Written by Hyzhou
Hu Jia (pseudonym) is an anesthesiologist at a third-class general hospital in a first-tier city. Unlike what everyone generally thinks, Hu Jia's hospital has a 100% rate of women choosing painless delivery.
Nineteen years ago, that figure was only 1%. According to incomplete statistics, before 2004, less than 1% of domestic mothers enjoyed childbirth analgesia, even in more developed areas, the rate of childbirth analgesia was still less than 10%, and in remote border areas, childbirth analgesia was even more blank.
The dramatic change in numbers is no accident, behind which is an exponential explosion in anesthesiologists' workloads. In order to improve the painless delivery rate, Hu Jia's hospital set up an on-duty anesthesia response mechanism, "As long as the obstetrics department calls, you have to immediately put down what you are doing and be ready to rush over at any time."
From 1% to 30%, anesthesiologists are available all over the board
Pain in childbirth is a barrier that cannot be crossed in front of women's fertility. Cesarean section was once a helpless solution for Chinese women to avoid the pain of vaginal labor.
In 2010, the world's authoritative medical journal The Lancet released a report that the non-medically indicated cesarean section rate of Chinese women was as high as 46.2%, which was more than three times the 15% warning line of cesarean section rate proposed by the WHO, ranking first in the world.
Since then, the establishment of awareness of cesarean section and painless delivery has gone through a process. On World Analgesia Day 2022, according to Mi Weidong, leader of the National Health Commission's Labor Analgesia Pilot Expert Working Group, the painless delivery rate in the pilot hospitals for childbirth analgesia increased from 27.5% at the end of 2017 to 53.2% at the end of 2020, but there is still a distance compared with the prevalence rate of childbirth analgesia (80~90%) in developed countries, and the national average penetration rate has only reached 30%.
Now, 2 years later, the painless delivery rate in some hospitals has "caught up with the Premier League". "Incomplete statistics, we can now have an average painless delivery rate of more than 70%, and more than 80% in many cases." Huang Lihua (pseudonym), head nurse of the obstetrics and gynecology department of a county-level hospital in southern Zhejiang, mentioned.
This is in stark contrast to previously extremely low figures. During this period, doctors carried the banner, and the role of anesthesiologists was crucial.
It is no exaggeration to say that at present, the explosive growth of the mainland labor analgesia industry has squeezed out the already weak anesthesiology manpower reserve.
Source: Visual China
In order to improve the rate of painless delivery, Hu Jia's hospital has set up an anesthesia response mechanism on call, "Painless delivery, unlike other surgeries, does not have a definite time. With a bit of luck, the obstetrician will give us a call and say that there may be a couple of painless deliveries today. But more often than not, it's a sudden phone call telling us to go to the obstetrics department as soon as possible without pain."
Large tertiary hospitals in first-tier cities have a huge surgical volume, and anesthesiologists are already in a state of shortage, and it is common to have eight or nine o'clock at night on the operating table. But the emergence of anesthesia response mechanisms for painless labor has added confusion to the already irregular anesthesiologists.
In primary hospitals, such an on-call is 24 hours. Huang Lihua has to face not only a call at any time during working hours, but also a 24-hour standby, "Our hospital only had a painless delivery rate of about 30% two years ago, and only painless delivery is carried out when the anesthesiologist is present. If it is not carried out on weekday evenings, weekends, and holidays, it is only possible for women to have painless beatings if they are 'lucky'."
In the past two years, in order to increase the painless delivery rate, Huang Lihua's hospital has seamlessly carried out painless 24/365.
Due to the different constitution of each mother, the dose of anesthesia required sometimes varies greatly, and the dose needs to be increased after painless treatment because the depth of anesthesia is not enough. However, due to the shortage of anesthesiologists' resources, they are often absent from the paternity: "According to the norm, painless births should be accompanied by anesthesiologists. But now because anesthesiologists are too busy, they often leave after anesthesia, and the follow-up observation is handed over to the midwife."
From Huang Lihua's current clinical treatment, painless delivery will lead to a relatively prolonged labor process, and some women who give birth during the day are delayed until the evening, which increases the workload of night shift doctors and nurses, but the corresponding income has not increased. Especially for midwives, after the anesthesiologist is painless, all the labor observation is done by the obstetric midwife."
