China's quiet revolution in reproductive health

China's quiet revolution in reproductive health

With a population of 1.3 billion, much of it crowded into the eastern third of the country, China's rulers remain convinced of the importance of slowing the growth in numbers. However, almost unnoticed, China is adopting a new 'people-centred' approach to reproductive health, which has already spread to 880 counties.

Zhang Xinhua, an attractive woman in her early 30s, sits on a bench outside the small family planning service station in the tiny township of Liangjiao, in Datonghui County, buried deep in the Loess Plateau of North-Western China. It is a rugged, unforgiving landscape. The Yellow River, often referred to as China's Sorrow, rises out of these eroded hills on its way to the Bo Hai Sea. But here, in this remote clinic, Zhang is benefiting from a quiet revolution in China's controversial population policy.

Though most of Qinghai Province, where Zhang's village is located, consists of hilly, semi-arid grasslands, this is farming country. Close to 60 per cent of the entire population of five million lives and works on just three per cent of the provinces land area. The treeless hills around the village have been cultivated continuously for some 3000 years. Every square metre of soil that can bear crops has been put to the plough. The entire landscape is a checkerboard of wheat, maize and vegetable fields.

Zhang's one-hectare farm grows mostly wheat and some vegetables for household consumption. The land is fertile and produces more than enough to feed the family, two adults and three children. During surplus years, she can even put some money in the bank. Still, Zhang's life is not easy. Her husband injured his back in an accident and is unable to perform most of the heavy work that must be done on a farm. Zhang does most of the farm work herself, with help from two of her three children. The third child, a boy, is afflicted with epilepsy and is enrolled in a special school. Her other son and daughter pitch in to help with chores after school.

Despite her difficulties, Zhang is optimistic about the future. She has advantages some of her neighbours do not. Zhang is a high school graduate and is literate.  Many women in her village, especially those belonging to the Hui minority which are predominately Muslim, did not even get a chance to pass through grade school. Traditionally, Muslim women were not educated and in some villages female illiteracy is as high as 60 per cent. Zhang values her daughter as much as her two sons and intends to keep all of them in school as long as possible. "I want them all to go to the university, if they have the aptitude and interest," she explains in a clear, even voice. "I want my children to make a living with their heads, not their hands."

Birth quotas

Zhang has come to the clinic for a routine checkup. "With a handicapped child and a crippled husband, life is difficult," she says matter-of-factly. "So I decided to switch to Norplant [a long-term injectible]. I do not want any more children." Now she is looking forward to the extra time so she can concentrate on raising her three children and make some extra money by selling vegetables and sewing clothes. Thanks to the upgrading of the clinic's services, including access to a complete array of contraceptive choices and better counseling, Zhang can now get most of the services she needs at her local community clinic, services she used to get only at the county hospital, an hour each way by bus from her home.

This out-of-the-way family planning clinic is part of a silent transformation in China's reproductive health services. In 32 counties in 22 of the country's provinces, the State Population and Family Planning Commission, working closely with the Ministry of Health and the China Family Planning Association (an NGO) has abandoned birth quotas and targets for family planning acceptors. At the same time, the services in family planning clinics and primary health care centres have been upgraded. Women and men now have more freedom of choice when selecting contraceptive methods, including wider access to alternatives such as condoms, pills and injectibles.

This ground-breaking initiative was made possible by a $14 million pilot project funded by United Nations Population Fund (UNFPA). Before this project was launched the most common family planning methods in these counties, as in the rest of the country, were limited to two methods: an IUD after the first child and often sterilization after the second. The quality of reproductive health services has been improved significantly through an expanded training programme for health care providers, the provision of modern diagnostic equipment and supplies and better interpersonal counseling, which includes informed consent.

Dr. Song Hou Qin, the physician in charge of the Qinghai Provincial Family Planning Commission, is enthusiastic about the results of the project in Datonghui County, an area of some 1,000 farming villages tucked away in the hills about 40 kilometres north of the provincial capital of Xining. "We chose this county as one of the project sites because it has a fairly mixed population; 45per cent consists of various minorities, with 55 per cent Han Chinese," she points out. "As a result, we have a significant number of Muslims, as well as Buddhists and some Christians. In addition, the county is rural and needs better services, and the provincial and local governments strongly support this effort."

Quality care

As part of the implementation strategy, Datonghui County has strengthened its capacity to deliver quality reproductive health services to more women and men. "We have trained our local family planning service providers, giving them better face-to-face counseling techniques," explains Dr. Song. "We also designed and distributed more focused IEC [Information, Education and Communication] materials, aimed at the needs and concerns of local women, and we are making full use of new technologies to improve the quality of reproductive health care, including better pre-natal, post-natal and peri-natal services and attended births for all women."

