Large reductions in cesarean delivery rates in China: a qualitative study on delivery decision-making in the era of the two-child policy

Background: In 2010, China’s cesarean delivery (CD) rates increased to one of the highest in the world, a significant proportion of which were without medical indication. However, recent studies have indicated some declines, coinciding with national and local efforts to promote vaginal birth, as well as the relaxation of the one-child policy. Considering these trends, we aimed to qualitatively explore attitudes towards childbirth and experiences of delivery decision-making among women and physicians. Methods: Semi-structured interviews were conducted with 45 postpartum women and 7 healthcare providers at one county-level and one provincial-level maternity hospital in Zhejiang Province. We also collected routine data from 2007 to 2016 and observed doctor-patient interactions and hospital facilities as context for the interviews. Interviews were recorded, translated and transcribed into English, and then analyzed using a framework approach. Results: From 2007 to 2016, cesarean delivery rates at the county-level and provincial-level hospital decreased from 46% to 32% and 68% to 44%, respectively. For low-risk women, vaginal birth was the primary choice of delivery method, encouraged by doctors and nurse-midwives. Elective CD was not as widely accepted, in contrast to previous years. Women were aware of and took into consideration the consequences of CD for future pregnancies. Among those who delivered vaginally, women viewed the existing pain relief methods, epidurals and transcutaneous electrical nerve stimulation, with caution or uncertainty. Even when requested, epidurals were only given under certain circumstances. For multiparas with previous CD, repeat CD remains the norm. Both women and professionals were cautious about vaginal birth after cesarean delivery (VBAC) given the associated risks. Conclusion: In China, changes in family planning policy and efforts to promote vaginal birth have greatly changed the culture of delivery decision-making, leading to decreased CD rates. This demonstrates the powerful role social factors and public policy can play, and provides a model for other countries with high CD rates. Further research should explore changes in other reproductive decisions during this new multiparous era, particularly across provinces

Estimate of global human papillomavirus vaccination coverage: analysis of country-level indicators

BACKGROUND: Mortality rates from cervical cancer demonstrate deep inequality in health between richer and poorer populations. Over 310 000 women died of this preventable disease in 2018, mostly in low-income and middle-income countries (LMICs) where screening and treatment are beyond the capacity of health systems. Immunisation against human papillomavirus (HPV) offers a primary prevention strategy, but rates of vaccination uptake are unclear. Understanding coverage levels and factors affecting uptake can inform immunisation strategies. OBJECTIVES: The aim of this study is to evaluate the status of HPV vaccination coverage from nationally reported indicators and to estimate global coverage in a single year cohort of vaccine-eligible girls. DESIGN: This study provides quantitative population-level estimates of important global health indicators. Using data from the Global Cancer Observatory and WHO/UNICEF, incidence of and mortality from cervical cancer and HPV vaccination coverage are described for countries, categorised by income group. Characteristics of LMICs achieving high coverage are explored using selected development indicators from World Bank sources. Global HPV immunisation coverage is calculated and its impact on cervical cancer mortality estimated. RESULTS: Incidence and mortality for cervical cancer correlate with poverty. Whilst all WHO member states report high infant measles vaccination rates, fewer than half report on HPV vaccination. Even amongst high-income countries, coverage varies widely. In upper-middle-income countries, there is a trend for higher coverage with increased health spending per capita. Four LMICs report good coverage levels, all associated with external funding. Global HPV immunisation coverage for 2018 is estimated at 12.2%. Of the global cohort of 61 million 15-year-old girls in 2018, 7000 are likely to die from cervical cancer, almost all in LMICs. CONCLUSIONS: Countries in all income groups must devise strategies to achieve and maintain higher levels of HPV immunisation. For all but the richest, affordability remains a barrier

High sex ratios in rural China: declining well-being with age in never-married men

