates at the county-level and provincial-level hospital decreased from 46% to 32% and 68% to 44%, respectively. For low-risk women, vaginal birth was the primary choice of delivery method, encouraged by doctors and nurse-midwives. Elective CD was not as widely accepted, in contrast to previous years. Women were aware of and took into consideration the consequences of CD for future pregnancies. Among those who delivered vaginally, women viewed the existing pain relief methods, epidurals and transcutaneous electrical nerve stimulation, with caution or uncertainty. Even when requested, epidurals were only given under certain circumstances. For multiparas with previous CD, repeat CD remains the norm. Both women and professionals were cautious about vaginal birth after cesarean delivery (VBAC) given the associated risks.

Conclusion

In China, changes in family planning policy and efforts to promote vaginal birth have greatly changed the culture of delivery decision-making, leading to decreased CD rates. This demonstrates the powerful role social factors and public policy can play, and provides a model for other countries with high CD rates. Further research should explore changes in other reproductive decisions during this new multiparous era, particularly across provinces.
Appendix
Available only for authorised users
Literature
1.
Hellerstein S, Feldman S, Duan T. China’s 50% caesarean delivery rate: is it too high? BJOG. 2014;122:160–4.CrossRefPubMed
2.
Lumbiganon P, Laopaiboon M, Gülmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet. 2010;375:490–9.CrossRefPubMed
3.
Feng XL, Xu L, Guo Y, Ronsmans C. Factors influencing rising caesarean section rates in China between 1988 and 2008. Bull World Health Organ. 2012;90:30–9A.CrossRefPubMed
4.
Klemetti R, Che X, Gao Y, Raven J, Wu Z, Tang S, et al. Cesarean section delivery among primiparous women in rural China: an emerging epidemic. Am J Obstet Gynecol. 2010;202:65.e1–6.CrossRef
5.
Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z. Cesarean delivery on maternal request in Southeast China. Obstet Gynecol. 2008;111:1077–82.CrossRefPubMed
6.
Sufang G, Padmadas SS, Fengmin Z, Brown JJ, Stones RW. Delivery settings and caesarean section rates in China. Bull World Health Organ. 2007;85:755–62.CrossRefPubMedPubMedCentral
7.
Bogg L, Huang K, Long Q, Shen Y, Hemminki E. Dramatic increase of cesarean deliveries in the midst of health reforms in rural China. Soc Sci Med. 2010;70:1544–9.CrossRefPubMed
8.
Liu Y, Li G, Chen Y, Wang X, Ruan Y, Zou L, et al. A descriptive analysis of the indications for caesarean section in mainland China. BMC Pregnancy Childbirth. 2014;14:410.CrossRefPubMedPubMedCentral
9.
10.
Tang S, Li X, Wu Z. Rising cesarean delivery rate in primiparous women in urban China: evidence from three nationwide household health surveys. Am J Obstet Gynecol. 2006;195:1527–32.CrossRefPubMed
11.
Lee LYK, Holroyd E, Ng CY. Exploring factors influencing Chinese women’s decision to have elective caesarean surgery. Midwifery. 2001;17:314–22.CrossRefPubMed
12.
13.
14.
15.
Hellerstein S, Feldman S, Duan T. Survey of obstetric care and cesarean delivery rates in shanghai, China. Birth. 2016;43:193–9.CrossRefPubMed
16.
Li H-T, Luo S, Trasande L, Hellerstein S, Kang C, Li J-X, et al. Geographic variations and temporal trends in cesarean delivery rates in China, 2008-2014. JAMA. 2017;317:69–76.CrossRefPubMed
17.
Hesketh T, Lu L, Xing ZW. The effect of China’s one-child family policy after 25 years. N Engl J Med. 2005;353:1171–6.CrossRefPubMed
18.
19.
Cheng P, Duan T. China’s new two-child policy: maternity care in the new multiparous era. BJOG. 2016;123:7–9.CrossRefPubMed
20.
Wang E. Requests for cesarean deliveries: the politics of labor pain and pain relief in Shanghai, China. Soc Sci Med. 2017;173:1–8.CrossRefPubMed
21.
22.
Zhu Y, Li H, Zhang Y, Li Z, Zhang L, Liu J. Secular trends of cesarean delivery and cesarean delivery on maternal request among primiparous women with singleton pregnancy in Southern and Northern China during 1993–2010. National Med J China. 2012;92:1734–7.
23.
Long Q, Klemetti R, Wang Y, Tao F, Yan H, Hemminki E. High caesarean section rate in rural China: is it related to health insurance (new co-operative medical scheme)? Soc Sci Med. 2012;75:733–7.CrossRefPubMed
24.
Qian J. China’s national cesarean rate. Analysis and suggestions. J Popul Dev. 2012:39–42.
25.
Gilliam M. Cesarean delivery on request: reproductive consequences. Semin Perinatol. 2006;30:257–60.CrossRefPubMed
26.
Grobman W, Caughey A, Hahn K. 177: reproductive consequences of elective cesarean: a decision analysis. Am J Obstet Gynecol. 2008;199:S61.CrossRef
27.
