Therese Hesketh, Li Lu, and Zhu Wei Xing. The effect of China’s one-child family policy after 25 years. N Eng J Med 2005; 353: 1171-1176.

Hesketh et al report on China’s 1979 one-child family policy, its implementation and impact on population growth, sex ratio, and elderly to adult ratio.

Background

As China emerged from the social disruptions and economic stagnation of the Cultural Revolution, its government launched market reforms to revitalise the economy. In 1979, recognising that population control was essential to raise living standards, the one-child family policy was introduced.

This policy limits family size, encourages late marriage and childbearing, and the spacing of children when second children are permitted. Family planning committees at local levels develop local strategies. The one-child rule applies only to urban residents and government employees. In rural areas, a second child is allowed after five years, if the first is a girl. A third child is sanctioned in some ethnic minorities and in remote, under-populated areas. Economic incentives for compliance, substantial fines, confiscation of property and loss of job, etc. are used to enforce the policy.

The policy is based on universal access to contraception and abortion. Eighty-seven per cent of all married women use contraception. (Ninety per cent of them use intrauterine devices or sterilisations.) Most women accept the method recommended by the family planning worker. Reliance on long-term contraception keeps the abortion rate low (25 per cent of Chinese women of reproductive age have had at least one abortion, as compared with 43 per cent in the United States). Abortions are sanctioned when contraceptives fail or when the pregnancy is not approved. Unattended and unsanctioned deliveries do occur. Maternal mortality doubles in such instances.

Impact on population growth

The fertility rate (mean number of children/woman) decreased from 2.9 in 1979 to 1.7 in 2004 (1.3 in urban areas, <2.0 in rural areas). This has resulted in urban families with predominantly one child and rural families with predominantly two children.

However, the fertility rate had already decreased from 5.9 in 1970 to 2.1 in 1979 under the voluntary “late, long, few” policy of postponed childbearing, greater spacing between children, and fewer children. With the implementation of the one-child policy, there was a further fall to 1.7 by 1995.

The sex ratio

The sex ratio (male : female live births) is 1.03 to 1.07 in industrialised countries. In China, this ratio has increased from 1.06 in 1979, to 1.11 in 1988 and 1.17 in 2001, with even higher ratios in rural areas. In rural areas, the sex ratio is 1.05 for the first birth and rises steeply subsequently. In urban areas, the sex ratio is 1.13 for the first birth and peaks at 1.30 for the second birth showing that some urban Chinese make the choice to perform sex selection with the first pregnancy, since they are allowed only one child. In rural areas, most couples are permitted to have a second child, especially if the first is female. So if the second (or subsequent) child is female, the pregnancy often “disappears”, allowing the couple to have another child in an attempt to have a son.

It is believed that sex-selective abortion and non-registrationa of female births account for the increased sex ratio. Sex-selective abortion is illegal but is known to be widely carried out, helped by a burgeoning private sector. Although female infanticide is probably very rare now, less aggressive treatment of sick female infants does occur.

The Chinese government has acknowledged the social consequences of this gender imbalance with possible increased mental health problems, socially disruptive behaviour among men, kidnapping and trafficking of women for marriage and increased numbers of commercial sex workers. This may have contributed to a rise in human immunodeficiency virus infection and other sexually transmitted diseases.

The one-child policy is probably just one contributory factor in the skewing of the sex ratio in favour of males. Female infanticide resulted in a high sex ratio in China in the 1930s and 1940s. Other Asian countries with declining fertility rates and a traditional male preference also show comparable ratios – Taiwan, 1.19; Singapore, 1.18; South Korea, 1.12, and north India, 1.20 – probably reflecting sex-selective abortion. In China, the marked increase in the sex ratio between the 1980s and 1990s coincided with much easier access to cheap ultrasonography. It is likely that, even in the absence of the policy, sex-selective abortion would continue. The solution will come only with a change in attitudes toward female offspring. Publicity campaigns promoting girls are now widespread and acknowledge the importance of such change.

Ratio of old-age dependency

The rapid decrease in the birth rate, combined with an improving life expectancy, has led to an increasing proportion of elderly people and an increase in the ratio between elderly parents and adult children. In the absence of old-age pensions, approximately 70 per cent of the elderly are financially dependent on their offspring. In China, this problem has been labelled the “4:2:1” phenomenon, meaning that a couple (two) are responsible for the care of one child and four parents. The government has eased access to government pensions and has launched schemes to encourage saving for private pensions in an attempt to reduce the burden of the 4:2:1 phenomenon. In addition, urban couples who are themselves both only children are now allowed to have more than one child.

The future of the policy

The Chinese government is aware of the need to balance the people’s right of reproduction with the national need to limit population growth. The policy could be relaxed only if fertility aspirations would not result in a baby boom. Surveys do show that China may be changing to a small-family culture. The massive socioeconomic change of the last 25 years makes it harder for the government to enforce the policy. Economic disincentives are not a deterrent to wealthy people, and increased freedom of movement has made it difficult for the authorities to track down those who flout regulations. Finally, the evidence of slowing population growth, the high sex ratio, the increasing number of elderly people, and the risks associated with avoidance of medical care by women with unapproved pregnancies suggest that a relaxation of the one-child policy would be desirable. Allowing couples to have two children spaced five years apart would yield a fertility rate of 1.7. This may normalise the sex ratio and reduce the 4:2:1 phenomenon.

