Author｜Jiang Feixiong
Source｜Medical World Obstetrics and Gynecology Channel
Over the past two decades, cesarean section rates have been rising in many countries around the world. In 2010, the World Health Organization (WHO) released a report stating that excessively high cesarean section rates would affect the health and lives of both mothers and fetuses, and the report identified a number of countries with excessively high cesarean section rates. According to data released by the WHO, at that time, China's cesarean section rate reached 46%.
(The image shows the global cesarean section rate trend in 2015, published by the WHO in The Lancet. China's cesarean section rate has declined.)
However, unexpectedly, nearly 10 years later, China has become the only country to have successfully controlled its cesarean section rate. This has shocked researchers, including relevant officials from the WHO…
Because other countries that have also been pointed out as having excessively high cesarean section rates in recent years have not only failed to effectively control their cesarean section rates, but have also seen them increase rapidly...
As shown in the figure, among countries with high cesarean section rates, China's cesarean section rate increased by only 6.1% from 2008 to 2014, which is lower than that of Brazil (8.6%), Turkey (10.7%) and Egypt (24.2%).
This unique phenomenon has been the subject of research by several top medical journals, including BMJ and JAMA, which have summarized three main reasons: changing attitudes towards pregnancy and childbirth, the relaxation of the one-child policy, and administrative regulation.
More and more mothers are opting for vaginal delivery.
With China's urbanization process, an increasing number of middle-class women in emerging cities are choosing natural childbirth. A 2017 paper published in JAMA (Journal of American Journal of Medicine) explains some of the reasons behind this phenomenon—
Analysis suggests that this emerging segment of urban middle-class pregnant women is very willing to learn. They obtain medical information about pregnancy and childbirth through the internet, recognize the potential harm and risks of cesarean sections to their health, and understand their unnecessaryness, thus choosing vaginal delivery.
These expectant mothers often have many online chat groups where they share information and experiences and learn together.
British media reports that the cesarean section rate in Scandinavia has always been extremely low, precisely because of the prevalent "health-conscious" culture among local women.
Meanwhile, many hospitals in China have also provided education on how to correctly choose between cesarean section and vaginal delivery, and offered services to help alleviate pain during vaginal delivery, so that more mothers no longer choose to have surgery to give birth.
The impact of the two-child policy
In its 2018 publication, BMJ suggested a subtle correlation between the two-child policy and whether women choose a cesarean section for their first childbirth…
In this study, researchers collected data from approximately 7 million pregnant women in 438 hospitals. The results showed that with the promotion of the two-child policy, the proportion of women choosing cesarean section for their first child has continued to decline significantly.
This may be because mothers believe that vaginal delivery makes it easier to have a second child.
However, researchers say this association is subtle, and the causal relationship is not very stable.
Administrative power regulation
Dr. Ana Pilar Betrán, head of the WHO's global cesarean section survey, believes this is the main reason why China's cesarean section rate has been controlled.
This regulation includes two aspects: first, increasing relevant public investment and providing more obstetric resources; second, controlling the number of cesarean sections performed in hospitals through administrative means.
In terms of public investment, the number of obstetric-related medical personnel positions has increased in recent years, and the number of midwives with professional skills has continued to rise.
Since 2010, professional midwife training centers have been established one after another. In recent years, thanks to repeated calls from the public, painless childbirth has also been gradually promoted.
On the other hand, administrative measures to control the cesarean section rate in hospitals have aroused much controversy.
According to data from the BMJ survey, most hospitals have policies to control and reduce cesarean section rates, and 67% of hospitals even have cesarean section rate targets.
A WHO official stated that using administrative means to directly control hospital cesarean section rates is very rare globally. Portugal, another country with a high cesarean section rate, also does this. However, Portugal uses administrative measures to reward hospitals with low cesarean section rates, rather than punishing those with excessively high rates.
Some experts also worry that using such methods to control the cesarean section rate will prevent rural mothers with scarce medical resources from receiving the necessary cesarean sections.
Undoubtedly, doctors would never refuse to perform a cesarean section on a patient who has surgical indications, given the circumstances. However, Dr. Betrán points out that "some mothers psychologically desire a cesarean section, and such intervention would deprive them of the opportunity to choose a cesarean section."
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