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Thijssen KMJ, Frenken MWE, Van der Hout-van der Jagt MB, Li W, Mo Z, Westerhuis MEMH, Swan GO. A randomized controlled trial reducing cesarean delivery rates in China by introducing trial of labor after cesarean and electrohysterography. J Matern Fetal Neonatal Med 2024; 37:2376661. [PMID: 39004516 DOI: 10.1080/14767058.2024.2376661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE A cesarean delivery (CD) can affect health of both mother and child and future pregnancies. Since the abandonment of the one-child policy in China, obstetricians tend to perform a repeat CD rather than a trial of labor after cesarean (TOLAC). This study aims to reduce CD rates by increasing vaginal births after cesarean (VBAC) rates and introducing electrohysterography (EHG) for accurate monitoring. METHODS In total, 82 women received counseling regarding TOLAC at the Shijiazhuang Sixth Hospital in China. Women opting for TOLAC were randomized for either external tocodynamometry (TOCO, i.e. standard care) or EHG. The primary outcome was the VBAC rate. Secondary outcomes were indications for CD, percentage of assisted vaginal deliveries, labor duration, maternal blood loss, complications and neonatal outcomes. RESULTS After accounting for preterm delivery and dropouts, all counseled women opted for a TOLAC (100%). After randomization, 42 women were included in the TOCO-group and 37 in the EHG-group. Women did not receive pain medication and labor was not augmented with oxytocin. The VBAC rate was 71.4% in the TOCO-group, versus 78.4% in the EHG-group (p = .48). Birth was assisted with forceps in 11.9% of TOCO-group versus 2.7% of EHG-group (p = .21). One secondary CD (i.e. a shift from intended vaginal delivery to surgical delivery within the same labor) was performed because of a suspicion of uterine rupture (TOCO-group). Other indications for CD were: fetal distress, labor dystocia, fetal position, cephalopelvic disproportion. There were no significant differences in secondary study outcomes. No complications were reported. CONCLUSION This study showed an average VBAC rate of 75%, without any complications, in a hospital with no previous experience with TOLAC. The VBAC rate with EHG-monitoring was higher than TOCO, although this difference was not significant. To demonstrate a significant difference, larger clinical studies are necessary. TRIAL REGISTRATION The Daily Board of the Medical Ethics Committee of The Maternal and Child Hospital of Shijiazhuang approved the study protocol (number 20171018, Dutch Trial Register NL8199).
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Affiliation(s)
- Kirsten Martine Johanna Thijssen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
- University MC Utrecht, Utrecht, The Netherlands
| | - Maria Wilhelmina Elisabeth Frenken
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Marieke Beatrijs Van der Hout-van der Jagt
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
- Faculty of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Wang Li
- Department of Obstetrics and Gynaecology, The Maternal and Child Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, P.R. China
| | - Zhongfu Mo
- Department of Obstetrics and Gynaecology, The Maternal and Child Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, P.R. China
| | | | - Guid Oei Swan
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
- Faculty of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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Kundu S, Sharif AB, Chowdhury SSA, Afroz S, Dey R, Hossain A. Socioeconomic and geographical inequalities in delivery by cesarean section among women in Bangladesh, 2004-2017. BMC Pregnancy Childbirth 2024; 24:131. [PMID: 38350916 PMCID: PMC10863140 DOI: 10.1186/s12884-024-06327-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/07/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND There is a dearth of evidence on the trends and inequalities in utilizing cesarean section (CS) among women in Bangladesh. Hence, this study aimed to estimate the socioeconomic and geographical inequalities in delivery by CS among Bangladeshi women from 2004 to 2017. METHODS Data from Bangladesh Demographic and Health Survey 2004, 2007, 2011, 2014, and 2017 were analyzed using the WHO's Health Equity Assessment Toolkit (HEAT) software. Inequalities were measured using four summary measures: Difference (D), Population Attributable Risk (PAR), Population Attributable Fraction (PAF), and Ratio (R). Socioeconomic inequalities were assessed using two equity dimensions: household wealth status, and level of education, while geographical disparities were measured using two equity dimensions: place of residence, and sub-national regions. For each measure, point estimates and their 95% confidence intervals were reported. RESULTS An increasing trend in the prevalence (weighted) of CS in Bangladesh use was found from 4.50% in 2004 to 32.73% in 2017 We found significant socioeconomic inequalities in CS in every survey point, with a higher concentration of CS among the rich (in 2017, PAR = 28.57; 95% CI: 26.69-30.46) indicating a pro-rich inequality, and higher educated (in 2017, PAF = 23.97; 95% CI: 12.26-35.68) sub-groups. We also identified significant geographical disparities in CS with a higher concentration of CS among people from urban areas (in 2017, PAR = 10.99; 95% CI: 10.19-11.79), and a coastal region (Khulna division) (in 2017, PAF: 30.48 (95% CI: 18.66-42.30). CONCLUSION We observed both socioeconomic and geographical inequalities in CS exist in Bangladesh, though the trends of these inequalities were curved over time. Thus, it is important to comprehend these pro-rich and geographical inequalities better and implement appropriate interventions and policies to alleviate them.
