On the 29th October 2015, after 36 years since the implementation of ‘one child policy’, China has declared that the policy would be reversed for its citizens. Couples would be allowed to have up to two children. It would affect about 90 million Chinese families, but how many of them would contemplate to have a second child is uncertain. Ethnic minorities, rural families, and couples that were both only child themselves were already exempt from the one child policy existing rule. When the policy was relaxed in 2013 so that couples in whom one parent was an only child could have a second baby, only about 14% of the eligible 11 million couples showed their interests. The response was poorer in wealthy urban areas.1, 2 People in China have been used to a culture of one child for so many years that, psychologically, it would not be easy for them to change their mind-set to have more than one child. The present generations of couples in the reproductive age group have grown up with the concept of one child per family as ‘normal’ or ‘usual’. In addition, some couples consider having more than one child as too expensive to afford. Only time will tell how many of the eligible couples would contemplate to have a second child.
While the actual increase in the number of deliveries of a second baby is uncertain, it is likely to be greater than what it is at present. It is more than likely to have substantial quantitative and qualitative impact on the health and social services, demography, social structures and relations, businesses, economy etc. Following implementation of the two children policy, the impact on the health services would be immediate, especially in relation to Obstetrics & Gynaecology, Midwifery, Anaesthesia and Neonatology. The services would feel the pressure as the numbers of secondary infertility, multigravidae, elderly pregnant women, women with previous Caesarean section, women with previous difficult vaginal instrumental delivery/third or fourth degree tear etc are likely to increase along with an increase in the number of delivery of babies. Therefore, a careful manpower and infrastructure planning in relation to Obstetrics & Gynaecology, Midwifery, Anaesthesia and Neonatology would be required to deal with the increased workload and provide a safe patient care. It is expected that more outpatient facilities, obstetric beds and theatre facilities, neonatal cots and facilities in the community would be required with adequate increase in the number of relevant skilled staff. This would need to be supported by appropriately increasing the financial allocation for the relevant healthcare areas in the health budget. Dealing with the expected increase in the number of elderly pregnant women, women with previous Caesarean section, women with previous difficult vaginal instrumental delivery, previous third or fourth degree tear etc would pose an additional challenge for the Obstetricians because of the increased risks of morbidity and complexity in decision making associated with them.3, 4 Increase in the number of pregnant women with previous Caesarean section might be substantial given the fact that the overall Caesarean section rate in China has increased from 22% in 1994 to 60% in 2003 and moderated to 56% in 2006. The corresponding rates of Caesarean section on maternal request were 0.8%, 22%, and 20% respectively, reaching about 50% of all Caesarean sections in some areas. Association between the rate of Caesarean section on maternal request and advanced maternal age, hospital level or maternal occupations, that was suggested previously, was not found in a recent study.5, 6A dramatic increase in the Caesarean section rate in primiparous women in rural China from 1% in 1991 to 17% in 2002 has also been reported.6 Another study on multiparous women has reported a significant rise in the Caesarean section rate over the years [13.1%, 28.3% and 50.4% (χ(2) trend = 17 829.0, p<0.001) during 1993-1995, 1996-2000 and 2001-2005 respectively]. In women with previous Caesarean section the rate during 2001-2005 was as high as 97.5% and in women without previous Caesarean section it was 40.3%. The rate of Caesarean section on maternal request did rise significantly as well [0.6%, 3.8%, and 12.9% (χ(2) trend = 7 729.0, p<0.001) during 1993-1995, 1996-2000 and 2001-2005 respectively], and 35.9% of the primary Caesarean sections during 2001-2005 were performed on maternal request in women without previous Caesarean section that were 14.4% of all Caesarean sections.7 Therefore, increase in the number of pregnant women with previous Caesarean section might have a substantial impact on the obstetric services and given the fact that, as the study has reported, 97.5% of them had a repeat Caesarean section, managing them in labour and keeping the Caesarean section rate down would be a major challenge for the Obstetricians. It might require change in the perception regarding their mode of delivery, change in practice, staff training and improvement in the availability of resources. There would potentially be increased demand on the social services as the numbers of pregnant women and babies increase. The staff involved in the family planning might be used to meet this increased demand as their work-load in family planning might become a bit lighter. More childcare and school facilities with increase in the number of staff and teachers would be needed as well. In 2005, the number of males under the age of 20 in China exceeded females by 32 million and sex selective termination was