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Booms and Busts

China’s sharply declining birth rate means maternity wards are seeing fewer patients, resulting in fiercer competition between public and private hospitals

By Yu Ran Updated Jun.1

Nurses at the Maternal and Child Health Care Hospital, Gansu Province, take care of newborns, February 16, 2016

On March 7, patients crowded the departments of Beijing No.1 Hospital of Integrated Traditional Chinese and Western Medicine Dongba Branch. Gynecology and obstetrics, however, was nearly empty.  

While space was still available, a nurse at Beijing No.1 cautioned against reserving a bed, as its maternity ward could shut down or be merged with another hospital at a moment’s notice.  

At its peak, the hospital delivered an average 3,000-5,000 babies per year. Between 2014 and 2016 the number dropped to around 1,800. In 2021, it plunged to less than 150, according to an insider that requested anonymity.  

Beijing No.1 is not the only one. The anonymous insider said that another high-end private hospital in Beijing will soon merge with Beijing United Family Healthcare, a leading private hospital in China, as fewer women have children. “The merger is still pending,” she said.  

According to China’s National Bureau of Statistics, China saw a small spike in births from 2016 to 2017 after the central government ended its one-child policy on January 1, 2016. The birth rate has been declining ever since. In 2021, 10.62 million babies were born in the Chinese mainland, 1.38 million less than in 2020 and 7.84 million less than in 2016. A January 2019 report from the Chinese Academy of Social Sciences warned that China’s era of negative population growth will arrive soon. This has directly affected obstetrics departments in hospitals nationwide. 

Goat Bad, Pig Good 
According to Dr. Wang Xia at the Maternity and Child Healthcare Hospital of Beijing, Dongcheng District, the last surge in births at her hospital was in October 2016. They delivered around 300 newborns that month, averaging 10 per day. “I remembered I once saw seven expectant mothers and did four C-sections in one night shift,” she told NewsChina.  

That was 10 months after China ended its one-child policy. “After the ban was lifted, many couples hoped to have another child before they got too old... Many new mothers were nearly in their 40s,” Wang said.  

Data from China’s National Health Commission (NHC) showed that second children made up more than 40 percent of total newborns in 2016.  

“The boom was also because of the Chinese zodiac,” Yu Yabin, president of the Maternity and Child Healthcare Hospital of Beijing, Chaoyang District, told NewsChina. “Traditionally, many Chinese prefer to avoid giving birth in the [less auspicious] Year of the Goat (2015), and prefer the years of the Dragon (2012), Monkey (2016) and Pig (2019) instead,” she said.  

In 2016, many hospitals were forced to put beds in corridors and courtyards to accommodate the increase in pregnancies. The baby boom spawned a black market for appointments. “I heard some hospitals had to make beds for expectant mothers out of benches,” Wang said.  

Wang Shuna, a mother who gave birth in Beijing in 2016, shared a similar experience. “I was in a makeshift bed in the corridor for a whole day after having my child before being moved into a ward,” she told NewsChina. “My friend who had a baby that same year had to turn to a private hospital after failing to get an appointment at a public hospital in her neighborhood. A hospital told her they’d booked up long ago and that if you were eight weeks pregnant, it was already too late,” she said.  

That year, the NHC issued a document that called for improved facilities for women’s and children’s hospitals at the provincial, municipal and county levels. It targeted an increase of 89,000 beds and 140,000 physicians and nurses for obstetrics departments during the 13th Five-Year Plan (2016-2020).  

To meet demand, high-end birth centers and private maternity hospitals popped up in big cities like Beijing, Shanghai and Guangzhou, while others seized markets in second-tier cities like Chengdu, Sichuan Province and Qingdao, Shandong Province. According to a Caijing Magazine report, the number of private maternity and prenatal hospitals rose from 262 in 2009 to 690 by the end of 2016. 

Sharp Decline
But before private hospitals could profit from the baby boom, birth rates dropped.  

“I sensed an obvious decline in 2019, since that year was the Year of the Pig, Chinese mothers’ preferred zodiac sign, but there were fewer births than in 2017,” Yu Yabin said. “Even if we assume the decline in 2020 was because of the pandemic... the birthrate remained low in 2021,” she added.  

Births at the Maternal and Child Healthcare Hospital of Beijing Chaoyang District have steadily declined from 5,800 in 2016 to around 2,000 in 2021, data shows.  

Wang Xia said that her hospital also saw fewer births, dropping 80 percent to about 30-40 per month.  

Other cities are in the same situation. “The number of newborns has declined by nearly half compared to several years ago,” Liu Jiangang, an associate chief physician at a private maternity hospital in Hangzhou, capital of Zhejiang Province, told NewsChina, adding the obstetrics department of the public hospital where he worked before is at 80 percent occupancy. He also said that the Maternity and Child Healthcare Hospital of Anji County in Zhejiang Province reduced the size of its obstetrics department by one-third, while Hangzhou No.2 Hospital closed half its maternity wards.  

“Deliveries at our hospital fell from 1,500 in 2016 to 789 in 2021,” Zhang Jiewen, associate chief physician at the OBGYN department of the People’s Hospital of Guantao County, Handan, Hebei Province, told NewsChina. “And in the first two months of this year, we only delivered around 50 babies.”  

