Cesarean Nation

The cautionary tale of how China came to have the world’s highest C-section rate.

Pregnant women share a room in the obstetrics ward at the Peking University First Hospital in Beijing
Pregnant women share a room in the obstetrics ward at the Peking University First Hospital in Beijing

Photograph by Frederic J. Brown/AFP/Getty Images.

In September 2010, the Chinese Web portal Netease posted a page titled “Why Are Chinese Women Afraid of Natural Childbirth?” The headline might have sounded hyperbolic, but it was anything but. The World Health Organization had just released the results of a survey examining delivery methods in Asia. In Chinese hospitals studied in 2007 and 2008, 46 percent of babies were born though cesarean section—the highest documented rate in the world. Interspersed with photos of pretty pregnant women, in a lavender font, Netease listed its six top reasons why women in China might opt for cesarean section. Some of them weren’t so different from the explanations you might see on an American Web site (No. 4 on the list: “I’d like to have a natural birth, but I’m afraid it will influence my sex life.”), while others were more exotic. (To wit: “My mother-in-law is superstitious about dates and wants to pick the time of birth.”) The No. 1 reason on the list? “Everybody else is having surgery.”

Skyrocketing numbers of cesarean births are hardly unique to China. The U.S. rate rose by 53 percent between 1996 and 2007, according to a recent report from the Centers for Disease Control and Prevention. Today, nearly one in three American babies are born via cesarean section, and many other countries are well beyond the WHO recommended threshold of 15 percent of deliveries. A previous WHO study [PDF] of Latin America found C-section rates topping 50 percent for private hospitals in Ecuador, Mexico, and Paraguay, while in much of Asia, a group of obstetrics researchers recently warned in the medical journal the Lancet, cesarean rates have reached “epidemic proportions.” But China is the leader of the pack by a long shot, due in part to its distinctive history. And understanding the causes of China’s surge in cesareans may help explain why C-section rates have risen as high as they have in other countries.

One of the leading causes of cesareans in countries such as the United States—hospital policies discouraging subsequent vaginal births by women who have had C-sections—isn’t an issue in China, thanks to the one-child policy. But the one-child policy has indirectly pushed the country’s C-section rate over the top, by setting off a cascade of cultural changes that transformed not just family size but the very nature of childbirth itself. When in 1970 the Italian director Michelangelo Antonioni filmed a cesarean birth at a hospital in Beijing, the conditions, as depicted in the documentary Chung Kuo, were crude. The nurses prepping the woman for surgery did not wear gloves, and the woman received only acupuncture as anesthetic. Still, the officials who chaperoned Antonioni’s tour of China were keen to show him the operation. Although it would be nine years before the one-child policy was unveiled, China’s experiments in birth control had already begun; other foreigners were invited to sit in on state-mandated abortions. Pregnant women’s bodies had already become the domain of not just doctors and hospital administrators but also of government officials.

Cesareans nonetheless remained rare for the next few decades, in part because they were relatively expensive. But in the 1990s, as a nationalized health care system gave way to a market-based model, C-sections took off. According to a study published in the Bulletin of the World Health Organization in 2007, China’s cesarean rate quadrupled in just eight years, from an estimated 5 percent of all births in 1993-94 to 20 percent in 2001-02.

Behind the spike was a profound cultural shift. Huang Juejue, the mother of a 3-month-old daughter born via cesarean section, told me that her parents’ generation “grew up in the countryside and thought every woman could have a natural birth.” For modern expectant women, by contrast, the combination of the one-child policy and feverish economic development has yielded an environment in which they—and the in-laws and husbands who have so much riding on a single birth—fear any potential misstep. Not only are pregnant women in China expected to take supplements, eat bitter medicinal soups, and avoid strenuous physical activity, they are pressured to wear antiradiation vests to protect their bellies from cellular phone signals and thick, unbecoming overalls adorned with teddy bears believed to soothe Baby. Masoud Afnan, chair of the

Obstetrics and Gynecology Department at Beijing United Family Hospital, said that “with the one-child policy, people don’t want to take any risks.” And many in China mistakenly believe cesareans to be safer for both mother and child. “As much as I try to tell patients what the evidence shows,” Afnan continued, “it’s not really so easy to convince them.”