Two thousand kilometres to the southeast the small farming village of Mudun is tucked away deep inside the rice growing region of Fujian Province. Ye Jianzhen, a petite women with round cheeks and raven hair, sits in her living room explaining how her life has improved over the past decade. She is 34 years old and the mother of a charming, intelligent 8-year-old girl - the only child in the family. Ye is part of a growing chorus of voices heard among younger Chinese women that having a child is the important thing, no matter whether a boy or a girl.

"I was delighted to have a girl child," she says in a quiet, steady voice. "A girl is just as good as a boy," she adds emphatically. "I want her to achieve as much as she can in life, and hopefully since she is intelligent and does well in school she will have a chance to go to the university." Ye didn't get beyond the 9th grade before being forced to dropout to help with farm chores.

Like Zhang, Ye lives in one of the 32 counties in China that have eliminated family planning targets and quotas. Ye does not want another child because she wants to give her daughter opportunities that she did not have, coming as she did from a family of four children, three of them boys. "My life has been confined to this village, but it is my hope that my daughter will acquire skills that will take her away from here and open up a world of opportunities for her."

With the family's fortunes on the rise, thanks to two rice crops a year and the success of her husband's small business shipping oranges to neighbouring provinces, Ye is looking forward to more disposable income. One of the first things she intends to buy: "a new computer for my daughter, with Internet access, so she can benefit from the global information revolution."

Ye is now using pills, instead of an IUD. She gets a check up three times a year at her local clinic to make sure that her family planning method is working properly and is counseled on other contraceptive methods; services the old system did not provide. "Before we were not given a choice of contraceptive methods," she shrugs. "This has all changed because of the new policies. The services are much better and tailored to my needs."

One-child choice

It's a similar story for Zhang Qingying and her husband Lu Hao, living in Deqing County, in Zhejiang Province. Unlike other regions, efforts to improve the quality of reproductive health care began here in 1995, following the International Conference on Population and Development (ICPD) in Cairo. Since 1998 when Deqing joined UNFPA's 32 county pilot programme, it has become a showcase for quality service delivery for the entire country.

Qingying and Hao are both busy professionals (school teachers) in their late 20s and have one child, a gifted six-year-old boy named Yihui. Even though the couple could have another child, since both come from one-child households, they do not want another child. "It is a difficult enough job raising one child," confesses Qingying. "Besides, with two children you don't have as many options and opportunities available. We want to concentrate our efforts on giving Yihui the best possible future."

Qingying is delighted with the services provided by her local family planning clinic. "The counselors are well informed, friendly and courteous," she says, "and the doctors are very professional, very competent." However, she is not taking any contraceptives. "I don't like pills," she says blushing slightly, "so my husband uses condoms."

Empowering women

Condom use in China is soaring, especially in urban areas. In Deqing, a full 10 per cent of family planning acceptors use condoms; in Shanghai and other large cities over 20 per cent do so.

Condom use is on the increase mainly for two reasons: the success of publicity campaigns to prevent sexually transmitted infections (STIs) and HIV/AIDS, and because Chinese women are being empowered in their personal and professional lives.

"We have certainly empowered women in this county," affirms Shao Huimin, Director of the Deqing Family Planning Bureau. "Most women here work and earn their own money. Three of our four government bureau directors are women, along with two deputy governors," she points out proudly. "In addition to comprehensive improvements in services, we have educated local politicians to be gender sensitive, included services for youth, introduced sexuality education in secondary schools and reached out to other partners."

An energetic, engaging woman in her early 50s, Shao has worked in the health and family planning fields her entire adult life. "Thanks to UNFPA's catalytic assistance, we have made tremendous progress in a short period of time," she states. "We now get around 60,000 visitors a year from all over China, as well as foreign countries. Most are family planning experts who come mainly to see our facilities and seek advice and guidance on best practices and lessons learned."

Shanghai centre

Just 200 kms to the northeast of Deqing lies Shanghai, home to 17 million people. Not surprisingly, China's largest metropolis is another centre of excellence in the new approach to reproductive health services. Even small, neighbourhood reproductive health stations come equipped with a reception area, counseling rooms, a private examination room, a library and a complete range of contraceptive supplies. Additionally, many sell baby supplies, including high-tech cribs that sport built-in toys and a variety of gadgets, even a sleep monitor.

"We provide a complete array of services for reproductive health, family planning and baby care under one roof," points out Zhang Yunxia, Director of the Da Pu Qiao Street Reproductive Health Station in the centre of Shanghai. "Our doctor, a highly popular gynecologist, comes twice a week at posted times to give examinations and provide special counseling if necessary. We also have a regular counselor here everyday to answer questions and give advice."