Official data showed that from 2017 to 2019, second children made up more than half of all annual births in China, but the rate returned to 40-50 percent in 2020. This shows policies encouraging couples to have a second child are having less effect. Similarly, when China started its three-child policy in May 2021, local government incentives did little to boost birthrates. Young people cited mounting work pressure, high housing prices and less desire to marry as reasons. 

Lasting Impact 
According to Duan Tao, a professor at the Shanghai No.1 Maternity and Child Healthcare Hospital, the declining birthrate has affected lower-tier hospitals more.  

“Pregnant women no longer had to settle for a lower quality hospital because there was no space in a top one,” Liu Jiangang said. Duan said that top public maternity hospitals are the least affected by the declining birthrate because of their highly trained staff and lessstrict pandemic controls compared to general hospitals.  

“Except for top public hospitals, the occupancy rates for maternity wards and workloads for obstetricians at public hospitals saw an obvious decrease after 2017,” said Liu Yanhui, a researcher at the Chinese Center for Disease Control and Prevention who has monitored data from public hospitals in Beijing, Chengdu, Wuhan and Shenzhen.  

As for private hospitals, Duan Tao said that smaller specialized maternity hospitals were hit the hardest, as they lacked skilled staff and often oversold their capabilities. Most large, high-end private hospitals came out unscathed, Duan said.  

But physicians and nurses saw salary cuts at both private and public hospitals. Wang Xia said her salary fell 30 percent. Liu Jiangang gave a similar figure, adding the cuts may reach 50 percent.  

“Our hospital will adjust staffing to meet patient demand,” Wang Xia said. “Around 2016, the maternity ward had seven physicians, making up the majority of total physicians working in the obstetrics department. As births decreased, physicians were transferred to the gynecology department,” she said.  

Zhang Jiewen said her hospital had three gynecology and obstetrics wards with 30 staff around 2010, but now there are two wards and only half the staff. “Some midwives moved on to other industries and some physicians transferred to other hospitals for higher pay,” she said. 

Public vs Private 
Fewer births created fiercer competition among hospitals, especially for skilled obstetricians, as more women choose to have children later in life.  

“The number of women who die while pregnant or in labor is an indicator of a local government’s healthcare, which is ranked worldwide,” Yu Yabin said. “Every death is discussed at a city-level conference attended by all the physicians and nurses and other people that served the woman,” she said.  

To better cater to pregnant women, Yu’s hospital plans to build VIP wards that provide a hotel-grade environment and services to match.  

“Over the past several decades, public hospitals focused on how to treat more pregnant women, but now the focus has shifted to how to better serve them,” Yu said. “It also meets the demands of people born in the 1990s, most of whom are only children and prefer not to share a ward with other patients,” she added.  

Guantao Hospital in Hebei Province, a county-level hospital, is building VIP wards. Wang Shijun, a professor at Beijing Xuanwu Hospital, Capital Medical University, told NewsChina that his hospital is renovating its obstetrics wards and they will make staff and space adjustments according to the number of patients. He revealed that the hospital is also planning to cancel its registration quota. In China, women must register with hospitals months in advance before giving birth in case of bed shortages.  

Private and public hospitals have extended their services to include prenatal care and postpartum recovery. “We found many women need prenatal consultation and treatment and we hope they remain with us,” Wang Xia said. “We didn’t do well with these services before because we had too many patients, but having fewer patients have pushed us to improve our one-stop service,” she added.  

To better train staff, the Maternal and Child Healthcare Hospital of Beijing, Dongcheng District set up an exchange with Peking Union Medical College Hospital, which sends senior obstetricians to help with rare diseases and difficult cases.  

Beijing Xuanwu Hospital and Guantao Hospital in Hebei opened postpartum recovery departments to treat common issues following childbirth, such as weak pelvic floor and osteoporosis. To ease women’s worries about childbirth, many hospitals are promoting epidurals. 

Such improvements at public hospitals aim to take market share from private ones. Also, public hospitals are covered by social insurance, making them an even more attractive choice. 
“Medical facilities need huge upfront investment and on average, a hospital will not see profits until five to seven years down the road,” Duan told NewsChina. “I think private maternity hospitals have entered the phase where competition has concentrated among existing ones, since it’s now very difficult for newcomers to survive.”  

Private hospitals have to either expand their business or move to other sectors, Liu Jiangang said. He revealed that some private hospitals have launched postpartum skincare and vaginoplasty services, while others have shifted their focus to oral medicine.  

“Private hospitals should shift to more academic areas and focus more on skills, though it would be a long-term process,” Duan said. “In addition, they should keep their present customers by providing excellent services. For example, they could set up expert teams to improve their existing services such as prenatal care and postpartum recovery.  

“In the future, the differences in obstetrics departments at public and private hospitals may be fewer and fewer, as the former will care more about quality service and the latter will concentrate more efforts on delivery and postpartum recovery,” he added.

With lower birthrates and pandemic-controls in place, each double room in the obstetrics ward is open to one mother only at the Maternal and Child Healthcare Hospital, Dongcheng District, Beijing