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.

SummaryBackgroundChina has achieved Millennium Development Goal 4 to reduce under-5 mortality rate by two-thirds between 1990 and 2015. In this study, we estimated the national and subnational levels and causes of child mortality in China annually from 1996 to 2015 to draw implications for achievement of the SDGs for China and other low-income and middle-income countries.MethodsIn this systematic analysis, we adjusted empirical data on levels and causes of child mortality collected in the China Maternal and Child Health Surveillance System to generate representative estimates at the national and subnational levels. In adjusting the data, we considered the sampling design and probability, applied smoothing techniques to produce stable trends, fitted livebirth and age-specific death estimates to natvional estimates produced by the UN for international comparison, and partitioned national estimates of infrequent causes produced by independent sources to the subnational level.FindingsBetween 1996 and 2015, the under-5 mortality rate in China declined from 50·8 per 1000 livebirths to 10·7 per 1000 livebirths, at an average annual rate of reduction of 8·2%. However, 181 600 children still died before their fifth birthday, with 93 400 (51·5%) deaths occurring in neonates. Great inequity exists in child mortality across regions and in urban versus rural areas. The leading causes of under-5 mortality in 2015 were congenital abnormalities (35 700 deaths, 95% uncertainty range [UR] 28 400–45 200), preterm birth complications (30 900 deaths, 24 200–40 800), and injuries (26 600 deaths, 21 000–33 400). Pneumonia contributed to a higher proportion of deaths in the western region of China than in the eastern and central regions, and injury was a main cause of death in rural areas. Variations in cause-of-death composition by age were also examined. The contribution of preterm birth complications to mortality decreased after the neonatal period; congenital abnormalities remained an important cause of mortality throughout infancy, whereas the contribution of injuries to mortality increased after the first year of life.InterpretationChina has achieved a rapid reduction in child mortality in 1996–2015. The decline has been widespread across regions, urban and rural areas, age groups, and cause-of-death categories, but great disparities remain. The western region and rural areas and especially western rural areas should receive most attention in improving child survival through enhanced policy and programmes in the Sustainable Development Goals era. Continued investment is crucial in primary and secondary prevention of deaths due to congenital abnormalities, preterm birth complications, and injuries nationally, and of deaths due to pneumonia in western rural areas. The study also has implications for improving child survival and civil registration and vital statistics in other low-income and middle-income countries.FundingBill & Melinda Gates Foundation.

Using human papillomavirus (HPV) testing for cervical cancer screening in lower-resource settings (LRS) will result in a significant number of screen-positive women. This analysis compares different triage strategies for detecting cervical precancer and cancer among HPV-positive women in LRS. This was a population-based study of women aged 25–65 years living in China (n = 7,541). Each woman provided a self-collected and two clinician-collected specimens. The self-collected and one clinician-collected specimen were tested by two HPV DNA tests—careHPV™ and Hybrid Capture 2; the other clinician-collected specimen was tested for HPV16/18/45 E6 protein. CareHPV™-positive specimens were tested for HPV16/18/45 DNA. HPV DNA-positive women underwent visual inspection with acetic acid (VIA) and then colposcopic evaluation with biopsies. The performance for detection of cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) among HPV DNA-positive women was assessed for different triage strategies: HPV16/18/45 E6 or DNA detection, VIA, colposcopic impression, or higher signal strength (≥10 relative light units/positive control [rlu/pc]). The percent triage positive ranges were 14.8–17.4% for VIA, 17.8–20.9% for an abnormal colposcopic impression; 7.9–10.5% for HPV16/18/45 E6; 23.4–28.4% for HPV16/18/45 DNA; and 48.0–62.6% for higher signal strength (≥10 rlu/pc), depending on the HPV test/specimen combination. The positivity for all triage tests increased with severity of diagnosis. HPV16/18/45 DNA detection was approximately 70% sensitive and had positive predictive values (PPV) of approximately 25% for CIN3+. HPV16/18/45 E6 detection was approximately 50% sensitive with a PPV of nearly 50% for CIN3+. Different triage strategies for HPV DNA-positive women provide important tradeoffs in colposcopy or treatment referral percentages and sensitivity for prevalent CIN3+.What's new?The careHPV™ test is a novel technology for primary cervical cancer screening of women from lower-resource settings. However, triage strategies are needed to identify which HPV-positive women are at highest risk of cervical precancer and cancer. Here, multiple viable and affordable strategies to manage HPV-positive women depending on local requirements and resources are identified, based on evaluation of the performance of different triage strategies for developing countries. The different strategies for women who test positive for HPV DNA provide important tradeoffs in colposcopy or treatment referral percentages and sensitivity for cervical intraepithelial neoplasia grade 3 or cancer (CIN3+).

