Increased Cesarean Section Rates and
Emerging Patterns of Health Insurance
in Shanghai, China
Wen-Wei Cai, MD, James S. Marks, MD, MPH, Charles H. C. Chen, PhD,
You-Xien Zhuang, MD, Leo Morris, PhD, and Jeffrey R. Harris, MD, MPH
Introduction
The worldwide increase in the
cesarean section rate has become a major
public health concern."'" In the past
3 decades, the rate of cesarean births has
risen dramatically, especially in developed
countries.",2'6-8 In developing countries,
such as Brazil,9 Singapore,'0 and Hong
Kong," a similar trend has been emerging.
The increases have been attributed to such
factors as fetal monitoring with early detec-
tion of distress, the need for repeat cesarean
section, increasing maternal age at delivery,
socioeconomic factors, and changes in clin-
ical management of labor.3'4'8'9"12 Method of
payment has also been associated with
cesarean section rates in the United States,
with women who are privately insured hav-
ing higher rates.5"3"4
In China, several hospital reports indi-
cate that the proportion of births delivered
by cesarean section has increased.'5- 8 How-
ever, population-based data on cesarean
sections have not been available. A popula-
tion-based household health survey con-
ducted in the Minhang District of Shanghai
in October 1993 enabled us to examine this
issue in a defined Chinese population.
The objectives of this study were to
observe the trend in cesarean deliveries to
compare women who had cesarean births
with those who had vaginal births and to
determine the factors affecting the cesarean
section rate. Specifically, we examined how
the clinical indications, background vari-
ables of the women, and the form of med-
ical payment affected the cesarean section
rate in recent years.
Methods
The survey was conducted in the fall of
1993 in the Minhang District of Shanghai, a
largely suburban area southwest of central
Shanghai with a population of more than
half a million. A 2-stage stratified cluster
probability sample was used to randomly
select households from the official house-
hold registry. A total of 2716 households
with 8876 individuals were selected to be
interviewed by trained medical students and
local health workers. Of the individuals
selected, 8552 (96.3%) were successfully
interviewed. The 3.7% nonresponse rate
represented either refusals or residents not at
home during 3 attempted visits.
The survey instrument included ques-
tions on demographics, socioeconomic
background, health status and health ser-
vices, behavioral risks, matemal health, and
elderly health. Within this sample, 1959
married women younger than age 50 with at
least 1 live birth were asked the maternal
health questions. Study data collected from
the survey included year and method of last
delivery, self-reported complications during
pregnancy, birthweight, current medical
insurance/payment, current occupation and
income, current residence, and socioeco-
nomic and demographic information.
We examined the rate of cesarean sec-
tion births for a woman's most recent deliv-
ery in 3 time periods, 1960 through 1979,
1980 through 1987, and 1988 through 1993,
Wen-Wei Cai is with the Department of Maternal
and Child Health, School of Public Health, Shang-
hai Medical University, Shanghai, China. James S.
Marks, Charles H. C. Chen, Leo Morris, and Jef-
frey R. Harris are with the National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention,
Atlanta, Ga. You-Xien Zhuang is with the Min-
hang District Bureau of Public Health, Shanghai.
Requests for reprints should be sent to
Charles H. C. Chen, PhD, Mail Stop K-35, Centers
for Disease Control and Prevention, 4770 Buford
Hwy NE, Atlanta, GA 30341-3717.
This paper was accepted April 25, 1997.
American Journal of Public Health 777
Cai et al.

and in terms of the variables listed above.
To determine the factors affecting cesarean
section, we employed logistic regression
analysis to estimate how maternal occupa-
tion, income, and method of medical pay-
ment affected the cesarean section rate in
1988 through 1993.
Results
Univariate Analysis
Since 1960, there has been a substan-
tial upward trend in the rate of women
whose most recent delivery was by
cesarean section. Table 1 shows that the
overall rate of cesarean section deliveries
increased from 4.7% in 1960 through 1979
to 9.3% in 1980 through 1987 and to 22.5%
weight, maternal age and education, and
birth order in the 3 periods. In 1960 through
1979, before the economic reform and 1-
child family policy, the cesarean rate was
not significantly associated with any of the
variables. But after the economic reform
and the 1-child policy in the last 2 periods,
the rate was significantly related to all vari-
ables except birth order.
The cesarean section rates with and
without complications presented in Table 1
must be interpreted with caution: (1) the
number of women who reported having
complications was small, (2) women with
complications may have failed to report
them owing to failure to recall or lack of
awareness of the event. Thus, the cesarean
section rates shown in the table could
have been higher for women with complica-
tions and lower for women without compli-
tions were few and were randomly distrib-
uted among the respondents.
A considerable difference in the
cesarean section rate by birth order in the
first period disappeared in the second and
third periods. Thus, the variable of birth
order did not affect the upward trend for the
cesarean rate.
Table 2 examines the cesarean section
rate in the most recent period, 1988
through 1993, by maternal occupation,
income, residence, and medical payment.
These variables are not included in Table 1
because they are more closely indicative of
the women's status in the most recent time
period, rather than in the earlier time
periods.
The table shows that during 1988
through 1993, the rates of cesarean sections
were highest among women with nonagri-

