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The possible impact of the universal two-child policy on pregnancy outcomes

  • Maternal-Fetal Medicine
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

The implementation of the universal two-child policy contributes to adverse pregnancy outcomes, but how the policy change leads to adverse pregnancy outcomes is not well elaborated. In this study, we aimed to compare maternal characteristics and complications, accessed the change in the proportion of maternal characteristics and maternal complications, and evaluated the mediation of maternal characteristics on maternal complications.

Methods

Demographic and clinical data of three-level sample facilities were extracted from China’s National Maternity Near Miss Obstetrics Surveillance System from Jan 1, 2012 to May 31, 2021. The associations between the universal two-child policy and maternal risk factors, the universal two-child policy and maternal complications, and maternal risk factors and maternal complications were evaluated using multivariate logistic regression analyses, with odds ratios (ORs) and 95% confidence intervals (CIs). Mediation analysis was used to estimate the potential mediation effects on the associations between the policy and maternal complications. Population-attributable fractions (PAF) were conducted to quantify the maternal complications burden attributable to the implementation of the universal two-child policy.

Results

In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facilities. After adjusting for covariables, there were significant associations between the universal two-child policy and maternal risk factors (P < 0.001), the universal two-child policy and an increased risk of maternal complications (P < 0.001), and maternal risk factors and maternal complications(P < 0.001). The effects of the universal two-child policy on maternal near miss and medical disease were significantly mediated by maternal risk factors with mediation proportions of 19.77% and 4.07% at the municipal-level sample facility, and mediation proportions for 2.72% at the county-level sample facility on medical disease. The universal two-child policy contributed 19.34%, 5.82%, 8.29%, and 46.19% in the incidence of the maternal near miss, antepartum or intrapartum complication, post-partum complication, and medical disease at municipal-level sample facility, respectively. The corresponding PAF% at county-level sample facility was 40.49% for maternal near miss, 32.39% for the antepartum or intrapartum complication, 61.44% for post-partum complication, and 77.72% for medical disease. For provincial-level sample facility, the incidence of maternal near miss, antepartum or intrapartum complications, and medical diseases decreased (P < 0.05) and no statistically significant difference occurred in the incidence of post-partum complications.

Conclusions

In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facility. Maternal risk factors may play a mediating role in the effect of policy change and maternal complications. Provincial hospitals have been able to improve the quality of perinatal health care and reduce adverse pregnancy outcomes by adjusting their obstetric service strategies in the context of the new birth policy.

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Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

NMNMSS:

National Maternal Near-Miss Surveillance System

NOMCHS:

National Office for Maternal and Child Health Surveillance

aOR:

Adjusted odds ratio

CI:

Confidence intervals

PAF:

Population-attributable fractions

References

  1. Zeng Y, Hesketh T (2016) The effects of China’s universal two-child policy. Lancet 388(10054):1930–1938

    Article  PubMed  PubMed Central  Google Scholar 

  2. Hesketh T, Zhu WX (1997) The one child family policy: the good, the bad, and the ugly. BMJ 314(7095):1685–1687

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Zhang X, Lou H, Tang X et al (2021) Socio-demographic characteristics and outcomes of pregnant women who delivered prior to and after the termination of the one-child policy in China: a comparative study. BMC Pregnancy Childbirth 21(1):318

    Article  PubMed  PubMed Central  Google Scholar 

  4. Feng W, Gu B, Cai Y (2016) The end of China’s one-child policy. Stud Fam Plann 47(1):83–86

    Article  PubMed  Google Scholar 

  5. Sun W, Gordon J, Pacey A (2016) From one to two: the effect of women and the economy on China’s one child policy. Hum Fertil (Camb) 19(1):1–2

    Article  PubMed  Google Scholar 

  6. Li HT, Xue M, Hellerstein S et al (2019) Association of China’s universal two child policy with changes in births and birth related health factors: national, descriptive comparative study. BMJ 366:l4680

    Article  PubMed  PubMed Central  Google Scholar 

  7. Zhang HX, Zhao YY, Wang YQ (2018) Analysis of the characteristics of pregnancy and delivery before and after implementation of the two-child policy. Chin Med J (Engl) 131(1):37–42

    Article  PubMed  Google Scholar 

  8. Zhao F, Xu Y, Chen YT et al (2020) Influence of the universal two-child policy on obstetric issues. Eur J Obstet Gynecol Reprod Biol 252:479–82

    Article  PubMed  Google Scholar 

  9. Zeng C, Yang M, Ding Y et al (2018) Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy. Int J Gynaecol Obste Off Organ Int Fed Gynaecol Obste 140(3):312–318

