Induced Abortion Among Chinese Women: I. Sociological Aspects

A.I.R.V.S.C.
Association for Interdisciplinary Research in Values and Social Change
Vol. 14, No. 1 July/August, 1999
Thomas W. Strahan, JD
Reproduced with Permission

Background

China is the most populated nation in the world with slightly over 1.2 billion people. After being pressured by certain women's groups, induced abortion was legalized in China in 1957 by a directive from the Ministry of Health over strong opposition from the medical profession.1 Since the legalization of abortion, it has been the official policy of the Chinese government that induced abortion is only to be used in the event of contraceptive failure. However, it was not until the early 1970's that much more sustained efforts in population control were undertaken by the Chinese government. The goals were summarized in the slogan 'wan, xi, shag' which meant encouragement of later age at marriage (25-27 for males, 23-25 for females); longer intervals between births (4 year spacing was advocated); and fewer total births (ideally two children per couple). Efforts were intensified by recruiting and training health personnel to carry out family planning; making the nation self-sufficient in the production of contraceptive drugs and devices; and creation of administrative bodies in every commune, neighborhood and factory to implement the population control goals. As a result, fertility fell from 5.4 to 2.7 in the years between 1971 and 1979.

In 1979, the government sought to head off a second wave of population growth by launching the 'one-child family' campaign, and developing a stringent new system of punishments and rewards to induce compliance. Further, the national Marriage Law of 1980 required couples to practice family planning. The 'wan, xi, shag' and one-child family campaigns touch on virtually every aspect of a couple's social, economic, and personal lives. This includes the decision of whether and when to have a child, how many children to ultimately bear, whether to practice contraception or not, and even, in some instances, what type of contraception to use. The policy reached a peak in late 1982 and early 1983, when circulars called for mandatory IUD insertions for women with one child; sterilization for couples with two or more children, and abortions for unauthorized pregnancies. However, due to international criticism and growing domestic opposition, the government issued a revised set of regulations which allowed for greater flexibility. As a result, there was a surge of higher order births between 1985 and 1986. In May, 1986 the government issued a more rigid set of regulations and called for heightened efforts in population control and the one-child family policy.2 In 1991, the Chinese government introduced a new "responsibility system" in which higher level officials hold local officials directly responsible for meeting population targets. If they fail, their wages are docked and promotions denied.3

On June I, 1995, the Chinese government passed another law initially called the Eugenics Law which later was renamed the Maternal and Infant Health Care Law. It was aimed at reducing the perceived burden of disability to Chinese society with an overall goal of fewer but healthier babies. This law made it compulsory for all couples to have a premarital medical examination for serious genetic diseases, and "relevant" mental disorders. If the disorder was serious enough, long-term contraception or tubal ligation (sterilization) was required to enforce childlessness, or otherwise the couple would not be allowed to marry. During pregnancy, prenatal testing was compulsory, followed by abortion if the fetus had a serious genetic or somatic (bodily) disorder. The tests to be used and how women would be selected for testing was not made clear in the law. It appeared that voluntary abortion remained an option but compulsory abortion would seemingly be at the discretion of the doctor.4 The passage of this eugenics law was subjected to international criticism by a significant number of geneticists and human rights advocates as being in contravention of the United Nations Universal Declaration of Human Rights. In August, 1998, the Chinese government issued an "explanation" that doctors could sterilize a couple suffering from a genetic condition only with the couple's consent or the consent of a guardian. The "explanation" also advised doctors that China was seeking advice from geneticists about which genetically linked diseases were serious enough to warrant sterilization.5

Based on reports in the medical literature, there was a great deal of prenatal testing occurring both before and after the passage of the national eugenics law. In addition, some local provinces already had eugenics rules in place at the time of passage of the national law. For example, the Sichuan provincial birth planning rules established prior to enactment of the national eugenics law stated: "Couples who have serious hereditary diseases, including psychosis, mental deficiency, and malformation, must not be allowed to bear children. Those who are already pregnant must terminate the pregnancy". There is a lack of published reports describing the extent to which the prenatal testing for eugenic purposes has resulted in induced abortions in China, but various genetic criteria have been established before a couple will be permitted to have a child. These include mental illness such as schizophrenia as well as physical conditions such as colon polyps or congenital hearing loss.6

The following studies provide details about the extent to which induced abortion, including repeated abortions, are involved in population control; the various techniques used to carry out population control policies; the characteristics of Chinese women who obtain abortions; additional moral and ethical issues related to abortion, such as coerced abortions; sex-selection abortions; and late term abortions. A subsequent article will describe some of the adverse physical, psychological, social and reproductive effects of induced abortion on Chinese women and children.

