Dramatic increase of Cesarean deliveries in the midst of health reforms in rural China

Social Science & Medicine 70 (2010) 1544–1549

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Short report

Dramatic increase of Cesarean deliveries in the midst of health reforms in rural Chinaq Lennart Bogg a, b, *, Kun Huang c, Qian Long d, e, Yuan Shen f, Elina Hemminki g a

¨g 9, 17177 Stockholm, Sweden Karolinska Institutet, Department of Public Health Sciences, Division of Global Health (IHCAR), Nobel’s va ¨lardalen University, SE-63105 Eskilstuna, Sweden School of Sustainable Development of Society and Technology (HST), Ma c Anhui Medical University, School of Public Health, China d Helsinki University, Finland e Chongqing Medical University, School of Public Health, China f Xi’an Jiaotong University, School of Medicine, China g National Institute for Health and Welfare, Finland b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 12 February 2010

Cesarean delivery (CD) rates were until recently low in rural China where the population lacked health insurance. In July 2003 the New Cooperative Medical Scheme (NCMS) was introduced. We report findings from a health systems study carried out in the EC-funded project ‘‘Structural hinders to and promoters of good maternal care in rural China’’ in central and western China. The purpose was to analyze how CD rates changed with the increased level of funding of the NCMS. The research design was a natural experiment. Quantitative demographic, administrative and accounts data for 2001–2007 were collected in five counties from the county public health bureaux, the county NCMS offices, the county statistical offices and the Maternal and Child Health (MCH) hospitals, using a structured data collection form. We found that the CD rates increased in four of the five counties in the period 2004–2007 by 36%, 53%, 61% and 131% respectively. In the fifth county the CD rate remained high at 60%. The revenue from CD made up 72–85% of total delivery fee revenue. CD fee revenue increased by 97%, 239% and 408% in the three counties with available data; a higher increase than in general health care revenue. Our conclusion is that the design of NCMS, the provider payment systems, and the revenue-related bonus systems for doctors need to be studied to rein in the unhealthy increases in rural CD rates. Ó 2010 Elsevier Ltd. All rights reserved.

Keywords: China Cesarean Delivery Maternal health Health insurance Health finance Health system Incentives Rural Childbirth

Introduction The Cesarean delivery (CD) rate is a useful indicator of the standards and ethics of delivery services, since there is widespread agreement that the CD rate on a population level should not exceed 15%, perhaps not even 5%, and that elective CD involves risk to the health of both mother and child (WHO, 1985).

q This report is based on data collected in the project "Structural hinders to and promoters of good maternal care in rural China – CHIMACA (015396)" funded by the European Commission 6th Framework INCO/DC Program, coordinated by the National Research and Development Center for Welfare and Health, Helsinki. The authors of the paper are grateful to the health bureaux in the study counties for their support in the data collection. The authors express thanks to all respondents for their valuable contributions to this research report and to two anonymous reviewers for helpful comments. * Corresponding author. Karolinska Institutet, Department of Public Health Sciences, Division of Global Health (IHCAR), Nobel’s va¨g 9, 17177 Stockholm, Sweden. Tel.: þ46 70 2424939; fax: þ46 8 311590. E-mail address: [email protected] (L. Bogg). 0277-9536/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.01.026

The purpose of this study was to analyze how CD rates have changed with the increased level of funding following the introduction of the new rural health insurance (NCMS) in China. Our study was carried out in the context of the project ‘‘Structural hinders to and promoters of good maternal care in rural China – CHIMACA’’ funded by the European Commission. In April 1985 the World Health Organization held an interregional meeting in Brazil, which ended in unanimous agreement to adopt specific recommendations for appropriate technologies for birth. One conclusion was that although CD can be life-saving in an emergency situation, there is no justification for cesarean delivery (CD) rates higher than 10–15% of all deliveries (WHO, 1985). It has been suggested that the proportion of medically necessary CD is far below the WHO recommendation and within the range from 1% to 5% (Bergstro¨m, 2001). CD has been linked to risk of surgical site infections (Barbut et al., 2004; Killian, Graffunder, Vinciguerra, & Venezia, 2001). Eriksen et al. concluded that in Norway, a country with one of the highest income levels in the world and with high and equitable standards of care, one in twelve women who undergo

