Through an unexpected opportunity at the end of 2018, I was invited to speak at a conference on Maternity Care in Qingdao, (pronounced Ching toe) which is a large coastal city on the North East coast of mainland China. The population of Qingdao is around 9,046,200 and the endless miles of high-rise apartment buildings pays testament to the housing needs of a densely populated urban community. I gleaned little of maternity care in rural areas during my visit other than in Qingdao province: the rural population itself is more than six million. Home birth is ‘illegal’ in the cities, but no-one could tell me if this was also the case in rural settings.
My point of contact for this visit, was Irene Chain Kalinowsky, a UK trained midwife who left New Zealand for China four years ago. Irene works for Meng Xue, who is a senior member of the Qingdao Midwife Union Group. Irene’s remit is focussed on assisting Meng to develop a training programme known as the Integrated Modern Maternity Service System (IMMSS).
Before agreeing to travel to China I wanted to know more and whether I was the right fit for their brief. As luck would have it I was able to meet Irene and Meng during a family visit they were making to the UK. I was keen to hear the background to the conference and what their aims were. Meng explained how the Chinese Government has directed each province to reduce the caesarean section rate, which is alarmingly high and up to 50% in some provinces. However, the Government did not issue any guidance as to how and Meng described how they have lost the skills to support straightforward labour and birth. She added that the role of the midwife in urban communities is all but extinct and she planned to bring the skills and knowledge of midwifery back to their training and development programmes.
What remained unclear due to language difficulties was whether there was an intention to train midwives, or whether it was to up-skill existing nurses and doctors involved in maternity care. It appeared to be a combination of both. Language barriers and limited translation apps, made further clarification difficult. What was evident was Meng’s passion and commitment to develop a strategy and training programme to enable nurses and doctors to work closely together, all with the aim of enabling more physiological births whilst reducing caesarean section rates. With the help of Irene, they have produced a manual, which promotes a ‘holistic approach to putting the mother and baby first’. The manual embraces complementary therapies, homeopathy and acupuncture. China has a legendary history of what in the West we label as ‘alternative’ medicine. I sensed that there is a move by some in China to combine the art and science of maternity care with their long established history of traditional Chinese medicine. This became more evident when a fellow speaker and I were unexpectedly flown to Cheng du to repeat our talks to a maternity team in a maternity hospital in central Cheng du. More of this later.
Meng’s husband, an orthopaedic surgeon, owns a factory and they have produced active birth aids such as stools and holding cloths and physiotherapy balls as well as birthing platforms with suitable railings to support upright positions. Mr Xue also has links to a birth pool company in the UK. He wanted to know more about labour and birth in water. So Meng asked me to talk about birth centres and water birth, two subjects close to my heart, and so I agreed to be one of their speakers for their three-day conference in November.
I presented in the company of other international speakers from Brazil, America, New Zealand and Australia. We did not have professional translation services and at times this was problematic. The three-day conference began at 08.30 and finished at 18.00. Meng held a gala dinner for delegates and speakers, and I was humbled by the appreciation and generosity of our hosts. The entertainment was fun, if not a little loud, and we joined in with my rendition of the twelve days of Christmas played to ‘A pinard in a pair tree’ and each day represented all we needed to set up a birth centre including ‘9 birthing rooms, 10 smiling midwives’ etc and ‘a mother with her baby’. You have to sing the tune to get the rythmn of it. It wasn’t long before the whole audience joined in with our efforts and laughter.
We went into the city on our one free afternoon. There we visited the harbour and an old German Brewery. Globalisation marches ahead at pace as last week in my village store, I was flabbergasted to see Tsingtao Beer ‘made in Qingdao’.
Edwin Borge, an obstetrician from Brazil, and I, were asked to go to Cheng du in Szechuan province to repeat our talks to staff in a small city maternity hospital. We were accompanied by three delegates from the Qingdao conference, a nurse, a midwife and an anaesthetist. Communication between us was slow at first, until we got the hang of translation Apps. Nevertheless, interactions were limited despite a genuine feeling of good will and professional camaraderie.
The Cheng du New Born Maternity Hospital situated off side roads in down- town Cheng du is, by Chinese standards a small facility with about 2700 births a year. It has a Caesarean section rate of less than 12% and hardly uses epidural. The team shared their anxieties about moving to a new hospital this year where there is projected to be up to 10,000 births per year. Both Edwin and I felt a sense of unease that they saw us as experts and yet their work was showing such remarkable outcomes. We were keener to learn from them. Nevertheless, we presented our talks and many questions were asked. The key elements of success in their hospital seemed to be a belief in normal birth processes and each member of the team was there to support women through their labour with the least intervention needed. We asked the anaesthetists about epidural and instead they shared how they use acupuncture and other non-invasive techniques to help women with their pain. Epidural was not a first line treatment. Whilst I was presenting, Edwin had a tour of labour ward and his photos showed women being nourished and cared for on birthing balls with maternity workers focused on their needs. He watched their hair being brushed, a significant recommendation in his own work, akin to us sitting on our hands, and commented on how quiet the rooms were.
During our discussion at the end of our presentations we encouraged the audience to write about what they do, to capture their philosophy and their practices so that they can lead the way after their move to the new and larger facility. If we achieved anything, we perhaps were able to reflect back the light on to them and reinforce how much we had to learn from them and not them from us.
Having been invited to China to talk about birth centres and water birth in England, I was mindful that our maternity system here is very different to the Chinese system, what little I know of it. Given the challenges we have faced in the UK with opening and then closing birth centres, I determined not to paint a falsely optimistic picture that failed to tell the whole story. Nevertheless, I showed positive images of wonderful birth centre births and happy women. I demonstrated their potential. I described our history and how we set up and run birth centres. I talked about how, for the UK, it seemed to be a midwife’s answer to the over-interventionist obstetric model. I quoted the late Marsden Wagner and how he recommended that ‘we get well women the hell out of labour wards.’ At the same time, I described some of our challenges, the economic crash of 2008, too few midwives and pressures to close otherwise successful birthing facilities in order to prop up acute services. I showed press cuttings headlining maternity unit closures. I emphasised that if they were to consider opening birth centres they could learn from our mistakes and ensure they have the right infrastructure and funding in place from the outset.
I was less than sure that birth centres are the way forward for Chinese maternity care in the areas we visited. If their integrated teams could work as well together as the Cheng du Hospital demonstrated, then I suggested they should build on that success primarily. Being mindful of their vast rural areas about which I knew little, I nevertheless suggested that a hub and spoke model might work for them with midwifery-led care for women in rural settings who would not have the means to transfer long distances to urban city hospitals. I outlined the Lancet Series framework for maternity services and encouraged them to explore the vast body of evidence that could help them on their journey to reducing unnecessary caesareans by offering the appropriate services to all women, families and babies in China.