Is Induced Abortion a Part of Family Planning in China?

*Jinlin Liu, Yvon Englert and Wei-Hong Zhang*

#### **Abstract**

Family planning policy is one of the basic policies in China. Since the founding of New China, it has gone through three stages during its development process, which include free fertility policy, one-child policy (including selective two-child policy), and universal two-child policy. The number of induced abortions in China has increased from 3,910,110 in 1971 to 9,626,731 in 2017, and the proportion of induced abortions in birth control surgeries of family planning in China has increased from 30.0% in 1971 to 50.6% in 2017. It is concluded that although induced abortion is not a part of the family planning policy of China, it has been a part of family planning services in China.

**Keywords:** family planning, induced abortion, policy, contraception, China

#### **1. Introduction**

As one of the basic policies in China, the family planning policy plays a vital role in regulating the fertility level of the population and the total population number. Before 2016, the one-child policy of China is well known all over the world due to its strict regulation and implementation. As one of the important means of birth control surgeries, many scholars think that induced abortion is a part of China's family planning policy and plays an important role during the implementation process of one-child policy. This chapter will make a macroanalysis of the history and current situation of the family planning policy and induced abortion in China and further analyze the relationship between them, thus to finally answer whether induced abortion is a part of family planning in China.

#### **2. The history and current situation of the family planning policy in China**

As is known to all, the family planning policy remains one of the basic policies in China. Actually, the family planning policy has existed since ancient China. Beginning with the establishment of Qin dynasty, the family planning policy was always implemented to encourage fertility from 221 BC to 617 AD. In Tang dynasty which was the height of feudal age, it had been a basic state policy to encourage fertility from 618 to 907 AD [1]. However, from then on, some scholars had begun to suggest to control the population growth speed.

Wang Fanzhi, who was a poet in the early period of Tang dynasty, was regarded as the first person to put forward that one couple should only have one child. In the

**14**

*Induced Abortion and Spontaneous Early Pregnancy Loss - Focus on Management*

[1] Fernandes AG. Aborto; aspectos jurídicos e políticos. In: Martins IGS, Carvalho PB, editors. Inviolabilidade do Direito à Vida. São Paulo: Noeses; 2013.

[2] Meira AR. Editorial da revista. Reprodução e Climatério. 2015;**30**(2). DOI: 10.1016/j.reclic 2015,09/003

[3] Meira AR. A incongruência no abortamento. Suplemento Cultural da

Revista da APM. 2019. n°310

[4] Torres JHR. Abortos; artigos [Abortion]. São Paulo; 2016

[5] Meira AR. Abortion and Family Planning in Family Planning. London: IntechOpen; 2018. pp. 279-298

[6] Proença NG. Abortamento sim ou não? Suplemento da Revista da APM.

abortamento. Suplemento Cultural da

[7] Meira AR. A Medicine e o

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[8] Meira, A.R. Abortamento: Introducão e Perspectivas, New Academic Editions, Saarbrucken; 2017.

pp. 79-92

**References**

2019. n°309

p. 80

**Figure 1.**

*Development process of family planning policy in China since 1949.*

later dynasties of Song, Ming, and Qing, although there were no specific regulations in family planning policies, the governments did not encourage fertility. Ma Duanlin, a famous scholar in the end of the Song dynasty and the author of *Wenxian Tongkao*, put forward a relatively complete family planning theory which included fewer births, healthier births, and paying more attention to comprehensive population quality. And it was very similar with the modern population and family planning policy in China. Wang Meicun, the demographer in Qing dynasty and the author of *Yi Bing Ri Ji*, was regarded as the first person to put forward that the government should reduce its population birth rate. He put forward the strategy for controlling population growth by implementing drug abortion on women after the first child [2–4].

After the founding of the New China, with the changes of country situation, the China's family planning policy has gone through three big stages with a series of reforms [5]. **Figure 1** shows the development process of family planning policy in China since 1949.


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*Is Induced Abortion a Part of Family Planning in China? DOI: http://dx.doi.org/10.5772/intechopen.86342*

policy also includes some key aspects as follows:

issuing a counterfeit certificate of family planning.

