Midwifery in Modern China
Tradition, technology, and turbulence
This article is being published anonymously. It was written by one of the students in my Fall 2018 History of Midwifery class at Vassar College.
China has one of the longest histories of any nation in the world, and with this comes a rich tradition of medicine. Many fundamental concepts within this practice have remained unchanged for centuries and perhaps seem immutable within Chinese culture; however, new developments in the Middle Ages began to allow the possibility for change, which would continue in the 19th and 20th centuries as China opened itself to external influence from and exchange with other nations.
The 20th century was especially turbulent, with paradigmatic shifts in politics and culture emerging alongside numerous Communist revolutions. A deep divide in resources and wealth opened up between urban areas on the eastern coast and rural areas in the west. Medicine, and reproductive and maternal care specifically, experienced dramatic changes during this time with direct consequences for the health and wellness of mothers and children across both urban and rural areas. The history of midwifery in modern China closely follows political, social, and geographic trends, resulting in a continued modernization that first included but then nearly eliminated midwives from practice.
Before the turn of the 20th century, most midwifery continued as it had been for thousands of years, in the hands of female midwives practicing traditional Chinese medicine. Because the majority of China was what Ngai Fen Cheung and Rosemary Mander refer to as an “agrarian empire,” the resources and societal structure for a large-scale medical or reproductive care profession were absent, so most of these practices were confined within small villages and neighborhood communities and performed within the home.
This care was considered to be women’s work and was carried out by traditional or lay midwives, usually older women who had had children themselves. They were valued and honored in their local communities, and learned their skills through apprenticeship with older generations of women as well as through their own personal experiences in childbirth. These women were often illiterate, and used holistic techniques of traditional Chinese medicine including qi, yinyang, and wuxing principles.
These practices stayed much the same, and were relegated to female midwives, until male medical practitioners began to formalize and control medicine in the 13th century.
Although traditional women midwives had prominence in the birthing room, a male authoritative presence eventually functioned to minimize women’s control over midwifery via professionalization. Women were perceived as inferior to men in Chinese culture, and were banned from practicing medicine other than that related to women’s health. Because women were excluded from literacy, midwives were unable to record their practices and were barred access from circulation of written knowledge.
As medical men recorded and formalized medical information and scientific discoveries in writing beginning in 770 BCE, a male interest in gynecology and midwifery grew, and the first book on the subject was published in 1237 by scholar Chen Ziming. This publication represented the establishment of women’s medicine as an independent branch of the larger profession of medicine, and allowed male medicine men entrance into the delivery room. They began to be summoned during emergency childbirth cases, and were seen to have “technical authority” over the event, even if traditional midwives continued to perform the physical labor of delivery assistance. This gradual professionalization of midwifery continued and was magnified by the wave of Westernization that commenced in the mid-19th century, as Western “explorers” introduced science, medicine, and technology into China.
In accordance with the increasing regulation and Westernization of the medical profession in China, 1929 saw the opening of China’s first midwifery school, enabling midwifery to expand. The Chinese Ministry of Health published a series of rules for midwives in 1928, which required them to pass practical and written examinations in an effort to eliminate the unregulated traditional practices that had dominated childbirth previously. The next year, Western-trained obstetrician Chong Rui Yang opened the first midwifery school in Beijing, Beiping Birth Attendant School, providing two-year bachelor’s degree programs in midwifery for women.
American and European models of maternity care heavily inspired Yang’s teachings. Cheung and Mander emphasize the context of changing national identity of this time, writing, “the educated elite in China between 1928 and 1949 worshipped pure science, technology, and trade in much the same ways as 19th-century Westerners did.” The midwifery programs therefore symbolized state regulation and control of midwifery, establishing it as a profession firmly located within male- and Western-dominated medicine. Although midwives may have had autonomy in caring for their patients, they were trained strictly within obstetric and nursing models, and were likely to have favored technocratic methods.
Schools rapidly expanded, with, by some estimates, over thirteen thousand midwives certified by 1949 mostly in urban areas. However, the growth of the profession was dramatically interrupted during the Cultural Revolution from 1966 to 1976.
The Cultural Revolution marked a stark break in the modernization and scientific progress of medical care and midwifery in China, halting all organized medicine for a ten-year span. Along with all other educational institutions, nursing and midwifery schools were abolished during this time, paralyzing medical services across the country. Midwives were seen, as Jane Butler writes, as associated with “the old order” of society and therefore eliminated. Medical professionals were replaced with “barefoot doctors,” semi- or untrained young men and women sent out to rural areas to help stem the shortage of basic care, including prenatal, childbirth, and postpartum needs. Because of their lack of training and preparation, birth outcomes as well as general health declined greatly across China during this time, leaving a dire need for medical education in the years after the Revolution.
Following the end of the Cultural Revolution, the previous Westernization of medical education continued to an extended degree, but now midwifery programs began to dwindle. Medical programs gradually reopened throughout the 1980s and 1990s, and degrees in higher education for nursing were newly established. In attempting to catch up with the rest of the modern world following the setbacks of the Cultural Revolution, these approaches to medical education clung more firmly than ever to the Western obstetric model, valuing obstetricians and nurses and at the expense of midwives. The one-child policy was introduced in 1979, reducing the number of births as well as the perceived need for midwifery care.
The midwifery programs that did exist during this time were very similar to nursing programs, and because midwifery was seen as inferior to other practices, many students transferred from midwifery into nursing programs. Those who graduated from midwifery programs found that midwives were paid the same as nurses, but had less autonomy over the care they provided for their patients, and were constantly supervised by doctors and nurses in the hospital system. Midwifery programs gradually closed, and by 1993 were eliminated entirely. This shift was concomitant with a continued Westernization of urban hospital equipment.