Incidence of Induced Abortion

It has been estimated that approximately 200 million induced abortions were performed in China during the 1970s and 1980s7. The incidence of induced abortion in any given year appeared to be related to the degree that population control measures were utilized (Table 1)8. There is limited information available on the incidence of induced abortion in China during the 1990s. One recent study by the Alan Guttmacher Institute (AGI) reported 7,930,000 abortions in China in 1995 although it was believed to be 15% to 30% low according to AGI estimates.9

According to other research, the incidence of abortion in China was about 40 per 100 live births in 1982, increased to 76 per 100 live births in 1984, and then fell to 53 per 100 live births in 1986.10 In another study conducted by researchers at Johns Hopkins University and Beijing Medical University among 12,000 women in eight Chinese provinces during 1983-1987, it was reported that the incidence of induced abortion was 101.5 abortions per 100 live births in urban areas, and 61.9 abortions per 100 live births in rural areas."

Demographic and Technical Data

Sichuan province is the most populous province in China with approximately 9.6% of the total population. The Family Planning Research Institute, Chengdu, China studied four thousand Chinese women aged 18-40 (median age 25) who underwent an early induced abortion at hospitals and family planning clinics in six counties in Sichuan province, China, between July 1, 1990- June 30, 1991. Marital status data indicated that 11.4% were single and 88.6% were married. Only 0.7% had a college education, 38.0% had graduated from high school, 42.8% had a middle school education, 9.0% primary school, and 9.5% had no formal education. The most frequent occupation was farmer (77.4%) followed by workers (10.4%) housewives (6.6%), and other occupations (5.6%). Some 84.7% lived in rural areas and 15.5% lived in urban areas. At the time of entering the study, women had a mean number of 1.57 births and a mean number of 1.37 pregnancies (apparently prior abortions and even some births were not counted as pregnancies).

The incidence of prior abortions was high with 33.6% having one prior abortion, 52.1% having had two or more prior abortions, and only 14.3% had prior pregnancies but no prior abortions. All of the abortions occurred during the first trimester with 5.5% at less than 40 days gestation, 69.5% at 40-59 days of gestation, and 25.0% at 60-90 days of gestation. The procedures used for the abortion were vacuum aspiration (47.8%), vacuum aspiration and curettage (3.7%), and curettage (48.3%). The abortions were performed by doctors who had graduated from medical college (13.5%), or a medical vocational school (26.4%) or a family planning technique training program (56.9%) with 90% performed by those who had more than 3 years experience. The reasons stated for having the abortion were unintended pregnancy (49.9%), contraceptive failure (36.8%), unmarried (10.6%), mother's health problem (0.9%), economic problem (1.0%), family problem (0.3%) or fetus' health problem (0.6%). The authors of the study stated that "all of the abortions were voluntary or were recommended as a way to avoid an unwanted pregnancy."12

Role of Induced Abortion in One Child Policy and Other Limitations on Childbirth

Induced abortion appears to be heavily relied upon as an instrument of population control. A study by researchers at the Institute of Population Research at Peking University and the Population Studies Center at the University of Pennsylvania used data collected from a retrospective study of 8603 married women younger than 35 years of age in 92 randomly selected villages in four counties in December 1991 and January,1992. Women who were age 35 or older were not studied because virtually all had been sterilized. Two counties were in Hebei Province and two counties were in Shandong Province. A policy of allowing rural couples to have a second child after a four year period if the first child was a girl was introduced in Shandong Province in 1985 and in Hebei Province in 1989. There were marked differences between the four counties. One county in Shandong Province is a district of an industrial city with a high proportion of agricultural workers. The other county in Shandong Province is a mountainous area, and the least developed among the four counties. One county in Hebei province is a coastal county while the other is inland and semi mountainous with a relatively high proportion of Manchu population in some of its townships. The county with a substantial Manchu population had the lowest proportion of pregnancies aborted and, in contrast to the other counties, the proportion of abortions remained virtually the same regardless of the sex of the first born child. In the other three counties, abortions were less likely to occur in a subsequent pregnancy if the first born child had been a girl (50%-73%) compared to the first born child having been a boy (86%-89%).

