What is an appropriate cesarean delivery rate for China: a multi-center survey.

Objective To assess the current status of cesarean delivery (CD) in China, propose reference CD rates for China overall and by regions, investigate the main indications for CDs, and identify possible areas for safe reduction. Design A multi-center cross-sectional study. Setting A total of 94 hospitals across 23 provinces in China. Population A total of 73977 randomly selected deliveries. Methods We used a modified Robson classification to characterize CDs in subgroups and by regions, and the WHO C-Model to calculate reference CD rates. Main outcome measures CD rates in China. Results In 2015 and 2016, the overall CD rate in China was 38.9% (95% CI: 38.6% to 39.3%). Considering the obstetric characteristics of the population, the multivariable model-based reference CD rate was estimated at 28.5% (95%CI: 28.3% to 28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% of relative reduction) may be considered. The CD rate varied substantially by regions. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labor dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). 12.7% women had prelabor CDs, contributing to 32.8% of the total CDs. Conclusions Nearly 39% of births were delivered by cesarean in China but a quarter of reduction may be considered. Repeat CD contributed more than one-third of total CDs. Given the large variation in maternal characteristics, region-specific or even hospital-specific reference CD rates are needed for precision management of CD.