Prevalence of and reasons for women’s, family members’, and health professionals’ preferences for cesarean section in China: A mixed-methods systematic review

Abstract

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...

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“…23,24 We evaluated the risk of bias by assessing the eligibility criteria, sample size, representativeness (whether a sampling methodology was used appropriately to produce an estimate representative of the target population or if a convenience sample or special group was selected), response rate, data collection tool, clarity of the questions/statements and definition of the outcome, clarity of the objective, ethical considerations, and consistency between research question and data reported (Appendix S2). 25 We present the evaluation results for each question for each included study. The potential risk of bias was characterised as follows: eligibility criteria (low risk, defined eligibility; high risk, not defined); sample size (low risk, 100 subjects or more; high risk, <100 or not explained); data collection tool (low risk, described with references; moderate risk, described without references; high risk, not described); definition of the outcome (low risk, well defined; high risk, improperly defined); clarity of results data (low risk, reported with numerators and denominators; high risk, not clearly reported), and representativeness (low risk, representative; moderate risk, not described or somehow representative; high risk, selected group).…”

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“…However, 40% expected to have a C-section when arriving at the hospital to give birth (76). Women that expect or prefer a C-section justify it by expressing their fear of fetal distress and mortality, excessive pain, or fear of trauma to the vagina (14)(15)(16)76).…”

“…Countries with alarming cesarean rates, such as Brazil, Dominican Republic, Egypt, Taiwan, China, India, and Iran, have many similar non-clinical factors identified as contributors to the high rates, as well as unique factors to each country's context (14)(15)(16)(17)(18)(19). Researchers found that social and cultural beliefs of women, families, and communities in these countries result in a similar viewpoint that a cesarean is a safer delivery mode for the mother and child when compared to vaginal birth.…”

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“…The CS rate in China began to rise in the early 1980s, with a sharp rise in the mid-1990s, and continued to rise from 28.8% in 2008 to 34.9% in 2014 [2,3]. Reasons for the rapid rise in CS rate in China were multifactorial [4][5][6]. Among the commonly cited reasons are fear of labor pain, concerns about complications such as urinary incontinence and lower quality of sex life after vaginal delivery, misconception of CS being safer than vaginal delivery for the baby, poor experience of previous vaginal delivery, and auspicious dates [3,4].…”

“…Reasons for the rapid rise in CS rate in China were multifactorial [4][5][6]. Among the commonly cited reasons are fear of labor pain, concerns about complications such as urinary incontinence and lower quality of sex life after vaginal delivery, misconception of CS being safer than vaginal delivery for the baby, poor experience of previous vaginal delivery, and auspicious dates [3,4]. The shortage of nurses/midwives and the large volume of deliveries often lead to more convenient and scheduled CS.…”