Rates of cesarean births in Hong Kong: 1987-1999

The trend of caesarean birth rate changes in China after 'universal two-child policy' era: a population-based study in 2013-2018

BACKGROUND

The universal two-child policy in China which was announced in October 2015 might affect the caesarean birth rate. Few studies reported the caesarean birth rate affected by the policy especially after the universal two-child policy period. This study aimed to demonstrate the caesarean birth rate changes before and after the universal two-child policy and further elaborate the underlying influencing factors.

METHODS

This nationwide, retrospective, population-based study was based on National Free Pre-Pregnancy Check-ups Project (NFPCP). Couples planning to conceive in next 6 months were encouraged to participate in NFPCP. Baseline information was collected using a standardized questionnaire with a face-to-face interview, and medical examinations were conducted. Two rounds of follow-up interviews were then conducted by trained nurses to update pregnancy status and outcomes. NFPCP participants who completed deliveries before December 31, 2018, were included in the current study. We used marginal effect of year to examine the trend of caesarean birth rate over time and interrupted time series (ITS) analysis to determine impacts of the universal two-child policy on the trend of caesarean birth rate.

RESULTS

A total of 9,398,045 participants were included in the final analysis. High-risk factors to increase caesarean birth rate were identified. In the current study, the standardized caesarean birth rate declined from 34.1% in 2013 to 31.8% in 2015 and increased to 35.6% in 2018. ITS analysis showed the caesarean birth rate decreased by 0.1% (95% CI 0.1-0.1) per month before the release of universal two-child policy, 1.3% (95% CI 0.6-2.1%) absolute drop during the policy release month, and increased by 0.2% (95% CI 0.1-0.2%) per month after the policy implementation. For the period after the policy release, the increasing trends were observed in rural participants and urban primiparas. The prevalence of caesarean birth rates within China varied regionally.

CONCLUSIONS

The decreasing trend of caesarean birth rate was reported after immediate release of the universal two-child policy. An increasing trend of caesarean birth rate was observed 2-3 years after the policy. It reminds us that the caesarean birth rate control is a long-lasting process and all the strategies need to be continually reinforced.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Socioeconomic and demographic factors associated with caesarean section delivery in Southern Ghana: evidence from INDEPTH Network member site

BACKGROUND

In recent years, caesarean section rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate caesarean section rate and the associated short- and long-term risks. This study sought to identify the rate of caesarean section and associated factors in two districts in rural southern Ghana.

METHODS

Pregnancy, birth, and socio-demographic information of 4948 women who gave birth between 2011 and 2013 were obtained from the database of Dodowa Health and Demographic Surveillance System. The rate of C-section was determined and the associations between independent and dependent variables were explored using logistic regression. The analyses were done in STATA 14.2 at 95% confidence interval.

RESULTS

The overall C-section rate for the study period was 6.59%. Women aged 30-34 years were more than twice likely to have C-section compared to those < 20 year (OR: 2.16, 95% CI: 1.20-3.90). However, women aged 34 years and above were more than thrice likely to undergo C-section compared to those < 20 year (OR: 3.73, 95% CI: 1.45-5.17). The odds of having C-section was 65 and 79% higher for participants with Primary and Junior High level schooling respectively (OR: 1.65, 95% CI: 1.08-2.51, OR:1.79, 95%CI: 1.19-2.70). The likelihood of having C-section delivery reduced by 60, 37, and 35% for women with parities 2, 3 and 3+ respectively (OR:0.60, 95% CI: 0.43-0.83, OR: 0.37, 95% CI: 0.25-0.56, OR:0.35, 95% CI: 0.25-0.54). There were increased odds of 36, 52, 83% for women who belong to poorer, middle, and richer wealth quintiles respectively (OR: 1.36, 95%CI: 0.85-2.18, OR: 1.52, 95% CI: 0.97-2.37, OR: 1.83, 95% CI: 1.20-2.80). Participants who belonged to the richest wealth quintile were more than 2 times more likely to have C-section delivery (OR: 2.14, 95%CI: 1.43-3.20). The odds of having C-section delivery reduced by 76% for women from Ningo-Prampram district (OR: 0.76, 95% CI: 0.59.0.96). Women whose household heads have Junior High level and above of education were 45% more likely to have C-section delivery (OR: 1.45, 95% CI: 1.09-1.93).

CONCLUSION

Age of mother, educational level, parity, household socioeconomic status, district of residence, and level of education of household head are associated with caesarean section delivery.

Mode of delivery and childhood hospitalizations for asthma and other wheezing disorders

BACKGROUND

Observationally, delivery by Caesarean section is associated with higher risk of childhood asthma and wheeze in developed Western settings, but associations are less consistent in other settings.

OBJECTIVE

To examine the association of mode of delivery with hospitalizations for asthma and other wheezing disorders in a developed non-Western setting with high rates of Caesarean section.

METHODS

Using Cox regression, we examined the adjusted association of mode of delivery with public hospital admissions for asthma, bronchitis, and bronchiolitis (International Classification of Diseases, Ninth Version Clinical Modification 466, 490 and 493) from 9 days to 12 years of age in a population-representative prospective birth cohort of 8327 Chinese children in Hong Kong. Confounders included sex, birth and parental characteristics, and socio-economic position (SEP).

