中國二胎媽媽們的新態度

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.

宜昌位於長江畔，緊挨着全世界最大的水電站大壩。在這座時常霧氣瀰漫的城市裏，萬歆笛照料着剛出生的女兒，心中充滿勝利的喜悅。這是她的第二個孩子，小女兒健康可愛，但最讓她自豪的是女兒來到這個世界的方式——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.

在中國，自然分娩本身就是了不起的成就，幾年前中國的剖腹產率還是世界最高的。與許多中國婦女一樣，萬歆笛在第一個寶寶降生時經歷了一場醫療上不必要的剖腹產手術。在懷二胎期間，25歲的萬歆笛走遍了宜昌每一家醫院，決心要找到一位願意讓她嘗試順產的醫生。在此過程中，她成了中國戒斷“剖腹產執念”大戰裏的一名戰士。

“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.

她說：“我們覺得自己好像地道戰的戰士或游擊隊員。爲了能順產，我們找了各種方法。”她首選的武器是智能手機。

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，中國決定允許多數夫婦生二胎，這需要改變許多在35年獨生子女政策下牢固確立起來的社會慣例，其中之一就是在沒有任何醫療需要的情況下，對剖腹產的偏好。

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.

在其他條件都相同的情況下，剖腹產對產婦的風險略高於自然分娩。剖腹產手術還增加了未來懷孕出現致命併發症的可能性，包括子宮破裂或胎盤異常附着。在近一半準備生二胎的女性頭胎都是剖腹產的情況下，這些風險就變成了一個舉國問題。

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，孕產婦死亡人數比去年同期增加了近三分之一。國家衛生和計劃生育委員會新聞發言人毛羣安表示：“這是二孩政策導致的。我們正在推廣一個理念，女性需要去考慮，如果她們頭胎選擇剖宮產，可能會影響她們第二次懷孕。”

“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.”

中國婦幼保健協會副會長龐汝彥表示：“這是很危險的。”該協會反對中國醫療體系中剖腹產氾濫的現象，主張助產士發揮更大作用，幫助產婦自然分娩。“剖腹產率如此之高的唯一原因就是人們預期只生一個孩子。他們不需要考慮再生一個，也就無需考慮子宮破裂的風險。”

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.

世界衛生組織(WTO)認爲從母嬰健康角度來說最適宜的剖腹產率在10%到15%之間。美國醫療體系訴訟多發，爲醫療干預提供了土壤，其剖腹產率爲33%；英國爲24%。中國剖腹產率在2008年達到46%，隨後衛生官員意識到了這個問題的嚴重性。有些城市醫院接生嬰兒70%以上是剖腹產，直到四年前政府開始遏制這種現象。

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.

隨着中國準備增加二胎，其醫療衛生系統正逐漸減少剖腹產。遵循計劃經濟精神，公立醫院被限定了剖腹產指標。醫生們被要求上自然分娩速成班——其中許多醫生從沒參與過自然分娩——或者進修外科技術，以降低產婦未來懷孕要面對的風險。

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.

中國官方公佈的剖腹產率已下降到35%，衛生部也開展了一項不尋常的行動，力求讓公衆轉變觀念，支持自然分娩。他們採取多項舉措對中國媽媽們進行再教育，包括網上課堂，和主推健康粉嫩嬰兒的智能手機信息應用；或是在母親節推廣血淋淋的剖腹產視頻。

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.

戒斷“剖腹產執念”大作戰的第二陣線由萬歆笛等女性充當主力。她們這些做過剖腹產手術的媽媽們決定在生二胎時採用順產，即“剖宮產後陰道分娩”(VBAC)。這種選擇自有其風險，第一次剖腹產留下的疤痕可能會在分娩時破裂。

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.

而給予她們鼓舞、支持的是一位五十多歲、胖乎乎的專業助產士，她的名字叫張宏玉。對於這些渴望掌握自己寶寶出生方式的中國女性來說，她就是她們的知心大姐。張宏玉家在海南省，她在家維護着多個智能手機應用，宣傳自然分娩的好處。她在互聯網和微信——中國無處不在的社交網絡應用——上主持了多個論壇，數百名準媽媽們在這些論壇上討論得熱火朝天。有些婦女甚至直接從產房發信息求助諮詢。張宏玉說：“很多人對自然分娩過程不是很清楚。”

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.

在聊天羣裏，像萬歆笛這樣已轉變觀念的媽媽們會親身上陣，爲沒有經驗的女性解答關於自然分娩的問題。她說：“我在這些網絡課堂上獲益匪淺，我覺得我應該把知識分享。有些媽媽懶得做太多研究。”

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.

萬歆笛對VBAC的追求在羣裏受到熱烈關注。她住進醫院的當日對關注者們表示：“我可不會直播啊。”不過她仍繼續進行文字更新，其中一條寫道：“這個疼受得了。”她說：“她們都等着看我能不能做到。我激勵了她們很多人。”

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.

