What’s hindering wider use of labor pain relief in China?
A woman in Northwest China’s Shaanxi Province jumped to her death from a maternity ward window after she could not withstand the severe labor pain. The unexpected suicide case was widely covered by the press, awakening many Chinese women to the fact that they may have no access to pain relief in childbirth.

Not enough anaesthetists

Till now, it remains a challenge for expectant mothers in the country to find a local hospital that could guarantee them painkilling procedures in childbirth, probably the most torturous period in their lives. About 85 percent of women in the United States use pain reduction medication during labor and delivery. The rate is 98 percent in the UK, and 86 percent in Canada. “It is accessible to less than 10 percent of maternity patients China,” the National Health and Family Planning Commission, China’s top regulator of health-related industries, announced at a “happy delivery room” launch event.

United Family Healthcare was the first international hospital established in China, and also the first to provide labor pain relief in the country. Roberta Lipson, co-founder and CEO of the hospital group, told Sino-US.com it’s a misnomer for the Chinese press to call it “painless” because there is always a little bit of pain involved. “We have the most modern techniques of pain control. We can reduce the discomfort tremendously but we can’t make it completely painless,” she noted, adding labor analgesia is capable of reducing the level of pain to an acceptable level.

She is surprised to see that “till now less than 10 percent of women have access to pain control during labor and delivery.” “I should think by now it’s much more available in China,” Lipson said. The maternity hospitals operated by United Family Healthcare have been providing labor pain relief in China since the late 1990s, and 98 percent of their patients would choose to use the procedures. Labor analgesia is commonly available in high-income countries. These techniques have been shown to be safe and effective for alleviating labor pain.

One reason could be that there are not enough trained anesthesia doctors in the public medical system, Yin Bo, the director of United Family’s Anaesthesiology Department, told Sino-US.com. “They (anesthesia doctors in public hospitals) are supposed to devote most of their time and energy to surgeries. And they’re already working extra hours, so don’t have any time for the maternity wards,” Yin analyzed.

The view is shared by many medical experts in the field. It was reported by the Southern Weekly magazine earlier that there were only 75,233 registered anesthesiologists in China in 2015, with the ratio of half every 10,000 Chinese people, while in the US and some European countries, there are at least 2.4 anaesthetists every 10,000 people.

“I really hope the tragic case could help raise awareness among people,” Ling-Qun Hu told Sino-US.com. The Chinese American anaesthesiologist has been strenuously pushing for wider use of pain reduction during childbirth in China over the past 10 years. He is the founder and executive director of the No Pain Labor & Delivery (NPLD), a nongovernmental program launched by the Northwestern University Feinberg School of Medicine in 2006. The NPLD is designed to help Chinese hospitals train more anesthesia doctors, increasing access to safe labor analgesia by 10 percent in 10 years.
 
A valuable photo taken in Hangzhou, the capital city of east China's Zhejiang Province in June 2008 when volunteers of the No Pain Labor & Delivery (NPLD) took their first trip to China  Photos: nopainld.org

At the start of 2004, a Xinhua News Agency article revealed that labor pain relief is accessible only to 1 percent of delivery women in China. As of September 9, 2017, Hu and hundreds of other medical experts in the NPLD from the United States, Belgium, Canada, Germany, Israel and China have worked with 80 hospitals in China, helped 77 percent of them provide pain reduction to over 50 percent of maternity patients.

Ling-Qun Hu talked about the “modern labor & delivery room” concept put forward by the NPLD. “The core idea is to have 24-hour availability of anesthesia doctors in labor & delivery rooms and to proceed team-based medical practice in perinatalogy.”

C-section rate too high in China

Many medical experts and hospital administrators agree that wider application of childbirth pain relief would lead to less Cesarean delivery, also called C-section. According to Lipson, the problem worth talking about is China’s very high proportion of C-section. “It’s too high. Too many women are having surgeries they don’t need to have. This worries me a lot,” she said, noting that in all United Family hospitals, the C-section rate is less than 30 percent, whereas in Chinese public hospitals, it’s mostly over 50 percent.