Overall, the probability of induced abortion in all four counties was strongly related to parity. Virtually no abortions occurred prior to first live birth (0%-2%), and a very high incidence of abortion (81%-91%) occurred after the second live birth. Women had a high risk of undergoing abortion after their first live birth because most (82%) had become pregnant again without meeting official requirements for late second births with long spacing between births. The authors stated that abortion serves as the main alternative that families can use to avoid penalties for an unplanned birth in the event of contraceptive failure, a last protection against penalties which would be imposed by local authorities for failure to meet their preset demographic target, and a sensitive indicator of shifts in official family planning policy and implementation.13

Another study of induced abortion was conducted by population researchers at Johns Hopkins University and Beijing Medical University in 1988 among 12,000 women which included both rural and urban women in eight provinces of China. The study reported that the incidence of induced abortion from 1983-1987 was 101.5 abortions per 100 live births in urban areas, and 61.9 induced abortions per 100 live births in rural areas. The study further found that induced abortion was an important means that urban couples used to strictly adhere to the one child policy. For example, 91.6% of urban couples with no previous births carried their pregnancy to term and only 5.8% had abortions. However, if urban couples had one prior childbirth less than 3% carried the subsequent pregnancy to term and at least 96% had abortions. Further, the compliance of urban couples to the one child policy seemed not to have been significantly affected by the sex of their already born children with rates of abortion ranging from 90%-100% regardless of the sex of prior children.

In rural areas, the one child policy did not appear to have worked nearly as well. Among rural couples, 95.6% with no previous births carried their pregnancy to term and only 2.2% had abortions. Overall, If rural couples had one previous birth, about 40% carried to term and about 60% had induced abortions. Among rural couples the sex of previous children did appear to have influenced the outcome of the next pregnancy, as rural women with one or two boys aborted more frequently (60-63%) compared to rural women with one or two girls (37%-51%). The authors concluded that this suggests that the rural Chinese surveyed preferred boys to girls.14

There is other evidence that induced abortion is heavily relied upon as a method of population control in China. A study was conducted by the UCLA School of Public Health and various family planning agencies in China under the auspices of the China State Family Planning Commission. In this study a pre-coded, closed response questionnaire was administered to 1200 women awaiting abortion at various abortion facilities during August, 1985. The 1200 women included 200 in Chengdu City, 200 in the Lianshan Yi autonomous region in Sichuan Province, 400 in Nanjing City and 400 in Shanghai. Some 574 described their residence as urban and 624 described their residence as rural areas or rural towns. Among the 1200 women only 1.5% were unmarried with a mean age of 31 years. Rural women generally married at an earlier age (22.5 years) compared to urban women (25 years) and generally had a longer duration of marriage (8.7 years) compared to urban women (6.1 years). The mean number of live born children was 1.08 for urban women and 1.60 for rural women. The number of abortions, counting the current abortion, ranged from one to six. About half (50.6%) were undergoing a second abortion while 18.0% were undergoing a third or more abortion. Women who had been married longer tended to report a higher number of abortions.