L. Bogg et al. / Social Science & Medicine 70 (2010) 1544–1549 Table 1 Cesarean delivery rates, total number of live births and percentage change of the cesarean delivery rates from 2004 to 2007 in five counties. Year/CD rate:

Sha’anxi LT

Sha’anxi ZA

Chongqing RC

Anhui XC

Anhui FC

2004, CD rate No. live births 2007, CD rate No. live births % Change in CD rate

8, 3% 4261 19,2% 3900 þ131.3%

12,2% 2009 18,6% 2406 þ52.5%

32,2% 6867 43,9% 8206 þ36.3%

35.0% 6946 56,4% 7450 þ61.1%

60.0% 4212 60.0% 4163 þ/0%

CD will develop a surgical site infection (Eriksen et al., 2009). Among the thirty OECD countries CD rates range from 16 to 17% in Iceland, Finland, Sweden, Denmark, Norway and the Netherlands, around 23% in the UK and New Zeeland to around 30% in the USA, Australia and Korea and up to around 40% in Mexico and Italy (OECD, 2008). Tang, Li, and Wu (2006) analyzed data from three national household surveys with regard to urban CD rates in China. They reported a steep increase in CD rates of urban primiparous women in China, rising from 18.2% in 1990–1992 to 39.5% in 1998– 2002. They found an association to socio-economic factors, including an adjusted odds ratio for having health insurance of 1.25 in 1998–2002. Klemetti et al., (in press) analyzed similar national household data for trends in rural CD rates and found that the development over the 12-year period 1991–2002 reflected an increase in average CD rates from just 1 to 17%.

The Chinese health care context A report from the WHO and China State Council Development Research Center (2006) shows that the maternal mortality rate for rural residents in China in 2002 was 2.6 times as high as that for urban residents, 58.2/100,000 vs. 22.3/100,000. An analysis of national maternal death surveillance data in 247 monitored areas; including urban and rural areas with a total population of more than 100 million in all provinces of China, found a maternal mortality rate for the period 1989–1995 of 95/100,000 in rural areas and 46/100,000 in urban areas, higher than the officially reported levels at the time. There were huge regional differences in MMR ranging from 26/100,000 to 308/100,000 (Zhang & Ding, 1994). Zhang, Wang, and Guo (2003) analyzed data from World Bank Health VI project in relatively poor areas of China and found a remarkable reduction in MMR during the implementation of the project, from 160/100,000 in 1995 to 78/100,000 in 2000. Yet, the MMR remained higher than the national average. The authors concluded that to further lower the MMR it will be necessary to increase the financial investments in health, to improve health facilities and to strengthen health education. Since 1990 the Ministry of Public Health has implemented a national plan of action for the reduction of MMR and IMR. The Ministry has put a national network in place to monitor maternal and under-5 mortality in all provinces of China (She, 1996; Xiang, Wang, & Xu, 1996).

