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

A randomized controlled trial reducing cesarean delivery rates in China by introducing trial of labor after cesarean and electrohysterography

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).

Establishment and Validation of a Machine Learning-Based Prediction Model for Termination of Pregnancy via Cesarean Section

Objective

This study aimed to investigate the risk factors of cesarean section and establish a prediction model for cesarean section based on the characteristics of pregnant women.

Methods

The clinical characteristics of 2552 singleton pregnant women who delivered a live baby between January 2020 and December 2021 were retrospectively reviewed. They were divided into vaginal delivery group (n = 1850) and cesarean section group (n = 702). These subjects were divided into training set (2020.1-2021.6) and validation set (2021.7-2021.12). In the training set, univariate analysis, Lasso regression, and Boruta were used to screen independent risk factors for cesarean section. Four models, including Logistic Regression (LR), K-Nearest Neighbor (KNN), Classification and Regression Tree (CART), and Random forest (RF), were established in the training set using K-fold cross validation, hyperparameter optimization, and random oversampling techniques. The best model was screened, and Sort graph of feature variables, univariate partial dependency profile, and Break Down profile were delineated. In the validation set, the confusion matrix parameters were calculated, and receiver operating characteristic curve (ROC), precision recall curve (PRC), calibration curve, and clinical decision curve analysis (DCA) were delineated.

Results

The risk factors of cesarean section included age and height of women, weight at delivery, weight gain, para, assisted reproduction, abnormal blood glucose during pregnancy, pregnancy hypertension, scarred uterus, premature rupture of membrane (PROM), placenta previa, fetal malposition, thrombocytopenia, floating fetal head, and labor analgesia. RF had the best performance among the four models, and the accuracy of confusion matrix parameters was 0.8956357. The Matthews correlation coefficient (MCC) was 0.753012. The area under ROC (AUC-ROC) was 0.9790787, and the area under PRC (AUC-PRC) was 0.957888.

Conclusion

RF prediction model for caesarean section has high discrimination performance, accuracy and consistency, and outstanding generalization ability.

RNA-Sequencing Reveals Gene Expression and Pathway Signatures in Umbilical Cord Blood Affected by Birth Delivery Mode

Cesarean section (CS) confers increased risk of type I diabetes, asthma, inflammatory bowel disease, celiac disease, overweight and obesity, etc., in the offspring. However, the underlying mechanism remains unknown. To investigate the influence of CS on gene expression in cord blood, we have performed RNA-sequencing followed by single-gene analysis, gene set enrichment analysis, gene co-expression network analysis, and interacting genes/proteins analysis in eight full-term infants born by elective CS and eight matched vaginally delivered (VD) infants. Crucial genes identified above were further validated in another 20 CS and 20 VD infants. We found for the first time that mRNA expression of genes involved in immune response (IL12A, INFG, IL1B, TNF, MIF, IL4, CA1, IFI27, HLA-DOB and EPHB1) and metabolism (DLK1, CYP2A6 and GATM) were significantly influenced by CS. Notably, serum TNF-α and IFN-γ were remarkably up-regulated in the CS infants (p = 5.0 × 10-4 and 3.0 × 10-3, respectively) compared to the VD infants. It is biologically plausible that CS may exert adverse impacts on offspring health through influencing expression of genes in the above processes. These findings will help understand the potential underlying mechanisms of the adverse health impacts of CS and identify biomarkers for future health of offspring born with different delivery modes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43657-022-00086-7.

Changes in the live birth profile in Henan, China: A hospital registry-based study

BACKGROUND

Preterm complications and neonatal asphyxia are the leading causes of death in those under 5 years of age. However, little information exists for the province of Henan, China. The purpose of this study was to explore changes in the live birth profile in a provincial hospital over the past 32 years in Henan, China.

METHODS

A retrospective analysis was conducted to reveal the characteristics of live neonates from 1987 to 2018.