RESULTS

Delivery by Caesarean section accounted for 27% of all births and was not clearly associated with hospitalizations for asthma and other wheezing disorders to 12 years [hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.91 to 1.36] compared to vaginal delivery. Similarly, there were no clear associations to 2 years (HR 1.07, 95% CI 0.83 to 1.38) or 6 years (HR 1.12, 95% CI 0.91 to 1.37), although we cannot rule out residual confounding by SEP.

CONCLUSIONS AND CLINICAL RELEVANCE

We cannot rule out an association, but our findings suggest that the observed associations of delivery by Caesarean section with childhood wheezing disorders may vary with setting and may not be biologically mediated. Further studies with different designs are needed to clarify the role of the microbiome and mode of delivery in the aetiology of asthma and other childhood wheezing disorders.

Predictors of breastfeeding initiation in Hong Kong and Mainland China born mothers

BACKGROUND

In recent years there has been a steady influx of immigrants into Hong Kong from Mainland China, where breastfeeding patterns differ. Studies in other regions have found substantial differences in breastfeeding rates between native-born and immigrant mothers. The purpose of this study was to examine factors associated with breastfeeding initiation in Hong Kong born and Mainland China born mothers living in Hong Kong.

METHODS

We used a multi-center cross-sectional study design and recruited 2761 new mothers from the postnatal wards of all eight public hospitals in Hong Kong that offer obstetric services. We assessed breastfeeding status as well as various socio-demographic, maternal and birth characteristics. Chi-square tests and multivariable logistic regression were used to identify the predictors of breastfeeding initiation in Hong Kong born and Mainland China born participants.

RESULTS

80.3 % of Hong Kong and 81.1 % of Mainland Chinese born women initiated breastfeeding. In the fully adjusted models, multiparity (Odds Ratio [OR] 0.53, 95 % CI 0.43-0.66) and maternal smoking (OR 0.29, 95 % CI 0.18-0.45) were strongly associated with failure to initiate breastfeeding in both Hong Kong and Mainland China born participants. In Hong Kong born mothers, participants with lower maternal education and those who had a cesarean section were significantly less likely to breastfeed. For Mainland China born mothers, paternal smoking (OR 0.70, 95 % CI 0.49-0.99) and having a pregnancy-related health problem (OR 0.60, 95 % CI 0.38-0.94) were both additional risk factors for not breastfeeding.

CONCLUSION

This study has identified predictors of breastfeeding initiation in Hong Kong and Mainland China born mothers. Given the current high breastfeeding initiation rates among both groups, antenatal breastfeeding education and promotion programmes need to specifically intervene with sub-groups of pregnant women at risk for not breastfeeding so that their efforts are more strategic and cost-effective.

Caesarean delivery and its correlates in Northern Region of Bangladesh: application of logistic regression and cox proportional hazard model

BACKGROUND

Caesarean delivery (C-section) rates have been increasing dramatically in the past decades around the world. This increase has been attributed to multiple factors such as maternal, socio-demographic and institutional factors and is a burning issue of global aspect like in many developed and developing countries. Therefore, this study examines the relationship between mode of delivery and time to event with provider characteristics (i.e., covariates) respectively.

METHODS

The study is based on a total of 1142 delivery cases from four private and four public hospitals maternity wards. Logistic regression and Cox proportional hazard models were the statistical tools of the present study.

RESULTS

The logistic regression of multivariate analysis indicated that the risk of having a previous C-section, prolonged labour, higher educational level, mother age 25 years and above, lower order of birth, length of baby more than 45 cm and irregular intake of balanced diet were significantly predict for C-section. With regard to survival time, using the Cox model, fetal distress, previous C-section, mother's age, age at marriage and order of birth were also the most independent risk factors for C-section. By the forward stepwise selection, the study reveals that the most common factors were previous C-section, mother's age and order of birth in both analysis. As shown in the above results, the study suggests that these factors may influence the health-seeking behaviour of women.

CONCLUSIONS

Findings suggest that program and policies need to address the increase rate of caesarean delivery in Northern region of Bangladesh. Also, for determinant of risk factors, the result of Akaike Information Criterion (AIC) indicated that logistic model is an efficient model.

Trend and socio-demographic differentials of Caesarean section rate in Addis Ababa, Ethiopia: analysis based on Ethiopia demographic and health surveys data

Background

According to the World Health Organization, Caesarean Section (CS) rate (percentage of births managed by CS) exceeding 15% lacks medical justification and it could be linked with adverse maternal and child health consequences. Nonetheless, the rate in Addis Ababa city is beyond the aforementioned level. The objectives of the study were to assess the trend and socio-demographic differentials of CS rate in the city.

Methods

The study was made based on the three Ethiopia Demographic and Health Surveys (EDHS) data (EDHS 2000, 2005 and 2011). The trend over the period of 1995–2010 was assessed using simple linear regression analysis whereas the differentials of CS rate were identified based on DHS 2011 data. CS rates were compared across categories of various socio-economic variables using chi-square test.

