"In 2016, there was a peak in the number of obstetric deliveries in our hospital, and then it gradually declined. The number of beds in the obstetrics unit has been reduced and the staff has been diverted into a small group. Recently, Cheng Yang, director of the obstetrics department of the First People's Hospital of Guangzhou, said in an interview with a reporter from Yangcheng Evening News. Obstetrics atrophy is a common helplessness in many hospitals. In the First Affiliated Hospital of Jinan University, the obstetrics department has not admitted new people for several consecutive years.
Tomorrow is the annual Mother's Day. It is true that for expectant mothers, obstetric beds are far more abundant than before, with seven or eight doctors and nurses revolving around a pregnant woman, who are carefully cared for and enjoy VIP treatment; But for obstetric professionals, change is imperative. As Duan Tao, a well-known obstetrician in China, worries, the downward trend in the number of deliveries is irreversible, and if the obstetrics department continues to use the CMI index (the higher the CMI index, the higher the difficulty and severity of the disease admitted) and the proportion of fourth-level surgeries, the development of obstetrics will face difficulties.
Pressure: Declining deliveries are the general trend
In the context of the fluctuation of the birth population, Guangdong's obstetrics, especially the obstetrics department of the head women's and children's hospital, may be the envy of peers - according to the National Bureau of Statistics, in 2023, at least 1 in 10 newborns in the country will be born in Guangdong; Among the country's 9.02 million births, Guangdong accounted for 1.03 million, becoming the only province in the country with a birth population of more than one million.
Cantonese people love to have children, especially the continuous influx of population and the relatively young age structure, which makes the Pearl River Delta region maintain a relatively high fertility rate.
As a National Children's Regional Medical Center (Zhongnan), the obstetric department of Guangzhou Women and Children's Medical Center does not appear to have been significantly affected. Due to the phenomenon of "siphoning" of pregnant women in lower hospitals and surrounding areas, the center is still the second largest hospital in the country in terms of the number of births. "More than 28,000 newborns are born every year in the three campuses of the center, and the number of newborns in the Zhujiang New Town campus remains at about 1,200 per month. Perhaps because of the Year of the Dragon this year, the number of births in the Maternal and Infant Hospital, Zhujiang New Town Hospital, and Zengcheng Hospital has increased slightly, with the total number of births remaining at about 2,500 per month, and it is currently predicted that the number of births will exceed 30,000 this year. Jiang Yanmin, director of the obstetrics department of the center, introduced.
However, looking at more medical institutions, the decline in the number of births is still the general trend.
The obstetrics department of the First Affiliated Hospital of Jinan University, which is across the road from the Guangzhou Women and Children's Medical Center, is one of the specialties designated by the provincial and municipal medical institutions for the treatment of critically ill pregnant women, and the peak of childbirth occurred in 2016, when the comprehensive two-child policy was implemented, and then in 2017 and 2019, the annual delivery volume reached 6,000-7,000 people. Less than five years later, the number has dropped to around 4,000. "It's something we didn't expect, and it's changing so quickly." Li Ruiman, the hospital's obstetrics director, who has worked in obstetrics for nearly 40 years, admits that most hospitals have had to make changes in obstetrics.
Pregnant women receive more detailed care Photo/Zhang Hua
Helpless: the number of beds is reduced, and the staff is diverted
The decline in the number of births means that the size and staff of the obstetrics department will be reduced. "We had three groups in the obstetrics department, but now we have reduced one, and four people have had to be shunted to other departments; The number of obstetric beds has also been reduced from 40 to 30. Cheng Yang, director of the obstetrics department of Guangzhou First People's Hospital, said. Recalling the busy scene of obstetrics in the past, Cheng Yang was full of emotion: "In 2016, our obstetrics director had a limit of 30 outpatient clinics, but often increased to 70. From 8 a.m. to 1 p.m., I couldn't get busy at all, and I had to find two doctors to help write medical records, and everyone didn't have time to go to the toilet. There was once an old director who went home from the outpatient clinic and was so tired that he couldn't even walk. ”
Once upon a time, obstetric beds in Guangzhou No. 1 Hospital, Jida Affiliated No. 1, and Municipal Women's and Children's Center were "hard to find", and even if they could add a bed in the corridor, mothers felt that it was rare. Just a few short years later, the situation is no longer what it used to be.
"The current number of births in our hospital has not changed much, but I have learned from my peers that [many hospitals], especially some relatively small traditional Chinese medicine hospitals or primary hospitals, are indeed under pressure for obstetric survival." Jiang Yanmin told reporters, "Some hospitals merge gynecology and obstetrics, and young doctors in obstetrics may have to be transferred to gynecology, and some older and senior doctors have to go to gynecological health care departments, physical examination departments, and some even transfer to administrative departments." ”
The obstetrics department is hard, risky and stressful, and the decision to be shunted to other departments is difficult for any obstetrics director.
In the single room of the obstetric department of a major hospital, the expectant mother is cared for by a number of medical staff Photo courtesy of the interviewee
Lift: Make the birth of mothers safer and more comfortable
Obstetrics is only a delivery, and there are very few fourth-level surgeries – this is perhaps the most superficial understanding of obstetrics by most people and even other doctors. In fact, the rising proportion of older, at-risk mothers is making a difference, and midwifery services are now more complex and sophisticated.
