Coronavirus disease 2019 (COVID-19) has caused substantial damage to China since its outbreak and spread in the first half of 2020. As of August 24, 2020, the cumulative number of confirmed cases of COVID-19 reported in China was 84,967, among which 68,139 (80.2%) were from Hubei Province (1). Although there have been numerous studies performed pertaining to this pandemic, only a few studies have quantitatively assessed the impact of this pandemic on medical providers in China (2–4). In a survey of junior doctors in the United Kingdom, most units limited face-to-face antenatal clinics and suspended elective gynecology services (5). Other reports showed the impact of COVID-19 lockdowns on the treatment of gynecologic cancer patients (6, 7), admissions to gynecological emergency care (8, 9), emergency surgery (10), and maternal and newborn healthcare (11). However, these studies had limited sample sizes and voluntary response sampling methods, restricting the generalizability of their findings. As well as in other fields, the lack of sufficient health and legal protection for surgeons and patients may result in a special reduction in the volume of surgical interventions during COVID pandemic and the immediately following period, therefore, determining inability to ensure health care to all patients (12–14).

As reported by the WHO, people living with non-communicable diseases (NCDs) are more vulnerable to becoming severely ill with or dying from COVID-19. The more severe the transmission phase of the COVID-19 pandemic, the more NCD services are disrupted (15). Although most physicians in obstetrics and gynecology were not involved in the immediate response to the pandemic, they represent a major force at the crossroads of politics, social justice, and reproductive rights in the fight for the preservation of reproductive healthcare (16). A representative quantitative assessment of the changes in clinical activities of obstetrics and gynecology during the pandemic would not only provide vital and accurate information for developing coping strategies during this time (17, 18), but also offer suggestions for health care reform, leading to the development of more flexible, and effective health care systems (19).

As previous studies were confined to local regions or used convenience sampling methods hence providing limited information, we performed a national survey in China among registered physicians who practice obstetrics and gynecology in public hospitals. To our knowledge, this is the first nationally representative survey of physicians describing the impact of the COVID-19 pandemic on clinical activities. We particularly examined whether such an impact varied between different municipal and hospital characteristics. In this way we were to explore the practical effects of COVID pandemic on clinical practicing in the view of obstetricians and gynecologists.

This was the first nationally representative survey of physicians describing the impact of the COVID-19 pandemic on clinical activities in China. In this national survey including Chinese obstetricians and gynecologists, all clinical activities except online consultations substantially decreased. Our findings provided a specific description and sceneria of the national reflection toward COVID pandemic in a medical speciality caring the health of the women and children. The data from our survey could offer a substantial basis for the discussion and reformation of health system coping with the global outbreak and persistence of severe pandemic. In our survey, cities with more hospital beds, hospitals with better resources, and general hospitals were more severely affected with regard to most clinical activities. There are several explanations for these differences. Larger, densely populated cities have a greater risk of infection; therefore, the general clinical activities were more severely impacted in these cities due to lockdown. Larger hospitals and general hospitals undertook the more pressing tasks of testing and caring for patients who had contracted COVID-19 than smaller hospitals and specialized hospitals for women health. In such conditions, medical staff and resources were significantly shifted to other priorities as an emergency measure spontaneously or according to the administrative regulations.

However, the need to shift resources and personnel to cope with an emerging crisis does not mean that the shift remains indefinitely sustainable (21). It is important to evaluate whether and how much this shift has exacerbated existing health inequities and to be proactive in creating policies that promote equity (22). A reform to create a more balanced, healthy medical service system may be warranted, and steps need to be taken after the pandemic to minimize the delay in routine care for women. In our study, cervical cancer screening and instructions regarding contraception and miscarriage had more significant reductions in cities with more hospital beds and in higher-level hospitals. These changes should be noted. With regard to cervical cancer screening, health professionals should focus on high-risk women and adhere to cost-effective policies, including self-sampling in the immediate postepidemic phase (23). The reduction in attention paid to contraception and miscarriage in large cities or high-level hospitals may reflect a substantial bias with regard to such topics (24), since the shutdown of or delays in contraception and safe abortion during COVID-19 will disproportionately impact the most vulnerable populations in low-income and middle-income regions and countries and lead to considerable increases in preventable mortality and lifelong disability (25).

Our survey provided insight into the management of specific diseases and conditions, including emergencies and less urgent medical issues. According to the survey, the changes in emergency visits, including changes in emergency gynecological or obstetrical surgeries, differed significantly between general and specialized hospitals. Although numerous reports on COVID-19 exist, only a few discussed the impact of COVID-19 pandemic on clinical activities. We used keywords of “clinical activity,” “COVID-19,” and “impact” had a search in clinical trials and reviews published in English in PubMed (https://pubmed.ncbi.nlm.nih.gov/), only 260 papers were available up to July, 2021. The COVID-19 lockdown substantially reduced admission to gynecological emergency departments, but triage allowed the separation of real emergencies from more deferrable emergencies (8), such as emergency surgeries (26). On the other hand, only less urgent or critical medical issues, including assisted reproduction, differed significantly according to the levels and characteristics of the cities and hospitals. While these services were temporarily disrupted, new strategies are needed to overcome these changes. It is essential for authorities and health care providers to identify patients who should be prioritized for the continuation of fertility care in a safe environment (27). Many guidelines or protocols are available to support prioritization in the field of obstetrics and gynecology (28, 29), and they should be considered on the basis of local resources and planning (30). In our study, we did not find significant differences in the treatment of gynecological malignancies according to city categories, hospital levels or hospital natures, which reflected the attention paid to these critical diseases across the country.