She warned about the risks that would come with C-section. “Some people think erroneously that C-section is less dangerous for mom and baby, but that’ not true.” Lipson believes if doctors tend to make things more convenient only for themselves, the rate would go up. “For example, if a doctor can schedule a C-section surgery at 8 o’clock, he will be home at 9 o’clock. He would not need to wait for the woman to have a baby,” she said, noting it’s good to see that Chinese women are becoming more discreet about C-section now.

In the past, many women opted for a caesarean delivery to avoid the pain, anxiety, and distress associated with vaginal delivery without analgesia. On the other hand, according to Lipson, the medical insurance system in China provides greater reimbursement for C-section than for natural childbirth, like in many other countries.

Based on statistics of the NHFPC, the Cesarean delivery rate was 46 percent in 2013, and 34.9 percent in 2014, well above the recommended 15 percent by the World Health Organization. “China had one of the highest caesarean delivery rates in the world in 2010, estimated at upwards of 16.4 million deliveries per year. In the same year, the World Health Organization reported that China has the highest rate of C-section by maternal request,” according to a 2016 paper published by the Society for Obstetric Anaesthesia and Perinatology.
 
Ling-Qun Hu discusses with medical staff in local hospital in China. Photos: nopainld.org

“At least 12% of these caesarean deliveries were not performed for medical indications,” said Ling-Qun Hu, “Some women could not stand long hours of labor pain and would ask for a C-section.” According to him, unnecessary C-section would result in excess maternal mortality, and are associated with increased infant mortality.

The ultimate goal of the NPLD initiative led by Hu is to decrease the Cesarean delivery rate in China through increasing access to safe labor analgesia. “When women are provided pain relief through labor, they could conserve more energy for delivering the baby. This increases the rate of vaginal delivery,” he elaborated.

Ling-Qun Hu and other NPLD volunteers have conducted impact studies to prove the point. One was conducted using data from the Shijiazhuang Obstetrics and Gynecology Hospital (2009–2011), a large urban maternity hospital in Hebei Province. As labor analgesia rates increased from 0% to 33.5% of total deliveries, cesarean deliveries decreased from 41% to 34%.

More pain relief, more gains for hospital?

According to Yin Bo, the other, often cited reason behind the sluggishness in pushing the procedures’ wider use is that hospitals usually could not make ends meet by providing the service. “Many public hospitals have not built up any standard pricing system for the procedures yet. They are not sure how much they should charge for it. And sometimes they’re not sure if they should charge for it at all,” he said.

Sino-US.com has learned that in most maternity hospitals in Beijing, pain reduction during labor and delivery usually costs around 2,000 yuan, much lower than the regulated price for C-section. “Obstetricians and anaesthetists could hardly earn any money from the procedures, while they need to pay attention to the whole process of over 10 hours most of the time. It’s simply not a good bargain,” said a doctor familiar with the situation.
 

The Volunteers of the No Pain Labor & Delivery (NPLD) Photos: nopainld.org
 
Hu believes the pain relief procedures could make hospitals more profitable in the long run. “Chinese people are these days preferring vaginal delivery to C-section. If hospitals could provide pain reduction service to help women go through the process, they will gain good reputation and have more people turn to them,” he said.

In 2011, a Chinese national mandate called for decreasing the cesarean delivery rate. In 2012, a breakthrough occurred with the establishment of a national billing code for labor analgesia by the National Development and Reform Commission. After all the years’ field experiences working with hospitals in China, Hu said that it is totally viable for the safe and efficient labor analgesia to be made widely available in China.

“We’re all expecting the Chinese government to really step in to give the course a final and decisive push,” he said, indicating the best method is for the government to regulate more favorable pricing for epidural anaesthesia than Cesarean delivery. 

 


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