After a partial shutdown, the obstetrics department waits for new births

Southern Weekly

2024-05-24 10:37Posted on the official account of Guangdong Southern Weekly

The fertility rate is declining, and obstetrics is in urgent need of transformation, just as the fetus struggles in the dark and bound birth canal, waiting for a new birth. (Visual China/Photo)

Zhang Li, the mother of two babies, did not expect that her two pregnancies had actually experienced changes in childbirth from hot to cold.

In 2016, with the implementation of the "comprehensive two-child" policy, coupled with the preference of the zodiac, 18.83 million "monkey babies" created the highest peak of China's fertility since the 21st century. She can't forget the sense of urgency, when the child was only 6 months old, she had to call the kindergarten and write an email to sign up.

In order to solve the sudden surge in demand, in 2016, the former National Health and Family Planning Commission and other five departments issued opinions to strive to reach 17 beds per 1,000 births, and strive to increase the number of obstetricians and midwives by 140,000 during the "13th Five-Year Plan" period.

Unexpectedly, after the peak, the fertility rate continued to decline. In 2023, Zhang Li will be pregnant with her second child, and the birth population will be less than half of that in 2016, and many hospitals will announce the closure of their departments.

On February 28, 2024, Duan Tao, an obstetrician who was the president of Shanghai First Maternity and Infant Health Hospital, called for "saving obstetrics" on social platforms. On March 27, the National Health Commission issued the "Notice on Strengthening the Management of Midwifery Services" (hereinafter referred to as the "Notice"), requiring public medical institutions to provide obstetric services.

However, behind the announcements of shutdown and transfer, the per capita obstetric resources of Chinese still lag behind those of developed countries. According to data from the WHO's official website, as of 2020, there were 33 nurses and midwives per 10,000 people in China, only one-third of Canada's, and one-quarter of the United States and Japan. With a long waiting time for prenatal examination, a low rate of painless delivery, and insufficient attention to postpartum depression, there is still a lot of room for improvement in how to make the experience of giving birth better.

The current obstetrics is like a fetus struggling in the dark and bound birth canal, waiting for a new birth.

Guan: Chinese medicine hospitals and infectious disease hospitals are the first to bear the brunt

According to hospital announcements and other statistics, from January 2022 to May 10, 2024, at least 31 medical institutions were "cut" in obstetrics-related business. In 2022, there will be only 2 official announcements, which will jump to 18 in 2023, and 11 in less than half a year in 2024.

Among the 31 medical institutions that have reduced obstetric services, traditional Chinese medicine hospitals and township health centers bear the brunt, with 9 and 6 respectively, accounting for nearly half. The strengths of these institutions, the main business of which they are not in obstetrics, are also not in obstetrics.

"Obstetric midwifery services will be suspended from now on, and pregnant women who need to give birth should go to other hospitals for treatment." On May 7, 2024, the Traditional Chinese Medicine Hospital of Loudi City, Hunan Province posted an announcement. This tertiary hospital has been established for more than 60 years and is a national key construction unit of traditional Chinese medicine with nearly 600 employees.

On May 19, Southern Weekend called the hospital's obstetrics and gynecology department, and the operator said that fewer and fewer people were giving birth, and local mothers also tended to go to the maternal and child health hospital.

The Fifth People's Hospital of Ganzhou City, Jiangxi Province, which is also a tertiary hospital, also announced the suspension of all obstetric services in 2024. According to the Lookout, this is a specialized hospital for infectious diseases, and the obstetrics department was originally established to serve pregnant women with infectious diseases. The dean said frankly that few people come to the infectious disease hospital to give birth, and the hospital's obstetrics and gynecology department usually has only single digits, while there are more than a dozen medical staff, and the obstetrics department has been set up for eight years, with an annual loss of about 3 million yuan.