ObjectivesWe investigated the mortality rate of pneumonia (PMR) among children under 5 and its time trend from 1996 to 2013 to determine the priorities for ending preventable deaths from pneumonia in children under 5, and share China’s successful experience in reducing PMR with other developing countries.MethodsWe used data from China’s Under 5 Child Mortality Surveillance System (U5CMSS) to calculate the PMR and the proportion of pneumonia deaths to total deaths of children under 5. The data were grouped by urban and rural areas with Cochran-Mantel-Haensel (CMH) test and Chi-square test to examine the differences of PMR and proportion. The time trend was tested by Cochran-Armitage trend test.ResultsThe overall PMR of children under 5 was reduced by 85.5% (from 1053.2 to 153.2 per 100,000 live births) from 1996 to 2013, with the urban and rural areas reduced by 69.1% (from 188.4 to 58.2 per 100,000 live births) and 84.7% (from 1252.8 to 191.9 per 100,000 live births), respectively. The overall proportion of pneumonia deaths to total deaths was also declined from 23.4% in 1996 to 12.8% in 2013, with the rural areas decreased from 24.4% to 13.2% and the urban areas decreased from 11.1% to 9.7%. The PMRs in neonates (0-27 days), post-neonates (1-11 months), and childhood (12-59 months) were reduced by 80.7%, 77.4%, and 80.1%, respectively in rural areas, and 71.7%, 69.6%, and 39.0%, respectively in urban areas. During 1996-2013, the PMR in children under 5 years was 4.9 fold higher in rural areas relative to that in urban areas, with relative risk (RR) of 3.6 and 6.4 in neonates and 1- to 59-month-old children, respectively.ConclusionsPMR in children under 5 significantly declined in China from 1996 to 2013, especially in rural areas. However, huge disparities still existed between rural and urban areas. Infants had the highest PMR, which indicated that interventions aiming at prevention and control of infant pneumonia should be the priority for further reducing PMR in China.

BackgroundIn China, high-risk human papillomavirus (HR-HPV) prevalence is unexpectedly high in older women, but the possible reasons have not been well studied yet. This study investigated the age trends of HR-HPV infection in a prospective study.MethodsA total of 7397 women aged 25-65 years without cervical precancer or cancer were evaluated during 2010-2011 with a stratified sample of 2791 women re-evaluated after one year. Test results for careHPV and careHPV16/18/45 were used to describe the HR-HPV prevalence, incidence and clearance. Risk factors associated with HR-HPV infections were explored using a logistic regression model.ResultsThe overall HR-HPV prevalence was 13.1% at baseline, with a peak of 19.3% in women aged 55-59 years. The prevalence of HR-HPV (p for trends < 0.001), HPV16/18/45 (p for trends = 0.002), and HR-HPV other than HPV16/18/45 (p for trends = 0.002) generally increased with increasing age. Number of infections that cleared was generally greater than number of incident infections within age groups. One-year clearance rate decreased with increasing age (p for trends < 0.001), however, incidence rate was unrelated to age (p for trends = 0.159). Risk factors that associated with HR-HPV infection differed between younger and older women.ConclusionsThe greater HR-HPV prevalence in older versus younger women in rural China may be explained by a cohort effect, higher than expected incidence, and/or poorer clearance at older age.

PurposeTo evaluate the association of p16/Ki-67 co-expression and persistence of high-risk human papillomavirus (HR-HPV) infection as well as cervical abnormalities.MethodsWe performed a 3-year cohort study among which 2498 Chinese women aged 25 to 65 years were screened by different HPV tests in 2011. 690 women who were positive at any of the tests and a random sample of 164 women with all negative results received colposcopy, cervical specimens for cobas HPV test (Roche diagnostics) were collected before colposcopy; of this group, 737 cervical specimens were collected to perform cobas, Liquid-based cytology, HPV E6 test (Arbor Vita Corporation) and p16/Ki-67 dual staining (Roche diagnostics) in 2014. Colposcopy and biopsies was performed on women with any abnormal result.ResultsCompared to women without HR-HPV persistent infection, women in the HR-HPV persistence group had a higher risk of p16/Ki-67 positive, with an adjusted Odds Ratio(OR) and 95% confidence interval (CI) of 6.29 (4.07-9.72); moreover, adjusted odds ratio for women who had HPV16/18 persistent infection was nearly 4-folder higher than women with other 12 HR-HPV persistent infection (adjusted OR = 17.15, 95% CI: 7.11-41.33 vs adjusted OR = 4.68, 95% CI: 2.89-7.58). Additionally, p16/Ki-67 positivity rate significantly increased with the severity of the cytological and histological abnormalities, and resulted strongly associated with a CIN2+ diagnosis (OR = 16.03, 95% CI: 4.46-57.59).Conclusionsp16/Ki-67 co-expressions associated strongly with HR-HPV persistence, especially with HPV16/18, and the presence of a CIN2+ lesion. Therefore, p16/Ki-67 could be considered as a suitable biomarker for cervical cancer screening, particularly in HPV-based screening programs.

