Family planning in China

Li Wei-xiong

1. China: one of the largest populated countries in the world

As one of the largest populated countries in the world, China needs to consider the carrying capacity of its land and water resources. Some experts suggest that a population size of 1.6 billion is the carrying capacity of China. One responsibility of medical doctors should be to support the establishment of a national population target.
The Chinese traditionally prefer early marriage, early child-bearing, and large families. Each married women usually raises between five and six children. The Chinese say: "...more children means great happiness". Due to poor health care, natural disasters, and long periods of war, the population of China increased from 250 million to 500 million within approximately 200 years. Since health care has been improved, as well as the ability to supply enough food, the population exploded between 1950 and 1980. The population increased from 500 million to 1000 million in only 30 years [1] (Fig. 1, Table 1).
Limited resources cannot support the heavy population burden. China has about as much territory as the United States, but much less arable land (Figs. 2, 3). The per capita cultivated land of China is one-eighth that of the United States. Fresh water is another scarce resource in China. With 2800 billion cubic meters of fresh water, China ranks sixth in the world; however, it ranks eighty-eighth in fresh water per capita. Even worse, the distribution of fresh water is poorly matched to the distribution of land. Considering all resources, experts suggest that a population size of 1.6 billion is the carrying capacity of China. Many economists believe that 700 million to 1 billion is the optimum population size for accelerating economical development in China. This is the reason China has held a tight family planning program over the past 25 years.

Table 1. Birth rate in China

Fig.1. Population growth in China

Fig.2. Ratio of China's land and population in the world

Fig.3. Arable land and per capita cultivated land in China

2. Current family planning policy in China

China's current family planning policy was made to meet the needs of a special period. Because of the huge population base and large annual increase, central government needs to establish a national target and policy. China is a big country, the economic level of development and cultural background vary considerably in different areas. Because of the family planning regulations made by local governments, there is great diversity in China and increased flexibility for minorities.
At present, the Chinese Family Planning Policy guidelines are as follows:

1. Controlling the rapid population growth and reducing birth defects.
2. Late marriages, later births, and fewer babies; couples are encouraged to have only one child. In rural areas, the birth of a second child should be spaced 4-5 years from the first [7].

lt took time for the Chinese government to recognize the population problem. In the 1950s, some leaders of the Chinese government preferred a large population. The government paid no attention to the population. In the 1960s, although the contraceptive pill had been introduced in China, national family planning programs were not implemented. Rapid population increase and fertility remained at very high levels in the late 1960s, leading the Chinese government to reduce the population growth rate, a key element of the National Economic Development Plan in 1973. In the 1970s, the principle of the family program was late marriage, fewer births, and spacing of births. Fewer births were advocated - one is good, two are acceptable and three are too many. In China, it is estimated that approximately 300 million births were averted between 1970 and 1994 due to the implementation of the family planning program. In spite of the program, the large population base and annual net increase still placed tremendous pressure on China's economic development, resources and environment. Therefore, while adhering to the policy of reform and opening up to the outside world so as to sustain a rapid and healthy development of the national economy, China must adopt a strategy of sustainable development, further promote its family planning program, and provide quality reproductive health service to eligible couples.
In the early 1980s, central government advocated one child per family in urban areas. For rural area couples, one child is impractical, which causes difficulties; therefore, couples are encouraged to have a second child after a gap of around 4 years. At present in large cities, the fertility rates are lower than other levels, for example in Shanghai the natural growth rate in 1994 was -1.20, but in minority areas the growth rates were still higher than 15%. The national average for each family is to now have two children, except for in minority areas where women may still raise between four and five children.

3. Family planning and the value system of a nation

The fundamental basis for the Chinese family planning policy decision is the value system of a nation. People have the right to make their own decisions, but they also need to take their social responsibility.
Confucian teaching has been the center of the value system of oriental countries. Confucians point out that people should set the stabilization and prosperity of their country over individual interests, and the ruler of the country should treat his people kindly. Oriental society tends to encourage people not only to work for themselves, but also to take responsibility for society by controlling their behavior. These are the grass roots of the integrated population and development policy of China. In remote areas, people still have a stronger reproductive ambition. There is still a gap between people's reproductive desire and government policy in some areas [2]. A hard decision has to be made. On the one hand we need to prevent human reproduction, while on the other we need to keep a stable, yet progressive society. In fact, in the economically developed areas, fertility is decreasing significantly [6]. Hopefully, within the next 20-30 years, as the economy develops, there may be a more flexible family program throughout the country.

