Wang Li (pseudonym), a 54-year-old obstetrician, experienced the busyness of obstetrics in the late 90s of the last century: 8 caesarean sections in one night, and one shift in 2-3 days. Come home from work, take a shower, get some sleep, and wake up and go to the delivery room again. But just over a year ago, the hospital's maternity department quietly closed. Wang Li still remembers that before the obstetrics department closed, sometimes there was not a single caesarean section patient all night, and no newborn baby was born on Chinese New Year's Eve.
Wang Li worked in a district-level general hospital in Shanghai and witnessed the development of the hospital's entire obstetrics department. "From the past 'hard to find a bed' to 'wide range of doors', and then to a complete shutdown, some obstetricians went to the administrative department, others to the hospital's infectious disease department. As soon as obstetrics was closed, gynecology also shrank. ”
Wang Luyao Design
At a time when the fertility rate continues to decline, obstetrics is entering a "cold winter". At the end of February 2024, Professor Duan Tao of Shanghai First Maternity and Infant Health Hospital issued an article calling for "saving obstetrics", which resonated with many obstetricians and also expressed the hidden concerns of this group: After the obstetrics department is closed, what will we do when we change careers?
In Shanghai, the obstetrics departments of district general hospitals and district maternal and child health hospitals are under greater pressure than those of tertiary obstetric hospitals. Even if they haven't even reached the point of closure, some hospitals are experiencing the reality of "shrinking maternity beds".
Across the country, hospital obstetric closures are no longer an isolated case. In the past year, hospitals in Zhejiang, Guangzhou, Fujian and other provinces have suspended or cancelled delivery services, and more than 10 have been reported by the media alone, and most of them are still concentrated in small and medium-sized hospitals.
In addition to "sorrow", there is another voice. "Obstetric closure is not a flood of beasts, it is not as scary as it seems. A person in charge of a tertiary specialized obstetric hospital believes that it is more necessary to face up to the current situation and actively respond to it and consider how to make obstetrics stronger.
As an obstetrician at a district-level general hospital, Wu Ying (pseudonym) saw the number of maternal deliveries in the department drop to one-quarter of the peak period. She said frankly, "It is precisely because there are fewer mothers that we have the opportunity to 'recharge', do a more detailed job in maternal management, and transform 'more births' into 'good births'." ”
On August 18, 2023, doctors were busy in the neonatal intensive care unit at Dongfang Hospital in Lianyungang, Jiangsu Province. Image in this article: Visual China
The sorrow of the obstetrician
At a time when the number of deliveries is declining year by year and the number of obstetric beds is shrinking, it has become an indisputable fact that obstetrics is cold.
"In the past, there was a buzzword in our industry: gold ophthalmology, silver surgery, exhausting obstetrics and gynecology. At the end of the 90s of last century, Wang Li became an obstetrician, when she was in her 30s, overtime became the norm, the cries of pregnant women in the delivery room came and went, and the operation was one after another. Due to physical reasons, she had to move from obstetrics to an administrative position, "I was forced to transform, after all, as an obstetrician, there are many opportunities to exercise, and pregnant women are not worried." ”
At that time, Wang Li never thought that the obstetrics department of the hospital would be closed one day. But in recent years, she has seen more and more pregnant women crowded into tertiary specialized hospitals, and the number of maternal and child health hospitals in the region has also decreased year by year, so she can only reluctantly accept this reality. Some of the obstetricians who worked with her also started to work in administration, and some went to the hospital's infectious disease department.
Wang Li still remembers that just over a year ago, when the obstetrics department of the hospital was closed, an obstetrician came to her and said, "We are a group that cannot keep up with the times" and "a group that is disliked", "especially some older obstetricians, their hearts are very lost." ”
Age is the biggest obstacle to the transformation of obstetricians. Wu Ying, a 45-year-old obstetrician, also sighed: "If you are still young, you still have the capital to learn new things and change jobs, but when you are old and 50 years old, you will not go to graduate school again, and it will be difficult to transform, or you can only do unrelated medical work." ”
Wu Ying is in another district general hospital, "I have experienced the highest peak of obstetrics, more than 400 children a month, working overtime every day, now there are only 70 or 80 at least a month, and more than 120 at most, which is almost only 1/4 of the peak." ”
Hua Min (pseudonym), an obstetrician from the district general hospital, also said that although the obstetrics department of her hospital has not been closed, she is not optimistic about her career prospects: "The fertility rate has declined, our business volume has been shrinking, and the number of beds in the ward has also been reduced and allocated to other specialties." At present, we are also adapting to the situation to make some transformations, such as the development of reproductive medicine, but the development of reproductive medicine also needs to be supported by market demand. ”
In Shanghai, obstetric departments such as district general hospitals and district maternal and child health hospitals are under greater pressure than tertiary obstetric hospitals, and the decline in the number of deliveries has been more obvious in recent years.