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Affiliation(s)
- Satyajit Kundu
- Global Health Institute, North South University, Dhaka, 1229, Bangladesh.
- Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Patuakhali, 8602, Bangladesh.
| | - Azaz Bin Sharif
- Global Health Institute, North South University, Dhaka, 1229, Bangladesh
- Department of Public Health, North South University, Dhaka, 1229, Bangladesh
| | - Syed Sharaf Ahmed Chowdhury
- Global Health Institute, North South University, Dhaka, 1229, Bangladesh
- Department of Public Health, North South University, Dhaka, 1229, Bangladesh
| | - Sadia Afroz
- Department of Public Health, North South University, Dhaka, 1229, Bangladesh
| | - Rakhi Dey
- Statistics Discipline, Khulna University, Khulna, 9208, Bangladesh
| | - Ahmed Hossain
- College of Health Sciences, University of Sharjah, Sharjah, 27272, United Arab Emirates
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Wu J, Feng L, Zhang H, Guo L, Pérez-Escamilla R, Hu Y. The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study. Front Public Health 2022; 10:782784. [PMID: 35433620 PMCID: PMC9005775 DOI: 10.3389/fpubh.2022.782784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background Previous studies have found that the rates of cesarean preference were much lower than the actual rates of cesarean births in China. We aimed to observe this inconsistency between preferred and actual modes of delivery and the factors associated with the inconsistency. Methods We conducted a prospective cohort study at the maternity hospital with the largest number of deliveries in Beijing. We collected data through a questionnaire applied in the outpatient department, and medical records from the hospital's information system. Unconditional logistic regression was used to identify factors influencing the inconsistency between preferred and actual delivery mode. Results The rates of actual cesarean section and of cesarean preference were 41 and 17%, respectively (χ2 = 82.9, P < 0.0001). The overall inconsistency rate was 31%, with 119 women preferred vaginal delivery but experienced cesarean section, accounting for 67% women undergoing cesarean section. Risk factors for this inconsistency between preferred vaginal delivery and actual cesarean section included: maternal obesity, receiving assisted reproduction, having an abnormal amniotic fluid volume, and fetal distress. Pre-labor rupture of membranes was a unique factor associated with such inconsistency between cesarean section preference and vaginal delivery at delivery. Conclusions The inconsistent rate between preferred delivery at late pregnancy and actual delivery is high in China. Further research is needed to understand how to lower cesarean rates in China, taking maternal preferences for vaginal deliveries into account.
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Affiliation(s)
- Jing Wu
- School of Agroforestry & Medicine, the Open University of China, Beijing, China
| | - Li Feng
- School of Agroforestry & Medicine, the Open University of China, Beijing, China
| | - Hongwei Zhang
- Obstetrics Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Li Guo
- Obstetrics Department, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | | | - Yifei Hu
- Department of Child, Adolescent health and Maternal health, School of Public Health, Capital Medical University, Beijing, China
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Ming Y, Huang R, Zhou W, Wang B, Yu H, Zhang J. Is age and socioeconomic status associated with preference for birth mode in nulliparous women in China? Arch Gynecol Obstet 2019; 300:33-40. [PMID: 31053947 DOI: 10.1007/s00404-019-05140-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 03/25/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE To examine the association between sociodemographic factors and preference for birth mode in nulliparous women in China. METHODS A total of 4606 women before or in early pregnancy were recruited from 2013 to 2016 in the Shanghai Birth Cohort Study. Generalized linear regression was used to examine the association of sociodemographic characteristics with preferred birth mode and actual cesarean section (CS) without clinical indications in 2713 nulliparous women, and the changes from preference of vaginal birth to actual CS without clinical indications in 2369 nulliparous women. RESULTS After controlling for potential confounders, preference for CS was associated with older maternal age [31-34 years: adjusted risk ratio (ARR) 2.73, 95% confidence interval (CI) 1.56-4.78; ≥ 35 years: 6.27, 3.28-12.01, p for trend < 0.0001] and lower level of education (below junior college vs college or above: 1.51, 1.10-2.09). Older maternal age (≥ 35 years: 3.37, 1.74-6.50), born in city or township (city vs countryside: 3.18, 1.93-5.24; township vs countryside: 1.97, 1.06-3.66), and lower level of education (below junior college vs college or above: 1.38, 1.01-1.88) were significantly associated with a CS without clinical indications. Women who preferred vaginal birth but had an actual CS without clinical indications were more likely to be older (≥ 35 years: 4.30, 1.44-12.83) and born in city (city vs countryside: 2.89, 1.33-6.30). CONCLUSIONS Older age, lower education level, and being born in city or township were risk factors for CS without clinical indication in China.