Results

The CS rate increased significantly from 2.3% in 1995–1996 to 24.4% in 2009–2010. From 2003 onwards, it persisted above 15%. The rates among women with secondary (32.3%) or higher (33.3%) levels of education were nearly two times higher than the corresponding figures in the illiterates (14.8%) and women with primary education (15.8%) (P < 0.001). The level among women from the ‘rich’ households (28.6%) was higher than those from the ‘poor’ (16.4%) and ‘middle’ (19.5%) households (P = 0.016). The rate also significantly increased with rising parity (P = 0.023). The rate among women who delivered in private health institutions (41.7%) was twice higher than their counterparts who delivered in public institutions (20.6%).

Conclusion

The CS rate in Addis Ababa has exceeded beyond the level recommended by the WHO. Accordingly, It should be maintained within the optimum 5-15% range by introducing medical audit for labor management both in the private and public health institutions. Further, during prenatal care pregnant women should be fully informed about the risks of medically unjustified CS.

Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns

BACKGROUND

Although exclusive breastfeeding is recommended for the first 6 months, the use of breast milk substitutes is widespread around the world.

OBJECTIVES

To describe the patterns of infant formula supplementation among healthy breastfeeding newborns, to identify factors contributing to in-hospital formula supplementation, and to assess the dose-response relationship between the amount of in-hospital formula supplementation and the duration of any breastfeeding.

METHODS

A sample of 1246 breastfeeding mother-infant pairs was recruited from 4 public hospitals in Hong Kong and followed prospectively for 12 months or until weaned. Multiple logistic regression analysis was used to examine factors associated with in-hospital supplementation. Cox regression analysis was used to explore the impact of in-hospital supplementation on breastfeeding duration.

RESULTS

Of the total, 82.5% of newborns were supplemented in the hospital; one-half received formula within 5 hours of birth. Assisted vaginal delivery (odds ratio [OR] = 2.06, 95% confidence interval [CI] 1.03, 4.15), cesarean section (OR = 3.45, 95% CI 1.75, 6.80), and higher birth weight (OR = 1.56, 95% CI 1.12, 2.18) were positively associated with in-hospital formula supplementation, whereas initiating breastfeeding in the delivery room (OR = 0.55, 95% CI 0.33, 0.89) was associated with decreased likelihood of in-hospital supplementation. Any infant formula in the first 48 hours was associated with a shorter duration of breastfeeding (hazard ratio [HR] = 1.51, 95% CI 1.27, 1.80), but there was no dose-response effect.

CONCLUSION

In-hospital formula supplementation is common in Hong Kong hospitals and appears to be detrimental to breastfeeding duration. Continued efforts should be made to avoid the provision of infant formula to breastfeeding babies while in the hospital unless medically indicated.

Mode of delivery and adiposity: Hong Kong's "Children of 1997" birth cohort

PURPOSE

To examine whether mode of delivery was associated with childhood adiposity in a developed non-Western context.

METHODS

We used generalized estimating equations to estimate the association of mode of delivery (vaginal or cesarean) with body mass index (BMI) z-score and overweight (including obesity) from 3 months to 13 years, in 7809 term birth (94% follow-up) from a population-representative Chinese birth cohort, "Children of 1997." We used multiple imputation for missing data.

RESULTS

The cesarean section rate (26%) was higher for children born in private hospitals, with lower gestational age, lower birth order, higher maternal age, higher maternal BMI, and higher family socioeconomic position. Cesarean section was not associated with BMI z-score from 3 months to 13 years (mean difference, 0.03; 95% confidence interval, -0.02 to 0.09) or overweight from 3 years to 13 years (odds ratio, 0.98; 95% confidence interval, 0.77 to 1.25) after adjusting for infant and maternal characteristics and family socioeconomic position.

CONCLUSIONS

In a non-Western developed setting, mode of delivery was not clearly associated with BMI or overweight (including obesity) into late childhood. From a public health perspective, the role of mode of delivery and its mechanistic pathway in the current burgeoning epidemic of obesity needs to be clarified.

Association between intrapartum interventions and breastfeeding duration

INTRODUCTION

Few women who reside in Hong Kong exclusively breastfeed, and one-half stop breastfeeding within the first few months. There is little research in this population on the association between intrapartum interventions and breastfeeding duration.

METHODS

A sample of 1280 mother-infant pairs were recruited from the obstetric units of 4 public hospitals in Hong Kong and followed prospectively for 12 months or until the infant was weaned. The outcome variables for this analysis were the duration of any and exclusive breastfeeding. Predictor variables were 4 intrapartum interventions: receipt of opioid pain medication, induction versus spontaneous labor, epidural administration, and mode of birth. We used Cox proportional hazards modeling to assess the impact of intrapartum interventions on the duration of any and exclusive breastfeeding, and we constructed Kaplan-Meier survival curves to evaluate the cumulative impact of multiple intrapartum interventions on breastfeeding outcomes.

