Second time around, Chinese mothers turn away from C-sections
In the fog-wrapped city of Yichang on the Yangtze in the shadow of the world’s largest hydroelectric dam, Wan Xindi is triumphant as she cares for her new baby daughter. Her second child is healthy and cute, but Wan is most proud of how she came into the world: the old-fashioned way.
宜昌位于长江畔，紧挨着全世界最大的水电站大坝。在这座时常雾气弥漫的城市里，万歆笛照料着刚出生的女儿，心中充满胜利的喜悦。这是她的第二个孩子，小女儿健康可爱，但最让她自豪的是女儿来到这个世界的方式——古老的自然分娩。
A natural birth is in itself an accomplishment in China, where caesarean section rates were, until a few years ago, the highest in the world. Wan was one of the many Chinese women who underwent a medically unnecessary C-section when her first baby arrived. During her second pregnancy, the 25-year-old went to every hospital in Yichang, determined to find a doctor willing to allow her to attempt a vaginal delivery. In the process, she became a foot soldier in the battle to wean China off its addiction to C-sections.
在中国，自然分娩本身就是了不起的成就，几年前中国的剖腹产率还是世界最高的。与许多中国妇女一样，万歆笛在第一个宝宝降生时经历了一场医疗上不必要的剖腹产手术。在怀二胎期间，25岁的万歆笛走遍了宜昌每一家医院，决心要找到一位愿意让她尝试顺产的医生。在此过程中，她成了中国戒断“剖腹产执念”大战里的一名战士。
“We think of ourselves as tunnel fighters or guerrillas. We find all kinds of ways to make it happen,” she says. Her weapon of choice: the smartphone.
她说：“我们觉得自己好像地道战的战士或游击队员。为了能顺产，我们找了各种方法。”她首选的武器是智能手机。
China’s decision in 2013 to allow most couples to have two children has involved undoing social practices entrenched over 35 years of the one-child policy. One of those is the preference for C-sections that are not needed for any medical reason.
2013年，中国决定允许多数夫妇生二胎，这需要改变许多在35年独生子女政策下牢固确立起来的社会惯例，其中之一就是在没有任何医疗需要的情况下，对剖腹产的偏好。
All else being equal, C-sections involve a slightly higher risk to the mother than natural births. They also increase the possibility of life-threatening complications in future pregnancies, including rupture of the uterus or abnormal attachment of the placenta. These risks become a national problem when nearly half of women approaching their second labour have had a C-section during their first.
在其他条件都相同的情况下，剖腹产对产妇的风险略高于自然分娩。剖腹产手术还增加了未来怀孕出现致命并发症的可能性，包括子宫破裂或胎盘异常附着。在近一半准备生二胎的女性头胎都是剖腹产的情况下，这些风险就变成了一个举国问题。
In the first half of this year already, the number of maternal deaths has climbed by nearly one-third compared with last year. “This is due to the second-child policy,” says Mao Qun’an, a spokesman for the National Health and Family Planning Commission. “We are promoting the idea that women need to consider that if they choose C-sections for their first birth it could affect their second pregnancy.”
今年上半年，孕产妇死亡人数比去年同期增加了近三分之一。国家卫生和计划生育委员会新闻发言人毛群安表示：“这是二孩政策导致的。我们正在推广一个理念，女性需要去考虑，如果她们头胎选择剖宫产，可能会影响她们第二次怀孕。”
“It’s very dangerous,” says Pang Ruyan, vice-president of the Chinese Maternal and Child Health Association, which argues against C-sections in the Chinese system and advocates a greater role for midwives to assist with natural births. “The only reason the rate of C-sections is so high is because people expected to only have one child. They didn’t need to think about having another, or the risk of ruptures.”