爲什麼這麼多中國女性會選擇剖腹產？醫生們歸咎於家庭。新手父母們，更關鍵的是祖父母們，願意做一切事以確保他們的獨苗是完美的，包括爲孩子的問世選擇良辰吉日。老人們認爲作爲獨生子女長大的年輕女性太嬌慣，吃不得苦。剖腹產多年來一直被標榜爲高科技、無痛手術，卻隻字不提術後的不適以及未來懷孕會遇到的風險。

“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.”

張宏玉說：“當人們只會有一個孩子時，他們會過於擔心。他們擔心缺氧，他們想孩子快點出生，得到一個健康的寶寶。他們還認爲手術是簡單快捷的。”

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.”

萬歆笛等女性認爲是醫生們較爲露骨的施壓，嚇得婦女們（或她們的丈夫和婆家人）在沒有醫療需要的情況下要求剖腹產。萬歆笛說：“醫生總是告訴你最壞的情況。頭胎媽媽總是會聽醫生的。二胎媽媽就有信心得多。”

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.

在人滿爲患的城市醫院，經濟動機是明顯的。在宜昌，順產費用約爲3000元人民幣（合450美元），且需要一名護士或助產士照顧幾個小時。剖腹產的費用可高達1.1萬元人民幣，且只佔用醫生半個小時左右，提供了一個更有吸引力的收入來源。感恩戴德的家庭還會給大夫包上一個大紅包。無良醫生賺錢門路更多，他們可以採用更快的豎切（但更難癒合）手術，對每根縫合線都收費，又在拆紗布或拆線時另收費。

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.

上世紀八十年代，去醫院生產是城裏人的特權。農村婦女在家生孩子，只有在計劃外懷孕後需要墮胎或絕育時纔去醫院。但進入21世紀，隨着人口向城市遷移速度加快，絕大多數中國婦女都在醫院分娩。同時剖腹產率自然也就急劇上升。

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.

一孩政策的放寬暴露出了將國家的未來匆忙交到外科醫生手術刀下的弊端。據北京市非官方統計顯示，剖腹產後懷孕併發症的發生率約爲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.

龐汝彥說：“家庭、母親、醫生都需要轉變想法。”她是醫學雜誌《柳葉刀》(The Lancet)上2008年一篇調查報告的合著者，該調查首次詳細披露了中國剖腹產問題的嚴重程度。憑藉在世衛組織的長期職業生涯，以及中國衛生部的支持，龐汝彥將這一調查結果發佈給了國家電視臺，引發了一場對該問題的全國討論。

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.

支持自然分娩的新輿論宣傳在北京主要婦產醫院找到了受衆，這裏每月新生嬰兒最多能達到1500名。挺着大肚子的孕婦們川流不息地走入醫院大門。5月的一天，每一位駐足接受簡短採訪的準媽媽都表示傾向自然分娩。僅僅幾年時間，人們的態度就發生了轉變。

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.

但改變輿論是一回事，改變醫院程序是另一回事。中國與美國一樣，由於醫生薪酬結構以及醫院治療方案等制度因素，剖腹產率居高不下。

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——在中國稱爲“無痛”分娩——如今在受歡迎程度以及創收潛力上都能與剖腹產相匹敵。龐汝彥認爲這只是把一種干預主義手段換成另一種。她說：“中國的情況不同。我們沒有足夠的麻醉師。”也正是出於這一原因，她認爲在中國大範圍推廣VBAC風險太大，因爲如果分娩中出現問題，需要能夠快速進行手術並保證有充足的血液供應。

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.

在中國農村地區，多數家庭負擔不起剖腹產費用，當地醫院鼓勵產婦在分娩期間四處走動，並按照傳統方法進食飲水。許多城市醫院禁止這麼做。一位準媽媽在張宏玉的羣裏說：“醫院讓我仰躺着別動！”就這麼幹躺着12個小時，不許進食和喝水。她寫道：“我力氣耗盡，做了剖腹產。”

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.

有些婦女沒用過智能手機信息應用，只在醫院分娩課程上接受過模糊的指導。這些課程向準媽媽們重點介紹懷孕八個月內的孕婦營養，但沒有詳細解釋分娩中可能遇到的情況。張宏玉表示：“開放式課堂就像大鍋飯或自助餐廳，不是針對個人需求而設。”

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.”

隨着中國醫療衛生系統着手扭轉這股偏好不必要剖腹產的趨勢，萬歆笛這些意志堅定的媽媽們所做的努力或許有助於堅定這一改革。她說：“你必須自己去了解信息。如果醫生看出你知道自己在說什麼，他們會尊重你，把你需要的信息告訴你。”