However, in 2002, the government announced that there would be no fundamental policy change, although couples would have greater choice of contraceptives and the freedom to have a first child when they want. These changes, together with declining fertility aspirations, have reduced (though not eliminated) the tensions associated with the government’s efforts to control population growth and have allowed the government to adopt a cautious and gradual approach to relaxing the one-child policy.

Commentary – implications for India

India and China are experiencing rapid economic growth. Both have huge, poor, rural agrarian populations. Neither country provides an effective social security net for the elderly. Both have realised that population control is essential to increasing per capita GDP. In both societies there is a strong cultural preference for sons. Both are facing declining sex ratios through use of sex selective abortions.

It is ethically unacceptable to take a human life, be it by murder, death penalty or abortion. Abortion becomes acceptable as the lesser of two evils when the life of an unborn child is pitted against that of the mother. Many societies also accept abortion to preserve the mental and social well being of the mother. Feminist groups have struggled long and hard to make abortion legal and easily available to women. They assert that women must have the absolute right to decide whether or not to carry the child to term as it is their body that will nurture this child and they will put in the labour to raise it till maturity. If we accept this position, we must also accept the right of a woman to choose the size and gender balance of her family. For the state to encroach on this right would be justifiable only on the principle that the good of the many, the society, supersedes the good of the few, the woman and her family. Many of the ills attributed to gender imbalance in China could also be explained by the massive migration of males from rural to urban areas. Until we can show, without ambiguity, that denying the right to sex selection prevents severe harm to the society, we are being unjust, arbitrary and dictatorial.

In both India and China the gender preference seems to be exercised not only through sex-selective abortions, but also through maltreatment and/or neglect of female infants and toddlers (1). As Gail Omvedt (2) quotes from Dreze and Sen, for India, most differences in the sex ratio come after the age of one. This statistic should give pause to those who think that preventing sex-selective abortion is all that is needed to correct the gender imbalance.

Recognising that low cost ultrasonography facilitates sex selective abortion, non-governmental organisations (NGOs) successfully lobbied the government of India to enact a law to ban this test. The Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, was enacted and brought into operation from January 1, 1996. The Act prohibits determination and disclosure of the sex of foetus. However, the continued decline in the number of female births particularly in parts of north India indicates that the law is not very effective. Under strong pressure from NGOs, the PNDT Act and Rules were amended in 2003 with stronger penalties. The rules even encourage entrapment of doctors by women posing as potential clients.

For the government, it is much easier to pass a law than make sustained efforts to bring about social change. But passing laws and imprisoning doctors alone cannot redress the problem. To do so, society needs to reduce the dependence of parents on sons and at the same time, enhance the social and economic value of daughters. The former could be achieved through an old age pension and retirement plan, easy access to free or subsidised health care and long-term care for the elderly. That economics may be a more potent force than tradition for male preference is indicated by a report from Italy showing that the Chinese living in Tuscany (3), where there are a state-sponsored social security net and old-age benefits, do not show the gender preference of China, though the authors attribute this change just to the absence of a coercive one-child policy.

Enhancing the economic and social value of women will need innovative programmes. Improved education, greater accessibility to better paying jobs and greater share in parental property will all add to the enhanced status of women. In addition, social practices will also need to change. In so many areas of the country, parents consider it inappropriate to even have a meal at the married daughter’s house. Will they consent to financial and physical assistance from a married daughter in their old age? And will the husband and his family accept that the wife should and will support her natal family? Without such profound changes in social mores, all the laws in the world will not succeed in reducing son preference.

Even the authoritarian government of China has had to make concessions to the cultural male preference in allowing a majority of its (rural) population a second child when the first is a girl. In urban areas, 50 per cent of women still want the single child to be a son. Thus, while sex selection is illegal in China, a high proportion of children (especially the second child) are boys (4), indicating that the ban on sex-selective abortion is not very effective. Recently acknowledging the complicated issue, the Chinese government has announced “preferential policies for girls and women in health care, education and employment.” (5)

We have seen from China’s example that laws affecting societal attitudes are difficult to enforce. If India follows in China’s footsteps the brunt of the defective enforcement will fall on the poor. For example, in India, the two-child policy has been enforced more strictly by denying government and panchayat jobs to those with more than two children. The penalties have affected mainly those from the lower caste and class while the upper castes and classes have been able to avoid them (6). If the PNDT Act is enforced stringently, the poor will have one more reason to be harassed by the local bureaucracy and police. Poor women will resort to surreptitious testing and abortions with disastrous consequences for their health.

Just as the less coercive Chinese “late, long and few” policy was slowly but steadily reducing fertility, similarly an Indian policy with greater emphasis on carrots, such as every female child going home from school at the end of the month with ration for the whole family, the recently announced allowance of Rs 3,000 for every female child who enrols in grade eight, etc, may be more effective in the long run.

Must we repeat China’s mistakes rather than learn from their example?