    Article  Google Scholar 

  10. Zhang X, Chen L et al (2020) Changes in maternal age and prevalence of congenital anomalies during the enactment of China’s universal two-child policy (2013–2017) in Zhejiang Province, China: An observational study. PLoS Med 17(2):e1003047

    PubMed  PubMed Central  Google Scholar 

  11. Sauer MV (2015) Reproduction at an advanced maternal age and maternal health. Fertil Steril 103(5):1136–1143

    Article  PubMed  Google Scholar 

  12. Cheng PJ (2016) Duan T China’s new two-child policy: maternity care in the new multiparous era. Bjog 123(Suppl 3):7–9

    Article  PubMed  Google Scholar 

  13. Teng X, Shane MI, Pan S (2020) The changing situation about maternal age, risk factors and pregnancy outcomes after the two-child policy: a retrospective cohort study. Ann Palliat Med 9(3):824–834

    Article  PubMed  Google Scholar 

  14. Yan J, Wang L, Yang Y et al (2020) The trend of caesarean birth rate changes in China after ‘universal two-child policy’ era: a population-based study in2013-2018. BMC Med 18(1):249

    Article  PubMed  PubMed Central  Google Scholar 

  15. Li H, Fan C et al (2022) 2022 Changes in adverse pregnancy outcomes in women with advanced maternal age (AMA) after the enactment of China’s universal two-child policy. Sci Rep 12(1):5048

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Zhang J, Williams GJ, Wang G et al (2021) Early-term birth and its association with universal two-child policy: a national cross-sectional study in China. BMJ Open 11(12):e054959

    Article  PubMed  PubMed Central  Google Scholar 

  17. Fan SL, Xiao CN, Zhang YK et al (2020) How does the two-child policy affect the sex ratio at birth in China? A cross-sectional study. 20(1):789

  18. Zhu J, Liang J, Mu Y et al (2016) Sociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014. Lancet Glob Health 4(2):e109–e118

    Article  CAS  PubMed  Google Scholar 

  19. Say L, Souza JP, Pattinson RC (2009) Maternal near miss–towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 23(3):287–296

    Article  PubMed  Google Scholar 

  20. Valeri L, Vanderweele TJ (2013) Mediation analysis allowing for exposure-mediator interactions and causal interpretation: theoretical assumptions and implementation with SAS and SPSS macros. Psychol Methods 18(2):137–150

    Article  PubMed  PubMed Central  Google Scholar 

  21. Bandoli G, Singh N (2020) Mediation of adverse pregnancy outcomes in autoimmune conditions by pregnancy complications: a mediation analysis of autoimmune conditions and adverse pregnancy outcomes. Arthritis Care Res (Hoboken) 72(2):256–264

    Article  PubMed  Google Scholar 

  22. Graubard BI, Fears TR (2005) Standard errors for attributable risk for simple and complex sample designs. Biometrics 61(3):847–855

    Article  PubMed  Google Scholar 

  23. Cakmak Celik F, Aygun C, Kucukoduk S et al (2017) Maternal and neonatal outcomes in advanced maternal age: a retrospective cohort study. J Matern Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet 30(20):2452–2456

    Google Scholar 

  24. Shan D, Qiu PY, Wu YX et al (2018) Pregnancy outcomes in women of advanced maternal age: a retrospective cohort study from China. Sci Rep 8(1):12239

    Article  PubMed  PubMed Central  Google Scholar 

  25. Liu Y, Qin Q, Xiao Y et al (2019) Changes of second-time mothers and their infants under the universal two-child policy in Changsha, China. Midwifery 77:32–36

    Article  PubMed  Google Scholar 

  26. Lin PD, Bromage S, Mostofa MG et al (2019) Mediating role of arsenic in the relationship between diet and pregnancy outcomes: prospective birth cohort in Bangladesh. Environ Health Glob Access Sci Source 18(1):10

    Google Scholar 

  27. Singh PM, Rodrigues C, Gupta AN (1981) Placenta previa and previous cesarean section. Acta Obstet Gynecol Scand 60(4):367–368

    Article  CAS  PubMed  Google Scholar 

  28. Brenner WE, Edelman DA, Hendricks CH (1978) Characteristics of patients with placenta previa and results of “expectant management.” Am J Obstet Gynecol 132(2):180–191

    Article  CAS  PubMed  Google Scholar 

  29. Berchuck A, Sokol RJ (1983) Previous cesarean section, placenta increta, and uterine rupture in second-trimester abortion. Am J Obstet Gynecol 145(6):766–767

    Article  CAS  PubMed  Google Scholar 

  30. Hemminki E, Meriläinenb J (1996) Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol 174(5):1569–74

    Article  CAS  PubMed  Google Scholar 

  31. Deneux-Tharaux C (2012) Women with previous caesarean or other uterine scar: epidemiological features. J Gynecol Obstet Biol Reprod 41(8):697–707

