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Perinatal care in China
203
Human Development, 29 (1992) 203-206 Elsevier Scientific Publishers Ireland Ltd.
Early
EHD 01275
Perinatal care in China Ji Xiaocheng Pediatric
Department,
PUMC
Hospital,
Wang
Fujng,
100730
Beging
(China)
China has a birth rate of 20/1000, maternal mortality of 48.8000 000, perinatal mortality of 15-20/1000 in cities, and 30-35/1000 in rural areas, infant mortality of 34.68/1000 and a LWB rate of 6%. Among LWBI 50-60% are SGA. As a result the prematurity rate is also quite low, 3-4%, and the rate of VLBWI is only 0.3-0.4%. Therefore, attention should be paid first to bigger birth weight groups. Regional&d perinatal care is important in the cities, but the rural areas suffer more from low staffing levels and poor transporation. In view of the vast areas which are in need of techniques and the uneveness of the situation, sense of appropriate technology is very important. B-ultrasonic scanner versus gravidogram, FHR monitoring versus monitoring of fetal movement, and methods of keeping babies warm are discussed as examples. Key words: perinatal mortality;
regionalized perinatal care; appropriate technology
Introduction The next four pages provide you with maternal and perinatal mortalities, rate of LBWI, regionalized perinatal care in cities and rural areas in China. You will have a few examples like B-ultrasonic scanner, FHR monitors and temperature reservation in the newborn to show an important question, use of appropriate technique, in perinatal care. Prospect in the development of perinatal service in China is indicated at the end. Format General status China is a vast country with a population Correspondence
to:
of 1 billion. The birth rate is around
Ji Xiaocheng, Pediatric Department, PUMC Hospital, Wang Fujing, 100730 Beijing,
China. 0378-3782/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
204
20/1000. Child birth is a very important event. However perinatal care in its modern sense has been introduced for less than 15 years. (1) Basic perinatal statistics Maternal mortality: According to the data published in 1986 the overall mortality
was 48.8/100 000. The survey was done in 21 provinces covering nearly 2.5 million live births, in which 1211 maternal deaths were identified. The death rate in the rural area, however, was much higher than in the urban, being 58.8 vs. 24.8/100 000, respectively. The leading cause of death in the countryside was obstetrical hemorrhage, while in the cities it was pregnancy induced hypertension. Perinatal mortality in most of the big cities is 15-20/1000, but is much higher in the rural part of China, 30-35/1000 live birth. There was some improvement of the perinatal death rate in the recent 6 years. In 1985, in Beijing, it was 13.75/1000 while in 1990 it fell down to 9.74/1000. Another indicator in perinatal events is LBW rate. It is about 6%. Traditional customs have a very strong impact in sexual and marital life. There is almost no teenager marriage and pregnancy. The age of marriage is concentrated at 23-25 years. The prevalance of venereal diseases is very low. Women almost never smoke and drink very little. Among the LBWI 50-60% are SGA infants. As a result, the prematurity rate is also quite low, 3-4% and the rate of VLBWI is only 0.3-0.4%. These figures deserve special attention, because if the VLBWI are not causing as many deaths in this country and if the major part of LBWI are SGA babies instead of prematures, the care should also be different. As to the causes of death, hypoxia is in the leading place for both fetal and intrapartum death, with cord and placental problems as the underlying pathologies. The number one killer of the neonates is birth asphyxia and aspiration syndrome, which is also hypoxic in nature. The conclusions from the above statistics are, therefore both the maternal and perinatal mortality are still relatively too high as compared with those of the advanced countries. A great advantage is a low LBW rate. If not for this the perinatal mortality would be still higher. Emphasis should be placed on the care of infants with high birth weight and monitoring of hypoxic disorders. (2) Organization of regionalized perinatal care has started in 46.8% of cities
Shanghai was the earliest where the regionalized perinatal service was initiated 15 years ago. In 1983 the International Peace MCH Hospital, one of the biggest referral hospitals in Shanghai, had a perinatal mortality of 13/1000. Beijing had had its perinatal service organized for 2 years. The municipal OB Gyn Hospital had a perinatal mortality of 19/1000. The Gansu MCH Hospital in Lanzhou had a perinatal mortality of more than 30/1000. All three hospitals were at the top level of their cities, they all have 6000-7000 child births per year. The professional staff are all well trained. The major difference which renders the Gansu unit a high mortality was a chaotic state in the management of the pregnant women in the city. This example is a best comparison to show how big differences regionalized perinatal care can make in the outcome of pregnancy.
