In May 2007 the National Association of Neonatal Nurses, in collaboration with the People to People Ambassador Program, led the first neonatal nursing delegation to China. Twenty-seven neonatal nurses and nurse practitioners from 14 different states visited 5 hospitals and 1 home health service in Beijing, Guilin, and Shanghai, China. The journey to China was designed for neonatal nursing professionals in the United States (US) to provide an opportunity to connect and exchange information with our neonatal colleagues. This 12-day delegation provided us with the opportunity to explore the Chinese healthcare system related to perinatal services and identify some of the basic differences in healthcare and cultures between the US and China.

The long trip over to China was exhausting, and it was a welcome relief to arrive in Beijing. We learned quickly on the ride from the airport to the hotel that China has had rapid improvement in the nation's economy, leading to more cars on an already crowded highway system. We learned about "Chinese chicken" in which the largest vehicle on the road has the right of way (Figure 1). Thank goodness we were in a bus!!

FIGURE 1. Traffic in China is an ongoing problem. With an increasing number of Chinese able to own vehicles, there are needs for new roads. Traffic similar to this was common when we traveled.

China has had huge economic and social changes in a very short period of time. Just 2 generations ago, Chinese woman still bound their feet; now they hold positions of considerable influence. There have also been tremendous achievements in perinatal care in both China and the US in the last few centuries. The rapid changes and advances have had far-reaching implications in the healthcare system and the health status of the country, with most of the change occurring in big cities. The countryside, where the majority of the population lives, has not seen the same improvements. China continues to have regional disparity, with higher infant and women mortality rates in the poor rural regions.

Our first official visit in China was to the Beijing Children's Hospital. We met many neonatal nurses who outlined for us the nursing issues in China. The care of patients is currently being affected by a worldwide shortage of nurses. China is faced with one of the most severe nursing shortages, which affects the quality of nursing education and practice.1 In speaking with our Chinese colleagues, we found that the education and role of nurses are extremely different in China than they are in the US. Care was described as the administration of medications, changing beds, observing patients, and reporting information to physicians. Currently China has more than 1.3 billion people who are cared for by about 1.24 million nurses, a huge difference from the US, in which 2.7 million nurses are available to cover approximately 300 million people.1,2 This means in China there is 1 nurse for about every 1,000 people, compared with the US, where there is 1 nurse for every 100 people.

At the hospital in Beijing, and in many of the facilities we visited, infants come from the outside and are brought in through the emergency room by their parents or medical staff from outlying hospitals. We saw conjoined twins who had been brought in by the parents. Families begin lining up around midnight so they can be seen early in the morning. Healthcare is provided on a first-come, first-served basis, and the lines extend outside of the hospital lobbies by the morning hours.

Our second visit was to the Peking University People's Hospital in Beijing. We were greeted by a roomful of nurses and physicians who talked to us about healthcare and nursing education in China. China currently has 3 levels of entry into practice for nursing. The diploma nurse is recruited from junior high to attend a 3- to 4-year program, beginning work at 17 to 18 years of age. The AND program takes 3 to 4 years after high school graduation, and the BSN is about the same time frame but requires an entrance exam. There are no waiting lists for these nursing programs. China has very few nursing programs and even fewer masters' programs in nursing. There are only 6 PhD-prepared nurses in China and very few male nurses. The nursing programs focus on medical and physiologic science. All nurses earn similar salaries, despite entry level or employment status. Many of the physicians work side by side with the nurses, sharing functions due to the severe nursing shortage and the overwhelming workload. They often cover nursing breaks and lunches. Physicians and nurses earn similar salaries, and both are paid by the government. The average nursing salary is about $500 a month. Nurses in the community hospitals or clinics make about half this. This is considered a medium income in China. The average age of nursing is the mid-30s, and nurses older than 50 generally do not work night shifts because of "poor eye sight." Retirement age is 55 years.

We discovered several differences in practices in China's care of infants. Touring the pediatric units, we learned quickly that there are no HIPAA regulations in China. We were introduced to patients and their parents and told of their illness. Mothers encouraged us to take pictures and were proud of their children. The discussions with our colleagues on these 2 days focused on neonatal jaundice, skin-to-skin care, nursing issues, and infant swimming. The idea of newborn swimming intrigued the entire delegation. Initiated in Germany and Japan in the 1960s, it was adopted in China in 2002.3 Newborn swimming is believed to benefit a baby's physical and psychological development, improve the growth of bones and muscles, and strengthen the heart, brain, and lungs.3 Some hospitals have baby swimming contests, in which babies younger than 6 months compete on facial appearance and ability to communicate with their mothers. Swimming has become very popular, and parents buy swimming rings and pools at local stores. Many of the hospitals we visited had swimming rooms (Figure 2). Swimming rooms are kept at 28[degrees]C, and pool water is 38[degrees]C.3 The babies are fed milk prior to swimming, and mothers are trained to work with their infants at home. There have been a few small studies from China indicating improvement in the nervous system of infants with mild asphyxia who are exposed to swimming.