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Wagstaff and Yu (2005) found that both demand and supply factors were influencing service utilization in their evaluation of the impact of World Bank Health VIII project, based on data from Gansu province. The project involved improved infrastructure especially at township level, essential drug lists, clinical treatment protocols, referral guidelines and other measures to improve quality and accessibility of services. The key findings were that the project had improved utilization and self-reported health, but that it had also led to a shift from lower levels of care to higher levels and from preventive services to curative services. The Chinese Central Government in October 2008 announced plans to address problems in health care related to inequity and inadequate access for those in greatest need, quality problems, inappropriate provision of drugs, increasing antibiotic resistance and unreliable reporting due to perverse incentives. (Hu et al., 2008; Liu, Rao, Wu, & Gakidou, 2008; Wang et al., 2008). The plans aim to put people’s welfare before profit and aim for safe, effective, convenient and affordable services for all citizens by 2020. It has been noted, however, that the reform plans are ‘long on aims, but short on details’ (The Lancet, editorial, 2008). In July 2003 a New Cooperative Medical Scheme (NCMS) was launched in over 300 of China’s more than 2000 counties, introducing for the first time financial support from the Central Government for rural health care. NCMS is designed with costsharing between the Central Government, local governments and participants, each contributing a modest RMB 10.00 per capita, totaling RMB 30.00 per capita per year, which corresponded to approximately 10% of the average annual health expenditure for rural residents in China that year (WHO/China and the State Council, 2006). The subsidies have in a subsequent reform package been increased to RMB 30.00 per capita per year from each level and are soon to be further increased. The design and implementation of NCMS are decentralized and vary with respect to funding, coverage, enrolment, regulations and in phasing across China’s 2000 þ counties (Wagstaff, Lindelow, Gao, Xu, & Qian, 2009). Coverage of the NCMS is one of 22 key indicators of economic and social development in the 11th Five-Year Plan. The coverage target is measured in percentage of the total number of counties that have implemented NCMS and the target is to have an increase from 23.5% in 2005 to 80% of all counties in 2010. The NCMS’ subsidies for delivery have different ceilings, thresholds and different coverage regulations in different counties. NCMS was preceded in some counties, e g in Anhui, by local government subsidies for delivery in hospital. Wagstaff et al. (2009) concluded in a regression analysis of early data from the National Household Survey and from routine health facility data from ten participating counties and five nonparticipating counties that NCMS appears to have resulted in increased out-of-pocket expenditures both for outpatient and inpatient care, but that it had reduced out-of-pocket payments for delivery. The authors cautioned that the observed increase in utilization should not be interpreted as an increase in welfare or an increase in clinically motivated care. Clearly, one of the objectives of health insurance is to improve access to health care for those who otherwise cannot afford the cost, which would lead to an increase

Table 2 Percentage increase in health care revenue from 2001 to 2007 in three counties. Health care revenue 2001–2007

Total health care funding

Public funding

Service fee revenue

MCH revenue

Delivery revenue

% increase CD revenue

Anhui, FC Mean per capita revenue 2007 Anhui, XC Mean per capita revenue 2007 Chongqing, RC Mean per capita revenue 2007

þ90.2% U174.2 þ90.7% U132.9 þ126.3% U148.9

þ81.0% U42.9 þ/0% U1.3 þ102.8% U11.6

þ93.4% U131.3 þ90.6% U131.6 þ128.5% U137.3

þ85.3% U10.1 þ88.1% U16.5 þ208.5% U14.5

þ64.5% U8.7 þ91.3% U15.7 þ134.5% U8.0

þ97.2% U6.3 þ239.1% U13.3 þ408.3% U6.1

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Fee Revenue (RMB)

3500000 3000000 2500000

Normal delivery

2000000

Cesarean delivery

1500000

Antenatal

1000000

Postpartum

500000 0 2000 2001 2002 2003 2004 2005 2006 2007 Year

Chart 1. FC County, Anhui delivery service fee revenue 2000–2007. Note: NCMS was introduced from 2005.

in health care expenditure. However, not all health care consumption is desirable from a societal perspective. If antibiotics are given to patients who do not need them it will lead to resistance problems. If patients are given the wrong medicine or the wrong dose it may harm them. Unfortunately, there are numerous observations of such problems in Chinese health care (Harris et al., 2007; Wagstaff et al., 2009). Since the income of doctors is related to the inflow of revenue to the hospital through bonus systems, there are obvious incentives for supply-induced demand for more services and more expensive procedures (Bogg, Wang, & Diwan, 2002). The Law of the People’s Republic of China on Maternal and Infant Health Care requires all deliveries to take place in hospital. However, the implementation of the law is hindered by the high cost of hospital delivery paid out-ofpocket in relation to the low and seasonal incomes in rural China. A strong association between home delivery and lack of health insurance coverage has been shown (Bogg et al., 2002).