in 1988 through 1993. The table also shows cations. However, such a bias might not cultural occupations and those with the
the cesarean section rate according to self- seriously affect the following logistic regres- highest family incomes. Suburban resi-
reported pregnancy complication, birth- sion analysis since the cases with complica- dents had a much higher rate of cesarean

TABLE 1-Percentage of Women Who Had a Cesarean Section, by Year of Their Most Recent Live Birth and by Selected
Variables: Minhang District, Shanghai, China (n = 1959)
Last Live Birth
1960 through 1979 1980 through 1987 1988 through 1993
% of Women No. Women % of Women No. Women % of Women No. Women
Who Had in Variable Who Had in Variable Who Had in Variable
Cesarean Category Cesarean Category Cesarean Category
Section Section Section
Total 4.7 621 9.3 884 22.5 454
Self-reported complication
at prenatal checkupsa
Yes 2.9 34 25.5 47 62.5 24
No 5.3 491 8.5 826 20.2 425
P .549 <.001 <.001
Birthweight, kg
1.30-2.49 5.0 20 5.5 31 20.0 15
2.50-2.99 5.0 100 8.6 162 24.3 74
3.00-3.49 5.7 299 7.9 392 18.6 210
3.50-3.99 3.2 158 8.9 259 21.1 128
4.00+ 2.3 44 25.0 40 55.6 27
P .720 .010 .001
Maternal ageb
18-23 3.7 108 5.5 363 12.1 231
24-25 4.6 223 6.1 245 27.1 92
26-27 5.9 169 15.4 149 31.3 67
28-43 4.2 119 18.3 126 43.8 64
P .829 <.001 <.001
Maternal education
Primary or less 4.2 354 9.4 224 8.2 49
High school 4.6 219 8.1 555 20.3 315
Junior college or higher 8.3 48 15.2 52 37.8 90
P .450 .069 <.001
Birth order
1st birth 6.5 292 9.2 813 22.5 423
2nd or higher 3.0 329 9.9 71 22.6 31
P .069 .879 .977
a1 12 women who did not have a prenatal checkup were excluded.
bWomen of unknown maternal age were excluded.