FIGURE 2. We saw swimming rooms in many of the facilities we visited. This was the swimming room in Shanghai. Infants are supported by a ring that fastens under the chin.

Prior to leaving Beijing, the delegation had an opportunity to visit the Forbidden City, Tian'anmen Square, and the Great Wall. China is rich in the history of dynasties and emperors, and the stories and folklore were steeped in the culture of this old world. China's history as well as the old architecture and way of life are truly the embodiment of this amazing country. The Great Wall, built over 10 dynasties and held together by sticky rice, was more amazing than any picture could represent. Although it was steep and no one would say "easy" to climb, we all spent time on the Great Wall taking pictures of it winding through the Chinese countryside (Figure 3). As we toured the country, we discovered that parents avoid using diapers by putting a slit in the bottom of the baby's pants. We all competed for the cutest split pant picture; who can resist a baby's bottom (Figure 4)?

FIGURE 4. A little girl with split pants on the streets of Shanghai.

FIGURE 3. The delegation climbing the Great Wall of China.

The next leg of our trip was to Guilin, and it was here that we would realize the contrasts between urban and rural China. In the 1980s, China ended socialized medicine. From 1952 to 1982, China phased out universal healthcare and began a fee-for-service business.4 Currently, there are few regulations in this healthcare business and, physicians often receive bonuses for generating revenue. They also generate revenue from drug sales.4 China's infant mortality rate was 200 per 1,000 live births prior to the change in healthcare but has dropped to about 31 per 1,000 live births, although it is higher in rural areas.5,6 Infant mortality is considered an indicator of public health worldwide. The United States ranks 25th among industrialized countries in national infant mortality even though we spend the most money on healthcare. Although infant mortality in the rural areas of China remain high, big cities such as Beijing and Shanghai, have similar or better rates than the big cities in the US.4,7 As the delegation moved from the cities to the poorer regions, the reason for infant and maternal disparities became evident. We found that the majority of hospitals did not have air conditioning or hot running water. Infection control practices did not routinely include hand washing. Without air conditioning, windows are left open for circulation. To protect the infants, mosquito netting is used over the infant beds in neonatal units (Figure 5). Although the babies are protected, the equipment and the bottles placed at the sinks between feedings are not (Figure 6). Hot water must be delivered to units in large thermoses throughout the day.

FIGURE 6. Infant feeding bottles are at the sink. Powdered formula is mixed at each feeding, and bottles are labeled with the baby's name.

FIGURE 5. Mosquito netting to protect the infants in the neonatal unit, Beijing.

Pregnancy and childbearing may be universal among women, but the process is steeped in the culture of every society. In China, most mothers enter the hospitals when they are in labor. The hospitals provide most of the care for all of the people of China. Entry is through the emergency room, and physicians make decisions on admissions. Once admitted, mothers may be required to move from room to room as their labor progresses. In many settings, there are early labor rooms, late labor rooms, delivery rooms, and postpartum rooms (Figure 7). Most of these rooms have multiple beds for delivery, and because there are multiple women in the rooms, husbands and significant others are not allowed in the delivery area. Although the maternal mortality rate (MMR) fell from 80 per 100,000 deliveries after socialized medicine ended, it still remains high at about 48.3.8 The MMR varies widely from cities such as Shanghai, which reports 9.6 per 100,000 deliveries, to Tibet, which reports 466 per 100,000 deliveries. The MMR in the rural areas is 4 to 6 times higher than in urban areas, and when looking at the country as a whole, the MMR may still be as high as 96 deaths per 100,000 deliveries.9 China continues to have one of the highest maternal death rates, with hemorrhaging being the leading cause of death, followed by anemia, obstructed labor, and sepsis.10

