MOTIVATING THE MASSES FOR IN THE PEOPLE’S REPUBLIC OF CHINA1 I 2

Virginia Li Wang, Ph.D., M.P.H.3

China’s family planning program has been praised by some for being among the most rational and extensive in the developing world (1). This paper focuses on Chinese attitudes, knowledge, and behavior in this area, and describes the network of supportive services and motivational efforts undertaken to promote in the People’s Republic.

Attitudes Toward Sex and Family Planning living quarters. It is not uncommon for parents and children to share one bedroom and the Lack of sexual and sex-related same bed. Children, sometimes not yet sound crime is an interesting feature of Chinese asleep, are on occasion aware of their parents society. Furthermore, the People’s Republic is making love; but this is regarded as a natural the only country in the world which claims to function in which the parents can engage. The have wiped out venereal disease. It should not attitude, in sum, is that sex is to be desired and be inferred from these observations that the enjoyed, but only in the bed. Chinese do not engage in sexual pursuits, but Other actions follow this same pattern. the physical pleasure of sex is not publicly Women are not embarrassed to breast-feed their commercialized or exploited. Nowhere in China infants around strangers, and children are do audio or visual media play up the sex image. fondled warmly. In nurseries and care centers, There is no , no sexually oriented boys and girls often share the same sleeping seminudity anywhere. quarters and bathing facilities in a perfectly Most Chinese accept sex as a normal part of natural manner. By custom and tradition, ado- life and view the sex act as a natural bodily lescent and adult men and women rarely function. Highly moralistic, they tend to be- demonstrate their affection by touching one lieve strongly in individual responsibility. More- another in public; but men and women mingle over, the Chinese household has little privacy freely and comfortably as associates and and several generations often share the same friends. Officially, the Government has adopted the term “eiren” (literally “lover” or “beloved one”) as a term of reference for use by IAlso appearing in Spanish in the Boletin de fa husbands and wives. The purpose is to describe Oficina Sanitaria Panamericana, Vol. LXXX, 1975. the nature of the desired relationship between %he author recently spent five weeks in the People’s Republic of China to observe health care husband and wife and to stress the two part- delivery services. She also assisted in the production ners’ equal status. of a film documentary on “The Barefoot Doctor in . Rural China.” Information about the film may be In perspective, we can see that the People’s obtained by contacting Professor Victor H. Li of Republic has developed a new mass culture Stanford University Law School or Mrs. Diane L. Li, Department of Communication, Stanford University, which stresses frugality, self-reliance, and self- Stanford, California. abnegation for the sake of mutual aid and what 3Associate Professor, Division of Health Educa- tion, Department of Public Health Administration, is regarded as the collective good. This culture, Johns Hopkins School of Public Health; and Asso- which allows little room for self-indulgence, is ciate Director, Office of Continuing Education, Johns Hopkins Medical Institutions, Johns Hopkins reflected in the drab color and utilitarian University, Baltimore, Maryland, 21205. appearance of women’s dress and the total lack

95 96 PAHO BULLETIN

PLATE 1-A barefoot doctor participating with peasants in agricultural work. of cosmetic effects. In theory, an individual is have trouble imagining how anyone could be so only attractive and desirable to the extent shameless as to want “the pill” without first merited by his or her personality and “correct having married. thinking” as shown by his or her actions At the same time, Government literature 3n relating to the community. Large signs reading family planning argues that limiting family size “serve the people” are posted everywhere to and spacing is essential for reasons of maternal remind citizens of the destiny they seek. and child health and for the development of the The Government believes that “correct national economy (2). Obviously, family plan- thinking” can be enhanced through education. ning is intimately tied to political ideology and It feels that once the right attitude is formed, Government policy. Birth control is not just an correct behavior will follow, enabling the individual matter, but a state affair. student to become ideologically “red” and , professionally “expert .” Delayed Marriage It would be erroneous to conclude that their beliefs make the Chinese asexual. Our own Postponement of marriage, which is tied to attitudes reflect commercial conditioning and a the reward system, delays childbearing and is tradition of male dominance which undoubted- therefore of strategic importance in family ly color our perceptions of appropriate sexual planning. behavior. It is barely comprehensible to the Traditional Chinese marriage contracts were Chinese that there are societies so immersed in made by parents for their children when the sex as ours, where sexual activities may be latter were in their mid-teens or even younger, engaged in premaritally and extramaritally from and were consummated for the sake of ensuring early . Their culture and education continuity of the family lineage. During the teach them to regard that kind of behavior as years immediately after the Revolution, a law abnormal to the point of sickness, and they was passed which set the legal marriage age at Wang . FAMILY PLANNING IN CHINA 97

