veruse of cesarean delivery can jeopardize maternal and child health. 1,2 Concerns about "alarming" 3 rates in China increased after the World Health Organization (WHO) 4 reported that 46.2% of births were delivered by cesarean in the years 2007 and 2008, based on an analysis of 14 541 deliveries in 21 hospitals in 3 provinces. With a population of approximately 1.37 billion in 2014, China's health care use is of substantial global interest. Over the past 2 decades, the nation has invested in improving maternal and child health. The Law on Maternal and Infant Health Care was passed in 1995 to provide a high-quality hospital delivery to all women. 5 Health insurance expansion began in 2003, to provide better financial access to maternity care. 6 In 2009, a comprehensive health care reform plan included subsidies for in-hospital delivery to pregnant women in rural areas. 7 In 2008, 89.9% of deliveries occurred in hospitals, and 87.9% of families had health insurance. 6 By 2014, 99.6% of deliveries occurred in hospitals. 8 China's increasing cesarean rate has been spurred by many factors, including expanded access to hospital care, medicolegal concerns, financial incentives for physicians to perform cesareans, and parents' focus on having a "perfect baby" under the one-child policy. 9,10 Since 2002, reducing the cesarean rate has been a national priority, 11 and a variety of policies, programs, and activities have emerged at the central government, 12 provincial or municipal, 13 city, 14 and city district or county levels. 15 There is no national IMPORTANCE The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China's cesarean rate have been based on surveys with limited geographic coverage. OBJECTIVE To provide updated information about cesarean rates and geographic variation in cesarean use in China. DESIGN, SETTING, AND DATA SOURCES Descriptive study, covering every county (n = 2865) in mainland China's 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014. EXPOSURES Live births. MAIN OUTCOMES AND MEASURES Annual rate of cesarean deliveries. RESULTS Over the study period, there were 100 873 051 live births, of which 32 947 229 (32.7%) were by cesarean delivery. In 2008, there were 13 160 634 live births, of which 3 788 029 (28.8%) were by cesarean delivery and in 2014 there were 15 123 276 live births, of which 5 280 124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation's 17 "super cities" had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality. CONCLUSIONS AND RELEVANCE Between 2...

ObjectiveTo measure the association of China’s universal two child policy, announced in October 2015, with changes in births and health related birth characteristics.DesignNational, descriptive before-and-after comparative study.SettingEvery county in 28 of 31 provinces of mainland China.ParticipantsBirths included in two national databases: 67 786 749 births from county level monthly aggregated data between January 2014 and December 2017; and 31 786 279 deliveries from individual level delivery information records between January 2015 and December 2017.Main outcome measuresMonthly mean number of births and mean proportion of multiparous mothers and mothers aged 35 and over, preterm deliveries, and caesarean deliveries.ResultsThe study had two phases: the baseline period (up to and including June 2016, nine months after the policy announcement) and the effective period (from July 2016 to December 2017). The estimated number of additional births attributable to the new policy between July 2016 and December 2017 was 5.40 million (95% confidence interval 4.34 to 6.46). The monthly mean percentage of multiparous mothers and mothers aged 35 and over increased by 9.1 percentage points (95% confidence interval 6.4 to 11.7) and 5.8 percentage points (5.2 to 6.4), respectively. This increase in older mothers, however, was not associated with a concurrent increase in the overall rate of preterm birth. The monthly mean caesarean delivery rate among multiparous mothers increased by 1.2 percentage points (0.8 to 1.6) from 39.7% to 40.9%, and decreased by 3.0 percentage points (−3.5 to −2.5) among nulliparous mothers from 39.6% to 36.6%.ConclusionsSince its announcement in October 2015, the universal two child policy has been associated with a rise in births in China and with changes in health related birth characteristics: women giving birth have been more likely to be multiparous, and more likely to be aged 35 and over. No evidence of concurrent worsening outcomes (that is, premature births) was seen.

China has one of the highest rates of caesarean delivery in the world. Of the 16 million babies born in 2010, approximately half were by caesarean, with 107 330 in Shanghai alone. 1 Understanding the reasons underlying this practice preference in China may provide insight into factors influencing caesarean rates in other countries.After the 1949 Communist revolution in China, national health policy emphasised public health. Health care was centrally planned, and focused on the provision of preventive care, vaccination, and basic medical care to a predominantly rural Chinese population. Obstetric care provided basic prenatal care and prevention of complications of pre-eclampsia, perinatal infections, and postpartum haemorrhage through the training of birth attendants.China's population grew to nearly 1 billion by 1978. Fears of over-population prompted the 'later, longer, fewer' campaign, which decreased total fertility rates from 5.8 to 2.7. 2 In 1979 the 'One Child Family' policy limited Han couples (the majority ethnic group) to a single child.In the 1980s, China's economy evolved from a socialist model to a state-controlled market economy, which grew at over 9% each year for decades, accompanied by the increasing urbanisation of the population. The centralized commune healthcare system was dismantled and replaced with a decentralised fee-for-service model that left most Chinese poorly insured. By 2002, 81% of the rural poor had no healthcare coverage, and out-of-pocket expenses that were 20% in 1979 rose to 58% by 2002. To offset reduced government healthcare spending, hospitals were allowed to increase fees and mark-up charges on medications, changes that resulted in increased costs of care, misuse of services, and the over-prescription of medications. 3