Obstetrics-related services are not just about delivery and delivery. (Southern Weekly reporter Huang Sizhuo/Photo)

It is worth noting that obstetrics-related services include not only childbirth, but also preconception examinations, pregnancy consultations, prenatal examinations, abortions, hospitalizations, etc. According to the announcement of the medical institution, only 7 obstetric services have been suspended. 3 companies only cancelled after-hours and night shifts due to lack of manpower and post adjustments; Twenty-one hospitals no longer provide midwifery services in hospitals, and other items such as prenatal check-ups remain as usual.

With the process of urbanization, the demand for obstetrics is also converging on the higher-level hospitals. Pregnant women in rural areas are more willing to go to the county seat to give birth, and in the statistics, grassroots township health centers are the first to bear the pressure. According to the Health Statistical Yearbook, from 2016 to 2021, the number of obstetrics and gynecology beds in township health centers shrank by 20,000, a decrease of 17%.

Duan Tao told Southern Weekend that "more than 60% of births in China are still in medical institutions at the county level or below." The above-mentioned "Notice" of the National Health Commission states that in principle, counties (cities, districts) with a population of more than 300,000 can provide midwifery services in at least two public medical institutions, and in principle, at least one with a population of less than 300,000.

Of the 31 medical institutions that have cut their obstetric departments, only three are in small cities (population < 300,000).

In medium-sized cities (with a permanent population of 500,000-2 million), 22 medical institutions have reduced their obstetric departments, accounting for 71%. Pregnant women in these cities may also gather at higher-level hospitals and have the capacity to go to specialized hospitals for women and children or tertiary general hospitals.

Busy: The "siphon" effect of large hospitals

Tertiary general hospitals and maternity and child specialist hospitals in big cities have also been affected by the decline in the birth rate, and there are fewer cases of "hard to find a bed" and "extra beds to sleep in corridors", but medical staff are still busy and even need to expand.

"Many peers are incomprehensible, isn't it that fertility is declining, why are you still expanding?" In the "big cradle" of Nanchang babies - Jiangxi Provincial Maternal and Child Health Hospital, Yu Lamei, deputy director of the obstetrics department, has been working for more than 20 years and heard the first cry in the lives of tens of thousands of babies. Nearly half of Nanchang's population was born here, and more than 20,000 births have been given in eight consecutive years.

In 2020, shortly after returning to Jiangxi from Hubei to support the fight against the epidemic, Yu Lamei devoted herself to the construction of the new hospital. The new hospital has recruited and reserved a certain number of obstetric medical staff, and will be officially opened in 2022, covering an area equivalent to 16 standard football fields, setting up 1,800 parking spaces, and the subway entrance can be reached from the hospital gate dozens of meters away.

At present, the obstetric department of the new hospital is running smoothly, and the more than 450 obstetric beds are rarely vacant, and 9 integrated delivery rooms, VIP suites and single rooms are the most popular.

Yu Lamei thinks that it would be perfect to add a few more people to the obstetrics. Similar to the obstetrics departments of many leading hospitals, the Jiangxi Provincial Maternal and Child Health Hospital also undertakes the work of providing guidance, free clinics, grassroots training, supporting border areas and even foreign aid in the province, and from time to time colleagues are not in the hospital.

On the eve of the implementation of the "comprehensive two-child" policy in 2016, Yu Lamei and her colleagues felt that the pregnant women they received were "different from before", and it became more obvious after the implementation of the three-child policy in 2021.

The first is that the average age of pregnant women is getting older. More than 10 years ago, Yu Lamei faced 23 and 24-year-old mothers, and in recent years, the main age of mothers has been postponed to about 30 years old, and there are many elderly women over 35 years old or even over 40 years old. Recently, the oldest of the women in charge of Yu Lamei is 46 years old.

"Women have longer been educated, the age of marriage is delayed, and the age of pregnancy is also older." Yu Lamei said, "With the advancement of reproductive medicine technology, people who are not in good physical fertility conditions can also conceive babies. ”

There is also an increasing number of pregnant women suffering from various pregnancy complications. When the primary maternal and child health care hospital encounters incurable diseases, it will transfer the pregnant woman to the primary general hospital, and if it is still difficult, she will be transferred to the head maternal and child health hospital in the provincial capital city and the obstetrics department of the comprehensive tertiary school.

