In Korea, which had even been labeled as a country that could be the first in the world to vanish due to low birth rates, the sound of babies crying is growing louder again. In the first quarter of this year (January–March), the number of births was 75,013, up 14.8% from a year earlier. But delivery rooms to receive babies remain in short supply. Expectant mothers are facing booking chaos, and hospitals are struggling with staffing shortages. We examined the problems in Korea's delivery infrastructure. [Editor's note]
Jang Yun-sil, president of the Korean Society of Neonatology, said this. Jang said the fundamental reason delivery infrastructure is faltering is that neonatal intensive care units (NICUs), related personnel, and transfer systems that should handle preterm or emergency cases collapsed first.
It is not simply that hospitals refuse pregnant patients because there are no delivery beds; more often, hospitals cannot accept mothers because they cannot backstop the baby if a problem arises. Jang said, "As with the 'pinballing of mothers,' deliveries could grind to a halt first in areas where the safety net has been cut."
The government is also rolling out measures. A representative step is the 'health insurance fee schedule restructuring plan' that the Ministry of Health and Welfare released on the 25th. It includes raising fees for surgeries and procedures related to pregnancy and delivery and creating an additional fee for high-risk cesarean deliveries.
Jang called it "a positive direction," but said investment is lacking for the core task of training personnel. "Without specialists and nurses, beds are meaningless," Jang said, adding, "Supporting their training and retention is most urgent."
Jang added, "Only when we have a transfer system that consolidation regional hub NICUs and gap areas, along with dedicated staff to coordinate transfers, can we take responsibility for mothers and babies within a region."
Jang also stressed that the burden of medical disputes must be eased. Jang said that unless the situation—where taking more high-risk mothers exposes providers to greater legal liability—is resolved, obstetrics and neonatology will continue to be shunned.
Jang is a "giant of neonatology" who has set successive records in treating early-born infants (premature babies) in Korea. After graduating from Seoul National University College of Medicine in 1989, Jang practiced in pediatrics at Samsung Medical Center and has been credited with broadening the horizons of premature infant care. Since last year, Jang has also served as director of the Samsung Advanced Institute for Health Sciences and Technology at Sungkyunkwan University. The following is a Q&A with Jang.
─What is the reason it has become harder to find a delivery hospital despite the low birth rate?
"As advanced-age pregnancies, multiple pregnancies, and pregnancies via infertility treatment increase, the share and difficulty of high-risk deliveries are actually rising. It means that even if the total number of deliveries declines, labor-intensive, risky deliveries are increasing.
The problem is that NICUs and neonatologists who can handle high-risk deliveries are decreasing even faster. More often, hospitals want to accept patients but cannot because there is no NICU to respond if a problem arises with the baby. The fundamental reason delivery infrastructure is faltering is that the intensive neonatal care infrastructure that should support it—especially personnel and transfer systems—is collapsing first."
─The gap between the Seoul metropolitan area and other regions is also large
"High-risk births are not rare, yet in many regions there is no NICU or capacity for highly complex surgery, so transfers to the Seoul metropolitan area are required in most areas except parts of the Chungcheong region. But the transfer system to move critically ill newborns is fragile.
A transfer system that consolidation regional hub NICUs and gap areas, and dedicated personnel to coordinate it, must be in place. Only then can we take responsibility for both mothers and babies. In particular, it must be established as a standing system, not a one-off pilot."
─The government has finalized a 'health insurance fee schedule restructuring plan' that strengthens compensation for pregnancy and delivery
"The direction itself—adjusting compensation around severe-case and regional maternal-newborn centers, considering maternal severity, neonatal condition, and region—is positive. But there are shortcomings in the details, so we will have to see whether it brings meaningful change to overcome the crisis on the ground."
─What specifically do you see as lacking?
"First, the most important plan to increase staffing is missing. Investment remains insufficient to train and retain specialists and nurses. Without people, beds are meaningless. The most urgent task is to directly support neonatologists' labor costs and to support the training and retention of residents and nursing staff. If this is missing, all other support only increases empty beds."
─We have heard many complaints on the ground about staff shortages
"Specialists are aging, but there is no new inflow. Looking at resident recruitment results in the second half of last year, the fill rates for obstetrics and gynecology and for pediatrics were 48.2% and 13.4%, respectively. The situation outside the metropolitan area is even more serious. In pediatrics, the fill rate outside the metropolitan area was just 8.0%.
If this trend continues, deliveries outside the metropolitan area will vanish within the next 10 years. So-called "expedition deliveries" to the metropolitan area will become routine, and more fetuses will die after missing the treatment window. The rebounding birth rate is also likely to eventually turn down."
─There are also calls to reduce judicial burdens.
"The more actively medical staff accept high-risk mothers, the more they are exposed to the risk of disputes. Not accepting has become the safer choice. Since the 2017 mass neonatal death incident at Ewha Womans University Mokdong Hospital, people even say that applicants to pediatrics have dried up. We need to create an environment where medical staff can accept high-risk patients without fear."
─Isn't the revised Medical Dispute Mediation Act, which reduces the burden of criminal punishment for high-risk essential medical acts, set to take effect in May next year?
"The revised law does not sufficiently distinguish between 'medical accidents' caused by physician negligence and 'medical outcomes' due to biological limits. When a patient dies or there is an accident related to high-risk essential medical acts, upon a guardian's application, mediation begins immediately. Medical staff, who had been in the position of saving patients, now bear the burden of proving their own lack of fault. Such investigations can last nearly five months at the longest. This leads to defensive medicine, choosing care with less liability instead of the best care.
Provisions that do not match reality must also be fixed. For example, a significant portion of neonatal prescriptions are 'off-label use' not specified in textbooks. To save babies weighing under 1 kilogram, providers adjust drug dosages to decimal points, going beyond standard ranges. If such essential acts are interpreted as 'deviations from guidelines' and bound as gross negligence, medical staff effectively cannot practice."
─These seem to be issues with limits beyond what the medical community alone can do
"Safeguarding NICUs is not about keeping a few hospitals open. It is about whether our society can safely receive babies anywhere. I believe it is time for the state to answer with a system."