RESULTS

There were 118 253 live births during the period, including 19 798 (16.74%) preterm births. The neonatal death rate was 6.45‰, and the top risk factor was preterm birth complications and birth asphyxia. Before 1998, neonatal death occurred primarily among term infants. Between 1999 and 2018, preterm infants, especially extreme and very preterm infants with very low birthweight, constituted more than half of all mortalities, and the preterm birth rate increased from 5.94% in 1999 to 16.69% in 2018. The risk factors associated with preterm birth were being male (aOR = 1.18, P < 0.001), advanced maternal age (>35 years old; aOR = 1.08, P = 0.008), gravidity ≥2 (aOR = 1.15, P < 0.001), parity ≥2 (aOR = 1.50, P < 0.001), placenta previa (aOR = 7.41, P < 0.001), twin or multiple births (aOR = 10.63, P < 0.001), hypertension (aOR = 2.08, P < 0.001), and rupture of membrane (aOR = 5.03, P < 0.001).

CONCLUSIONS

The preterm birth rate has increased over the past 32 years from 4.98% to 16.69% in a provincial hospital in China. Preterm birth was the leading reason for neonatal death, and birth asphyxia was the major risk factor for death in term infants.

Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies

Background

To assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes.

Method

This was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital.

Results

The primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals.

Conclusion

Selective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04790-0.

The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study

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.

Changes in caesarean section rates in China during the period of transition from the one-child to two-child policy era: cross-sectional National Household Health Services Surveys

OBJECTIVES

Since 2009, China has introduced policies, principally targeting health professionals, to reduce caesarean section (CS) overuse. In 2016, China endorsed a universal two-child policy. Advanced maternal age and previous CS may indicate changes in obstetric risks, which raise concerns on the need for and safety of CS. This study investigated changes in CS rates in 2008-2018, and factors associated with CS use during the period of transition from the one-child to two-child policy era.

DESIGN

We used births data from the cross-sectional National Household Health Services Surveys in 2013 and 2018.

SETTING

Population-based national survey.

PARTICIPANTS

Women who had the last live birth within 5 years before the survey.

PRIMARY OUTCOME MEASURE

CS rate.

RESULTS

Overall CS use increased from 40.9% in 2008 to 47.2% in 2014 with significant increase in rural areas and the western region, and slightly decreased to 45.2% in 2018 with the greatest decrease among nulliparous women. Maternal request for CS by urban nulliparous women decreased from 36.8% in 2008-2009 to 22.2% in 2016-2018, but this change was not statistically significant in rural areas. Maternal age over 35 years old (OR 2.40, 95% CI 1.72 to 3.35) and births that occurred at a private hospital (OR 1.52, 95% CI 1.25 to 1.86) were associated with CS use among nulliparous women in 2016-2018. The CS rate among multiparous women increased over time. Individual socioeconomic factors associated with CS use among multiparous women.

CONCLUSIONS

The CS rate rise in China in 2008-2018 is attributable to increased use in rural areas and the less developed western region. The population policy shift, alongside facility policies for unnecessary CS reduction, are likely factors in CS reduction in urban areas. The challenge remains to reduce unnecessary CS, at the same time as providing safe, universal access to CS for women in need.

Medical expenditure of women during pregnancy, childbirth and puerperium at the beginning of China's universal two-child policy enactment: a population-based retrospective study

OBJECTIVES

To describe and explore women's medical expenditures during pregnancy, childbirth and puerperium at the beginning of the universal two-child policy enactment in China.

DESIGN

Population-based retrospective study.

SETTING

Dalian, China.

PARTICIPANTS

Under the System of Health Accounts 2011 framework, the macroscopic dataset was obtained from the annual report at the provincial and municipal levels in China. The research sample incorporated 65 535 inpatient and outpatient records matching International Classification of Diseases, 10th Revision codes O00-O99 in Dalian city from 2015 through 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study delineates women's current curative expenditure (CCE) during pregnancy, childbirth and puerperium at the beginning of the universal two-child policy in China. The temporal changes of medical expenditure of women during pregnancy, childbirth and puerperium at the beginning of China's universal two-child policy enactment were assessed. The generalised linear model and structural equation model were used to test the association between medical expenditure and study variables.

RESULTS

Unlike the inverted V-shaped trend in the number of live newborns in Dalian over the 3 studied years, CCE on pregnancy, childbirth and puerperium dipped slightly in 2016 (¥260.29 million) from 2015 (¥263.28 million) and saw a surge in 2017 (¥288.65 million). The ratio of out-of-pocket payment/CCE reduced year by year. There was a rapid increase in CCE in women older than 35 years since 2016. Length of stay mediated the relationship between hospital level, year, age, reimbursement ratio and medical expenditure.