中国妇幼保健协会副会长庞汝彦表示：“这是很危险的。”该协会反对中国医疗体系中剖腹产泛滥的现象，主张助产士发挥更大作用，帮助产妇自然分娩。“剖腹产率如此之高的唯一原因就是人们预期只生一个孩子。他们不需要考虑再生一个，也就无需考虑子宫破裂的风险。”
The World Health Organisation puts the optimal C-section rate for the health of mothers and babies at between 10 and 15 per cent. In the US, with its lawsuit-prone system geared towards medical intervention, the rate is 33 per cent. In the UK, it is 24 per cent. In China, the rate had reached 46 per cent by 2008 before health officials realised the extent of the problem. Some urban hospitals delivered more than 70 per cent of babies by C-section until the government began to stem the practice about four years ago.
世界卫生组织(WHO)认为从母婴健康角度来说最适宜的剖腹产率在10%到15%之间。美国医疗体系诉讼多发，为医疗干预提供了土壤，其剖腹产率为33%；英国为24%。中国剖腹产率在2008年达到46%，随后卫生官员意识到了这个问题的严重性。有些城市医院接生婴儿70%以上是剖腹产，直到四年前政府开始遏制这种现象。
As China prepares for an increase in second births, the health system is moving away from C-sections. In the spirit of the planned economy, public hospitals have been given C-section quotas. Doctors — some of whom have never attended at a vaginal delivery — are being given crash courses in natural birth or are being retrained in surgical techniques to reduce the risks in future pregnancies.
随着中国准备增加二胎，其医疗卫生系统正逐渐减少剖腹产。遵循计划经济精神，公立医院被限定了剖腹产指标。医生们被要求上自然分娩速成班——其中许多医生从没参与过自然分娩——或者进修外科技术，以降低产妇未来怀孕要面对的风险。
China’s official C-section rate has dropped to 35 per cent, and the health ministry has embarked on an unusual attempt to change public perceptions in favour of natural birth. Efforts to re-educate Chinese mothers range from online classes and smartphone information apps featuring healthy pink infants, to gory videos of C-sections that go viral on Mother’s Day.
中国官方公布的剖腹产率已下降到35%，卫生部也开展了一项不寻常的行动，力求让公众转变观念，支持自然分娩。他们采取多项举措对中国妈妈们进行再教育，包括网上课堂，和主推健康粉嫩婴儿的智能手机信息应用；或是在母亲节推广血淋淋的剖腹产视频。
The second front in the battle to wean China off C-sections is being led by women like Wan. Some mothers like her who have already had a C-section have decided to attempt vaginal delivery the second time around (known as a “vaginal birth after caesarean”, or VBAC). This option carries its own risks: the first scar can rupture during the birth.
戒断“剖腹产执念”大作战的第二阵线由万歆笛等女性充当主力。她们这些做过剖腹产手术的妈妈们决定在生二胎时采用顺产，即“剖宫产后阴道分娩”(VBAC)。这种选择自有其风险，第一次剖腹产留下的疤痕可能会在分娩时破裂。
Their inspiration and support come from a stocky professional midwife in her 50s named Zhang Hongyu, an agony aunt for women in China hoping to take control of how their babies are born. From her home in the southern island province of Hainan, Dr Zhang maintains smartphone apps that extol the benefits of natural birth. She hosts forums — online and on the ubiquitous Chinese social-networking app WeChat — that buzz with discussions between hundreds of expectant mothers. Some women text for help and advice straight from the delivery room. “A lot of people are not very clear about this natural process,” Dr Zhang says.
而给予她们鼓舞、支持的是一位五十多岁、胖乎乎的专业助产士，她的名字叫张宏玉。对于这些渴望掌握自己宝宝出生方式的中国女性来说，她就是她们的知心大姐。张宏玉家在海南省，她在家维护着多个智能手机应用，宣传自然分娩的好处。她在互联网和微信——中国无处不在的社交网络应用——上主持了多个论坛，数百名准妈妈们在这些论坛上讨论得热火朝天。有些妇女甚至直接从产房发信息求助咨询。张宏玉说：“很多人对自然分娩过程不是很清楚。”
In the chatrooms, converted mothers like Wan jump in to answer the concerns of novices to natural birth. “I learnt so much in all these online classes, I feel I should share it. Some of the mothers, they don’t bother to research much,” she says.