778 American Joumal of Public Health May 1998, Vol. 88, No. 5
 Shanghai Cesarean Sections

cesarean sections are performed because of

Table 2-Percentage of Women Who Had a Cesarean Section for Their Most a previous cesarean birth since the largest
Recent Birth, 1988 through 1993, by Maternal Occupation, Household proportion of deliveries in China are first
Income, Residence, and Medical Payment births. In this survey, over 90% of births to
1988 through 1993 women younger than age 35 were first
No. Women births. In comparison, more than 45% of
Variable Rate of Cesarean Section, % in Category the increase in US cesarean section rates
during the 1980s was due to repeat cesarean
Total 22.5 454 6
sections. Similarly, repeat cesarean sec-
Maternal occupation tions accounted for more than two thirds of
Farming 11.9 67 the increase in Canadian rates.3
Industry 25.4 244 Other factors seen in developed coun-
Services 21.2 118
tries should also be less important in
Housewife 28.0 25
p .110 China. In most countries, older maternal
Average annual per capita income, yuana age is strongly associated with an increased
500-1999 16.5 194 likelihood of cesarean section.5 8'12 In
2000-2999 23.6 127 China, however, an overwhelming propor-
3000 or more 30.8 133 tion of births occur before age 30. From
P <.001 1988 through 1993, more than 85% of live
Place of residence births were to women younger than age 28.
Rural 13.3 301 Women surveyed reported low rates of ele-
Suburban 40.5 153
P <.001 vated birthweight or medical complica-
Medical payment tions. Fetal monitoring is also much less
Government insurance (GI) 45.2 42 common in China than in the United
Labor insurance (LI) States. Thus, there would appear to be few
Suburban area 40.5 116 medical reasons for the increased rate of
Rural area 14.8 54 cesarean births.
Partial GI or LI 10.3 29
Cooperative insurance 10.8 176 Many studies have reported that
Self-payment 15.6 37 socioeconomic status and health insurance
P <.001 influence the rate of cesarean sec-
tion.89 2 In China, where the method of
a8.3 Yuan = US $1. health care financing has shifted greatly
since the 1980s, we found that the cesarean
section rate was closely associated with
health insurance that covers all or part of
delivery than rural residents. In terms of weight in 500-g increments (OR= 1.3), and the costs of cesarean section. The cesarean
medical payment, women with government method of payment (a categorical variable). rate was the highest among women with
health insurance had the highest rate of For the method of medical payment, government insurance, followed by those
cesarean births (45.2%), followed by those we excluded partial government and partial with labor insurance in suburban areas.
with labor insurance in suburban areas labor insurance because too few families Women with labor insurance in rural areas,
(40.5%), while those who had partial were in this category. We included self cooperative insurance, and self-payment
(10.3%) or cooperative (10.8%) insurance payment in the cooperative insurance cate- had equally low cesarean section rates.
had the lowest rates. gory, since cooperative insurance covers Government insurance for government
very little of the cost of cesarean sections. employees covers all the fees associated
Logistic Regression Analysis With cooperative insurance as the reference with cesarean sections, while a growing
category, women with government insur- proportion of the population that works in
To determine the independent effects ance (OR= 5.8) and women with labor factories receives labor insurance, which
of variables on a woman's likelihood of insurance in suburban areas (OR= 3.3) had covers different proportions of the costs of
having a cesarean section, we performed a significantly higher cesarean section rates, cesarean section depending on financial
series of logistic regression analyses for the while labor insurance in rural areas conditions and the site of factories. Gener-
births that occurred from 1988 through (OR= 1.3) was not statistically significant. ally, labor insurance in suburban areas cov-
1993. In these analyses, the method of ers higher proportions of the cost than in
delivery was treated as the dependent vari- rural areas. Cooperative insurance formerly
able and the factors described earlier as Discussion covered more than 80% of farmers, the
independent variables. Variables that no largest occupational group.22 This insurance
longer remained significant after other vari- The population-based data from this paid little of the costs for a cesarean sec-
ables were controlled for were not included survey document a dramatic increase in tion, especially in the poorer villages. 23,24
in the final model. cesarean section rates in the Minhang Dis- Other factors also probably affect the
The final model (Table 3) shows that trict of Shanghai. These rates in urban China cesarean section rate in China. In the past,
the cesarean section rate was significantly now approximate levels found in the United most Chinese physicians received most of
associated with self-reported complications States and other developed countries. their income as salary. Increasingly, they
(odds ratio [OR] = 4.5), maternal age in The rate in Shanghai is particularly must earn their income on a quasi fee-for-
single-year increments (OR= 1.1), birth- disturbing given that relatively few service basis. In many Chinese hospitals,

May 1998, Vol. 88, No. 5 American Journal of Public Health 779
Cai et al.
Table 3-Proportion of Births Delivered by Cesarean Section, 1988 through 1993
Independent Variable Odds Ratio
Complicationa 4.47
Birthweightb 1.32
Maternal agec 1.10
Medical paymentd
Government insurance 5.77
Labor insurance
Suburban area 3.31
Rural area 1.29
Cooperative insurance 1.00
aComplication (coded 1) vs no complication (coded 0).
b500-g increment.
Cl-year increment.
dA dummy variable with cooperative insurance (includes self-payment)
category. Code of 1 was used for government insurance, labor insurance (suburban), or
labor insurance (rural), and code of 0 was used otherwise. Partial government insurance
and labor insurance were excluded from this analysis because there were too few cases.
physicians now receive a higher payment
for a cesarean section than for a vaginal
delivery. This extra payment comes from
the hospital as well as from the patient's
insurance. The hospital also collects more
fees from the longer stay. In China, the
tremendous importance of having a healthy
baby (since a couple can have only one)
provides much of the impetus for having a
cesarean section.25 Many women request a
cesarean section, believing it to be easier
on the baby, more modem, and perhaps
easier on them.'3"14 Some also believe that
babies delivered by cesarean section will
be more intelligent.26
This study was conducted in one of the
most developed districts in China. It is
likely that there are differences in the type
and extent of insurance and the ease of
obtaining cesarean sections in Shanghai as
compared with other districts in China.
However, the pressures that lead toward an
increased cesarean section rate are unlikely
to diminish during the next several years
unless methods of payment and incentives
within the insurance system are changed.
The trend of increasing cesarean section
rates is a problem in itself, but more impor-
tant, it may indicate that China is headed
780 American Joumral of Public Health
95% Confidence Interval
1.76, 11.37
1.05,1.67
1.03, 1.18
2.72,12.24
1.83, 6.00
0.54, 3.09
(reference)
as the reference
toward a more costly, technology-driven
medical care system. D
Acknowledgment
This survey was supported by a grant from the
Rockefeller Foundation in collaboration with the
Centers for Disease Control and Prevention.
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