Development and Future Perspectives of Obstetric Intensive Care Units in China

Overview and purpose of the review In commemoration of the 100th anniversary of the Chinese Medical Association, this review highlights the remarkable advancements and future prospects of Obstetric Intensive Care Unit (OICU) in China — a cornerstone of maternal critical care. However, the pregnancy is generally considered low risk; a subset experiences complications that necessitate admission to OICU. This article delineates the developmental trajectory of OICU in China across three distinct phases: the formative stage (pre-2008), the expansion phase (2009-2015), and the current quality-oriented stage (2016-present). In addition, it presents a prospective analysis of future directions for OICU development in China, with a focus on technological innovation and clinical translation, the training of specialized personnel, the promotion of multidisciplinary collaboration and integrated diagnostic-treatment models, the coordinated development of regional medical systems, and the establishment of robust quality control and patient safety frameworks. By comprehensively examining the historical evolution, current landscape, and anticipated future trends of Chinese OICU, this review aims to offer valuable insights to enhance diagnostic, therapeutic, and management capabilities in the care of critically ill obstetric patients. Introduction Maternal health is a critical public health priority, with direct implications for family well-being and societal stability. With the advancement of modern medical practices, maternal healthcare systems have become increasingly comprehensive. The OICU functions as the ultimate safeguard within this framework, bearing the critical responsibility of providing care for critically ill pregnant and postpartum women. OICU are specialized units designed to care for patients experiencing severe medical or surgical complications, organ failure, or other life-threatening conditions. These units provide advanced life support, hemodynamic monitoring, and timely, systematic, high-quality medical care for critically ill pregnant women.1 The development of OICU not only reflects the overall capabilities of individual hospitals but also serves as a key indicator of maternal healthcare within a country or region.2 Globally, the establishment and advancement of OICU have become integral to modern healthcare systems, significantly contributing to reductions in maternal mortality and improvements in maternal health outcomes. High-income countries have accumulated extensive experience in the design, equipment, staffing, and management of OICU.3–5 In China, the development of OICU began in the late 20th century. Through years of exploration and clinical practice, these units have evolved from an initial absence to a well-established system with distinct national characteristics.6 Driven by socioeconomic progress and growing public demands for high-quality healthcare, the role of OICU in China has become increasingly prominent. In recent years, the Chinese government has prioritized maternal and infant safety, with a target to reduce the maternal mortality rate to fewer than 12 per 100,000 live births by 2030. In this context, it is both timely and essential to review the historical evolution of OICU in China, objectively assess their current status, and explore future developmental trajectories, as these efforts hold substantial theoretical and practical significance. This article aims to provide a systematic overview of the past, a critical appraisal of the present, and a forward-looking perspective on the future development of OICU in China. The development history of OICU in China The initial stage (late 20th century – 2008) Critical care medicine is a specialized discipline dedicated to understanding the pathophysiological deterioration of the human body due to severe illness or injury, with the goal of guiding precise and effective treatment for critically ill patients. The field originated in the 1950s, marked by the establishment of the world’s first Intensive Care Unit (ICU) at Boston City Hospital in the United States in 1952.7 In China, critical care medicine began with the founding of the first ICU at Peking Union Medical College Hospital in 1982, which marked a significant milestone in the discipline’s domestic development. Reflecting global trends, the evolution of OICU in China has paralleled advancements in critical care medicine. The inception of OICU in China dates back to the late 20th century, driven by an increasing demand for enhanced maternal safety management. In 1998, the first “Critical Pregnant Women Rescue Center” in China was inaugurated in Guangzhou, focusing on the monitoring, transfer, and treatment of critically ill pregnant women. This initiative accumulated valuable experience in improving the management of obstetric emergency care, reducing maternal and neonatal adverse outcomes, and advancing the level of obstetric care.8 A key feature of this phase was the centralized management of severe obstetric complications, such as preeclampsia, postpartum hemorrhage (PPH), and acute fatty liver of pregnancy, as well