18 for women and 20 for men, and which he or she remain so during the course of study. stated that people were free to choose their Despite such circumstances, is own marriage partners. Romantic love was thus extremely rare, for several reasons. The desire popularized and made a social norm. Later on, to succeed-to be “red” and “expert’‘-appears the legal age for marriage was moved to 20 for to have considerably influenced public attitudes women and 23 for men. By the 1960’s, women and behavior. The absence of sex-oriented were being urged to delay marriage until 24 or commercial stimulants and of role models 25 and men were being asked to wait until 28, relating sex to status may have been influential. on grounds that until then they would not have Other social conditions have also played an achieved their full physical growth (3).4 important part: Officially, China’s romantic The official argument for late marriage is not hero or heroine is the peasant, worker, or just that it enhances physical maturation and soldier who serves the people and resists deca- development, but also that the need for mar- dence; and in general it is true that a young riage is superseded by the more urgent need for woman is looked down upon if she is flirtatious revolutionary to expand its intellectual and has many boy friends. capacity, so that it can heighten the class Of the two medical schools, one university, struggle and acquire knowledge and skills and one public health school visited by the needed for socialist construction. It is thus author, none reported any case of a student suggested that if one assumes family responsi- falling in love and being unable to finish school. bilities while still very young, it will tend to Since a student enters college only after being retard his or her development as a good selected by the community, he bears an enor- socialist. This aspect of delayed marriage was mous responsibility; he is sent off with consid- discussed in an article printed on a poster in a erable fanfare as a “hero,” and there is tremen- factory at Shanyang, a Manchurian industrial dous pressure to be worthy of the trust. This is center. The final paragraph of that article (4) is one more reason why the relationship between translated below: men and women is invariably one of fraternity On the surface the question of marrying and not of courtship. early or late is a personal question. In reality, it We interviewed 36 “barefoot doctors,” is a point of conflict between capitalism and “worker doctors,” and “red medics” from 20 the proletariat since it represents two different to 49 years of age in six localities scattered views. Delayed marriage is a form of revolution which abolishes old traditions and establishes from Shanghai to Shanyang, Manchuria. Bare- new social forces. Revolutionary must foot doctors are part-time agricultural workers heighten their consciousness and resist the trained in preventive care and health educa- decadent thinking of the capitalist world. tion; worker doctors are their city factory Hence, we must practice late marriage in order counterparts; and red medics are housewives to eliminate traditional attitudes, customs, and habits and to proclaim socialism and establish a stationed at neighborhood clinics. In all, 23 new order. were married, the remainder being single. Of those 34 years of age or less, the average age To encourage conformity to this new stan- at marriage was 24.5 for men and 24 for dard, a range of incentives has been established. women. Of those 35 and over, these average For example, eligibility for admission to col- ages were 33 for men and 20 for women. lege, medical school, or other professional Except for the two men 35 or older, those schools in China today depends on the candi- interviewed came from families with an aver- date being single, and regulations require that age of five or six children. The seven women 4This information was given to us by an obstetri- in the older group had an average of 3.6 cian in the Eight One Commune Hospital and was children each, whereas the average for the confirmed by the Provincial Health Office of tiaoning. See also Questions and Answers Idama on younger women was 1.4 (see Table 1). Most Pliznned Birth (3). of the younger men and women indicated a 98 PAHO BULLETIN . Vol. IX, No. 2. 1975

TABLE 1 -Average marriage age, number of siblings, and number of children of barefoot doctors, worker doctors, and red medics in five localities, by age and sex, 1973.