Policies also encourage "diversion". In 2017, the former National Health and Family Planning Commission promulgated the "Specifications for Maternal Pregnancy Risk Assessment and Management", which requires that maternal risks are divided into five types: "green (low), yellow (general), orange (high), red (high), and purple (infectious diseases)". Except for pregnant women with "green" labels, it is recommended to have prenatal examination and delivery in medical institutions above the second level.

In this way, the "siphon" effect of the head hospital is formed, and the number of deliveries is maintained, but the situation of the mother is becoming more and more complicated. For example, the Jiangxi Provincial Maternal and Child Health Hospital, as a provincial perinatal medicine center and a provincial critical maternal treatment center, has admitted a large number of critically ill pregnant women who have been referred, and the requirements for the development of obstetric subspecialties are also increasing day by day.

Subspecialties are further subdivided on the basis of major specialties. Yu Lamei said that over the years, her obstetrics department has opened subspecialties such as gestational diabetes, hypertension, liver disease, fetal medicine and breastfeeding guidance center.

For example, placenta accreta is a serious complication for pregnant women, and the normal placenta is separated from the uterus by the endometrium, but when the endometrium is injured, the placenta may directly invade the muscular layer of the uterus, which can lead to postpartum hemorrhage and even life-threatening. In this regard, Yu Lamei introduced that the placental disease subspecialty in the hospital has multidisciplinary consultation, comprehensive assessment and surgical cooperation, which greatly reduces the probability of intraoperative hemorrhage and hysterectomy.

Liters: Public schools are private, private schools are public

Although techniques such as painless delivery are becoming more widely used, many mothers still feel that the process of giving birth can be more decent and comfortable. Under Duan Tao's Weibo of "Save Obstetrics", a highly praised message is "Girls who give birth to children are more or less afraid, and they are treated as 'inappropriate people' in obstetrics." ”

Southern Weekend reporters visited several public hospitals in Shanghai and found that there were only cold stainless steel seats in the waiting room of the general obstetric outpatient clinic, and there were not enough seats, and some pregnant women could only stand. There is no hot water and paper towels for washing hands in the women's toilet, and there are often queues to go to the toilet, and there are few toilets, most of which are squatting pits, and it is very inconvenient for pregnant women with big bellies to do urine tests. Some netizens also complained that a row of pregnant women lying in a delivery room during labor, family members could not accompany them, they rang the call bell, and it was difficult for midwives to respond immediately, anesthesiologists were limited, and women who wanted to give birth early and painless were not allowed.

In order to provide better services, many pregnant women choose private hospitals, and do not hesitate to spend 5-20 times the cost.

In recent years, public hospitals have been providing services such as schools for pregnant women and painless childbirth, which have been popular in public hospitals for more than 20 years, in large private hospitals such as United Family Hospital. "Many people have the impression that private hospitals are a supplement to public hospitals, but in fact, the two have been learning from each other over the years, with private learning from public and public learning from private." Liu Wei, general director of United Family Healthcare Shanghai Region, told Southern Weekend.

Before joining United Family Clinic, Liu Wei was an anesthesiologist working at Peking Union Medical College Hospital, where the obstetrics and gynecology department is one of the top in the country, so Liu Wei knows not only about private hospitals, but also about public hospitals.

Many public hospitals have taken action to upgrade their hardware facilities. Warm decoration style, integrated delivery room, independent toilet, smart toilet, WiFi full coverage...... In the past year, the Huangpu Campus of the Obstetrics and Gynecology Hospital Affiliated to Fudan University in Shanghai, the South District of Shandong Provincial Maternal and Child Health Hospital, and the Second Obstetrics District of the First Maternal and Child Health Hospital of Huizhou City, Guangdong Province have all been optimized.