CONCLUSIONS

The rise in CCE on pregnancy, delivery and puerperium lagged 1 year behind the surge of newborns at the beginning of China's universal two-child policy. Length of stay acted as a crucial mediator driving up maternal medical expenditure. Reducing medical expenditure by shortening the length of stay could be a feasible way to effectively address the issue of cost in women during pregnancy, childbirth and puerperium.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BACKGROUND

A high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the "Two-child Policy" in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.

METHODS

Data were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.

RESULTS

The rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984-9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116-14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311-0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007-16.455).

CONCLUSIONS

"Maternal request" has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.

Epidural analgesia during labor and its optimal initiation time-points: A real-world study on 400 Chinese nulliparas

ABSTRACT

Recent research has suggested that 6 cm of cervical dilation should be the threshold for the active labor phase, and it has confirmed that epidural analgesia (EA) is a safe method of pain relief during labor. However, the evidence provided for these findings comes mainly from randomized controlled clinical trials (RCTs), which suffer from the limitation of real-world generalizability.To test the generalizability of the conclusions from these previous RCTs, we conducted a prospective cohort, real-world study (RWS) on 400 Chinese term nulliparas. A total of 200 of the participants (the EA group) received EA upon request. The participants in the EA group were further subdivided as follows according to their cervical dilation when the EA administration was initiated (CDE): [EA1 group (CDE < 3 cm), EA2 group (3 cm ≤ CDE < 6 cm), and EA3 group (CDE ≥ 6 cm)]. We compared the labor duration of the EA group versus the non-EA (NEA) group, and the NEA group versus the 3 EA subgroups. We also compared delivery outcomes between the EA and NEA groups.The median total labor duration for the EA group [676 (511-923) minutes] was significantly longer than that of the NEA group [514 (373-721) minutes] (P < 0.001). The median durations of both the first- and second-stages of labor for the EA group [600 (405-855) minutes, 68 (49-97) minutes] were longer than those of the NEA group [420 (300-630) minutes, 50 (32-85) minutes] (P < .001, P < .001)]. In addition, the median total labor durations in both the EA1 [720 (548-958) minutes] and EA2 groups [688 (534-926) minutes] were longer than in the NEA group (P < .001 and P < .001, respectively), and the first- and second-stage labor durations of these subgroups were similar to their total labor durations. A Cox regression analysis showed that EA was associated with longer first-stage labor [hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.42-0.71, P < .001] and longer second-stage labor (HR 0.66, 95% CI 0.51-0.85, P = .001). The delivery modes and neonatal outcomes between the EA and NEA groups were not statistically different, however.Our findings suggest that EA administered before a cervical dilation of 6 cm may be associated with longer total, first-, and second-stage labor durations compared with no EA, while later EA administration is not. In addition, though EA prolongs labor duration, it does not impact delivery outcomes. These results confirm the significance of a 6 cm cervical dilation threshold in real-world labor settings.

Survey of factors influencing women's selection of the delivery method of their second child in Shanxi Province, China

Objective:

To explore the factors influencing women’s selection of the delivery method of their second child.

Methods:

A questionnaire survey was administered among 431 women in the age range of interest from January 2015 to January 2017, and the survey results were evaluated and analyzed statistically. The experts evaluating the questionnaire are professionals in the Department of Obstetrics and Gynecology, Heji Hospital Affiliated to Changzhi Medical College.

Results:

A total of 70.99% of subjects were 28-35 years old. Approximately 82.35% wished to undergo vaginal delivery, and the remaining 17.65% expressed to undergo cesarean delivery. The reasons for cesarean delivery included the following: fetal factors: worry about fetal health (33.33%), birth trauma (12.90%), and fetal macrosomia (38.17%); maternal factors: advanced age (36.56%), inability to bear uterine contraction pains (21.51%), worry about uracratia after vaginal delivery (10.75%), worry about perineum laceration (8.60%) and the impacts on sexual gratification after delivery (5.38%); social factors: faster delivery mode (54.84%), selection of birth time (27.96%), and better planning of maternity leave (17.20%).