Age 34 or Less Age 35 or More Men Women Men Women

Number of persons 6 12 2 7 Average marriage age 24.5 24 33 20 . Average No. of siblings 5.3 4.5 2 4.1 Average No. of children 1 1.4 2 3.6 preference for having only two children and organizational levels, those of the brigade or for using family planning to keep births residents’ committee and the production team spaced apart. or residents’ group. The population base for a commune or street office can vary from Family Planning Organization 20,000 to 60,000 or more. Each of these local entities has a family The highest family planning body, the planning unit with which it shares responsibili- State Family Planning Commission, is directly ty for family planning in its area. This respon- responsible to the State Council, the Govern- sibility is also shared with the local women’s ment’s highest decision-making body. The committee and individual health workers in members of the Commission, which was estab- the area, including local practitioners (e.g., lished during the years 1956-1958, include barefoot doctors, worker doctors, and red representatives from the ministries of health, medics), midwives, and physicians. Activities propaganda, culture, and commerce, and from of the local family planning units are sup- the All-China Women’s Federation, the Young ported by local public health departments, Communist League, the Chinese Medical Asso- clinics, and hospitals. ciation, and many other groups. The Commis- sion’s main tasks are to assure that the impor- Education and Persuasion tance of family planning is recognized, to coordinate and help set basic policies relating The Government provides a wide range of to birth control, and to support the Ministry information about family planning to encour- of Health in planning and implementing fami- age late marriage and to limit births. To start ly planning activities (see Figure 1). with, the advantages of planned parenthood One and two levels down, in the provinces and the need for it are widely publicized and counties, family planning committees are through the mass media, leaflets, other printed responsible for seeing that family planning materials, person-to-person contacts, and policies are implemented and for working with group meetings. But what is so extraordinary the public health department in shaping those in China’s case is that the messagein favor of policies. They also contribute to periodic family planning is reinforced from every con- large-scale health education campaigns, seeking ceivable direction as a result of a concerted thereby to provide local organizations with effort by the Party, the public health depart- leadership and a sense of direction in family ment, and local organizations. Nevertheless, planning matters. local governments and local communities The commune in rural areas and the street enjoy a good deal of autonomy in making office in urban ones are the basic govern- decisions, and so there is great variation in the mental units of political organization and eco- intensity and methods with which family plan- nomic production. Below them are two other ning is promoted in different communities. ft4nzg . FAMILY PLANNING IN CHINA 99

FIGURE 1 -Family planning elements and their relationship to political organizations.

I I r STATE I STATE COUNCIL FA~~ll~LiNN;NG tp I t--l

FACTORY,

PLANT,

AND

ENTERPRISE

FAMILY

PLANNING

COMMITTEES

ORGANIZED

STREET OFFICE AT STREET 0R COMMUNE OR COMMUNE - FAMILY PLANNING e REVOLUTIONARY LEADERSHIP GROUP VARIOUS COMMITTEE LEVELS

RESIDENTS’ COMMITTEE OR BRIGADE REVOLUTIONARY COMMITTEE b t-- PAHO BULLETIN . VO’OE.Ix, NO. 2, 1975

Education for family planning is considered million people to sweep the snow off the distinct from . In fact, it is hard streets before dawn during President Nixon’s for most Chinese to envision the latter as a fit 1972 visit. The means of passing the message subject for education at all. Middle school5 was the omnipresent loudspeaker. pupils learn of the advantages of family plan- Local practitioners such as barefoot doc- ning in classrooms and at mass meetings where tors, midwives, and woman volunteers pro- propaganda in favor of family planning is mote family planning through person-to- presented. Human reproduction is taught at person contact and group meetings. They are the upper middle school level via biology, instructed to be alert for the appropriate anatomy, and physiology. But boys and girls moment, such as the period following a pain- learn about , for the most ful birth or any time when an individual part, from peers and relatives. expresses a desire for information. Group dis- Young couples receive information on con- cussions are conducted in the courtyards of traception at marriage. After marriage, the village compounds or during the biweekly or production units which employ them assume triweekly political study sessions which are responsibility for contraceptive information. mandatory for everyone. Many young couples are not singled out as A technique called “criticism and self- targets for persuasion until after the first criticism” employed in these sessions is used or birth of the first child. But in by the Party and has been universally adopted two communes we visited on the outskirts of as a method in educating cadres and the Shanghai and in Shanyang, a family planning public alike. It is a forceful form of persua- manual was presented to newlyweds with their sion. The participants, after a soul-searching marriage certificate as a gift from the State. self-examination assisted by others, usually The principal means of mass communica- reach a decision of compliance or cormnit- tion in China is the loudspeaker. It was visible ment. At times, such persuasion through everywhere we went-hanging from roofs, in group pressure may contain an element of the corners of rooms, or raised on poles in coercion. fields where thousands of farm workers spend As a guiding principle for birth control most of the day. Propaganda, which is broad- propaganda, promoters are supposed to “extol cast at least twice daily, can include any first, praise second, criticize third, and impel message the Party or the local production fourth.” Rumor has it that clothing and grain unit, school, or hospital wishes to transmit. In rations have been withheld for the third or contrast, there is only a limited quantity of fourth child in some communities as a way of printed matter on health education, because discouraging numerous births, but everyone paper is a precious commodity and is used we asked during our investigation vehemently mostly to make posters, displays, and book- denied this. It is reasonable to assume that lets. Although there is usually a radio at home such measures have rarely if ever been used, and a television set in the communal hall, the since they would have an adverse effect on loudspeaker is present in every household. the welfare of the child, if not the family, and Someone mans the loudspeaker station 24 would counter the key official doctrine of hours a day to forewarn of any disaster such social benevolence. But there is no doubt that as flood or snow and to broadcast Party dissenters are subjected to severe criticism and messages. It is therefore not surprising that constant harrassment in the name of per- Peking was able to mobilize an estimated one suasion. The natural targets for family planning 5Middle school in China is roughly equivalent to education are, of course, the young men and high school (junior and senior) in the United States, ;~~p;;l middle school corresponding to senior high women contemplating marriage and the mar- ried couples who have had one or more Wang . FAMILY PLANNING IN CHINA 101

