| Objective Under PRECEDE-PROCEED mode, this paper reported the caesarean section (CS) situation from a community-based household survey. In view of epidemiology, behavioral and social environment, policy and administration, determinants associated with demography, economy, policy, clinic and culture aimed to be diagnosed for choosing a CS.Based on the integrative diagnosis, interventions aiming at both maternal health suppliers and demanders were designed and evaluated. In the meanwhile, an additional research on postnatal quality of life was performed. All-above findings were expected to provide evidence in controlling alarming CS rate in rural China.Methods Thirty townships in two counties (FC and XC) were selected as the study site, in which 18 from FC and 12 from XC.In December 2006, 1/3 townships (6) from FC and 1/4 (3) townships from XC were randomly chosen to perform baseline research using mixed-methods to complete epidemiology, behavioral and social environment, policy and administration diagnosis of CS. These methods included: 1. Basic information on demographic characteristics, facilities and staff from local governmental institutions of two counties. 2. Situation of New Cooperative Medical Scheme (NCMS). 3. All villages in these 9 townships were included in the sample. Within these villages, women who gave birth between January 2005 and December 2006 and were rural residents were recruited to participate in a household survey to collect socio-economic data, pregnant history and utilization of maternal health services during the latest childbirth. 4. In qualitative research, Focus Group Discussions (FGD) with township and village level health care providers as well as health users were conducted to explore their perceptions on current CS situation and possible causes.During 2007 and 2009, the NCMS reimbursement strategy for childbirth was altered or designed in two counties by original intention to control the rising CS rate. In FC county, it altered from proportional reimbursement to fixed reimbursement for normal delivery and caesarean section. And in 2007, NCMS was introduced to XC and fixed equaled reimbursement was designed for childbirth reimbursement.From September 2007 to June 2008, a cluster randomized trial was completed in XC county, providing health education training to health providers. A total of 12 townships in XC county were stratified into 3 groups (4 in each group) by different geographic characteristics. Two interventions were designed. Township maternal health workers in Group 1 and village family planning (FP) workers in Group 2 respectively received health education training. Balanced control group was set up in Group 3. The content of health education training included maternal health laws and regulations, safe motherhood and evidence-based health services, key points of antenatal, delivery and postnatal care, theories and skills of maternal health education.Therefore, comprehensive epidemiological and social evaluation for economic policy regulation and health education training was conducted. In January 2009, all thirty townships were included in the post-intervention research and 1/3 villages were randomly selected in each township. Women who gave childbirth between March to December 2008 participated in the household survey. A structured questionnaire was used to evaluate women’s socio-demographic characteristics, previous pregnant experiences, fetal characteristics and utilization of maternal health services. Between March and April in 2009, In-depth individual interview (IDI) and FGDs were organized with county leaders of maternal health care, NCMS directors, township managers, doctors and women to explore stakeholders’perception on changes in NCMS policies and their effects on maternal health suppliers and demanders. In XC county, deputy leader of county health bureau, director of county maternal and child health station, township managers, doctors and women were invited to participate in IDIs and FGDs, to understand policy change during intervention period and stakeholders’perceptions on health education (training).Additionally, during post-intervention household survey, the scale for rural postnatal quality of life (RPQoL) was adopted to assess postnatal QoL from six dimensions: physical complaints and pain, sleep and energy, sex satisfaction, interpersonal communication, self-evaluated living stress and perceived life satisfaction. A further longitudinal research was conducted in three townships in XC to follow up women’s postnatal QoL respectively during 1, 3, 6, 12 months after childbirth, using the same structured questionnaire and scale as post-intervention household survey.Results A total of 2326 women (1227 in FC county and 1099 in XC county) were interviewed in baseline survey and 1515 women (896 in FC county and 619 in XC county) completed household survey. The community-based CS rates in two counties were 46.0% and 64.7% in 2006, increasing to 63.6% and 82.1%, respectively in 2009. The increasing speed in township hospitals was faster than that in county level (by 9.3 v.s 23.6 percentage points in county FC and 4.4 v.s 20.1 percentage points in county XC). Most caesarean sections were on maternal requests and the proportion increased in both counties, increasing from 46.8% to 50.9% in FC and from 53.6% to 67.5% in XC. Fear of pain and concerns about safety of mothers and babies were two leading causes for their selection.It was observed that there were complex and different interactions among determinants to influence