In parts of rural China male-biased sex ratios at birth, combined with out-migration of women, have led to highly male-biased adult sex ratios, resulting in large numbers of men being unable to marry, in a culture where marriage and reproduction are an expectation. The aim of this study was to test the hypotheses that older unmarried men are more predisposed to depression, low self-esteem and aggression than both those who are married, and those who are younger and unmarried. Self-completion questionnaires were administered among men aged 20-40 in 48 villages in rural Guizhou province, southwestern China. Tools used included the Beck Depression Inventory, the Rosenberg's Self-esteem Scale and the Bryant-Smith Aggression Questionnaire. Regression models assessed psychological wellbeing while adjusting for socio-demographic variables. Completed questionnaires were obtained from 957 never-married men, 535 married men aged 30-40, 394 partnered men and 382 unpartnered men aged 20-29. After adjusting for socio-demographic variables, never-married men were more predisposed to depression (p < 0.05), aggression (p < 0.01), low self-esteem (p < 0.05) and suicidal tendencies (p < 0.001). All the psychological measures deteriorated with age in never-married men. In contrast, married men remained stable on these dimensions with age. Never-married men are a psychologically highly vulnerable group in a society where marriage is an expectation. Since the highest birth sex-ratio cohorts have not yet reached reproductive age, the social tragedy of these men will last for at least another generation.This article is part of the themed issue 'Adult sex ratios and reproductive decisions: a critical re-examination of sex differences in human and animal societies'

Experiences and Perspectives of Traditional Bullying and Cyberbullying Among Adolescents in Mainland China-Implications for Policy

The prevalence of traditional bullying and cyberbullying is high among Chinese adolescents. The aims of this study are to explore: (1) characteristics of children who are targets or perpetrators of traditional bullying or cyberbullying; (2) causes of bullying in middle school; (3) reactions and coping strategies of bullying victims; and (4) impacts of bullying on victims' psychosocial well-being. Students were selected based on the findings of previous quantitative research at schools in Zhejiang, Henan, and Chongqing. Snowball sampling led to identification of more informants. Semi-structured interviews were conducted with students involved in traditional bullying and cyberbullying as perpetrators, victims, and bystanders. Forty-one students aged 12–16 years (21 boys and 20 girls) from 16 schools in three provinces participated. Data collection and analysis followed a grounded theory approach. Among these students traditional bullying was much more common than cyberbullying, but there was a large overlap between the two types. The results informed a conceptual framework which identified the main causes of bullying in these settings: these included lack of education about bullying, inadequate classroom and dormitory management, and teachers' failure to recognize and punish bullying. Children with specific characteristics (such as being unattractive or low-achieving), were more likely to be bullied. Most victims lacked support of parents and teachers even when requested, leading to poor psychosocial well-being, difficulties with socialization, and poor academic performance. Our findings suggest that schools need to address bullying culture, through multi-faceted locally-appropriate approaches, based on zero tolerance. It is crucial to ensure that students, teachers and parents recognize the importance of such interventions

Intimate Partner Violence and Depression in Women in China

Intimate partner violence (IPV) is recognized as a major public health and social problem globally, with consequences for the individual, family, and society. But there is relatively little research on IPV in China. The aim of this study was to estimate the prevalence of different types of violence among women and to determine the risk factors and the association with depression. A cross-sectional study among women who had ever been in a relationship was conducted in six provinces across the three regions of China from July to September 2018 using a self-completion questionnaire developed for the study. The provincial capital and one rural county were purposively selected in each province. Questionnaires were distributed in hospitals and public places. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure depression. Data for 2,987 women were analyzed. The prevalence of psychological, physical, and sexual violence was 77.7%, 40.2%, and 11%, respectively: 52% had experienced two or three types of violence in their life. After adjustment, risk factors for all-type IPV were low occupational status, having one child or more, living in western provinces, having an income lower than partner’s, and economic pressure. The prevalence of depression was 65.8% in women who experienced psychological violence, 69.5% for physical violence, and 75.8% for sexual violence. For psychological, physical, and sexual violence, the odds ratio for depression were 2.57 (95% confidence interval [CI] = [2.15, 3.07]), 2.07 [1.76, 2.43], and 2.26 [1.73, 2.95], respectively, after controlling for age, occupation, education attainment, and residence. There is a clear need to raise awareness about IPV and to develop approaches for prevention and management. The new Domestic Violence Law represents a step in the right direction

