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investigation motivation

"i didn't expect that i would be labeled as 'incapable of hardship' and 'selfish' when i wanted to have an epidural during childbirth." not long ago, zhu zhu (pseudonym), a chongqing citizen, was due to give birth soon. fearing the pain, she decided early on to have an epidural during childbirth. unexpectedly, she was opposed by both her mother and mother-in-law, who were afraid that injecting drugs into the body would hurt the baby.

zhu zhu said that fortunately her husband stood firmly on her side and supported her decision to have an epidural, "otherwise she would have suffered so much more."

after giving birth successfully, she talked with many new mothers and found that some of them thought that painless delivery would have adverse effects on the baby, some felt that painless delivery would cost thousands of yuan per injection and were reluctant to spend the money, and some did not even know that painless delivery could reduce the pain during childbirth. only two or three out of a dozen mothers chose painless delivery.

how is painless childbirth developing in my country at present? what are the shortcomings in the construction of relevant systems? with these questions, the reporter launched an investigation.

□ our reporter wen lijuan

□ ma ziyu, trainee reporter of this newspaper

on the day of giving birth, zhang meng felt like she was about to be torn into pieces when she experienced the pain of contractions and dilation. "every minute and every second was like purgatory." countless times, she felt like she couldn't hold on any longer, but when she thought of the baby in her belly, she gritted her teeth and held on.

zhang meng lives in changping district, beijing. she gave birth in a local tertiary hospital. the doctor reminded her that "if you really can't stand it, you can get an epidural." after reaching a consensus with her family, zhang meng decided to have an epidural. finally, when her cervix was two fingers dilated, she got the epidural as she wished, and soon she felt like she had "returned from hell to the world."

many mothers describe natural childbirth as "the most painful experience in their life". statistics from the chinese medical association show that about 50% of first-time mothers experience obvious pain, and 44% experience unbearable severe pain. labor analgesia (a medical term for painless childbirth) is a mature medical method that can greatly reduce the pain of childbirth for mothers and has been implemented in my country for many years.

relevant data show that the overall penetration rate of labor analgesia in my country is still low, only 30% by the end of 2022. in an interview, the legal daily reporter found that there are many reasons for the low penetration rate: misunderstandings in public perception, shortage of anesthesiologists and midwives, unclear charging standards and other factors have hindered the further promotion of labor analgesia, and many women still have to face unbearable pain.

experts interviewed pointed out that at present, relevant departments and localities in my country have taken many measures to help popularize labor analgesia services, including making labor analgesia a separate item and incorporating painless delivery into medical insurance. in addition, the number of professionals such as anesthesiologists and anesthesia nurses needs to be increased urgently. it is recommended to introduce relevant policies to increase the training of labor analgesia professionals. while optimizing services, positive publicity can be used to reverse some of the public's misunderstanding of labor analgesia and further increase the popularity of labor analgesia.

family members have concerns about painless treatment

worried about affecting the fetus

zhang meng is lucky to have received painless childbirth. however, a recent interview by a reporter found that many pregnant women do not choose painless childbirth even if the pain is unbearable during childbirth.

"giving birth is bound to be painful, we've all gone through this," "don't give the epidural, it'll damage the baby's brain," "the needle is long and thick, it will hurt during the injection, and we don't know if it will affect the baby"... during the interviews, many pregnant women and their families were skeptical about painless childbirth, believing that injected anesthetics may have adverse effects on both the mother and the child.

there are also pregnant women who want painless childbirth, but they are unable to do so for various reasons. a sichuan netizen named pingchangxin gave birth during the national day holiday last year. because the anesthesiologist on duty went to the emergency room, there was no one else to give her an epidural, and she was in pain for 18 hours.

"i had a consultation for painless delivery, and the out-of-pocket expense was more than 2,000 yuan. it was too expensive. after hesitating, i decided not to go for it." a pregnant woman in quanzhou, fujian, was deterred by the cost of painless delivery and decided to "grit her teeth and endure it."

during the interview, some pregnant women chose painless childbirth, but because they still felt pain during delivery and had back pain after surgery, they questioned the childbirth analgesia technology.

meng li from jinan, shandong, received an injection of painless labor medicine during childbirth. "i felt very good at the moment, and the pain was gone immediately, but about two hours later, the pain started to get worse again. isn't painless labor really 'painless'?" after the operation, she began to feel that the painless injection had many side effects: "it's now the fourth day after delivery, and i feel back pain, pain at the injection site, and i can only lie down."

many industry experts said that the public still has a lot of misunderstandings about labor analgesia technology, such as the belief that medication is unnecessary, that it will hurt the baby, and that there are side effects after surgery. but in fact, my country's labor analgesia technology is now very mature, and the more mainstream spinal block labor analgesia can help most women relieve 60% to 90% of pain, and has a wide range of applications. most women who have passed the obstetrics and anesthesia department's evaluation can use it.

xu mingjun, director of the department of anesthesiology at beijing women and children's health care hospital, beijing obstetrics and gynecology hospital, capital medical university, said that the so-called "painless childbirth" is medically called "labor analgesia", which aims to significantly reduce or even eliminate the pain during childbirth through various technical means. "the public may have a misunderstanding. in fact, painless childbirth does not mean that the childbirth process is completely painless. it is more about reducing the pain burden of the mother while retaining some uterine contraction pain and contraction. in this way, when the cervix is ​​fully dilated, the mother can better cooperate with the midwife and obstetrician to give birth to the fetus smoothly."