as major obstetric comorbidities.9–11 Previous studies have indicated that the leading causes of admission to OICU were hypertensive disorders of pregnancy (accounting for 30%–40%) and PPH (20%–25%), highlighting the urgent need for improved management of high-risk pregnancies.12 During this period, the majority of tertiary hospitals began integrating obstetrics and critical care resources. However, the development of specialized teams and the establishment of advanced infrastructure remained in early stages; only 15%–20% of OICU had access to a 24-hour on-call multidisciplinary team.3,13 Notably, since 2008, Chinese researchers have developed a localized version of the Maternal Early Warning Scoring System. This system incorporates seven physiological parameters, including blood pressure, heart rate, and respiration rate, to create a predictive risk model, increasing the accuracy of severe complications to 78.6%.10,14 The multidisciplinary team model was first implemented in major medical centers in Beijing, Shanghai, and Guangzhou, fostering interprofessional collaboration among obstetricians, anesthesiologists, critical care physicians, and neonatologists. In this initial phase, the criteria for admission to OICU generally followed conventional intensive care guidelines, while specific monitoring protocols addressing obstetric pathophysiological features—such as circulatory overload and alterations in coagulation function during pregnancy—remained under investigation.15,16 Studies reported that the average length of stay for early OICU patients ranged from 14 to 21 days, with a mechanical ventilation rate of 32.9%. Importantly, the maternal mortality rate significantly declined from 8.7% to 4.5%.17 These foundational practices established a robust foundation for the future specialization and refinement of OIUC in China.14,18 The development stage (2009–2015) Beginning in 2009, OICU in China entered a phase of rapid development. This progress was driven by advancements in medical technology and increased availability of healthcare resources, which collectively heightened national attention toward the establishment and expansion of OICU. Consequently, numerous hospitals significantly increased their investment in OICU infrastructure, acquiring advanced equipment such as high-performance ventilators and extracorporeal membrane oxygenation (ECMO) systems. Concurrently, the development of specialized medical teams advanced substantially, with the multidisciplinary collaboration model gaining widespread adoption across hospitals. This led to the gradual information of integrated care teams comprising anesthesiologists, intensive care physicians, obstetricians, critical care nurses, and midwives, establishing a more structured and coordinated approach to the management of critically ill obstetric patients.19,20 Since 2013, China has undergone a series of fertility policy reforms, transitioning from the selective two-child policy to a universal three-child policy. These changes have contributed to a growing proportion of older mothers and pregnancies conceived via in vitro fertilization and embryo transfer, resulting in increased rates of pregnancy-related complications and comorbidities. Elevated high-risk pregnancies also present new challenges to OICU. During this period, the service capacity of OICU was notably enhanced, leading to a substantial increase in the success rate of treating critically ill pregnant women. For instance, the mortality rate associated with postpartum hemorrhage decreased by 21.1%.21 High-quality development stage (2015–present) Since 2015, OICU in China have entered a phase of high-quality development, characterized by significant advancements in technological innovation, service quality, professional training, and quality and safety management. The widespread integration of intelligent monitoring systems, telemedicine platforms, and mobile health technologies, combined with the application of precision medicine and personalized treatment approaches, has significantly enhanced both the clinical capabilities and operational efficiency of OICU.22,23 Simultaneously, the continuous refinement of multidisciplinary collaboration models, the promotion of birth-friendly hospital initiatives, and the enhancements in midwifery service management have collectively optimized the medical experience and improved the quality of healthcare services provided to pregnant women.24 Recent studies underscore the importance of multidisciplinary teams in providing comprehensive prenatal guidance, particularly in the management of rare genetic or syndromic conditions during pregnancy.25,26 In addition, the development of structured professional training systems, the cultivation of interdisciplinary expertise, and the implementation of talent incentive mechanisms have established a solid foundation for the long-term, sustainable development of OICU.19 Furthermore, the establishment and continuous improvement of quality control frameworks, the enhancement of safety management protocols, and the construction of regionally coordinated treatment networks have further effectively improved the equity and safety of medical services. In