Approximately 89% of the women claimed that they were using a birth control method at the time they became pregnant with the IUD as the most commonly used method. However, many claimed that their pregnancy was a result of IUD expulsion. After the expulsion, no other method appears to have been used to avoid pregnancy. Other women who claimed they relied on the pill as their sole method of contraception said they skipped the entire cycle of pill taking in the event they missed one pill. The researchers concluded that one reason women fail to use contraception is behavioral. They also concluded that the one-child policy is one of the most unpopular policies among the Chinese, the great majority of whom still regard a larger family as an ideal. Therefore, there are limits on the extent to which the government can enforce compliance, and to which the government is sensitive. They also stated that reducing the incidence of abortion in China is desirable on ethical, health and economic grounds.15

Other later studies have also found a high rate of contraceptive failure among Chinese women. This may result in the high utilization of induced abortion for purposes of birth control in order to comply with the 'one child policy'. One study of 2088 induced abortions performed during 1984-1991 at the Hospital of Peking University found that there was an excessive use of artificially induced abortion with some women having four or five artificial abortions in a single year. It was concluded that this was detrimental to women's health.16 In another study of 1520 women obtaining abortions at eight large hospitals in Henan Province in 1996, 71.9% reported contraceptive failure. Less than 1% of the women in this study utilized what was referred to as emergency contraception.17 Still another study of 2880 women in East China found that women who had no sons had high oral contraceptive failure rates prior to undergoing a first abortion.18 Recent efforts to involve husbands in contraceptive use to limit pregnancies and abortions reportedly have had some limited success.19

Coerced Abortions

The Chinese government claims that the one child policy is simply a policy and not a law and, therefore, there is no coercion but only voluntary compliance. However, there are many possible penalties for failure to comply. Penalties may include financial penalties including fines, denial of free social services and demotion. Sometimes property is confiscitated or destroyed. In some cases, fines or other financial penalties or detention may be imposed not only on the couple, but also on other family members and co-workers. An ob/gyn, known only as Dr. Wong, testified that she worked in a Chinese public hospital during 1983-1989 in recent testimony before an Australian parliamentary committee. She stated, "Men could lose their jobs if their wife got pregnant with a second child. Governmental officials sometimes bargained with women to get abortions than failed to deliver on their promises afterwards... Some have physical force, emotional force and psychological force applied... In the hospital you can see it every day. Women may be taken from the workplace and forced to go to the hospital. It is really hard. You see them screaming. You see them being dragged. You do not feel as if they are human beings.... Maybe I think I am not human too."20

There are also incentives

Considerable efforts have been made for couples to agree to have only one child. In return, there may be preferential access to food, housing, medical care, and educational benefits. In the rural areas, couples may receive extra land, and in urban areas there may be salary supplements.

Various studies reveal evidence of coercion in a substantial number of instances. In a study of 163 married fertile women in an urban area who accepted induced abortion, results indicated that 84% had psychological pressure to do so in varying degrees depending upon their particular circumstances.21 In another study of 12,000 Chinese women in 8 Provinces in 1988, who were asked about the reason for their last abortion, approximately 30% said it was voluntary to meet government requirement for population control, while only 19% said the reason was because they wanted no more children. Some 1.6% of urban women and 11.2% of rural women said they were "persuaded" to have the abortion. Women who said they were persuaded had the highest mean gestational age (10-13 weeks) at the time of their abortion compared to other respondents.22

In another study of 4000 Chinese women in Sichuan Province who had a first trimester abortion in 1991-1992, the authors of the study who were affiliated with a the Family Planning Research Institute in Chengdu, China stated, "all abortions were voluntary or were recommended as a way to avoid an unwanted pregnancy." The language of the authors implies that some of the abortions were not voluntary, Also these women were highly distressed at the time of their abortion and about one out of four still exhibited depressive symptoms six months after their abortion.23

Women who have not yet reached the legal age to marry and become pregnant may be required to obtain an abortion for being underage and unable to legally marry. In a study of 457 unmarried Chinese women who obtained abortions in Sichuan Province in 1991, nearly all (92.5%) said the reason for abortion was because she was unmarried. Twenty-eight percent (28.2%) were under age 20, 64.8% were age 20-24 and 7% were age 25 or higher. The article pointed out that the minimum age for marriage of Chinese women was 20.24 A circular issued by governmental officials of Sichuan Province in late 1987 stated that "Illegal relationships which should be dissolved must be dissolved. Those who have reached the legal marriage age must carry out marriage registration procedures. Those who are pregnant out of wedlock and have not reached the legal age of marriage must undergo remedial operations (abortion) within a prescribed time."25 Therefore, it appears that at least 28.2% of the women in the study would have been required to undergo the "remedial operation" of abortion.

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