RESULTS

Bivariate analysis showed that induction of labor (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.09-1.41), opioid pain medication (HR, 1.21; 95% CI, 1.06-1.37), and having an emergency cesarean birth (HR, 1.22; 95% CI, 1.01-1.48) were associated with a shorter duration of any breastfeeding. Induction of labor (HR, 1.23; 95% CI, 1.08-1.39) and having an emergency cesarean birth (HR, 1.25; 95% CI, 1.05-1.51) were associated with a shorter duration of exclusive breastfeeding. After controlling for known confounding variables, there was no longer any association between individual intrapartum interventions and the duration of any or exclusive breastfeeding. The median duration of breastfeeding for participants who experienced a natural birth with no intrapartum interventions was 9 weeks compared with 5 weeks for participants who experienced at least 3 intrapartum interventions.

DISCUSSION

Clinicians working with new breastfeeding mothers should focus on providing additional support to mothers who experience a difficult labor and birth with multiple interventions to improve their breastfeeding experiences.

Determinants of infant growth: Evidence from Hong Kong's "Children of 1997" birth cohort

PURPOSE

A high rate of infant growth may be associated with adult cardiovascular disease. We investigated factors associated with infant weight growth in a large sample from the recently transitioned population of Hong Kong.

METHODS

We used a nonlinear shape invariant model with random effects among 5949 term, singletons (77% follow-up) from a population-representative Hong Kong Chinese birth cohort "Children of 1997" to investigate factors associated with weight growth in the first year of life.

RESULTS

Overall birth weight was lower but infant growth was more rapid than the 2006 WHO standards. Shorter gestation and lower birth order were associated with lower birth weight and faster infant growth. Female sex, maternal smoking in pregnancy, and a mother born in Hong Kong were associated with lower birth weight, but not with faster growth. Higher maternal education was associated with faster infant growth, grades 10-11 (1.03, 95% confidence interval [CI] = 1.03-1.05), greater than or equal to grade12 (1.07, CI = 1.04-1.09) compared with less than or equal to grade 9.

CONCLUSIONS

Infant growth may respond more rapidly to socio-economic development than birth weight. Whether mother's education is associated with rapid infant growth via current conditions or her own "constitution" is unclear, nevertheless we believe this study illustrates the importance of contextually specific research for understanding the determinants of population health.

Cesarean section delivery among primiparous women in rural China: an emerging epidemic

OBJECTIVE

The purpose of this study was to describe the trends and determinants of cesarean section (CS) delivery rates in rural China.

STUDY DESIGN

Data on rural primiparous women aged 15-49 years (n = 10,754) were obtained from 3 nationwide representative surveys in 1993, 1998, and 2003. The CS rate per 100 births and odds ratios by women's background characteristics were calculated with the use of logistic regression.

RESULTS

The CS rate increased from 1% in 1991 to 17% in 2002. After age adjustment, CS was most common among more educated women, who lived in Eastern China, who had high household income and health insurance, who used antenatal care, and who gave birth at a high-level hospital.

CONCLUSION

This development over the 10-year period may indicate very high CS rates in the near future; the epidemic of the use of CS that has been observed in urban China is likely to occur also in rural China. Further studies on the reasons and consequences of such excessive use of operative delivery are needed.

The Meanings and Experiences of Cesarean Birth Among Cambodian, Lao and Vietnamese Immigrant Women in Australia

We examined the experience of cesarean birth among 67 Cambodian, Lao and Vietnamese women who are now living in Melbourne, Australia, based on a larger ethnographic research project on childbearing, childrearing and motherhood among Southeast Asian women in Australia. We found a range of responses in the discourses of the women: some women preferred cesarean birth, but others resisted it. Women's social construction of their feelings stemmed from three interpretive frameworks: trust in medical knowledge, expectations (personal ideology of reproduction and motherhood) and communication with an understanding of their caregivers' preferences (as opposed to choice). Our findings have ramifications for health care providers working in multicultural settings. An effective dialogue between women and their health caregivers is required to keep the cesarean section rates down. In the case of immigrant women in a multicultural society like Australia, it is not the passive receipt of information but a two-way communication with adequate interpreter support that will lead to informed choice, fewer cesarean births, more satisfaction and less regret.

Impact of first childbirth on changes in women's preference for mode of delivery: follow-up of a longitudinal observational study

BACKGROUND

A woman's childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth.

METHODS

This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section.

RESULTS

Twenty-four percent (23.8%, 95% CI 18.4-29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7-767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1-353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4-20.6), higher family income (OR 3.2, 95% CI 1.1-8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0-6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0-1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%).

CONCLUSIONS

A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women's wish to change to elective cesarean section.