205
(3) Perinatal care in the rural areas
The administrative infrastructure of rural society is composed of 3 levels: village, township (former commune) and county. In regard to perinatal service, there is either a village doctor or a birth attendant at the grass root level in the villages. In the township hospital there may or may not be an obstetrician but always physicians and surgeons. In the county more than one obstetrician but much less pediatricians. The geographic distribution of population predetermines the nature of the care delivery, which is naturally regionalized. The problems with the perinatal service in the rural area are the following: (A) Social and economic status of the farmers is still very poor. (B) 27% of the child births are still attended by non-trained birth attendants or family members and yet just in these places 80-90% of the child births take place at home. Low quality training is the most critical problem. (C) Transportation is a serious difficulty in mountains and grasslands. There are places where helpless mothers die of postpartum hemorrhage either at home or during transportation. 2. Appropriate technology in perinatal care
An appropriate technique is one which is scientifically sound, efficient, cost effective, accessible, easily maintained and culturally acceptable. (1) One of the technological advances in prenatal monitoring is the use of ultrasonic B-scanners. A lot of important informations can be obtained thru serial ultrasonography, not only detection of fetal anomaly but also its growth. However, an imported scanner cost about 60 000 US. dollars. Instead, for the monitoring of fetal growth, many hospitals use gravidogram. This is done by periodical measurement of uterine fundal height and plot the values against a normal curve. All that is needed for this method is a tape ruler and an adequately trained hand. (2) FHR monitoring have been proven to be very useful in labor management. It has become also quite popular in the obstetrical practice in urban China. However, an imported FHR monitor again will cost about 10 000 U.S. dollars. It is too expensive for a county hospital to afford. A much simpler method to monitor fetal distress is to count fetal movement. The Shanghai International Peace MCH Hospital developed a method, called family monitoring of labor and pregnancy. The pregnant women are taught to count fetal movement 3-times or at least once a day. If the total number in 12 h duration falls below 30 times, both the family and the doctors should be alerted. The medical personnel visits the family from time to time to give them instructions. It has now been disseminated to 19 hospitals and the perinatal mortality in this units fell to 8.54000, that of the control group being 15/1000. (3) Temperature preservation: Even the simplest techniques like drying up the newborn baby and using some radiant heat sources or keeping warmth of the tiny infants has not yet been routinely adapted in China. Isolett incubators and radiant warmers are locally produced, quality needs to be improved but the Chinese pediatricians are happy to have their own things available. Swaddling (or wrapping) is popular. There are concerns that it might hinder the
206
growth of the infants and calls for its abandonment. However, since it has been incorporated into people’s custom, study is needed as to its use and substitution should be found, before to talk of abandoning it. 3. Prospect in the development of perinatal care in China (A) Regionalzed perinatal care should be popularized in the cities and then to the countryside. (B) Training of personnel is a key measure, especially in the rural area. (C) Reduce maternal mortality, especially those due to hemorrhage. (D) Reduce perinatal mortality, specifically due to hypoxia. Perinatology is in progress; however, China is a huge developing country. Everything takes time.
Human Development, 29 (1992) 203-206 Elsevier Scientific Publishers Ireland Ltd.
Early
EHD 01275
Perinatal care in China Ji Xiaocheng Pediatric
Department,
PUMC
Hospital,
Wang
Fujng,
100730
Beging
(China)
China has a birth rate of 20/1000, maternal mortality of 48.8000 000, perinatal mortality of 15-20/1000 in cities, and 30-35/1000 in rural areas, infant mortality of 34.68/1000 and a LWB rate of 6%. Among LWBI 50-60% are SGA. As a result the prematurity rate is also quite low, 3-4%, and the rate of VLBWI is only 0.3-0.4%. Therefore, attention should be paid first to bigger birth weight groups. Regional&d perinatal care is important in the cities, but the rural areas suffer more from low staffing levels and poor transporation. In view of the vast areas which are in need of techniques and the uneveness of the situation, sense of appropriate technology is very important. B-ultrasonic scanner versus gravidogram, FHR monitoring versus monitoring of fetal movement, and methods of keeping babies warm are discussed as examples. Key words: perinatal mortality;
regionalized perinatal care; appropriate technology
Introduction The next four pages provide you with maternal and perinatal mortalities, rate of LBWI, regionalized perinatal care in cities and rural areas in China. You will have a few examples like B-ultrasonic scanner, FHR monitors and temperature reservation in the newborn to show an important question, use of appropriate technique, in perinatal care. Prospect in the development of perinatal service in China is indicated at the end. Format General status China is a vast country with a population Correspondence
to:
of 1 billion. The birth rate is around
Ji Xiaocheng, Pediatric Department, PUMC Hospital, Wang Fujing, 100730 Beijing,
China. 0378-3782/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
204
20/1000. Child birth is a very important event. However perinatal care in its modern sense has been introduced for less than 15 years. (1) Basic perinatal statistics Maternal mortality: According to the data published in 1986 the overall mortality