    Article  CAS  Google Scholar 

  32. Hofmeyr GJ, Say L, Gülmezoglu AM (2005) WHO systematic review of maternal mortality and morbidity: the prevalence of uterine rupture. Bjog 112(9):1221–8

    Article  PubMed  Google Scholar 

  33. Zwart JJ, Richters JM, Ory F et al (2009) Uterine rupture in The Netherlands: a nationwide population-based cohort study. Bjog 116(8):1069–78 (Discussion 78-80)

    Article  CAS  PubMed  Google Scholar 

  34. Fitzpatrick KE, Kurinczuk JJ, Alfirevic Z et al (2012) Uterine rupture by intended mode of delivery in the UK: a national case-control study. PLoS Med 9(3):e1001184

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rotas MA, Haberman S, Levgur M (2006) Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 107(6):1373–1381

    Article  PubMed  Google Scholar 

  36. Hemminki E (1991) Long term maternal health effects of caesarean section. J Epidemiol Community Health 45(1):24–28

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Smith GC, Pell JP, Dobbie R (2003) Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 362(9398):1779–1784

    Article  PubMed  Google Scholar 

  38. Kennare R, Tucker G, Heard A et al (2007) Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol 109(2 Pt 1):270–276

    Article  PubMed  Google Scholar 

  39. Hemminki E, Shelley J, Gissler M (2005) Mode of delivery and problems in subsequent births: a register-based study from Finland. Am J Obstet Gynecol 193(1):169–177

    Article  PubMed  Google Scholar 

  40. Oliveira FC Jr, Costa ML, Cecatti JG et al (2013) Maternal morbidity and near miss associated with maternal age: the innovative approach of the 2006 Brazilian demographic health survey. Clinics (Sao Paulo, Brazil) 68(7):922–7

    Article  PubMed  Google Scholar 

  41. Blomberg M, Birch Tyrberg R, Kjølhede P (2014) Impact of maternal age on obstetric and neonatal outcome with emphasis on primiparous adolescents and older women: a Swedish medical birth register study. BMJ open 4(11):e005840

    Article  PubMed  PubMed Central  Google Scholar 

  42. Liu J, Song L, Qiu J, et al (2020) Reducing maternal mortality in China in the era of the two-child policy. BMJ Glob Health 5(2):e002157

    Article  PubMed  PubMed Central  Google Scholar 

  43. Liu X, Huang D, Wang Y et al (2020) Birth and birth-related obstetrical characteristics in southwestern China associated with the current adjustment of family planning policy: a 7-year retrospective study. Sci Rep 10(1):15949

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We sincerely thank the department of obstetrics of 14 hospitals for their help in data collection and staff of maternal and child health institutions for data manage.

Funding

This work was supported by the Starup Fund for scientific research, Fujian Medical University (Grant number:2021 QH1170); Sponsored by Fujian provincial health technology project(Grant number:2020GGA021).

Author information

Authors and Affiliations

  1. Department of Healthcare, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, People’s Republic of China

    Li-hua Lin

  2. Department of Traditional Chinese Medicine, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, People’s Republic of China

    Qiuping Lin

  3. Department of Obstetrics, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, People’s Republic of China

    Xiao-mei Wang, Rong-hua Zhang & Liang-hui Zheng

  4. Department of Pathology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Maternity and Child Health Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, People’s Republic of China

    Huibin Zhang

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  1. Li-hua Lin
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Contributions

LHL: project development, data analysis, manuscript writing. QPL: project development, manuscript editing. XMW: data collection, data analysis. RHZ: data management. LHZ: data management. HBZ: project development, manuscript editing. All authors read and approved the final manuscript as submitted.

Corresponding authors

Correspondence to Qiuping Lin or Huibin Zhang.

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Conflict of interests

All the authors declared they have no conflicts of interest.

Ethics approval and consent to participate

There was no direct interaction with patients and all the needed data are extracted from China’s National Maternal Near-Miss Surveillance System and the data used in the study containing no personally identifiable information. Therefore, there was unnecessary to get informed consent from individual patients. This study was approved by the ethics committee of the Fujian Maternity and Child Hospital. All methods were carried out in accordance with relevant guidelines and regulations. Need for informed consent to participate was waived by the ethics committee of the Fujian Provincial Maternity and Children Hospital.

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Lin, Lh., Lin, Q., Wang, Xm. et al. The possible impact of the universal two-child policy on pregnancy outcomes. Arch Gynecol Obstet (2023). https://doi.org/10.1007/s00404-023-07283-3

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