The Effect of Maternal Age and Parity and the Density of Doctors on Caesarean Section in China

Background: There is a growing concern about the high caesarean section (CS) rate in China and the Chinese government has implemented a series of policies to reduce the CS rate. The relaxation of the one-child policy means more women will have a second birth at an older age, calling for a comprehensive understanding of how maternal age and parity are associated with the use of CS. The effect of the density and education of service providers on the CS rate has scarcely been explored, yet important given the financial incentive towards CS in the Chinese health system. Methods: I did a systematic review to summarise the non-clinical factors that have been examined as determinants of CS in China and meta-analyses to summarise the strength and shape of the associations between maternal age and parity and CS. I also conducted a county-level analysis to estimate the strength of association between the density and education of obstetric and gynaecologic doctors (OGD) and the CS rate in Sichuan province in 2014. Results: Existing studies mostly focused on individual determinants of CS including maternal age and parity, while few studies looked at the density of doctors. The metaanalysis found a linear positive association between maternal age and CS and a lower risk of CS in multiparas than nulliparas before the relaxation of the one-child policy and a higher risk in multiparas afterwards. I found a very high density of OGD per 1000 live births in Sichuan, many of whom had low levels of formal education. There was a positive association between the density of OGD and the CS rates between prefectures, independent of the level of education of OGD and the socio-demographic characteristics of the county. Conclusion: The linear association between maternal age and CS cannot be explained by clinical or socio-demographic characteristics of women, suggesting that women and/or obstetric providers may prefer CS at an older maternal age. Results from the county-level analysis imply that a health system where obstetricians predominately provide most delivery care may fuel the use of CS, this may be partly due to the payment mechanism that encourages the use of expensive care