The elimination of professional midwifery training in favor of nursing and obstetrics has been matched with a trend towards hospitalization and technological control of birth. With the introduction of a free market economy into China and extreme economic growth in the 1980s and 1990s, birth and health services have become “big business,” prioritizing expensive equipment and monitoring technology especially in large hospitals in eastern urban areas of the country. Following the Western obstetric model, caesarean section rates have seen a huge jump since the Cultural Revolution: Ling-ling Gao writes that “in mainland China, the nationwide caesarean rate rose from 3.4% in 1988 to 39% in 2008, with a higher rate in urban areas (64% in 2008).” Within certain urban hospitals, some cesarean section rates reached 100% by the early 2000s.
In addition to this marked increase in obstetric surgery, women in labor often experience a number of other interventions over which they have no control, including “unnecessary routine pubic shaving, enema, rupture of membranes and excessive use of oxytocin and pharmacological analgesia.” The Chinese government has recently introduced changes in its plan for reproductive and maternal care, however, perhaps offering the possibility of reducing these invasive and unnecessarily harmful practices.
Despite the near-total Westernization and technological control of childbirth enacted in Chinese hospitals, the state has begun to recognize a need for change, allowing for a small resurgence of midwifery training programs. Chinese health has on the whole improved, and both infant and maternal mortality rates have decreased significantly over the past decades as shown in figures 1 and 2, although they still have not reached the World Health Organization’s recommendations.
Birth outcomes vary across the country, and are generally poorer in rural areas with fewer resources; studies have found that 86 percent of maternal deaths across China could be avoided. In accordance with this, the Chinese government has begun to recognize a need for an increased midwifery workforce, especially in light of the amendment of the one-child policy to a two-child policy in 2015. As China’s birth rates grow, the need for trained birth attendants will rise: the World Health Organization has reported that in order to achieve universal access to reproductive and maternal care, “midwifery services must respond to 24.8 million pregnancies per annum by 2030.”
In response to this demand, China’s National Health Commission has launched a new residency program in nursing and midwifery to promote midwifery education and provide improved healthcare for women and infants. This represents an unprecedented reversal of the decades-long trend of eliminating midwives in China, although the system still retains numerous flaws.
As of today, the lack of formal recognition of midwifery and resulting nonexistence of an organized midwife body has meant that midwives’ positions and abilities are sharply contested in the Chinese medical community. Even as new midwives are trained through midwifery programs, once they enter the hospital they are still governed by nursing and obstetric models, and their only pathways for job promotion are within those roles.
They seem to only work within urban hospitals, and their status in this workplace is characterized by confusion, especially as midwifery lacks a national system for registration. Midwives are only regulated by the state health authority, and as such cannot expand as an organized profession separate from doctors and nurses. Jane Butler argues that this roadblock to coordination holds political significance: “There do not appear to be opportunities to bring women together to lobby for change, as this would be discouraged and potentially perceived as an unwelcome challenge to the one-party state.” These structural confusions within the national medical system translate to struggle within the day-to-day lives of midwives practicing in China.
The few midwives that work in Chinese hospitals face myriad professional and practical challenges. Because of the uncertainty of their professional identities, they are forced to navigate between the limiting definitions of obstetrician and nurse, often ending up on the bottom of the hierarchy of authority. This chain of command manifests in a Foucault-like surveillance of both midwives and their patients, in that “closed-circuit television and cardiotocograph monitoring systems” are often used in labor rooms and serve to depersonalize care and dissolve trust in their care relationships.
Midwives also struggle against popular conceptions of their work, observing that laboring women often specifically request medical intervention when not necessary, limiting their ability to promote natural birth. Technology is often seen as a symbol of social status in China, and its prevalence in urban hospitals is difficult for midwives to overcome. Despite these challenges, opportunities may still arise across China for improved healthcare in childbirth using anti-technocratic models.
Although dramatic changes in China’s medical education and care have been seen across both rural and urban areas throughout the 20th and 21st centuries, the midwifery model of compassionate care still finds places to emerge. Even as midwives lack authority in urban hospital settings, they are occasionally able to enact the midwifery model in advocating for natural births when doctors are busy or absent, for example during night shifts. In this small way, birthing women in highly technocratic urban areas receive exposure to the possibility of birth not dictated by Western models of obstetric control.
In rural areas, many women do not have the ability to reach hospitals in time for childbirth even if they wanted to; clearly this represents a dire lack of resources that should be amended in coming years, but it also allows space for the continuation of traditional midwifery models. Traditional lay midwives still use techniques passed down from previous generations, and their distribution within local rural villages allows them to provide care much more quickly, and perhaps more effectively, than licensed practitioners. Cheung and Mander remark that these lay midwives are “four times more plentiful than [licensed] midwives in China,” attesting to the possible viability of a non-medicalized model of birthing care across greater China.
The large-scale shifts in reproductive care education and practice in China over its modernizing period has resulted today in a system with many conflicting players and models of care. The continued increase in China’s birth rate leads to a series of pressing questions: will China’s infant and maternal mortality rates improve to the standard recommended by the WHO? Will growing midwifery programs create a viable workforce of midwives capable of promoting natural birth and reducing cesarean section rates? How will these changes affect rural lay practitioners, and will the dramatic gap in health between urban and rural areas change?
And finally, is it possible to achieve a national balance between Western scientific medicine and technology, international midwifery models, and native traditional practices? If China’s turbulent political and medical past is any indication, the answers the these questions will be difficult to predict.
