While nearly all women today have their children in the hospital, many of them do so by cesarean section and many of these have no medical indication. In 2008, 29% of births in China were by cesarean section, reaching 35% by 2014.
The overuse of cesarean section negatively affects maternal and neonatal health. In China, cesarean sections have been associated with obesity in childhood and postpartum depression, but there is no evidence of adverse psychological development.
A study in Shanghai found no difference in the frequency of severe maternal complications in those who had an elective cesarean section compared with a vaginal birth.
The reasons that explain the high cesarean section rates in China are complex, women may request an elective cesarean section for fear of a vaginal birth or because they consider it safer, perverse financial incentives encourage the performance of expensive procedures with medico-legal implications, Total spending on cesarean sections has increased and has become an important source of income for hospitals and health care administrators.
In the last 10 years, the Chinese government has had growing concern about the increase in cesarean section rates and several programs and policies have been implemented at different health levels (state, district, hospitals of different levels of complexity).
Concerns about caesarean section rates increased in 2010 when a report showed that China had one of the highest caesarean section rates in the world. Interventions included Hands on training for doctors and obstetricians, revision of guidelines for the management of dystocia, education of women on the advantages of vaginal birth and the risk of cesarean sections, audits of cesarean sections without medical indication, elimination of financial incentives, establishment of a maximum number of cesarean sections and incentives for successful establishments.
Although the total cesarean section rate continued to increase, it did so more slowly until 2014, rates began to decline in large urban areas and in areas that had very high rates in 2008. In Beijing the cesarean section rate decreased from 60% in 2009 to 43% in 2014, similarly in Shanghai with a decrease from 67 to 52% respectively.
Given that China released its one-child policy in 2013, and many Chinese couples today are allowed and encouraged to have a second child, care in monitoring cesarean sections becomes more urgent, as the same situations are repeated. cesarean sections the risk of it may increase.
Evidence on how the change in state policy affected the distribution of obstetric risk is still lacking, but if obstetric risk changes, the need for cesarean sections also changes and they may become less safe and may increase maternal and perinatal mortality.
In this work, the authors examined how the change in the number of children policy and the policies to reduce cesarean sections may have affected the trends in cesarean section rates and pregnancy-associated and perinatal mortality rates between 2012- 2016.
Method
Three data sources were used:
-Individual data collected by the China Maternal Surveillance System Survey (NMNMSS- National Maternal Near Miss Surveillance System).2012-2016
-Institutional data collected from each hospital through NNMMSS in 2015
-2016 survey collecting information about policies that could have influenced the cesarean section rate in model hospitals.
Definition of variables
Common definitions were used for maternal age, marital status, and education.
Maternal complications were classified into two exclusive categories:
- Obstetric complications : uterine rupture, placenta previa, abruptio placentae, nonspecific antepartum hemorrhage, preeclampsia, eclampsia, HELLP syndrome, dystocic fetal presentations.
- Diseases : heart disease, embolism, thrombophlebitis, liver disease, severe anemia, kidney disease, lung disease, HIV, connective tissue disorders, gestational diabetes, cancer.
Women were categorized into risk groups for cesarean sections using the modified version of Robson’s classification. Robson proposes a system that classifies women into 10 groups based on their obstetric characteristics (parity, previous cesarean section, gestational age, onset of labor, type of presentation, number of fetuses).
Monitoring cesarean sections with Robson groups allows evaluation of clinical practice, including whether cesarean section rates are justified. The Robson scale was adapted since the information provided by NMNMSS does not differentiate whether labor was spontaneous or induced.
8 mutually exclusive categories were created:
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The number of perinatal deaths, pregnancy-related deaths, and uterine ruptures were collected. Pregnancy-related deaths were defined as deaths from any cause in women who died after 28 weeks of gestation or with a fetus weighing at least 1000 grams at birth (whether born or not). Uterine rupture was defined as uterine dehiscence in late pregnancies or during childbirth, including partial or complete rupture.
Statistic analysis
The analysis was restricted to women who completed 28 weeks of gestation or with a fetus weight of 1000 grams. or more, consistent with the definition of perinatal period in China.
