Electronic supplementary material
Jiangshan Maternity Hospitala
Number of births
Cesarean deliveries (% of births)
Age > 35 years (% of births)
Repeat CD (% of all CDs)
Pain reliefb (% of all vaginal deliveries)
Zhejiang Women’s Hospital
Number of births
Cesarean deliveries (% of births)
Age > 35 years (% of births)
Repeat CD (% of all CDs)
Epiduralsb (% of all vaginal deliveries)
VBAC (% of eligible CDs)
Pain Relief Use/Support During Labor
Transcutaneous Electrical Nerve Stimulation (TENS)
Mean age of first child ± SD (range)
7 ± 5.1 (2–21)
8.3 ± 5.2 (2–17)
Previous vaginal delivery
Previous cesarean delivery
Mean ± SD (range)
32.5 ± 0.90 (25–44)
32.2 ± 1.28 (23–45)
Highest Educational Qualification
Master’s and up
Attitudes of primiparas
Vaginal birth as the primary choice
“With vaginal birth, you only have to wait one or two years before having another. But if you had a C-section, you have to wait at the very least three years. That’s what I heard from my friend… Also, [with a previous C-section], you have an incision. What if you’re older? What if your first was small, and your second is bigger? Your belly is going to be stretched out even larger. It might rupture. So then there’s more risk, dangerous both to the mother and child.” (JVF3, vocational high school).
“The doctor will say, if you want to have a second child, you have wait at least five or six years. If you delivered vaginally, you can have another in one to two years, because you recover more quickly if you deliver vaginally. It’s better for the woman’s body and physique.” (HVF1, master’s).
“It seems that more women at the hospital want natural birth because with a uterine scar, the second child is usually a cesarean birth. [A previous C-section] restricts the choice of delivery method and also adds some risks.”
Social norms and hospital promotion
“They say that recovery is faster, and it’s better for the baby. So I wanted a vaginal delivery.” (JCF1, high school).
“With a cesarean, recovery is slower, and it might have more complications than vaginal birth. Usually women will all choose to have a vaginal birth.” (HVF4, vocational college).
“Everyone, at first, wants a vaginal birth. It’s only if something happens during labor that you get a C-section. Like my sister, when they told her she needed a C-section [before labor], she ran to the bathroom and cried…she wasn’t mentally prepared for a cesarean surgery—the news came so suddenly.” (JVF3, vocational high school).
“They’ve [the hospital] done health promotion pretty well. They really push natural birth. They constantly recommend natural birth, especially for the first child.” (HCF1, bachelor’s).
Role of the health care providers
“I did consider a cesarean birth [during labor] because it hurt so much. But the doctor said the baby was very small. They encouraged me to deliver vaginally, because there are more benefits to vaginal birth. If you are already hurting to that point, and you had the C-section, would you not suffer twice?” (JVF1, high school).
“During labor, I could not handle it. I was anxious, and I was afraid. I just wanted to get the baby out. When I requested a C-section, [the nurse-midwife] said ‘right now, there’s no problem so you should keep on going.’ She said that a C-section is not good for your recovery.” (JVF2, middle school).
“I actually wanted a cesarean, because I feel like it isn’t as difficult or painful as vaginal birth. But, now if you are suitable for vaginal birth, you can’t get a cesarean section.” (HVF5, bachelor’s).
Attitudes of multiparas with prior vaginal delivery
“The problem is that for those who are older, everything has hardened. We don’t have any elasticity down there, so we can’t give birth. I fear that the child would get stuck and suffocate. My physique is not good—I’m too fat, too old.” (HVS4, middle school).
“The doctor recommended I give birth myself and give it a try. She also said that the second child might be faster and that it would be a pity if I had a C-section for the second child.” (JVS3, vocational college).
Attitudes of multiparas with prior cesarean delivery
Previous culture of cesarean births
“[The cesarean rate] was higher before because of ‘social factors.’ Women would get a cesarean just because their family members wanted one, they feared the pain, or for the slightest problem, like if the amniotic fluid was a bit low. Even women who had severe myopia would get cesareans. Now all these will try for vaginal birth.”
“People are finicky. We all knew that labor pain was very painful, and a lot of people did not want to bear it…And during that time everyone was only having one child, so they figured, they would just do the C-section and it would be fine. It also had to do with how people could bear hardship. Before [the widespread availability of CDs] there was no other way—you had to give birth yourself. Now, with this choice, of course people hoped that birth would go more smoothly.” (JCS7, bachelor’s).
“I thought I would only have one child! And I thought I might as well just get it over with with a cesarean...” (JCS1, bachelor’s).
“The first time around I was worried she could not stand the pain. At the time, we were not allowed a second child so we never considered the risks. Right now, we regret that decision to get a C-section.”
“During that time, I did not even consider [vaginal birth] an option because my belly was so big, and I did not think I would have another baby. [If I had known I would be able to have a second child,] I would have considered vaginal birth, because I heard that then having the second child is easier, and not as painful.” (JCS3, high school).
“Now we’ve realized that we did too many unnecessary cesarean deliveries. As OB/GYNs, we can see that these cesareans have consequences now. There are a lot of women who have cesarean scar ectopic pregnancies or placenta previa. Before there were not that many. There’s definitely a relationship there.”
Vaginal birth after cesarean (VBAC) as the safer option
“The doctors told my family that the rate of success [of a VBAC] is only 25%! They want to scare you. So then my family members said: ‘oh, C-section, C-section, let’s just do that.’” (JCS8, high school).
