Carlos Barria (Courtesy Reuters)
By Yanzhong Huang
For those who were born in the Chinese countryside in the 1970s, the story of my birth—as my mother used to tell me—is not atypical. When the labor pains began, my mom sent my siblings to the local midwife asking her to come and deliver the baby at home. Few people then heard of cesarean section (C-section)—the delivery of a baby through one or more incisions in the mother’s belly and uterus. In fact, only about 10 percent of children in China were born through C-section.
The story is dramatically different for those who were born two decades later. Indeed, over the past two decades, we have seen C-section deliveries increase by 50 percent worldwide. The highest C-section rate is found in China, where nearly half of all births (47 percent) use this procedure; in some Chinese provinces, the rate is reportedly as high as 70 to 80 percent. According to a Chinese doctor, more than 80 percent of the pregnant women in China could have a natural delivery.
Multitudes of factors, many of which are unique to China, have driven the astonishing C-section rate. Chinese people, for example, like to pick specific days or times for their children to be born. For practical reasons, some young couples may decide to give birth before September 1 (the first day of school) so that their children can go to school a year earlier. Still others may be so superstitious that they prefer even-numbered birth dates for their babies. Reasoning along this line, we would anticipate a C-section spike closer to Feb. 19, 2015, the beginning of the zodiac Year of Sheep, as children born in that year are considered unlucky.
Despite these practical or cultural factors, the rising C-section rate should be viewed more as a byproduct of the transitioning health system in China. The cultural mindset is put into practice largely because of the increasingly easy access to hospital delivery (nearly 100 percent of the babies in China are now delivered in hospitals) and modern medical technology (which has not only made it easier to identify women with high-risk pregnancies, but also improved the safety of surgery and anesthesia). This systemic change nurtures the perception of mothers-to-be that a single surgical incision is much easier to deal with than hours of labor pain.
Other health system changes have also fueled the shift toward C-sections. Midwives, who cannot perform C-sections, had played an important role in keeping the C-section rate low in China until the 1990s. By the turn of the century, traditional midwives had been phased out in China’s countryside. But in even many urban hospitals, many experienced midwives (zhuchanshi) left their profession due to poor pay and high career risk. As a result, the number of midwives in China is only 1/8 of that of Cambodia and 1/20 of United States. The shortage of experienced midwives to perform natural delivery means that obstetricians sometimes have no choice but to conduct C-sections. This is especially true when would-be mothers insist on having a C-section. Given the increasing violence against healthcare providers in Chinese hospitals, doctors who want to avoid conflict find it difficult to say no to the requests for a C-section. Also, since C-sections are more profitable than natural birth—hospitals generally have to spend more on natural childbirths, but are only allowed to charge half of the fees of a C-section—unscrupulous hospitals and doctors may take advantage of the information asymmetry between patients and healthcare providers to encourage the use of C-section.
In addition, the increasing demand for C-sections has been indirectly fueled by the one child per couple family planning policy. If women are not allowed to have a second baby, they tend to shorten their time horizon and become less worried that their uterus would be harmed by C-section.
True, C-sections are generally considered a safe procedure; they can help women at risk for complications with their pregnancy or labor avoid dangerous delivery situations and can save the life of the mothers and/or baby when emergencies occur. But as with any type of abdominal surgery, C-sections are also associated with risks and complications for both the mother (e.g., infection, hemorrhage or increased blood loss, injury to organs, adhesions, and extended hospital stay/recover time) and the baby (e.g., premature births, breathing problems, and fetal injury). For most pregnancies, cesarean delivery poses greater risk of maternal morbidity and mortality than vaginal births.
Indeed, a growing body of research over the past years points to previously unknown public health risks of C-sections. A 2011 study found that C-sections are a barrier to breastfeeding, as the former is associated with delayed skin-to-skin contact between mother and baby, increased formula feeding, and separation of mother and baby. Research also suggests that delivery shapes the establishment of children’s microbiota (the microbe population inhabiting a bodily organ) and subsequently plays a role in child health. Babies born through C-section are less exposed to their mother’s microbiota than those born through vaginal delivery. For example, C-section may inhibit the full growth of bifidobacteria probiotics in a baby’s gut, which could negatively affect her ability to extract nutrition from breast milk. A 2013 article published in Science Translational Medicine suggests that such a dysfunctional microbiome could lead to severe childhood malnutrition and early stunting (the irreversible outcome of chronic malnutrition in early childhood). In China, an estimated 12.7 million children are stunted. Stunted children are more likely to suffer later in life from non-communicable diseases, such as heart and kidney disease, obesity, and diabetes.
Research also suggests that by affecting the initial microbiota to which a neonate is exposed, C-section deliveries may lead to modification of the baby’s immune response system, which in turn may make her more susceptible to allergies and asthma later in life, evenput her at higher risk of type 1 diabetes (T1D). The high C-section rate in China is indeed paralleled by rising T1D incidence. A recent study found a mean annual increase of 14.2 percent in the incidence of childhood T1D from 1997 to 2011 in Shanghai, which is expected to double from 2016 to 2020. In 2013, a team of scientists also discovered thatpeople with altered gut microbiota are at risk of developing type 2 diabetes. In this sense, C-sections might be considered another important trigger of the looming diabetes epidemic in China.
In order to prevent the high C-section rate from translating into another public health crisis, the Chinese government should act now. In the short term, it should launch a nationwide public health education campaign so that the health risks of C-section are widely known in the society. But better informed moms-to-be alone are not going to significantly bring down the C-section rate, unless the government is willing to invest in the training of more experienced midwives, to deepen the healthcare delivery and payment reform, and to completely abandon the notorious one-child policy.