Conclusion:

Most women tend to undergo vaginal delivery. However, due to the influence of age, educational level and other factors, an increasing number of women prefer cesarean delivery. Medical institutions have the responsibility for providing overall and fair medical information to women of childbearing age to help them make informed choices regarding mode of delivery.

Women's experience and satisfaction with midwife-led maternity care: a cross-sectional survey in China

BACKGROUND

Low risk pregnancy ending in a vaginal birth is best served and guided by a midwife. Utilizing a midwife in such cases offers many emotional and economic advantages and does not increase the risks for mother or neonate. However, women's experience and satisfaction of midwife-led maternity care is rarely reported in China. The primary objective of this study is to describe the experience of Chinese women receiving midwife-led maternity care, and to report their satisfaction level of the experience.

METHODS

The study is a cross-sectional survey of 4192 women who had natural birth from March-June 2019 in a maternity care center, Shanghai, China. We used a self-administered questionnaire addressing items related to women's experience during childbirth, as well as their satisfaction with midwife-led maternity care. We also included demographic and perinatal characteristics of each participant. Descriptive statistics and correlations analysis between groups of different experience and satisfaction were used.

RESULTS

In this sample, 87.7% of women had a Doula and a family member present during childbirth. Epidural anesthesia was used in 75.6% and episiotomy was needed in 23.2%. Free positioning during the first stage of labor and free positioning during the second stage of labor and delivery were adopted in 84.3 and 67.9% of the cases, respectively. Moderate to severe perineal pain and moderate to severe perineal edema were reported in 43.1 and 12.2% of the participants, respectively. High satisfaction level was found when there was midwife-led prenatal counseling and presence of Doula and family member, Lamaze breathing techniques, warm perineal compresses, epidural anesthesia, free positioning during the first stage of labor, and midwifes' postpartum guidance. Negative satisfaction was seen with perineal pain and edema.

CONCLUSION

Women in this survey generally had high satisfaction with midwife-led maternity care. This satisfaction is probably felt because of the prenatal counseling by the midwife and allowing a Doula and a family member in the room during childbirth. Other intangible factors to improve the satisfaction level were Lamaze breathing techniques, warm perineal compresses, epidural anesthesia, free positioning during first stage of labor, and early skin to skin contact.

The combined effects of Lamaze breathing training and nursing intervention on the delivery in primipara: A PRISMA systematic review meta-analysis

BACKGROUND

Lamaze breathing has been widely used as a breathing training method. Nursing intervention including postural nursing, delivery ball, doula nursing, massage and psychological nursing is usually provided by nurses during labor. A number of clinical studies have investigated the effect of Lamaze breathing training combined with nursing intervention on maternal pain relief and outcomes improvement. But there were some scholars who were against it.

METHODS

Randomized controlled trials from January 2000 to November 2019 in PubMed, Cochrance Library, Medline, Web of Science, Embase, Chinese Academic Journals, Chinese Biomedical Literature Database, VIP Database, Wanfang Database were searched. Two researchers independently screened the literature according to the criteria. After extracting the data, the researchers used Cochrane system to evaluate the literature quality. Statistical analyses were performed by using Comprehensive Meta Analysis V2 software.

RESULTS

Twenty-two randomized controlled trials conducted on 7035 primiparas were eligible. The results revealed that Lamaze breathing training combined with nursing intervention increased the rate of natural delivery (relative risk [RR] = 2.97, 95% confidence interval [CI] [2.48, 3.56]), shortened the length of labor (-2.604, 95% CI [-3.120, -2.087]), alleviated labor pain (RR = 0.194, 95% CI [0.115, 0.325]) and reduced postpartum bleeding (-2.966, 95% CI [-4.056, -1.877]).

CONCLUSIONS

Lamaze breathing training combined with nursing intervention was effective for ameliorating the process and outcomes of childbirth in primiparae and deserves to be promoted and applied in clinical practice.