children. In some communities where tradition These contraceptive supplies and services are has a strong hold. an additional target popula- available at all local clinics and community tion consists of the elderly wornerr who still hospitals. Pills can either be picked up at the exert considerable influence on the family and clinic attached to one’s place of work or who consider having many grandchildren to be delivered to the woman’s home by a health their right. Mothers-in-law, for example, are volunteer or local practitioner. persuaded to give their daughters-in-law per- A person’s production unit provides trans- mission to practice birth control. We were also portation to family planning services when told that certain production units considered one must travel some distance-for instance to . “advanced” have developed schedules for fam- visit a district or city hospital. These facilities ily rotation of childbearing. Given the total give such travellers preferential access to free lack of privacy in present-day Chinese society services, and the State pays the cost out of a and the intimate awareness that neighbors special budgetary account handled by the pub- have of one another, it is conceivable that lic health department. discussions on the need for community plan- Prenatal and postnatal maternity care is ning and planned births could lead to some provided by physicians, midwives, and local such agreement for scheduling birth events. practitioners at the community hospital, The International Maternity Hospital in health station, factory clinic, or medical Shanghai provides family planning education center outpatient department. For those wish- for clinic outpatients and for mothers after ing early confirmation of pregnancy, a urinaly- delivery. Again, emphasis is placed on mater- sis is done on demand. In rural areas, babies nal health and child welfare, and on the are delivered either by the physician at the relationship to economic production and so- commune hospital or by the midwife in the cialist construction. Mothers must attend at home. (Of the six communes we visited, only least one class session during their period of the Eight One Commune in Shanyang had prenatal care. This deals with the reproductive trained midwives assigned to its brigades.) process, prenatal care, preparation for birth, Emphasis is placed on proper coordination of and family planning. Vasectomy is encouraged midwifery services and those of the commune for the husband as a sound way of preventing hospital, where maternity care is supervised by future . a qualified obstetrician. Should there be se- rious complications or need for a cesarean Family Planning Services section, the patient is usually referred to the Not only educational efforts but also fami- district hospital, which has more specialists ly planning services are geared to elicit a and better equipment. In cities, babies are strong general public response. The barefoot delivered at city or district hospitals. doctors, estimated at one million strong, par- The pill is a very popular contraceptive. h ticipate in education of the citizenry, as well Both a daily piIl taken on a 22-day cycle as in delivery of family planning services (active ingredients: norethindrone and ethinyl- wherever these services are desired. estradiol and a pill taken once a month are Contraceptive devices are manufactured by available, but the latter is still experimental . pharmaceutical companies owned by the and its use is restricted to selected cities and State, and contraceptives are distributed local- surrounding areas. This monthly pill, contain- ly through the official health agency, i.e., the ing cyclopentyl ether of ethinylestradiol and public health department. cost one chlormadinone acetate, is recommended only cent apiece and contraceptive jelly sells for “for women who are very healthy.” The bare- ten cents a tube; but the pill, insertion of the foot doctor can dispense both pills without a IUD, and the services required for tubal liga- physician’s prescription after questioning and tion, vasectomy, and abortion are all free. examining the woman. Sometimes a “number 102 PAHO BULLETIN . Vol. IX. No. 2. 19 75