hospital accounts, MCH revenue, patient fees, out-of-pocket and public health expenses (PHB and MCH hospital), NCMS enrolment, revenue and expenditure (NCMS office). The term ‘revenue’ is here used in accordance with the definition in International Accounting Standards (IAS 18); the gross inflow of economic benefits during a period in the course of the ordinary activities of the entities. With ‘hospitals’, we include data from all hospitals in the counties; the county hospital, the county MCH hospital and all township hospitals. Data from 2001 to 2007/8 were collected by the members of the research team and staff from the MCH office of the public health bureaux, who received training in how to use the instruments. The financial data had to be checked and re-collected due to misunderstandings, mainly resulting from inadequate financial training of the data collectors. The data forms were constructed so that the data could be cross-checked for consistency. Problems were found in the data from two of the counties, which were excluded from the analysis presented here.

Methods, data and setting

Results

Our research design was an observational pre-post study, a natural experiment, involving five counties in three provinces in China, two counties in Anhui, two in Sha’anxi and one in Chongqing. It was agreed with the county leaders not to disclose the identity of the participating counties in publications, so acronyms are used in place of full names in this short report. Ethical approval was given by the participating universities in China; Xi’an Jiaotong University, Chongqing Medical University and Anhui Medical University. Data collection forms were developed by the project for collection of data from the county public health bureaux (PHB), the county Maternal and Child Health (MCH) hospitals, the county statistics offices (CSO) and the county NCMS offices. The forms covered demographics (CSO), human resources and hospital facilities,

The CD rates increased from 2004 to 2007 to reach extremely high levels, 44% (Chongqing), 56% (XC, Anhui) and 60% (FC, Anhui), and increased from 8.3% to 12.2% in the two Sha’anxi counties to 19.2% and 18.6% (Tables 1 and 2). The relative increase in CD rates as a percentage of all deliveries, including home deliveries, was 36%, 53%, 61% and 131% respectively from 2004 to 2007 in four of the five counties. The CD rate in the fifth county had already reached 60% (Table 1). Charts 1–3 show the trend of delivery fee revenue in each of three counties. NCMS was introduced from 2005 in FC, Anhui and in RC, Chongqing, while it was launched only from 2007 in XC, Anhui. However, in Anhui, local funding of delivery fees was in place before the introduction of the NCMS. In RC, Chongqing, the NCMS

Fee Revenue (RMB)

12000000 10000000 Normal delivery Cesarean delivery Antenatal Postpartum

8000000 6000000 4000000 2000000 0

2001 2002 2003 2004 2005 2006 2007 Year

Chart 2. XC County, Anhui delivery service fee revenue 2001–2007. Note: NCMS was introduced from 2007.

L. Bogg et al. / Social Science & Medicine 70 (2010) 1544–1549

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Fee Revenue (RMB)

6000000 5000000 Cesarean delivery Normal delivery Antenatal Postpartum

4000000 3000000 2000000 1000000 0 2001 2002 2003 2004 2005 2006 2007 Year

Chart 3. RC County Chongqing, delivery service fee revenue 2001–2007. Note: NCMS was introduced from 2005.