In September 2002, the *Population and Family Planning Law of the People's Republic of China* came into effect. From then on, the Chinese government encouraged the couple who are both from one-child families to have two children. In November 2013, it was proposed to implement the policy of selective two-child policy in the *Decision of the Central Committee of the Communist Party of China on Some Major Issues Concerning Comprehensive Deepening the Reform*, which meant that the couple that as long as one of them was from the one-child family could have two children. However, it did not work well. Some scholars pointed out that China has fallen into the low fertility rate trap. In October 2015, the 18th Central Committee of the Chinese Communist Party decided to abolish the basic one-child policy and selective two-child policy and to replace them by a universal two-child policy which meant that every couple can have two children. The revised *Population and Family Planning Law of the People's Republic of China* has come into effect since January 1, 2016 [8–11].

In general, after being implemented for 40 years, the Chinese government considers the family planning policy to be a great success, because it has significantly reduced population growth. The fertility rate has dropped from 5.8 in the 1970s to 1.7 in 2013 [12]. China has entered the ranks of low-fertility-level counties. The ability and quality of family planning services are quickly upgraded. And it has significantly improved the population quality. However, the policy has its drawbacks. For instance, the age structure of population is unbalanced, the birth sex ratio is unbalanced, the population quality is different between urban and rural areas, etc. [13]. At present, besides the universal two-child policy, the Chinese family planning

First, in terms of the reproduction regulation, (1) family planning shall be implemented chiefly by means of contraception. The state creates conditions to ensure that individual citizens have the rights of informed choice to choose safe, effective, and appropriate contraceptive methods. When birth control operations are performed, the recipients' safety shall be ensured; (2) couples of reproductive ages shall conscientiously adopt contraceptive methods and accept technical services and guidance for family planning. Incidence of unwanted pregnancies shall be prevented and reduced; and (3) couples of reproductive ages who implement family planning shall receive the

basic items of family planning technical services specified by the state for free.

**3. The history and current situation of induced abortion in China**

Induced abortion is a concept of modern medicine which is different from spontaneous abortion. However, induced abortion has existed since ancient times in China. In ancient China, encouraging fertility is not only a kind of conception

Second, in terms of the family planning technical services, (1) the state establishes premarital healthcare and maternal healthcare systems, thus to prevent or reduce the incidence of birth defects and improve the health of newborns; (2) the governments at all levels shall take measures to ensure citizens' access to technical services for family planning in order to improve their reproductive health; and (3) persons who provide technical services for family planning shall give guidance in citizens who implement family planning in choosing the safe, effective, and appropriate contraceptive methods. Third, the illegal behaviors include (1) illegally performing operations to family planning on other persons, (2) using ultrasonography or other techniques to identify fetal gender or to bring about sex-selective pregnancy termination for nonmedical purposes for other persons, and (3) providing a fake medical report or

*Induced Abortion and Spontaneous Early Pregnancy Loss - Focus on Management*

later dynasties of Song, Ming, and Qing, although there were no specific regulations in family planning policies, the governments did not encourage fertility. Ma Duanlin, a famous scholar in the end of the Song dynasty and the author of *Wenxian Tongkao*, put forward a relatively complete family planning theory which included fewer births, healthier births, and paying more attention to comprehensive population quality. And it was very similar with the modern population and family planning policy in China. Wang Meicun, the demographer in Qing dynasty and the author of *Yi Bing Ri Ji*, was regarded as the first person to put forward that the government should reduce its population birth rate. He put forward the strategy for controlling population growth by implementing drug abortion on women after the first child [2–4]. After the founding of the New China, with the changes of country situation, the China's family planning policy has gone through three big stages with a series of reforms [5]. **Figure 1** shows the development process of family planning policy in

*Development process of family planning policy in China since 1949.*

1.The first stage was from the time of country founding to the early 1970s. Affected by the former Soviet Union's theory of encouraging population growth, the Great Leap Forward and the national famine from 1959 to 1961 in China and other factors, although the Chinese government advocated independent birth control, the society presented a trend of substantially fair

2.The second stage was from the mid-1970s to late 1990s. The family planning policy was adopted by the Chinese Government in the mid- and late 1970s to respond to the challenge of China's enormous population. It was identified as one of the basic national policies in the 12th National Congress of the Communist Party of China and was written into the national constitution in December 1982. From then on, the family planning policy of advocating that one couple should only have one child was implemented forcibly to strictly control the population growth speed. In particular, the Chinese government relaxed the policy regulation in rural areas and allowed families with a girl as

3.The third stage was from the early 2000s to date. With the continuous decline of population total fertility rate and serious challenge by the impending aging society, the Chinese government began to pay more attention on how to make adjustment on the family planning policy thus to promote population growth to a certain extent and change the imbalanced age structure of the population.

fertility which has led to the rapid population growth [6].

the first child to have a second child [7].