4. Support for safe, efficient, low-cost contraception

There is great support for providing various safe, efficient, and low cost contraceptive methods to the national family planning program by most Chinese scientists and doctors.
Only a few scientists or doctors may be involved in policy-making for the family planning field, but most doctors contribute to the family planning program by providing safe and efficient services. China is able to produce and provide most of the contraceptive medicine or devices sold on the international market (Table 2) [5]. More than 98% of contraceptive medicine or devices are provided without charge. In recent years, more attention has been paid to improving the quality of service for couples. A national service network has been set up on six levels: state, province, city, county, township, and village. Nearly 40 000 full- or parttime family workers are employed in providing the service nationwide. The successful experiences of our family planning program are the so-called three firsts: education, regular service, and contraceptive use.
The most common contraceptive methods used in China are intrauterine devices (IUD), tube legation, and vasectomy (Tables 3, 4) [1a]. About 40% of women choose the IUD as the contraceptive method of choice after having raised their first child. A total of 40% of women use tube ligation as a fertility control method after having raised their second child. Only 11 % of Chinese men used vasectomy as a fertility control method. The IUD is an efficient, safe, low-cost, and reverse contraceptive method. A lot of women and family workers like using the IUD for contraception. Originally, we used the Stainless Steel Ring. After evaluating different types of IUDs on a large scale, we decided to use the Tcu or Vcu instead of the Stainless Steel Ring (Table 5) [4]. Some women insert the IUD 48 days after delivery. Most family workers routinely check to see if the IUD has escaped from the uterus with an ultrasound examination every 3 months. During these regular checks, the family workers may provide some kind of reproductive health service (for example, treatment of vaginal infection) in addition to providing family planning consultation.

Table 2. Contraceptive methods available in China

• Intrauterine devices (IUD)
  Tcu 220, 280, 380
  Vcu
  Multiloid
• Oral contraceptive tablets
  Short-acting oral contraceptive
  Tablet: No. 1, 2, 0, Norethisterone
  Compound drip pill, Laevonorgtrel
  Compound drip pill
  Rapid-acting oral contraceptive
  Tablets: Megestrol tablet, Norgeestrel
  Tablet, Anorethidrane Dipropionate
  Tablet, vacation anticonceptive pill
• Contraceptive injections
  Hydroxyprogesterone caproate composition
  Megestrol and estradiol
  Norethisterone enanthate compound
• Implant
  Six rods
  Two rods
• Condoms
• Spermicides
  "Le An Mi" vaginal contraceptive tablet
  Nonoxynol-9 medicinal pellicle
  Nonoxynol-9 suppository
  Contraceptive unguent

Table 3. Contraceptive methods used by Chinese women (1994)

• Intrauterine device (IUD) 40.66
• Tube ligation 40.25
• Pill and injection 3.22
• Implant 0.19

Table 4. Contraceptive methods used by Chinese men (1994)

• Vasectomy 10.97
• Condom 3.22
• Spermicides 0.56

Although the government encourages couples to only have one child, the average family in China in 1996, had two children. lf women decide not to have a second child. the IUD can be used for 8-10 years. lf women decide to have a second child, the IUD can be taken out; pregnancy may occur very soon thereafter. We also take out most IUDs when women reach menopausal age.
The tube ligation technique has been improved. Experienced family workers may perform a tubal ligation in only 8-10 min, and women need only stay in hospital for a few hours. Ort average, side effects occur in one per thousand. Usually, we only perform tube ligation when the woman has had her second or third child and the first child is 5-6 years old. In the event that a couple should lose a child, tube reconstruction can be done by using a micro-surgery technique. In some county family service stations, the doctors are able to perform this kind of operation.

