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Delivery Dilemma

A delivery room tragedy has challenged a millennium-old belief held by the Chinese public: childbirth should be painful

By NewsChina Updated Nov.1

For many, no place brings more happiness than a delivery room does, where countless young moms and dads witness the miracle of life happen with tearful wonder. Yet never had Yan Zhuangzhuang, a 29-year-old man from Suide county, Shaanxi Province, imagined how this place of happiness could turn into a hell.
  
August 31 was supposed to be a big day for Yan and his 26-year-old wife Ma Rongrong, as she was about to give birth to their baby boy. But what waited for him that day was her cold body lying in front of the hospital – his wife jumped from the fifth floor of the building while in labor, and died soon after.  

Speculation and discussions soon flooded China’s social media. Although there is no confirmation of the reason for her suicide, one thing for certain is that the young woman had suffered extreme pain during childbirth, which, many argue, possibly led to her desperation.  

Pain, as experts point out, has been medically classified on a scale of one to 10, and labor pain is placed between level 8 and level 9, equivalent to the pain of cancer or of cutting into your fingers with a knife. In a culture where having offspring is of utmost importance, enduring the pain of childbirth is seen as a mandatory hurdle that every Chinese woman has to tackle, no matter how crucifying it is.  

Yet Ma’s tragedy has challenged the rationality of this ritualized process with a question: why does childbirth have to be painful? And so a topic that has rarely received much attention before in China is now being discussed more and more: pain relief during childbirth.  

A Suicide that Shocked the Country 

Accounts of the event differ, but it is generally understood that on August 30, Ma was admitted to the First Hospital of Yulin to give birth. Medical checks showed that the baby���s head was larger than normal, suggesting higher risks during natural birth. But the doctor-in-chief, Li Ruiqin, told the couple that a successful natural delivery was still highly possible.  

Both Ma and her husband Yan agreed on a natural birth and signed a document to confirm that Ma would deliver naturally.  

Ma was transferred to the delivery room on August 31, but she later left the room several times because of the pain. Leaving the room during labor is usually not allowed.  

“She said she couldn’t take the pain any more. She wanted to have a C-section instead. And I said, ‘if you want to do C-section, then we do it. I will go and find the doctor,’” recalled Yan in an interview with NewsChina, about the conversation he had with his wife after she left the delivery room for the first time.  

Yan asked Ma’s physician Li to change the delivery method from a natural birth to a cesarean section. A physical check was made afterwards, and the doctor responded that, “She is going to give birth very soon. It’s too late to change.” 

Ma left the delivery room once again to beg for a C-section. Informed that it was too late to do the C-section, Ma returned to the delivery room, dismayed.  

Fifty minutes later, Ma was found dead on the ground outside the building. 
Surveillance footage showed that she jumped from the fifth floor.  

On September 3, the hospital posted a statement on its official Weibo account, China’s Twitter-like social media platform, saying that doctors had advised the patient and her family to opt for a C-section in advance, and it was Ma’s relations who had refused to consent to a cesarean delivery, and had insisted on a natural delivery instead.  


Ma’s family and the hospital blamed each other for rejecting her request to have a C-section, but the reason behind Ma’s suicide remains publicly unknown.  

Many believe that the pain caused Ma to take leave of her senses. One opinion that gained a lot of traction on social media was that if the woman had been given an epidural in advance, her and her baby’s lives would have been saved.  

No Pain, No Gain? 

Although pain relief is commonly applied in high-income countries – 85 percent of women in the US use pain relief medication, 98 percent in the UK, and 86 percent in Canada – it is still a new word in the Chinese dictionary.  

“It [labor pain control] is accessible to less than 10 percent of maternity patients in China,” the National Health and Family Planning Commission, China’s top regulator of health-related industries, announced at a “happy delivery room” launch event. 