Our survey highlighted feasible innovative treatment strategies during the pandemic. According to the WHO report (15), telemedicine is currently one of the mitigation strategies most often used (27). As previously reported (31), and as expected during the design of the questionnaire, online consultations increased by 51.6% in our survey. The pandemic afforded ambulatory clinicians with the opportunity to expand care to vulnerable populations in ways that were previously underutilized, thus improving health equity (32) by adopting the necessary regulatory framework for the wide application of telemedicine (33). However, telemedicine has its own limitations with regard to examinations and procedures necessary for the diagnosis and treatment of gynecological and obstetrical diseases (34, 35). The quality and trustworthiness of social media are also questionable (36). Legal issues pertaining to telemedicine have yet to be resolved in China (37). Last, in our study, little evidences suggested telemedicine would provide a sufficient and satisfactory solution for the lack of direct clinical interviews during pandemic lockdown. A more exhaustive survey would prudently translate the changes of tendency in medical service into specific, quantified clinical activities, such as outpatient's visits, medication, and examination. However, in our study, in order to quantize the impact, we must include a lot more respondents as to decrease the greater bias caused by epidemiological and personal characteristics. In conclusion, as no study could forward direct evidences discovering and resolving the gaps between telemedicine and face-to-face interviews, we must keep discreet optimism toward the prosperity of telemedicine.

Our survey revealed critical differences in the changes in medical services among various regions of different situations with respect to the pandemic. The comparison between Hubei Province and other provinces in China suggested that general clinical activities did not significantly decrease in Hubei; however, the management of all specific gynecological or obstetrical conditions declined significantly. These differences suggested the shift of medical sources to cope with COVID-19, including new assignments for obstetricians and gynecologists, since 80.2% of confirmed cases in China occurred in Hubei Province.

The large nationally representative sample and a comprehensive assessment of the impact on clinical activities were the strengths of our study. Specifically, our results revealed that COVID-19 pandemic had significantly different impact on the clinical activities across various municipal and hospital characteristics. However, there are several limitations in our study. We did not include private health services in the survey since they account for a very limited proportion of the total volume of the healthcare market in China. This study did not explore the impact of the pandemic on the lives, professional careers, and mental health of obstetricians and gynecologists, although many reports have discussed the stress experienced by these clinicians (4, 38), which may be associated with changes of medical service during the pandemic (39). Physicians' reported qualitative assessment about changes in clinical activities lacks of uniform evaluation, which should be supported by more data from national statistical data. However, although personal feeling had its limitation of clear description, it indeed reflected an invaluable experience in caring their patients.

One of the most important limitations is that we did not consider the national and/or local policies and interventions in this study. The national policies would have played a great role of resumption of medical service and social economics. Just like the situations in other society activities, a temporal trend in the decrease or increase would be most strongly affected by the restrictions, measures of dealing with the pandemics by federal and local governments and organizations (40, 41). A successful control of COVID-19 pandemics depends on the unselfish devotion of the healthcare staffs, comprehensive society movement against pandemics, and national decisions and policies. Although widespread gaps in the quality of primary health care still exist in China (42), a series effective, rapid measure have been implemented to tackle the disease (43). The most serious outbreaks occurred in February and March, 2020, and accordingly, the most rigorous restrictions from personal, organizational and national requirements were performed (44–47). These restrictions, undoubtedly, would cause great changes in clinical activities. It is regret that we couldn't quantitatively take these changes in this analysis. However, since all the provinces and hospitals in China were under a series of relative consistent policies, changes among these administrations and different diseases have their significances in coping with COVID-19 pandemics. Authors' clinical experiences during the COVID-19 pandemics accorded with the trends discovered in this study. In the principle investigational hospital, one of the teaching tertiary hospitals, in February and March of 2020, only less half outpatient and inpatient workload was required for gynecologic services.

In this national, stratified, two-stage, random cluster sampling survey, clinical activities in obstetrics and gynecology were majorly reduced during the COVID-19 pandemic in China. Cities and hospitals with more resources or general hospitals were more severely affected, resulting in delays or other disparities in the medical care of vulnerable populations, such as women needing cancer screening or assisted reproduction. However, the magnitudes of the decline varied among other specific diseases or conditions.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Institutional Review Board of Peking Union Medical College Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

LZ, HZ, and JLv conceived of the original idea for the study, interpreted results, carried out the statistical analysis, edited the paper, and were overall guarantor. LL obtained ethical approval, contributed to the preparation of the data set, interpreted results, and contributed to drafts of the paper. YC, JF, TL, and JLa contributed to the study design, data collection, interpretation of results, and commented on drafts of the paper. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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