But from the perspective of the anesthesiologist, such a request is somewhat "unreasonable": "200 yuan, let you get up from home at night to the hospital without pain, are you willing to do it?" If this 200 yuan is divided by several people, will you do it?"
A "not cost-effective" account
Qiu Min (pseudonym) is a pregnant woman and an obstetrician-gynecologist. In her view, the change in the painless delivery rate in the department in recent years is an increase in the stacking of manpower, "without mentioning the cost accounting of budget, income, etc., like playing hooligans."
Painless childbirth is an "investment" in the health system, but every hospital has a difficult book to read.
Lin Xi (pseudonym), an obstetrician and gynecologist at a general hospital in Guangdong, said that the medical quality management assessment of a third-class public hospital requires hospitals to submit their own painless delivery data, but the hospital does not make clear performance index requirements for this.
Source: Visual China
General hospitals are accustomed to investing in anesthesiologist working hours, but this touches the saturation extremes. Lin Xi believes that compared with specialized hospitals such as maternal and child health hospitals, anesthesia resources can be tilted towards obstetrics, it is relatively easy for anesthesiologists to take care of obstetrics, and the situation in general hospitals is even less optimistic. "In large tertiary general hospitals, the number and complexity of surgical procedures and invasive treatments are high, and the requirements for anesthesia are high, so it is quite difficult to balance anesthesia resources with obstetrics."
"Only some hospitals with relatively large delivery volumes, in the form of setting up shift anesthesiologists in the delivery room, send anesthesiologists to work in the delivery room, but anesthesiologists specially assigned to the delivery room often need to take care of all anesthesia operations in the delivery room, the work intensity is high, coupled with the rapid change of obstetric patients, and many women give birth at night, especially in the second half of the night, resulting in anesthesiologists often need to work at night."
In a long working and high-pressure environment, the anesthesiologist is like a sandwich cookie. "Sometimes it happens that anaesthesiologists refuse to be stationed in the delivery room because they are unable to work or are mentally and mentally exhausted, resulting in painless deliveries being affected. But this is really helpless." Lin Xi explained.
The manpower extremum is one problem, willingness is another. Slightly different from the problem of "can't do it" caused by the scarcity of anesthesiologists, anesthesia in primary hospitals is more faced with the dilemma of "unwillingness to do it". Due to the small number of high-risk cases, the shortage of primary anesthesia is relatively much more moderate than that of large tertiary hospitals, but for painless delivery, the enthusiasm of anesthesiologists is also not high. In addition to the intensity of the work and irregular hours, getting less paid is another obstacle.
The government of Hu Jia's area has put forward a pricing requirement for the hospital for the "total cost of painless delivery", "24 hours on call to do a painless delivery, anesthesiologists can get 200~300 yuan, which is a bit thankless." If we have a choice, we are not willing to do it. But the hospital has pressure, and the hospital gives pressure to the department director, and the department director gives it to us."
In this regard, Lin explained that although some hospitals will use painless childbirth as a special needs service, or give part of the income from obstetrics to anesthesiologists who actually participate in painless work, in general, it is difficult for anesthesiologists to get remuneration commensurate with their work, "which is an important reason why anesthesiologists are not motivated to participate in painless childbirth."
In The Other Half of the Sky, the author reluctantly writes: "Maternal investment cannot be as cost-effective as other types of health work."
Returning to the source of the calculation, Qiu Min believes that this is not only a "not cost-effective" account for individual doctors, but also for hospitals, "As a mother, this is a profit for me. But on the other side, my hospital charges 200 yuan for a painless delivery, and sometimes the hospital even needs to post the doctor's technical labor fee."
"Although we can't just use economic benefits to calculate patient benefits, considering that hospitals need to bear their own profits and losses, and the reduction of cesarean sections in the long run is also a profit reduction, it is always unrealistic to continue to reduce costs through manpower replacement." Qiu Min even believes that this will lead to another question: "Behind these raised numbers, do every 1% experience painlessness?"
Maternity: I'm still "in pain"
Qiu Min herself encountered such a problem when she gave birth as a mother, and although she had communicated painlessly from the beginning (in principle, anesthesia could be given during labor), she actually waited until some time after the start of labor that the anesthesiologist rushed to the delivery room as needed.
"It's hard for me to describe the pain, like a pound of boulders crushing back and forth, like intermittent whipping. But what is even more difficult to describe is my emotional confusion: I have to endure a completely unintruded labor process despite making an appointment without pain."