**16**

China since 1949.

**Figure 1.**

In September 2002, the *Population and Family Planning Law of the People's Republic of China* came into effect. From then on, the Chinese government encouraged the couple who are both from one-child families to have two children. In November 2013, it was proposed to implement the policy of selective two-child policy in the *Decision of the Central Committee of the Communist Party of China on Some Major Issues Concerning Comprehensive Deepening the Reform*, which meant that the couple that as long as one of them was from the one-child family could have two children. However, it did not work well. Some scholars pointed out that China has fallen into the low fertility rate trap. In October 2015, the 18th Central Committee of the Chinese Communist Party decided to abolish the basic one-child policy and selective two-child policy and to replace them by a universal two-child policy which meant that every couple can have two children. The revised *Population and Family Planning Law of the People's Republic of China* has come into effect since January 1, 2016 [8–11].

In general, after being implemented for 40 years, the Chinese government considers the family planning policy to be a great success, because it has significantly reduced population growth. The fertility rate has dropped from 5.8 in the 1970s to 1.7 in 2013 [12]. China has entered the ranks of low-fertility-level counties. The ability and quality of family planning services are quickly upgraded. And it has significantly improved the population quality. However, the policy has its drawbacks. For instance, the age structure of population is unbalanced, the birth sex ratio is unbalanced, the population quality is different between urban and rural areas, etc. [13].

At present, besides the universal two-child policy, the Chinese family planning policy also includes some key aspects as follows:

First, in terms of the reproduction regulation, (1) family planning shall be implemented chiefly by means of contraception. The state creates conditions to ensure that individual citizens have the rights of informed choice to choose safe, effective, and appropriate contraceptive methods. When birth control operations are performed, the recipients' safety shall be ensured; (2) couples of reproductive ages shall conscientiously adopt contraceptive methods and accept technical services and guidance for family planning. Incidence of unwanted pregnancies shall be prevented and reduced; and (3) couples of reproductive ages who implement family planning shall receive the basic items of family planning technical services specified by the state for free.

Second, in terms of the family planning technical services, (1) the state establishes premarital healthcare and maternal healthcare systems, thus to prevent or reduce the incidence of birth defects and improve the health of newborns; (2) the governments at all levels shall take measures to ensure citizens' access to technical services for family planning in order to improve their reproductive health; and (3) persons who provide technical services for family planning shall give guidance in citizens who implement family planning in choosing the safe, effective, and appropriate contraceptive methods.

Third, the illegal behaviors include (1) illegally performing operations to family planning on other persons, (2) using ultrasonography or other techniques to identify fetal gender or to bring about sex-selective pregnancy termination for nonmedical purposes for other persons, and (3) providing a fake medical report or issuing a counterfeit certificate of family planning.

#### **3. The history and current situation of induced abortion in China**

Induced abortion is a concept of modern medicine which is different from spontaneous abortion. However, induced abortion has existed since ancient times in China. In ancient China, encouraging fertility is not only a kind of conception

but also an official policy implemented by the rulers; thus the rulers were opposed to abortion. Since the Qin dynasty and Han dynasty, forced abortions of pregnant women or causing death by abortions would be regarded as criminal acts [14]. The earliest records about abortion in Chinese history began in the Han dynasty, and it had formed three kinds of abortion skills which included drug abortion, external force abortion, and acupuncture abortion. After the Tang dynasty and Song dynasty, due to the pressure of population growth, abortions had become a universal tendency in some areas, which finally led to the open and profession of abortion [15]. In the Qing dynasty, the Republic of China, and the early period of New China during twentieth century, abortion is still regarded as a criminal act which was clearly specified in related criminal laws. At the beginning of New China, the central government strictly restricted sterilization and induced abortion. However, in August 1953, with the promulgation of the Guide for Contraception and Induced Abortion in China, induced abortion had been legalized basically. Since 1979, the crime of abortion had been abolished from the new criminal law of China [16]. At present, abortion in Taiwan of China still remains a crime unless during emergency [17].