For those who were born in the Chinese countryside in the 1970s, the story of my birth—as my mother used to tell me—is not atypical. When the labor pains began, my mom sent my siblings to the local midwife asking her to come and deliver the baby at home. Few people then heard of cesarean section (C-section)—the delivery of a baby through one or more incisions in the mother’s belly and uterus. In fact, only about 10 percent of children in China were born through C-section.
The story is dramatically different for those who were born two decades later. Indeed, over the past two decades, we have seen C-section deliveries increase by 50 percent worldwide. The highest C-section rate is found in China, where nearly half of all births (47 percent) use this procedure; in some Chinese provinces, the rate is reportedly as high as 70 to 80 percent. According to a Chinese doctor, more than 80 percent of the pregnant women in China could have a natural delivery.
Multitudes of factors, many of which are unique to China, have driven the astonishing C-section rate. Chinese people, for example, like to pick specific days or times for their children to be born. For practical reasons, some young couples may decide to give birth before September 1 (the first day of school) so that their children can go to school a year earlier. Still others may be so superstitious that they prefer even-numbered birth dates for their babies. Reasoning along this line, we would anticipate a C-section spike closer to Feb. 19, 2015, the beginning of the zodiac Year of Sheep, as children born in that year are considered unlucky.
Despite these practical or cultural factors, the rising C-section rate should be viewed more as a byproduct of the transitioning health system in China. The cultural mindset is put into practice largely because of the increasingly easy access to hospital delivery (nearly 100 percent of the babies in China are now delivered in hospitals) and modern medical technology (which has not only made it easier to identify women with high-risk pregnancies, but also improved the safety of surgery and anesthesia). This systemic change nurtures the perception of mothers-to-be that a single surgical incision is much easier to deal with than hours of labor pain.
Other health system changes have also fueled the shift toward C-sections. Midwives, who cannot perform C-sections, had played an important role in keeping the C-section rate low in China until the 1990s. By the turn of the century, traditional midwives had been phased out in China’s countryside. But in even many urban hospitals, many experienced midwives (zhuchanshi) left their profession due to poor pay and high career risk. As a result, the number of midwives in China is only 1/8 of that of Cambodia and 1/20 of United States. The shortage of experienced midwives to perform natural delivery means that obstetricians sometimes have no choice but to conduct C-sections. This is especially true when would-be mothers insist on having a C-section. Given the increasing violence against healthcare providers in Chinese hospitals, doctors who want to avoid conflict find it difficult to say no to the requests for a C-section. Also, since C-sections are more profitable than natural birth—hospitals generally have to spend more on natural childbirths, but are only allowed to charge half of the fees of a C-section—unscrupulous hospitals and doctors may take advantage of the information asymmetry between patients and healthcare providers to encourage the use of C-section.
In addition, the increasing demand for C-sections has been indirectly fueled by the one child per couple family planning policy. If women are not allowed to have a second baby, they tend to shorten their time horizon and become less worried that their uterus would be harmed by C-section.
True, C-sections are generally considered a safe procedure; they can help women at risk for complications with their pregnancy or labor avoid dangerous delivery situations and can save the life of the mothers and/or baby when emergencies occur. But as with any type of abdominal surgery, C-sections are also associated with risks and complications for both the mother (e.g., infection, hemorrhage or increased blood loss, injury to organs, adhesions, and extended hospital stay/recover time) and the baby (e.g., premature births, breathing problems, and fetal injury). For most pregnancies, cesarean delivery poses greater risk of maternal morbidity and mortality than vaginal births.
Indeed, a growing body of research over the past years points to previously unknown public health risks of C-sections. A 2011 study found that C-sections are a barrier to breastfeeding, as the former is associated with delayed skin-to-skin contact between mother and baby, increased formula feeding, and separation of mother and baby. Research also suggests that delivery shapes the establishment of children’s microbiota (the microbe population inhabiting a bodily organ) and subsequently plays a role in child health. Babies born through C-section are less exposed to their mother’s microbiota than those born through vaginal delivery. For example, C-section may inhibit the full growth of bifidobacteria probiotics in a baby’s gut, which could negatively affect her ability to extract nutrition from breast milk. A 2013 article published in Science Translational Medicine suggests that such a dysfunctional microbiome could lead to severe childhood malnutrition and early stunting (the irreversible outcome of chronic malnutrition in early childhood). In China, an estimated 12.7 million children are stunted. Stunted children are more likely to suffer later in life from non-communicable diseases, such as heart and kidney disease, obesity, and diabetes.
Research also suggests that by affecting the initial microbiota to which a neonate is exposed, C-section deliveries may lead to modification of the baby’s immune response system, which in turn may make her more susceptible to allergies and asthma later in life, even put her at higher risk of type 1 diabetes (T1D). The high C-section rate in China is indeed paralleled by rising T1D incidence. A recent study found a mean annual increase of 14.2 percent in the incidence of childhood T1D from 1997 to 2011 in Shanghai, which is expected to double from 2016 to 2020. In 2013, a team of scientists also discovered that people with altered gut microbiota are at risk of developing type 2 diabetes. In this sense, C-sections might be considered another important trigger of the looming diabetes epidemic in China.
In order to prevent the high C-section rate from translating into another public health crisis, the Chinese government should act now. In the short term, it should launch a nationwide public health education campaign so that the health risks of C-section are widely known in the society. But better informed moms-to-be alone are not going to significantly bring down the C-section rate, unless the government is willing to invest in the training of more experienced midwives, to deepen the healthcare delivery and payment reform, and to completely abandon the notorious one-child policy.