Factors affecting Taiwanese women's choice of Cesarean section

The rising rate of cesarean section (CS) is a subject of concern, intensive discussion, and investigation. However, few, if any, systematic studies of this trend have been recorded among the oriental populations. This study examines factors that may contribute to the high incidence of CS in Taiwan, where the rate of CS is among the highest in the world. Multiple logistic regression and stratified analyses were used to determine the association between CS and various factors, including provider and patient parameters. Our study sample of 2,497 cases was drawn from a total of 10,654 in-patient deliveries in Chang Gung Memorial Hospital of Taiwan. A number of factors associated with the use of CS were explored, including maternal age, occupation, education and marital status of the mother, sex and body weight of the infant at birth, parity, insurance status, source of admission, and time of birth. Our study also shows that CS in Taiwan is affected by the folk belief of Pe-Ji, which influences the preference of some patients for delivery at a specific time. Such a preference reflects a unique right of choice by women in Taiwan.

The effect of the baby-friendly hospital initiative on long-term breast feeding

The aim of this study was to evaluate the effects of 'baby-friendly hospital initiative' (BFHI) on breast feeding. In the four consecutive months after BFHI in Gazi University Hospital (November 2002-February 2003), breast feeding status until the second year of life in 297 babies, born in the same hospital was compared with the values of 258 babies born before BFHI (November 2001-February 2002). The exclusive breast feeding rate in the first 6 months was higher in the babies born after BFHI. Cox regression analysis revealed that BFHI increases the duration of breast feeding 1.5 times. At the end of the second year, cumulative rate of breast feeding was higher in the group after-BFHI (p=0.0036). The rate of breast feeding was increased by BFHI implementation.

Health Care Consequences of Cesarean Birth During the First 18 Months of Life

OBJECTIVE

Elective cesarean delivery is increasingly common. The potential effects of surgical delivery in an unselected sample of infants beyond the immediate neonatal period remain poorly defined.

METHODS

We carried out an 18-month follow-up of a population-based cohort of 8327 Hong Kong Chinese infants born in 1997. The main outcome measures were utilization of outpatient visits and hospitalizations, categorized by doctor-diagnosed causes as reported by parents.

RESULTS

Among term singleton infants, there was no association of cesarean (compared with vaginal) birth with subsequent hospital admission (adjusted odds ratio = 0.92; 95% confidence interval = 0.79-1.08) or with above versus below the median number of outpatient episodes (1.10; 0.96-1.26) in the first 18 months of life. There were weak positive associations with afebrile gastrointestinal, respiratory, skin and a few other conditions.

CONCLUSION

Cesarean birth is not associated with hospitalization or outpatient care overall during the first 18 months after adjustment for confounders. We cannot rule out isolated associations with minor morbidities.

A longitudinal observational study of preference for elective caesarean section among nulliparous Hong Kong Chinese women

OBJECTIVE

To establish whether women's preference for elective caesarean section (ELCS) changes as gestation advances.

DESIGN

A prospective longitudinal observational study.

SETTING

Two units providing obstetric care in Hong Kong, one public and one private.

SAMPLE

Five hundred and one nulliparous Chinese pregnant women attending their routine fetal anomaly scan in either unit.

METHODS

Consented subjects had two interviews using a structured questionnaire at 18-22 weeks and 35-37 weeks of gestation, respectively. Multivariate analysis was performed to identify determinants for preferring ELCS at the two gestational ages.

MAIN OUTCOME MEASURE

The preferences for the mode of delivery at the two gestational ages.

RESULTS

The prevalence of maternal preference for ELCS in the study cohort was 17.2% (95% CI 13.9-20.5) and 12.7% (95% CI 9.6-15.8) at mid-trimester and at term, respectively. Significantly more women who preferred ELCS at mid-trimester changed to a trial of vaginal delivery (VD) at term than vice versa (42.0 versus 3.8%). The partner's preference for ELCS was a significant determinant for women preferring ELCS throughout the antenatal period. Among the women booked in the public sector, more women who preferred ELCS at term changed to deliver in private hospitals than those who preferred VD (46.2 versus 9.7%).

CONCLUSIONS

Many women changed from preferring ELCS to preferring VD as their pregnancy approached term. The partner's preference was a significant determinant for the women's choice. If a decrease in the proportion of women preferring ELCS is desired, the intervention programme should target the women and their partners who hold such a preference at 20 weeks.

Age-period-cohort analysis of cervical cancer incidence in Hong Kong from 1972 to 2001 using maximum likelihood and Bayesian methods

OBJECTIVE

To examine the secular effects of opportunistic screening for cervical cancer in a rich, developed community where most other such populations have long adopted organised screening.

DESIGN, SETTING, AND PARTICIPANTS

The analysis was based on 15 140 cases of invasive cervical cancer from 1972 to 2001. The effects of chronological age, time period, and birth cohort were decomposed using both maximum likelihood and Bayesian methods.

RESULTS

The overall age adjusted incidence decreased from 24.9 in 1972-74 to 9.5 per 100,000 in 1999-2001, in a log-linear fashion, yielding an average annual reduction of 4.0% (p<0.001) during the 30 year period. There were two second order and thus identifiable changes: (1) around the mid-1920s cohort curve representing an age-period interaction masquerading as a cohort change that denotes the first availability of Pap testing during the 1960s concentrated among women in their 40s; (2) a hook around the calendar years 1982-83 when cervical cytology became a standard screening test for pregnant women.

