The epidemic of Caesarean section (CS) is worldwide, and it has been argued that it is mainly due to non-medical factors, including healthcare financing patterns. We investigated the use of CS in rural China and the related factors, particularly health insurance in the form of the New Co-operative Medical Scheme introduced in 2003. A cross-sectional survey of women who gave birth in 2008-2009 was conducted in five rural counties in central and western China. Of the 5049 new mothers, 73% were interviewed. The association between health insurance coverage and self-reported CS (divided into emergency and non-emergency CS) were examined by cross-tabulation and logistic regression, adjusting for maternal age, education, occupation, household income, previous abortions, parity and type of birth health facility. We found that 46% of all births (3550) were CSs, with 13% having an emergency and 33% a non-emergency CS. Women reported that half of the non-emergency CSs were recommended by a doctor and half were requested by themselves. In those counties with mid-range CS rates (28%-63%), health insurance coverage was associated with having CS, and particularly with having non-emergency CS. In those counties with the highest (82%) and lowest (13%) rate, there was no statistically significant association. The findings suggest that health insurance coverage may have facilitated the overuse of CS. Further studies are needed to develop appropriate interventions to reduce non-medically indicated CS, focussing on payment mechanisms, healthcare provider practice patterns, and maternal requests. (C) 2012 Elsevier Ltd. All rights reserved.