"labor analgesia will not affect the development and growth of the fetus. the drug concentration and dosage used for labor analgesia are only 1/10 to 1/5 of that used for cesarean section anesthesia. the drug is injected into the spinal canal of the mother's lumbar spine through a catheter. the amount of drug that enters the blood circulation or is absorbed by the placenta is negligible, so it has no adverse effects on the fetus." xu mingjun explained that in fact, labor analgesia also has a protective effect on the fetus. standardized labor analgesia can promote the expansion of placental blood vessels, thereby making the fetus' blood supply and oxygen supply more sufficient, reducing the possibility of fetal intrauterine asphyxia. survey data show that the intrauterine asphyxia rate of fetuses with labor analgesia is basically about 10 times lower than that of natural delivery without analgesia.

as for whether the postpartum lumbar pain mentioned by some mothers is related to labor analgesia, xu mingjun said: "pregnant women often maintain a forced passive position for a long time during childbirth, which can be as short as a few hours, as long as more than ten hours, or even as long as more than 20 hours. the passive position of the mother and postpartum breastfeeding can easily cause low back pain. labor analgesia happens to be a puncture on the waist, so many people think it is caused by the puncture for labor analgesia."

shortage of professional teams

the charging standards are still unclear

the reporter found that the national health commission has issued a number of policy documents in recent years to promote labor analgesia.

in 2018, the national health commission issued a notice on the implementation of a labor analgesia pilot program, stating that pilot hospitals would be selected from secondary and above general hospitals, maternal and child health care hospitals, or obstetrics and gynecology specialized hospitals that have obstetrics and anesthesia diagnosis and treatment subjects to carry out a labor analgesia pilot program. after the notice was issued, 913 hospitals across the country established labor analgesia pilot bases.

in august 2022, 17 departments including the national health commission and the national development and reform commission issued the "guiding opinions on further improving and implementing active fertility support measures", which specifically proposed to expand the labor analgesia pilot and improve the level of labor analgesia. the national health insurance administration stated that it will guide local governments to comprehensively consider the affordability of medical insurance (including maternity insurance) funds, relevant technical specifications and other factors, and gradually include appropriate labor analgesia and assisted reproductive technology projects into the scope of medical insurance funds according to procedures. labor analgesia services currently have corresponding medical service price items. most places charge for spinal anesthesia projects on a per-time basis, without distinguishing the length of anesthesia time, which is indeed different from the characteristics of long labor and long anesthesia operations for parturients. for some time, the national health insurance administration has guided local governments to adapt to the actual clinical needs of labor analgesia and improve the price policy of related anesthesia projects, mainly by adjusting the pricing method, charging additional fees according to the length of time, and adjusting and improving the charging policy to better match the technical labor value of anesthesia operations.

according to data released by the national health commission, the rate of labor analgesia in 913 pilot hospitals increased from 27.5% to 60.2% in 2022 compared with 2015. in recent years, some regions such as zhejiang, jiangxi, shanghai, guizhou, and guangxi have included painless childbirth-related expenses in the scope of medical insurance, and zhengzhou, henan and other places have also issued documents to clearly adjust the prices of medical services such as labor analgesia to reduce the medical costs of childbirth.

but why is the childbirth rate in our country still low in reality?

industry experts said that the popularization of painless delivery is inseparable from the hard work of anesthesiologists. however, in reality, the number of anesthesiologists is seriously insufficient, which has become a major bottleneck restricting the promotion of painless delivery. painless delivery requires experienced anesthesiologists to perform the operation, but the current number of anesthesiologists in my country is far from meeting clinical needs. some hospitals are unable to provide painless delivery services to all parturients in a timely manner due to a shortage of anesthesiologists.

xu mingjun introduced that survey data showed that the united states has 2.5 anesthesiologists per 10,000 people, the united kingdom has 2.8 anesthesiologists per 10,000 people, and china has 0.4 anesthesiologists per 10,000 people. the huge shortage of anesthesiologists is an important factor in the low rate of labor analgesia in my country.

in his opinion, the shortage of anesthesiologists has led to continuous overtime work, lack of energy and serious overdraft. in particular, anesthesiologists in general hospitals are under great pressure from routine surgical anesthesia and emergency rescue of critically ill patients, and cannot guarantee sufficient time and energy to take care of labor analgesia. "the number of labor analgesia surgeries is small, which easily leads to a vicious cycle in which anesthesiologists cannot focus on labor analgesia and mothers want labor analgesia but cannot get it."

