Dr. Constance Keefer was first invited to China by the Chinese Medical Association (CMA)'s pediatric division in 1988 as one of a group of ten developmental pediatricians from the United States. During that trip eleven years ago, she visited pediatric teaching hospitals in five cities: Beijing, Shanghai, Xian, Chengdu, and Guiyang where she lectured on child development and on the NBAS. Dr. Zhang Peiying, who was director of Taiyuan Children's Hospital at the time, accompanied the US pediatric group to several cities. Dr. Keefer and Dr. Zhang have remained in close contact ever since, exchanging ideas and discussing new developments in pediatrics. Earlier this year, Dr. Keefer was invited to return to China by Dr. Zhang, who is now retired as Director of Taiyuan Children's Hospital, although he is still very active in teaching and bringing forward new developments in pediatrics. In this interview Dr. Keefer discusses the changes she observed in pediatric practice in China and the clinical implications of her observations.

Q. What are the major changes you observed in pediatric care since your visit to China in 1988?

A. Well, the first thing I noticed was that many new hospitals are being built Ð there was a new children's hospital in Taiyuan Ð and many of the hospitals in Shanghai were being expanded. This meant that there was a lot more space for the care of mothers and infants and the wards were not as crammed as before. In 1988, they used very little electricity and all the hallways and offices were minimally lit in order to save power. Now there is much more lighting and they are also using more western techniques, such as medications. Despite these changes, my colleagues there, in the hospitals in Shanghai and Taiyuen, maintain that teaching hospitals are struggling, not unlike academic hospitals here in North America. They are being pushed to do more for less money and are being asked to cut back. While they weren't using many resources before, the squeeze is on now to cut back even more.

Q. In terms of newborn care, what was the most notable change you saw?

A. In '88 there wasn't any "rooming-in". It was like our old fashioned hospitals: the babies were down the hall, in a nursery separated from their mothers, and maybe every four hours, they were brought out to their mothers for feeding. Today in the maternity division in Taiyuan for example, the mothers were all rooming in, that is, the babies were in the mother's rooms. There were two to four mothers in each room, and the mothers had nurses in these rooms. Dr. Zhang said that it was our visit in '88 that helped to change that. We had discussed the value of rooming-in with Dr. Zhang at that time and they implemented it. They are very responsive to ideas that are inexpensive and they do put them into effect.

Q. What form of follow up-care do new mothers receive?

A. All mothers stay in the hospital for about three days, although it is not as long as it used to be. The postpartum nursing staff is very good in terms of the number of nurses who attend to all the mothers and babies. Their skills, their knowledge are all very good. The Chinese do have a good system for primary health care so that the mothers will have easy access to a clinic for themselves and their babies. Prenatal care is more complete that the kind of prenatal care we provide here in the United States, where the focus of classes is on childbirth as if that is the end and not the beginning. In China, all mothers are required to take prenatal classes, where there is a great deal of attention on preparation for becoming a parent. Mothers also receive a visit from a visiting nurse. Because mothers have such easy access to clinics, immunization rates are better than those in the United States

Q. How do they achieve this high level of prenatal care?

A. Chinese society is organized hierarchically as it has been for several thousands of years. In each community unit, of 20 to 200 people, someone has the responsibility to make sure mothers get their prenatal care and attend classes, for example. It is usually a woman in her fifties, who is in charge of these things. She also ensures that before a child enters childcare, both parents must attend parenting classes. She will also monitor the menstrual cycles of women in her community, as a way of enforcing the "one child only" policy. Birth control options are plentiful and available through primary care. Parents are required to take these classes, so that it is a very good system of primary care. It has a "seamlessness" between home and hospital, hospital and clinic, clinic and childcare, etc. something that we are still struggling to achieve in this country.

Q. Was there any interest in the CLNBAS or the NBAS?

A. Among the pediatricians in primary care, neonatology and developmental pediatrics, interest in the NBAS is very high. In Beijing, Dr. Bao, at Peking Union Medical College, has used it for more than a decade in research on normal newborns, premature infants, and infants with hypoxia. NBAS trained pediatricians carry out similar works in Shanghai. Even more compelling was the interest in the use of the CLNBAS for all infants in nurseries and in the first months of life. Chinese pediatricians and child psychologists are studying child development with great interest on the effects of the "one-child policy" on the outcome for young children. For example, on my first day in Taiyuan in June, I lectured to 250 developmental pediatricians and child psychologists, who were there from all over China, at the Third Annual Conference on Brain Growth and Child Development. I examined five neonates in the hospital in Taiyuan with the CLNBAS, and noted great interest on the part of the mothers, nurses, students, and my faculty colleagues.

Q. What role do the fathers play in the lives of their children in China?

A. Fathers appear to be highly involved with their children. Both in1988 and this year, I observed just as many fathers as mothers attending to their child's needs. For example, I noticed many fathers bicycling to and from work with their child. In museums and parks I frequently watched a father with his toddler. Whether the child wanted to climb a set of stairs dozens of times, run to the edge of a bridge, or pass some urine, each time the father demonstrated skill and understanding in responding to the child.

Q. What role do Chinese grandparents play in children's lives?

A. They play a very important role because the child (especially their own son's child) represents a link between past ancestors and future generations. For grandparents, this means in effect, that they will be cared for as they grow old. The fervor of devotion, shown by affluent and comfortable men and women to their grandchildren, bespeaks a strong Chinese cultural value of "other-centeredness" with regard to forbears and future generations.

Q. What can we learn from China in our care for infants and families?

A. From China, specifically, we can learn the value of preventive and primary health care services for children and parents. They have a better system, in many ways, than ours---very high rates of immunization and prenatal care, and very low rates of prematurity.