terms of policy support and institutional protection, the National Health Commission has issued several key documents, including the Construction and Management Guidelines for Critical Maternal Rescue Centers in 2017 and the Maternal and Infant Safety Action Improvement Plan (2021–2025) in 2021. These policies have played a crucial role in standardizing treatment protocols for critically ill pregnant women and have provided clear guidance for the high-quality advancement of OICU. The policy documents not only underscored the public welfare aspect of midwifery services but also proposed the establishment of policy guarantee mechanisms to foster the high-quality development of obstetrics, thereby fully mobilizing the enthusiasm of obstetric medical staff. The official establishment of the Critical Care Medicine Group under the Perinatal Medicine Branch of the Chinese Medical Association further propelled the development of maternal critical care in China.27 Through annual academic conferences and contributions to the clinical guidelines and expert consensus statements, the group has significantly deepened professional understanding of Chinese OICU and facilitated broader recognition and support for OICU nationwide. Current status of OICU in China Currently, OICU in China is advancing towards greater standardization and specialization. Most hospitals have instituted comprehensive OICU management systems, and the field of obstetric critical care medicine has achieved notable progress, characterized by stringent regulations governing key areas such as patient admission criteria, condition assessment, treatment plan formulation, and the implementation of nursing measures. Concurrently, academic research and professional exchange activities have become more dynamic, contributing to both theoretical innovation and the practical development of the discipline.27 By 2023, approximately 3000 critical maternal rescue centers had been established across China, and the number of OICU beds had tripled compared to 2010. The mortality rate associated with PPH has decreased from 3.1% in 2000 to 0.8% in 202028, and the success rate for treating preeclampsia complicated by multiple organ failure now exceeds 90%.29 Resource allocation and regional disparities Despite the substantial progress of OICU in China, several challenges remain. According to data from the 2023 China Health Statistics Yearbook, the national average number of OICU beds stands at 2.1 per 100,000 live births. However, significant regional disparities persist: developed eastern regions, such as Shanghai and Jiangsu, report 4.3 beds per 100,000 live births, while less-developed western provinces like Guizhou and Gansu offer only 0.9 beds per 100,000 live births. In terms of equipment, although the penetration rate of invasive hemodynamic monitors in tertiary hospitals has reached 78%, primary-level hospitals continue to rely predominantly on central venous pressure monitoring (92%).30,31 Current status surveys show that only 43.7% of OICU physicians possess formal critical care certifications, and fewer than 60% of nurses have undergone systematic critical care training.32,33 In addition, the talent pool also reflects an “inverted pyramid” structure: senior physicians account for 12.3% (compared to 21.5% in general ICU), while junior physicians account for 51.8%. This imbalance leads to a concerning scenario where, during night shifts, up to 63% of OICU are staffed by junior doctors managing critically ill patients independently. Weak links in quality control Although national obstetric quality control indicators have been established, their implementation remains inconsistent across regions. Multiple clinical studies have reported that approximately 0.1% to 0.8% of pregnant and postpartum women require admission to a general ICU, while an additional 1% to 2% require management in a high-dependency unit (HDU). This means that 1% to 3% of pregnant and postpartum women need comprehensive care in ICU/HDU.34,35 However, most OICU established within critical maternal rescue centers in China do not fully meet ICU standards. In practice, they function more as HDUs, typically equipped with only basic cardiovascular monitoring systems and lacking specialized critical care medical personnel. Even where OICU exist, they often rely on support from general ICU or other specialized ICU, such as surgical ICU and cardiovascular ICU, to manage critically ill obstetric patients. Obstetricians are usually involved only through consultative roles, leading to a fragmented and unsystematic management of complex cases. In the quality monitoring process, there are problems such as incomplete and inaccurate data collection, as well as shallow and untimely data analysis. Some hospitals do not pay enough attention to quality control processes, failing to effectively leverage data to inform and drive clinical improvement initiatives.36 Patient economic burden and insurance gap The average daily cost of a critically ill pregnant woman in the ICU is as high as 12,000–38,000 RMB, but the medical insurance reimbursement rate (42%–65%) is significantly lower than that of general critical conditions (70%–85%). Survey data show that 24.3% of families were forced to forgo advanced life-support interventions, such as ECMO, due to unaffordable treatment costs.37 Commercial insurance coverage remains low, at less than 7%, with marked regional disparities: the eastern region contributes more than 50% of the national premiums revenues, while the western region, despite experiencing the fastest growth in commercial insurance uptake between 2006 and 2015, still contributes less than 20% of the total premiums, thereby exacerbating financial vulnerability among patients in economically disadvantaged areas.38 In addition, some hospitals also face disproportionately high labor expenditures, excessively high proportions of drug and material costs, and inadequate budget management. These issues underscore the urgent need for innovation-driven, refined management strategies to promote high-quality and sustainable development in obstetric critical care services.39 Lagging status of information technology construction Although research has demonstrated that the use of early warning scoring systems can significantly improve clinical and nursing quality, reduce the average treatment duration for pregnant and postpartum women, and lower the incidence of acute obstetric events and ICU transfer rates40,41, their implementation in China is still limited. Challenges include inconsistent regional deployment and insufficient sensitivity to the unique physiological and pathological characteristics of obstetric populations.42 Overall, while OICU in China have made notable strides toward high-quality development, continued investment and efforts are needed in areas such as technology application, service quality improvement, talent cultivation, multidisciplinary collaboration, and regional coordinated development to better meet future development needs. Future prospects of Chinese OICU Technological innovation and application With the rapid development of intelligent and digital healthcare, the integration of cutting-edge medical monitoring and treatment technologies has become an important direction for OICU construction. Remote medical monitoring systems and intelligent monitoring equipment will improve the efficiency and service quality of OICU. At the same time, the application of artificial intelligence technology in the diagnosis and treatment of obstetric critically ill patients is expected to further improve the success rate of treatment.43–45 Simulation training and multidisciplinary team building To ensure the delivery of high-quality medical care, it is essential to strengthen the training of intensive care and obstetric physicians and nurses.46 Simulation-based training is emerging as a critical tool for enhancing emergency response capabilities.47 By simulating high-risk obstetric scenarios, medical staff can refine their professional skills in a controlled environment, improve team communication efficiency, and strengthen clinical decision-making ability, thereby enhancing their confidence and practical ability in dealing with emergency situations.48,49 It helps to improve patient outcomes and reduce maternal mortality. Personalized and precision medicine Future OICU will place greater emphasis on the application of individualized treatment and precision medical strategies. With ongoing advances in biotechnology, including genomics and proteomics, more precise treatment plans can be provided based on the patient’s genetic characteristics, disease type, and changes in condition. This personalized medical model will help improve treatment effectiveness and reduce the occurrence of complications.50 Regional coordinated development Considering the uneven distribution of medical resources across different regions of China, it is imperative to accelerate the development of OICU infrastructure and the upgrading of technical capabilities in the central and western regions in the future, so as to gradually achieve the homogenization of medical services nationwide. By building an efficient regional coordinated treatment network, the service capabilities of primary healthcare institutions can be effectively improved, ensuring that pregnant and postpartum women in more regions can receive timely, high-quality, and effective critical care services. Conclusion Reflecting on the development of OICU in China, substantial progress has been made in improving maternal critical care. However, challenges remain, including shifting fertility patterns and patterns of imbalances in healthcare delivery. Looking forward, continued investment in technological innovation, enhanced clinical training, and robust regional coordination strategies offers a promising pathway toward overcoming these barriers and further reducing maternal mortality. Funding This work was supported by the National Key R&D Program of China (No. 2022YFC2704500). Conflicts of Interest None. Editor Note Dunjin Chen is one of the deputy editors-in-chief of Maternal-Fetal Medicine. The article was subject to the journal’s standard procedures, with peer review handled independently of this editor and the associated research groups. Data Availability Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.