Many public hospitals have begun to provide services such as schools for pregnant women, doulas, painless delivery, and family companion delivery. The above-mentioned "Notice" of the National Health Commission also emphasizes the provision of humanized childbirth services centered on mothers.

A school course for pregnant women at a hospital in Shanghai. (Southern Weekly reporter Huang Sizhuo/Photo)

Liu Wei revealed that private hospitals are also learning from the strengths of public hospitals, comprehensively building departments, and improving multidisciplinary consultation and critical care capabilities. "The labor cost of private hospitals is high, and those who can survive to the end must have the strongest comprehensive strength and the best service experience."

After stepping down as the president of Shanghai First Maternity and Infant Health Hospital, Duan Tao is also working as a consultant for private institutions, and is now the chairman of the Obstetrics and Gynecology Committee of the China Association of Non-public Medical Institutions. He judged that if public hospitals are willing to change their minds and are committed to providing a more comfortable medical and delivery experience for pregnant women, they will crowd out the living space of a large number of private hospitals.

"It is not difficult to improve the hardware in the public and private schools, but the most difficult thing is to do services, and the doctors and nurses are not willing to do it, because patients have been begging them for a long time. Now that the number of births is decreasing and the competition is fierce, changes have to be made, which requires certain process norms and system adjustments. Duan Tao said.

When public hospitals seriously "roll" up the environment and services, the number of visits to private hospitals will also decline, and they can only lay off staff, reduce salaries and even go bankrupt and liquidate - such as Nanjing Huashi Jiabao Obstetrics and Gynecology Hospital and Shenglujia Obstetrics and Gynecology Hospital in Shijiazhuang. The latter is a wholly-owned private medical institution in Hong Kong, with an investment of nearly 600 million yuan and 500 beds, which ended in disgrace after seven or eight years of operation, and the final asset auction price was less than 10 million yuan.

However, fertility is shrinking rapidly, and both private and public hospitals are feeling threatened. Of the 31 hospitals counted by Southern Weekly, seven private hospitals had their obstetric services cut or shut down.

Shortage: Chinese per capita obstetric resources are low

After completing the prenatal examination in China for the first 31 weeks of pregnancy, Zhang Li flew to Seattle, USA to give birth and experienced the comparison of prenatal examination between China and the United States.

The maternal and infant mortality rates are important indicators of the health level of the population. The success rate of critically ill pregnant women and critically ill newborns in China has been significantly improved, and the number of newborns with congenital defects has decreased rapidly, ranking among the top middle- and high-income countries in the world.

The difference between China and the United States in prenatal examination is not in the incurable diseases, but in the service experience.

Zhang Li was impressed by the fact that even in the special needs clinic in Shanghai, obstetricians have to see many patients a day, with fatigue on their faces, and the time for each consultation may be about five minutes, and it is difficult to have the time and energy to explain the examination results one by one.

During the prenatal check-up in the United States, the doctor will chat with her for 20 minutes, and the doctor will patiently answer any questions in detail. During childbirth, the pregnant woman's small emotions are taken care of well, and what the nurse has done and the conversation with the pregnant woman will be recorded on the computer in real time - the hospital should ensure that the nurse is energetic and focused, even if the shift changes, every nurse knows what the pregnant woman has experienced before.

Behind the difference, it is because the per capita obstetric resources of Chinese are not enough.

Sissy, a Canadian nurse in obstetrics and gynecology, told Southern Weekend that her hospital is a general hospital that delivers more than 3,000 babies a year, and nurses take care of mothers "1 to 1". The annual salary of nurses is about 8-100,000 Canadian dollars (about 42.5-531,000 yuan) before tax. The delivery room is spacious and bright, with its own bathtub and toilet, and the application is painless as long as the anesthesiologist is free. But according to WHO data, China's nursing and midwifery ratio per 10,000 people is only one-third of Canada's.

For example, painless childbirth, which is called the "light of mankind" by many mothers, has a low prevalence rate in Japan.