3 pill” is dispensed to counter side-effects. 63 used condoms, and 10 had vasectomies. This contains ethinylestradiol with .005 mg of The reported birth rate for 1972 in this estrogen. community was 8.47 births per 1,000 people, The barefoot doctor maintains a record of one of the lowest reported to us anywhere. the menstrual cycle of each woman, and the Other contraceptive methods are also used. 22-day pills are delivered to her home at the Contrary to the information given in birth appropriate time. In the case of the monthly control manuals (5), breast-feeding is regarded p-8, the barefoot doctor brings a thermos as an effective contraceptive method by many bottle along for the house visit and makes local practitioners and even by some physi- sure that the patient swallows the pill in his cians. This may partly account for the many or her presence. There is also limited experi- contraceptive failures which end in abortion. mentation with a once-a-month injection Manuals also describe the diaphragm and how which contains estradiol valerate and it should be used, but we did not come across 17-or-hydroxyprogesterone capronate. any clinic or hospital which promoted its use. The IUD is another popular contraceptive, This is very understandable, in view of the one which is said to be 70 to 90 per cent lack of privacy and bathroom facilities in effective. A type called the “plastic flower” is many homes. popular. In Liaoning Province the device used At one time the was very popuiar, is a coiled stainless steel ring that comes in but there is less official encouragement for three sizes ranging from approximately 13 to this method now than in the past. The proba- 20 mm in diameter. A physician usually in- ble reason is that many people failed to use it serts the ring, but midwives have also been regularly, and this caused too many unwanted trained to perform insertions in the home. pregnancies. Also, unless the user checks the The device is generally inserted about six condom first, there is a chance that it will be months after delivery, when normal menstrua- defective and that protection against impreg- tion resumes. The expulsion rate is said to be nation will be lost. as high as 15 per cent; and at least in Acceptance of vasectomy varies from place Liaoning Province the patient is X-rayed, once to place, but it is generally less acceptable after the first menstrual period and again at than other forms of contraception. Only in six-month or yearly intervals, to make sure the Four Season Green Commune on the the ring is still in place.6 outskirts of Hanchow did we find that as Tubal ligation is often preferred by older much as 60 per cent of all sterilizations women with three children or more. The performed within the last two years were operation is performed transabdominally in vasectomies. This commune provides a most the hospital. In general, women appear to interesting case, in that the commune hospital, show increasing acceptance of sterilization. We created in 1970, is staffed by 10 barefoot visited one residential neighborhood in a doctors. One of these, who bears the title Hanchow street office where tubal ligations “Western Medicine Doctor and Surgeon,” had were the most common form of contracep three years of training in medicine and sur- tion. Of the 357 couples capable of reproduc- gery. This was acquired mostly by apprentice- tion, 25 were taking the pill, 76 had IUD ship in a city hospital program, and through a insertions, 105 had undergone tubal ligations, work practicum arrangement supervised by an 60ur impressionis that the Chineseare somewhat internist and surgeon assigned to the com- careless about radiation effects. In the School of mune to assist barefoot doctors through in-ser- Chinese Medicine of Shanyang, a fracture reduction vice training. This man has performed over was demonstrated on the right femur of a nine-year- old girl. In an effort to demonstrate treatment 100 vasectomies in the last two years at the techniques, the doctor made multiple fluoroscopy ex osures without providing any shielding for him- little commune hospital, and he apparently seP f or the patient. enjoys the confidence of the people. Wang . FAMILY PLANNING IN CHINA 103

PLATE 2-Primary care and fiit aid is provided in the brigade clinic.

PLATE 3-A group discussion of family planning guided by a midwife. 104 PAHO BULLETIN . vol. Ix. No. 2. 197.5

