Hospital variations in caesarean delivery rates: An analysis of national data in China, 2016-2020

Background The impact of China's use of caesarean deliv-ery on global public health has been a long-term concern. The number of private hospitals is increasing in China and likely driving up caesarean delivery rates, yet specifics remain un-known. We aimed to investigate variations in caesarean deliv-ery rates across and within hospital types in China.Methods We retrieved data on hospital characteristics and na-tional hospital-level annually aggregated data on the number of deliveries and caesarean deliveries from 2016-2020, covering 7085 hospitals in 31 provinces of mainland China, from the National Clinical Improvement System. We categorized hospi-tals as public-non-referral (n = 4103), public-referral (n = 1805) and private (n = 1177). Among the private hospitals, 89.1% (n = 1049) were non-referral regarding obstetrical services for uncomplicated pregnancies.Results Among 38 517 196 deliveries, 16 744 405 were caesare-an, giving an overall rate of 43.5% with a minor range of 42.9%-43.9% over time. Median rates differed across hospital types, from 47.0% (interquartile range (IQR) = 39.8%-55.9%) in pub-lic-referral, 45.8% (36.2%-55.8%) in private, and 40.3% (30.6%-50.6%) in public-non-referral hospitals. The stratified analyses corroborated the results, except for the northeastern region, where the median rates did not differ across the public-non-re-ferral (58.9%), public-referral (59.3%), and private (58.8%) hos-pitals, while all ranked higher than the other regions, regardless of hospital type and urbanization levels. The rates within hos -pital types differed as well, especially in the rural areas of the western region of China, where the difference of rates between the 5th and 95th percentiles was 55.6% (IQR = 4.9%-60.5%) in public-non-referral, 51.5% (IQR = 19.6%-71.1%) in public-refer-ral, and 64.6% (IQR = 14.8%-79.4%) in private hospitals.Conclusions Variation across hospital types in China was pro-nounced, with the highest rates either in public-referral or pri -vate hospitals, except in the northeastern region, where no variation was observed among the high rates of caesarean de-liveries. Variation within each hospital type was pronounced, especially in rural areas of the western region.