In general, as shown in **Figure 2**, according to the statistical results in *China Health Statistics Yearbook 2018*, the overall level of induced abortion of family planning in China presents a trend of ups and downs from 1971 to 2017. In 1971, the number of induced abortions was 3,910,110, and it reached the highest level in history in 1983 with 14,371,843. Then the number was maintained between 600 and 800 million in the twentieth century. At present, the number of induced abortions in China was 9,626,731 in 2017, which was about 2.5 times than that in 1978. **Figure 3** shows the proportions of induced abortions in birth control survey of family planning in China from 1971 to 2017. It presents an overall trend of gradual growth from 30.0% in 1971 to 50.6% in 2017.

In addition, there are some other research results about the induced abortion situation in China [18–22]. First, induced abortion among females presents a younger trend. The age of women who had induced abortions is mainly distributed from 20 to 29 years old, and those who are under 25 years account for nearly half. Second, the proportion of induced abortions of young unmarried women ranges from 20 to 30% among all induced abortions, and their age are basically under 24 years old. Third, among married women who have induced abortions, the peak

**19**

*Is Induced Abortion a Part of Family Planning in China? DOI: http://dx.doi.org/10.5772/intechopen.86342*

period of induced abortions is within 4 years after being married. Fourth, the

**4. Relationship between the family planning policy and induced** 

There are four main reasons related to the overall induced abortion in China [23–25], including unintended pregnancy with non-contraception, unintended pregnancy with contraception failure, sex selection (son preference especially in rural areas), and non-compliance with regulations of the family planning policies.

Since the founding of New China, the family planning policy is implemented chiefly relying on the means of contraception. Induced abortion is just a remedial measure for contraceptive failure. However, induced abortion was considered to have played an important role in the early period of the rapid decline of fertility rate after the implementation of the one-child policy in China, which attracted wide

The Chinese government has always advocated the contraceptive prevention for achieving the goal of birth control. The methods of intrauterine devices (IUD), sterilization, and tubal ligation were widely used in the early period of one-child policy. However, with the population boom in the late 1970s and the implementation of one-child policy in the early 1980s, the strict control indicator on fertility number has made induced abortion as one of the most important technical means for local governments at all levels in China from the 1980s to the early 1990s [28, 29], which resulted in the rapid increase of induced abortion rate and the rapid decline of fertility rate. Actually, at that time, the strict control indicator on fertility number, "one-vote negation system" of family planning, standard assessment on contraceptive rate, etc. had been the important ways for local government performance assessment and cadre promotion. What is more, many forced abortions have taken place in China [30, 31]. Since the mid-1990s, the family planning policy has undergone several adjustments and improvements, one important adjustment of which was the intervention action to reduce the number of policy-caused induced abortions, and followed by a signifi-

proportion of repeat abortions is generally from 30 to 50%.

*Proportion of induced abortions in birth control surgery of family planning.*

attention from the international community [26, 27].

cant decline of the induced abortion rate later in China [32].

**abortion in China**

**Figure 3.**

**Figure 2.** *Number of induced abortions within family planning services in China.*

*Is Induced Abortion a Part of Family Planning in China? DOI: http://dx.doi.org/10.5772/intechopen.86342*

#### **Figure 3.**

*Induced Abortion and Spontaneous Early Pregnancy Loss - Focus on Management*

Taiwan of China still remains a crime unless during emergency [17].

30.0% in 1971 to 50.6% in 2017.