In 2022, Mi Weidong, head of the expert working group of the National Health Commission for labor analgesia, introduced that in the four years since the implementation of the national labor analgesia pilot work, the penetration rate of painless delivery in pilot hospitals has increased from 27.5% in 2017 to 53.2% in 2020, and the national average penetration rate has reached 30%, but there is still a distance from the 80%~90% penetration rate in developed countries.

Postpartum depression is also becoming more common and requires attention and intervention. According to a 2019 paper, the incidence of postpartum depression in mainland women of appropriate age is 14.7%, while the incidence of postpartum depression in elderly women can be as high as 36.9%. In addition to postpartum depression, women who have miscarriage, stillbirth, and infertility also need professional psychological support.

Price: To meet the diversified needs of childbirth

Better service also means higher fees. Zhang Li is very satisfied with the delivery environment and experience in the United States, and after receiving the bill, except for other expenses, the cost of a smooth delivery is about 30,000 US dollars (217,000 yuan). If there was commercial insurance, it would cover a large part of the cost, but she didn't.

"If it costs tens of thousands of dollars to have a child in China, even if the fertility volume declines, obstetrics can survive, but it's almost impossible." Duan Tao told Southern Weekend that the obstetric business is very low, with a smooth delivery of less than 1,000 yuan in small cities and more expensive in big cities, and generally not tens of thousands of yuan.

According to the data of the National Health Insurance Administration, in 2021, the per capita medical cost of natural delivery in public hospitals was 3,547 yuan, and the per capita medical cost of cesarean section was 9,119 yuan. In 2022, the average reimbursement of maternity medical expenses for female employees participating in the national maternity insurance will be 5,899 yuan.

Duan Tao laughed at himself in the obstetric "distress letter", and the earliest obstetric fee standard was set according to the standard of rural midwives.

"The principle of obstetrics is to ensure the safety of mothers and babies, and the best way to give birth is to have no surgery - a smooth birth, without any complications." Duan Tao said. This is also contradictory to the current obstetrics assessment, which should not be evaluated by the proportion of CMI (Case Mix Index, the more difficult the treatment, the higher the value) and high-level surgery.

Special outpatient clinics in public hospitals can meet the needs of pregnant women who are more able to pay. However, it is difficult to get a special needs number, and the proportion of special needs services in public hospitals cannot exceed 10% in principle.

Some members of the National Committee of the Chinese People's Political Consultative Conference (CPPCC) have suggested adjusting this policy. In February 2022, the National Health Commission responded in a letter in response to the proposal that public hospitals are the main body of the medical service system, and the provision of fair and accessible basic medical services is the primary responsibility, and the scale of special medical services should be strictly controlled by 10%, and the introduction of commercial health insurance should be encouraged.

Obstetric special needs outpatient clinic at a hospital in Shanghai. (Southern Weekly reporter Huang Sizhuo/Photo)

There are still not many women who use commercial insurance to give birth in China, because the basic medical insurance system also has some protection, but the cost is low. At the special needs outpatient clinic of a tertiary hospital in Shanghai, a reporter from Southern Weekend saw a poster of commercial insurance, and there were more than 30 health insurance companies that could pay for maternity and other health insurance.

Some pregnant women who have purchased supplementary commercial insurance for themselves or by their company will choose the international department of a public hospital or a private hospital. In addition to being able to reimburse part of the prenatal examination and maternity expenses, they also value the convenience of appointment, no queue for prenatal examination, painless whole process, delicious meals, quiet and comfortable environment, etc. However, the annual premium of these commercial insurance plans is not cheap and may exceed the fertility itself, but it meets the diversified needs of childbirth.

Tuo: Pay attention to women's health, part-time in other departments

Obstetrics, which has been partially shut down, is looking for a path to transformation.

Before and after the issuance of the "Notice" of the National Health Commission, Duan Tao was twice invited to participate in the symposium organized by the National Health Commission, and the consensus of obstetric experts was that the fees were low, the treatment was poor, the risks were high, people could not be retained, and the development of the discipline was difficult. "Documentation and implementation are two different things, in the end, each hospital still has autonomy, and there are so many resources at hand, whether to save the obstetrics department, how to save it?" Duan Tao said.

