Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers

Zhao, Peishan; Cai, Zhen; Huang, Aihua; Liu, Chunyuan; Li, Huiling; Yang, Shuwei; Hu, Ling

doi:10.1371/journal.pone.0251345

Cited by 9 publications

(6 citation statements)

References 27 publications

(41 reference statements)

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“…Similarly, when the patient load was high, midwives could not call anesthesiologists even when women demanded. The shortage of health workers in Japan and China has also led to a low incidence of labor epidural analgesia [11,26], which corroborates with our setting. As of January 2022, Bhutan has only six national anesthesiologists (0.9 per 100,000); two are on study leave.…”

Section: Challenges and Factors For Low Incidencesupporting

confidence: 89%

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Childbirth in Bhutan: A study on the use of neuraxial analgesia for labor pain

Yoezer¹,

Gyeltshen²,

Tshering³

2023

Public Health Challenges

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Background The practice of neuraxial labor analgesia (NLA) as a mode of pain relief was introduced in Bhutan in 2016 despite it being in practice for more than five decades. There is a lack of data on NLA in Bhutan. Therefore, this study describes the use of NLA and its outcome over 4 years in Bhutan. Methods A retrospective descriptive study was conducted from 1 January 2018 to 31 December 2021. The data were obtained from the Anesthesia Department, medical records, admission forms, and birth‐registers. A total of 524 women were included. Data were recorded using 2021 Microsoft Excel version 16.57 (22011101) and analyzed using Epi Info 7.2.5.0. Categorical data were summarized using frequencies and percentages. Continuous data were summarized using mean and standard deviation. Results The incidence of NLA usage was 3.5% (524/15,119). Most women were between 21 and 30 years (67.2%). Modes of delivery following NLA were spontaneous vaginal delivery, cesarean section, and assisted vaginal delivery 63.4%, 18.4%, and 18.3%, respectively. Non‐reassuring fetal status (37.5%) and failed progression of labor (36.5%) were the leading indications of cesarean section. The primary reason for assisted vaginal delivery was poor maternal effort (55.2%). Neonates of the mother who received neuraxial analgesia had neonatal jaundice in 8%, neonatal intensive care unit admission in 0.76%, and Apgar score less than 7 in 5.1% and 0.2% at 1 and 5‐min, respectively, after birth. Conclusion Although NLA is safe for both mothers and babies, its use is low in Bhutan. The probable reason for the low incidence could be a shortage of anesthesiologists, cultural beliefs, and lack of awareness. The Ministry of Health and the Department of Anesthesia should work together to improve the service.

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Section: Challenges and Factors For Low Incidencesupporting

confidence: 89%

“…Most Asian cultures believe birth is a natural process; pain builds the mother-child bond and represents the strength of the woman [11]. Due to these misconceptions, the NLA rate was low even in developed Asian countries like Japan and China [1,26]. Those beliefs are also seen among Bhutanese.…”

Section: Challenges and Factors For Low Incidencementioning

confidence: 99%

Childbirth in Bhutan: A study on the use of neuraxial analgesia for labor pain

Yoezer¹,

Gyeltshen²,

Tshering³

2023

Public Health Challenges

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“…Seven studies explicitly discussed providers’ beliefs around the relative safety of CS 37 41 51 54 60–62. The inclination to perform CS to avoid litigation risk can be motivated by providers’ belief that CS is a safer option than VB, and that CS guarantees the best outcome for mother and child 63.…”

Section: Resultsmentioning

confidence: 99%

“…Nineteen studies explicitly examined FoL as a driver for providers to agree to a CS based on maternal request and/or pressure by mothers and families 32 47 53 56 58–63 66–74…”

