Therese Hesketh, One Child Policy: impacts on reproductive health and attitudes

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Since its introduction in 1979, the one child policy has had a direct impact on the lives of over one-fifth of the world’s population. The policy has influenced reproductive choice, preferred family size and access to abortion. In a country where preference for male offspring is common, and where there is easy access to abortion, it has also contributed to an excess of male births. Some relaxation of the policy has started, and this is expected to continue.

Therese Hesketh is Professor of Global Health at the UCL Centre for International Health and Development. She trained in paediatrics and public health in the UK and has extensive experience as a clinician and health researcher in Asia. She has taken the lead on a number of large collaborative population studies in China: in health system reform, the health needs of rural-urban migrants, reproductive health, and the demographic, health and social effects of the one child policy.

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  • Includes attitudes
  • Assume all know about the policy how it works etc Caveat: what changes are attributable to the Policy?
  • Has created mostly one-child urban families, mostly two-child rural families, third and higher order births 9% Rural popualtion around 70%
  • One and a half polcvy
  • Long term contraception
  • PUBLIC HEALTH DILEMMAS - CHOICE VS POPULATION BENEFIT Feels very oppressive/ Dracnonian. Today’s world of carbon footp[rints – world should be grateful.
  • Tantalising question: would the decline have continued? Population still growing because 0.65% 148 in the world
  • Just some perspective – look at other countries with no policy.
  • How to make people accept restriction of choice in something so fundamental as reproduction
  • How did the Chinese achieve this? Winning hearts and minds-Propaganda and carrots and sticks Too many people in China
  • Quality, not quantity
  • Example of extreme choice which has been influenced by the Policy. Normal sex ratio at birth 103-107 males to 100 females SSA illegal
  • It was high in the 1930s and 40s, then declined after the Communist Revolution Many other Asian countries have high sex ratios: Taiwan 1.19, South Korea 1.12, parts of India 1.2 (Sen, 2002) Increase in sex ratio on China coincided with cheap, accessible ultrasound in rural and suburban areas
  • Highest sex ratio in medium strict provinces 7 normal provinces have sex ratios of <110 only 8% of the population % high provinces have 25% of the population
  • One and a half polcvy
  • Reproductive Choice to go for sex selective abortion being made with second births
  • 19% of People’s congress female. Women’s status increased paradoxically
  • BUT did they mind….?
  • Dramatic change in South Korea with enforcement of the law and publicity campaigns. But IS THIS because of the Policy??
  • Graduate unemployement concerns When allowed to have more they choose not to
  • People said thay knew others who hadn’t wanted an abortion but were pressurised into getting on e
  • Therese Hesketh, One Child Policy: impacts on reproductive health and attitudes

