Secular Change In Rates Of Cesarean Section And Its Influencing Factors In Rural Areas Of South Anhui

Objectives To describe the situation of antenatal, delivery and postnatal care in rural South Anhui, understand the cesarean section (CS) rate and to analyze the impact factors of increasing CS rate in rural areas of South Anhui.Methods By using mixed quantitative and qualitative methods, the situation of cesarean section (CS) rate and affecting factors of increasing CS rate were investigated. In the quantitative study, two counties (county A and county B) were selected from south of Anhui. Using a stratified randomized cluster-sampling method, women who delivered during March 1st to December 31st, 2008 from the two counties were selected for a questionnaire survey. Informed consents were obtained and finally 1515 women completed face-to-face interviews, in which 896 women from county A and 619 women from county B. Information drawn from questionnaires included demographic characteristics, use of antenatal, delivery and postnatal care, choice and decision-making of caesarean section and related influencing factors, which were displayed by descriptive analysis. Theχ2-test identified differences in maternal care usage as well as CS rate. Non-conditional multivariate logistic analysis was performed to explore related factors influencing choice of caesarean section. In qualitative research, pregnant women, family members, health providers and managers from two counties of Anhui were selected to participate in focus group discussions and /or individual in-depth interviews. Topic guide included stakeholders'perception on current CS situation, advantages and disadvantages of vaginal delivery and caesarean section and possible causes of increasing CS rate.Results With regard to maternal health care services, prenatal examination, hospital delivery, postpartum visit and health education were all carried out in the township hospitals. Qualitative study showed that maternal health care was unbalanced, the coverage rate of prenatal checkup was high with the township hospitals were the predominant medical unit. Rate of postpartum visit in country A (17.0%) was significantly higher than that in country B (11.8%) (P<0.05). In county B, rates of prenatal checkup in first trimester of pregnancy and postpartum telephone visit (73.0%, 19.9%, respectively) were significantly higher than those in country A (57.7%, 15.1% respectively) (P<0.05).In the quantitative study, all 1 515 women (100%) had hospital deliveries. The rate of CS in county A and county B was 63.6%, 82.1%, respectively, with statistically difference (P<0.001). The rate of elective cesarean by maternal request in was 50.9% (290/570) and 67.5% (343/508) respectively in county A and county B. The study found that the two leading reasons for women's request were fear of childbirth and worry about baby's health.Higher education level was risk factor of caesarean section in both two counties(OR value=1.08, 95%Confidence interval=1.03~1.14 in county A,OR=1.10, 95%Confidence interval=1.03~1.18 in county B). Adverse pregnancy outcome(OR value=1.88, 95%Confidence interval=1.03~1.14), frequent antenatal care(OR value=1.36, 95%Confidence interval=1.03~1.18) , delivery at county level and above (OR value=1.52, 95%Confidence interval=1.37~2.57) were risk factors of caesarean section in county A. In county B, delivery at township level was risk factors of caesarean section (OR value=2.11, 95%Confidence interval=0.30~0.76). The rate of delayed onset of lactation for CS was higher than that for vaginal delivery.In qualitative study, it showed that factors affecting choice of caesarean section included young puerpera's age, women's fear of pain, recommendations from doctors and elders, hospital's defensive medical care, inappropriate cognition of quality of life after cesarean section and poor skills of young obstetricians and midwives.Conclusion The dramatically high caesarean section rate is a conjunctive results from increasing demands of health providers (hospitals and doctors) and health consumers (pregnant women and their family members) in rural area. Maternal request played an important role in rising cesarean delivery rate. It is requested that appropriate interventions be made according to different situation in different areas.