Cesarean section in Shanghai: women’s or healthcare provider’s preferences?

Abstract

BackgroundCesarean section (CS) rate has increased rapidly over the past two decades in China mainly driven by non-medical factors. This study was to compare recalled preferences for CS among first-time mothers in early and late pregnancy with actual delivery mode; to explore factors related to CS preference and CS performed without medical indications; and to consider the role of healthcare providers in delivery mode preferences.MethodsAn anonymous questionnaire survey, combined with data on CS indications taken from the patient record, was conducted among 272 first-time mothers having their first postnatal check-up in one university affiliated obstetrics and gynecology hospital in Shanghai, China, between September 2006 and January 2007. Logistic regression was used to study factors related to the recalled preference for CS and CS performed without medical indication, adjusting for maternal age, education and income.ResultsThe CS rate was 57% (151/263) among all women, 17% with medical indications and 40% without medical indications. For women without medical indications for CS (n = 215), there was no significant difference between women’s preference for CS in early (25%) and late pregnancy (28%); 48% of women actually had CS. Women recalled preferring a vaginal delivery but who had CS were more likely to have had a CS suggested by a prenatal care doctor [OR (95% CI): 20 (3.88-107.1)] or by a delivery obstetrician [OR (95% CI): 26 (6.26-105.8)]. Among women recalled preferring and having CS, a suggestion from the prenatal care doctor to have CS was very common.ConclusionsIn the primiparous women without a medical indication for CS, women recall of a provider suggestion for CS was a strong predictor of CS both among women who recalled a preference for CS and among women who recalled a preference for vaginal delivery. Public health education needs strengthening, including discussion of the risks associated with CS and psychological and social support given to women to help them prepare for and cope with childbirth.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2393-14-285) contains supplementary material, which is available to authorized users.

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“…Women's requests for caesarean section have been cited as a reason for the rising rates but only a minority of women in a wide range of countries have expressed a preference for caesarean section . Studies in a number of countries have shown that many women who ended up having caesarean section would have preferred vaginal delivery and are influenced by models of care and healthcare providers’ preferences . The results of the WHO global surveys of maternal and perinatal health in Latin America and Asia have pointed to the potential dangers and excessive costs associated with caesarean sections that are clinically unnecessary …”

Role of the private sector in childbirth care: cross‐sectional survey evidence from 57 low‐ and middle‐income countries using Demographic and Health Surveys

“…The Caesarean section rates above 30% observed in Middle East/Europe and Latin America regions likely reflect unnecessary interventions, and there is evidence to suggest that these are being differentially provided to the rich and higher in the private sector. A substantial literature elucidates how private providers are incentivised to overperform Caesarean sections either because they are financially more lucrative, because they can be conveniently scheduled or because of women's demands for care from one individual [44][45][46].…”

Why Do Niches Develop in Caesarean Uterine Scars? Hypotheses on the Aetiology of Niche Development

“…In the UK the CS rate increased from 12 to 29% between 1990 and 2008 (Betran et al, 2007). In the USA in 2011 one in three women delivered by CS, whereas in China the CS rates have even risen from 2% in 1985 to 36-58% in 2010 and in Brazil from 15% in 1970 to even 80% in the private sector in 2004 (Barros et al, 2011;Deng et al, 2014;Feng et al, 2014;Osterman and Martin, 2014). There is no discussion that a CS is a lifesaving procedure for some women, for example for women with placenta praevia or truly obstructed labour, or for babies with proven distress either antenatal or intrapartum.…”