FIGURE 7. Mothers often move from room to room as their labor progresses. (

In Guilin, we spent a day visiting the Affiliated Hospital of Guilin Medical College and the People's Hospital of Lingchuan County. It gave us the opportunity to see the contrast in China's hierarchical network of maternal and child health services. The quality of services varies greatly, with country doctors (previously known as barefoot doctors) working out of their homes with a stethoscope, sphygmomanometer, and thermometer; village maternal and child health services that provide basic services to families; township health centers staffed by doctors or midwives; and county- and city-level hospitals.11 The higher-level hospitals are supposed to supervise and teach the lower-level ones. Physician education can range from a 3- to 6-month program after junior high school (barefoot doctors) to 3 years of medical school after high school in the villages. The county hospitals have physicians with 4 to 5 years of training. In the cities, there are specialized women's and children's hospitals with neonatal and pediatric intensive care units. The contrasts in care related to infection control stood out to all of us. In a modern and fairly well-equipped nursery, we were asked to wear shoe covers, and yet nonrelated infants shared warmers, and hand hygiene efforts were not clearly visible. The delivery rooms have old equipment that is torn and exposed in an area of high contamination (Figure 8). The more rural facilities were poorer, with fewer amenities, but again we found our neonatal colleagues had a passion for all they do, with a drive to improve care for newborns and infants.

FIGURE 8. This is a delivery room in the more rural areas of China. Notice the torn bed and old equipment. It was a stark contrast to the conditions in Shanghai.

In both of the hospitals, we discussed maternal and infant mortality. Although the statistics have improved, it is still thought that Chinese birth and infant mortality statistics are underreported.12 Some of this is attributed to the one-child policies that affect the lives of families.12 Before the 1980s, China encouraged people to have large families and did not take the advice of population experts. From 1949 to the end of the 1980, China's population reached 1.2 billion people.13 It wasn't until 1979 that China adopted the one-child family policy. This form of population control has been widely adopted, partly due to the overcrowded cities, cramped living spaces, and issues with child care.13 China uses a reward system to enforce the policy, ensuring better child care and education to families with one child. Having a second child can result in loss of the first-child benefits but also can go as far as loss of jobs and possessions.13

Many couples fear reporting because of the punishments, and health officials are eager to meet the population targets. Births of females (due to a strong desire for sons) or births outside of marriage often go unreported. This is evident in the high sex ratios noted among newborns in China. Sex ratios at birth are remarkably constant in human populations and are defined as the number of male live births for every 100 female births. The birth ratio of males to females in China is approximately 117 to 100 at birth and in some regions as high as 152 to 100, compared with worldwide ratios of 105-107 to 100.14 This is believed to be due to underreporting of female births, selective abortions of female infants, and excess neonatal mortality of females.14 The belief that males are more honorable than females is a strong part of the culture of China. In many countries, sons are preferred because they have a higher wage-earning capacity, they continue the family line, and they are recipients of inheritance. Girls are considered costly because of dowry systems, and after marriage they enter the husband's family, ceasing to have responsibility for their parents in illness or old age. The one-child policy was modified so that couples in rural areas with a first-born girl could have a second child and try for a boy. China has a very strong family planning network at every level of government in both rural villages and cities. Pregnancies are approved, and for those not approved, abortion is strongly encouraged.14 The use of medical technology to determine the sex of the fetus has been outlawed in China since 1994; however, it has been difficult to enforce, and screening for fetal sex is still widely practiced.14 The abortion of female fetuses is believed to play the strongest role in the birth ratio differences. The effects of a male surplus are beginning to become a problem in many countries, and it is believed that the gender preference will gradually decline during the next few decades.11

The last leg of our trip was from Guilin to Shanghai. Our first visit was to the Shanghai First Maternal and Infant Health Hospital, built in 1947. It is said to be one of the finest in the country and is considered the highest level of hospital. The disparity in healthcare was most apparent when spending time in this state-of-the-art facility compared not just to the rural areas but also the hospitals in Beijing (Figure 9). The contribution from the Chinese government for healthcare has dropped during the last century, which has caused a large disparity in China's healthcare system between wealthy urban areas and the poor rural regions.15 Only 30% of Chinese, mostly the wealthy, have health insurance.15 To assist with the rural poor, the government covers inpatient care but not primary care or drug therapy, and patients are expected to pay about 58% of the cost.15 Most Chinese have no coverage and are expected to pay out of pocket. Consequently, the rural poor are unable to afford hospital care (approximately $15 dollars a day, equivalent to 2 weeks' salary).16 Patient care is expensive because of unnecessary tests and treatments because physicians receive bonuses for many of these.17 The vast difference in economy from rural to urban was apparent as we traveled back into the city. The massive economic growth and prosperity of China was centered in Shanghai. Housing in the city is growing, with many people living in apartments and condominiums; however, housing in the rural rice communities, such as Guilin, still consists of dirt floors without indoor plumbing or kitchens (Figure 10).

