Alongside the improvement in Chinese people’s living standards thanks to recent economic and technological developments has come an increased demand for high-quality medical care. In order to meet this demand, China is undertaking a significant reform of its healthcare system to promote an international level of health practice. Shenzhen, once a trailblazer in the reform and opening-up of China, is now the pioneering demonstration area of socialism, and the government has recognised that nurses need to go out and learn new international concepts of nursing care.
After 12 years of nursing, this is my first overseas education opportunity. I have been in New Zealand for six weeks. I have participated in lectures and workshops on topics such as the Ministry of Health, District Health Boards (DHBs), the nursing and midwifery education system, the Code of Ethics, simulations and reflections. I have toured midwifery units and birthing centres at Rotorua Hospital, and also visited Hospice Waikato and aged care institutions in the area.
Contrast in roles
In New Zealand, midwives work in many different ways, but they all contribute to the safe and effective provision of maternity services. In contrast, midwives in China all work the same way. While both countries provide excellent midwifery care, the table below shows the occupational differences between the two countries.
Table1: The differences in midwifery roles between China and New Zealand.
|China||Midwife||Works in the birthing room to help pregnant women deliver.||by hospital||Full-time (eight hours per day, five days per week).|
|Nurse||Works in the postpartum ward to nurse mother and new baby.||by hospital||Full-time (eight hours per day, five days per week).|
|New Zealand||LMC (Lead Maternity Carers)||Provides continuity of care to women through pregnancy, labour and birth until six weeks after birth.||self-employed||24 hours on call, freedom of working hours, working time is not fixed.|
|Hospital midwife||Provides 24-hour, three-shift cover in a maternity facility.||by DHBs||Full-time or part-time, it’s up to the midwife.|
|Continuity care midwife||Provides continuity of care for mothers and babies.
|by DHBs or other organisations||Full-time or part-time, it’s up to the midwife.|
In New Zealand, maternity care is provided by Lead Maternity Carers (LMC), most of whom are midwives. Women are entitled to free maternity services during pregnancy, labour and the postnatal period (until the baby is six weeks old). At the beginning of her pregnancy, the woman can make an appointment with the midwife, at which they each decide whether they are the ‘right fit’. No agreement can be reached if either one finds the fit to be inappropriate; it is a two-way choice. Once an agreement is reached, the midwife will take care of the woman throughout her pregnancy. The midwife will visit her at home to do a checkup, and help her make appointments with her GP or obstetrician.
In China pregnant women have their checkups in a hospital. No information is provided on how to choose an obstetrician, or who they should contact; the woman must make an appointment with an obstetrician by herself. She can then come to the hospital to see the doctor. No one doctor or midwife cares for the woman throughout her pregnancy. I believe there is room for improvement in this area.
In New Zealand when a woman is giving a birth in the birthing room she can decide how many people, and who, will accompany her. The ‘birth partners’ wear their own clothes in the birthing room. It is totally different in China: no one can come in except in special situations, and then only one person can come in, wearing a sterile gown – usually the woman’s husband.
In New Zealand there is no restriction on the number of people who come to visit the mother and new baby after delivery. Family members can visit whenever they want to. In China, however, there are strict restrictions in most hospitals about visiting in postpartum wards. Some hospitals let only one or two family members visit during the day, and they cannot stay overnight. Some hospitals will let one family member stay in the postpartum ward at night.
These rules are in place mainly from the perspective of infection control, for the sake of mother and new baby, but do not take human care into account. How to balance both? This is where we need to consider changes. While this doesn’t mean we should follow New Zealand’s approach completely, we should learn from others and amalgamate changes into our culture to achieve better humanistic care.
Shortage of nurses and midwives
Staffing levels are low in China, especially at night, often with a nurse/patient ratio of 1:20-30, despite the Chinese government stating that a nurse should not be caring for more than 15 patients at a time. The Outline of National Medical and Health Service System Planning (2015-2020) states that nurse/bed ratio in China is 0.6:1; compared with 0.45:1 in 2013, it has increased significantly. The nurse/patient ratio in New Zealand is markedly different; in New Zealand one nurse will have a patient load of four to five patients. One LMC will take care of four to six women who will deliver in the same month.