Recovery of uterine and ovarian function in patients with complete placenta previa after caesarean delivery: A retrospective study

This retrospective study was designed to explore the recovery of uterine and ovarian function in patients with complete placenta previa (PP) after caesarean delivery (CD). 136 complete placenta previa patients (group completed placenta previa) and 140 patients without complete PP (group non-PP, control group) were included in this study from Jan 2016 to Dec 2018. Subgroup analysis of patients with complete PP was made to determine the impact of different hemostatic methods used during CD on the recovery of uterine function. There were no statistically significant differences between the 2 groups in postpartum menstrual cycle changes, ovarian hormone, and uterine vascular supply as measured by pulsatility index and systolic/diastolic ratio (P > .05). However, the group with complete PP had a reduced endometrial thickness (0.47 ± 0.11 vs 0.50 ± 0.12, P < .001), a lower uterine resistance index at 42nd days (0.84 ± 0.03 vs 0.90 ± 0.03, P < .001), and a delayed resumption menstruation (7.07 ± 2.61 vs 5.31 ± 2.16, P < .001) when compared with control group. Subgroup analysis showed that RI index of all subgroups in completed PP group was lower, endometrial thickness was thinner and the time to menstrual recovery was longer than that of non-PP group. In conclusion, the endometrial thickness and blood supply at 42nd days, not ovarian function, maybe affected after CD in patients with complete PP.

Trends in cesarean delivery rates in primipara and the associated factors

Background

Few studies have focused on cesarean delivery (CD) trends among primipara under the one-child and the two-child policies. This study aimed to explore the trends in CD rates among primipara during 1995–2019 and the associated factors with CD risk.

Methods

This study obtained clinical data on primiparous mothers and newborns from 1995 to 2019 at a large tertiary hospital in Wuhan, China. Trends in CD rates were calculated using the joinpoint regression analysis. The Chi-square tests and log-binomial regression analyses were used to evaluate the associations between primary variables and CD risk.

Results

CD rates showed a significant upward trend with an average annual percentage change (APC) of 2.2% (95% CI: 0.6, 3.8%) during the study period. In 1995–2006, the CD rates continued to increase with an APC of 7.8% (95% CI: 4.8, 10.9%). After 2006, the CD rates started to decline by an APC of − 4.1% (95% CI: − 5.5, − 2.6%). The CD rates non-significantly increased from 36.2% in 2016 to 43.2% in 2019. Moreover, the highest CD rate during 2015–2019 was observed on August 30 (59.2%) and the lowest on September 1 (29.7%). Primipara of older age and those with >3pregnancies had higher risks of CD. Furthermore, primipara who gave birth to newborns with low birth weight and macrosomia had higher risks of CD.

Conclusions

Maternal and fetal as well as social and cultural factors may contribute to the rising trend of CD rates. Effective measures should be taken to control CD under the two-child policy, especially for primipara.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03398-6.

Birth and birth-related obstetrical characteristics in southwestern China associated with the current adjustment of family planning policy: a 7-year retrospective study

In China, the adjustment of the family planning policy was expected to increase the number of births and trigger a change in the demographic and obstetrical background of pregnant women. The policy itself, and corresponding background variations of the pregnant mothers, might have various influences on certain birth-related characteristics. Moreover, the adaption of the medical system to the policy needs to be demonstrated. To address these issues, over 50,000 individual records from January 2012 to December 2018 were collected from a large tertiary care centre of southwest China as a representative. The monthly numbers of deliveries and births showed stabilized patterns after remarkable upward trends. Policy-sensitive women, among whom older age and multiparity were typical features, contributed considerably to the remarkable additional births. Indeed, multivariable logistic regression analysis identified the child policy and these two background characteristics as factors influencing CS (caesarean section) rate and certain pregnancy complications or adverse outcomes. After the implementation of the two-child policy, a care provider was faced with fewer but more difficult cases. Briefly speaking, more individual-based studies on family planning policy and more efforts to improve obstetrical service are needed to better guide clinical practice in the new era.

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.

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Paternal depressive symptoms during the early postpartum period and the associated factors following the implementation of the two-child policy in China

AIM

To evaluate the prevalence of paternal depressive symptoms during the first three days of childbirth, as well as the associated factors, following the implementation of the two-child policy in China in 2015, which allows couples to have two children in the Chinese mainland.

METHODS

A cross-sectional study was conducted among 318 fathers. Paternal depressive symptoms and self-efficacy of fathers were screened using the Edinburgh Postnatal Depression Scale and the General Self-Efficacy Scale, respectively. In addition, basic information of all parents and neonates was collected. Univariate analysis, binary logistic regression analysis, and principal component analysis (PCA) were used to identify the relationship between paternal depressive symptoms and its associated factors.