Pointing to a young woman with the doctor, Zhang says, "this lady came in for a routine health examination, only to discover that she has a reproductive tract tumour. The doctor is setting up an appointment with the local hospital right away so she can get a complete array of tests." Before the emphasis on quality of care, this station did not offer such comprehensive services. "It's one more reason why we see dozens of clients a day here," confirms Zhang. "Even nearby university students drop in to get information, borrow tapes on various reproductive health issues, get advice and help themselves to our free condoms."

This centre, like all others in the city, hands out dozens of pieces of literature and hundreds of condoms every week. All municipal buildings in Shanghai sport condom dispensers - anyone is free to take as many as they need. But, astonishingly, even apartment buildings now have condom dispensers in discreet locations. As a result, STIs have dropped dramatically in many parts of the city. "It's September," says Zhang, "but we haven't had one case of an STI yet this year in our centre."

Extended impact

The impact of UNFPA's programme in China has been remarkable.. Based on the results and impact of the 32 county pilot project, the State Population and Family Planning Commission has extended the quality of care package of services to another 880 counties, one-third of the country's total. Though these counties will still have birth quotas and targets, at least initially, the Commission is counting on being able to keep fertility rates down by providing a wider choice of contraception, improved care and better counseling, based in informed consent.

The Fund's pilot project has not only helped establish client-centred services, including informed choice, as hallmarks of the Commission's approach to reproductive health, it has "opened the eyes of many officials and politicians regarding population issues in general and family planning in particular," notes one population expert from Beijing. UNFPA's efforts have helped "change fundamental attitudes towards these issues," he says.

"Of course we still have old guard politicians in this country who want draconian population laws, but this initiative has demonstrated that you can have voluntary family planning programmes that work; without quotas, without targets and most importantly without increases in the population."

Lower population growth rates remain a top priority for the Chinese government, which views the issue as one of crucial importance for the future of the country. "Anyone who has visited China will see right away how important it is to limit population growth," observes a former World Bank economist and diplomat, stationed in Beijing from 1998 until 2002. "China has a population of close to 1.3 billion people, with 94 per cent of them living in the eastern third of the country. Imagine that many people all crammed together east of the Mississippi River in the United States, and you get a picture of how crowded this country is by comparison."

Fewer children

Even so, the one-child family is not a universal policy. In fact, the average number of children per family in China today is close to two. There are plenty of exceptions to the rule.

In rural areas couples can have two children: if the first baby is a girl, if both husband and wife are only children, if the parents of the wife had two girls and no boys, and if both husband and wife are from rural areas. Ethnic minorities can have up to three children and Tibetans have no limits on family size.

Perhaps most importantly, the new strategy "reflects major changes in Chinese society," states Baige Zhao, the dynamic, English-speaking Vice Minister of the State Population and Family Planning Commission in Beijing. "China is in transition from a state-planned to a free market economy; from a largely rural, traditional society to a modern, urban one." These underlying changes are also driving people's decisions to have fewer children.

"Our efforts to deliver client-centered, quality reproductive health services to more people, including access to a full range of contraceptives," she observes, "must be seen in the context of the economic and social forces at work. UNFPA came in with the right strategy at the right time."

The right strategy at the right time has allowed China's reproductive health revolution to take off. Ru Xiao-mei, Assistant Counsel of the State Population and Family Planning Commission, underscores what this transition means: "we are no longer preaching population control. Instead, we are emphasizing quality of care and better meeting the needs of clients. It's a service-based approach, not a demographic-based approach."

Funding tragedy

As the new system takes root throughout the country, it has not only transformed the way services are delivered, it has forged new partnerships between the Commission, the Health Ministry and NGOs. The Maternal and Child Hospital in Jianou City, capital of Jianou County, about 50 kilometres from where Ye Jianzhen lives, has become a model facility. The hospital delivers 1,400 babies a year. Moreover, with only three infant deaths over the past three years - one per year - this achievement has earned it UNICEF's "Baby Friendly Hospital" award.

Dr. Han Xiaoqing, Deputy Director of the Family Planning Commission of Jianou County, says the hospital's success rests on four factors, "a good foundation for services, a client-oriented approach, very affordable fees and close collaboration between the Ministry of Health and the Commission." Ten years ago," confesses Han, "we were a self-contained agency, we seldom even spoke to colleagues in the Ministry of Health, now we work closely with them, as well as other partners."

Tragically, just as China's new policies are having real impact across the country, UNFPA finds itself the hapless victim of US domestic politics. UNFPA's mere presence in China has prompted the Bush Administration to withhold $34 million in Congressional appropriations for the Fund in 2002 and again in 2003. The excuse provided by the State Department (speaking on behalf of the White House) was that UNFPA had violated the terms of the Kemp-Kasten Amendment (to the 1985 foreign appropriations bill), which states that no agency can receive US funds if it participates in a program of coercive abortion or sterilization.

