Intended for healthcare professionals

Education And Debate

Health in China: The one child family policy: the good, the bad, and the ugly

BMJ 1997; 314 doi: (Published 07 June 1997) Cite this as: BMJ 1997;314:1685
  1. Therese Hesketh, research fellowa,
  2. Wei Xing Zhu, programme manager, East Asiab
  1. a Centre for International Child Health, London WC1 N1EH
  2. b Health Unlimited, London SE1 9NT
  1. Correspondence to: Dr Hesketh


    Rapid population growth in China during the 1950s and '60s led to the “late, long, few” policy of the 1970s and a dramatic reduction in the total fertility rate. However, population growth remained too high for the economic targets of Deng Xiao Ping's reforms, so the one child family policy was introduced in 1979 and has remained in force ever since. The strategy is different in urban and rural areas, and implementation varies from place to place depending on local conditions. The policy has been beneficial in terms of curbing population growth, aiding economic growth, and improving the health and welfare of women and children. On the negative side there are concerns about demographic and sex imbalance and the psychological effects for a generation of only children in the cities. The atrocities often associated with the policy, such as female infanticide, occur rarely now. China may relax the policy in the near future, probably allowing two children for everyone.

    “Late, long, few”

    Mao Ze Dong said there could never be too many Chinese: human resources would be China's greatest defence in the widely predicted third world war. So the population of China rose from 540 million in 1950 to over 850 million by 1970 (fig 1). This rapid increase led to the “late, long, few” policy in the mid-'70s. This policy called for later child bearing, longer spacing, and fewer children and was a largely conventional family planning programme.1 As a result the average number of children born to each woman dropped from 5.93 in 1970 to 2.66 in 1979. But this was still too high; the baby boomers of the 1950s and ‘60s were entering their reproductive years, and by 1979 around two thirds of the population were under 30.

    FIG 1
    FIG 1

    Population growth in China

    One family, one child

    Population projections worried Deng Xiao Ping, who was launching his economic reform programme. He regarded the curbing of population growth as essential for economic expansion and improved living standards, so the one child family policy was introduced in 1979. The boldness of the policy is all the more remarkable in view of the Chinese traditional love of children, the dependence of parents on their children in old age, and of course the thorny problem of the traditional preference for boys.

    By 1984 the fertility rate was reported to have dropped to 1.94. The apparent demographic success of the policy together with its unpopularity, especially in the countryside, led to some relaxation. (It was later discovered that there was considerable underregistration of births in rural areas and the actual fertility rate was probably closer to 2.5.) Since 1984 there have been alternate relaxations and tightenings according to population projections, but the policy has never returned to the stringency of the early 1980s

    How does it work?

    The State Family Planning Bureau, which is separate from the Ministry of Public Health, sets overall targets and policy direction. Family planning committees at provincial and county level devise the strategy for implementation, specifying rewards for taking the One Child Pledge and the penalties for failure to comply.2 In the cities (where around 25% of the population lives) the policy is strictly applied, with a few exemptions. In the cities in Zhejiang province, for example, a couple is exempt:

    • If the first child has a defect (defects which are allowed are specifically defined)

    • In the case of remarriage if one partner has no child by the previous marriage

    • If they belong to certain groups of workers such as miners

    • If both partners are themselves from one child families.

    The final exemption, although not yet universally applied, is very important, since it implies that the policy will hold for one generation only.

    In the cities young people marry late (the minimum age allowed by family planning policy for marriage is 23 for women and 25 for men). The favoured methods of contraception in the cities are the intrauterine device and the contraceptive pill, which is routinely distributed to married women in many work units. Women who become pregnant for a second time or outside marriage are expected to have an abortion.

    What appears to us a draconian policy is accepted with equanimity by many urban Chinese. This is perhaps not so surprising considering the suffocating overcrowding of many Chinese cities, the cramped living conditions, the pressures of child care with two working parents (as is almost always the case), and the high cost of raising children. Compliance is encouraged through the Chinese propaganda machine with its range of slogans: “With two children you can afford a 14 inch TV, with one child you can afford a 21 inch TV”; “The One Child Family Policy can guarantee that children will be better cared for and educated.”

    In the countryside the picture is rather different. Here the one child family policy is a misnomer. The traditional preference for boys is acknowledged, so in most places a couple is allowed after a five year gap to try for a second child if the first is a girl. In some areas this is permitted irrespective of the sex of the first child. Third and fourth children are still not rare and are officially permitted for ethnic minorities and in underpopulated areas. The 1990 national population census showed that the proportion of third and higher parity births was 19.5%,3 and the total fertility rate was 2.31. This had fallen to 2.1 in 1992.4


    The two child family is the norm in most of rural China

    In the countryside most women use the intrauterine device, which in most places is inserted routinely at the six week postpartum check. Sterilisation is more common in rural areas than in the cities, especially after second or third children. Women may be pressured into having abortions, but physical force seems to be a thing of the past. The penalties for an “illegal” pregnancy carried to term vary, often at the whim of local officials, from no penalty through loss of benefits for the first child, fines, job loss, and seizure of possessions. To avoid coercion and penalties many women now go and deliver elsewhere, where they cannot be tracked down by family planning authorities. The new mobility of the workforce, free to seek work in the cities, has made this much easier.