In general, as shown in **Figure 2**, according to the statistical results in *China Health Statistics Yearbook 2018*, the overall level of induced abortion of family planning in China presents a trend of ups and downs from 1971 to 2017. In 1971, the number of induced abortions was 3,910,110, and it reached the highest level in history in 1983 with 14,371,843. Then the number was maintained between 600 and 800 million in the twentieth century. At present, the number of induced abortions in China was 9,626,731 in 2017, which was about 2.5 times than that in 1978. **Figure 3** shows the proportions of induced abortions in birth control survey of family planning in China from 1971 to 2017. It presents an overall trend of gradual growth from

In addition, there are some other research results about the induced abortion situation in China [18–22]. First, induced abortion among females presents a younger trend. The age of women who had induced abortions is mainly distributed from 20 to 29 years old, and those who are under 25 years account for nearly half. Second, the proportion of induced abortions of young unmarried women ranges from 20 to 30% among all induced abortions, and their age are basically under 24 years old. Third, among married women who have induced abortions, the peak

but also an official policy implemented by the rulers; thus the rulers were opposed to abortion. Since the Qin dynasty and Han dynasty, forced abortions of pregnant women or causing death by abortions would be regarded as criminal acts [14]. The earliest records about abortion in Chinese history began in the Han dynasty, and it had formed three kinds of abortion skills which included drug abortion, external force abortion, and acupuncture abortion. After the Tang dynasty and Song dynasty, due to the pressure of population growth, abortions had become a universal tendency in some areas, which finally led to the open and profession of abortion [15]. In the Qing dynasty, the Republic of China, and the early period of New China during twentieth century, abortion is still regarded as a criminal act which was clearly specified in related criminal laws. At the beginning of New China, the central government strictly restricted sterilization and induced abortion. However, in August 1953, with the promulgation of the Guide for Contraception and Induced Abortion in China, induced abortion had been legalized basically. Since 1979, the crime of abortion had been abolished from the new criminal law of China [16]. At present, abortion in

**18**

**Figure 2.**

*Number of induced abortions within family planning services in China.*

*Proportion of induced abortions in birth control surgery of family planning.*

period of induced abortions is within 4 years after being married. Fourth, the proportion of repeat abortions is generally from 30 to 50%.

There are four main reasons related to the overall induced abortion in China [23–25], including unintended pregnancy with non-contraception, unintended pregnancy with contraception failure, sex selection (son preference especially in rural areas), and non-compliance with regulations of the family planning policies.

#### **4. Relationship between the family planning policy and induced abortion in China**

Since the founding of New China, the family planning policy is implemented chiefly relying on the means of contraception. Induced abortion is just a remedial measure for contraceptive failure. However, induced abortion was considered to have played an important role in the early period of the rapid decline of fertility rate after the implementation of the one-child policy in China, which attracted wide attention from the international community [26, 27].

The Chinese government has always advocated the contraceptive prevention for achieving the goal of birth control. The methods of intrauterine devices (IUD), sterilization, and tubal ligation were widely used in the early period of one-child policy. However, with the population boom in the late 1970s and the implementation of one-child policy in the early 1980s, the strict control indicator on fertility number has made induced abortion as one of the most important technical means for local governments at all levels in China from the 1980s to the early 1990s [28, 29], which resulted in the rapid increase of induced abortion rate and the rapid decline of fertility rate. Actually, at that time, the strict control indicator on fertility number, "one-vote negation system" of family planning, standard assessment on contraceptive rate, etc. had been the important ways for local government performance assessment and cadre promotion. What is more, many forced abortions have taken place in China [30, 31]. Since the mid-1990s, the family planning policy has undergone several adjustments and improvements, one important adjustment of which was the intervention action to reduce the number of policy-caused induced abortions, and followed by a significant decline of the induced abortion rate later in China [32].

The informed choice promoted in the International Conference on Population and Development in 1994 had provided good external environment for the transformation of China's contraceptive work, in particular, to reduce the induced abortion level [33]. Since March 1995, China began to implement the policy of informed choice and cancel part of related assessment indicators such as sterilization rate, induced abortion rate, etc. Through implementing the combined way, guided by the professional technical person and self-selection of contraceptive measures by the residents, it popularized the high-quality services of family planning and reduced the induced abortion rate [34]. The importance of the informed choice right was confirmed legally by the *Population and Family Planning Law of the People's Republic of China* promulgated in December 2001. Meanwhile, the legality of social upbringing fee or compensation fee was clarified for the first time, which made those women of unintended pregnancy have the possibility of unplanned fertility and further reduced the rate of induced abortion.