reimbursement for a delivery, whether vaginal or cesarean, was increased from 2007 from RMB 100 at county hospital and RMB 150 at township hospital to RMB 400 at both levels of care. In XC, Anhui, a fixed amount NCMS reimbursement of any hospital delivery of RMB 200 was introduced from 2007. In FC, Anhui, the NCMS reimbursement of a delivery was changed from 2006 from a percentage of actual cost up to a ceiling of RMB 40,000 to a fixed amount of RMB 150 for a vaginal delivery and RMB 600 for a cesarean delivery. In FC, the hospital fee revenue from CD procedures dropped in 1996 when the fixed amount reimbursement was introduced, but increased again in 1997. The share of delivery fee revenue related to CD is large and has increased over the study period to 72%, 76% and 85% of the total delivery fee revenue. The revenue from CD contributed 42%, 62% and 85% respectively of the total MCH fee revenue (Table 2). The total revenue increased by 90%, 91% and 126% in FC, XC and RC respectively. In all three counties, private funding, i e out-of-pocket paid user fees, increased more than the public budget funded portion of the revenue. In the two Anhui counties, the MCH revenue increased less than total health care revenue, while in RC county, Chongqing, the MCH revenue increased by 209%. The fee revenue from cesarean sections increased more than total MCH service revenue and more than total health care revenue in all three counties. In XC, Anhui, the increase in CD fees was 239% or 2.6 times the increase in total health care revenue and in RC, Chongqing, the increase in CD fee revenue was 408% or 3.2 times the increase in total health revenue. We found a wide spread between the counties in what was actually paid for a CD with a range from RMB 1177 to RMB 2669 (Table 3). The reported fees for CD services are clearly not including all other ‘services’ that may be provided, whether medically necessary or not. We found surprising differences in the number of delivery beds, the number of specialists in obstetrics and gynecology (ob/gyn doctors) and the number of midwives in the five counties. The differences underline the decentralized character of the Chinese health system and differences in how reforms of the systems have played out (Table 4).

In LT and ZA counties in Sha’anxi province, the number of midwives increased by 41% and 91% in the study period, while the number of midwives in RC county in Chongqing decreased by 54%. The density of midwives varied from 1.1 to 7.1 per 100,000 population in the study counties. The number of ob/gyn doctors increased in three counties and decreased in one during the same period. Notably, the number of delivery beds increased in all the counties and by more than 60% in two of the counties. Discussion We found an alarming increase in CD rates during the period when the NCMS was launched. We are not, however, arguing that we show evidence of a direct causal link between the increased health insurance funding, hospital revenue and the increased CD rates. A multitude of factors apart from financial resources, payment mechanisms and incentives impact on medical practices; medical guidelines and training, ethics, traditions, regulations, policies, evidence, equipment, facilities and patient expectations and demand. Clearly the mode of delivery is a result of the meeting between the provider and the patient, thus both supply and demand factors are at play. Since the income of doctors is related to the inflow of revenue to the hospital through bonus systems, there are obvious incentives for supply-induced demand for more expensive procedures (Bogg et al., 2002). We cannot determine how much of the observed increase in CD rates is resulting from provider push or patient pull. Many women ask for CD out of fear of pain, or belief that CD is better or safer for the child. Even so the demand for CD from the mothers is dependant on the advice and information from the doctors (Hemminki, Klemetti, & Gissler, 2009). Health financing systems involve different provider payment mechanisms which imply different incentives for control of quantity and quality. If providers are paid on fee-for-service basis and especially if there is a link, through bonus systems, between hospital revenue and doctors’ incomes, there will be an incentive to provide as many services as possible and as costly procedures as possible, resulting in what is termed supplier-induced demand

Table 3 Cesarean delivery revenue in RMB and as a percentage of total delivery fee revenue in three counties. CD fees as % of total delivery revenue

2001

2002

2003

2004

2005

2006

2007

Anhui, FC Mean revenue per CD Anhui, XC Mean revenue per CD Chongqing, RC Mean revenue per CD

60.3% U1040 47.7% U1346 35.1% U980

69.7% U1303 55.6% U1699 43.1% U989

70.4% U1054 65.5% U2034 84.0% U996

72.2% U1028 70.2% U2473 87.7% U1530

74.9% U1102 75.9% U2960 75.1% U1500

74.9% U1059 81.1% U3115 76.6% U1375

72.4% U1177 84.5% U2669 76.0% U1400

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Table 4 Number of delivery beds, ob/gyn doctors and midwives per 100,000 population (most recent year/2001) and relative change from year 2001–2007/8 in five counties. No. per 100,000 pop/percentage change

