In 2016, when the two-child policy was implemented, we welcomed 18.67 million newborns, and in 2023, the number of births is 9.02 million, less than half of that in 2016.
经历过"二孩"生育潮，产科最先感受着当下新变。
A striking sign is the frequent announcements of hospital obstetric closures and adjustments. In January this year, Jinshazhou Hospital of Guangzhou University of Traditional Chinese Medicine issued a notice of suspension of obstetric treatment, and in February, Zhejiang Jiangshan Hospital of Traditional Chinese Medicine announced that it would no longer carry out obstetric delivery business. Since 2022, similar cases have appeared in dozens of hospitals in Jiangsu, Zhejiang, Henan, Anhui, Guangxi and other places, and some private hospitals have also quietly stopped obstetric services.
Confusion and anxiety spread among obstetricians. In February, Duan Tao, chief physician of Shanghai First Maternity and Infant Health Hospital, and the director of obstetrics in Pudong, Shanghai, held a meeting together, and a director of obstetrics who had worked in obstetrics for more than 20 years cried that the obstetrics department of her hospital was closed, and that she loved obstetrics and could only do obstetrics, and did not know where she could be transferred.
An obstetric nurse is nursing a newborn
After that, Duan Tao called for "saving obstetrics" on Weibo, saying that "all kinds of situations are not conducive to the development of obstetrics" and worried about "the collapse of obstetrics".
Subsequently, on March 27, the Notice of the General Office of the National Health Commission on Strengthening the Management of Midwifery Services (hereinafter referred to as the "Notice") was issued, which not only set the bottom line and norms for the adjustment of obstetric services, but also put forward new requirements for improving the quality of midwifery services. In the future, obstetricians will continue to watch over the millions of mothers and newborns that occur every year, looking for a way out.
One is cold and the other is hot
Xiao Jie is a midwife at a township health center in Fujian, but since about 2018, she has been working more like a nurse than a midwife. Because she no longer needs to help pregnant women give birth in the delivery room.
Before that, there were still pregnant women in villages and towns who came to deliver babies every year, but "there was no more". Now her main job is to help the pregnant women in the town to file up, remind them of prenatal check-ups, and do information management.
Even for prenatal checkups, health centers often recommend that pregnant women go to the county or city to do it. "Now there are a lot of prenatal check-up items, and the early prenatal check-ups are important deformity check-ups, and we have no conditions to do it at the grassroots level, and there is also a shortage of manpower, so everyone will not run to us, but will move to the county or city. Xiao Jie told Nanfeng Window.
Stills from "This Life is the First Time".
In addition, Xiao Jie's health center does not have the ability to deal with dystocia and postpartum hemorrhage, and the referral may also delay time, for the sake of safety, pregnant women also tend to go to hospitals with better conditions to give birth.
"Nowadays, many people marry later and have children later, plus a second child, there are more high-risk groups, such as those over 35 years old, multiple miscarriages, and cesarean sections, which are considered high-risk factors, and they have to be more careful, and now children are more precious. Xiao Jie said.
After 10 years of work in the primary obstetrics, Xiao Jie has witnessed the changes in childbirth in the nerve endings of the system and in the annual number of pregnant women.
After the second child was released, the number of pregnant women in her township reached a peak, with more than 600 women a year. By 2019, the number of registered people had dropped to less than 300, and in the past three years, "there were more than 100 a year".
Not only that, but one of the original private hospitals in Xiao Jie's township has also stopped giving birth, and the other two private hospitals in the county no longer provide midwifery services.
Even large tertiary hospitals specializing in women and children, such as the Shanghai First Maternity and Infant Health Hospital, where Duan Tao works, have seen the number of deliveries drop from 34,000 in 2016 to between 24,000 and 25,000 today.
It's been more than a year since Huang Yameng left obstetrics. Before resigning in 2023, she worked in the obstetrics department of a tertiary hospital in Jiangsu for 8 years. She never imagined that the maternity department would be closed and that she would be shunted from midwives to other departments as nurses.
On the same night shift, she had to force herself to adapt to the transition from "welcoming new lives" to "rescuing patients", facing male patients and deaths. Overwhelmed, she quit her job and joined a medical company and lived a 9-to-6 life. Only when the news of "obstetric shutdown" popped up on the hot search, she recalled with embarrassment the bitterness of "washing dolls" in the delivery room in the past.
Paramedics are knocking footprints on newborns
But for others, the delivery room is still busy.
At least Xue Yu, an obstetrician at a tertiary hospital in Beijing, has no obvious perception of the change in the number of mothers. "Big hospitals don't feel the impact as much as small hospitals, a little less," she told Nanfengzhuang, "big hospitals are still rescue centers, and those that can't be handled elsewhere will be transferred to hospitals, so there's not much difference...... The vast hospitals in the north are always overcrowded. ”
When people lamented the news that some obstetric departments were cold, some pregnant women came forward to express their doubts: The hospital I went to, there were too many people queuing up for prenatal checkups, and the waiting time was too long.
We can still read this cold and warm reality from the statistics: although the number of newborns is decreasing, the base of 9.02 million newborns in 2023 is still very large.