CS rate. We found that, maternal age had a dual effect on CS and had strong interactions with medical and social-economic factors. Older women were more likely to directly have a CS or chose CS due to complications during their pregnancy. Younger women were more likely to have a CS through being primiparous. High maternal education level had a modest direct association with CS rate, but was more strongly related indirectly. Women in FC with a higher education achievement were more likely to be primiparous, to have a greater income level and to have more reported pregnancy complications, resulting in more likelihood to choose CS. While in XC, higher educated women tended to be greater users of antenatal care facilities and were more likely to have a CS. From qualitative study, it was revealed that absence of effective supervision, health providers’defensive medicine, financial incentive, poor delivery assistance skills, women’s fear of pain, perceptions of giving birth on a date or at a time believed to be auspicious, tubal ligation during caesarean section, pursuing phenomenon on level of hospitals where to give childbirth and on delivery mode, as well as more emphasis on advantages of CS by both suppliers and demanders together promoted more CS use. Since it was difficult to remove far-reaching cultural effect, and national macroscopic policy adjustment and control still needed time, policy regulation as well as strategies to improve maternal health suppliers’and demanders’could be attempted to control the alarming CS rate in rural areas.After regulation of NCMS reimbursement for childbirth, it was found that , however, logistic regression analysis, after adjusting for socio-economic, maternal and fetal characteristics, did not indicate a significant influence of either proportional reimbursement or fixed amount reimbursement on CS choice in FC (OR 95%CI: 0.851-1.520 and 0.605-1.396 respectively). Fixed amount reimbursement in XC was not found to significantly affect CS as well (OR 95%CI: 0.571-1.841). Interviews with stakeholders reflected that NCMS promoted maternal health service utilization in grass-rooted facilities and provided some financial protection to some degree. But economic interventions would not suffice to control the rising CS rate.It was revealed by survey data that average family income per capita per year significantly increased in three groups, and women’s education level also improved in Group 1 and Group 2 in XC county. After training intervention, the coverage of antenatal care and postnatal care, rate of early and systematic antenatal checkups all significantly improved, while the rate of caesarean section had been still rising. In Group 2, there were highest average increasing velocities in rate of early and systematic antenatal checkup as well as postnatal visits. In Group 1, most newborns had breastfeeding within half an hour to 24 hours after delivery. Caesarean section rate had increased by 10.0% and 12.4% respectively in Group 1 and Group 2, even approaching to 86.0% in Group 2. In qualitative research, it was found that local government also initiated some policies to improve maternal health service. Most township doctors and village FP workers perceived that maternal health care knowledge was updated after health education training, especially that on protective health care. Skills of services and communication developed after training so that they had more enthusiasm and confidence in performing health education. Neither health providers nor users regarded it effective to control or decrease caesarean section rate solely by health education.After excluding women with previous adverse pregnancy outcomes and severe pregnancy complications, a total of 1375 women entered into final data analysis for postnatal quality of care. The overall CS rate was 70.0% (962/1375) and most of them (59.7%) were by maternal request. None of six dimensions and total score of QoL displayed significant difference between women with normal delivery and CS. It was found that postnatal home visit related to good postnatal QoL and lower husband education level, male gender of infant were associated with poor QoL. It was illustrated from longitudinal study that, except for the improved physical complaints and pain, sleep and energy in CS group, none of other indicators showed significant changes or trends in different postnatal periods, or between ND and CS.Conclusions This study shows extremely high caesarean rates in two counties in rural Eastern China. In rural areas with pretty high CS rate and relatively high economic level, delivery reimbursement strategies are not suffice to control the alarming rise in CS rate. It is helpful to improve protective maternal health services by health education training towards township doctors and village FP workers. But it also makes no sense to control the alarming caesarean section rate in rural areas. Delivery mode is not observed to affect postpartum QoL in rural China. Social, medical-cultural, and political-economic contexts of maternity care in rural areas comprehensively determines the high CS rate, as brings hinders in controlling CS rate in rural areas.MeSH Caesarean Section / Natural Childbirth / Epidemiologic Factors / Insurance, Health / Reimbursement Mechanisms / Maternal Health Services / Health Education / Intervention Studies / Cluster Randomized Trial / Quality of Life / Evaluation Studies / Qualitative Research / Follow-up Studies / Rural Health... |
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