• Hong-Tian Li, Shusheng Luo, Leonardo Trasande, Susan Hellerstein, Chuyun Kang, Jia-Xin Li, Yali Zhang, Jian-Meng Liu, and Jan Blustein.
• Institute of Reproductive and Child Health, Ministry of Health Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China2Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China3Office for National Maternal and Child Health Statistics of China, School of Public Health, Peking University Health Science Center, Beijing, China.
• JAMA. 2017 Jan 3; 317 (1): 69-76.

ImportanceThe 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.ObjectiveTo provide updated information about cesarean rates and geographic variation in cesarean use in China.Design, Setting, And Data SourcesDescriptive 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.ExposuresLive births.Main Outcomes And MeasuresAnnual rate of cesarean deliveries.ResultsOver 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 RelevanceBetween 2008 and 2014, the overall annual rate of cesarean deliveries increased in China, reaching 34.9%. There was major geographic variation in rates and trends over time, with rates declining in some of the largest urban areas.

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