Table 5. Comparative study of three types of IUD

5. Abortion is legal in China

In China abortion is not used as a contraceptive method. lt is used when contraceptive methods have failed or for unwanted pregnancies. Regulations have been set up for providing safe abortions. To reduce the number of abortions, we recently began focusing more on emergency contraceptive research.
With regard to abortions legal status in China, the Ministry of Public Health issued a document, "The Regulation on Use of Contraceptive and Induced Abortion". An abortion can only be performed in a hospital or family service station. Providing abortion Services is illegal for private doctors. In the 1950s, Chinese doctors developed a safe abortion method; however, during that period women needed to show a marriage certificate when they wanted to have an abortion. It caused some women to see private doctors, resulting in unsafe abortions. At present, women have the right to decide to terminate a pregnancy. We are also providing this type of Service to unmarried women or young people, in the event of unwanted pregnancy.
In the 1990s, Mifepristone was produced in China for ending early pregnancy or as an emergency contraceptive. For safety reasons, the government decided that only registered hospitals or family planning stations should be allowed to provide this type of Service. Usually, the hospital needs to have a blood transfusion facility or to be located near a larger hospital which is easily accessible for transfer. Private doctors are not authorized to provide this type of Service. Teenage pregnancies are now becoming a problem in our country. To reduce the number of teenage abortions, we are paying attention to the development of emergency contraceptive methods instead of educating young people.

6. China has a long history of discrimination against females

Preferential treatment towards the male son is part of the Confucian value System. Since 1949, much effort has been made to alter the traditionally low status of women, but discrimination against female children will continue to be a problem in China.

Fig.4. Juvenile sex ratio in the censues of China and South Korea

Women still bear much heavier burdens in family planning. National contraceptive prevalence rates (CPRs) among current married women was 83.5% in 1992. It is clearly stated in China's Constitution that: "Chinese women enjoy equal rights with men in respects of politics, economies, social and family life". We should realize that there is still a large gap between reality and the documents. The CPR in men is not more than 20%. Vasectomy ranks first in male contraceptive methods. There are about 22.62 million men using vasectomy as the contraceptive method of choice, accounting for half the worlds vasectomy users. Vasectomy is a simple, inexpensive, safe and efficient method. Chinese family planning workers have worked very hard to increase success rates and decrease the number of incidents involving operative complications. The prevalence rate of vasectomy is 9.5, much lower than that of the female sterilization prevalence rate. The situation is not improving very much. Men's participation in family planning activities is affected by varying complex factors, including social, economic, political, and cultural factors. Although we want to change the situation, eliminating the traditional socioeconomic and cultural obstructions to male participation is impossible in a short period of time in China.
The juvenile sex ratio has been rising steadily since the 1960s in China. China has a long history of discrimination against females. "Son" preference is sometimes attributed to the Confucian values system, although determining the sex of a fetus and sex-selected abortions are illegal in China. Juvenile sex ratios rose most rapidly during the 1980s in rural areas, propelled by fertility decline (Fig. 4). Discrimination against girls is not unique to China-, it is also found elsewhere in East and South Asia. In China and India, the practice of female infanticide was noted at least a century ago [3]. The more normal sex ratio of children born in the city suggests that area development may gradually alter son preference in the future.

7. Population growth as a global issue

Not only does china need to control rapid population growth, the population issue is a global issue. Each country needs to decide its population policy according to its resources, economics, and culture. Each policy may have advantages and disadvantages. The exchange of ideas is important for the entire scientific community, and it would benefit all mankind.
It is true that China's fertility rate has been reduced to a relatively low level. China is a developing country with the largest population in the world. A large portion of its population is devoted to agriculture, while a considerable proportion is illiterate, semiliterate and impoverished. In the northwest or southwest, where economies and education are low, fertility rates continue to rise ever higher. This basic characteristic determines the long-term, arduous, and complicated nature of addressing China's population problem. Population studies in the next century will receive more attention and require further development. The advancement of population science requires international communication and collaboration. Chinese scientists would like to work with their foreign counterparts in various academic areas and subjects and to learn from other countries' advanced research findings and working experience in order to make our due contribution to China's modernization drive and to the peace, development, and progress of mankind.

References

Li Wei-xiong
National Research Institute for Family Planning
Beijing, China 100081
email: wxli@public.bta.net.cn