C-Section Rate Varies Across China from 4% to 64%

MedicalResearch.com Interview with:
Jianmeng Liu, PhD, MD
Professor in Epidemiology and Biostatistics
Director, Institute of Reproductive and Child Health/key Laboratory of Reproductive Health Ministry of Health
Director, Office for National Maternal and Child Health Statistics of China
Peking University Health Science Center
Beijing, China

MedicalResearch.com: What is the background for this study?

Response: Cesarean overuse can jeopardize maternal and child health. It has been widely concerned that cesarean rate in China is at an extremely high level. Concerns about “alarming” rates increased after a World Health Organization (WHO) report that 46.2% of births were delivered by cesarean in 2007-2008, based on analysis of deliveries in 21 hospitals of 3 provinces of China.

Since 2002, reducing the cesarean rate has been a national priority, and a variety of policies, programs and activities have emerged at both the central and local governments. Previous national estimates of cesarean rates have been based on surveys with limited geographical coverage. Given the marked diversity of geography, economy, and life circumstances throughout China, survey estimates are likely to be sensitive to the area sampled.

By analyzing county-level national data on cesarean rates that have been collected since 2008, this study aimed to determine the overall rate and change in rate of cesarean deliveries, examine geographic variation, and, in areas where declines occurred, assess changes in maternal and perinatal mortality.

MedicalResearch.com: What are the main findings?

Response: The overall cesarean rates increased from 28.8% in 2008 to 34.9% in 2014 in China. However, there were diverse trends in cesarean rates among subgroups of counties. Over the period, rates rose linearly in rural and general urban areas and in those with the lowest and intermediate rates in 2008, but declined beyond baseline rates in supercities and in areas that had the highest baseline rates. In the super-cities with the largest declines (>15.0 percentage points), maternal or perinatal mortality were kept stable.

While the overall rate was not so high as previously reported, a great deal of variation across China’s 31 provinces was observed, ranging from 4.0% to 62.5% in 2014. The variation at county-level was much greater, and substantial geographical clustering was observed: approximately 3/4 of the variation in county-level was accounted for by the regional clustering within cities and provinces.

MedicalResearch.com: What should readers take away from your report?

Response: The overall cesarean rate in China was not as high as what was previously reported. In 2014, the overall cesarean rate in China was slightly higher than the US rate of 32%, but substantially lower than middle-income countries such as Brazil (56%). The large variation across China suggests the coexistence of cesarean underuse and overuse in the mainland of China.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Given new two-child policy in China, its potential impacts on cesarean delivery is of importance (i.e., will more people choose to give birth by vaginal delivery at their first pregnancy? Will the increased number of repeated cesarean deliveries change the declining trends in overall rate in the areas with evidence of decrease?). Future studies may also focus on whether the greater variability in cesarean rates across the country could be effectively reduced after implementation of diverse policies (i.e. to control medically-unnecessary cesareans in areas with high rates; in areas with low rates, to improve cesarean service capacity as well as its accessibility.

MedicalResearch.com: Is there anything else you would like to add?

Response: My coauthors and I declare no conflicts of interest.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.


Li H, Luo S, Trasande L, Hellerstein S, Kang C, Li J, Zhang Y, Liu J, Blustein J. Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014. JAMA. 2017;317(1):69-76. doi:10.1001/jama.2016.18663

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