Cesarean section in China, Taiwan, and Hong Kong: A safe choice for women and clinicians?

Recent high cesarean section (CS) rates around the world have sparked intense interest in the underlying drivers, partly to inform efforts to reduce CS rates. This week in PLOS Medicine, Long and colleagues report on these trends from multiple perspectives in mainland China, Taiwan, and Hong Kong, where recent social, political, and economic changes have impacted birth plans [1]. These settings—with respective CS rates of 34.9%, 27.4%, and 35%—reside near the top of the CS birth rate tables, alongside Brazil, Egypt, and Turkey, each reporting rates of over 45% [2].

Using meta-analysis and meta-ethnography to synthesise quantitative and qualitative studies respectively, Long and colleagues assessed the proportion of women who prefer CS at various time points in pregnancy and the factors influencing CS preferences among women, their family members, healthcare providers, and policy makers. The prospectively registered study stands out among related work because of the meticulous efforts made to understand and contextualise how nonclinical considerations lead to plans for CS births. After screening 22,932 citations identified in a systematic search, the authors included 66 papers, 45 of which were Chinese-language publications. In addition to detailing why many CS plans are made, the authors also report a recent shift towards placing greater value on vaginal birth in studies from mainland China. The latter observation supports previously reported impressions that removal of China’s one-child policy, in addition to multiple strategies to reduce CS rates, has led to an increase in vaginal births in women who previously gave birth by CS