CONCLUSIONS

Hong Kong's cervical cancer rates have declined since Pap tests first became available in the 1960s, most probably because of increasing population coverage over time and in successive generations in a haphazard fashion and punctuated by the systematic introduction of routine cytology as part of antenatal care in the 1980s.

Evidence-informed obstetric practice during normal birth in China: trends and influences in four hospitals

Background

A variety of international organizations, professional groups and individuals are promoting evidence-informed obstetric care in China. We measured change in obstetric practice during vaginal delivery that could be attributed to the diffusion of evidence-based messages, and explored influences on practice change.

Methods

Sample surveys of women at postnatal discharge in three government hospitals in Shanghai and one in neighbouring Jiangsu province carried out in 1999, repeated in 2003, and compared. Main outcome measures were changes in obstetric practice and influences on provider behaviour. "Routine practice" was defined as more than 65% of vaginal births. Semi-structured interviews with doctors explored influences on practice.

Results

In 1999, episiotomy was routine at all four hospitals; pubic shaving, rectal examination (to monitor labour) and electronic fetal heart monitoring were routine at three hospitals; and enema on admission was common at one hospital. In 2003, episiotomy rates remained high at all hospitals, and actually significantly increased at one; pubic shaving was less common at one hospital; one hospital stopped rectal examination for monitoring labour, and the one hospital where enemas were common stopped this practice. Mobility during labour increased in three hospitals. Continuous support was variable between hospitals at baseline and showed no change with the 2003 survey.

Provider behaviour was mainly influenced by international best practice standards promoted by hospital directors, and national legislation about clinical practice.

Conclusion

Obstetric practice became more evidence-informed in this selected group of hospitals in China. Change was not directly related to the promotion of evidence-based practice in the region. Hospital directors and national legislation seem to be particularly important influences on provider behaviour at the hospital level.

Birth and social class: Northern Thai women's lived experiences of caesarean and vaginal birth

This paper, based on in-depth interviews with Thai women in Northern Thailand, contributes to a sociological understanding of women's childbirth discourses. The findings indicate that the lived experiences of birth differ between individual women. It clearly shows that social resources such as financial resources and education play a salient role in shaping the embodied experience of birth among women in Northern Thailand. Because of their 'everyday lifestyle', middle class women have more control over the experience of childbirth than that of the rural poor women. Middle class women are able to choose where to give birth, have access to private care and actively seek medical technology as a way to have control over their birth. Their material resources enable their choices. These choices seem to be denied to the rural poor women. But not all rural poor women are passive victims of their material resources. No matter how limited the resources women have, they use them. Hence, there are some poor women who actively seek birthing care that enables them to have more control. But regardless of their social positions (urban middle class or rural poor), obstetric interventions are commonly experienced, and most women perceive caesarean birth in a positive light. Several discourses are employed to explain these findings including women's interpretations of their lived world including risk and the medicalisation of childbirth in Thailand. Taking a feminist standpoint, I argue that differences between women need to be taken into account in providing care to women in childbirth so that sensitive and appropriate birthing care can be achieved.

Becoming a role model: the breastfeeding trajectory of Hong Kong women breastfeeding longer than 6 months

While a substantial proportion of breastfeeding women stop early in the postpartum period, some women are able to breastfeed for longer periods. The aim of this research was to explore the experience of breastfeeding with a subsample of Hong Kong women who have breastfed for longer than 6 months. Participants (n=17) were recruited from a larger infant-feeding study (n=360) conducted in tertiary-care hospitals in Hong Kong. In-depth qualitative interviews were conducted and content analysis was used to analyse the data. Data analysis revealed four themes that encompassed the women's experiences: (1) making the decision, (2) maintaining family harmony, (3) overcoming barriers, and (4) sustaining lactation. Antenatally, participants anticipated that breastfeeding would be very 'difficult' and described how the practice did not fit with the image of a professional woman in Hong Kong. Despite family opposition, frequently from their mother-in-law, and lack of societal acceptance, difficulties were overcome by what the Chinese people call hung-sum or determination. This study highlights unique cultural and social findings affecting breastfeeding women in Hong Kong which may be useful to health-care providers working with Chinese women locally and internationally.

Effects of maternal characteristics on cesarean delivery rates among U.S. Department of Defense healthcare beneficiaries, 1996-2002

BACKGROUND

National rates of cesarean birth continue a three decade-long escalation, despite widespread recognition that a reduction in the use of the procedure is a continuing appropriate public health goal, as evidenced by the Healthy People 2010 reduction targets. Nonclinical factors associated with cesarean delivery include maternal age, race, socioeconomic status, and insurance coverage. This study compared cesarean delivery rates and trends for the U.S. Department of Defense healthcare beneficiary population from 1996 to 2002 with those observed nationally, and assessed the association of these nonclinical factors with cesarean rate variation in the U.S. Department of Defense healthcare beneficiary population.

METHODS

Hospital discharge and claims records for babies born in the military and civilian hospitals that comprise the Department of Defense healthcare network were used to calculate total and primary cesarean delivery rates and vaginal birth after cesarean (VBAC) rates from 1996 to 2002. Annual cesarean rates for subgroups defined by maternal age, race, and socioeconomic status were calculated to examine rate variations and rate trends within the study population. Pooled data from 1999 to 2002 were used to compare rates across socioeconomic status, stratified by age and race. Statistical significance of the differences calculated for subgroups was assessed using chi-square.