Results
China is the only country that has been successful in reversing the rising rate of cesarean sections
Changes over time in the obstetric population at risk, between 2012 and 2016, according to NMNMSS there were 6,838,582 births of pregnancies of 28 weeks or more with birth weights of 1000 grams or more in 438 hospitals.
Substantial changes occurred over time in the age and parity of women, the proportion of women with uterine scars, and the proportion of women in each group on the modified Robson scale.
The proportion of births in women over 35 years of age increased from 7.8% in 2012 to 10.9% in 2016, the proportion of second births increased from 34.1% in 2012 to 46.7% in 2016, and the proportion of women with uterine scars doubled from 9.8 to 17.7%. The big change in Robson’s groups was in the proportion of women with a uterine scar and a full-term birth (from 8.6% to 15.6%).
Determinants of cesarean sections
3,000,000 women had cesarean sections, bringing the cesarean section rate to 43.5% which was higher in urban areas compared to rural areas. Tertiary care hospitals performed more cesarean sections than lower complexity hospitals; this is explained by the sociodemographic variants and obstetric characteristics of the women treated in those hospitals.
Hospitals with 6 or more obstetricians per 1000 births had the highest rate of cesarean sections, and this trend persisted after adjustment for hospital complexity level and for sociodemographic and obstetric conditions.
The lowest cesarean section rates were in women with fewer prior controls (35.8%), women with a low level of education (35.2), and single women (28.8%).
Caesarean section rates increase notably with maternal age, the rate in women under 20 years old was 27.5% while in women over 40 years old the rates were 60.7%, these differences also persisted after adjustments by level complexity of the hospital and by sociodemographic and obstetric conditions.
As expected, cesarean section rates were higher in women with obstetric complications (83.1%) or diseases (51.2%) but were also high (40%) in women in whom the medical history did not record complications.
The cesarean section rate was lower among multiparous women without uterine scar with a singleton, cephalic fetus at term (19.5%) and higher among women with uterine scars who had a singleton birth at term (91.2%).
Trend in cesarean section rate over time
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Trend in perinatal and maternal evolution over time
Perinatal mortality declined substantially from 10.1 per 1000 births in 2012 to 7.2 per 1000 in 2016. This trend was maintained after adjustment for sociodemographic and obstetric factors; it decreased in the same proportion in nulliparous and multiparous women. There were no changes in pregnancy-related mortality over time.
The incidence of uterine rupture was much higher in women with uterine scars where the incidence increased from 28.4 per 10,000 births in 2012 to 87.3 per 10,000 births in 2016, among nulliparous women there was an increase in the incidence of uterine rupture between 2012 and 2013 but after that the rates were stable.
Survey on policies to reduce the cesarean section rate
90.9% of hospitals completed the survey regarding policies that would potentially influence cesarean section rates.
The cost of cesarean sections is double the cost of vaginal births, about 92.7% of hospitals reported that they had institutional policies to reduce cesarean section rates, 67.1% established an objective cesarean section rate and almost all reported having a list of indications for cesarean sections (93%), 86.9% trained health workers and 95% offered health education to women.
Discussion
Using data from more than 6 million births in 438 hospitals in China, the authors found that cesarean section rates declined steadily between 2012 and 2016, reaching an overall rate of 41% in 2016.
The liberalization of the state’s one-child policy led to an increase in the proportion of multiparous births from 34.1% in 2012 to 46.7% in 2016, and vaginal births in women with uterine scars doubled, all of these changes amplifying the reduction in the incidence of cesarean sections over time leading to a decrease of 18% between 2012 and 2016.
The reduction in cesarean section rates was more pronounced in hospitals with higher rates in 2012, coinciding with China’s government policy to focus on those hospitals. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period and there was no change in pregnancy-related mortality over time.
Comparison with other studies
The liberalization of the state’s one-child policy in November 2013 and the introduction of the two-child policy in October 2015 has led many families to have a second child, the proportion of second births increasing from a third in 2012. (34.1%) to about half of the births in 2016.
Multiparous women are highly heterogeneous, however the associated risks vary particularly whether or not they have a uterine scar, although births increased in multiparous women without a uterine scar from 24.2 to 28.9% between 2012 and 2016, those with a uterine scar had an increase of births that almost doubled (from 9.8% to 17.7%).