considered as the main reason.8 A recent study has also reported a male:female ratio of 1.2 in late pregnancy.9 The policy change is likely to have an effect on the demography, social structures and relations, and might reverse the consequences of the one child policy.10 Even if the programme could be implemented successfully, the change in demography e.g. male:female ratio, working age population would require many years to happen and might not reach optimum level as the population projection suggests that China’s population aged 65 and above would almost triple from 9% in 2010 (114 million) to 24% (331 million) by 2050. The working population aged 20-34 is projected to shrink from 25% (333 million) in 2010 to 16% (228 million) by 2050. The total population has grown by around 200 million over last 20 years despite having below replacement fertility for the same period, and is likely to continue growing for another 15 years.2 According to data from the United Nations, over 67% of the population is aged between 15 and 59. But by 2050, that number will shrink to 50%, while over a third of the population will be over 60.1 The impact on the businesses involved in pregnancy and baby related products, private healthcare and childcare etc are likely to get a boost within a year or so of the policy implementation, followed by private schools, other educational institutions, publishers of educational materials etc.1 The impact on the overall Chinese and Global economy would depend on the rate of increase in the population, the working age population in particular, that would take many years even if the number of babies born in China increases substantially from 2016. The reversal of ‘one child policy’ in China is likely to increase the number of babies born from 2016 onwards. While the exact volume of increase is hard to predict as it depends on multiple variables, the authorities should be prepared for the potential increase in the workload, especially in the relevant healthcare services that are likely to face the brunt first. An estimation of the potential increase in the workload could be made by collecting data on the number of couples expressing intention to have a second baby and the number of early pregnancies diagnosed. If, for example, 10 million couples express their wish to try for a second baby, up to about 2 million early pregnancies would be expected after a month of trying (based on 20% chance of conceiving in the first month of trying). The number of early pregnancies in 12 months would be about 8.4 million (based on 84% chance of conceiving after 12 months of trying).11, 12 The corresponding numbers of ongoing pregnancies beyond the first trimester would be 1.7 million and 7.14 million for a month and 12 months of trying respectively (based on a 15% first trimester miscarriage rate).12 It would help planning ahead to provide for the optimum infrastructure and resources. The healthcare professionals, the Obstetricians in particular, should prepare well to deal with an increased workload and potentially a different composition of pregnant women with a greater number of multigravidae, especially women with previous Cesarean section. It would probably take 15-20 years following implementation of the ‘two children policy’ before we could assess its impact reasonably well.
1. Mak R. China’s two-child policy delivers wrong baby boom. Breakingviews, Reuters. 30 October 2015. http://blogs.reuters.com/breakingviews/2015/10/30/chinas-two-child-policy-delivers-wrong-baby-boom/. Accessed on 30 October 2015. 2. Basten S, Jiang Q. China’s family planning policies: recent reforms and future prospects. Stud Fam Plann 2014;45(4):493-509. 3. Smith GCS, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003; 362(9398):1779-84. 4. Daltveit AK, Tollånes MC, Pihlstrøm H, Irgens LM.Cesarean delivery and subsequent pregnancies. Obstet Gynecol 2008;111(6):1327-34. 5. Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z.Cesarean delivery on maternal request in southeast China. Obstet Gynecol 2008;111(5):1077-82. 6. Klemetti R, Che X, Gao Y, Raven J, Wu Z, Tang S, Hemminki E. Cesarean section delivery among primiparous women in rural China: an emerging epidemic. Am J Obstet Gynecol 2010;202(1):65.e1–65.e6. 7. Cui HS, Li HT, Zhu LP, Li ZW, Zhou YB, Liu JM. [Secular trends in cesarean delivery and cesarean delivery on maternal request among multiparous women who delivered a full-term singleton in Southern China during 1993-2005]. [Article in Chinese] Beijing Da Xue Xue Bao 2013;45(3):422-6. 8. Zhu WZ, Lu L, Hesketh T. China’s excess males, sex selective abortion, and one child policy: analysis of data from 2005 national intercensus survey. BMJ 2009;338:b1211. 9. Hou L, Wang X, Li G, Zou L, Chen Y, Zhang W. Cross sectional study in China: fetal gender has adverse perinatal outcomes in mainland China. BMC Pregnancy Childbirth 2014;14:372. 10. Feng W. The Future of a Demographic Overachiever: Long-Term Implications of the Demographic Transition in China. Population and Development Review 2011;37:173–90. 11. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline. Fertility: assessment and treatment for people with fertility problems, 2nd edn. London: National Institute for Health and Clinical Excellence 2013. 12. Paul S. Infertility – A Growing Problem, The Facts and Solutions. Themedideas. http://themedideas.com/health/obst-gynae-health/gynaecology-gynecology/infertility-gynaecology-gynecology/introduction-to-infertility/. Accessed on 31 October 2015.
© Dr Sudipta Paul, themedideas.com, 2015