A Study On Associated Factors Related To High Cesarean Section Rate And Future Intervention Strategies From Perspectives Of Both Clients And Providers In One District Of Shanghai

BackgroundClinical data indicate that cesarean section is a fast, important, safe, commonly used and most effective method to solve dystocia. However, the rising cesarean section rate worldwide has aroused extensive concern of medical professionals. In particular, cesarean section rate in China has increased rapidly and was the highest in WHO global survey. It’s worth to expore the reasons behind.There are a large number of studies on assiciated factors of cesarean section, involving different factors at individual level, interpersonal level, organizational (hospital) level and social level. However. there are lack of researches on how maternal self-efficacy of vaginal delivery works on mode of delivery. Besides, most studies are delivery data analysis or one-time survey or qualitative research, and lack of chasing the changes of attitude on mode of delivery, the willingness to mode of delivery and associated factors in different stages of gestation, so as to determine critical periods and critical factors for intervention. In addition, there are a few:studies concerning factors from the perspectives of both providers and pregnant women.ObjectivesThrough a follow-up study of the gestation periods of primipara and qualitative study of physicians in department of obstetrics of two hospitals in one district in Shanghai, to explore the associated factors related to high cesarean section rate and propose interventions in terms of providers, pregnant women, health care financing and regulatory departments.Methods1. Quantitative research:outpatient department nurses included832primipara in second trimester and guided the included subjects to finish questionnaires firstly in the prenatal checkup department of obstetrics. The nurses then followed up the included primipara and guided them to finish questionnaires secondly in third trimester. Finally clinic nurses followed up the included primipara and guided them to finish questinonnaires after delivery.2. Qualitative research:personal in-depth interviews were conducted for12health providers with different titles and positions. Results1. Quantitative study:proportion for the willingness to cesarean section in second trimester was13.2%, in third trimester17.0%, and actual cesarean section rate was59.8%.1) Pregnant women who were older, had low self-efficacy of vaginal delivery and Shanghai local resident, intended to have one child, and misunderstood mode of delivery tended to have the willingness to cesarean section in second trimester. Self-efficacy was an independent factor of the willingness to cesarean section in second trimester.2) Cognition level of mode of delivery for pregnant women in third trimester had been improved compared with those in second trimester. But self-efficacy, proportion of the willingness to certain mode of delivery didn’t change. Pregnant women, who had low self-efficacy, Shanghai local resident and more times of previous abortions, intended to have one child, agreed that cesarean section was safe and had less birth pain intended to have the willingness to cesarean section in third trimester. Self-efficacy was an independent factor of the willingness to cesarean section in third trimester.3) Pregnant women who had low efficacy and Shanghai local resident, and agreed that cesarean section was safe were more likely to have cesarean section without indications. Low self-efficacy was an independent factor for cesarean section without indications. Self-reported reasons for cesarean section without indications included low self-efficacy and fear of vaginal delivery pain. Pregnant women with more times of previous abortions and Shanghai local resident were more likely to have cesarean section with ambiguous indications. Self-reported reason for cesarean section with ambiguous indications mainly focused on trust of cesarean section security. Physicians played a more important role during actual mode of delivery decision-making process in pregment women who had cesarean section with explicit and ambiguous indications than in those who had vaginal delivery and cesarean section without indications.2. Qualitative study:health providers fully understood the relationship of mode of delivery and maternal and child health, agreed that regulations of the hospitals to control cesarean section rate were stringent, denied that they could relax cesarean section indications due to physicians’income, agreed that lack of human resources would lead to that hospitals didn’t carry out Dola childbirth and pain-reducing interventions and agreed that tense doctor-patient relationship and pressure of medical disputes were reasons for relaxation of cesarean section indications.Conclusions and recommendationsLate period of third trimester and the period staying in maternity wards were critical periods for reducing cesarean section rate. Low self-efficacy and fear of childbirth pain were important reasons for pregnant women to have cesarean secions without indications. Physicians played a more important role in mode of delivery decision-making process in cesarean section with explicit indications and ambiguous indications. However, tense doctor-patient relationship was an important factor for relaxation of cesarean section indications. The whole society should strive to improve the strained doctor-patient relationship; policymakers should strengthen the human resources in maternity facilities and implemented mandatory second opinion of mode of delivery to promote health providers to recognize indications correctly. Health providers should improve evidence for pregnant women to increase self-efficacy of vaginal delivery and cognition the benefits or harms of different mode of delivery throughout the whole process of maternal health care.