1. From one child policy to economic boom: factors affecting recent trends in child birth in China Tony Duan Dec. 6, 2015

2. Outline C-section rate and its changing trend in China C-section rates between resident and immigrant population C-section rates between medical practitioners and general population Change of one child policy and possible effects on C-section rate The C-section reduction initiative in China

3. Basic Stats and Background Annual birth in China: 17 millions （ New Austrilia ） C Section rate 46.2% Lancet 2010; 375: Maternal mortality ： 23.2/100,000 Infant and perinatal mortality:9.5‰ Chinese Obgyn Physicians:190,000+

4. Basic Stats and Background Shanghai Population:25 Millions Annual birth:240,000 Life expectancy:82.47 yrs Maternal mortality:7.08/100,000 ， Perinatal mortality:3.78‰ Shanghai Obgyn Physicians: 5000

5. Basic Stats and Background Shanghai First Maternity and Infant Hospital(SFMIF) annual birth 25,000 Capacity 465 OB beds, Capacity of Annual birth 35,000-40,000

6. C-section rate in China

7. C Section Rate in Asia

8. C-Section Rate & GDP in Shanghai city & SFMIH

9. C-section rates by different socio- demographic areas and provinces

10. a The data of 1994 and 1995 was missing. b Five categories of areas in China were divided by the national health Ministry. The areas of the Urban and Rural Type I were the richest, and the rural type Iv was the poorest. The changing trends of C-section rates from 1988 to 2008 a by socio- economic areas b Data source: Feng X L, Xu L, Guo Y, et al. Factors influencing rising caesarean section rates in China between 1988 and 2008[J]. Bulletin of the World Health Organization, 2012, 90(1): 30- 39A. a The family per capita income = family total income/ family members The changing trends of C-section rates from 1988 to 2008 by socio-demographic areas by household income a The changing trends of C-section rates in China

11. The changing trends of C-section rates from 1988 to 2008 a by medical insurance a Mother’s education The changing trends of C-section rates from 1988 to 2008 a by maternal education a The changing trends of C-section rates from 1988 to 2008 a by socio-demographic areas by parity a The changing trends of C-section rates in China

12. C-section rate in China during 2015 The rates of different delivery modes in China (n=2507) a a 2507 cases were randomly selected from the national delivery survey in 2015

13. C-section rates between resident and migrant population The rates of delivery mode in resident and migrant population in China during 2015 (n=2507) a % %

14. The rates of delivery mode in resident and migrant women in Shanghai First Maternity & Infant Hospital from 2012 to 2014 (n=41295) a A pregnant migrant women in Shanghai City, China C-section rates between resident and migrant population P < 0.05 %

15. C-section rates between medical practitioners and general population However, the status seemed different in 2014.

16. Change of one child policy and possible effects on C-section rate 1979 “One-child” per family policy 2001 “Two-children” policy if parents all from one-child families 2014 “Two-children” policy if one of the parents from one-child families a large proportion of women with previous CS a large proportion of women with previous CS Policy transition in China

17. Robson 10 groups 16864/3919 3 (43.0%) Size of group % C/S rate in gp % Contr of each gp (43.0%) 1 Nullip single ceph >=37 wks spon lab 794/1361634.75.8 2.0 2 Nullip single ceph >=37wks ind. or CS before lab 11217/1692 2 43.266.3 28.6 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 104/21385.54.9 0.3 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 2061/26396.778.1 5.3 5 Previous caesarean section single ceph >= 37 wks 660/7101.893.0 1.7 6 All nulliparous breeches 168/1760.495.5 0.4 7 All multiparous breeches (incl previous caesarean sections) 33/350.194.3 0.1 8 All multiple pregnancies (incl previous caesarean sections) 1050/11042.895.1 2.7 9 All abnormal lies (incl previous caesarean sections) 39/510.176.5 0.1 10 All single ceph <= 36 wks (incl previous caesarean sections) 738/18024.641.0 1.9 The C-section reduction initiative in China Robson ten-group classification as a tool of quality improvement

18. Clinical solution package Quality improvement tools Clinical epidemiology research The C-section reduction initiative in China

19. C section audit C section rate ranking for OB physicians Control of macrosomia Training of vaginal brith skills Instrumental vaginal delivery External version of breech presentation VBAC or TOLAC guideline and clinics Reduction of episiotomy Epidural The C-section reduction initiative in China

20. Trail of Labor After Cesarean 240,000 births in Shanghai(2013) 20% multips 50% with prior CD 80% success rate 24,000 with prior CD(240,000 × 20% × 50%) Repeat → 24,000 TOLAC 10% → 22,080 (24000-24000 × 10% × 80%) TOLAC 50% → 14,400 (24000-24000 × 50% × 80%) 7680(22080-14400) 10% to 50% 50.0% →CD to 46.8%[( 240000 × 50%-7680)/240000] The C-section reduction initiative in China

21. External Cephalic Version 50.0% → CD to 48.6% [( 240000 × 50%-3300)/240000] Extending 2 nd Stage of labor 50.0% → CD to 47.5%[(240,000 × 50%-6,000)/240,000] Decreasing rate of fetal macrosomia 50.0% → CD to 47.6% [( 240000 × 50%-5760)/240000] The C-section reduction initiative in China

22. Training Analyzing & Reporting the effectiveness Data recording Quality Control The C-section reduction initiative in China Establishing a website for reducing C-section rate

23. Thanks for your attention!