“You have to look at the conditions of the hospital. You have to ensure the patients’ safety. Only once this prerequisite is fulfilled, and only if they want to try vaginal birth, then we will let them try it. But how can we control these risks?”
“A lot of it depends on the doctors’ skills. You have to assess all of the woman’s conditions, plus the details of the previous C-section. To tell you the truth, [the circumstances of the previous CD are] not easy to understand, because it might have been five to six years ago, or maybe it wasn’t done at our hospital. So I haven’t attempted to handle many VBACs.”
“Originally I also wanted to try for vaginal birth. But the doctor did an assessment and saw [my scar] was too thin, like 0.7 millimeters thick. She said that a C-section was safer.” (HCS5, bachelor’s).
“I had a uterine scar, which is risky. Also, I felt like I did not have any self-confidence to deliver vaginally. Add to that my age, I felt like the possibility of me giving birth vaginally was practically zero.” (HCS6, bachelor’s).
“When they examined my scar, they saw that it was rather thick. I also had gotten pregnant two years after my first which is when the scar’s elasticity is the best. I did my own assessment and figured I could possibly deliver vaginally. If I had had any doubt I probably would not have considered it, because after all, safety comes first.” (HVS5, bachelor’s).
“When I heard how tall she was, I felt like she would not be able to do it. She was only 1.5 meters. Her first was a C-section, [the baby was] around 3.5 kg. I did not recommend [VBAC], but her family members wanted her to try…but she ended up with a CD.”
“In China, the doctor-patient relationship is rather tense. If the patient does not have the desire to, we won’t force them to a vaginal birth…after all, there’s certain risks.”
Use of and attitudes towards pain relief
“I adamantly wanted an epidural. But then my cervix dilated too quickly, so I could not use it in time… There are not many anesthesiologists here, and many women request epidurals. Even when you call for one, the time it takes the doctor to get there can’t match the speed of your cervix dilation. I was already sent to the delivery room before the anaesthesiologist got to me. I could only brace myself to give birth without it.” (HVF5, bachelor’s).
“I have heard of epidurals, but some people say it’s effective, others say it only slightly relieves the pain, and some say it doesn’t work, because everyone’s physique and ability to handle labor is different.” (HVS1, bachelor’s).
“I feared [the epidural] would be painful. They said they would insert the needle into the spine, and when I heard that, I thought: forget about it. In any case, I’ll go with labor pain—and there’s medical consequences to [the epidural]. I hear that people’s backs will hurt.” (HVS2, bachelor’s).
“At 3cm they gave me an epidural. The epidural only works for two hours. Then they would add some more for a total of 3.5 hours. During that 3.5 hours, I had only opened from 3cm to 4cm. It wasn’t really effective. 4cm until 10cm, I had to depend on myself.” (HVF1, master’s).
“To be honest, I think that having someone with you [during labor] is more effective than [the epidural]. You’ll feel more calm, especially for your first child because you don’t know what it’s like.” (HVS1, bachelor’s).
“This time I did not ask for a doula, so I just lay on the bed. At that time, the doctor had inserted a drip. When it was all used up, I called for the doctor, but no one came over. Because no family members are allowed in, if there’s a person next to you, you’ll feel a little better. I think that doulas are great, if you have the money to get one.” (HVS2, bachelor’s).
“I used the stick-on pads, on the hands and back (TENS). The 1000 RMB one. They say it helps open the cervix. But as for the pain…it was still painful.” (JVS2, vocational college).
“Well, the nurses just asked me if I wanted [TENS], and I said I did. She explained to me the benefits, that I would give birth more quickly. I had already labored for a long time, so I decided to use it. I’m not too sure [if it was effective]. They say it is. I think that I gave birth more quickly. Labor was shorter.” (JVS5, middle school).
“For vaginal birth? They don’t have that for vaginal birth, right? It seems like in the delivery room everyone used the electrode pads (TENS).” (JCF3, high school).
“[The nurses] don’t really promote the epidural, just the pads…They say that if you do the shot in the back, it will harm the back. If you stick the pads on, it’s like massage, it will be like electric stimulation. It was like a massaging sensation...But usually whatever the doctor says and we’ll listen.” (JVS1, college).
“The stick-on ones don’t have any side effects. But if you have an injection, then it might affect your body. This is my impression. At the very least you have a needle stuck into you.” (JVF3, vocational high school).
“If they did a shot, then, that might as well be a C-section—that’s anesthesia. They only give anesthesia with a C-section. In any case, no matter C-section or vaginal birth, it’s all painful.” (JVF2, middle school).
“I was afraid there could be side effects [to the epidural]. I did not trust it. My family is very traditional. They definitely won’t agree to using wutong.” (JVS4, vocational college).
“With an epidural, it depends on whether they know about it or their ability to accept it. Some people feel like epidurals are great because it can relieve the pain. If they fear the pain, of course they hope to use it. Some think that because it’s a drug, they don’t want to use it. Most people who have understood that it’s a widely-recognized, safe method would accept it.”
“We promote natural birth… there are also other [non-pharmacological] methods of pain relief to ease the pain [referring to also doulas, massage, water showers, and Lamaze breathing]. The end goal is that they can give birth vaginally.” (Hangzhou Nurse-Midwife).
“[The use of epidurals] depends on the doctors’ assessment. We also have to see if we can do it—like if the anesthesiologist is very busy, if it’s nighttime, or if they’re in surgery, then we won’t do the epidural. Most people will choose [TENS] because you just need a nurse to put it on and that’s it. But for some patients, if they did not sleep the entire night, we’ll do an epidural for them so they can rest.” (Jiangshan OB/GYN).