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

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

“In 30 years, the current problem of especially 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. According to a survey by Peking University researchers, it affects about 18% of couples of reproductive age, compared with a global average of around 15%.

For years, the government 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 University 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 governments, 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 “Hundred Days, No Child.” A 2012 documentary by Hong Kong-based Phoenix Television 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-year-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 birth offenders 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 more than five billion yuan, equivalent to $780 million, according to the provincial health commission. That corresponds to more than one-fifth 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, according to National Health Commission data. The number was just below nine million in 2020. More striking is that the number of family-planning centers, primarily used for abortions, sterilizations and insertions of intrauterine devices, 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 four to six weeks—have more than doubled, from about 485,000 in 2013 to more than one million in 2018. In the U.S., a little over 300,000 rounds were performed at 456 reporting clinics in 2018, according to the Centers for Disease Control and Prevention.

“What is 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.

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 Beijing gynecologist, delivered China’s first baby conceived through IVF. Another followed three 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 government 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 children a woman has over her lifetime—already dropped below replacement levels in the early 1990s 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 government, though in recent years, the rate has started falling again.

China currently has 536 infertility centers, according to the health commission, but most are clustered in wealthy metropolitan areas like Beijing and Shanghai, and vary widely in their quality. Major hospitals have added fertility services to family-planning clinics, and China is 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 million to three 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 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, 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 more than 180,000 babies since its inception, according to its website. The average 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 professor at a Beijing university who gave only her last name, Wang, said she wasn’t sure she would 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 would have another one if I were a few years younger and if the whole process wasn’t so difficult,” said Ms. Wang, 36, who agonized over the possibility of another miscarriage.

Infertility-treatment costs aren’t covered by public insurance in China. In Japan, the government 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 government’s latest efforts can’t easily reverse that, said Yi Fuxian, a U.S.-based researcher who has long criticized the Chinese government’s population policies. Mr. Yi expects 2021 data may even show China’s population has started to shrink, years ahead of government forecasts.

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

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

“It all comes down to money,” Mr. Liang said. “You cannot 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 government 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 children.

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

Beijing’s about-face—in six years going from harshly restricting how many children 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.

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

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

The provincial government also said it won’t pay back any fines meted out for “historical” birth violations, adding that officials need to explain to residents punished for having too many children that the situation has changed and now it needs to “stimulate birth potential.”

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