The characteristics of obstetrical inpatients in the obstetrical department of Peking University third Hospital, a critical care referral center for pregnant women in Beijing, changed after the policy was implemented. The main changes were as follows: the average age of pregnant women rose from 31.86 years to 33.04 years; the proportion of older pregnant women increased from 25.34% to 37.15%; the proportion of much older pregnant women increased from 4.58% to 7.45%; and the incidence of pregnancy complications, such as GDM/PGDM, hypertensive disorder of pregnancy, placenta previa, postpartum hemorrhage, cesarean section and dangerous placenta previa, increased in older pregnant women. Reports in the literature 【6】 indicate that advanced-age pregnancy has become increasingly common in both developing and developed countries. Family planning policies, delays in pregnancy planning and the development of assisted reproductive technology have led to an increase in the number of older pregnant women. Bekir Kahveci found that compared with pregnant women aged less than 35 years, older women show increased rates of pregnancy complications, such as hypertensive disorder of pregnancy, GDM/PGDM, and cesarean section. The incidences of placenta previa, postpartum hemorrhage, ART, cesarean section and severe placenta previa are also significantly increased compared with those before the implementation of the policy. These factors have led to an increase in critical obstetric inpatients, longer hospital stays and higher hospitalization costs in the short term after the implementation of the policy in China.
3.1 Rate of cesarean section
In the study group, the cesarean section rate of older pregnant women rose from 15.92% to 30.15%, but the total cesarean section rate in the study group decreased from 59.26% to 54.35%. An indicated cesarean section can effectively decrease the probability of an adverse pregnancy outcome in women with complications. However, a 2015 World Health Organization statement concluded that a cesarean section rate of more than 10% does not contribute to a decline in maternal or infant mortality. In contrast, a statement issued by the WHO in 2015 indicates that when the cesarean section rate is higher than 10%, the operation can lead to more complications and deaths.【8】The rate of cesarean section in China rose rapidly from the mid–1980s to the 1990s. By the beginning of this century, the cesarean section rate was as high as 70% in multiple hospitals and even 100% in specific hospitals【9】. This situation, which is the basis of the obstetrical problems observed after the implementation of the current “policy”, has caused concern in the domestic medical profession. With the standardization of obstetrical management and further integration with international standards, the cesarean section rate in China has declined steadily year by year from 2012 to 2016【10】. With the implementation of the policy, a couple can have two children, and the risk and benefit assessment of cesarean section has changed, which is an important reason for the decrease in the cesarean section rate.
3.2 Improvement of prognosis in patients with severe placenta previa
The mean number of hospitalization days decreased from 13.5 days to 11.75 days (P < 0.05) for patients with severe placenta previa. There was no difference between the two groups in terms of the mean hospital stay before surgery, but the average hospital stay after surgery decreased from 8 days to 6.66 days (P < 0.05). The average usage of plasma decreased from 711.83 ml to 445.61 ml, and the average usage of suspended red blood cells decreased from 7.36 U to 4.54 U in recent years (P < 0.05). A history of cesarean section increases the risk of severe placenta previa in the second pregnancy, and generally, the amount of cesarean section hemorrhage in placental accretion cases is more than that in other patients. In recent years, with the increasing incidence of placental accretion, Peking University third Hospital has documented many experiences in the diagnosis and treatment of placental accretion. We use the ultrasound scoring system to predict the type and severity of placental implantation【11】based on the following parameters: the placental location and thickness, whether the retroplacental hypoechoic vocal cords had disappeared, whether the bladder lines are continuous, the placental lacuna characteristics, the placental basal blood flow signals, cervical morphology, whether there are blood sinuses in the cervix, and the history of cesarean section. There are 2 points per item, and the total score is calculated. A score ≥ 5 is used to predict the adhesive type and severe type (including implantation and penetrating type, respectively) of placental accretion. When the score is ≥ 10, the possibility of a penetrating type of placental accretion is higher than that of the other two types of placental accretion. Prenatal dynamic ultrasound examination combined with MRI provides an important reference value for evaluating the severity of placental accretion. These preoperative preparations are effective measures to reduce intraoperative bleeding and the transfusion of blood products. This approach provides important clinical guidance for preparation before termination of pregnancy. In addition, we use a balloon catheter to temporarily block the blood supply artery, which effectively reduces intraoperative bleeding, maintains clarity of the surgical field and provides an opportunity to preserve the uterus【12】. Placental hemorrhage is greatly reduced by ultrasound diagnosis for high-risk cases, the application of the balloon hemostatic method, and the cooperation of the surgical team. Multidisciplinary collaboration and effective collaboration by the MDT team reduces clinical blood consumption and improves patient prognosis.
