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veruse of cesarean delivery can jeopardize maternal and child health. 1,2 Concerns about "alarming" 3 rates in China increased after the World Health Organization (WHO) 4 reported that 46.2% of births were delivered by cesarean in the years 2007 and 2008, based on an analysis of 14 541 deliveries in 21 hospitals in 3 provinces. With a population of approximately 1.37 billion in 2014, China's health care use is of substantial global interest. Over the past 2 decades, the nation has invested in improving maternal and child health. The Law on Maternal and Infant Health Care was passed in 1995 to provide a high-quality hospital delivery to all women. 5 Health insurance expansion began in 2003, to provide better financial access to maternity care. 6 In 2009, a comprehensive health care reform plan included subsidies for in-hospital delivery to pregnant women in rural areas. 7 In 2008, 89.9% of deliveries occurred in hospitals, and 87.9% of families had health insurance. 6 By 2014, 99.6% of deliveries occurred in hospitals. 8 China's increasing cesarean rate has been spurred by many factors, including expanded access to hospital care, medicolegal concerns, financial incentives for physicians to perform cesareans, and parents' focus on having a "perfect baby" under the one-child policy. 9,10 Since 2002, reducing the cesarean rate has been a national priority, 11 and a variety of policies, programs, and activities have emerged at the central government, 12 provincial or municipal, 13 city, 14 and city district or county levels. 15 There is no national IMPORTANCE The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China's cesarean rate have been based on surveys with limited geographic coverage. OBJECTIVE To provide updated information about cesarean rates and geographic variation in cesarean use in China. DESIGN, SETTING, AND DATA SOURCES Descriptive study, covering every county (n = 2865) in mainland China's 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014. EXPOSURES Live births. MAIN OUTCOMES AND MEASURES Annual rate of cesarean deliveries. RESULTS Over the study period, there were 100 873 051 live births, of which 32 947 229 (32.7%) were by cesarean delivery. In 2008, there were 13 160 634 live births, of which 3 788 029 (28.8%) were by cesarean delivery and in 2014 there were 15 123 276 live births, of which 5 280 124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation's 17 "super cities" had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality. CONCLUSIONS AND RELEVANCE Between 2...

The article revisits spatial interaction and distance decay from the perspective of human mobility patterns and spatially-embedded networks based on an empirical data set. We extract nationwide inter-urban movements in China from a check-in data set that covers half a million individuals within 370 cities to analyze the underlying patterns of trips and spatial interactions. By fitting the gravity model, we find that the observed spatial interactions are governed by a power law distance decay effect. The obtained gravity model also closely reproduces the exponential trip displacement distribution. The movement of an individual, however, may not obey the same distance decay effect, leading to an ecological fallacy. We also construct a spatial network where the edge weights denote the interaction strengths. The communities detected from the network are spatially cohesive and roughly consistent with province boundaries. We attribute this pattern to different distance decay parameters between intra-province and inter-province trips.

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SummaryBackgroundAs one of only a handful of countries that have achieved both Millennium Development Goals (MDGs) 4 and 5, China has substantially lowered maternal mortality in the past two decades. Little is known, however, about the levels and trends of maternal mortality at the county level in China.MethodsUsing a national registration system of maternal mortality at the county level, we estimated the maternal mortality ratios for 2852 counties in China between 1996 and 2015. We used a state-of-the-art Bayesian small-area estimation hierarchical model with latent Gaussian layers to account for space and time correlations among neighbouring counties. Estimates at the county level were then scaled to be consistent with country-level estimates of maternal mortality for China, which were separately estimated from multiple data sources. We also assessed maternal mortality ratios among ethnic minorities in China and computed Gini coefficients of inequality of maternal mortality ratios at the country and provincial levels.FindingsChina as a country has experienced fast decline in maternal mortality ratios, from 108·7 per 100 000 livebirths in 1996 to 21·8 per 100 000 livebirths in 2015, with an annualised rate of decline of 8·5% per year, which is much faster than the target pace in MDG 5. However, we found substantial heterogeneity in levels and trends at the county level. In 1996, the range of maternal mortality ratios by county was 16·8 per 100 000 livebirths in Shantou, Guangdong, to 3510·3 per 100 000 livebirths in Zanda County, Tibet. Almost all counties showed remarkable decline in maternal mortality ratios in the two decades regardless of those in 1996. The annualised rate of decline across counties from 1996 to 2015 ranges from 4·4% to 12·9%, and 2838 (99·5%) of the 2852 counties had achieved the MDG 5 pace of decline. Decline accelerated between 2005 and 2015 compared with between 1996 and 2005. In 2015, the lowest county-level maternal mortality ratio was 3·4 per 100 000 livebirths in Nanhu District, Zhejiang Province. The highest was still in Zanda County, Tibet, but the fall to 830·5 per 100 000 livebirths was only 76·3%. 26 ethnic groups had population majorities in at least one county in China, and all had achieved declines in maternal mortality ratios in line with the pace of MDG 5. Intercounty Gini coefficients for maternal mortality ratio have declined at the national level in China, indicating improved equality, whereas trends in inequality at the provincial level varied.InterpretationIn the past two decades, maternal mortality ratios have reduced rapidly and universally across China at the county level. Fast improvement in maternal mortality ratios is possible even in less economically developed places with resource constraints. This finding has important implications for improving maternal mortality ratios in developing countries in the Sustainable Development Goal era.FundingNational Health and Family Planning Commission of the People's Republic of China, China Medical Board, WHO, University of ...