We had the opportunity to interview two after an hour’s rest in the clinic’s observation men whose vasectomies were done by this room. Over 100 abortions were performed in barefoot doctor. One, a 42.year-old peasant, the Eight One Commune in 1972, mostly had three daughters; the other, a 28-year-old because of contraceptive failures. At the Inter- brigade accountant and Party member, had national Maternity Hospital in Shanghai about one daughter. The latter had undergone the 1,200 abortions have been performed annually operation while his wife was pregnant. Both since 1962, again mostly because of contra- expressed confidence in Chairman Mao’s ceptive failures. teachings and were grateful for his concern Therapeutic abortion is permitted-if both about the people’s health and welfare. They husband and wife request it-in order to safe- said they were not worried about having only guard the health of the mother, or to hrevent daughters, because the new society values the the birth of children who would be subject to female sex as much as the male. Nevertheless, known hereditary defects or whose mothers the young accountant was extremely happy contracted German measles in the early when he learned that his second child was a months of pregnancy. boy. In contrast to some countries, there is no Emancipation of Women monetary reward for those undergoing vasec- tomies in China (6, 7). However, in a society The political and economic emancipation where monetary prices have been removed of women has contributed significantly to the from services and enterprises, one way for an promotion of family planning. individual to receive recognition and social Female infanticide was fairly common in approval is by being a good citizen and what China before World War II, and girls were the Government calls an “advance element” in sometimes sold into slavery by their parents in society. In general, aside from the desire for time of need. This situation was changed better health and welfare, patriotism does drastically by the Revolution and by the appear to provide frequent motivation for marriage law of 1950, which stipulated that family planning measures. As an additional there must be free choice of partners, monog- incentive, a week of paid vacation is provided amy, equal rights for both sexes, and protec- for anyone undergoing a vasectomy; similarly, tion of the legitimate interests-~. of women in a patient receives 3 days of paid vacation for education, employment, and family relations. IUD insertion, 2 weeks for an abortion, and 3 There is now scarcely a field from which weeks for a tubal ligation. women are barred, and the emphasis is on Abortion in China does not have the same equal pay for equal work. There are women emotional overtones as in many Western so- machine tool operators, geological prospectors, cieties, and the operation is freely performed pilots, navigators, spray painters, engineers, during the first three months of pregnancy. and scientists. Women also participate in Consent between husband and wife is neces- managing State affairs, Communist Party com- sary, and in some locales community consent mittees, and revolutionary committees at all is also desired. In the case of premarital levels. Nurseries and care centers for young pregnancy, which is very rare, abortion is the children have been developed to facilitate this invariable solution; but here consent from the process. community is required. This community in- The assertion of women’s rights has had a volvement is designed to discourage promis- very positive effect on family planning. So it cuity among the unmarried, and to encourage is not surprising that women often volunteer contraception by married couples. to limit the number of their births when their The abortion is usually performed by vacu- husbands decide that the condom is inconve- um aspiration, and the patient is sent home nient and vasectomy too threatening, or that Wang . FAMILY PLANNING IN CHINA 105 many more women than men should appear reproductive age, as well as the precise num- to adopt contraceptive measures. Women’s bers of men and women adopting family organizations are fervent supporters of family planning techniques and the methods they planning and are instrumental in delivering used. family planning services. They generally regard Three local health stations in Hanchow, freedom from unwanted pregnancies as a de- Peking, and Shanyang provided family plan- sirable achievement in itself-and one which is ning records that we found to be quite com- necessary for full female emancipation. plete. These records were designed for women patients. They gave the name and age of the patient and her spouse, the number of chil- How Effective is China in Controlling Its dren, the type of family planning method Population? adopted, and other personal data. Pledges to have no more children were made by some Statistical Data women and were recorded as such. An exam- ple of such a birth control record card is During the course of our tour, we repeated- shown in Figure 2. ly attempted to obtain statistical data on vital As indicated on the card, separation of trends at the national, provincial, city, and marriage partners is considered a form of county levels. These attempts were generally contraception. This means that the spouses are unsuccessful, but at the same time our hosts stationed in different areas, and therefore no did not seem concerned about the apparent intercourse occurs except during vacations. serious lack of systematic vital data. Whenever During our visit to five cities and their population figures were quoted, they were surrounding areas we were shown recorded usually qualified by such statements as “in the annual birth rates for communities; these vicinity of’ or “approximately,” and no more ranged from 20 per 1,000 inhabitants in a information was forthcoming. This could Peking suburban commune to 8 per 1,000 in mean either that statistics is a weak link in two residential neighborhoods, one in China’s health intelligence system, or that Hanchow and the other in Shanghai. Our these kinds of population data are not being hosts were also able to cite precise figures provided to outsiders. concerning the number of persons accepting One official statement of China’s popula- various types of contraception and the num- tion size is posted on a large billboard in front ber of children enrolled in school. of the guest house in Sin Jen, the first stop The vice-chairman of the revolutionary for visitors who enter China. The display reads committee with jurisdiction over one Shanghai “650 million welcome our brethren from over- neighborhood school gave the student enroll- seas.” Other estimates have ranged from 600 ment figures shown in Table 2. These data million to 820 million. The figure 700 million provide some circumstantial evidence that was used when Premier Chou met with schol- family planning may be having an impact on ars in 1972, an occasion at which an annual school enrollment. China’s universal education target growth rate of 1.5 per cent was set. system requires all children to enter primary While no one seemed sure just how many school at the age of seven. Kindergarten is men and women were sterilized or were using part of the school system, and the majority of contraceptive devices in a given city or children attend. However, day care center county, the barefoot doctors at brigade clinics enrollment does not reflect the number of and the worker doctors in the street and lane children in the community, partly because health stations were often able to give detailed people prefer to keep very young children at information on the number of local women of home if there is a grandmother around. 106 PAHO BULLETIN . Vol. IX, No. 2, 1975

FIGURE 2-Front and back of a birth control record card.