was 48.8/100 000. The survey was done in 21 provinces covering nearly 2.5 million live births, in which 1211 maternal deaths were identified. The death rate in the rural area, however, was much higher than in the urban, being 58.8 vs. 24.8/100 000, respectively. The leading cause of death in the countryside was obstetrical hemorrhage, while in the cities it was pregnancy induced hypertension. Perinatal mortality in most of the big cities is 15-20/1000, but is much higher in the rural part of China, 30-35/1000 live birth. There was some improvement of the perinatal death rate in the recent 6 years. In 1985, in Beijing, it was 13.75/1000 while in 1990 it fell down to 9.74/1000. Another indicator in perinatal events is LBW rate. It is about 6%. Traditional customs have a very strong impact in sexual and marital life. There is almost no teenager marriage and pregnancy. The age of marriage is concentrated at 23-25 years. The prevalance of venereal diseases is very low. Women almost never smoke and drink very little. Among the LBWI 50-60% are SGA infants. As a result, the prematurity rate is also quite low, 3-4% and the rate of VLBWI is only 0.3-0.4%. These figures deserve special attention, because if the VLBWI are not causing as many deaths in this country and if the major part of LBWI are SGA babies instead of prematures, the care should also be different. As to the causes of death, hypoxia is in the leading place for both fetal and intrapartum death, with cord and placental problems as the underlying pathologies. The number one killer of the neonates is birth asphyxia and aspiration syndrome, which is also hypoxic in nature. The conclusions from the above statistics are, therefore both the maternal and perinatal mortality are still relatively too high as compared with those of the advanced countries. A great advantage is a low LBW rate. If not for this the perinatal mortality would be still higher. Emphasis should be placed on the care of infants with high birth weight and monitoring of hypoxic disorders. (2) Organization of regionalized perinatal care has started in 46.8% of cities
Shanghai was the earliest where the regionalized perinatal service was initiated 15 years ago. In 1983 the International Peace MCH Hospital, one of the biggest referral hospitals in Shanghai, had a perinatal mortality of 13/1000. Beijing had had its perinatal service organized for 2 years. The municipal OB Gyn Hospital had a perinatal mortality of 19/1000. The Gansu MCH Hospital in Lanzhou had a perinatal mortality of more than 30/1000. All three hospitals were at the top level of their cities, they all have 6000-7000 child births per year. The professional staff are all well trained. The major difference which renders the Gansu unit a high mortality was a chaotic state in the management of the pregnant women in the city. This example is a best comparison to show how big differences regionalized perinatal care can make in the outcome of pregnancy.
205
(3) Perinatal care in the rural areas
The administrative infrastructure of rural society is composed of 3 levels: village, township (former commune) and county. In regard to perinatal service, there is either a village doctor or a birth attendant at the grass root level in the villages. In the township hospital there may or may not be an obstetrician but always physicians and surgeons. In the county more than one obstetrician but much less pediatricians. The geographic distribution of population predetermines the nature of the care delivery, which is naturally regionalized. The problems with the perinatal service in the rural area are the following: (A) Social and economic status of the farmers is still very poor. (B) 27% of the child births are still attended by non-trained birth attendants or family members and yet just in these places 80-90% of the child births take place at home. Low quality training is the most critical problem. (C) Transportation is a serious difficulty in mountains and grasslands. There are places where helpless mothers die of postpartum hemorrhage either at home or during transportation. 2. Appropriate technology in perinatal care
An appropriate technique is one which is scientifically sound, efficient, cost effective, accessible, easily maintained and culturally acceptable. (1) One of the technological advances in prenatal monitoring is the use of ultrasonic B-scanners. A lot of important informations can be obtained thru serial ultrasonography, not only detection of fetal anomaly but also its growth. However, an imported scanner cost about 60 000 US. dollars. Instead, for the monitoring of fetal growth, many hospitals use gravidogram. This is done by periodical measurement of uterine fundal height and plot the values against a normal curve. All that is needed for this method is a tape ruler and an adequately trained hand. (2) FHR monitoring have been proven to be very useful in labor management. It has become also quite popular in the obstetrical practice in urban China. However, an imported FHR monitor again will cost about 10 000 U.S. dollars. It is too expensive for a county hospital to afford. A much simpler method to monitor fetal distress is to count fetal movement. The Shanghai International Peace MCH Hospital developed a method, called family monitoring of labor and pregnancy. The pregnant women are taught to count fetal movement 3-times or at least once a day. If the total number in 12 h duration falls below 30 times, both the family and the doctors should be alerted. The medical personnel visits the family from time to time to give them instructions. It has now been disseminated to 19 hospitals and the perinatal mortality in this units fell to 8.54000, that of the control group being 15/1000. (3) Temperature preservation: Even the simplest techniques like drying up the newborn baby and using some radiant heat sources or keeping warmth of the tiny infants has not yet been routinely adapted in China. Isolett incubators and radiant warmers are locally produced, quality needs to be improved but the Chinese pediatricians are happy to have their own things available. Swaddling (or wrapping) is popular. There are concerns that it might hinder the
206
growth of the infants and calls for its abandonment. However, since it has been incorporated into people’s custom, study is needed as to its use and substitution should be found, before to talk of abandoning it. 3. Prospect in the development of perinatal care in China (A) Regionalzed perinatal care should be popularized in the cities and then to the countryside. (B) Training of personnel is a key measure, especially in the rural area. (C) Reduce maternal mortality, especially those due to hemorrhage. (D) Reduce perinatal mortality, specifically due to hypoxia. Perinatology is in progress; however, China is a huge developing country. Everything takes time.