3.3 Establishment of the criteria for admission to the ICU
The results show that the number of patients with internal and surgical diseases admitted to the ICU is lower than that in the control group, which may be related to the establishment of the MICU (Maternal ICU) in our obstetrics department in recent years. With the increase in pregnancy complications in ICU patients and the shortage of ICU resources, patients with internal and surgical complications who do not need invasive surgery or life support are observed in the MICU. Among the inpatients admitted to the ICU, the proportion of inpatients with pregnancy complications increased from 26.32% to 43.47% (P < 0.05). The rational use of ICU resources and cooperation of obstetrics and ICU doctors provide a guarantee for the diagnosis and treatment of critical obstetric inpatients. In China, most regions and hospitals do not have specialized obstetrical ICUs, and critical obstetric inpatients are usually admitted to the surgical ICU (Public ICU). Due to the physiological characteristics of pregnant women, cooperation between obstetricians and ICU doctors is needed for the management of these women during the perinatal and peri-operative periods. Considering the shortage of ICU resources, relevant criteria for the transfer of patients to the ICU should be established and would ensure not only the rational use of resources but also medical safety. The WHO defines women who are dying of complications during pregnancy as maternal near miss (MNM) and have developed MNM diagnostic criteria to help identify critical pregnant women【3,13】. The MNM standard clarifies the related factors leading to maternal mortality from three perspectives, namely, the clinical manifestation, laboratory examination and treatment measures, which are not only helpful to identify critical pregnant women but also helpful to guide the treatment and management of critical pregnant women. In our previous study【14】, we used acute physiology and chronic health evaluation II, Marshall’s MODS scoring standard and the MNM Diagnostic criteria to evaluate patients admitted to the ICU from 2006 to 2011 in Peking University third Hospital and found that the MNM diagnostic criteria can better identify critical pregnant women. The MNM diagnostic criteria are suitable for China’s national conditions and have a higher positivity rate.
3.4 Increase in hospitalization cost
Our results showed that the average hospitalization cost rose from 8766.40 yuan in the control group to 11,595.58 yuan in the study group. The average hospitalization cost increased from 10,250.77 yuan to 14,666.33 yuan for patients undergoing cesarean sections due to pregnancy complications. Although the average hospitalization cost was high for both the patients with severe placenta previa and the patients admitted to the ICU, there was no significant difference between the study group and the control group. According to the Law of Social Insurance of China, maternity insurance is a type of social insurance that is provided by the state and society for the temporary interruption in the woman’s participation in the labor force due to the birth of a child. However, some scholars have noted that  the scope of reimbursement is narrow and that the rate of reimbursement is too low to meet the needs of social development. Most areas of maternity insurance are reimbursed in accordance with local policies, which means that no matter how much money is spent, patients can only be reimbursed a certain amount of money. In some complicated situations during pregnancy, many more of the expenses will not be reimbursed.
After the implementation of the policy, in addition to the pressure to increase the number of pregnancies, the obstetrical risks resulting from the associated increase in pregnancy complications are also a problem that needs attention. To make better use of medical resources, ensure medical safety and reduce the occurrence of adverse maternal and infant outcomes as much as possible, obstetricians should promote the standardization of clinical diagnosis and treatment and a more detailed management strategy based on to the new characteristics of inpatients under the new policy.