RESULTS

Total and primary cesarean delivery rates among the U.S. Department of Defense population were lower than those reported nationally for every year examined. Cesarean delivery and VBAC rate trends in the national and Department of Defense populations were similar. Within the Department of Defense population, total cesarean delivery increased with increasing maternal age and was more highly associated with racial minorities relative to white women. The higher socioeconomic subgroup (defined as active duty, retired, and warrant officers and their families in this study) was generally associated with reduced cesarean delivery rates.

CONCLUSIONS

Cesarean deliveries are performed less frequently for the U.S. Department of Defense healthcare beneficiary population relative to the national population. Associations between socioeconomic factors and cesarean rates reported for the national population were not apparent in the study population. The consistent pattern of rate variation across racial subgroups in the Department of Defense population suggests that factors beyond those examined in this study are needed to explain the elevated cesarean rates for racial minorities.

Rising trends in cesarean section rates in Egypt

BACKGROUND

Cesarean section rates have been increasing worldwide, but little research exists on trends of cesarean section delivery for any country in the Arab world. The purpose of this study was to document recent levels and trends of cesarean section rates in Egypt, and to estimate trends in cesarean section by type of hospital from three population-based national surveys.

METHODS

This descriptive study used merged data files from three nationally representative samples of ever-married women aged 15 to 49 years.

RESULTS

A significant rise in cesarean deliveries occurred for all births, from a low of 4.6 percent in 1992 to 10.3 percent in 2000. However, hospital-based cesarean deliveries were much higher in 1987-1988 (13.9%), increasing to 22.0 percent in 1999-2000. Although the cesarean section rate was slightly higher in private hospitals, the rate also increased consistently in public hospitals.

CONCLUSIONS

The high and unprecedented increase in cesarean section rates reported in this study may be partly due to cesarean sections that are not medically indicated, and suggest that physician practice patterns, financial incentives or other profitability factors, and patient preferences should be explored.

Networked for change? Identifying obstetric opinion leaders and assessing their opinions on caesarean delivery

The objective was to determine whether obstetric opinion leaders can be identified and to characterize them in terms of their demographic and professional characteristics and their attitudes toward caesarean delivery. In late 1998, we surveyed 527 obstetricians, 138 family physicians, and 80 certified nurse midwives (overall response rate, 57.8%) practicing in a stratified random sample of California hospitals with at least 1000 annual deliveries (n=52). Participants reported on demographic and professional characteristics and attitudes towards caesarean delivery; they also checked off those hospital colleagues from whom they had sought or would seek advice on labour and delivery. A composite measure of nomination frequency was used to characterize each respondent's degree of "opinion leadership". All analyses were corrected for the complex survey design. Using a nomination cutoff of 0.4 (0-1 scale), opinion leaders were identified in 31% of California hospitals; they were identified in 81% of hospitals using a cutoff of 0.2. Compared with their peers in the lowest fifth of the nomination distribution, clinicians in the top fifth were younger and more likely to be male, to speak English as a first language, to practice obstetrics, to have a maternal-foetal medicine subspecialty, and to practice in higher volume hospitals (p<0.05). Regardless of discipline, opinion leaders held attitudes concordant with reducing the caesarean delivery rate more often than non-opinion leaders. However, only 48% of obstetrical opinion leaders would support reducing the caesarean delivery rate to levels targeted by Healthy People 2000. In conclusion, obstetric opinion leaders could be identified in many California hospitals. However, they did not consistently support policies designed to reduce the caesarean delivery rate. The results have implications for the generalizability of opinion leader strategies.

Obstetricians' attitudes, subjective norms, perceived controls, and intentions on antibiotic prophylaxis in caesarean section

Over 10% of current births in all countries of the world are delivered by caesarean section. Single-dose ampicillin or cefazolin administered after cord clamping has been proven to be effective for the prevention of post-caesarean infections as indicated in many randomised trials and reviews in the Cochrane Library. This study aimed to determine three determinants of behavioural intention using the theory of planned behaviour: attitudes, subjective norms, and perceived controls. Intentions were examined for five aspects of the use of antibiotic prophylaxis, namely whether or not antibiotics were used, used in all caesarean sections, after rather than before cord clamping, whether ampicillin/cefazolin or broader-spectrum antibiotics were used, and whether single or multiple doses were given. Fifty obstetricians selected from university, regional, and general hospitals in southern Thailand, were surveyed using a questionnaire and in-depth interview. Their intentions to use a single dose and to use in all cases were low, and this was related to negative attitudes and reference groups who did not approve of the single dose. The negative attitude was based on scepticism concerning the applicability of well-equipped trials from the developed world and fear of consequences of post-caesarean infections. Norms carried over from residency training had more long-term influence in their practice than newer information from books or journals. Perceived external controls on their practice were less predictive of intentions. Intentions were only partly predictive of behaviour. Changing attitudes, introducing evidence-based information into residency training and strengthening control systems in the hospital are essential to improve intentions.