Sha’anxi ZA 2001/08

Sha’anxi LT 2001/08

Chongqing RC 2001/07

Anhui XC 2001/07

Anhui FC 2001/07

Delivery beds/pop 2007/08 Delivery beds/pop 2001 Delivery beds, % change Ob/gyn doctors/pop 2007/08 Ob/gyn doctors/pop 2001 Ob/gyn doctors, % change Midwives/pop 2007/08 Midwives/pop 2001 Midwives, % change

26.2/100,000 16.2/100,000 þ61.7% 11.0/100,000 10.9/100,000 þ0.9% 2.1/100,000 1.1/100,000 þ90.9%

12.3/100,000 11.4/100,000 þ7.9% 15.7/100,000 12.9/100,000 þ21.7% 6.5/100,000 4.6/100,000 þ41.3%

32.1/100,000 31.0/100,000 þ3.5% 9.8/100,000 8.9/100,000 þ10.1% 1.1/100,000 2.4/100,000 54.2%

19.1/100,000 11.7/100,000 þ63.2% 11.6/100,000 9.8/100,000 þ18.4% 7.1/100,000 5.5/100,000 þ29.1%

26.9/100,000 19.8/100,000 þ35.9% 17.7/100,000 21.5/100,000 18.6% 6.2/100,000 5.9/100,000 þ5.1%

(Barnum & Kutzin, 1993; Saltman, Busse, & Figueras, 2004). Reports have noted that the Chinese health reforms have led to financial autonomy of the hospitals, although still with public ownership, and to widespread practices of revenue-related bonus systems directly linking the personal income of doctors to the volume of hospital revenues (Bogg, 2002; Bogg, Dong, Wang, Cai, & Diwan, 1996). The primary objective of health insurance is reducing the risk of catastrophic expenditures by cost-sharing across the population and over the time line of the individual patient’s life. Health insurance agencies can also act as agents on behalf of the patient population to ensure the safety and quality of health services and to achieve a sound balance between promotive, preventive and curative services. Assessing whether health services provided to patients are optimal or even safe, is complicated. CD rates are interesting as an indicator, since there is agreement that on a population level CD rates should not exceed 15% of all deliveries. We believe that it is important that public funding of hospital delivery is strengthened in rural China. We are not asserting that NCMS funding is the sole or primary cause of the high and increasing levels of CD rates. We suspect it is the provider payment mechanisms in the NCMS in combination with the revenue-related bonus systems that are the culprits. The CD rates were increasing even before the introduction of NCMS. However, the increased funding of NCMS may have added fuel to the fire. Xu, Dong, Zhao, and Bogg, (2006) showed that when free diagnosis and treatment for sputum positive tuberculosis were introduced in project areas in China, providers adapted to the situation by prolonging the treatment period before TB diagnosis, thereby increasing the risk of spreading infection and antibiotics resistance while increasing the cost to the patient to reach almost the level before the introduction of free services. Our study was based on observation of real-life policy implementation, where the influence of individual variables could not be isolated and measured. Murray and Elston (2005) found in their study in Chile that promotion of private health insurance had led to highly technologized obstetric practices and to higher CD rates. Wagstaff and Lindelow (2008) examined data from three surveys in China on the influence of health insurance on household financial risk and found that in all three surveys the financial risk increased, quite contrary to the stated purpose of the health insurance. They suggested that the findings could be explained by different forms of supplier-induced demand. Our findings seem to conflict with the findings of Wagstaff et al. (2009), who reported a reduction in expenditure for delivery services after the introduction of NCMS. Wagstaff’s observed reduction in out-of-pocket payments for delivery may, however, have resulted from using household survey data rather than facility-based data. Econometric multivariate analysis of facility-based data could provide more insight into the relations between the financing system, the provider payment mechanisms and the service supply.

