Academic journal article Bulletin of the World Health Organization

Delivery Settings and Caesarean Section Rates in China/Influence Du Lieu Ou S'effectue I'accouchement Sur Les Taux De Cesarienne En Chine/Entorno De Parto Y Tasas De Cesarea En China

Academic journal article Bulletin of the World Health Organization

Delivery Settings and Caesarean Section Rates in China/Influence Du Lieu Ou S'effectue I'accouchement Sur Les Taux De Cesarienne En Chine/Entorno De Parto Y Tasas De Cesarea En China

Article excerpt

Introduction

Rates of caesarean section in many countries have increased beyond the recommended level of 15%, (1) almost doubling in the last decade, especially in high-income areas such as Australia, France, Germany, Italy, North America and the United Kingdom of Great Britain and Northern Ireland (UK). (2-7) Similar trends have also been documented in low-income countries such as Brazil, China and India, especially for births in private hospitals. (8-12) Advanced healthcare technologies are becoming more widely available in different regions of China. Following health-care reforms introduced in the 1990s, a large proportion of Chinese women, including those from the less-developed western region, now seek early antenatal and delivery care in health institutions. The number of caesarean-section births has increased sharply especially in the eastern region, which covers the major cities of Beijing, Shanghai and Tianjin. (12) Recent evidence also shows increasing demand for caesarean section among young, educated women residing in urban areas. (13)

Many Chinese couples now delay childbearing, aim to have not more than one birth experience and opt for delivery by caesarean section to avoid pain. (13,14) Data from hospital-based studies in urban China showed rates of caesarean section of between 26% and 63% during the late 1990s. (15-18) 18 Another population-based study reported a substantial increase during the last three decades, from 4.7% to 22.5%. (12) These trends are expected to persist in view of the unparalleled economic growth and rapid expansion of private health care and health insurance systems across China. Apart from the clinical indications for caesarean section--breech presentation, dystocia and suspected fetal compromise--there is growing evidence that many women choose delivery by caesarean section for personal reasons, particularly in profit-motivated institutional settings that may provide implicit or explicit encouragement for such interventions. (13,19) The goal of our research was to quantify the influence of increased overall use of health-care services on rising rates of caesarean section in China. We hypothesized that the increase in institutional births and use of modern obstetric technologies explain the observed increase in rates of caesarean section.

Methods

Data sources

We used data from a population-based survey conducted during September 2003 in 30 selected counties covering all provinces in all three regions of China. The survey was coordinated by the United Nations Population Fund (UNFPA) in collaboration with Chinas National Population and Family Planning Commission and health ministry. The counties were selected on the basis of planned future participation in UNFPA-linked reproductive health programmes. The sample of countries chosen in the survey was not intended to be nationally representative, but it covers the three regions and represents relatively developed Chinese areas in terms of socioeconomic status. The survey was based on household population records and the design included a stratified multi-stage selection of a sample of women aged 15-49

years. The 30 selected counties defined a population of townships. In the first stage of the analysis, these were stratified by region (eastern, central, western) and by residence (rural or urban). Within each region, 35 townships were selected; this sample was divided between urban and rural strata proportional to the population of women aged 15--49 years, subject to a minimum urban sample of seven townships. At the second stage, four local communities were selected proportional to the population of women aged 15-49 years from each selected township. At the final stage, a systematic random sample of 20 women was selected from a list ordered by age of all women aged 15-49 years within each selected community. This led to a final sample of 8400 women aged 15-49 years from 8400 households (2800 women per region and 80 women from each of the 105 sampled townships). …

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