LAUSR

Objectives Since 2009, China has introduced policies, principally targeting health professionals, to reduce caesarean section (CS) overuse. In 2016, China endorsed a universal two-child policy. Advanced maternal age and previous CS may indicate changes in obstetric risks, which raise concerns on the need for and safety of CS. This study investigated changes in CS rates in 2008–2018, and factors associated with CS use during the period of transition from the one-child to two-child policy era. Design We used births data from the cross-sectional National Household Health Services Surveys in 2013 and 2018. Setting Population-based national survey. Participants Women who had the last live birth within 5 years before the survey. Primary outcome measure CS rate. Results Overall CS use increased from 40.9% in 2008 to 47.2% in 2014 with significant increase in rural areas and the western region, and slightly decreased to 45.2% in 2018 with the greatest decrease among nulliparous women. Maternal request for CS by urban nulliparous women decreased from 36.8% in 2008–2009 to 22.2% in 2016–2018, but this change was not statistically significant in rural areas. Maternal age over 35 years old (OR 2.40, 95% CI 1.72 to 3.35) and births that occurred at a private hospital (OR 1.52, 95% CI 1.25 to 1.86) were associated with CS use among nulliparous women in 2016–2018. The CS rate among multiparous women increased over time. Individual socioeconomic factors associated with CS use among multiparous women. Conclusions The CS rate rise in China in 2008–2018 is attributable to increased use in rural areas and the less developed western region. The population policy shift, alongside facility policies for unnecessary CS reduction, are likely factors in CS reduction in urban areas. The challenge remains to reduce unnecessary CS, at the same time as providing safe, universal access to CS for women in need.