Multiple considerations for obstetric ebb and flow
The change in the number of newborns is the general environment and fuse of obstetric adjustment, but it is not the only factor.
It is not difficult to find that among the hospitals that have adjusted their obstetric business, the most significant category is the county-level traditional Chinese medicine hospital.
The Second Hospital of Traditional Chinese Medicine of Huangdao District, Qingdao City, made the consideration of adjusting obstetric services in the notice: our hospital will give more prominence to the characteristics of traditional Chinese medicine.
The announcement issued by the Second Hospital of Traditional Chinese Medicine of Huangdao District, Qingdao City
The other type of adjustment is the township primary health center. Similar to Xiao Jie's situation, the Central Health Center of Luxin Town, Wuxuan County, Guangxi Province also said in the notice: the number of high-risk pregnant women who give birth in hospitals is increasing year by year, and the potential risk index is very high.
At the same time, the term "closing and suspending the department" is not rigorous, because the obstetrics department has a number of services including but not limited to childbirth, and most of the hospitals that have announced the suspension of consultations are only for "delivery services", while outpatient obstetric examinations, postpartum rehabilitation and other services are mostly retained; in contrast, hospitals that directly suspend all obstetric services are a minority.
The Fifth People's Hospital of Ganzhou City is a tertiary hospital that directly announced the cessation of obstetric services, and this hospital's specialty is the prevention and treatment of liver diseases, lung diseases, occupational diseases, and infectious diseases.
The obstetric resources and services of the Second Hospital of Yinzhou District, Ningbo, which also announced the suspension of obstetrics, were merged into the Women and Children's Medical Center of Yinzhou People's Hospital. Some local people said that the strength of Yinzhou Second Hospital is kidney disease, and friends around them will generally choose Mingzhou Hospital not far from it when they give birth.
If we check the list of medical institutions that provide midwifery services in various cities, we will find that they are mainly concentrated in specialized maternal and child hospitals and comprehensive tertiary hospitals, with the former focusing on specialized surgical specialties and the latter undertaking the treatment of incurable and miscellaneous diseases and critically ill pregnant women. Hospitals that are not one of the two tend to be more easily adjusted.
On March 27, in response to related questions, the National Health Commission emphasized in the "Notice" that public medical institutions should assume the responsibility of obstetric services, but did not negate the planning and layout of midwifery services and the adjustment of resources, but according to the size of the population and regional characteristics, the number of medical service institutions that should be equipped gave a principled bottom line and norms.
In fact, over the past decade or so, Chinese hospitals have experienced a period of rapid expansion, which has also raised many new problems, and bed utilization is one of them.
In the neonatal unit, medical staff are caring for newborns
In 2019, Huazhong University of Science and Technology published a paper on "Research on the Construction and Application of Obstetric Performance Appraisal System in Tertiary Comprehensive Public Hospitals", which pointed out after empirical comparison that in reality, the utilization efficiency of obstetric beds is seriously polarized.
In one of the hospitals surveyed, the supply of beds exceeded the demand, and the high workload of medical staff would also reduce the patient experience and the corresponding number of medical disputes, while the other two sample hospitals had low bed utilization and idle resources.
Under the baton of improving efficiency, there is room for replanning and adjusting resources. Not only that, the bed utilization rate is a key indicator of the hospital's performance appraisal, which has become another driving force for adjusting department resources.
As a result, we saw that the Second Hospital of Yinzhou District was merged into the Women's and Children's Medical Center of the People's Hospital, and the traditional Chinese medicine hospitals began to slim down and focus on their own specialties, while the township health centers with congenital deficiencies accepted their limitations.
Obstetric difficulties
Whether it is the need for optimal allocation of resources or the consideration of maternal safety, obstetrics is in a relatively weak position compared with other departments.
In the Weibo appeal of "Save Obstetrics", Duan Tao mentioned: "The operation cost of obstetrics is high, no matter how many children you give birth to a day, you must have a 24-hour delivery room and operating room, and you need obstetricians, neonatologists, anesthesiologists, and midwives who are on site 24 hours a day, 365 days a day, three shifts a day." ”
Not only that, but obstetric risks are high. "Even normal pregnant women who give birth to children may have postpartum hemorrhage, amniotic fluid embolism, uterine rupture, umbilical cord prolapse, and fetal intrauterine distress, not to mention those high-risk pregnant women with medical and surgical comorbidities. Once there is an accident, it will bring a lot of medical disputes and huge compensation, not only the hospital will have to pay, the department will have to pay for it, but the obstetrician himself will also have to compensate according to the proportion. Duan Tao wrote.
Stills from "Dear Life".
At the same time, tertiary public hospitals also face the pressure of performance appraisal known as the "national examination" in the industry. The original intention of the national examination to guide tertiary hospitals to solve difficult diseases and perform difficult surgeries is not compatible with the service principle of "ensuring the safety of mothers and babies" in obstetrics.
