title: Lowering the high rate of caesarean delivery in China: an experience from Shanghai.
abstract: OBJECTIVE
  To examine the trends of caesarean delivery (CD) after an intervention to lower the high rate of CD at a Chinese maternity hospital.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  A large tertiary obstetric centre in Shanghai, China, from 2007 to 2014.
  
  
  METHODS
  81 459 nulliparous women who delivered a term singleton infant.
  
  
  METHODS
  Logistic regression was used to calculate the odds of CD while adjusting for confounders.
  
  
  METHODS
  Rate of CD before and after the intervention.
  
  
  RESULTS
  The rate of CD decreased from 51.5% in 2008 to 36.1% in 2014, mostly due to a reduction in non-indicated antepartum CD from 27.9% in 2010 to 11.9% in 2014. After adjustment, a period effect remained with delivery between 2011 and 2014 associated with a 31% reduction in the odds of CD compared with delivery between 2007 and 2010 [odds ratio (OR): 0.69, 95% CI: 0.66-0.71)] and a 33% reduction in the odds of antepartum CD (OR: 0.67, 95% CI: 0.64-0.69). The frequencies of perinatal mortality (0.5 versus 0.4/1000), hypoxic ischaemic encephalopathy (0.9 versus 1.2/1000), meconium aspiration syndrome (0.5/1000), birth trauma (0.6/1000), respiratory distress syndrome (0.5% versus 0.4%) and necrotising enterocolitis (0.9 versus 0.6/1000) were similar. The frequency of neonatal infection increased slightly (0.6% versus 0.8%), although this could be explained by other factors.
  
  
  CONCLUSIONS
  A marked reduction in CD has occurred at an urban tertiary care centre as a result of efforts to reduce the high rate of caesarean delivery. No notable differences in neonatal outcomes were observed.
  
  
  CONCLUSIONS
  High rates of caesarean delivery can be lowered without increases in neonatal morbidity and mortality.
authors.affiliation: Obstetrics Department, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.
authors.forename: X
authors.initials: X
authors.lastname: Liu
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics & Gynaecology, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: C D
authors.initials: CD
authors.lastname: Lynch
authors.affiliation: Obstetrics Department, International Peace Maternity & Child Health Hospital, Shanghai Jiaotong University, Shanghai, China.
authors.forename: W W
authors.initials: WW
authors.lastname: Cheng
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics & Gynaecology, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: M B
authors.initials: MB
authors.lastname: Landon
mesh_terms: D001720:Birth Injuries / Q000453:epidemiology; D002585:Cesarean Section / Q000401:mortality / Q000706:statistics & numerical data*; D002681:China / Q000453:epidemiology; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007231:Infant, Newborn; D009774:Obstetrics; D054238:Perinatal Mortality; D011247:Pregnancy; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Caesarean delivery; China; pregnancy; quality improvement