RESULTS

Twenty-two percentage of fathers had depressive symptoms during the first three days of childbirth. Binary logistic regression analysis revealed that older fathers, those who slept for more than 8 h per night, or were dissatisfied with their living conditions were more susceptible to developing the symptoms. On the contrary, protective factors such as the educational level of fathers, planned pregnancy, prenatal guidance, having the second-born child, and higher self-efficacy were found to reduce the development of paternal depressive symptoms. PCA showed that the main components that influenced the paternal depressive symptoms were parental age and parity.

CONCLUSIONS

The prevalence of paternal depressive symptoms during the postpartum period did not increase significantly after the implementation of the two-child policy in China. However, focusing on the associated factors is necessary in order to manage postpartum depression during the early postpartum period.

Changes in maternal age and prevalence of congenital anomalies during the enactment of China's universal two-child policy (2013-2017) in Zhejiang Province, China: An observational study

BACKGROUND

China implemented a partial two-child policy (2013) followed by a universal two-child policy (2015), replacing the former one-child policy mandated by the government. The changes affect many aspects of China's population as well as maternal and infant health, but their potential impact on birth defects (BDs) remains unknown. In this study, we investigated the associations of these policy changes with BDs in Zhejiang Province, China.

METHODS AND FINDINGS

We used data from the BD surveillance system in Zhejiang Province, China, which covers 90 hospitals in 30 urban districts and rural counties, capturing one-third of the total births in this province. To fully consider the time interval between conception and delivery, we defined the one-child policy period as data from 2013 (births from October 2012 to September 2013), the partial two-child policy period as data from 2015 (births from October 2014 to September 2015), and the universal two-child policy period as data from 2017 (births from October 2016 to September 2017). Data from 2009 and 2011 were also used to show the changes in the proportion of births to women with advanced maternal age (35 years and older) prior to the policy changes. Main outcome measures were changes in the proportion of mothers with advanced maternal age, prevalence of BDs, rankings of BD subtypes by prevalence, prenatal diagnosis rate, and live birth rate of BDs over time. A total of 1,260,684 births (including live births, early fetal losses, stillbirths, and early neonatal deaths) were included in the analyses. Of these, 644,973 (51.16%) births were to women from urban areas, and 615,711 (48.84%) births were to women from rural areas. In total, 135,543 (10.75%) births were to women with advanced maternal age. The proportion increased by 85.68%, from 8.52% in 2013 to 15.82% in 2017. However, it had remained stable prior to policy changes. Overall, 23,095 BDs were identified over the policy changes (2013-2017). The prevalence of BDs during 2013, 2015, and 2017 was 245.95, 264.86, and 304.36 per 10,000 births, respectively. Trisomy 21 and other chromosomal defects increased in both risk and ranking from 2013 to 2017 (crude odds ratio [95% confidence interval] 2.13 [1.75-2.60], from ranking 10th to 5th, and 3.63 [2.84-4.69], from ranking 16th to 6th, respectively). The prenatal diagnosis rate increased by 3.63 (2.2-5.1) percentage points (P < 0.001), from 31.10% to 34.72%, and identification of BDs occurred 1.88 (1.81-1.95) weeks earlier (P < 0.001). The live birth rate for infants with BDs born before 28 gestational weeks increased from 1.29% to 11.45%. The major limitations of this observational study include an inability to establish causality and the possible existence of unknown confounding factors, some of which could contribute to BDs.

CONCLUSIONS

In this study, we observed significant increases in maternal age and the prevalence of total and age-related anomalies following China's new two-child policy. Increases in live birth rate for infants with BDs born before 28 gestational weeks suggest that healthcare for very preterm births with BDs may be warranted in the future, as well as updating the definition of perinatal period.

The impact of the "Health Transformation Plan" and related policies on the prevalence rate of cesarean section in Iran: Insights from an interrupted time series analysis

BACKGROUND

The high prevalence of cesarean section represents a major public health challenge worldwide. In 2014, the Iranian Health Transformation Plan (HTP) included programs promoting vaginal delivery.