Breastfeeding patterns of primiparous mothers in Hong Kong

BACKGROUND

An understanding of patterns of breastfeeding is necessary for the effective implementation of breastfeeding promotion and intervention programs. In Hong Kong, little current data have been gathered on women's breastfeeding rates. The objective of this study was to determine how patterns of breastfeeding, maternal demographics, and maternal employment affect continuation of breastfeeding in primiparous women in Hong Kong.

METHOD

A longitudinal self-report survey was used to collect data when first-time mothers (n=218) were in the hospital, at 1, 3, 6, 9, and 12 months postpartum, or until they weaned their infant. All data (self-report survey, demographic data, and follow-up telephone surveys) were collected in Cantonese and then translated into English. Data were analyzed by determining, first, the influence of individual variables on the length of breastfeeding using a simple Cox regression analysis, and second, by grouping variables according to time sequence and entering them into a Cox regression model in 4 sequential phases.

RESULTS

Factors that were significantly associated with continuation of breastfeeding were maternal age (HR=0.97; p=0.048); attendance at a prenatal breastfeeding class (HR=0.69; p=0.020); intended weeks of breastfeeding (HR=0.97; p<0.001); breastfeeding score in hospital (HR=0.99; p=0.009); and length of exclusive breastfeeding (HR=0.93; p<0.001). Similar results were obtained in the multiphase Cox regression analysis; only the breastfeeding score in hospital became marginally insignificant (p=0.053) after adjusting for demographics, prenatal, and other immediate postpartum factors.

CONCLUSIONS

Short periods of exclusive breastfeeding and early supplementation were common in this sample. Unlike previous research, maternal employment was not a statistically significant factor in length of continued breastfeeding. Study findings show that multiple factors influence continued breastfeeding in Hong Kong, suggesting further areas for investigation. Changes in practice may improve continued and exclusive breastfeeding rates.

Breastfeeding rates in Hong Kong: a comparison of the 1987 and 1997 birth cohorts

BACKGROUND

Low breastfeeding rates are an issue of international public health concern. Anecdotal reports suggest very low breastfeeding rates in Asia, but no population-based studies have been conducted in the region. To determine the secular trend in breastfeeding practice in an Asian postindustrialized metropolitan community, we examined data from two population-based birth cohorts of Hong Kong infants in 1987 and 1997.

METHODS

Annual population rates of breastfeeding initiation and duration were estimated from the birth cohorts, considering the change in breastfeeding rates over 10 years with correction for sociodemographic and birth characteristics. Factors associated with breastfeeding practice were identified using multivariate logistic regression modeling in a pooled analysis of individual data of both cohorts.

RESULTS

Overall, 26.8 percent of mothers initiated breastfeeding in 1987, and the rate increased to 33.5 percent in 1997. The rate would have been 27.4 percent in 1987 if the distributions of method of delivery, birthweight, birth order, maternal age, education, and employment status had been the same as in 1997. Only 7.6 percent of infants remained on the breast for more than 1 month in 1987 compared with 20.4 percent a decade later. Similarly, the rate for breastfeeding more than 3 months increased from 3.9 to 10.3 percent. Total breastfeeding duration was significantly longer in 1997 than 10 years earlier.

CONCLUSIONS

This is the first systematic report of secular variations of breastfeeding rates in Asia. Hong Kong should set higher but realistic goals for breastfeeding that emphasize both initiation and maintenance. Given the wide latitude for improvement in terms of readily modifiable risk factors, such as smoking and cesarean section, these new goals should focus on improving rates in these targeted groups where breastfeeding rates are lowest.

Strategies to address global cesarean section rates: a review of the evidence

BACKGROUND

The steadily increasing global rates of cesarean section has become one of the most debated topics in maternity care. This paper reviews and reports on the success of strategies that have been developed in response to this continuing challenge.

METHODS

A literature search identified studies conducted between 1985 and 2001 from the Cochrane Database of Systematic Reviews, Medline, Sociofile, Current Contents, Psyclit, Cinahl, and EconLit databases. An additional search of electronic databases for Level 1 evidence (systematic reviews), Level 2 (randomized controlled trials), Level 3 (quasi-experimental studies), or Level 4 (observational studies) was performed. Selection criteria used to identify studies for review included types of study participant, intervention, outcome measure, and study.

RESULTS

Interventions that have been used in an attempt to reduce cesarean section rates were identified; they are categorized as psychosocial, clinical, and structural strategies. Two clinical interventions, (external cephalic version, vaginal birth after a previous cesarean) and one psychosocial intervention (one-to-one trained support during labor) demonstrated Level 1 evidence for reducing cesarean section rates.

CONCLUSIONS

Although the evidence for one-to-one care and external cephalic version came from both developed and developing settings, the systematic review for vaginal birth after a cesarean was restricted to studies conducted in the United States. The effective implementation of the preceding strategies to reduce cesarean rates may depend on the social and cultural milieu and on associated beliefs and practices.