Miller ES, Hahn K, Grobman WA, Society for Maternal-Fetal Medicine Health Policy Committee. Consequences of a primary elective cesarean delivery across the reproductive life. Obstet Gynecol. 2013;121:789–97.CrossRefPubMed
28.
Ecker J, Frigoletto F. Cesarean delivery and the risk–benefit calculus. N Engl J Med. 2007;356:885–8.CrossRefPubMed
29.
Ouyang YQ, Zhang Q. A study on personal mode of delivery among Chinese obstetrician-gynecologists, midwives and nurses. Arch Gynecol Obstet. 2012;287:37–41.CrossRefPubMed
30.
Gao Y, Xue Q, Chen G, Stone P, Zhao M, Chen Q. An analysis of the indications for cesarean section in a teaching hospital in China. Eur J Obstet Gynecol Reprod Biol. 2013;170:414–8.CrossRefPubMed
31.
Ji H, Jiang H, Yang L, Qian X, Tang S. Factors contributing to the rapid rise of caesarean section: a prospective study of primiparous Chinese women in shanghai. BMJ Open. 2015;5:e008994.CrossRefPubMedPubMedCentral
32.
Deng W, Klemetti R, Long Q, Wu Z, Duan C, Zhang W-H, et al. Cesarean section in shanghai: women’s or healthcare provider’s preferences? BMC Pregnancy Childbirth. 2014;14:285.CrossRefPubMedPubMedCentral
33.
Cheng YW, Eden KB, Marshall N, Pereira L, Caughey AB, Guise J-M. Delivery after prior cesarean: maternal morbidity and mortality. Clin Perinatol. 2011;38:297–309.CrossRefPubMedPubMedCentral
34.
Menacker F. Trends in cesarean rates for first births and repeat cesarean rates for low-risk women: United States, 1990–2003. National Vital Statistics Reports. 2005;54:1–8.
35.
Black M, Entwistle VA, Bhattacharya S, Gillies K. Vaginal birth after caesarean section: why is uptake so low? Insights from a meta-ethnographic synthesis of women’s accounts of their birth choices. BMJ Open. 2016;6:e008881.CrossRefPubMedPubMedCentral
36.
Dexter S, Windsor S, Watkinson S. Meeting the challenge of maternal choice in mode of delivery with vaginal birth after caesarean section: a medical, legal and ethical commentary. BJOG. 2014;121:133–40.CrossRefPubMed
37.
Wanyonyi S, Ngichabe S. Safety concerns for planned vaginal birth after caesarean section in sub-Saharan Africa. BJOG. 2014;121:141–4.CrossRefPubMed
38.
Kamal P, Dixon-Woods M, Kurinczuk JJ, Oppenheimer C, Squire P, Waugh J. Factors influencing repeat caesarean section: qualitative exploratory study of obstetricians’ and midwives’ accounts. BJOG. 2005;112:1054–60.CrossRefPubMed
39.
Cox KJ. Providers’ perspectives on the vaginal birth after cesarean guidelines in Florida, United States: a qualitative study. BMC Pregnancy Childbirth. 2011;11:72.CrossRefPubMedPubMedCentral
40.
41.
Moffat M, Bell J, Porter M, Lawton S, Hundley V, Danielian P, et al. Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study. BJOG. 2007;114:86–93.CrossRefPubMed
42.
Raven J, van den Broek N, Tao F, Kun H, Tolhurst R. The quality of childbirth care in China: women’s voices: a qualitative study. BMC Pregnancy Childbirth. 2015;15:113.CrossRefPubMedPubMedCentral
43.
Fenwick J, Staff L, Gamble J, Creedy DK, Bayes S. Why do women request caesarean section in a normal, healthy first pregnancy? Midwifery. 2010;26:394–400.CrossRefPubMed
44.
Qian X, Smith H, Zhou L, Liang J, Garner P. Evidence-based obstetrics in four hospitals in China: an observational study to explore clinical practice, women’s preferences and provider’s views. BMC Pregnancy Childbirth. 2001;1:1.CrossRefPubMedPubMedCentral
45.
46.
Chinese Ministry of Health. Ministry of Health on the Issuance of the “2011 Health Working Points”. 2011.
47.
48.
49.
Metadata
Title
Large reductions in cesarean delivery rates in China: a qualitative study on delivery decision-making in the era of the two-child policy
Authors
Eileen Wang
Therese Hesketh
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Pregnancy and Childbirth / Issue 1/2017
Electronic ISSN: 1471-2393
DOI
https://doi.org/10.1186/s12884-017-1597-9

Other articles of this Issue 1/2017

BMC Pregnancy and Childbirth 1/2017 Go to the issue

Research article

Measurement properties of comorbidity indices in maternal health research: a systematic review

Research article

Experiences and wishes of women regarding systemic aspects of midwifery care in Germany: a qualitative study with focus groups

Research article

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews

Research article

Active delivery of the anterior arm and incidence of second-degree perineal tears: a clinical practice evaluation

Research article

Determinants of physical activity frequency and provider advice during pregnancy

Research article

Factors associated with recovery from 1 minute Apgar score <4 in live, singleton, term births: an analysis of Malaysian National Obstetrics Registry data 2010–2012