FRONT No. Record for married women who have already had children

Name: Age: Work unit:

Husband’s name: Address:

Reporting interval: Every six months

Family planning methods Reasons for not having Date already adopted adopted family planning

Injec- Dio- Absence Breast. Absence fr. MO. Pills +ionr ‘“D phragm of 0th Pregnancy fesding of Remarks SPO”M spouse Wang . FAMILY PLANNING IN CHINA 107

TABLE 2-Priiary and middle school student she enters the third trimester of pregnancy. enrollment, bygrade, at Young Pao Fung Chen New Later, after the birth of her child, she may Village in Shanghai, 1973; grade 1 is the lowest grade in both the primary and middle schools, higher take off more than the 56 holidays entitled to numbers designating progressively higher grades. her, especially if there is no older woman in the household who can be a mother surrogate. Grade No. of classes No. of students But the mother is still unable to accumulate Primary school: work points except by participating in produc- Day care ...... 19 360 tive labor. This all creates a situation where Kindergarten ...... 19 720 the income of the sexes is not equal and Grade1 ...... 12 512 9) 2 ...... 17 658 where men have a definite advantage. For 99 3 ...... 34 1,643 cadres and people in professional ranks, the 1, 4 Gwer) . . . . . 16 799 reward system is the same for both sexes; but 1, 4 (lower) . . . . . 27 1,374 1, 5 ...... 32 1,592 these personnel make up only a small part of -3 6 ...... 37 1,967 the work force. Subtotal ...... 213 9,625 While the Government promotes family Middle school: planning as a life-style, it also provides eco- Grade 1 ...... 22 1,136 nomic incentives for having more children. In >> 2 ...... 26 1,484 most areas a basic grain allotment is guaran- 99 3 ...... 27 1,480 33 4 ...... 26 1,409 teed. This constitutes the bulk of one’s in- come in agricultural areas. The amount re- Subtotal ...... 101 5,509 ceived is rationed according to one’s age and Total ...... 314 15,134 type of occupation. Children O-3 years of age usually receive 50 per cent of the adult ration Institutional Barriers (some locales award the full ration regardless of age). Children between three and seven In spite of the rather intense effort to generally receive 70 per cent, and the full promote family planning that has been de- ration is given when a child reaches age seven. scribed, institutional barriers still encourage Consequently, a young child that cannot con- large families and prompt a desire for male sume its full share may actually bring income children. These barriers are primarily eco- into the family, since the surplus can be sold nomic. China is basically an agrarian country back to the State for cash. While mothers may whose technology is primitive and whose labor lose work points when they have children and force is employed on farms. Although are detained at home, this loss can be made women’s emancipation has equalized the sta- up by the cash income accrued from sale of tus of the sexes and enabled women to partic- the surplus grain. At some point the child ipate in economic activities, there is still some may consume its entire allotment, but by then discrimination inherent in the reward system, it will also begin to earn work points to \ which bases the earning power of a worker on increase the family income. accumulated work points. Those tasks which Age-old cultural values favoring large fami- require the most physical exertion are general- lies and male offspring also run counter to the ly awarded a greater number of points. Such family planning program. In rural areas, espe- tasks are rarely assigned to women. Conse- cially, many parents would still like to see quently, the points accumulated by women their sons and daughters marry early. If the working in the fields usually amount to brigade should refuse the young couple mar- 5,000.6,000 a year, while men accumulate an riage registration, they will sometimes have a average of 6,000.7,000. marriage ceremony with the blessings of their Further, a woman may quit work entirely parents and move in together, living as hus- or be assigned to less strenuous work when band and wife. The brigade leaders are in a 108 PAHO BULLETIN . voz. 1x. No. 2. 19 75 position to refuse marriage registration if they The manner of disseminating birth control deem the couple too young; they also have a propaganda is both interesting and significant. responsibility to persuade them to delay the The method involves creation of strong public marriage; but they are not empowered to stop sentiment, use of positive incentives and re- the marriage ceremony. When a child is born inforcement, and emphasis on the ready avail- of such a union, it is considered legitimate ability and accessibility of family planning and is entitled to all of a child’s normal rights. services. The birth control publicity campaign, Therefore, sometime between the marriage in general, is a successful example of propa- ceremony and the birth of the child, marriage ganda work. certification is issued as a matter of necessity The Chinese spend a great deal of time in to ensure the welfare of all concerned. “study” sessions concerning family planning. Clearly, then, the norms and mores promul- These are part of an overall program of man- gated by the Government in favor of small datory study which may involve anywhere families can be nullified by human desires, from four to 10 hours or more a week, both for economic improvement and for con- depending on the political climate. Obviously, tinuity of one’s blood-line from generation to Chinese leaders consider this a useful way of generation. creating social norms and instilling new values. Study of family planning takes place under Discussion and Conclusions the leadership of a barefoot doctor, midwife, Birth control workers often use the four or community leader. The process goes some- key words “late,” “spaced,” “small,” and thing like this: The discussion leader reads “good.” “Late” refers to late marriage, from a booklet showing the advantages and “spaced” refers to having children four or five desirability of limiting births. Each point is years apart, “small” refers to having only a discussed in turn, and concrete local examples few children, and “good” refers to the ability are usually brought in. If the discussion partic- to care for and educate children properly ipants are playing the “game” correctly, some- when there are few children in the family. one raises objections. The group then discusses There is little in the way of sex or birth the objections and points out the error in the control information in the schools. According person’s thinking. The group position, of to the Chinese, a high school student is too course, is then accepted by the objector. young to be thinking of marriage. Propaganda A person might point out, for example, favoring late marriage is passed to older teen- that children are necessary to support parents agers and 20;year-olds through organizations in their old age. Others could then explain such as the Youth League. how the new society provides assistance for The first concrete birth control information old age through the guarantee of food, shel- a couple is apt to receive is a family planning ter, clothing, medical care, and burial. The manual provided at their marriage registration. objector would acknowledge this. The group This practice, however, is not universal. It is might then discuss various birth control meth- more likely that newlyweds will only learn ods. Various objections to each method would about family planning methods during the be raised and defeated. Thus, one person wife’s first pregnancy or after the birth of the might voice concern about taking medicine first child. If they are not given birth control which could affect a body humor, or about information right away, the possibility of im- inserting a piece of plastic or metal into the mediate pregnancy is very high; but if the body, or about having the tubes tied; others couple does not marry until 25 and 28, and if might then state that there are no side-effects, the partners adhere to five-year spacing of and perhaps some people who have already their children, immediate pregnancy could be accepted the various methods would come desirable in view of the mother’s age. forward to uresent their views. Wang . FAMILY PLANNING IN CHINA 109