在聊天群里，像万歆笛这样已转变观念的妈妈们会亲身上阵，为没有经验的女性解答关于自然分娩的问题。她说：“我在这些网络课堂上获益匪浅，我觉得我应该把知识分享。有些妈妈懒得做太多研究。”
Wan’s own quest for a VBAC was followed avidly by the group. “I’m not going to livestream,” she told her followers the day she checked into the hospital. She nonetheless proceeded to text updates. “The pain is bearable,” read one. “They were all waiting to see if I could do it. I’ve inspired a lot of them,” she says.
万歆笛对VBAC的追求在群里受到热烈关注。她住进医院的当日对关注者们表示：“我可不会直播啊。”不过她仍继续进行文字更新，其中一条写道：“这个疼受得了。”她说：“她们都等着看我能不能做到。我激励了她们很多人。”
Why do so many Chinese women choose C-sections? Doctors blame the families. New parents and, critically, grandparents, will do anything to make sure their one baby is perfect, including selecting the right day and even hour for an auspicious birth. Older people believe that young women brought up as single children are too pampered to bear pain. For years, C-sections have been marketed as high-tech and pain-free, with no mention of discomfort after the operation or the risk to future pregnancies.
为什么这么多中国女性会选择剖腹产？医生们归咎于家庭。新手父母们，更关键的是祖父母们，愿意做一切事以确保他们的独苗是完美的，包括为孩子的问世选择良辰吉日。老人们认为作为独生子女长大的年轻女性太娇惯，吃不得苦。剖腹产多年来一直被标榜为高科技、无痛手术，却只字不提术后的不适以及未来怀孕会遇到的风险。
“When people only have one child they are overly worried,” says Dr Zhang. “They are worried about loss of oxygen; they want to hurry up and get it out and have their healthy baby. Plus they think surgery is simple and fast.”
张宏玉说：“当人们只会有一个孩子时，他们会过于担心。他们担心缺氧，他们想孩子快点出生，得到一个健康的宝宝。他们还认为手术是简单快捷的。”
Women like Wan argue that not-so-subtle pressures from doctors scare women (or their husbands and in-laws) into asking for medically unnecessary C-sections. “The doctors always tell you the worst-case scenarios. First-time mothers always listen to the doctors,” she says. “Second-time mothers are much more confident.”
万歆笛等女性认为是医生们较为露骨的施压，吓得妇女们（或她们的丈夫和婆家人）在没有医疗需要的情况下要求剖腹产。万歆笛说：“医生总是告诉你最坏的情况。头胎妈妈总是会听医生的。二胎妈妈就有信心得多。”
For overcrowded urban hospitals, the financial incentives are clear. In Yichang, a natural birth costs about Rmb3,000 ($450) and requires a nurse or midwife’s attention for several hours. A C-section costs up to Rmb11,000 and only takes up about 30 minutes of the doctor’s time, providing a much more attractive revenue stream. Surgeries also yield a larger hongbao (a gift packet) from grateful families. Unscrupulous doctors can pad out revenues further by making quicker (but harder to heal) vertical incisions, charging per suture to close the wound or adding extra fees to remove gauze or stitches.
在人满为患的城市医院，经济动机是明显的。在宜昌，顺产费用约为3000元人民币（合450美元），且需要一名护士或助产士照顾几个小时。剖腹产的费用可高达1.1万元人民币，且只占用医生半个小时左右，提供了一个更有吸引力的收入来源。感恩戴德的家庭还会给大夫包上一个大红包。无良医生赚钱门路更多，他们可以采用更快的竖切（但更难愈合）手术，对每根缝合线都收费，又在拆纱布或拆线时另收费。
In the 1980s, hospital births were the privilege of China’s urban citizens. Women in rural areas had their babies at home and went to hospital for abortions or sterilisations after out-of-plan pregnancies. But by the 2000s, as migration to cities accelerated, the vast majority of Chinese women gave birth in hospital. It is no coincidence C-section rates rose steeply at the same time.
