China is haunted by its one-child policy as it tries to encourage couples to get pregnant

When China introduced its one-child policy four decades ago, policy makers said they would simply shift gears if births fell too much. It has proven not to be that easy.

“In 30 years’ time, the current problem of particularly dire population growth may have been remedied and beyond [we can] adopt different population policies, ”the Communist Party said in an open letter from 1980 to members and young people.

With the number of births falling year after year, China is now heading in the opposite direction, closing abortion clinics and expanding services to help couples get pregnant. But a legacy of the one-child policy scrapped in 2016 is a dwindling number of women of childbearing age as well as a generation of only children who are less eager to marry and start a family.

In addition, infertility seems to be a bigger problem in China than in many other countries. According to a study by researchers at Peking University, it affects about 18% of couples of reproductive age compared to a global average of about 15%.

For years, the government encouraged women to postpone marriage to encourage smaller families. Researchers say that the higher age at which Chinese women try to have children may partly explain its relatively high infertility rate. And some researchers say that widespread use of abortions over the years to follow birth restrictions may also play a role.

Demographers say it will be difficult for China to stop the decline in births without financial subsidies to help families afford children.


Photo:

wu hong / Shutterstock

More abortions affect women’s bodies, and infertility is a possible consequence, said Ayo Wahlberg, an anthropologist at the University of Copenhagen, who has written a book on fertility research in China.

Decades of policies to keep births low have left not only deep wounds but also financial obligations for many local governments, which cut into what they can spend on encouraging births.

Shandong Province is known in China for sometimes extreme enforcement of birth restrictions, including a 1991 campaign in parts of Liaocheng City called “One Hundred Days, No Child.” A 2012 documentary by Hong Kong-based Phoenix Television describes how local officials, in order to make their birth data look better, forced women who were found to be pregnant into abortion centers, even though the child was their first and allowed under to the one-child policy.

“Almost everyone old enough here has heard something about what they did,” said a 45-year-old university teacher in Liaocheng, though he added, “It’s something you can never find anywhere in the written story.”

Beijing years later banned the enforcement of birth control that was considered too cruel, including the imprisonment or beating of birth criminals and the destruction of their property. The National Health Commission did not respond to a request for comment. A Shandong Provincial Health Commission official declined to comment, adding that Shandong is revising its Family Planning Act to encourage births.

Today, Shandong pays compensation or subsidies to millions of couples who lived by the rules, including pensioners who now have no support because their only child died or became disabled, or women who suffered injuries from abortions or other methods of contraception. In 2019, such outlays amounted to more than five billion yuan, equivalent to $ 780 million, according to the provincial health commission. That equates to more than one-fifth of the year’s largest budget item, education spending.

The use of abortions has not fallen off a cliff. In 1991, the year of the 100-day campaign in Shandong, about 14 million abortions were performed in China, according to data from the National Health Commission. The number was just under nine million in 2020. More striking is that the number of family planning centers used primarily for abortions, sterilizations and insertions of intrauterine equipment has dropped to 2,810 across China by 2020, less than 10% of the number in 2014.

Meanwhile, rounds of in vitro fertilization or IVF – each round is a multi-step process over four to six weeks – have more than doubled, from around 485,000 in 2013 to more than one million in 2018. In the US, just over 300,000 rounds were performed on 456 reporting clinics in 2018 according to the Centers for Disease Control and Prevention.

“What’s so amazing to me is that after all these years [birth] restrictions, fertility clinics may become more important than abortion clinics, ”said Prof. Wahlberg.

According to his research, assisted reproduction has a surprisingly long history in China. In March 1988, a decade after the world’s first test tube baby was born in Britain, Zhang Lizhu, a gynecologist in Beijing, gave birth to China’s first baby, conceived through IVF. Another followed three months later in Changsha under the guidance of Lu Guangxiu, a geneticist.

Both physicians mostly had to conduct their research in secret; with the one-child policy defining the demographic agenda, infertility services only became legal in the early 2000s.

A woman in Wuhan, Hubei Province, is receiving treatment for in vitro fertilization, which has grown in popularity in recent years.


Photo:

aly sang / Reuters

Now the methods Dr. Zhang and Lu were pioneers among the measures the government expects to change the demographic trajectory.

