China Is Haunted by Its One-Child Policy as It Tries to Encourage Couples
to Conceive
By Liyan Qi, 1/3/22, Wall St. Journal

When China put in place its one-child policy 4 decades ago,
policy makers said they'd simply switch gears if births dropped
too much. That has turned out to be not so easy.

“In 30 years, the current problem of esp. dreadful population
growth may be alleviated and then [we can] adopt different
population policies,” the Communist Party said in a 1980 open
letter to members and young people.

With the number of births declining year after year, China is
now racing in the opposite direction, closing abortion clinics
and expanding services to help couples conceive. 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 appears to be a bigger problem in China
than in many other countries. Acc. to a survey by Peking U.
researchers, it affects about 18% of couples of reproductive
age, compared with a global avg of around 15%.

For years, the govt called on women to postpone marriage to
encourage smaller families. Researchers say the higher age at
which Chinese women are trying to have children might partly
account for its comparatively high infertility rate. And some
researchers say a widespread use of abortions over the years to
heed birth restrictions may also play a role.

Multiple abortions impact women’s bodies and infertility is a
possible consequence, said Ayo Wahlberg, an anthropologist at
U. of Copenhagen who has written a book about fertility research
in China.

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

Shandong province is known in China for sometimes extreme
enforcement of birth restrictions, including a 1991 campaign
in parts of the city of Liaocheng dubbed “100 Days, No Child.”
A 2012 documentary by Hong Kong-based Phoenix TV details how
local officials, to make their birth data look better, forced
women found to be pregnant to abortion centers, even if the baby
was their first and allowed under the one-child policy.

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

Beijing years later banned birth-control enforcement deemed as
too cruel, including imprisonment or beating of couples violating
the one-child policy and destruction of their property. The
National Health Commission didn’t reply to a request for comment.
An official with the Shandong Provincial Health Commission declined
to comment beyond saying that Shandong is revising its family-
planning law to encourage births.

Today, Shandong pays compensation or subsidies to millions of
couples who lived by the rules, including retirees who now don’t
have support because their only child died or became disabled or
women who suffered injuries in connection with abortions or other
birth-control methods. In 2019, such outlays totaled over 5 billion
yuan, equivalent to $780 million, acc. to the provincial health
commission. That corresponds to over 1/5 of that year’s biggest
budget item, education spending.

The use of abortions hasn’t fallen off a cliff. In 1991, the year
of the 100-day campaign in Shandong, around 14 million abortions
were performed in China, acc. to National Health Commission data.
The number was just below 9 million in 2020. More striking is that
the number of family-planning centers, primarily used for abortions,
sterilizations and insertions of IUD's, has dwindled to 2,810
across China in 2020, less than 10% of the number in 2014.

Meanwhile, rounds of in vitro fertilization, or IVF—each round
being a multistep process over 4-6 weeks—have more than doubled,
from about 485,000 in 2013 to over one million in 2018. In the
U.S., a little over 300,000 rounds were performed at 456 reporting
clinics in 2018, acc. to the CDC.

“What's so mind-boggling for me is that after all of these years
of [birth] restrictions maybe fertility clinics will become more
important than abortion clinics,” Prof. Wahlberg said.

Acc. 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 Beijing
gynecologist, delivered China’s first baby conceived thru IVF.
Another followed 3 months later in Changsha, under the guidance
of Lu Guangxiu, a geneticist.

Both doctors had to conduct their research mostly in secret;
with the one-child policy defining the demographic agenda,
infertility services didn’t become legal until the early 2000s.

Now, the methods Drs. Zhang and Lu pioneered are among measures
the govt is counting on to shift the demographic trajectory.

The number of Chinese newborns fell 18% in 2020 from the year
before, and data expected in January is likely to show another
steep drop in 2021. China’s fertility rate—the number of kids
a woman has over her lifetime—already dropped below replacement
levels in the early 90s and in 2020 came in at 1.3, below even
Japan’s 1.34. After dipping to a record low of 1.26 in 2005,
Japan’s fertility rate, among the world’s lowest, began to
recover with the help of support measures by the govt, though
in recent years, the rate has started falling again.

China currently has 536 infertility centers, acc. to the
health commission, but most are clustered in wealthy metro
areas like Beijing and Shanghai, and vary widely in their
quality. Major hospitals have added fertility services to family-
planning clinics, and China's also trying to get such services
to smaller cities.

The health commission has set a goal of at least one institution
offering IVF for every 2.3-3 million people by 2025. Nationwide,
China isn’t far from the goal but less economically developed
provinces say existing services can’t meet rising demand. There
are only 3 fertility institutions in the W province of Gansu, all
in Lanzhou, the provincial capital. Gansu aims to have 7 by 2025.

Dr. Lu, one of the early IVF pioneers, in 2002 set up one of the
world’s largest fertility hospitals in Changsha, the Reproductive
and Genetic Hospital of Citic-Xiangya, which has delivered over
180,000 babies since its inception, acc. to its website. The avg
cost of a treatment cycle at the hospital is about 40,000 yuan,
equivalent to some $6,000.

After a miscarriage in 2018, an assistant prof at a Beijing
university who gave only her last name, Wang, said she wasn’t
sure she'd be able to ever become a parent. But last year, she
gave birth to a baby boy after IVF treatment.

Her treatment cost a little over 50,000 yuan. “I'd have another
one if I were a few years younger and if the whole process wasn’t
so difficult,” said Wang, 36, who agonized over the possibility
of another miscarriage.

Infertility-treatment costs aren’t covered by public insurance
in China. In Japan, the govt has proposed expanding public
medical-insurance coverage for some infertility treatments.

But advancing infertility services only goes so far, said Prof.
Wahlberg, the Copenhagen anthropologist. “Low births is a social
issue, not simply a biological one,” he said.

Chinese people’s views about family and birth have been reshaped
over the past few decades, and the govt’s latest efforts can’t
easily reverse that, said Yi Fuxian, a U.S.-based researcher who
has long criticized the Chinese govt’s population policies. Yi
expects 2021 data may even show China’s population has started
to shrink, years ahead of govt forecasts.

To encourage births, some local govts have promised cash rewards
and longer maternity leaves. But some researchers question whether
that's enough.

James Liang, a well-known businessman and a research prof of
economics at Peking U. who's long been an advocate for the
lifting of China’s birth restrictions, says it'll be hard for
China to stop the decline in its birthrates without huge
financial subsidies to help families afford more kiddies.

“It all comes down to money,” Liang said. “You can't change
people’s mind or force upon them some kind of value system.”

He estimates that to raise the fertility rate to the replacement
level, the govt needs to subsidize families by an average of one
million yuan, or around $160,000 per child in the form of cash,
tax rebates and housing and daycare subsidies.

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

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

Beijing’s about-face—in 6 years going from harshly restricting
how many kids couples could have to now encouraging them to
have more—makes little mention of the lingering effects of the
one-child policy on demographics, nor its human cost.