As one of the important assisted birth control methods in the implementation process of family planning policy in China, the level of induced abortion is significantly affected by the development trend of the family planning policy [7]. The rate of induced abortion when the one-child policy is implemented strictly to control the fertility rate is significantly higher than when the family planning policy is implemented moderately. A previous study showed that the induced abortion risk of married women of reproductive age was reduced by about 24% [32]. Under the background of moderate family planning policy, on the one hand, the establishment of social upbringing fee or compensation fee system makes it possible for women of reproductive age with unintended pregnancies to have the unplanned fertility choice; on the other hand, the implementation of informed choice policy gives women a certain amount of informed choice right in which they can choose the appropriate contraceptive measures by themselves, which can improve the contraception effect and avoid the unintended pregnancy to a certain extent, thus to reduce the risk of induced abortion relatively in China [35–39]. Using *China Population and Reproductive Health Survey Data* in 1997, Chen Wei analyzed the influencing factors of induced abortion of Chinese women, and the results showed that the family planning policy did not have significant impact on induced abortion of the women pregnant for the first time, but the effect would be increased significantly with the increase of pregnancy time [27, 40]. Other related studies found that unwanted pregnancy caused by contraceptive failure was the primary reason of induced abortion in China [26, 41]; however, non-compliance with the regulations of family planning policy was the main reason of induced abortion in rural areas in China [29].

In addition, although there is no clear regulation in the latest *Population and Family Planning Law of the People's Republic of China*, many local governments, family planning service institutions, and other related organizations have implemented the post-abortion family planning service (PAFPS) to reduce the risk of repeat abortion. Meanwhile, the *Family Planning Branch of Chinese Medical Association* has developed the guide of post-abortion family planning service [42].

#### **5. Conclusions**

In general, although induced abortion is never being regulated or clarified specifically in any related authoritative family planning policies or family planning laws actually in which it always emphasizes the importance of contraception, as the primary remedial measure of contraceptive failure, induced abortion has played a non-negligible and important role in controlling the fertility rate. Meanwhile, the induced abortion level in China is constantly changing with the development of

**21**

*Is Induced Abortion a Part of Family Planning in China? DOI: http://dx.doi.org/10.5772/intechopen.86342*

it has been a part of the family planning service in China.

Seventh Framework Programme (FP7), grant number 282490.

**Acknowledgements**

**Conflict of interest**

**Author details**

Jinlin Liu1

We declare no conflict of interest.

, Yvon Englert<sup>2</sup>

Assessment, Xi'an Jiaotong University, Xi'an, China

family planning policy. Undeniably, China has achieved its objective of birth control by implementing the one-child policy, but it has also led to higher rate of induced abortion which means that Chinese women face higher risks of reproductive health. However, with the implementation of universal two-child policy and further advancement of PAFPS in China, the induced abortion level of family planning in China maybe further reduced which is worth looking forward to. Meanwhile, induced abortion of unmarried women who are not in the scope of family planning policy and service should be paid much more attention to. Therefore, although we cannot conclude that induced abortion is a part of family planning policy in China,

We appreciate the funding provided by the European Commission (EC)'s

and Wei-Hong Zhang2,3,4\*

1 Research Center for the Belt and Road Health Policy and Health Technology

2 Research Laboratory for Human Reproduction, Faculty of Medicine, School of

3 International Centre for Reproductive Health (ICRH), Department of Public

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium

4 Research Centre for Public Health, Tsinghua University, Beijing, China

Health and Primary Care, Ghent University, Ghent, Belgium

\*Address all correspondence to: weihong.zhang@ugent.be

provided the original work is properly cited.

*Is Induced Abortion a Part of Family Planning in China? DOI: http://dx.doi.org/10.5772/intechopen.86342*

family planning policy. Undeniably, China has achieved its objective of birth control by implementing the one-child policy, but it has also led to higher rate of induced abortion which means that Chinese women face higher risks of reproductive health. However, with the implementation of universal two-child policy and further advancement of PAFPS in China, the induced abortion level of family planning in China maybe further reduced which is worth looking forward to. Meanwhile, induced abortion of unmarried women who are not in the scope of family planning policy and service should be paid much more attention to. Therefore, although we cannot conclude that induced abortion is a part of family planning policy in China, it has been a part of the family planning service in China.
