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Background: In China, the increases in caesarean section (CS) rates and in delivery costs have posed questions about the reform of the medical insurance payment system. Case payment is useful in regulating the behavior of health providers and in controlling CS rates and the unreasonable increase in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aim to observe the change in CS rates, compare the changes in delivery-related variables, and find variables related to delivery cost before and after the CPR in Xi County. Methods: A total of 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. The one-way ANOVA and chi-squared test were adopted to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationship between medical expenses and variables. Results: The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), the total medical cost, and the proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups and total samples was significantly influenced by patient age, LOS, and hospital type and had a significant correlation with the CPR in the VD group and total samples. Conclusion: The CPR might fail to control the unreasonable medical expense growth and regulate the behavior of providers, possibly resulting from the unreasonable compensation standard of case payment, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit the motivation of providers to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals. [ABSTRACT FROM AUTHOR]