"Judging from Japan's experience, the prospect of obstetrics and gynecology is not bleak, and some hospitals will still achieve strong development." Zhao Heng, founder of Latitude Health, a medical strategy consulting company, told Southern Weekend that the transformation of obstetrics and gynecology in Japan can be used as a reference.

The obstetrics situation is special, and patients in many departments can wait, but not to give birth. Regardless of how many babies are delivered a day, the delivery rooms and operating rooms of the hospital need to be open 24 hours a day, 365 days a year, with obstetricians, neonatologists, anesthesiologists, midwives ...... Multiple positions are on standby.

Zhao Heng introduced that although the obstetrics department of many Japanese hospitals is retained, many doctors are part-time, and the wards are mixed, and more than 50% of the mixed wards in small and medium-sized cities are available, and the nursing staff can also provide services for other patients during the off-season of obstetrics.

Zhang Li also found that obstetric resources in the United States are relatively scattered: prenatal examinations are in the private clinics of obstetricians and gynecologists, tests are in the laboratory outside, giving birth to children is in the hospital, anesthesiologists come from their own clinics, and the hospital does not have a pharmacy, so you have to take the doctor's prescription to the pharmacy outside the hospital to open it. The domestic prenatal examination is more centralized and efficient, "no matter what disease you have, what tests you want to do, what drugs you prescribe, you can basically complete it in the same hospital in a short time."

Ten years ago, UFH's focus extended from obstetrics and gynecology to women's health needs throughout the life cycle, and established a women's health center, covering breast specialties and oncology clinics. At present, the maternity business now accounts for only about 10% of UFH's total revenue, and the proportion of revenue from surgery, gastroenterology, pediatrics, acute and critical diseases has increased significantly, and consumer medical projects such as medical aesthetics and stomatology are also being improved.

A sleeping newborn. (Visual China/Photo)

After the obstetrics "reshuffle", pediatrics and other departments will also be affected. In addition to focusing on high-risk mothers, neonatal care has also become a focal point. Japan, for example, is focusing on increasing the number of NICUs (neonatal intensive care units) where babies are admitted from 30.4 per 10,000 live births in 2014 to 40.4 in 2020. "However, the geographical distribution is uneven, and medical resources are concentrated in metropolitan areas."

At present, the obstetrics departments and maternal and child health hospitals of general hospitals in many places are also exploring group operations, integrating local maternal and child medical resources, lengthening the obstetric service chain, and tapping prenatal, intrapartum and postpartum needs - first satisfying the first child, and then driving the demand for the second and third children. Some maternal and child health hospitals have also opened confinement centers and one-stop centers for early pregnancy. In addition, in the context of advanced age and pregnancy, assisted reproductive medical services that are gradually included in medical insurance are also new business growth points.

As for the flow of obstetric personnel, nearly half of the consultation calls of the 31 medical institutions that have cut off obstetric services have not been answered or have empty numbers. The medical institutions that answered the phone also refused to disclose the whereabouts of obstetric care, and only two hospitals in Hunan and Jiangxi said that some obstetric staff were transferred to gynecology.

It is worth noting that obstetrics is a basic medical service with strong public welfare attributes, and it takes at least ten years to train an obstetrician who is independent and accumulates experience in incurable diseases. According to Southern Weekend, obstetric nurses in some hospitals have worn multiple hats, but it is difficult for obstetricians to move across departments. "Young doctors may be fine, they can do gynecology without doing obstetrics, but it is difficult for senior obstetricians, and they have been doing it all their lives." Duan Tao sighed.

(Zhang Li is a pseudonym, Southern Weekly reporter Haiyang also contributed to this article)

Southern Weekly reporter Huang Sizhuo, Southern Weekly intern Wang Qixin, Zhao Yongqi

Editor-in-charge: Wang Tao

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