Effect of a two-stage intervention package on the cesarean section rate in Guangzhou, China: A before-and-after study

• Published in: PLoS medicine 2019-07, Vol.16 (7), p.e1002846-e1002846
• Main Authors: Xia, Xiaoyan, Zhou, Zehong, Shen, Songying, Lu, Jinhua, Zhang, Lifang, Huang, Peiyuan, Yu, Jia, Yang, Li, Wang, Ping, Lam, Kin-Bong Hubert, Jacobsson, Bo, Mol, Ben Willem, Xia, Huimin, Qiu, Xiu
• Format: Article
• Language: English
• Subjects: Adult; Biology and Life Sciences; Capacity Building - trends; Cesarean section; Cesarean Section - adverse effects; Cesarean Section - mortality; Cesarean Section - trends; Childbirth & labor; Children & youth; Childrens health; China; Cross-Sectional Studies; Evaluation; Family planning; Female; Funding; Gynecology; Health care facilities; Health care industry; Health education; Health Education - trends; Health Personnel - education; Health risk assessment; Humans; Infant mortality; Infant, Newborn; Inservice Training - trends; Maternal health services; Maternal mortality; Maternal Mortality - trends; Medical personnel; Medical personnel training; Medicine and Health Sciences; Mortality; Obstetrics; Obstetrics, Gynecology and Reproductive Medicine; Patient education; Patient Education as Topic - trends; People and Places; Perinatal Care - trends; Perinatal Mortality - trends; Population growth; Population studies; Practice Patterns, Physicians' - trends; Pregnancy; Program Evaluation; Public health; Regression analysis; Reproduktionsmedicin och gynekologi; Retrospective Studies; Risk Factors; Sensitivity analysis; Statistics; Studies; Supervision; Surveillance equipment; Time series; Training; Women; Young Adult
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1002846

The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China. This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010-September 2014 and October 2014-December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period. A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067, p < 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: -0.09 [95% CI -0.16 to -0.02] between Stage 1 and baseline, p = 0.014; -0.11 [95% CI -0.20 to -0.02] between Stage 1 and Stage 2, p = 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (Z = -4.368, p < 0.001) and PMR (Z = -13.142, p < 0.001) declined by stage over the intervention period. One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given