The cesarean section rates described in this work are similar to those of the WHO in 2008 and 2010 in a sample of Chinese hospitals, but they are higher if the population data is taken according to resources.
The National Health Service Survey 2009-2011 reported a rate of 36.3% in 2011 and 40.9% in 2013 (this is unpublished) while the Office for Women and Children Statistics published a rate of 34.9% in 2014.
Findings of this study
The decrease in the cesarean section rate coincided with the Chinese government’s explicit concern about the associated risks and the introduction of specific policies
China is the only country that has been successful in reversing the rising rate of cesarean sections. In a global review of the cesarean section rate between 1990-2014, a study found only two countries, Guinea and Nigeria, where the cesarean section rate had decreased, in countries with excessive cesarean section rates such as Brazil and the Dominican Republic, they have had stable growth reaching 56% in 2013.
China’s success is even more remarkable given that the decrease in the cesarean section rate was more pronounced in women who did not have an indication for a cesarean section and remained stable in those who had a medical indication for it. The question is whether the decrease in the cesarean section rate is due to the modification of the one-child policy or to the introduction of policies specifically designed to reduce this rate.
It is not certain whether the decrease in the rate of cesarean sections in nulliparous women can be explained by the change in policy and the possibility of second pregnancies, knowledge of the possibility of future pregnancies where the risks of cesarean sections are greater may have led some doctors and women opt for a vaginal birth in the first pregnancy.
However the greatest decrease in the rate of caesarean sections was in multiparous women without uterine scarring, a group on whom the relaxation of the one-child policy is unlikely to have had an impact. Many women who are pregnant for the first time may not know if they will want another child and medical decisions are unlikely to be made with this in mind.
The passage of time is required to evaluate whether the trend in the cesarean section rate in China has to do with the relaxing one-child policy. Three studies have reported cesarean section rates in China,
- Feng et al. used data from 4 national surveys between 1993 and 2008 and reported an increased rate of nulliparous and multiparous women in urban and rural areas.
- Meng. et al using the same survey but between 2003-2008 and adding a national survey reported an increase in the rural rate between 2008 and 2011. However, for the first time the authors reported a decrease in the cesarean section rate in urban areas.
-Li. et al using information from the national report between 2008 and 2014 demonstrated a global increase in the cesarean section rate but a decrease in the same in large cities that had a high rate in 2008. In large cities the cesarean section rate decreased stably from 53%. in 2009 to 47% in 2014 and in areas with a high rate of cesarean sections in 2008 the decrease was similar.
These studies were compared with data from WHO research in 2007-2008 and 2010-2011 suggesting that this trend could have started before the relaxation of the one-child policy.
The timing of the decline in the cesarean section rate coincided with the Chinese government’s explicit concern about the risks associated with cesarean sections and the introduction of specific policies to decrease the rate.
The approach to reducing rates was regulated by national and local policies, and scientific societies that defined objectives in the rate of cesarean sections with positive incentives or penalties according to the results.
The number of cesarean sections without medical indication is used as an indicator of hospital performance, including whether hospitals qualify as baby-friendly hospitals; cesarean sections performed without medical indication must be reported to the hospital director for review.
Some hospitals also took educational initiatives for pregnant women, at the same time included various interventions including prenatal classes informing women of the benefits of vaginal births, pain control, and a bonus for those doctors who had low cesarean section rates.
As a result, in-hospital cesarean sections decreased from 51 to 43% over a 4-year period. The authors point out that 78% of hospitals reported having clinical guidelines for indications for cesarean section. Cesarean section costs remain higher than vaginal birth costs, however a few hospitals have introduced the same rate for any type of birth.
Other measures to sustain the reduction in the cesarean section rate include a review of clinical guidelines for labor management, training in the use of forceps, and training and education of obstetricians.
In 2014, the Association of Gynecologists and Obstetricians of China held a consensus of experts on cesarean sections, first allowing doctors to reject requests for cesarean sections when there were no medical indications for them, in case women continued with their request for a cesarean section, the case was Referred to the head of the obstetrics department for review.
Secondly, they reviewed the indications for cesarean sections for some types of dystocia. Prolonged labor was previously an indication for cesarean section, with this consensus it was removed and the concept of starting labor with 3 to 6 cm of dilation was incorporated.
