BackgroundChina 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 findingsWe 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).Concl...

Background Many evidence-based preventive services are unaffordable. Pay-it-forward offers an individual a gift (e.g. a test for sexually transmitted diseases) and then asks whether they would like to give a gift (e.g. a future test) to another person. This study examined the effectiveness of a pay-it-forward program to increase gonorrhea and chlamydia testing among men who have sex with men (MSM) in China. Methods We conducted a randomized controlled superiority trial at three HIV testing sites run by MSM community-based organizations between November 2018 to January 2019. We included MSM aged 16 and older seeking HIV testing who met indications for gonorrhea and chlamydia testing. Restricted randomization was employed using computer-generated permuted blocks. Thirty groups were 1:1:1 randomized into three arms: a pay-it-forward arm where men were offered free gonorrhea and chlamydia testing and then asked whether they would like to donate others' tests; a pay-what-you-want arm where men were offered free testing and given the option to pay any desired amount for the test; and a standard-of-care arm where testing was offered at 150RMB (US$22). There was no masking to arm assignment. The primary outcome was gonorrhea and chlamydia test uptake ascertained by administrative records. We used generalized estimating equations to estimate intervention effect with one-sided 95% confidence intervals and a pre-specified superiority margin, 20%. The trial was registered (NCT03741725). Findings Three hundred and one men were recruited and included in the analysis: 101 were randomized to pay-it-forward, 100 to pay-what-you-want, and 100 to standard-of-care. Test Interpretation Pay-it-forward strategy can increase gonorrhea and chlamydia testing among Chinese MSM and may be a useful tool for scaling up preventive services that carry a mandatory fee.

Syphilis was an important cause of pregnancy loss and infant disability, particularly among women who did not receive prenatal care or had late or inadequate treatment. These study results can inform antenatal programs on the importance of early syphilis testing and prompt and appropriate treatment. Some strategies targeted at other risk factors areas may be helpful.

Mobile phone applications may enhance the delivery of critical health services and the accuracy of health service data. Yet, the opinions and experiences of frontline health workers on using mobile apps to track pregnant and recently delivered women are underreported. This evaluation qualitatively assessed the feasibility, usability, and acceptability of a mobile Client Data App for maternal, neonatal, and child client data management by community health nurses (CHNs) in rural Ghana. The mobile app enabled CHNs to enter, summarize, and query client data. It also sent visit reminders for clients and provided a mechanism to report level of care to district officers. Fourteen interviews and two focus groups with CHNs, midwives, and district health officers were conducted, coded, and thematically analyzed. Results indicated that the app was easily integrated into care, improved CHN productivity, and was acceptable due to its capacity to facilitate client follow-up, data reporting, and decision-making. However, the feasibility and usability of the app were hindered by high client volumes, staff shortages, and software and device challenges. Successful integration of mobile client data apps for frontline health workers in rural and resource-poor settings requires real-time monitoring, program investments, and targeted changes in human resources.