In New Zealand a nurse or midwife can choose to work full-time or part-time. Someone who has a child can choose to work only day shifts or just work three days one week. Nurses or midwives of the same skill level will get the same salary for the same working hours, regardless of whether they are part-time or full-time.
It is very difficulty to retain experienced nurses in China, mainly because of the lack of flexibility in shifts. Almost no flexible work is offered, only full-time, with rigid shift patterns once a nurse’s child turns one year old contributing to a high resignation rate. Some nurses say that if they had part-time jobs they would not quit. Recently some hospitals have tried to offer part-time work, but it is not at the same salary with the same work and is considered unfair to those nurses or midwives. So it is difficult to maintain a continuous and stable workforce
Although nurses work very hard in China, in many hospitals call bells are often out of reach. The baby boom since 2016 has exacerbated the shortage of ward beds in Chinese hospitals. The ward environment is of concern; wards contain beds in such close proximity that it is almost impossible to protect patients’ privacy and dignity. In the postpartum wards each bed has a curtain to separate it from other beds.
New Zealand has birthing centres. These are not hospitals, they are places in which pregnant women can give birth and bond with their babies before going home. Generally, they can stay there for about 48 hours. Some women deliver in hospital and move to a birthing centre seven to eight hours after the birth, which releases hospital beds. It is also good for every mother and her new baby to stay in a single room, with signage to remind staff and visitors of the importance of privacy and dignity. We were also reminded to be quiet on our visit to a birthing centre.
Circular referral system
In New Zealand, from the beginning of a woman’s pregnancy to the six weeks after her child is born, her midwife will take care of her and her baby and consult with her about everything related to a healthy pregnancy – diet, exercise, breastfeeding, baby vaccinations and so on.
If something is not normal during the pregnancy, the midwife will make an appointment with a GP or hospital obstetrician for her client. If everything goes well, six weeks after delivery the midwife will provide a referral to the GP and Plunket – a handover all of the necessary information to ensure that that medical staff continue to take care of the mother and baby. The LMC, the hospital, the GP and Plunket form a circular referral system.
In China, midwives work only in the birthing rooms. Their main job is helping pregnant women to deliver vaginally. Two hours after a baby is born, if everything has gone well they will discharge the mother and baby to the postpartum department. After that their work is complete. In the postpartum wards, other nurses take care of the mother and baby until the obstetrician discharges them. The nurses will give booklets to the mother about how to take care of her baby and herself and will tell her to come back to the hospital 42 days postpartum. There is no handover to any other medical personnel.
We are now recognising that follow-up nursing care is important for the health of both mothers and babies, but, owing to a nursing shortage in China, we also recognise that this would increase the workload of hospital nurses. Nonetheless, to truly achieve humanistic and continuous care in China, I believe we should learn from the New Zealand model to establish a comprehensive care and circular referral system.
Co-authors: Zhijing Feng, Yanfeng Sun, email: firstname.lastname@example.org, Xiaoqing He.
- The Seventh Affiliated Hospital of Sun Yat-sen University.
- Bao’an Central Hospital of Shenzhen.
Sincere thanks to the Seventh Affiliated Hospital of Sun Yat-sen University Clinical Medicine Humanities Research Fund, Shenzhen Municipal Health Commission and Shenzhen Health Capacity Building and Continuing Education Center for funding this study.
- Outline of National Medical and Health Service System Planning (2015-2020). Retrieved from www.gov.cn/zhengce/content/2015-03/30/content_9560.htm.
- Shenzhen health commission Retrieved from http://wjw.sz.gov.cn/xxgk/ghjh/gmjjshfzghjh_3/
- Waikato District Health Board (2019). Professional Development and Recognition Programme (PDRP) for nurses working for Waikato DHB. Retrieved from www.waikatodhb.health.nz/jobs-and-careers/professional-development-and-education/nursing-and-midwifery-professional-development/professional-portfolios/pdrp-for-nurses-working-for-waikato-dhb.
- Midwifery Council of New Zealand (2019). Retrieved from www.midwiferycouncil.health.nz/.
5. Nursing Council of New Zealand (2019). Retrieved from www.nursingcouncil.org.nz/