上世纪八十年代，去医院生产是城里人的特权。农村妇女在家生孩子，只有在计划外怀孕后需要堕胎或绝育时才去医院。但进入21世纪，随着人口向城市迁移速度加快，绝大多数中国妇女都在医院分娩。同时剖腹产率自然也就急剧上升。
The relaxation of the one-child policy has revealed a disturbing downside to entrusting the future of the nation to the knives of surgeons in a hurry. Unofficial statistics for Beijing show a rate of complications in pregnancies after C-sections of about 10 per cent.
一孩政策的放宽暴露出了将国家的未来匆忙交到外科医生手术刀下的弊端。据北京市非官方统计显示，剖腹产后怀孕并发症的发生率约为10%。
“Families, mothers, doctors all need to think differently,” says Dr Pang, who co-authored the 2008 study in The Lancet medical journal that detailed, for the first time, the extent of China’s C-section problem. With the protection of a long career at the WHO — and the blessing of the health ministry — she released it to the state television broadcaster, triggering a national discussion of the problem.
庞汝彦说：“家庭、母亲、医生都需要转变想法。”她是医学杂志《柳叶刀》(The Lancet)上2008年一篇调查报告的合著者，该调查首次详细披露了中国剖腹产问题的严重程度。凭借在世卫组织的长期职业生涯，以及中国卫生部的支持，庞汝彦将这一调查结果发布给了国家电视台，引发了一场对该问题的全国讨论。
New public messaging in favour of natural birth has found a receptive audience at Beijing’s main maternity hospital, where up to 1,500 babies are born each month. Heavily pregnant women stream through the doors. One day in May, every expectant mother who stopped for a chat agreed she would prefer a natural birth — a switch in attitudes from just a few years ago.
支持自然分娩的新舆论宣传在北京主要妇产医院找到了受众，这里每月新生婴儿最多能达到1500名。挺着大肚子的孕妇们川流不息地走入医院大门。5月的一天，每一位驻足接受简短采访的准妈妈都表示倾向自然分娩。仅仅几年时间，人们的态度就发生了转变。
But altering public opinion is one thing; changing hospital procedure is another. In China, as in the US, institutional factors such as doctors’ pay structure and hospital protocols keep C-section rates high.
但改变舆论是一回事，改变医院程序是另一回事。中国与美国一样，由于医生薪酬结构以及医院治疗方案等制度因素，剖腹产率居高不下。
In bigger cities, epidurals, known in Chinese as “no pain” births, now rival C-sections in popularity (and revenue potential). Dr Pang believes this is simply trading one interventionist approach for another: “Conditions are different here. We don’t have enough anaesthesiologists.” For that matter, she thinks VBACs are also too risky to be carried out widely in China, given the need for quick surgery and ample blood supply if labour goes wrong.
在大城市，硬膜外麻醉——在中国称为“无痛”分娩——如今在受欢迎程度以及创收潜力上都能与剖腹产相匹敌。庞汝彦认为这只是把一种干预主义手段换成另一种。她说：“中国的情况不同。我们没有足够的麻醉师。”也正是出于这一原因，她认为在中国大范围推广VBAC风险太大，因为如果分娩中出现问题，需要能够快速进行手术并保证有充足的血液供应。
In hospitals in rural areas, where most families cannot afford C-sections, women are encouraged to walk around during labour and eat or drink for strength and hydration in line with traditional practice. Many urban hospitals forbid that. “The hospital has me lying on my back and won’t let me move!” one expectant mother told Dr Zhang’s group. Twelve hours later, denied food or water, “I ran out of energy and went for the C-section”, she texted.