Monitoring missions

In withholding funds from UNFPA, the Bush administration not only ignored the findings of over 160 UN monitoring missions to China over the past decade, they ignored the detailed reports of three major independent missions fielded over the past two years. In April 2002 three members of an all-party group of British Parliamentarians visited China, followed in May by the US State Department's own three-person assessment team. Both concluded that there was absolutely no evidence to support allegations of misconduct by UNFPA. The State Department's hand-picked team found "no evidence that UNFPA has knowingly supported or participated in the management of a program of coercive abortion or involuntary sterilization in the PRC. Indeed, UNFPA has registered its strong opposition to such practices."

Another independent mission, organized by Catholics for a Free Choice, sent a nine member team of faith-based organization leaders and ethicists to China in September 2003. Their conclusions were unequivocal: "On the basis of our meetings with Chinese family planning officials and ordinary citizens, we can say with confidence that all of the programs with which UNFPA is currently working are committed to avoiding any practice of forced abortions or involuntary sterilizations."

The sad fact is that the "Bush Administration has made UNFPA a sacrificial lamb for the religious right in America," says Professor Ronald Green, Chair of the Department of Religion at Dartmouth College and a member of the faith-based delegation that visited China in September 2003. "President Bush is pandering to militants on the extreme right wing of the Republican Party," insists Dr. Green. "It's crass election politics. These groups not only oppose abortion, they are against family planning and reproductive health in general. Their positions are unethical, contradictory and have no basis in reality."

The ironies of the Bush policy are as thick as treacle. In the first place, not one dollar of American aid went to UNFPA's China programme; those funds were provided by European donors. This fact seems to have escaped the attention of religious conservatives, who now seem to be making US foreign policy in the field of reproductive health and family planning.

Fewer abortions

A much more poignant testimony to UNFPA's presence is the plain fact that in the 32 counties where UNFPA's programme is being implemented, the abortion rate has dropped by an average of 30 per cent. In Yuzhong county, Gansu Province, data show an 85 per cent decline in abortions, from 512 in 1997 (before UNFPA assistance began) to 75 in 2002. Similarly, in UNFPA supported counties, the voluntary sterilization rate for women under 35 decreased significantly, from 36 to 26 per cent (for the period 1998-2003). Moreover, the overall sterilization rate for all men and women of reproductive age in these counties is 30 per cent, nearly the same as in the United States!

The results of the UNFPA-sponsored programme are so impressive that high-level officials in Beijing are looking forward to extending the same package of services to every corner of the country. If the trends hold and the reforms do spread throughout China, it is conceivable that quotas and birth targets will become redundant. Underscoring these momentous changes is the fact that women are being empowered in China through increasing opportunities for economic and social advancement. Even in the countryside, most women work. Increasingly, it is economic considerations, not government decrees, which are keeping one-child families the norm in cities and towns.

Wanting girls

Two other important factors are reinforcing China's shift to a quality of care, service-based approach. In the first place, "the small family ethos has become part of Chinese culture," observes Dr. Ronald Green. "Through public education and civic involvement, Chinese attitudes towards the family have changed dramatically."

Secondly, younger Chinese women do not have 'a boy bias'. "Our research shows that even in rural areas a preference for boys is no longer as pronounced as it once was," explains Dr. Zhang Rong Zhou, Director of the Shanghai Population Information Center, an NGO. "The younger generation has no preferences whatsoever; they value girls as much as boys." In fact, in Shanghai, he points out, "couples now prefer girl children because they cost less and are easier to raise than boys." As a result, the sex ratio in Shanghai is 105 boys to every 100 girls, the normal international average. "In other urban areas the ratio is also beginning to even out," claims Dr. Zhou.

"Centuries of prejudice are not easy to overcome, especially in the countryside," admits Zhou. "In some rural provinces the disparity is still striking, but the younger generation in China shares many of the characteristics of its counterparts in the West: they want a better life, much smaller families and more opportunities for education, travel and work." It is these powerful trends that are helping to drive China's quiet revolution in reproductive health.

"The demographic profile of China, like its economic profile, is changing rapidly and so policies and programmes must adjust to new realities," points out Baige Zhou, the eloquent Vice Minister of the State Population and Family Planning Commission. "The policy that we see evolving is more fluid, based on continued improvements in the provision of client-oriented quality services that meet the needs of modern families."

She is grateful for the help afforded by international partners. "We could not have come this far so quickly without help from the international community. The lesson here is clear," she concludes, "if you want to influence Chinese policy, stay engaged."