The number of Chinese newborns fell 18% in 2020 compared to the previous year, and data expected in January are likely to show another steep decline in 2021. China’s fertility rate – the number of children a woman has during her lifetime – is already dropped to below the compensation level in the early 1990s and by 2020 came in at 1.3, below even Japan’s 1.34. After falling to a record low of 1.26 in 2005, Japan’s fertility rate, which is among the lowest in the world, began to recover through government support measures, although in recent years the rate has begun to decline again.

China currently has 536 infertility centers, according to the Health Commission, but most are concentrated in affluent metropolitan areas such as Beijing and Shanghai and vary widely in their quality. Large hospitals have added fertility services to family planning clinics, and China is also trying to get such services for smaller cities.

The Health Commission has set a target of at least one institution offering IVF for every 2.3 million to three million people by 2025. Nationwide, China is not far from the target, but less economically developed provinces say existing services cannot meet the rising demand. There are only three fertility institutions in the western province of Gansu, all in Lanzhou, the provincial capital. Gansu aims to have seven by 2025.

Dr. Lu, one of the early IVF pioneers, established in 2002 one of the world’s largest fertility hospitals in Changsha, the Reproductive and Genetic Hospital of Citic-Xiangya, which has given birth to more than 180,000 babies since its inception, according to its website. The average cost of a hospital treatment cycle is about 40,000 yuan, equivalent to about $ 6,000.

To encourage births, some local governments in China have promised cash rewards and longer maternity leave.


Photo:

Tang Ke / Sipa Asia / Zuma Press

After an abortion in 2018, a lecturer at a university in Beijing who only gave her last name, Wang, said she was not sure she would ever be able to become a parent. But last year, she gave birth to a baby boy after IVF treatment.

Her treatment cost just over 50,000 yuan. “I would have one more if I were a few years younger and if the whole process was not so difficult,” said Ms Wang, 36, who was tormented by the possibility of another abortion.

Costs of infertility treatment are not covered by public insurance in China. In Japan, the government has proposed expanding the public health insurance coverage for some infertility treatments.

But the promotion of infertility services only goes so far, said Prof. Wahlberg, the Copenhagen anthropologist. “Low birth is a social problem, not just a biological one,” he said.

China’s views on family and birth have been reshaped over the past few decades, and the government’s recent efforts cannot simply reverse that, said Yi Fuxian, a U.S.-based researcher who has long criticized the Chinese government’s population policy. Mr. Yi expects 2021 data to even show that China’s population has begun to shrink, years ahead of government forecasts.

To encourage births, some local governments have promised cash rewards and longer maternity leave. But some researchers question whether that is enough.

James Liang, a well-known businessman and research professor of economics at Peking University who has long advocated for the lifting of China’s birth restrictions, says it will be difficult for China to stop the decline in its birth rates without huge financial subsidies to help families with to afford more children.

“It all comes down to money,” Mr Liang said. “You can not change people’s opinion or impose on them some kind of value system.”

He estimates that in order to raise the fertility rate to the level of compensation, the government needs to subsidize families with an average of one million yuan, or about $ 160,000 per year. child in the form of cash, tax rebates and housing and day care allowances.

Wang Pei’an, a former family planning official who in 2017 said China would hardly face a population shortage, “not in 100 years”, is now urging young people to be more responsible and have children.

“We should pay attention to the social value of births,” Wang, now a political adviser, told state media.

Beijing’s focal point – about six years to go from a strict limit on how many children couples can have to now encouraging them to have more – mentions only a little of the lingering effect of one-child policy on demographics, nor its human cost.

“I really have a lot of thoughts and sympathy for women who have grown up with the system that is now listening to the state that tells young women about having children,” Prof. Wahlberg said. “My heart breaks when I think of that situation.”

Jilin, one of the northeastern provinces with the country’s lowest fertility rate, said last month that local banks would offer a state-subsidized credit line of 200,000 yuan at lower interest rates for each married couple with children.

The provincial government also said it would not reimburse any fines paid for “historic” birth defects, adding that officials have to explain residents being punished for having too many children that the situation has changed and now it must “stimulate birth potential.”

Write to Liyan Qi at liyan.qi@wsj.com

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