On February 10, 2024, at the Obstetrics and Gynecology Hospital Affiliated to Fudan University, the first dragon baby in Shanghai was born. Obstetrics and Gynecology Hospital Affiliated to Fudan University Data map
"There are fewer births, and mothers are more willing to go to big hospitals to build cards, after all, big hospitals are more experienced in dealing with difficult and critical situations, and district-level hospitals often undertake the delivery of ordinary pregnant women. An obstetrician from a tertiary obstetric hospital said.
Wu Ying sometimes worries that with the shrinkage of the obstetrics department of the hospital, there will be fewer and fewer people who are willing to come to be obstetricians, "As a training base, in the past, we recruited at most 4 (regular trainees), but now there are only 2 in a session, since 2012 became a regular training base, we have graduated a total of 15 regular trainees, 2 are not doctors, and 1 has transformed into a B ultrasound doctor." Wu Ying said that perhaps it will be more and more difficult to recruit students in the future.
Such concerns also exist in many groups such as pediatricians and preschool educators. As Duan Tao said in an interview with the media: "The decline in the number of births in obstetrics directly affects pediatrics, because there are fewer children, and the business of pediatrics is also less, correspondingly, the maternity, infant and child industry, education and training institutions, kindergartens, primary schools, middle schools, universities, and the entire education system and industry will be affected." ”
Midwives accompany and guide expectant mothers throughout the process to relieve pain.
Behind the cold in obstetrics
At present, the closure of obstetric departments in hospitals is not an isolated case, and throughout the country, hospitals in many provinces such as Zhejiang, Guangzhou, Fujian and other provinces have suspended or cancelled delivery services. In just over a year, more than 10 have been publicly reported by the media.
In fact, China's midwifery resources are not abundant. As of 2020, there were 33 caregivers and midwives per 10,000 people in China, one in seven in Finland, one-fifth in Australia, one-third in Canada, and a quarter in France and Japan, according to Caixin Weekly, citing data from the World Health Organization.
The most direct reason for the cold obstetric situation is the decline in fertility, especially after the birth peak in 2016, the number of births across the country has a significant downward trend. From 2017 to 2023, the number of births in the country will be 17.23 million, 15.23 million, 14.65 million, 12 million, 10.62 million, 9.65 million, and 9.02 million, and the number will decrease year by year.
According to the China Health Statistical Yearbook, the number of obstetrics and gynecology hospitals in the country decreased from 809 in 2019 to 793 in 2021, a decrease of 16. At the same time, the bed utilization rate of obstetrics and gynecology hospitals nationwide also decreased from 52.24% in 2019 to 44.08% in 2021.
In Duan Tao's view, the reasons for the decline in the number of births are very complex, one of which is economic development, "economic and social development is the best contraceptive, in a sense, the production of things is inversely proportional to the production of people." It's a spell that's hard to break, and it's not just China's problem, it's the whole world. ”
An official statistic answers the reasons why women "don't want to have children" and "don't want to give birth". According to the results of the 2022 Population Change Sample Survey released by the Shanghai Municipal Bureau of Statistics in 2023, among the permanent residents of Shanghai, the most important reason for not planning to have a child (the next child) is "satisfaction with the current situation", accounting for nearly half (41.8%), followed by "high cost of raising and heavy financial burden" (28.5%), "age or physical reasons" accounting for 13%, followed by "others", "no one to take care of children" and "hope for a more relaxed and free life" Concerns about the impact on work or personal development", "Lack of suitable public services for childcare and enrollment" (tie), "Opinions of other family members" (tie).
According to the survey of the "ideal number of children", more than seventy percent of Shanghai's permanent residents want to have one child, and nearly half of the foreign permanent residents hope to have two children.
But there are also more options for migrant mothers. "Originally, at the peak of our obstetrics, 4/5 were foreign pregnant women, but in recent years, foreign pregnant women have dropped significantly, and some of them are more willing to go back to their hometowns to give birth for the sake of their children's education. Wu Ying sighed.