Third, the use of forceps and suction cups was reinforced throughout the country.
And finally, to avoid the collapse of obstetricians, the Chinese government introduced a new training curriculum for midwives in 2012.
Repeat cesarean sections are associated with an increased risk of:
- previous placenta
- placenta accreta
- infection
- bladder and bowel injury
- Deep venous thrombosis
- rarely uterine rupture
Evidence suggests that in women with uterine scarring, a scheduled cesarean section or a natural birth carries the same risk for mother and baby. But the evidence is observational and biases cannot be excluded.
In China, repeat cesarean sections are the preferred delivery model for women with uterine scars and opinions vary on whether more women should have a vaginal delivery.
The cesarean section rate remains high in patients with uterine scars, a vaginal birth after a cesarean section is uncommon, and the dramatic increase in the incidence of uterine rupture in women with uterine scars is worrying.
Although some of these ruptures could have been a dehiscence without major clinical consequences. The authors report that they have not been able to investigate the reasons for this increase but highlight the need for policies, doctors, and researchers in China to address the growing number of women with uterine scars.
During the study period, perinatal mortality decreased while that related to pregnancy did not change. The decrease in perinatal mortality was maintained once the values were adjusted for sociodemographic factors, suggesting that obstetric characteristics did not explain the change. evaluated trends in unfavorable neonatal outcomes, such as birth trauma or respiratory distress.
The number of cesarean sections remained stable in high-risk births. In sum, the Chinese government incorporated several strategies that may have contributed to the reduction of perinatal mortality, including greater prenatal controls, a supervision system between first and tertiary hospitals, the incorporation of neonatal intensive therapies in county hospitals and intensive neonatal training in neonatal care and resuscitation.
Strengths and limitations of the study
The NMNMSS is an established surveillance system that has rigorous quality controls but there are data and analysis limitations.
First, this is not an intervention study and the decline in cesarean section rate cannot be attributed to a particular policy, however the time and rate of decline in cesarean sections in the hospitals that had the highest rates was consistent with government policy focused on such hospitals.
Using a statistical model, adjusted for demographics and clinical conditions, the changes would potentially be associated with the relaxation of the one-child policy, which allowed us to separate the effects of the one-child policy and those policies developed to reduce the cesarean section rate. .
Second, the accuracy of the cesarean section rate over time needs rigorous monitoring, especially when decreasing the rate involves incentives. The NMNMSS was originally designed to collect data on maternal death and comorbidity rather than cesarean section rate; however, when completing the data, it was not known which type of birth would be the focus of the investigation, since these data were taken from individual women. practically impossible to manipulate the data to show a decrease in the cesarean section rate.
Third, the information was only collected in obstetrics areas, so life-threatening neonates admitted to the NICU were not registered. The early neonatal mortality rate was surprisingly low, but consistent with that found in other studies.
Fourth, Robson’s classification was the most appropriate for comparing the rate of cesarean sections, but it was not possible to differentiate women who had spontaneously initiated labor from those who were induced and those who ended in cesarean section, which is a critical point to understand the rate.
In WHO research in 2007-2008 and 2010-2011, cesarean section rates were lower in singleton deliveries of nulliparous women where labor was induced, or in cases where cesarean sections were performed before the onset of labor. Birth.
Finally, the definition of complications depends on the diagnosis, which can lead to bias. In particular, the certain diagnosis of uterine rupture in the presence of a uterine scar may be variable given that the data do not differentiate between asymptomatic dehiscences that may be present in a second elective cesarean section or uterine ruptures that present as an emergency during the procedure. labor.
Although the incidence of uterine rupture reported in this study in women with uterine scars is similar to those presented in other studies, trends over time have to be interpreted with caution.
Conclusion and implications
The evidence on strategies that contribute to reducing cesarean section rates is limited, and interventions that have been shown to be beneficial have resulted in small reductions in cesarean section rates.
The Chinese experience shows that change is possible when strategies are devised that are oriented towards decisions that lead to the overuse of a surgical practice.
The authors conclude that in light of the change in the one-child policy in China, the proportion of births in women with uterine scars will increase. In this way, conditions must be created that increase the safety of repeated cesarean sections, while work must continue to reduce unnecessary cesarean sections.