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Affiliation(s)
- Yanhong Ming
- School of Public Health, Guilin Medical University, Guilin, Guangxi, China.,Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, Hunan, China.,Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Huang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Wei Zhou
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin Wang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongping Yu
- School of Public Health, Guilin Medical University, Guilin, Guangxi, China. .,Guangxi Medical University Affiliated Cancer Hospital, Nanning, Guangxi, China. .,Department of Epidemiology, School of Public Health, Guangxi Medical University, Nanning, Guangxi, China.
| | - Jun Zhang
- School of Public Health, Guilin Medical University, Guilin, Guangxi, China.,Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Rutayisire E, Wu X, Huang K, Tao S, Chen Y, Tao F. Childhood emotional and behavior problems and their associations with cesarean delivery. ACTA ACUST UNITED AC 2017; 40:145-153. [PMID: 28977068 PMCID: PMC6900761 DOI: 10.1590/1516-4446-2016-2152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 05/08/2017] [Indexed: 01/15/2023]
Abstract
Objective: To determine the prevalence of childhood emotional and behavioral problems and examine their associations with cesarean delivery. Methods: Our sample consisted of 8,900 preschoolers from 35 kindergartens in four cities in East China. Parents completed the Strengths and Difficulties Questionnaire (SDQ) and provided other information. Children’s emotional and behavioral problems were assessed using five subscales of the SDQ. Mode of delivery was classified as vaginal or cesarean section (CS); in sub-analyses, we divided CS into elective or emergency delivery. Logistic regression was used to examine associations. Results: A total of 1,209 (13.6%) children had a total SDQ score within abnormal range; 25.5% had peer problems within abnormal range, 9.0% had abnormal emotional symptoms, 13.9% had abnormal conduct problems, 18.9% had abnormal hyperactivity problems, and 16.2% were rated abnormal in pro-social behavior. Overall, 67.3% of the children who participated were delivered by CS. In fully adjusted analysis, CS was significantly associated with abnormal total SDQ score (OR = 1.27; 95%CI 1.10-1.46; p < 0.05) and pro-social behavior (OR = 1.27; 95%CI 1.12-1.45; p < 0.0001). No significant association was found between CS and risk of having conduct problems (OR 1.13; 95%CI 0.98-1.29), peer problems (OR 1.11; 95%CI 0.99-1.24), hyperactivity (OR 1.02; 95%CI 0.91-1.15), or emotional problems (OR 1.06; 95%CI 0.90-1.24). Conclusion: In this sample, CS was associated with risk of behavioral problems, but not with emotional problems. Further research is needed to better understand these associations.