In Wang Li's view: "On the one hand, the times are advancing, women's status has improved, and they have more independent choices about childbearing, and on the other hand, scientific and technological advances, such as the emergence of assisted reproductive technology, have given many women of childbearing age reasons to delay childbearing." ”
Attention should also be paid to the economic nature of obstetric services themselves. A person in charge of a tertiary specialized obstetric hospital said that the business volume determines the evaluation of obstetric performance and the income of obstetricians. Under the national standards for hospital performance appraisal, obstetrics does not involve high-level four-level surgery, which makes obstetrics not have an advantage in the assessment of hospital departments, "There is also a very paradoxical point that obstetrics should do well, should be done well in preventive health care, and should not be assessed key diseases, obstetrics is different from other departments, that is, we have moved the gate forward." ”
At 11:06 on February 10, 2024, the first day of the Lunar New Year of the Dragon, the obstetrics delivery room of Zhoushan Hospital in Zhejiang Province ushered in the birth of the first "dragon baby" in the Year of the Dragon.
Obstetrician's expectations
At present, it is more important to retain obstetricians and obstetricians.
"Especially in some general hospitals, don't completely give up obstetrics, although obstetrics economic benefits are low, but the responsibility is heavy, a pregnant woman behind is two lives, once obstetrics shrinks, the talent team will also be lost, maternal and infant safety will be difficult to achieve. As an obstetrician with more than 30 years of clinical experience, Cheng Weiwei, honorary president of the International Peace Maternity and Child Health Hospital of the China Welfare Association, also made such an appeal.
On March 27, 2024, the National Health Commission (NHC) issued the Notice on Strengthening the Management of Midwifery Services (hereinafter referred to as the "Notice"), emphasizing that public medical institutions should bear the responsibility for obstetric services. According to the requirements, counties (cities, districts) with a population of more than 300,000 should in principle have at least two public medical institutions capable of providing midwifery services, and counties (cities, districts) with a population of less than 300,000 should in principle have at least one;
"As a regional medical center in the suburbs, we will definitely retain the maternity service function of our hospital, which also serves the four surrounding towns. In order to stabilize the team of obstetricians, Hua Min's hospital gives a certain tilt to the salary of obstetricians, "Many general hospitals will consider putting obstetrics and gynecology together to calculate performance, and the same is true for our hospital, so that the income of obstetricians will be relatively stable." ”
Wu Ying also has some expectations. In her opinion, the age structure of the obstetrics department of the hospital where she is located is relatively good, most of the doctors are around 30 years old, "for our low-seniority doctors in obstetrics and gynecology, they will rotate between gynecology and obstetrics, this year may be in obstetrics, next year in gynecology, which means that the obstetric business volume is reduced, and the impact on everyone's income is relatively small, and even if there are fewer obstetricians, there can be gynecologists on duty together 24 hours a day to ensure the safety of childbirth." ”
Compared with the busy work of overtime in the past, Wu Ying can now commute to and from work normally, and her work is also fulfilling, "There are fewer patients, but the requirements for our work are stricter, and as far as a single pregnant woman is concerned, we actually pay much more work than before, and the management is more meticulous." "This is an experience that Wu Ying has never had before.
Wu Ying explained that compared with more than 20 years ago, although the number of births has declined, there are more high-risk pregnant women who have been treated, "In the past, among the delivery population, women in their 20s were the main group, and there were very few women over 40 years old who gave birth, but now whether it is the first child or the second child, women over 30 years old are the main force, there are very few people in their 20s, and a large part of them are people over 40 years old, and this change has been particularly obvious in the past five years." At the same time, these pregnant women are also better financially equipped, and their needs for clinical services are more diversified. ”
"It is the decline in the number of deliveries that allows our obstetricians to have the energy and time to deal with these elderly and high-risk pregnant women and give them more attention to ensure the safety of childbirth. Wu Ying further said that in the past, most of the pregnant women encountered in obstetrics were ordinary cases, and now doctors have to do something to do is to strive to improve the quality of their services, "not only the overall improvement of hardware facilities, we also hope that in the future, we can give pregnant families better physical examinations in all aspects such as neonatal touch, family participation, and pregnant women's schools." ”
Cheng Weiwei, Honorary President of the International Peace Maternity and Child Health Hospital of the China Welfare Association, also believes that there is still a lot to be done in obstetrics in the future, "such as caring services for pregnant women, including their psychology, sleep problems and nutritional health, as well as postpartum outpatient clinics, newborn child care work, etc., only by actively responding to the current challenges brought by obstetrics can we truly promote the healthy development of this discipline." ”