    1. 1. One Child Policy: impacts on reproductive health and attitudes Therese Hesketh UCL Centre for International Health and Development
    2. 2. <ul><li>The One Child Policy has directly affected the lives of over one fifth of the world’s population for 30 years </li></ul>
    3. 3. Overview of the presentation <ul><li>How the Policy has reduced reproductive choice </li></ul><ul><li>How the Policy has come to be accepted </li></ul><ul><li>The impact of the Policy </li></ul><ul><ul><li>demography and gender </li></ul></ul><ul><ul><li>benefits </li></ul></ul><ul><ul><li>negatives </li></ul></ul><ul><li>Attitudes </li></ul><ul><ul><li>Policy </li></ul></ul><ul><ul><li>family size </li></ul></ul><ul><li>Policy </li></ul><ul><li>What is changing? </li></ul>
    4. 4. Why the Policy? Source: World Bank <ul><li>“ There can never be too many Chinese” Mao Ze Dong </li></ul><ul><li>Population increase 1950-70 because of high fertility, improved survival </li></ul><ul><li>By late 70s 2/3 of the population under 30 </li></ul><ul><li>In 1979 population containment seen as essential to economic reform and improvement in living standards </li></ul>
    5. 5. Policy works through reducing reproductive choice <ul><li>A set of rules and regulations governing approved family size </li></ul><ul><li>The State Family Planning Bureau sets targets and policy direction </li></ul><ul><li>Implementation of policy is the responsibility of family planning committees at provincial and county level </li></ul><ul><li>Local officials responsible for day-to-day implementation </li></ul>
    6. 6. The Policy – how it works <ul><li>Late marriage </li></ul><ul><li>Births permitted only within marriage </li></ul><ul><li>One child rule applies to urban areas and government workers </li></ul><ul><li>Two children allowed in most rural areas </li></ul><ul><li>In some rural areas a second child is allowed only after the birth of a girl </li></ul><ul><li>Local quotas previously in force in many areas </li></ul>
    7. 7. Provincial Policies XINJIANG QINGHAI NEI MONGOL GANSU NINGXIA SHAANXI XIZANG SICHUAN CHONGQING YUNNAN GUIZHOU GUANGXI HAINAN TAIWAN HUNAN JIANGXI ZHEJIANG FUJIAN GUANGD ONG HONG KONG MACAU Shanghai SHANGHAI SHI Guangzhou Chengdu JIAN GSU ANHUI HUBEI HENAN SHANXI SHANDONG Beijiing Shenyang HEBEI BEIJING SHI TIA NJIN LIAONING JILIN HEILONGJIANG Relaxed 1 Child Policy Medium 1 Child Policy Strict 1 Child Policy
    8. 8. Policy underpinned by easy access to contraception and abortion
    9. 9. How does the Policy work for individuals? <ul><li>Late marriage </li></ul><ul><li>After first child IUD inserted-usually at delivery </li></ul><ul><li>In rural areas IUD removed for second child after 4-5 years – sometimes only if first is a girl </li></ul><ul><li>If pregnancy “outside the Policy” abortion is necessary </li></ul><ul><li>Later sterilisation </li></ul>
    10. 10. Benefits of the Policy <ul><li>Prevented around 300m births </li></ul><ul><li>Helped to lift over 200m people out of poverty </li></ul>
    11. 11. Has reduced Total Fertility Rate Late, Long, Few One Child Policy Great Leap Forward
    12. 12. Source: World Bank And compared to other nations
    13. 13. How did the Chinese achieve acceptance of the Policy? <ul><li>Timing </li></ul><ul><li>Incentives and Penalties </li></ul><ul><li>Propaganda </li></ul>
    14. 14. Carrots and sticks <ul><li>Rewards: economic incentives, low interest loans, preference in schooling, health insurance </li></ul><ul><li>Penalties: fines, confiscation of belongings, </li></ul><ul><li>loss of employment </li></ul><ul><li>Considerable social pressure to comply </li></ul><ul><li>Now widespread acceptance </li></ul>
    15. 15. Propaganda <ul><li>Propaganda -massive campaign focusing on: </li></ul><ul><li>- societal dangers of overpopulation </li></ul><ul><li>- the personal material benefits of having only one child </li></ul><ul><li>- quality of the offspring </li></ul>
    16. 17. The other side of choice: gender preference <ul><li>Son preference very common in pre-Communist China led to infanticide and neglect of girls resulting in skewed sex ratio </li></ul><ul><li>During Mao years less obvious and sex ratios within normal limits (at birth 103-107) </li></ul><ul><li>NOW sex ratios have risen - caused by: </li></ul><ul><ul><li>Son preference </li></ul></ul><ul><ul><li>Access to abortion </li></ul></ul><ul><ul><li>Low fertility </li></ul></ul>
    17. 18. Sex Ratio at birth in China since onset of Policy Sex-selective Abortion
    18. 19. Sex ratio in 1-4 age band XINJIANG QINGHAI NEI MONGOL GANSU NINGXIA SHAANXI XIZANG SICHUAN CHONGQING YUNNAN GUIZHOU GUANGXI HAINAN TAIWAN HUNAN JIANGXI ZHEJIANG FUJIAN GUANGD ONG HONG KONG MACAU Shanghai SHANGHAI SHI Guangzhou JIAN GSU ANHUI HUBEI HENAN SHANXI SHANDONG Shenyang HEBEI BEIJING SHI TIA NJIN LIAONING JILIN HEILONGJIANG 110 - 120 120 - 130 > 130 < 110
    19. 20. Provincial Policies XINJIANG QINGHAI NEI MONGOL GANSU NINGXIA SHAANXI XIZANG SICHUAN CHONGQING YUNNAN GUIZHOU GUANGXI HAINAN TAIWAN HUNAN JIANGXI ZHEJIANG FUJIAN GUANGD ONG HONG KONG MACAU Shanghai SHANGHAI SHI Guangzhou Chengdu JIAN GSU ANHUI HUBEI HENAN SHANXI SHANDONG Beijiing Shenyang HEBEI BEIJING SHI TIA NJIN LIAONING JILIN HEILONGJIANG Relaxed 1 Child Policy Medium 1 Child Policy Strict 1 Child Policy
    20. 21. SRB by birth order rises dramatically in some provinces Source: 2005 1% survey 142 138 111 Hainan 167 146 108 Guangdong 176 166 104 Henan 206 178 108 Jiangxi 227 190 107 Anhui Third Second First
    21. 22. Problems of excess males <ul><li>Men: problems of partners/marriage, mental health problems, socially disruptive behaviour </li></ul><ul><li>Daughters more valued because not competing with sons. Female education levels increased </li></ul><ul><li>But…trafficking, selling of women as brides </li></ul>
    22. 24. The reproductive health benefits <ul><li>Fewer pregnancies </li></ul><ul><li>Safe, legal abortion </li></ul><ul><ul><li>Work and education: acquire skills, education and training </li></ul></ul><ul><ul><li>Women’s status increased </li></ul></ul>
    23. 25. On the negative side <ul><li>Forced abortions/ pressure to have abortion </li></ul><ul><li>Problems with unapproved pregnancies: </li></ul><ul><ul><li>women with unapproved pregnancies less likely to seek antenatal care or to deliver in a modern medical facility </li></ul></ul><ul><li>Lack of choice in contraception </li></ul><ul><ul><li>80% of women interviewed for the NFPRHS (2001) said thay had no choice in contraception </li></ul></ul>
    24. 26. Attitudes <ul><li>To family size </li></ul><ul><li>To the Policy </li></ul>
    25. 27. Attitudes to family size Source Ding & Hesketh 2006
    26. 28. Attitudes to the Policy: qualitative study <ul><li>It is necessary- too many Chinese </li></ul><ul><li>One child is enough </li></ul><ul><li>Not equitable </li></ul><ul><li>Not aware that other countries have no restrictions </li></ul><ul><li>Life has changed – the Policy is not necessary anymore </li></ul><ul><li>Policy is getting more difficult to enforce </li></ul><ul><li>It’s bad when people can break the rules and get away with it </li></ul><ul><li>Even if there is a limit on the number of children there should be choice about when to have them </li></ul>
    27. 29. Abortion <ul><li>It is good that abortion is easy to get. </li></ul><ul><li>Bad that there is sometimes pressure to have abortion </li></ul><ul><li>If you know you’re going to have an abnormal child it is best to have an abortion </li></ul><ul><li>Sex-selective abortion is wrong. </li></ul><ul><li>People who do sex selective abortions should be punished </li></ul>
    28. 30. What is changing? <ul><li>More choice in contraception </li></ul><ul><li>Relaxation of the policy </li></ul><ul><li>Campaigns to promote the girl child </li></ul>
    29. 31. END

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