Evidence map›Paper›PMID 29506980›Full record

Observational studyBMJ (Clinical research ed.)2018

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births.

Juan Liang, Yi Mu, Xiaohong Li, Wen Tang, Yanping Wang, Zheng Liu, Xiaona Huang, Robert W Scherpbier, Sufang Guo, Mingrong Li and 7 more

Open access · hybridAbstract readObservational Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in BMJ (Clinical research ed.), 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 109 papers, 3 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
109citing papers in PubMed, 3 pooled it
29.3field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

109 citing papers in PubMed, 3 syntheses or guidelines pooled it, 248 citations in OpenAlex.

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  13. Are the Risk Factors for Developing Type 1 and Type 2 Cesarean Scar Pregnancy Different?Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine · 2025
    Article
  14. [Application of Magnetic Resonance Imaging in the Diagnosis and Treatment of Middle Compartment Defect].Sichuan da xue xue bao. Yi xue ban = Journal of Sichuan University. Medical science edition · 2025
    Review
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49 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

17 authors at 4 institutions in 2 countries.

Juan LiangNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Yi MuNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Xiaohong LiNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Wen TangNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Yanping WangNational Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Zheng LiuNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Xiaona HuangHealth, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China.
Robert W ScherpbierHealth, Nutrition and Water, Sanitation & Hygiene, UNICEF China, Beijing, China.
Sufang GuoUNICEF Regional Office for South Asia, Kathmandu, Nepal.
Mingrong LiNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Li DaiNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Kui DengNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Changfei DengNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Qi LiNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Leni KangNational Office for Maternal and Child Health Surveillance of China, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Jun ZhuNational Office for Maternal and Child Health Surveillance of China, Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
Carine RonsmansWest China School of Public Health, Sichuan University, Chengdu, Sichuan, China Carine.Ronsmans@lshtm.ac.uk.
West China Second University Hospital of Sichuan University · CNSichuan University · CNBeijing Institute of Water · CNLondon School of Hygiene & Tropical Medicine · GB

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectiveTo examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China.

designObservational study.

settingChina's National Maternal Near Miss Surveillance System (NMNMSS).

participants6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016.

main outcome measuresObstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time.

resultsCaesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time.

conclusionsChina is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter.

Indexed as

Family CharacteristicsParityAdultAge DistributionCesarean SectionChinaDelivery, ObstetricFamily Planning PolicyFemaleHospitalsHumansInfant, NewbornMaternal MortalityPerinatal MortalityPregnancyYoung Adult

Identifiers

PMID29506980
PMCPMC5836714
OpenAlexW2792650728

What OpenQuestion holds

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LicenceCC BY-NC
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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.