"In many cases, primary hospitals will refer high-risk mothers to higher-level hospitals to ensure the safety of mothers and newborns." Cheng Yang said, "Our obstetrics department often receives high-risk pregnant women from grassroots hospitals such as Jinshazhou and Baiyun District, and often seven or eight doctors and nurses are transferred around a pregnant woman and provide 24-hour service. ”
Similarly, nearly 70% of the maternity wards of the First Affiliated Hospital of Jinan University are high-risk mothers. "Most of them have high blood pressure, diabetes, placenta accreta, etc. These comorbidities can make the process of pregnancy and childbirth thrilling and dangerous. Li Ruiman said that even healthy pregnant mothers can have emergencies at any time, let alone critically ill pregnant women - the situations they face are often unpredictable, and potential dangers are always with them. Therefore, obstetricians in large hospitals need to devote more energy and time to ensuring the safety of high-risk mothers.
How do you measure the safety and medical level of the delivery room? Maternal mortality is a key indicator, and high-risk pregnancies are an important factor in maternal mortality. Since the implementation of the two-child policy, the number of high-risk pregnant women has been increasing. "Because it is a second child, many pregnant women are over 30 years old, or even 35 years old." Li Ruiman said, "For the same critical and serious illness, a 25-year-old woman may be saved, but a woman over 40 years old may not be saved. Therefore, it is necessary to strengthen the professional skills training of medical staff and improve the level of diagnosis and treatment of obstetrics and neonatology. ”
On March 16 this year, the General Office of the National Health Commission issued the "Notice on Strengthening the Management of Midwifery Services", which clearly weaved the "bottom line" of obstetrics, and also mentioned that it is necessary to encourage qualified midwifery institutions to strengthen the setting of high-quality and inclusive obstetric beds, and increase the number of single and double rooms in obstetric wards in combination with the adjustment and optimization of hospital resources, so as to effectively improve the conditions of obstetric hospitalization and enhance the sense of gain, happiness and security of the majority of pregnant women.
In fact, pregnant women themselves have also put forward higher requirements for obstetric services, and single and double rooms are very popular.
38-year-old Miss Liu recalled the experience of adding an extra bed in the corridor when she gave birth to Dabao, and felt that she had "suffered too much", and now she has given birth to Erbao and can live in a single room. "In the delivery room, the child's father accompanied me throughout the whole process, painless delivery, doula accompanied me, how comfortable and how to give birth. Discharge from the hospital 48 hours after delivery, everything should not be too smooth and comfortable. Miss Liu said with a smile.
"Not only have we improved the hardware, such as the maternity ward, which has changed from a triple room to a double room, a single room; It also pays more attention to the humanistic care for mothers, such as doula accompaniment, painless delivery and other services are more refined. "At present, 25%-30% of pregnant women will take the initiative to ask for doula to accompany them. Obstetrics is paying more and more attention to providing women with services throughout the life cycle, from pre-pregnancy consultation, pregnancy health care to childbirth, postpartum health care and other one-stop services, because pregnancy-related diseases are also related to women's health status, such as gestational diabetes and gestational hypertension are high-risk factors for diabetes and hypertension in women's later life cycle. Therefore, in addition to clinical practice, obstetricians are also paying more and more attention to scientific research, focusing on Chinese pregnancy and childbirth and other related research and thinking. ”
Obstetrics experts from the First Affiliated Hospital of Jinan University guide the surgical monitoring of pregnant women with complicated heart disease in the operating room
Appeal: Let obstetricians no longer suffer from income losses
When you give birth to a child, you will be accompanied by at least seven medical staff from admission to discharge. If the delivery is natural, the hospital will be discharged within 48 hours; If it doesn't go well, the mother and son may pass through a ghost gate.
"We have an obstetrician, a neonator, an anesthesiologist, a midwife, a nurse and so on, 24 hours a day, 365 days a year, because a child can be born at any time. The labor cost is extremely high, but the effort is not proportional to the income. The three obstetric directors invariably confided in reporters, "Obstetricians are tired and hard, but their income is not high." ”
For the general public, the expectation of safe mothers and babies after giving birth to a child requires obstetricians to minimize maternal and infant complications and mortality. The prenatal examination is done well, the problems are found to be dealt with in time, the prevention work is done well, the child is born smoothly, and there are no complications, there is no need for surgery, not to mention any rescue fourth-level surgery such as uterine removal - this is the best result for the mother.
However, there is no fourth-level surgery in obstetrics, and it is quite "at a loss" in the national assessment. Duan Tao, a well-known obstetrician doctor, once said that the indicators and guidance of the national examination are to encourage large hospitals to become bigger and stronger, hoping that hospitals can see more incurable diseases and do more difficult surgeries, and the two most important indicators are the CMI index and the proportion of fourth-level surgeries. "We have almost no fourth-level surgeries, and placenta implantation and complex cesarean sections can only be counted as second-level surgeries." Cheng Yang said, "In this case, we suffer a lot if we use the CMI index and the proportion of fourth-level surgeries to assess this situation." ”
In fact, for the relatively low income of obstetricians, the "Notice on Strengthening the Management of Midwifery Services" also emphasizes that efforts should be made to make the salary level of obstetric doctors in general hospitals not lower than the average salary of hospital doctors, and it is strictly forbidden to issue income-generating targets to obstetrics and obstetric medical personnel, and the salary of obstetric medical personnel shall not be linked to the income of medicines, sanitary materials, examinations, laboratory tests and other services.
Duan Tao's concern about the future of obstetrics has resonated with many obstetric directors. "We haven't had any new obstetricians for several years in a row, and once there's a breakdown, it's the general public that will ultimately be affected." Li Ruiman particularly called for a separate evaluation standard for obstetrics to ensure that obstetricians' incomes reach a reasonable level.
Text| Reporter Zhang Hua, correspondent Zhang Cancheng, Li Wen, Wei Xing
Fig Provided by the interviewee
Editor: Gan Zhuoran