As disposable income grew, the C-section came to be seen as the logical endpoint of the micromanaged pregnancy. Today this 21st-century brand of control mixes with ancient numerology and fortune-telling. Ding Lidan, a 26-year-old Hangzhou resident who is eight months pregnant, told me, “If a woman here gets a cesarean, she will typically hire a fortune teller to predict a good date and time of day for the operation.” Those who can’t afford to hire out turn to free fortune-telling websites or rely on their own intuition. (The sixth and eighth days of the lunar month are popular. Conversely, no one wants to give birth on Tomb Sweeping Day.) In some cities, obstetrics ward administrators consult the lunar calendar in scheduling doctors’ shifts.

Occasional overtime headaches notwithstanding, many doctors are happy to oblige. Though once ubiquitous in Chinese villages, midwives are rare today—some young women I spoke with did not know the Mandarin term for midwife—and, for the most part, childbirth is the domain of overworked obstetricians. “Patients demanding to have a cesarean do play a role,” said Yap-Seng Chong, an obstetrician at National University Hospital in Singapore and a critic of the increase in cesareans across Asia. But, he added, because of the convenience of scheduling cesarean births and a defensive approach to liability issues, “unfortunately physicians are quite happy to go along with that.”

Others say that doctors in China have another motivation: “Hospitals want to increase their revenue,” said Chen Fenglin, director of Antai Maternity Hospital in Beijing, a private facility that encourages natural childbirth. In large cities, a cesarean can cost upwards of $1,000—more than twice the fee for a vaginal birth. And according to the WHO study, 62 percent of Asian hospitals surveyed have a financial interest in performing C-sections.

As a result, even women intent on natural childbirth are now pressured into having the operation. Some Chinese doctors claim that because women today eat better than their mothers did, large fetal weight, or macrosomia, has become more frequent—fueling the need for C-sections. With few studies done on the matter, it’s difficult to say to whether macrosomia is genuinely on the rise. But doctors outside of China are skeptical. The situation may be similar to that in America, where suspected macrosomia is increasingly given as an indication for cesarean, even though the incidence of macrosomia is holding steady.

But whatever the exact mix of reasons for cesareans becoming normalized in the first place, their popularity is now self-perpetuating. In what may well be a cautionary tale for other countries whose rates are rising, many Chinese women now ask for cesareans, with the result that C-sections with no medical indication account for a quarter of cesareans in China, according to the WHO study (compared with 7 percent for all of Asia).

Ultimately, the one-child policy’s most significant contribution to China’s high C-section rate may lie in having erased any fear of the complications cesareans create for later deliveries. After all, the cesarean’s most significant risks to the mother—like a ruptured uterus or hemorrhaging caused by abnormalities in the placenta—only arise with later births. That may explain the attitude of women like Huang Na, a 31-year-old dentist in Shanghai who planned to have a natural birth but opted for a cesarean at the last minute in order to get the baby out before her husband left on a business trip. (She is not related to Huang Juejue.)

China may be approaching a turning point, however. Earlier this year a Beijing municipal health official condemned the popularity of C-sections and announced his department would launch a training program for midwives. Meanwhile, signs point to natural childbirth becoming trendy. Water births, while still rare, are now available in the most developed cities, as are an array of posh services directed at women wanting natural births; Antai Maternity Hospital, for example, offers birthing rooms with themes like “Mongolia” and “White House.” And some expectant women in the urban elite are beginning to seek out hospitals with lower cesarean rates, believing they’ll get better care.

If the C-section rate doesn’t start coming down soon, the Chinese government may find itself in a quandary. The one-child policy was only intended to last one generation, and calls for scaling it back are mounting. “The problem will be when they relax the one-child policy,” Beijing United Family Hospital’s Afnan said. “They’re going to have to be careful with all of these women who have had a C-section.”