China's Cesarean Section Delivery Rate Excessive

At 50%, China has one of the highest caesarean section (CS) delivery rates in the world, and efforts must be made to decrease it, according to a new commentary. 

Researchers at Brigham and Women's Hospital (Boston, MA, USA) found that although the exact rate is not known, current Chinese language literature on CS rates in China report them as ranging from 36% to 58%; of the 16 million babies born in 2010, approximately half were by caesarean. However, before the 1980s, the caesarean rate was below 5%, and it did not rise above 10% until after 1990. The increase in CS over the last few decades appears to be driven by three factors: the structure of the obstetric care system, provider incentives, and patient preference.

Factors related to the Chinese obstetric care system and provider factors identified as contributors to the rise in CS rates include a high overall number of deliveries, since the advantages of managing an enormous volume of births with limited resources may favor a high caesarean rate. Staffing levels in Chinese public hospitals are low and limited by Government regulation; with 1.5 nurses or midwives per 1,000 population (compared to 9.8 per 1,000 in the United Kingdom), CS delivery requires less nursing hours compared with vaginal delivery.

Financial incentives that promote CS delivery over vaginal delivery include insurance coverage for childbirth, physician income, and hospital revenues. Another factor is that many physicians' salaries are supplemented by bonuses on patient volume and collections; since CS deliveries collect more than vaginal deliveries, they provide an additional incentive for physicians to conduct them. Patient preference, on the other hand, is driven by cultural aspects, and in particular by the One Child Policy. 

The authors noted that in the second generation of the One Child Policy, a demand was created for a perfect outcome, and both patients and doctors see CS delivery as more effective than harmful. The fear of labor on wards that do not offer pain control, epidural anesthesia, and nursing or family support, reinforces this expectation. However, current practice may change soon due to a more relaxed policy, introduced in November 2013, which encourages Chinese couples to have a second child. The study was published ahead of print on August 20, 2014, in BJOG.

“Efforts must be made to encourage vaginal delivery by reforming certain aspects of the Chinese obstetric care system,” concluded study coauthor assistant professor in obstetrics and gynecology Susan Hellerstein, MD. “However, it is important to recognize that any efforts to decrease the caesarean section rate must take into account the safety and effectiveness of this delivery method in modern China and preserve maternal and perinatal health.”

The one-child policy was introduced in 1979 to alleviate social, economic, and environmental problems in the People's Republic of China, and it is estimated that the policy averted 200 million births between 1979 and 2009. The policy has been implicated in an increase in forced abortions, female infanticide, and under-reporting of female births, and has been suggested as a possible cause behind China's sex imbalance. The policy is enforced at the provincial level through fines that are imposed based on the income of the family and other factors. 

Many demographers consider the term "one-child" a misnomer, as the policy allows many exceptions: for example, rural families may have a second child if the first child is a girl or is disabled, and ethnic minorities are exempt. Families in which neither parent has siblings are also allowed to have two children. In November 2013, the Chinese government announced that it would further relax the policy by allowing families to have two children if one of the parents is an only child. 

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