As noted previously it is not uncommon that hospitals in China charge for complementary services, e g vitamins, antibiotics or other intravenous fluids, whether medically required or not. Harris et al. (2007) and others have described how hospitals in China charge women for a plethora of services which can increase the regulated cost of a delivery tenfold. Such fee charges would be a heavy burden on the women, although not recorded as delivery fees. The development in recent years is positive from the perspective that funding has been increased and modest reallocation from rich cities to poor rural areas has been initiated. It is equally important that the increased funding is channeled in a way that will contribute to healthy medical practices. The increase in CD rates implies a considerable cost in foregone opportunity to invest in evidence-supported strategies to further reduce maternal and infant morbidity and mortality. We suggest that the increase in CD rates indicates a need to further study how to improve medical ethics, the impact of abolishing revenue-related bonus systems, better information to expecting mothers of the evidence for good obstetric practices and the impact of a shift to prospective payment for essential MCH services. References Barbut, F., Carbonne, B., Truchot, F., Spielvogel, C., Jannet, D., Goderel, I., et al. (2004). Infections de site ope´ratoire chez les patients ce´sarisees: bilan de 5 anne´es de surveillance. Journal De Gyne´cologie, Obste´trique Et Biologie De La Reproduction, 33, 437–496. Barnum, H., & Kutzin, J. (1993). Public hospitals in developing coutries: Resource use, cost, financing. Johns Hopkins University Press. Bergstro¨m, S. (2001). Appropriate obstetric technologies to deal with maternal complications. In V. De Brouwere, & W. Van Lerberghe (Eds.), Safe motherhood Strategies: A review of the evidence, studies in health services organisation & policy, Vol. 17 (pp. 175–194). ITG Press. Bogg L. 2002, Health care financing in China: Equity in transition, PhD thesis, Karolinska University Press. Bogg, L., Dong, H. J., Wang, K. L., Cai, W. W., & Diwan, V. (1996). The cost of coverage: rural health insurance in China. Health Policy and Planning, 11(3), 238–252. Bogg, L., Wang, K. L., & Diwan, V. (2002). Chinese maternal health in adjustment: claim for life. Reproductive Health Matters, 10(20), 95–107, Elsevier Science Ltd, UK. China unveils plans for health-care reform. (2008). The Lancet, 372(Nov 8), 1608, editorial. Eriksen, H. M., Saether, A. R., Lower, H. L., Hjetland, R., Lundmark, H., & Aavitsland, P. (2009). Infections after cesarean sections. Tidskr Nor Laegeforen, 129(7), 618– 622, Mar 26. Harris, A., Yu, G., Barclay, L., Belton, S., Zeng, W., Hao, M., et al. (2007). Consequences of birth policies and practices in post-reform China. Reproductive Health Matters, 15(30), 114–124, Elsevier. Hemminki, E., Klemetti, R., & Gissler, M. (2009). Cesarean section rates among health professionals in Finland, 1990–2006. Acta Obstetricia et Gynecologica Scandinavica, 88(10), 1138–1144. Hu, S. H., Tang, S. L., Liu, Y. L., Zhao, Y. X., Escobar, M.-L., & de Ferranti, D. (2008). Health systems reform in China 6; reform of how health care is paid for in China: challenges and opportunities. The Lancet, 372(22), 1846–1853. Killian, C. A., Graffunder, E. M., Vinciguerra, T. J., & Venezia, R. A. (2001). Risk factors for surgical-site infections following cesarean section. Infection Control and Hospital Epidemiology, 22(10), 613–617. Klemetti R., Che X., Gao Y., Raven J., Wu Z., Tang S. & Hemminki E. Ceasarean section delivery among primiparous women in rural China: an emerging epidemic,

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