China's new two‐child policy: maternity care in the new multiparous era

Thirty-six years after the introduction of the one-child policy in China, the Chinese government has repealed this policy for its citizens. As of 2016, couples in China are allowed to have two children. China's decision to implement this revised policy was stimulated by concerns related to the country's shrinking population and ageing workforce. In 2013, China eased certain restrictions in the one-child policy, allowing married couples where at least one of the spouses is an only child to have two children. The National Health and Family Planning Commission, which enforces the new policy on reproduction, declared that complete relaxation of the restriction on family size will increase the supply of labour and ease the pressures engendered by an ageing population, in addition to providing sustained and healthy economic development. With the implementation of the two-child policy there are concerns that there will be an immediate shortage of the obstetricians, sonographers, midwives, anaesthetists and neonatologists required to meet the additional demand for maternity care services. In addition, there may be a further shortage of healthcare professionals due to female workers themselves becoming pregnant with a second child and having to take maternity leave. Furthermore, there may be an increased demand for assisted reproductive services due to the anticipated higher number of women in their late 30s and early 40s wishing to get pregnant again with a second child, the potential complications of multiple pregnancies and having to provide obstetric care to older pregnant women following such conceptions. According to official estimates, the policy will entitle an additional 90 million couples in China to have a second child. Of these couples, 60% are estimated to be older than 35 years, and 50% will be at least 40 years old (http://en.nhfpc.gov.cn/2015-11/06/c_45715.htm). Managing the expected increase in the number of older pregnant women will pose an additional challenge for obstetricians.1 Many of these women would have had an elective caesarean section to deliver their first child in the belief that they would have no further pregnancies. Since the 1990s, China has registered a considerable increase in the rate of caesarean delivery. Consequently, for these patients, the higher maternal morbidity inherent in a subsequent pregnancy and delivery will be a major burden on the maternity care system. The obstetric experience and skills required to manage any attempt at vaginal delivery following a previous caesarean section will be lacking because there previously has been no need to provide such care under the one-child policy. A population-based cohort study in Sweden demonstrated that, compared with young women, women aged 30 years or older exhibited a significantly increased risk of premature birth, perinatal laceration, pre-eclampsia, placental abruption, placenta praevia, postpartum haemorrhage and unfavourable neonatal outcome.2 A retrospective cohort study conducted in Taiwan on a Chinese population revealed that this population demonstrated an increasing trend in mean maternal age at birth of the first child and in the proportion of women of advanced maternal age (over 35 years). In that study population, advanced maternal age was independently associated with operative vaginal delivery, caesarean delivery and preterm delivery, in addition to a lower Apgar score, higher rates of fetal demise and more neonatal deaths.3 A multicentre, cross-sectional study conducted according to a data set from the World Health Organization (WHO) Multicountry Survey on Maternal and Neonatal Health involving more than 314 000 deliveries from 29 countries reported that advanced maternal age significantly increased the risk of adverse maternal outcomes, including maternal near miss and maternal death, as well as the risk of stillbirth and perinatal mortality.4 If a trend towards advanced childbearing age occurs in China, then society can anticipate an increase in demand for more sophisticated prenatal, peripartum and neonatal care. Although a small increase in maternal age poses little increase in absolute risk for an individual woman, small shifts in the distribution over the entire female population can affect numerous women, with important implications for the maternal and fetal healthcare system in China (Figure 1). The 2010 WHO global survey on maternal and perinatal health reported that China had one of the highest caesarean delivery rates (46.2%) worldwide.5 China has registered an exponential increase in caesarean delivery rates since the 1980s, during the implementation of the one-child policy. Simultaneously, the government passed the Law on Maternal and Infant Health Care, which guarantees the right of a pregnant woman to have a safe delivery in a maternity unit. In 2000, the government further launched a comprehensive safe motherhood programme involving improved infrastructure, enhanced training for obstetric staff and the provision of subsidies to women and hospitals to encourage hospital delivery. As hospital delivery became nearly universal, both midwives and traditional birth attendants were replaced by obstetric specialists. Such public health policies were reported to be associated with a rapid increase in caesarean deliveries in China.6, 7 The National Health Survey demonstrated that the overall caesarean rate rose rapidly from 3 to 39% between 1993 and 2008. Moreover, urban caesarean rates increased from 15 to 64% during the same period.6, 7 The WHO global survey also reported that the rate of caesarean delivery without medical indications in China was 12.6%, considerably higher than that observed in other countries surveyed. The WHO survey demonstrated that caesarean delivery without medical indications increases the risks of maternal mortality and severe morbidity. Accordingly, the American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine developed an obstetric care consensus on safe prevention of primary caesarean delivery from a professional perspective.8 With the introduction of the new two-child policy, the avoidance of unnecessary caesarean delivery in the first pregnancy will be important in China in order to reduce the risk of a repeat caesarean section in the next pregnancy and the maternal mortality and morbidity associated with this mode of delivery. Therefore, primigravidae in China will need to be counselled carefully about the request for an elective caesarean section without a clear clinical indication. A recent prospective observational survey demonstrated that Chinese doctors played a major role in the decision of pregnant women to deliver by caesarean section without any justified clinical indications.10 Concerted action must be taken to target obstetric care providers as well as pregnant women to increase effectively rates of vaginal delivery. Previous caesarean section has been identified to be associated with an increased risk of poor placentation such as placenta praevia, placental abruption and placental accreta. Increases in other surgical morbidities, including massive blood transfusion, cystectomy, bowel injury, ureteral injury, ileus, maternal postoperative ventilation and intensive care unit admission, and increased operative time and days of hospitalisation were also reported for women who underwent repeated caesarean section.9 In addition, previous caesarean section is associated with the risk of uterine rupture following spontaneous or induced labour in a subsequent pregnancy.11 Because more than a quarter of eligible couples are expected to have a second child following the universal two-child policy, the anticipated increase in pregnancies where there is maternal co-morbidity and poor placentation may place a considerable burden on healthcare resources for the management of these high-risk pregnancies. China unveiled the universal two-child policy in 2016. The government's implementation of this policy is aimed at raising the working-age population, curtailing the ageing of the population and normalising the sex ratio at birth in the near future. Henceforth, China will enter an entirely new era of a multiparous maternity care. Therefore, the nation faces the challenges that a higher number of older pregnant women and women who have had a previous caesarean delivery will entail. Establishing national evidence-based guidelines on the management of high-risk pregnancies, increasing the number of providers of maternity care and incorporating patients’ values and preferences are all required to ensure the successful implementation of the new two-child policy and to improve maternal and perinatal outcomes in China. None declared. Completed disclosure of interests form available to view online as supporting information. PJC conceived and designed the study, collected the data, and was primarily responsible for drafting the article. TD helped to interpret the data, structure and revise the article, and devise the framework for publication. None required for this commentary. None. None.