Section: Resultsmentioning

confidence: 99%

Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review

et al. 2023

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ObjectiveTo explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates.DesignScoping review.Data sourcesWe searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to 9 March 2022).Data extraction and synthesisData were extracted using a form specifically designed for this review and we conducted content analysis using textual coding for relevant themes. We used the WHO principles for the adoption of a behavioural science perspective in public health developed by the WHO Technical Advisory Group for Behavioural Sciences and Insights to organise and analyse the findings. We used a narrative approach to summarise the findings.ResultsWe screened 2968 citations and 56 were included. Reviewed articles did not use a standard measure of influence of fear of litigation on provider’s behaviour. None of the studies used a clear theoretical framework to discuss the behavioural drivers of fear of litigation. We identified 12 drivers under the three domains of the WHO principles: (1) cognitive drivers: availability bias, ambiguity aversion, relative risk bias, commission bias and loss aversion bias; (2) social and cultural drivers: patient pressure, social norms and blame culture and (3) environmental drivers: legal, insurance, medical and professional, and media. Cognitive biases were the most discussed drivers of fear of litigation, followed by legal environment and patient pressure.ConclusionsDespite the lack of consensus on a definition or measurement, we found that fear of litigation as a driver for rising CS rates results from a complex interaction between cognitive, social and environmental drivers. Many of our findings were transferable across geographical and practice settings. Behavioural interventions that consider these drivers are crucial to address the fear of litigation as part of strategies to reduce CS.

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“…However, the historical estimated overall prevalence of neuraxial analgesia use in China was 10% [ 21 ], while this ratio in France and the United States was 88% and 73%, respectively [ 4 , 22 ]. Meanwhile, the rate of cesarean delivery in China was among the highest worldwide in 2007 (46%) and 2014 (35%) [ 23 – 25 ]. The high rate of caesarean section may be explained by medical, social, cultural and individual factors, and can also be influenced by family members and health professionals [ 26 ].…”

Section: Discussionmentioning

confidence: 99%

Procedural analgesic interventions in China: a national survey of 2198 hospitals

Wang

Xu²,

Zhao³

et al. 2022

BMC Anesthesiol

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Background Humane treatment requires the provision of appropriate sedation and analgesia during medical diagnosis and treatment. However, limited information is available about the status of procedural analgesic interventions in Chinese hospitals. Therefore, a nationwide survey was established to identify challenges and propose potential improvement strategies. Methods Forty-three members of the Pain Group of Chinese Society of Anesthesiology established and reviewed the questionnaire, which included (1) general information on the hospitals, (2) the sedation/analgesia rate in gastrointestinal endoscopy, labor, flexible bronchoscopy, hysteroscopy in China, (3) staff assignments, (4) drug use for procedural analgesic interventions, and (5) difficulties in procedural analgesic interventions. The data were obtained using an online questionnaire sent to the chief anesthesiologists of Chinese hospitals above Grade II or members of the Pain Group of Chinese Society of Anesthesiology. Results Valid and complete questionnaires were received from 2198 (44.0%) hospitals, of which 64.5% were Grade III. The overall sedation/analgesia rates were as follows: gastroscopy (50.6%), colonoscopy (53.7%), ERCP (65.9%), induced abortion (67.5%), labor (42.3%), hysteroscopy (67.0%) and fiber bronchoscopy (52.6%). Compared with Grade II hospitals, Grade III hospitals had a higher proportion of procedural analgesic interventions services except for induced abortion. On average (median [IQR]), each anesthesiologist performed 5.7 [2.3—11.4] cases per day, with 7.3 [3.2—13.6] performed in Grade III hospitals and 3.4 [1.8—6.8] performed in Grade II hospitals (z = -7.065, p < 0.001). Conclusions Chinese anesthesiologists have made great efforts to achieve procedural analgesic interventions, as evidenced by the increased rate. The uneven health care provided by hospitals at different levels and in different regions and the lack of anesthesiologists are the main barriers to optimal procedural analgesic interventions.

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Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers

Cited by 9 publications

References 27 publications

Childbirth in Bhutan: A study on the use of neuraxial analgesia for labor pain

Childbirth in Bhutan: A study on the use of neuraxial analgesia for labor pain

Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review

Procedural analgesic interventions in China: a national survey of 2198 hospitals

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