FIGURE 10. Stark contrast of rural China (A) compared with the city of Shanghai (B).

FIGURE 9. Beautiful labor, delivery, recovery, and postpartum suites with state-of-the-art equipment in Shanghai. These rooms meet the needs of families from admission to discharge.

Our last visit was to the Achieve Easy Housekeeping Service (Figure 11). The staff shared many of the beliefs of the Chinese with us. The Chinese believe that good health is based on the accumulation of vital life force called "qi" along with a balance of cold ("yin") and hot ("yang").18 Women during parturition and postpartum periods are in a cold state and are thought to require hot foods and herbs due to the loss of blood or vital life force. In many of the hospitals, the family provides the food for their loved ones. Mothers spend 3 days in the hospital on average for a normal delivery and 7 days for cesarean section. There is no routine pain control provided to patients for routine deliveries. Hospitals do not have baths or showers, and there are common bathrooms for all to use. When the mother goes home, she stays in one room with the baby, and they do not go out for the first month. She is considered weak and in the cold state and is confined for a period of 30 days. It is not appropriate for males to visit the mother's room, but she can come out to visit friends. It is not considered appropriate for mothers to cook, clean, or shop during this time. Some families hire home services to assist with these chores during this time. The Achieve Easy Housekeeping Service shared with us how a Chinese woman should avoid any type of draft and should not take a bath or wash her hair. Mothers are not encouraged to bathe until day 7, at which time a bath in ginger red wine is recommended.13 They spend their time in bed, resting. Families, mostly fathers, hire this service to provide care in the home for the mother and infant for 1 to 2 months or longer if needed.

FIGURE 11. The delegation with the Achieve Easy Housekeeping Service.

During the confinement period there are rituals for the infants as well. The infant is considered to be in a hot state. Some Chinese administer herbal tea sweetened with brown sugar in the first 3 days of life to cleanse the infants of dirty blood swallowed during delivery.18 Some believe that a cool fluid, made with honey, yellow in color, will protect the infant from jaundice. Babies are kept bundled in China during the first 100 days of life in an effort to protect them from colds. Despite the heat in several of the hospitals, infants were often difficult to see in their cribs because of the clothing and blankets (Figure 12). Many dietary rules are in place to protect the infant from infection, and mothers who are breastfeeding are expected to follow these rules, consisting mostly of a full vegetarian diet.18 Breastfeeding is strongly encouraged; however, formula is available. Grandparents are very involved in the care of the child. In many situations, it is the mother-in-law who looks after the mother and infant during confinement. Women who work for the government have 12 to 18 months of fully paid maternity leave. Fathers also receive some time off with pay.

FIGURE 12. Infant bundled in a crib in a postpartum unit.

We expected the breastfeeding rates in China to be very high, but they have dropped considerably since the introduction of breast milk substitutes in the 1970s. In the 1990s, Beijing reported a breastfeeding rate of 24.7% in the first week of life and only 13.6% at 4 months.19 The Chinese government supported the Baby Friendly Hospital Initiative in the early 1990s, increasing breastfeeding rates in the cities to about 61% in the first week of life and 26% at 4 months.19 There is a huge campaign by the government to increase breastfeeding rates in China, and rates are currently reported at about 70%.19 Despite all this, breast milk is not used in neonatal intensive care units. Powdered formulas are used and shared among infants. Visitation is limited, and it is believed that this decreases infection. Parents are usually updated once a day and in some units allowed to visit once a day. Mothers usually remain in a state of confinement, even if their infant is in critical condition.

After spending time in different healthcare facilities, we thought it was apparent that both nursing and neonatal care in China are far behind those in the US. It was also apparent that cultural differences exist that have been accepted in China for centuries. It is essential that we continue to work with our Chinese colleagues to evaluate their perinatal care needs. More nursing programs are needed to overcome the severe nursing shortage, and the role of nursing needs to be expanded to meet the growing needs within healthcare in both countries. Understanding the cultural practices and beliefs of Chinese families during childbearing and after will assist us in caring for the many families and infants in the US. Chinese Americans represent 23% of the 10.6 million Asian American/Pacific Islanders in the US.20

NANN should continue to play an important role in international healthcare for infants by providing more exchange efforts, information of professional issues and nursing practices, and help to our Chinese nursing colleagues to move forward. We should continue to encourage an ongoing 2-way exchange of ideas, knowledge, and experience. Despite our cultural, economic, and language difference, it was evident everywhere we visited that we all have a "passion for little people." When we first decided to lead the delegation to China, we said it would "widen our eyes and broaden our minds," and truly it did.

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