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Affiliation(s)
- Erigene Rutayisire
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China
| | - Xiaoyan Wu
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China.,Anhui Provincial Key Laboratory of Population Health & Aristogenics, Hefei, Anhui Province, China
| | - Kun Huang
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China.,Anhui Provincial Key Laboratory of Population Health & Aristogenics, Hefei, Anhui Province, China
| | - Shuman Tao
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China
| | - Yunxiao Chen
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China
| | - Fangbiao Tao
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China.,Anhui Provincial Key Laboratory of Population Health & Aristogenics, Hefei, Anhui Province, China
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Rutayisire E, Wu X, Huang K, Tao S, Chen Y, Tao F. Cesarean section may increase the risk of both overweight and obesity in preschool children. BMC Pregnancy Childbirth 2016; 16:338. [PMID: 27809806 PMCID: PMC5094065 DOI: 10.1186/s12884-016-1131-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 10/25/2016] [Indexed: 12/16/2022] Open
Abstract
Background The increase rates of cesarean section (CS) occurred at the same period as the dramatic increase of childhood overweight/obesity. In China, cesarean section rates have exponentially increased in the last 20 years and they now exceed World Health Organization (WHO) recommendation. Such high rates demand an understanding to the long-term consequences on child health. We aim to examine the association between CS and risk of overweight and obesity among preschool children. Method We recruited 9103 children from 35 kindergartens in 4 cities located in East China. Children anthropometric measurements were taken in person by trained personnel. The mode of delivery was classified as vaginal or CS, in sub-analyses we divided cesarean delivery into elective or non-elective. The mode of delivery and other parental information were self-reported by parents. Multivariate logistic regression analysis was used to examine the associations. Results In our cross-sectional study of 8900 preschool children aged 3–6 years, 67.3 % were born via CS, of whom 15.7 % were obese. Cesarean delivery was significantly associated with the risk of overweight [OR 1.24; (95 % CI 1.07–1.44); p = 0.003], and the risk of obesity [OR 1.29; (95 % CI 1.13–1.49); p < 0.001] in preschool children. After adjusted for child characteristics, parental factors and family income, the odd of overweight was 1.35 and of obesity was 1.25 in children delivered by elective CS. Conclusion The associations between CS and overweight/obesity in preschool children are influenced by potential confounders. Both children delivered by elective or non-elective CS are at increased risk of overweight/obesity. Potential consequences of CS on the health of the children should be discussed among both health care professionals and childbearing women.
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Affiliation(s)
- Erigene Rutayisire
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui Province, 230032, China
| | - Xiaoyan Wu
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui Province, 230032, China.,Anhui Provincial Key Laboratory of Population Health & Aristogenics, Hefei, 230032, China
| | - Kun Huang
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui Province, 230032, China.,Anhui Provincial Key Laboratory of Population Health & Aristogenics, Hefei, 230032, China
| | - Shuman Tao
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui Province, 230032, China
| | - Yunxiao Chen
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui Province, 230032, China
| | - Fangbiao Tao
- Department of Maternal, Child & Adolescent Health, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui Province, 230032, China. .,Anhui Provincial Key Laboratory of Population Health & Aristogenics, Hefei, 230032, China.
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Wang L, Xu X, Baker P, Tong C, Zhang L, Qi H, Zhao Y. Patterns and Associated Factors of Caesarean Delivery Intention among Expectant Mothers in China: Implications from the Implementation of China's New National Two-Child Policy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070686. [PMID: 27399752 PMCID: PMC4962227 DOI: 10.3390/ijerph13070686] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/22/2016] [Accepted: 07/05/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study explores the basic demographic characteristics of expectant mothers in the context of their intentions regarding mode of delivery, in particular, the preference for caesarean delivery, and analyzes the social and psychological factors that influence delivery preference. METHOD A cross-sectional survey of pregnant women was conducted during June to August in 2015. This study adopted a stratified sampling method, and 16 representative hospitals in five provinces of China were included. RESULTS 1755 and 590 of expectant mothers in their first and second pregnancies, respectively, were enrolled in this study. 354 (15.10%) intended to deliver by caesarean section and 585 (24.95%) participants were uncertain prior to delivery. 156 (8.89%) of expectant mothers in their first pregnancy and 198 (33.56%) expectant mothers in their second pregnancy intended to deliver by caesarean section. Ordinal logistic regression analysis found that nationality, parity, trimester of pregnancy, and advanced maternal age were factors associated with intention to deliver by caesarean (ordered logistic regression/three-level caesarean delivery intention criterion; odds ratios p < 0.05). CONCLUSIONS 8.89% of first pregnancy expectant mothers and 33.56% of second pregnancy expectant mothers intended to deliver by caesarean section. Any intervention program to reduce the rate of Caesarean delivery should focus on the Han population, older pregnant women, and expectant mothers in their second pregnancy, at an early gestation.
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Affiliation(s)
- Lianlian Wang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Department of Reproduction Health and Infertility, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
| | - Xianglong Xu
- School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China.
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China.
- The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing 400016, China.
| | - Philip Baker
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
- College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester 3182, UK.
| | - Chao Tong
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
| | - Lei Zhang
- Research Center for Public Health, School of Medicine, Tsinghua University, Beijing 100062, China.
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3182, Australia.
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3053, Australia.
- Melbourne Sexual Health Centre, Alfred Health, Melbourne 3053, Australia.
| | - Hongbo Qi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
- Canada-China-New Zealand Joint Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing 400016, China.
| | - Yong Zhao
- School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China.
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China.
- The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing 400016, China.
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