In China, this year is a lucky year — the year of the Dragon — so hospitals are bracing for an increase in deliveries

In China, this year is a lucky year — the year of the Dragon — so hospitals are bracing for an increase in deliveries. Credit: Wikicommons/Melimama

For Vivienne Chen, having a first child was easy. Having a second was the problem. She is a citizen of the People’s Republic of China and her government has declared this choice illegal. But she was determined.

“We thought we would just pay the fine,” Chen says. With earnings equivalent to more than £80,000, Chen and her husband were in a good position compared with the average Chinese office worker, who earns only £3,600 a year.

Then they found out that the penalty would be somewhere between £28,000 and £48,000. Chen had no choice but to give birth in Hong Kong. The one-child policy does not apply in this territory, although they could still face a fine on their return. At this late stage of her pregnancy — seven months — there was also no guarantee that she would be able to find a bed; the Hong Kong government has capped the number of non-locals that hospitals will accept.

“When I arrived in Hong Kong, it was too late. Everywhere was booked,” Chen recalls. She resorted to an illegal agent, who, for a fee of £600 found her a place. Her package, which included a check-up and three-day stay for the delivery, cost £3,200 — more than ten times what locals pay, but only one-tenth the penalty she would have faced in China. Eight days later, she took a 24-hour train journey back to Beijing with her newborn. It was an exhausting, stressful process, but she felt it was worth it. She is not alone in her choice. Chinese mothers account for about 45 per cent of births in Hong Kong. But it is still an option that only a minority of Chinese can afford.

Even for women who stick by the rules and have one child in China, giving birth is often a costly and laborious affair.

Li Huichai is three months pregnant. Today should have been her first check-up. In China, it’s not possible to book appointments at public hospitals. Instead, patients queue to see doctors on the same day. Li went to the hospital where she is registered at 8am, but tickets for that day had sold out. She tried another two hospitals. Here too, LED screens flashed “full”. At the last hospital, scalpers approached offering help for £20. Such is the overcrowded state of Chinese hospitals, that a whole new labour force of “haofan”, or professional queuers, has developed.

Obstetricians will be even busier this year. It’s the year of the Dragon — a lucky time to be born in the Chinese zodiac — so hospitals are bracing for a 5 per cent increase in deliveries.

Lin Zhu went to register at the prestigious Xiehe Hospital 40 days into her pregnancy. Around her due date, all the beds had been reserved. Eventually, Lin used her “guanxi”, or family connections, to secure a bed. She goes for a monthly check-up, paying different prices depending on whether she sees a doctor or associate professor. At every stage of maternity, Chinese women are treated as consumers. They can choose to pay extra for better doctors, extra for Western medicine, and extra for better beds.

For Vivienne Chen’s first birth at Fuchan Hospital in Beijing, she paid more for separate accommodation. “We paid so I could be comfortable by myself and so that my husband would be allowed in with me.” Such “upgrades” would have been inconceivable under the old socialist system when healthcare provision was free and — at least in theory — equal. Following Deng Xiaoping’s reforms in the 1980s, a system developed whereby about 95 per cent of the population have insurance plans which cover 40 to 90 per cent of basic medical costs. But patients must pay upfront before they can be reimbursed, placing a major strain on the poor. Meanwhile, many services and drugs are not covered and hospitals make money pushing expensive drugs.

This has created a large gap between the quality of care at the top obstetrics hospitals in the cities and at rural clinics. “Women are travelling great distances from the countryside to get the best service. The staff at the top hospitals are overwhelmed,” says Professor Eleanor Holroyd, a medical anthropologist with expertise in Chinese women’s reproductive health.

With doctors overworked, many women are taking desperate measures to ensure that they get adequate attention. Lin Zhu chose a special ward at Xiehe, even though it would cost her £3,000 to deliver there, instead of £400 in a normal ward. “I didn’t want the experience my friends had. Most of them paid around 2,000RMB (£200) in bribes to the doctors. Everyone knows giving money is bad, but in these crowded wards, you want to make sure the staff spend time with you.”

As well as fuelling a culture of bribery, the overcrowding of China’s state hospitals has helped push the country’s Caesarean section (C-section) rate up to 46 per cent, and up to an astounding 75 per cent in some urban areas. In the UK, C-sections account for 24 per cent of deliveries. While a C-section can take as little as 20 minutes, natural labour can take more than ten hours. So, with charges for C-sections double, or quadruple, the price of natural births, it is easy to see why doctors promote them.

However, there is also demand from patients. Around a quarter of C-sections in China are not medically necessary. “There are many reasons why women are choosing to have Caesareans: sometimes it is so they can schedule a birth on a lucky day; some think it will be less painful or that vaginal births are more likely to cause damage to the baby’s head. There’s also this idea that if you’re spending more money on a service, it must be better,” Holroyd says.

Perhaps inevitably, the number of private obstetric hospitals has mushroomed. Having opened in Beijing last September, Harmonicare offers a service comparable with Britain’s private sector. It has the latest “LDR” rooms — where women can stay in the same space for labour, delivery and recovery — neonatal units with high-tech warmers from Sweden and a hotel-like foyer.

Huang Xinghua, the chief obstetrician at the hospital, remembers giving birth in 1966 and it being a very different experience. “It was completely natural, no anaesthetic. Doctors only came to help women if there was actually a problem. Today, with the one-child policy, baby is precious. Mother, father and two sets of grandparents pool their money together for this one birth.”

Even with the combined wealth of four adults, Harmonicare’s services are expensive. They range from £3,600 for a natural birth and three nights in a standard room, to £7,500 for a package that includes a C-section and five nights in a luxury suite.

This “VIP” suite is flaunted on the hospital website. A few clicks further in is a promotion for its ultrasounds, showing 3-D images of the baby. This “unborn baby video shoot” is marketed as a special keepsake: “Watch your unborn yawn, stretch and suck its thumb!” Less explicitly, the page hints that the mother will be able to see if “baby is ugly like dad, or beautiful like me”. The words are chosen carefully, as it is illegal for doctors to tell parents-to-be the sex of their child, to prevent the abortion of female foetuses.

While mothers like Vivienne Chen and the clients of Harmonicare are able to spend their way round China’s restrictive birth policies, others are being left behind. Increased investment and better technologies have helped to halve overall maternal death rates since 1991, but women in poorer rural areas are three times more likely to die during childbirth than their urban counterparts.

Rosemary Mander is a professor of midwifery at the University of Edinburgh. While researching maternity in China, she discovered that unprivileged women often receive substandard care. She says: “Low-status women in China are often not attended. You can see that in the maternal death reports. Nobody was present when the woman died to record the way she died. It is a serious reflection of the poor care that poor women in China receive. It really is iniquitous.”

While birth has become an expensive business for many in China, it is these women who are paying the ultimate price for the country’s new competitive maternity care.

Some names have been changed. Additional reporting by Clare Pennington

First appeared in The Times on February 28, 2012