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Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k817 (Published 05 March 2018) Cite this as: BMJ 2018;360:k817
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  1. Juan Liang, professor1,
  2. Yi Mu, research assistant1,
  3. Xiaohong Li, associate research fellow1,
  4. Wen Tang, research assistant1,
  5. Yanping Wang, professor2,
  6. Zheng Liu, research assistant1,
  7. Xiaona Huang, maternal and child health specialist3,
  8. Robert W Scherpbier, chief3,
  9. Sufang Guo, health specialist4,
  10. Mingrong Li, research assistant1,
  11. Li Dai, professor1,
  12. Kui Deng, research assistant1,
  13. Changfei Deng, research assistant1,
  14. Qi Li, research assistant1,
  15. Leni Kang, research assistant2,
  16. Jun Zhu, professor1 5,
  17. Carine Ronsmans, professor6 7
  1. 1National Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
  2. 2National Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
  3. 3Health, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China
  4. 4UNICEF Regional Office for South Asia, Kathmandu, Nepal
  5. 5Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
  6. 6West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
  7. 7Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to: C Ronsmans, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK Carine.Ronsmans{at}lshtm.ac.uk
  • Accepted 1 February 2018

Abstract

Objective To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China.

Design Observational study.

Setting China’s National Maternal Near Miss Surveillance System (NMNMSS).

Participants 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016.

Main outcome measures Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time.

Results Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government’s policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time.

Conclusions China is the only country that has succeeded in reverting the rising trends in caesarean sections. China’s success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China’s experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter.

Footnotes

  • Contributors: JL and YM are joint first authors. JZ (zhujun028@163.com) and CR contributed equally to the correspondence work. JL, YM, JZ, and CR designed the study with contribution from all authors. YM and WT did the statistical analysis with support from XL and CR. CR wrote the first draft of the paper and all authors contributed to critical interpretation of the results and development of the report. All authors saw and approved the final version. JZ and CR are guarantors.

  • Funding: This study was supported by the National Health and Family Planning Commission of the People’s Republic of China, the National Natural Science Foundation of China (grant No 81330016), the China Medical Board (grant No 11-065), WHO (grant No: CHN-12-MCN-004888), UNICEF (grant No 2016EJH016), and the National “Twelfth Five-Year” Plan for Science and Technology Support (2014BAI06B01).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the ethics committee of the West China Second University Hospital (protocol ID, 2012008).

  • Data sharing: No additional data available.

  • Transparency: The lead authors (JZ and CR) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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