AIM

The aim of this study was to investigate the effect of the HTP on the rate of cesarean section in Iran.

METHOD

The interrupted time series analysis (ITSA) was used. Cesarean section- and vaginal delivery-related monthly data were collected from eight public hospitals affiliated with the Lorestan University of Medical Sciences, from March 2012 to February 2019. The autocorrelation plots and the Durbin-Watson test were used for evaluating the autocorrelation between data points in the generalized least squares regression model.

RESULTS

The ITSA showed that the rate of cesarean section decreased immediately after the HTP, by -0.002 per 1000 persons (95% CI, -0.004 to -0.001; P = .069). After the HTP, a significant decreasing trend of cesarean section per month was computed (-0.003; 95% CI, -0.005 to 0.012; P = .043).

CONCLUSION

The present study showed that the implementation of the HTP policy was effective in reducing the rate of cesarean section. This policy should continue, involving relevant stakeholders, raising mothers' awareness and motivation, and providing financial support.

Analysis of prenatal diagnosis before and after implementation of the two-child policy in northeastern China

The universal two-child policy has now been fully implemented in China. This change requires adaptations to maternal care and childcare systems, but the features of prenatal diagnosis before and after implementation of the policy have not been reported.We conducted a retrospective study of 6736 prenatal cytogenetic diagnoses performed on amniotic fluid cells over a 4-year period, including 2 years before and after implementation of the second child policy. Amniotic fluid cells collected through amniocentesis were cultured, harvested, and stained for chromosome analysis using standard laboratory protocols.The study included 3222 pregnant women referred before implementation of the policy, which we used as a control group, and 3514 pregnant women referred after policy implementation as an investigational study group. There were significantly fewer pregnant women aged <25 years in the investigational group than in the control group (P < .001). There were no significant between-group differences for other pregnant women aged >31 years and 27-28 years old (P > .05). A total of 358 cases with chromosomal abnormalities were diagnosed, including 129 (4%, 129/3222) in the control group which was significantly lower than the 229 (6.5%, 229/3514) in the study group (P < .001). In particular, significantly more trisomy 21 cases were observed in the study group than in the control group (120 vs 59). More pregnant women underwent non-invasive prenatal testing (NIPT) in the study group (46%) than in the control group (20%). In the study group, the average age of pregnant women who underwent NIPT was significantly higher than that of women who did not receive NIPT (P < .05). However, there were no significant between-group differences for the control group (P > .05).The number of cases with chromosomal abnormalities increased in northeastern China in the 2 years after implementation of the two-child policy. The number of pregnant women of advanced maternal age did not increase significantly, perhaps because of the widespread application of NIPT. However, the number of fetuses with Down syndrome increased significantly, suggesting that prenatal screening and diagnosis should be strengthened.

Impact of the Universal Two-Child Policy on the Workload of Community-Based Basic Public Health Services in Zhejiang Province, China

We aimed to quantitatively estimate the amount of pressure that was placed on basic public health care services (BPHS) due to the universal two-child policy issued in 2015 by comparing the workload change in maternal and child health management and the immunization of children. BPHS performance surveillance data from 2014 to 2018 in Zhejiang Province, China were analyzed to calculate the workload of the above three services using the equivalent method of BPHS cost estimation of community health services. From 2014 to 2018, the numbers of births from the Statistical Yearbook in Zhejiang Province were 578,000, 581,000, 624,000, 670,000, and 628,000, respectively, and those from the surveillance data were 416,941, 41,490, 434,163, 546,816, and 45,964, respectively. The number of births reached a peak in 2017, with the yearbook and surveillance data showing increases of 15.92% and 31.15%, respectively, over 2014. The workload of maternal and child health management and children’s immunization also peaked in 2017, increasing by 30.37%, 12.70%, and 4.33% over 2014, respectively. In 2018, the workload of maternal and child health management and children’s immunization dropped to 107.34%, 107.73%, and 98.81% over 2014, respectively. The indicators of maternal and child health management and children’s immunization services remained stable, and the related services did not decline, even in 2017. The maternal health management workload was more affected by the universal two-child policy than child health management and children’s immunization.