Childhood Maltreatment: Experiences and Perceptions Among Chinese Young People

The study aimed to investigate young Chinese people’s childhood and adolescence exposure to maltreatment from all types of perpetrators, and to explore their perceptions of such experiences. A cross-sectional study was carried out among 1,255 young people at three universities located in Zhejiang Province, Eastern China. A questionnaire drawing on validated tools was developed to measure childhood and adolescence exposure to physical and emotional maltreatment. Physical and emotional maltreatment by any perpetrator before the age of 18 years was reported by 83.3% and 85.9% of the students, respectively; extreme forms were not rare. Overall, 68.8% of the students reported physical maltreatment by parents, 56.1% by teachers, 29.8% by peers, 11.7% by siblings, and 9.1% by grandparents; 58.5% reported emotional maltreatment by parents, 43.3% by teachers, 53.3% by peers, 12.0% by siblings, and 10.0% by grandparents. Physical or emotional maltreatment by any perpetrator was common in all sociodemographic groups, irrespective of urban/rural residence and economic status. Risk factors for maltreatment differ with type of maltreatment and perpetrator. Personal experience of emotional maltreatment was generally perceived as more harmful and less acceptable than physical, especially in females. In conclusion, high levels of maltreatment of children and adolescents in China indicate the need for (a) parent education about appropriate discipline measures when raising children, (b) teacher education and enforcement of existing laws banning institutional corporal punishment, (c) the adoption of a comprehensive anti-bullying strategy, and (d) the development of a formal child protection system to protect and support the most vulnerable families

Educational aspirations and expectations of adolescents in rural China: Determinants, mental health and academic outcomes

Educational aspirations and expectations of adolescents have implications for educational and psychological outcomes. This study aimed to determine factors associated with educational aspiration–expectation discrepancies and to examine the associations between the discrepancies and psychological and academic outcomes in rural left-behind children and non-left-behind children aged 14–16 in mainland China. Cross-sectional data from a self-report survey were collected in 2020 among 606 rural students (mean age = 14.85 years) in two public middle schools in Songzi county, Hubei Province. Participants filled in questionnaires measuring their socio-demographic infor-mation, educational aspirations and expectations, academic performance, parental and friends’ as-pirations, academic self-perception, academic self-regulation, depression, and self-esteem. Results showed that more than half of the participants reported that they felt they were not likely to attain the level of education to which they aspired. Parental migration, academic performance, mother’s educational aspirations for children, and close friends’ educational aspirations were the main factors associated with students’ educational aspiration–expectation discrepancies. Both left-behind children and non-left-behind children whose aspirations exceed expectations were more likely to report lower self-esteem, higher depression, lower academic self-perception, and poorer self-regu-lation than those without a discrepancy. These findings have implications for families, schools, and policymakers through informing the development of interventions that target positive development in rural youth

Syphilis in China: the great comeback

China is currently witnessing a major resurgence of syphilis from the elimination of the disease in the 1960s to 5.3 per 100,000 people incidence in 2000–2005. The reasons for the elimination and subsequent resurgence of syphilis in China lie at the heart of much public health debate, highlighting both the relationship between politics and public health, and the role of government in controlling disease. Were the Draconian measures to control syphilis during the early Mao years a price worth paying for the effective control? Is the recent resurgence of syphilis an inevitable consequence of economic development and greater freedom for the individual, which will ultimately lead to better health for the majority of the population? Could tougher control measures such as those of the early Mao years be re-introduced in the current social and economic climate in China? In this review, we briefly chart the history of the syphilis epidemic in China, its elimination in the 1960s, and its gradual resurgence in the past two decades. We explore the reasons for this resurgence, and we conclude with a discussion on the options for control