    There are rewards for those who take the One Child Pledge. Urban couples receive a monthly stipend of around 5% of the average worker's wage until the child reaches the age of 14, preferential treatment when applying for housing, increased maternity leave, highest priority in education and health care for the child, and a supplementary pension because of the problem of lack of support in old age. In rural areas the family receives a larger allocation of farming plot.1

    Consequences of “one family, one child”

    The good

    There is much good about the one child family policy. That China is controlling its population is clearly of benefit for the whole world as natural resources per capita diminish. There have even been calls for a one child world.5 China would certainly be heavily criticised if unrestrained population growth was allowed. It is also arguable that for people accustomed to little freedom in many areas of their lives, control over fertility is easier to accept. Impressive evidence is now emerging that couples, even in the rural areas, no longer see large families as an asset. Concerns about division of farmland among children are cited as one important reason.6 In 1985, the in depth fertility study, carried out in three rural areas of different socioeconomic level, found that the mean number of children preferred by young married couples was 1.8 in the wealthy Shanghai hinterland, 2.7 in middle income Hebei, and 2.87 in Shaanxi, one of the poorest provinces

    And there are direct benefits to children and mothers. Children benefit from the increased resources devoted to them, and girl children benefit particularly, since families place all their investment in them, with no competition from sons. Mothers are freed from the burden of continuous pregnancy and its associated morbidity and mortality. Easy access to safe abortion means that illegal abortion is a rare cause of death.7 Mothers also have greater freedom to work outside the home and to acquire skills and training. In more advanced agricultural areas many women are choosing to have only one child because of the economic benefits for their families.1

    The bad

    Lack of choice in an area as fundamental as reproduction can never be popular, and coercion cannot be condoned. With the evidence that more couples would opt for a smaller family, though, it is encouraging that the need for coercion at a local level is diminishing. But there are other problems too.

    Firstly, the policy is resulting in an excess of boys. Data from the in depth fertility survey for 1979-84, when the policy was at its most stringent, put the male: female ratio of reported births at 115:100 in rural Hebei and 116:100 in Shaanxi. This compares with an expected ratio at birth of 106:100 in China.8 The reasons for the imbalance related to not reporting female births, female infanticide, sex selective abortion, and unreported adoption of baby girls.9 The relative contributions of each are unknown. The relaxation in the policy and strict legislation on infanticide and antenatal sex determination suggests that the ratios are less worrying now. The 1995 population survey reported average ratios of around 108:100 in rural areas and stated that now “about 51.03% of the population is male.”10

    A second concern is the issue of support of elderly people, traditionally a responsibility of children, especially in the countryside. (Around 60% of the urban workforce is entitled to a pension.) But the proportion of the population above 65 will rise from a modest 8% now to 18% by the year 2025, about the same as most Western countries today.11


    Health education material for family planning on display at an advice centre on the street in Zhejiang province

    Finally, what of the psychological consequences for all these only children? Much publicity has been given to the “little emperor syndrome,” supposedly suffered by those only children who are the pride and joy of adoring parents and grandparents. Reports about behavioural problems in the so called spoiled generation abound, although they often seem trivial when compared with the behavioural problems of Western children. But there is little hard evidence of causation and in such a rapidly changing society many factors are undoubtedly contributory.

    The ugly

    The ugliest aspects of the policy have received great attention: female infanticide, forced abortions, and selective abortion of female fetuses. There is no doubt that all of these have occurred, but they have now disappeared completely in many places. This is because people are accepting birth limitation more readily and because of the strict legislation covering these acts. Not only do individuals risk imprisonment, but health institutions allowing such practices are liable to heavy fines. Abandonment of baby girls and babies with defects persists, but this was common long before the one child policy.

    The way forward

    China has managed to win large scale acceptance of a relatively drastic birth limitation in less than a decade. However, with the new economic freedom it will not be possible to contain family size through communal pressure and economic disincentives. There needs to be a shift of values towards a “small family culture” reinforced by improved living standards, assured survival of children, and financial security in old age.12 This is starting to happen in many areas. However, some regulation will be necessary for the time being.

    The one child family policy was never intended to be a long term measure, and several options are being considered for the near future. In making a choice several factors must be considered: population size and aging, the family's ability to support elderly members, economic factors, the position of women, and cultural acceptability. One possibility, favoured by demographers, is that everyone should be allowed to have two children–but only two children, and with at least five years between them. It is predicted that this option would give a fertility rate of 1.72 in the years 2000-2025 and would be acceptable to most people.2 A number of the alternatives would perform better than the current haphazard system. It will be fascinating to see what route the Chinese decide to take.


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