WHAT THIS PAPER ADDSThis meta-analysis presents the pooled quantitative evidence of basic profiles, initial treatment strategies, and clinical outcomes in patients with isolated abdominal aortic dissection. Major findings suggest that appropriate initial treatment strategies can obtain acceptable clinical outcomes, with a 30 day mortality of 3%, a long term mortality of 8%, and a re-intervention rate of 8%. Endovascular repair or open surgery is necessary if patients match certain indications for intervention. Regular imaging surveillance should be provided for all patients, especially those treated conservatively, who appear to be most at risk of second intervention.Objective: To present the pooled quantitative evidence of basic profiles, initial treatment strategies, and clinical outcomes in patients with isolated abdominal aortic dissection (IAAD). Methods: A comprehensive systematic review and meta-analysis was performed of all available studies reporting IAAD, retrieved from the MEDLINE, Embase, and Cochrane Databases. The logistic normal random effect model was fitted using the generalised linear mixed model with random intercepts to calculate the pooled proportion estimates.Results: Seventeen studies with 482 patients were included in this meta-analysis. Male smokers with hyperlipidaemia and hypertension were the most prominent basic profile. IAADs were predominantly spontaneous and infrarenal, and roughly half were acute and symptomatic. Approximately 67% [95% confidence interval (CI) 42e86%] of patients were managed initially conservatively. In the overall population, the 30 day all cause mortality was 3% (95% CI 1e5%) and the long term mortality during follow up was 8% (95% CI 5e14%). Re-intervention during follow up occurred in 8% (95% CI 5e15%) of patients. In the subgroup analysis, patients with conservative treatment had a 30 day mortality of 1% (95% CI 0e8%), a long term mortality of 5% (95% CI 1e29%), and a re-intervention rate of 18% (95% CI 10e29%). Patients with open surgery had a 30 day mortality of 9% (95% CI 0e82%), a long term mortality of 12% (95% CI 4e31%), and a re-intervention rate of 9% (95% CI 1e44%). Patients with endovascular repair had a 30 day mortality of 2% (95% CI 0e10%), a long term mortality of 5% (95% CI 2e13%), a re-intervention rate of 6% (95% CI 3e 13%), and a persistent endoleak rate of 4% (95% CI 2e10%). Conclusion: Appropriate initial treatment strategies can be used to obtain acceptable clinical outcomes in patients with IAAD. Invasive intervention is necessary if patients match certain indications for intervention. Regular imaging surveillance should be provided for all patients, especially those treated conservatively.

ObjectiveTo examine the trends and safety of vaginal birth after caesarean section around the period of the one-child policy relaxation in China.MethodsWe used data from China's National Maternal Near Miss Surveillance System between 2012 and 2016. To examine trends in vaginal birth after caesarean section, we used Poisson regression with a robust variance estimator. We also assessed the association between vaginal birth after caesarean section and maternal and perinatal outcomes.FindingsWe analysed 871 636 deliveries by women with a previous caesarean section. Both in 2012 and 2016, the rate of vaginal birth after caesarean section was 9.8%. After adjusting for institutional, sociodemographic and obstetric characteristics, the rate increased by 14% between 2012 and 2016 (adjusted relative risk, aRR: 1.14; 95% confidence interval, CI: 1.07–1.21). Compared to women with a repeat caesarean section, women with a vaginal birth after caesarean section experienced lower incidence of uterine rupture (aRR: 0.26, 95% CI: 0.16–0.42), blood transfusion (aRR: 0.68, 95% CI: 0.53–0.87) and admission to the intensive care unit (aRR: 0.36, 95% CI: 0.25–0.52), but higher incidence of intrapartum stillbirths, (aRR: 7.20, 95% CI: 6.09–8.51), newborns with a 5-minute Apgar score less than 7 (aRR: 1.75, 95% CI: 1.54–1.99) and neonatal death before discharge (aRR: 1.90, 95% CI: 1.61–2.24).ConclusionPromotion of vaginal birth after caesarean section could increase the rate even further in China. To ensure the safety of mothers and their newborns, national policies and guidelines on vaginal birth after caesarean section are needed.