"in addition, labor analgesia usually requires collaboration among obstetricians, anesthesiologists and midwives. during the delivery process, in order to ensure the safety and comfort of the mother, a team of medical staff from multiple professional fields such as anesthesiologists, obstetricians, midwives, etc. is needed to provide continuous monitoring and assistance. this process may last from several hours to more than ten hours. considering the manpower cost required for such long-term and high-intensity team collaboration, from the perspective of economic operation, some hospitals may face the problem of insufficient motivation, which in turn limits the widespread development of labor analgesia. in this regard, the reward mechanism for anesthesiologists should be improved, and efforts should be made on the treatment level." xu mingjun said.

huang yuguang, member of the national committee of the chinese people's political consultative conference and director of the department of anesthesiology at peking union medical college, found in his research that the implementation of the special charging items for labor analgesia was not perfect. the charging of labor analgesia was packaged with natural childbirth or cesarean section, which meant that the more labor analgesia work the hospital performed, the more compensation it had to pay. this objectively made the hospital unwilling to actively provide labor analgesia medical services.

increase policy support

facing the pain of childbirth

in june this year, the national healthcare security administration issued the "guidelines for the establishment of obstetric medical service pricing projects (trial)" (hereinafter referred to as the obstetric project establishment guidelines), which clearly defined "labor analgesia", "doula delivery", "family delivery" and other projects as separate projects, supported medical institutions to provide humane delivery services centered on mothers, and encouraged the active development of pain relief delivery services.

according to the relevant person in charge of the national medical insurance administration, judging from the situation of front-line surveys, the current demand for obstetric development in clinical practice is to add new medical service price items. with the development of medical technology, the optimization of population policies, and the advancement of fertility concepts, many medical institutions have launched some more humane obstetric medical services in recent years, such as "labor analgesia". in practice, some places charge according to the original spinal anesthesia items, and medical institutions have reduced their enthusiasm for providing labor analgesia due to the lack of independent price items; in some places, due to the limited number of anesthesiologists, they are unable to provide services and cannot meet the demand for such fertility medical services well. therefore, medical institutions hope to clarify the direction of relevant price policies, give full play to the function of price in regulating resource allocation, guide medical institutions to provide relevant services, and better meet the diversified fertility service needs such as painless childbirth.

according to a third-party survey, 13% of young women are afraid of pregnancy and childbirth. this obstetric project guideline sets up separate projects for "labor analgesia", "doula delivery" and "family accompanying delivery". it clearly supports medical institutions to provide maternity-centered humanized delivery services, encourages the active development of analgesia delivery services, and supports qualified medical institutions to provide professional accompanying delivery and doula delivery services to pregnant women.

huang yuguang submitted a proposal during the two sessions, suggesting that more efforts should be made to train anesthesiologists and that anesthesiology should be offered at the undergraduate level in medical schools. he also suggested strengthening the construction of anesthesia specialist nursing teams in primary medical institutions, adding more anesthesia nursing staff, and improving the treatment and promotion opportunities of primary anesthesia specialist nurses, so as to increase the attractiveness of the anesthesia specialist nursing professional team.

"the popularization of painless childbirth still requires the government to continue to increase policy support, improve relevant systems and charging standards, and provide policy protection for the popularization of painless childbirth." xu mingjun said that independent standards for painless childbirth charges should be formulated and implemented in various provinces and cities as soon as possible, or painless childbirth should be included in medical insurance and the maternity insurance quota should be increased. otherwise, once painless childbirth is used, the insurance quota will be occupied, which will lead to medical insurance excess and restrict the promotion of painless childbirth.

"doctors should strive to popularize knowledge of the delivery process to pregnant women and their families, and help them establish correct concepts about delivery analgesia." xu mingjun said that on the one hand, the scope of delivery analgesia should be continuously expanded, popular science education should be deepened, misunderstandings such as "painless delivery harms the fetus" should be clarified, and public doubts and prejudices should be eliminated based on science; on the other hand, advanced delivery analgesia technology should be actively promoted, and its service quality should be continuously improved to build a more humane and comfortable medical service environment. by implementing 24-hour delivery analgesia services, the fine management of the entire delivery process can be strengthened, so as to more comprehensively respond to and meet the needs of diversified reproductive services.

xu mingjun also mentioned that medical institutions should rationally plan the human resource allocation of the anesthesia department to ensure that there are enough anesthesiologists and anesthesia nurses to support the implementation of clinical services such as painless delivery, increase the number of personnel in the anesthesia team, and optimize the scheduling system to ensure that medical staff can get enough rest and recovery. the overall attractiveness of the anesthesia profession can be enhanced by measures such as increasing the remuneration of anesthesiologists, improving the working environment, and enhancing the sense of professional honor. "establishing a delivery analgesia team, forming an effective collaboration model of the trinity of obstetricians, anesthesiologists, and midwives, and introducing anesthesia nurses to alleviate the manpower problems of anesthesiologists are effective ways to establish a more complete painless delivery service system."

he hopes that in the future, with the help of advanced intelligent equipment, a central station will be set up to observe the vital signs of multi-partum mothers in real time, intelligently monitor the progress of mothers' uterine contractions, and use ai intelligence to automatically control the medication of painless delivery under the professional management and operation of anesthesiologists, thereby improving work efficiency, reducing the workload of anesthesiologists, and allowing more mothers to enjoy painless delivery services.

(all pregnant women interviewed in this article are pseudonyms)

comics/li xiaojun