Changes of second-time mothers and their infants under the universal two-child policy in Changsha, China

BACKGROUND

China announced the implementation of the universal two-child policy in Oct, 2015; every couple was allowed to have two children. However, its influences on maternal well-being and infants' outcomes are still to be discovered.

OBJECTIVES

To detect influences of the universal two-child policy. To provide information for maternal health care under the new policy.

STUDY DESIGN

This study enrolled 859 and 1230 women who delivered their second child (hereafter second-time mothers) before and after the policy's implementation, respectively, and the data included maternal demographic characteristics, gestational complications, delivery mode and infants' outcomes.

RESULTS

After the policy's implementation, the proportion of second-time mothers with advanced age increased significantly. The advanced gestational age is well acknowledged to correlate with higher risk during the pregnancy, both for pregnant women and their babies. However, in our study, the incidence of hypertensive disorders in pregnancy, placenta previa and postpartum haemorrhage decreased significantly after the introduction of the policy and no differences were noted in other gestational complications. Moreover, the hospitalization time was shortened, and caesarean delivery was chosen less frequently. As for the infants, foetal distress exhibited an alleviation and the incidence of premature labour and low birth weight decreased as well.

CONCLUSIONS

Even though the age of second-time mothers increased after the introduction of the universal two-child policy, their general gestational health condition improved and their infants also exhibited a better outcome, which might be attributed to the improvement of China's maternal medical care system.

Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in China: A mixed-methods systematic review

BACKGROUND

China has witnessed a rapid increase of cesarean section (CS) rates in recent years. Several non-clinical factors have been cited as contributing to this trend including maternal request and perceived convenience. We aimed to assess preferences for mode of delivery and reasons for preferences for CS in China to inform the development of future interventions to mitigate unnecessary CSs, which are those performed in the absence of medical indications.

METHODS AND FINDINGS

We conducted a mixed-methods systematic review and included longitudinal, cross-sectional, and qualitative studies in mainland China, Hong Kong, and Taiwan that investigated preferences for mode of delivery among women and family members and health professionals, and the reasons underlying such preferences. We searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, and one Chinese database (CNKI) using a combination of the key terms 'caesarean section', 'preference', 'choice', 'knowledge', 'attitude', 'culture', 'non-clinical factors', and 'health professionals-patient relations' between 1990 and 2018 without language restriction. Meta-analysis of quantitative studies and meta-synthesis of qualitative studies were applied. We included 66 studies in this analysis: 47 quantitative and 19 qualitative. For the index pregnancy, the pooled proportions of preference for CS reported by women in longitudinal studies were 14% in early or middle pregnancy (95% CI 12%-17%) and 21% in late pregnancy (95% CI 15%-26%). In cross-sectional studies, the proportions were 17% in early or middle pregnancy (95% CI 14%-20%), 22% in late pregnancy (95% CI 18%-25%), and 30% postpartum (95% CI 19%-40%). Women's preferences for CS were found to rise as pregnancy progressed (preference change across longitudinal studies: mean difference 7%, 95% CI 1%-13%). One longitudinal study reported that the preference for CS among women's partners increased from 8% in late pregnancy to 17% in the immediate postpartum period. In addition, 18 quantitative studies revealed that some pregnant women, ranging from 4% to 34%, did not have a straightforward preference for a mode of delivery, even in late pregnancy. The qualitative meta-synthesis found that women's perceptions of CS as preferable were based on prioritising the baby's and woman's health and appeared to intensify through interactions with the health system. Women valued the convenience of bypassing labour because of fear of pain, antagonistic relations with providers, and beliefs of deteriorating quality of care during labour and vaginal birth, fostering the feeling that CS was the safest option. Health professionals' preference for CS was influenced by financial drivers and malpractice fears. This review has some limitations, including high heterogeneity (despite subgroup and sensitivity analysis) in the quantitative analysis, and the potential for over-reporting of women's preferences for CS in the qualitative synthesis (due to some included studies only including women who requested CS).

CONCLUSIONS

Despite a minority of women expressing a preference for CS, individual, health system, and socio-cultural factors converge, contributing to a high CS rate in mainland China, Hong Kong, and Taiwan. In order to reduce unnecessary CSs, interventions need to address all these non-clinical factors and concerns.

SYSTEMATIC REVIEW REGISTRY

Prospero CRD42016036596.