For many women, especially those who give birth for the first time, the pain of not using labor analgesia is often considered "very severe" or "intolerable" [3,4]. Severe pain in labor is associated with adverse effects such as hyperventilation, increased blood pressure, and decreased blood supply to the placenta [5]. Labor analgesia significantly relieves labour pain, with epidural reduced median pain from 7.0 to 0 in a retrospective study of more than 10,000 people[4].
Qiu Min believes that the original intention of increasing the painless delivery rate is for the overall comfort of delivery, but behind the high proportion of painless, the actual pain faced by women still exists: "Sometimes, it is not enough to just 'use'."
Also as a woman, head nurse Huang Lihua also said bluntly, "Although the painless delivery rate in the hospital has increased, in fact, sometimes even if the pain is painless, the analgesic effect of the mother is not ideal." Because anaesthesiologists don't have time to stay and observe the real-time situation of the mother, clinical intervention in midwifery is always limited."
Labor companionship is another important factor that affects the comfort of delivery, which refers to the presence of the woman throughout the birth and delivery process, providing information about the mother's moral support, pain coping strategies, and the delivery process [6]. Accompanied deliveries have been shown to be associated with higher rates of vaginal birth, higher maternal satisfaction, shorter labor durations, lower rates of caesarean/assisted vaginal births, and higher five-minute Apgar scores [6].
In reality, due to the shortage of anesthesiologists and midwives, it is difficult to accompany the delivery, which also leads to many women feeling unnoticed and unvalued during the process of waiting for delivery. Lin Xi said, "Many women think that if there is no family member and more than 2 medical staff dedicated services during childbirth, there will be a strong sense of helplessness, which will increase the discomfort and unpleasant experience during childbirth."
"In practice, family accompaniment may involve the violation of basic medical operating principles such as aseptic operation, and the specialized services of more than 2 medical staff are basically impossible in the existing obstetric work environment."
Source: Visual China
When giving birth alone, Wang Xiaoxiao (pseudonym) recorded the scene of the first birth in her diary:
"At first, the delivery room was quieter than I expected. The absence of family members also means that there are no family members to make noise. I wasn't as nervous as I expected, and everyone lay quietly, sometimes breathing hard, but there was no chaos in the TV series. Only the occasional sound of a doctor sitting at a computer typing on a keyboard and the occasional collision of instruments by a nurse can be heard.
However, this silence was broken in the second half of the night. The improvised pregnant woman looked badly in shape, with constant humming and crying from pain, and although she didn't shout loudly, we could hear the hoarseness in her voice.
Listening to the nurse's communication with her, she also chose painless delivery like us. However, the nurse said that she did not "catch up with the good times" like us. Because the anesthesiologist who gave us painless just now is now dealing with an emergency surgery on the operating table.
In the hot space, we were all a little irritable, but still comforted each other, "Wait a minute." After a while, I was pushed away, with no way of knowing what was going on.
But only later did I learn that the anesthesiologist on duty that night in this hospital was the only one."
Painless childbirth, the revolution still unsuccessful.
Acknowledgements: This article has been professionally reviewed by Zhong Zixing, attending physician of the Department of Obstetrics and Gynecology of Zhejiang Provincial People's Hospital
Curator: Carollero | Executive Producer: Gyouza
Source: Visual China
Resources:
[1]. Lilac Garden "Behind the 4 million surgeries that should not be carried out, is the magical reality that they "treat diseases and deduct wages"
[2]. Lilac Garden "This may be the greatest medical invention about mothers, but only 1% of women in China have enjoyed it"
[3]. Ranta, P., et al., Maternal expectations and experiences of labour pain--options of 1091 Finnish parturients. Acta Anaesthesiol Scand, 1995. 39(1): p. 60-6.
[4]. Melzack, R., et al., Labour is still painful after prepared childbirth training. Can Med Assoc J, 1981. 125(4): p. 357-63.
[5]. Gilbert J Grant, M. Pharmacologic management of pain during labor and delivery. 2023 Sep 30 [cited 2023 Mar 6]; Available from: UpToDate.
[6]. Bohren, M.A., et al., Continuous support for women during childbirth. Cochrane Database Syst Rev, 2017. 7(7): p. CD003766.