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\begin{document}

\title{The rising cesarean section rate in China: a call for action}



\author[1]{Rui-Hong Xue}%
\affil[1]{International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China}%


\vspace{-1em}



  
  \date{June 07, 2024}


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\emph{Commentary}

\textbf{The rising cesarean section rate in China: a call for action}

Rui-Hong Xue\textsuperscript{1,2,3,MD}

\emph{\textsuperscript{1}International Peace Maternity and Child Health
Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai,
China}

\emph{\textsuperscript{2}Shanghai Key Laboratory of Embryo Original
Diseases, Shanghai 200030, China;}

\emph{\textsuperscript{3}Institute of Birth Defects and Rare Diseases,
School of Medicine, Shanghai Jiao Tong University, Shanghai 200030,
China}

\textbf{Correspondence:} Rui-Hong Xue, \textsuperscript{MD}

Postal address: No.910 Hengshan Road, Shanghai, China

Postal code: 200030. Work phone: +86-021-64070434

E-mail:\emph{wfmcxrh@alumni.sjtu.edu.cn}

\textbf{Disclosure of interests:} The author declares no conflict of
interests.

\textbf{Funding:} None

\textbf{Word Count: 856}

Dear editor,

In the past several decades, the world has been experiencing a rapid
increase in cesarean section rate, and the increase varies across global
regions. Cesarean section without a medical indication has become a
cause of public concern.

In the United States around 30~\% of women deliver by cesarean section,
and across Europe general cesarean section(CS) rates vary from 17\% to
52\%, and United Kingdom ranging from 24.6\% in England to 29.9\% in
Northern Ireland.~Australia's cesarean delivery rate increased from less
than 20\% in 1998 to approximately 30\% in 2008. ~In 2014, the cesarean
section rate in China was 34.9\%, with geographic variation ranging from
greater than 60\% in some supercities to less than 10\% in some rural
areas. What was worse, from 2008 to 2018, the rate displayed an
increasing trend. However,~the increase in cesarean rate were not
associated with improved perinatal outcomes, regardless of whether
starting cesarean rates were already high or not. On the contrary,
adverse perinatal outcomes, such as neonatal intensive care unit
admissions increased under this tendency. After the outbreak of
COVID-19, this situation is getting worse. It calls for action to reduce
the proportion of cesarean without indication.

The increase in cesarean rate is largely driven by cesarean without
indication, cesarean delivery on maternal request(CDMR) has been a major
concern. About 2.5\% of all births in the United States are cesarean
delivery on maternal request. While in China, from a 18-year
retrospective study included 1317774 primiparous women with singleton
pregnancy from 1993 to 2010 in 26 counties/cities in 3 provinces in
China, they found that the prevalence of cesarean births and CDMR were
37.6\% and 10.0\%, respectively. Cesarean delivery on maternal
request(CDMR) accounted for 26\% of all cesarean births. While what
shocked us was the increasing tendency. In Southern urban area in China,
the prevalence of cesarean births increased from 29.4\% (during the
1993-1995) to 58.7\% (during the 2006-2010) . In Southern rural area,
this rate increased from 18.2\% to 58.3\%. In Northern rural area, the
rate increased from 4.3\% to 49.5\%. More importantly, the prevalence of
cesarean delivery on maternal request(CDMR) increased by 34 folds from
0.6\% (during1993-1995) to 21.3\% (during 2006-2010) in Southern urban
area, and by 40 folds from 0.6\% to 24.4\% in Southern rural area, and
by 44 folds from 0.6\% to 27.3\% in Northern rural area.The proportions
of cesarean delivery on maternal request(CDMR) significantly increased
in all three regions.

For years, the Chinese Obstetricians have been striving to reduce the
cesarean birth rate and improve the medical technologies and services.
The medical administrators repeatedly stress the importance of medical
indications in clinical daily work. However, these measures did not
obtain satisfactory effects, even though financial~penalties had been
imposed on specific wards and doctors. Facing with a big number of
pregnant women strongly requesting for cesarean section without
indications, the doctors would be caught in a dilemma when the
persuasion is always invalid, and they sometimes would be complained to
the political office by the patients. In this context, the high
prevalence of cesarean birth rate is not only a medical problem, it is
more of a social issue.

How should the doctor do when a pregnant woman request for cesarean
delivery without medical indication? In clinical practice, positive
interventions, including persuasion and encouragement, could sometimes
alter the cesarean decision if the pregnant woman would be willing to
trust the doctor. First, the doctor should first be a listener and try
to determine pregnant woman the ``pain point'' of unwilling to take
vaginal birth. Some women may have specific concerning factors, such as
age, body mass index, accuracy of estimated gestational age,
reproductive history, personal values, and cultural context.~Second, the
health care provider should be an educator in correcting wrong concepts.
Pregnant woman should be informed the advantages and disadvantages of
delivery modes, including the risks of placenta previa, placenta accreta
spectrum, and gravid hysterectomy risks after cesarean section. Third,
encouragement is important. In clinical practice, pregnant women may
feel anxious when the baby seems large under B-ultrasound scanning. Some
fear that vaginal delivery would be too painful to tolerant. Some afraid
that laceration~of~perineum after vaginal delivery will reduce the
degree of satisfaction in sexual life, which has been their
``shameful~secrets''. Promoting the popularization~of~science,
encouraging the pregnant women, and saving them from wrong concepts are
doctors' responsibilities. Last but not least, the
epidural~analgesia~use during~labor could greatly alleviate the pain for
pregnant women. Darkness before epidural~analgesia is hailing the light
at the end of the tunnel. Finally, interventions based on scientific
evidence, such as the Robson 10-group classification method could
contribute to a reduction in cesarean section rates.As in a multi-center
cross-sectional study across 23 provinces in China, they found that
cesarean rate was 38.9\% in China in 2015--2016 while the reference rate
was 28.5\% with a modified Robson classification to characterize. The
Robson 10-group classification was rarely used in China, because it has
not been widely known to most obstetricians. We also appeal for a
promotion of Robson classification method to reduce the cesarean birth
rate.

\textbf{Disclosure of interests:} The author declares no conflict of
interests.

\textbf{Funding:~} None.

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