title: Factors contributing to the rapid rise of caesarean section: a prospective study of primiparous Chinese women in Shanghai.
abstract: OBJECTIVE
  To identify factors contributing to the rapid rise of caesarean section in Shanghai through the prospective observation of changes in the preferred mode of delivery in pregnancy among primiparous Chinese women.
  
  
  METHODS
  Prospective study.
  
  
  METHODS
  Two general hospitals in Shanghai.
  
  
  METHODS
  A cohort of 832 low-risk primiparous women participated in the investigation from 2010-2012 three consecutive times, from their second to third trimester and, finally, 1-2 days post partum.
  
  
  METHODS
  Participants were interviewed, using standard questionnaires, for information on demographic characteristics, maternal childbirth self-efficacy, their preference of delivery mode before childbirth and on the people most influential to them when making decisions on delivery mode. Caesarean section indications in the medical records were extracted by the investigators and assessed against clinical guidelines. Caesarean sections were categorised into three groups: guideline-defined indications, doctor-defined indications and maternal request.
  
  
  METHODS
  Preferred mode of delivery; indications for caesarean section; actual mode of delivery; determinants of caesarean section.
  
  
  RESULTS
  Of 832 pregnant women enrolled, 13.2% preferred caesarean section in the second trimester. This figure rose to 17.0% in the third trimester among 599 followed women. Of 523 women completing all three interviews, 58.1% underwent caesarean section. However, 34.9% of women undergoing caesarean section did not have any indications listed in the clinical guidelines nor based on maternal request. Multinomial regression analysis showed that doctors' influence was one of the significant risk factors of undergoing caesarean section, with doctor-defined indications. Participants with low maternal childbirth self-efficacy were more likely to request caesarean sections themselves.
  
  
  CONCLUSIONS
  When deciding to deliver via caesarean section without justified clinical indications in the guideline, Chinese doctors played an important role in decision-making. Among primiparous Chinese women, decisions to use caesarean sections were often made during the third trimester or during the process of labour.
authors.affiliation: Department of Epidemiology and Social Science, Shanghai Institute of Planned Parenthood Research/WHO Collaborating Center for Research in Human Reproduction, Shanghai, China Department of Maternal, Child and Adolescent Health, School of Public Health and Global Health Institute, Fudan University, Shanghai, China.
authors.forename: Honglei
authors.initials: H
authors.lastname: Ji
authors.affiliation: Department of Maternal, Child and Adolescent Health, School of Public Health and Key Laboratory of Public Health Safety (Ministry of Health), Fudan University, Shanghai, China.
authors.forename: Hong
authors.initials: H
authors.lastname: Jiang
authors.affiliation: Maternity and Child Health Institution of Zhabei District, Shanghai, China.
authors.forename: Limin
authors.initials: L
authors.lastname: Yang
authors.affiliation: Department of Maternal, Child and Adolescent Health, School of Public Health and Global Health Institute, Fudan University, Shanghai, China.
authors.forename: Xu
authors.initials: X
authors.lastname: Qian
authors.affiliation: Duke Global Health Institute, Duke University, Durham, North Carolina, USA.
authors.forename: Shenglan
authors.initials: S
authors.lastname: Tang
mesh_terms: D000328:Adult; D044466:Asian People; D002585:Cesarean Section / Q000706:statistics & numerical data*; D002755:Choice Behavior; D003258:Consumer Behavior; D005260:Female; D006801:Humans; D010298:Parity; D011247:Pregnancy; D011446:Prospective Studies; D013997:Time Factors
keywords: EPIDEMIOLOGY; OBSTETRICS; PUBLIC HEALTH