Over the past 10 years, Professor Hu Lin-qun, an American Chinese anesthesiologist of the Feinberg School of Medicine at Northwestern University, has strenuously promoted the wider use of labor pain relief in China. Hu is the founder and executive director of No Pain Labor & Delivery (NPLD), a nongovernmental program launched by the Feinberg School of Medicine at Northwestern University in 2006.  


In 2008, the program detailed several specific aims to fulfill within a decade: it planned to build more than 10 training centers for analgesia doctors, increase access to safe labor analgesia by 10 percent in 10 years and benefit 1.5 million maternity patients each year. 
 
Shijiazhuang Maternity Hospital of Hebei Province is the only grade A maternity hospital in the province. Since 2010, it has worked with the NPLD and started to apply safe labor analgesia. Unlike most noisy and chaotic delivery rooms in other hospitals in China, the delivery center of this hospital is unusually quiet, with no cries or screams. 

Before 2010, 9,000 women a year gave birth there. With the application of the labor pain relief service, more and more women are coming to the hospital. In 2016 alone, at least 31,000 babies were born in this hospital, and 90 percent with the assistance of safe labor pain relief.  

Although the NPLD has worked with 80 hospitals in China, talking about the spread of pain-relief management in this country, Hu told our reporter with a sigh, “It makes inroads too slowly.” 

A giant obstacle that promoters of safe labor analgesia battle with is the conventional notion deeply rooted in Chinese minds for generation after generation: no pain, no gain. Labor has long been seen as a process, even a ritual, during which every new mother has to beat the hellish pain to attain the final reward, the new baby.
  
In a culture where having offspring is of great importance, every development in obstetrics will hit a sensitive nerve among Chinese parents and grandparents. Many suspect that the anesthetics used for pain control might cause harm to babies. 
 
“It’s a problematic way of thinking. Society doesn’t see it as a necessity to alleviate pain during childbirth. But that pain is not a must-have experience that every woman has to endure,” said Lian Qingquan, president of the Second Hospital Affiliated to Wenzhou Medicine University.  

The hospital has worked with the NPLD and applied safe labor analgesia since 2010.  
“It’s been scientifically proven as a misunderstanding that using pain relief might do harm to babies. In fact, it not only does very little harm, but also takes away some of the complications of childbirth,” Lian told NewsChina.  


Duan Tao, president of the No.1 Maternity Hospital of Shanghai, agreed with Lian that pain relief can reduce emergencies. “Emergencies happen rarely in the obstetrics department, but if there is one, it might be fatal. Nevertheless, the majority of the medical institutions in China pay no attention to emergencies during childbirth […] Adopting labor analgesia is not merely about relieving pain. One of its significances lies in that it offers much convenience for doctors to conduct an immediate operation if any emergency occurs to either the mother or the baby in the process of delivery,” Duan told NewsChina.  

“If an emergency happens, we have to conduct an operation immediately to take the baby out within five minutes. It’s called the ‘Five-minute Instant C-section’ in obstetrics. The time to start the operation can be shortened if anesthetics have been administered in advance. Thus, applying safe labor analgesia is like buying life insurance to guarantee the safety of mother and baby’s lives, not simply dealing with the problem of pain,” Duan said.  

Predicament 

Over the years, the NPLD has emphasized the significance of establishing the “modern labor and delivery room.” From Professor Hu’s perspective, a modern labor and delivery room is supposed to be a combination of operating room, delivery room and ICU.  

“The core idea is to have 24-hour availability of anesthesia doctors in labor and delivery rooms and to proceed with team-based medical practice in perinatology,” Hu told NewsChina. He emphasized that the management of modern labor and delivery rooms not only depends on skills and techniques, but also on the system of support. 
 
Nevertheless, to put such a design into practise is far from easy considering the current Chinese medical care situation.  

One reason could be that there are not enough trained anesthesia doctors in the public medical system. There were only about 85,000 registered anesthesiologists in China in 2017 and at least 300,000 anesthesia doctors are needed to meet the demand, the deputy president of the Chinese Society of Anesthesiologists, Huang Wenqi, told Yangcheng Evening News.  