在中国农村地区，多数家庭负担不起剖腹产费用，当地医院鼓励产妇在分娩期间四处走动，并按照传统方法进食饮水。许多城市医院禁止这么做。一位准妈妈在张宏玉的群里说：“医院让我仰躺着别动！”就这么干躺着12个小时，不许进食和喝水。她写道：“我力气耗尽，做了剖腹产。”
Women who have not used the smartphone information apps only receive vague guidance at hospital birth classes. The focus is on maternal nutrition until the eighth month, when mothers-to-be are given a cursory explanation of what to expect during the birth. “Open classes are like a big rice bowl or a cafeteria — they aren’t tailored to personal needs,” Dr Zhang says.
有些妇女没用过智能手机信息应用，只在医院分娩课程上接受过模糊的指导。这些课程向准妈妈们重点介绍怀孕八个月内的孕妇营养，但没有详细解释分娩中可能遇到的情况。张宏玉表示：“开放式课堂就像大锅饭或自助餐厅，不是针对个人需求而设。”
As China’s health system reverses the trends that tipped the scales towards unnecessary C-sections, advocacy by determined mothers like Wan could help make reforms stick. “You have to inform yourself,” she says. “If the doctors see that you know what you are talking about, they respect you and give you the information you need.”
随着中国医疗卫生系统着手扭转这股偏好不必要剖腹产的趋势，万歆笛这些意志坚定的妈妈们所做的努力或许有助于坚定这一改革。她说：“你必须自己去了解信息。如果医生看出你知道自己在说什么，他们会尊重你，把你需要的信息告诉你。”
Additional reporting by Luna Lin
Luna Lin补充报道
With wealth comes improved health
财富改善健康
China has achieved notable success in the past 15 years in improving maternal health and bringing down its child mortality rates — two of the eight Millennium Development Goals that the UN established in 2000. Its high population means such gains in China translate into survival for hundreds of thousands of women and children.
过去十五年里，中国在改善孕妇健康和降低儿童死亡率——联合国在2000年确立的八大“千年发展目标”(Millennium Development Goals)中的两点——方面取得了显著成功。中国庞大的人口意味着这一成就相当于挽救了几十万名妇女儿童的生命。
That success is partly a result of the country’s rapid increase in wealth, which has led to improvements in nutrition for pregnant women and babies. The state has also been able to invest more in medical care, including prenatal check-ups and neonatal intensive care units.
这一成就部分源于中国财富迅速增长，从而改善了孕妇和婴儿的营养状况。同时政府也有能力加大医疗保健方面的投资，包括产前检查和新生儿重症监护病房。
“Before, some babies were simply not treated because of family poverty. But now fewer and fewer are left untreated, because parents have health insurance and the state has more resources,” says Dr Liu Cuiqing, head of the neonatal unit at Hebei Provincial Children’s hospital in Shijiazhuang. “But that puts more pressure on us, given the shortage of doctors, because to treat babies with serious conditions requires more work, more equipment and more time.”
河北省儿童医院新生儿科负责人刘翠青医生表示：“以前一些病重的孩子由于家庭经济困难放弃治疗了，现在有了医疗保险，部分医疗费用由政府负担，放弃治疗的越来越少了。但是对于目前儿科医生短缺的我们来讲，压力很大，因为救治危重病孩需要做更多的工作和需要更多更好的医疗设备以及更长的时间。”
There are also darker explanations behind the shining improvements in the statistics. China’s rigid population control policies — which have been eased over the past three years to allow almost all couples to have a second child — have meant that most families would abort at any sign of irregularity in prenatal scans, to avoid a possible health problem in their only child.
统计数据上闪闪发光的成绩背后，也有着更阴暗的解释。中国的刚性人口控制政策——过去三年已有所缓和，几乎所有夫妇都获准生二胎——意味着在孕检出任何异常迹象时，大多数家庭都会选择中止妊娠，以避免唯一的孩子可能出现健康问题。
Some doctors and parents admit privately that stillborn babies, or newborns with untreatable conditions, are sometimes handed to their parents unregistered so that hospitals do not miss their targets for reducing infant mortality.
一些医生和家长私下承认，死产婴儿或患有不治之症的新生儿有时未经登记就交给父母，这样院方就可以完成降低婴儿死亡率的目标。