The contradiction is concentrated in the CMI index and the two assessment indicators of fourth-level surgery. A higher CMI index means a higher level of admission to a hospital for difficult and critical cases. "The CMI in obstetrics is very low, with a pitiful less than 1. Duan Tao pointed out, "Fourth-level obstetric surgery is rare, even rarer than rare diseases. ”
Researchers from the Third People's Hospital of Chengdu, Sichuan Provincial People's Hospital, and the Affiliated Hospital of Chengdu University confirmed this. They analyzed the case information of 16,380 cases in a tertiary hospital from 2015 to 2020, and found that among the pregnant women who had undergone surgery, primary and secondary surgeries were the mainstay, accounting for 93.71%.
"When obstetrics is doing well, it is more about natural delivery, and when the prevention work is done well, there will be no complications, the CMI index is very low, and there is no need for surgery, and it can be born naturally. When the management of pregnancy is not done well, and the management of childbirth is not good, there will be many complications, there will be a lot of big rescues, the CMI index and the level of surgery have gone up, and the indicators are good, but it is the pregnant women who suffer. Duan Tao explained.
Not only department managers, but also front-line obstetricians have another layer of pressure.
Xue Yu deeply felt that the distrust of pregnant women and their families towards doctors was increasing day by day, and the number of patients with audio and video recordings had almost doubled: "Pregnant women often can't accept some sudden complications during pregnancy, or give birth to a child with bleeding rescue, and firmly believe that the hospital has seen her bad." A Guangxi obstetrician also sighed: I didn't feel tired when I was so busy when the second child was released, and now there are fewer mothers, but the medical insurance DRG, and other meetings and accounts have to be done, and I am getting more and more tired.
Xue Yu thought about resigning many times, but even so, when she was sitting in the outpatient clinic, she met a patient who resisted treatment and just wanted to take Chinese medicine, and finally she used her own affection to contact the other party with the expert number of the director the next day.
The next target, fertility-friendly hospitals
In the years when her work has shifted to maternal management, Xiao Jie's work has not been easy. After the establishment of a pregnant woman file, the management requirements are becoming more and more stringent.
"Remind them to do NT initial screening at 3 months of pregnancy, Down's screening at 4 months, and three-dimensional color ultrasound at 5 months, these are all important deformity examinations. Xiao Jie said.
At the township health center where she works, she reminded that prenatal examination is an important task added after the liberalization of the "two-child" policy, and now, the requirements are higher than before. After reminding her that she also needs a telephone return visit to confirm whether the prenatal examination is completed, a woman will probably complete about 10 prenatal examinations, and high-risk pregnant women are the focus of attention, and the management is becoming more and more refined - Xiao Jie attributed this change to: from the pursuit of quantity to the pursuit of quality.
The pregnant woman is undergoing prenatal checkups
In the "Notice" of the National Health Commission, "strengthening the quality management of midwifery services" is written in a prominent position, and higher detailed requirements are also put forward for the time of cesarean section surgery: the time from the decision of the operation to the delivery of the fetus for emergency cesarean section is controlled within 30 minutes and gradually shortened.
Not only that, "fertility-friendly hospitals" have also become a common expectation of policy documents, practitioners, and ordinary pregnant women - it is specific to whether mothers can live in more humane single rooms, whether they can enjoy analgesic delivery services, or whether family members have the opportunity to accompany childbirth, whether doctor-patient communication is benign, and whether service prices are inclusive......
Miao Ling is a novice mother, during the first trimester of pregnancy, she hung up the general outpatient clinic of a maternity and infant hospital in Shanghai, and it took more than half a day to wait for the number to be called, and the day passed after the examination. In order to save time, she had to go to the more expensive special needs clinic, so that she had a smooth experience with a green light.
When she showed signs of suspected labor in the third trimester, she went to the emergency room twice, but the doctor's explanation at the first hospital did not answer her confusion, but only told her to go home and continue to observe. A few days later, anxious, she changed to a second hospital, only to be answered and reassured.
At the Obstetrics and Gynecology Center of Shanghai East Hospital, she felt a different service for the same special needs outpatient clinic. Not only did the pre-examination table help open the examination and let her enter the consultation room directly, but the doctor Liu Ming patiently answered her doubts. "She comforted my glass heart as soon as she came up, including other doctors and nurses, and the whole team was very able to give me a sense of security and humanistic care, that is, she would remember every mother, and she would take the initiative to solve problems and comfort them. Miao Ling said.
In fact, many hospitals and doctors are updating their concepts to provide more humane obstetric services.
Stills from "Dear Life".
One of the most significant advances has been the promotion of painless births. There is a growing awareness that labor pain only adds to maternal pain and fear, and that tolerating labor pain does not bring real value to childbirth. According to data from the National Health Commission, in 2022, the labor analgesia rate in 913 pilot hospitals increased from 27.5% seven years ago to 60.2%.
However, it is worth noting that due to factors such as traditional concepts, economic burdens, and insufficient anesthesiologists, Mi Weidong, head of the Expert Working Group on Labor Analgesia Pilot of the National Health Commission, pointed out in 2022 that the overall prevalence rate of labor analgesia in China is only 30%, and nearly seventy percent of women still suffer from labor pain.
Fertility rates are declining, but the population of people who want to have children remains huge. After the contraction and adjustment, the survival and development of obstetrics in the future is nothing more than technology, service and quality.