In China, there are only 0.5 anesthesia doctors for every 10,000 people, compared with 2.5 in the US and 2.8 in the UK.  

Another factor that holds back the pace of pushing the wider use of labor analgesia is that hospitals usually cannot make enough profit by providing the service.
  
Duan Tao told NewsChina that obstetrics is a department that is not profitable yet it is highly risky. “Hospitals make little profit from obstetrics since most normal delivery costs are covered by social medical insurance. Obstetrics, anesthesiology and neonatology are all ‘cheap and less important’ in the eyes of many hospital executives. Establishing a modern delivery room requires enough numbers of obstetricians, anesthesiologists and neonatal doctors: what hospital executive is going to be willing to commit to something with huge inputs but little gains?” Duan said.  

A director of a maternal and childcare service hospital in Beijing, who insisted on anonymity, told NewsChina that in Beijing, childbirth pain reduction usually costs about 2,000 yuan ($300), much lower than the price of a C-section. Obstetricians and anesthetists barely earn any money from the procedure, but they have to be highly attentive during the entire process, which takes over 10 hours most of the time. 
  
“After China revised the One Child policy, many families are planning to have two children, which exacerbates the problem further and also puts more pressure on doctors and nurses,” the director said. He also suggested that the government could increase the [payout] limit of social medical insurance, or cover the salaries of hospital staff, to guarantee a modern obstetrics service. 

Another hindrance comes from the current management system of most hospitals in China. Modern labor and delivery rooms call for multi-divisional collaboration, and, ideally, an individual operating room should be available in the delivery room. But this is hard to fulfill under the current department-based management system that most hospitals in China adopt.  

Obstetrics departments in China are usually separate from others. Thus, delivery rooms and operating rooms, which belong to different departments, can’t be arranged close to each other.  

Worse still, in many general hospitals, obstetrics departments and delivery rooms are in different buildings due to the large number of patients. Therefore, it’s hard to establish a modern delivery system with cross-functional support. 

“Hospital managers are usually very conservative in their approach to management system reconstruction. China has run delivery departments separately for several decades, and, for many hospital executives, there’s no need to make a change,” Lian told NewsChina.  

The misguided conventional values, the serious shortage of anesthesia doctors, unaffordable costs and the rigid management system of hospitals – all these factors, from the perspective of Hu, impede the establishment of modern labor and delivery rooms.  

“It’s not a simple problem of importing techniques. The dilemma that China is facing in this field is a very complicated one resulting from historical, social, economic and cultural elements,” Hu said.  

Many experts hope that the Chinese government can step in to give the country’s modernization of obstetrics a decisive boost. In an interview with Cover.cn, Zhang Deming, deputy to the National People’s Congress and deputy president of the People’s Hospital of Ya’an, in Sichuan Province, stressed that safe labor analgesia should be included in public medical insurance and the government needs to give more financial support to encourage hospitals to develop this service.  

For the future development of obstetrics in China, Duan argues that the country should learn from the best practices from abroad and formulate a strategy for developing obstetrics.  

“It is urgent for Chinese hospitals to establish a scientific, regulated, refined procedure and management practices. Seldom does a hospital think of its own long-term strategy. What’s the best experience from around the world we can learn from? How can we draw up our own strategies and policies that suit our own conditions? We need to frequently challenge ourselves with such questions,” Duan told NewsChina.
 
“Since my visits to China in 2006 to now, this country has made remarkable progress in the establishment of modern labor and delivery rooms,” Dr Philip Hess, the well-known obstetrical anesthesiologist from Beth Israel Deaconess Medical Center of Harvard Medical School, told NewsChina.  

Hess has been to China six times to visit hospitals in multiple cities, and has also given training courses for anesthesiologists at Shijiazhuang Maternity Hospital.  

“Many hospitals in China are already equipped with advanced facilities, and what they need now is to establish a normalized and efficient functioning system to guarantee refined management and provide better services to patients. System is the core to everything,” Hess said.
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