Obstetrics in China is facing unprecedented challenges. As the number of newborns declines year by year, more and more obstetricians and hospitals are facing the dilemma of reduced business and department closure. As the "frontline" for welcoming new life, obstetrics has become the first "barometer" of population structure changes, and it also makes people realize that behind the decline in fertility intentions, there are a series of complex social, economic and cultural problems hidden.

The sudden drop in the number of newborns: the survival dilemma of obstetrics

Dr. Cheng, who works in a municipal maternal and child hospital in Henan, clearly feels that the hospital's obstetric business volume is declining year by year. Only a few years ago, when the two-child policy was first implemented, she and other obstetricians were full of hope and believed that they would usher in the "golden age" of their profession. In 2016, the number of newborns in China once reached 18.83 million, but after a short peak, the birth rate dropped sharply. In 2023, the number of newborns will be only 9.02 million, and the natural population growth rate has long turned negative. Faced with the sharp decline in the number of births, the business volume of many obstetric hospitals has dropped sharply, and many obstetrics have been forced to close.

According to public reports, obstetrics services in dozens of hospitals across China have been eliminated in 2023, and even some comprehensive tertiary hospitals cannot escape this fate. As a frontline doctor at a maternal and child hospital in Henan, Dr. Cheng has witnessed colleagues choosing to take the civil service exam, change careers or leave the medical industry. She herself is also anxious about her declining income and considering seeking new career development.

Difficult choices for local hospitals: shut down or maintain?

As obstetrics business shrinks, it becomes increasingly difficult to maintain operations. A county-level hospital in Ganzhou City, Jiangxi Province, welcomed 144,000 newborns in 2017, but it fell to 63,600 in 2023. Dean Yuan Shihai pointed out that the current hospital delivery volume is as low as less than 50 cases a year, an average of less than 1 person per week, while obstetricians, nurses and other medical staff still need to maintain their positions. This huge contrast between cost and benefit has forced some hospitals to make the decision to stop obstetrics business.

Not only county-level hospitals, but even comprehensive hospitals with a high reputation are facing the crisis of marginalization of obstetrics. A vice president of the Fifth People's Hospital of Ganzhou City revealed that the obstetrics department of the hospital loses 3 million yuan every year, and there are very few inpatients. The hospital finally chose to shut down obstetrics services. Gong Xiaoming, a Chinese obstetrician and gynecologist, said that the necessity of maintaining obstetrics in some hospitals has become less and less, because the number of births is too low to meet the income needs of medical staff, and it has gradually lost its appeal.

Low income of obstetricians and the "embarrassment" of their profession

The income problem of obstetricians has further aggravated the cold winter of the department. Dr. Cheng's monthly salary depends largely on performance bonuses, but the reduction in business volume has caused her to have no performance bonuses since May 2023. She admitted that the income of obstetricians is at a relatively low level among all departments of the hospital, and the performance distribution method based on business volume as the main salary structure makes the reduction in births directly affect income, forcing many doctors to find new ways out.

In China, the status of obstetrics has long been on the edge of hospitals because obstetrics lacks difficult technical innovations or cutting-edge surgeries, which does not meet the assessment standards of public hospitals that attach importance to scientific research results. Many hospitals prefer to invest resources in other specialties, and the "clinical nature" of obstetrics is seen as a manifestation of lack of scientific research value.

Behind the sluggish birth rate: the contradiction between population policy and social environment

The dilemma of obstetrics is not just a reduction in business, but a microcosm of the decline in the willingness of the entire society to have children. China has implemented the two-child policy since 2016 and the three-child policy in 2021. Local governments have even encouraged childbirth by issuing subsidies and extending maternity leave. However, data show that the effect of the incentive policy is extremely limited, and the number of births continues to decline.

Dr. Cheng lamented: "We frontline obstetricians want to see more babies born more than anyone else." She sees the encouragement of the policy, but also sees that a large number of families still choose to have fewer or no children. One of the reasons is that pregnant women lack sufficient support in society. She pointed out that the pressure faced by women is not only economic, but also includes unequal treatment in the workplace, gender bias in the family, and even various social issues surrounding childbirth. Many of the patients she receives every day come to consult or deal with abortions due to accidental pregnancy. Women's reproductive choices are closely related to the support system of the entire society.

The transformation of the status of obstetrics: from prosperity to cold winter

Once upon a time, obstetrics was an attractive department in the medical industry. Especially in the early stage of the implementation of the universal two-child policy, many private obstetrics and gynecology hospitals were opened, and the market was once prosperous. However, the reality of a sharp decline in population has quickly brought obstetrics into a cold winter. The head of a well-known private obstetrics and gynecology hospital in Shanghai said frankly that the hospital had hoped to welcome the dividends of the two-child policy by expanding departments and improving the quality of delivery rooms, but after just a few years, the sharp decline in the number of newborns turned the original investment into a heavy burden.

Similar to the plight of private hospitals, obstetricians in public hospitals also feel helpless. Ms. Ding is a regular trainee at a top medical school in Shanghai. She frankly said that she did not want to be assigned to obstetrics because obstetrics has low income, high work intensity, and many disputes. Almost no classmates around her are willing to choose obstetrics, and some medical students even said that they would rather choose other directions to avoid the high intensity and low returns of obstetrics.

The double test of older mothers and birth rate

At present, the main force of fertility in China is no longer young families, but older mothers. The relaxation of the multiple-birth policy has attracted a group of older couples to choose to have their second and third children, but the risks of giving birth at an advanced age are higher, and the responsibilities that obstetricians need to bear have also increased accordingly. In addition, the increase in the number of older pregnant women means that the proportion of high-risk obstetric surgeries has increased, and the pressure on doctors has doubled.

Many hospitals in Shanghai, Guangzhou, Fujian and other places announced the suspension or adjustment of obstetric services in 2023. Medical student Ms. Ding analyzed that this phenomenon is partly due to the impact of personnel mobility caused by the epidemic. She pointed out that many migrant workers chose to return to their hometowns to live, which led to a further decline in the fertility rate in large cities. With limited resources in their hometowns, township hospitals are unable to meet the needs of these people.

Future obstetric development: where to go?

Facing the fertility winter, obstetrics in China is at the crossroads of transformation. China's National Health Commission has issued regulations requiring counties and cities to retain at least a certain number of midwifery institutions to ensure the normal operation of basic medical services. Hospitals at all levels have also begun to pay attention to the salary and benefits of obstetricians to avoid talent loss. However, the fundamental problem remains how to enhance the society's willingness to give birth and improve support for pregnant women and women.

Dr. Cheng said that she still loves obstetrics, but she is worried about the future development. Many of her classmates and colleagues have chosen to leave, but she sticks to her post, hoping that the arrival of newborns can bring vitality to obstetrics. However, she also knows that in order to restore the birth rate, reforms must be made in social security, education, economic policies and other aspects to create a better working environment for future obstetricians.

Obstetricians' Voice and Social Thinking

Chinese obstetricians are more eager than anyone to see more newborns and the birth of life. However, they have encountered an unprecedented crisis in the "fertility winter". Where will obstetrics go in the future and whether it can get out of the winter is a severe challenge facing China. The adjustment of the population structure is not only a matter of the medical industry, but also a problem of comprehensive social transformation. Only through joint efforts of all parties can we usher in a healthy and vibrant future.