R. William Stones

Delivery settings and caesarean section rates in China

OBJECTIVE To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China. METHODS We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables. FINDINGS Institutional births increased from 53.5% in 1993-1994 to 82.2% in 2001-2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4-11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001). CONCLUSION The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and womens demand for the procedure.

HIV/AIDS in rural India: context and health care needs.

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their childrens care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations.

Pathways to evidence-based reproductive healthcare in developing countries

Objective Developing country clinicians are aware of the discourse of evidence‐based medicine but heavily constrained in their ability to access and apply new knowledge. This study aimed to obtain primary descriptive data about access to and application of reproductive health‐related medical knowledge in developing countries.

Pelvic girdle pain in pregnancy

Exercises may help, and evidence is increasing that acupuncture reduces pain

Entorno de parto y tasas de cesárea en China

Introduction Rates of caesarean section in many countries have increased beyond the recommended level of 15%, (1) almost doubling in the last decade, especially in high-income areas such as Australia, France, Germany, Italy, North America and the United Kingdom of Great Britain and Northern Ireland (UK). (2-7) Similar trends have also been documented in low-income countries such as Brazil, China and India, especially for births in private hospitals. (8-12) Advanced healthcare technologies are becoming more widely available in different regions of China. Following health-care reforms introduced in the 1990s, a large proportion of Chinese women, including those from the less-developed western region, now seek early antenatal and delivery care in health institutions. The number of caesarean-section births has increased sharply especially in the eastern region, which covers the major cities of Beijing, Shanghai and Tianjin. (12) Recent evidence also shows increasing demand for caesarean section among young, educated women residing in urban areas. (13) Many Chinese couples now delay childbearing, aim to have not more than one birth experience and opt for delivery by caesarean section to avoid pain. (13,14) Data from hospital-based studies in urban China showed rates of caesarean section of between 26% and 63% during the late 1990s. (15-18) 18 Another population-based study reported a substantial increase during the last three decades, from 4.7% to 22.5%. (12) These trends are expected to persist in view of the unparalleled economic growth and rapid expansion of private health care and health insurance systems across China. Apart from the clinical indications for caesarean section--breech presentation, dystocia and suspected fetal compromise--there is growing evidence that many women choose delivery by caesarean section for personal reasons, particularly in profit-motivated institutional settings that may provide implicit or explicit encouragement for such interventions. (13,19) The goal of our research was to quantify the influence of increased overall use of health-care services on rising rates of caesarean section in China. We hypothesized that the increase in institutional births and use of modern obstetric technologies explain the observed increase in rates of caesarean section. Methods Data sources We used data from a population-based survey conducted during September 2003 in 30 selected counties covering all provinces in all three regions of China. The survey was coordinated by the United Nations Population Fund (UNFPA) in collaboration with Chinas National Population and Family Planning Commission and health ministry. The counties were selected on the basis of planned future participation in UNFPA-linked reproductive health programmes. The sample of countries chosen in the survey was not intended to be nationally representative, but it covers the three regions and represents relatively developed Chinese areas in terms of socioeconomic status. The survey was based on household population records and the design included a stratified multi-stage selection of a sample of women aged 15-49 years. The 30 selected counties defined a population of townships. In the first stage of the analysis, these were stratified by region (eastern, central, western) and by residence (rural or urban). Within each region, 35 townships were selected; this sample was divided between urban and rural strata proportional to the population of women aged 15--49 years, subject to a minimum urban sample of seven townships. At the second stage, four local communities were selected proportional to the population of women aged 15-49 years from each selected township. At the final stage, a systematic random sample of 20 women was selected from a list ordered by age of all women aged 15-49 years within each selected community. This led to a final sample of 8400 women aged 15-49 years from 8400 households (2800 women per region and 80 women from each of the 105 sampled townships). …

Management of chronic pelvic pain: evidence from randomised controlled trials

Chronic pelvic pain is a common condition in women and rates of consultation in general practice are similar to those for asthma and migraine. USA and UK population‐based studies, together with data from UK hospital settings, demonstrate a substantial impact of chronic pelvic pain on health related quality of life. In this review we examine the current evidence for treatment of the condition, focusing on randomised controlled trials and including some insights from studies of women with dysmenorrhoea.