Throughout this process, praise and other cally, with minimum involvement, and hence positive incentives are employed. For example, expense, by the State. a person voicing objections is praised for This is not to suggest that -all the work is caring enough to think about the potential done by local units, or that people come to problems; those arguing against the objections adopt family planning only because their are praised for their level of understanding; minds were changed during the educational and the objector, who acknowledges his process described above. On the contrary, errors, is then praised for his capacity to central and local efforts are combined, as are learn. Sometime during the process someone, ideological and material incentives. let’s say a woman, declares that she wishes to The State sets policies which make family use a particular contraceptive method. Consid- planning a high-priority item. It also prints the erable praise is heaped upon her for her brochures and supports the training of the progressive thinking. This has a twofold effect. barefoot doctors, midwives, and others. More First, with all of this public praise and rein- directly, the State invests in factories and forcement, it becomes quite difficult for the distribution systems for birth control pills and woman to change her mind later or “forget” devices, and gives most of these to the public to take the pill. Second, if practicing birth free of charge. It also subsidizes sterilizations control is progressive, then the implication is and other family planning activities performed that those who fail to practice it are less in hospitals, such as abortions and even health progressive or even reactionary. education. The effect of this study process is quite The barefoot doctors and midwives play a striking. At the beginning the people neither pivotal role in the family planning program. know nor necessarily care about birth control, As mentioned above, they lead the discussions but the leadership wishes to implement a on family planning work. Because they are program of family planning. Now, everyone local people with good local ties, their advice may know from the beginning that the leader- carries a great deal of weight, certainly much ship’s desires will in fact prevail. But the issue more than that of any stranger coming to talk is not phrased in that way. Rather than about family planning. ordering people to practice birth control, the Moreover, these practitioners are extremely idea is to have them talk about it. By means important in implementing family planning of the discussions, everyone is drawn into the work after the initial decisions have been process of implementing family planning made. In several communities that we saw, the work. Once drawn in, it is very difficult to get local practitioners kept a card on each married out. Everyone learns various reasons to sup- woman of childbearing age that specified the port family planning and also learns the argu- birth control method being used. This proce- ments against various objections. dure put pressure on both the practitioner and Perhaps most important, the final step in the woman being registered to have her speci- agreeing to use birth control methods is fy, and hence use, some contraceptive meth- “voluntary.” This is true even though every- od. Moreover, since pills and IUDs are the one “knows” at the beginning of the process preferred methods, a woman not using either that family planning work must be carried would fee1 somewhat isolated when figures are out. The voluntariness, the praise, and the made public. publicity one receives make it very difficult to The barefoot doctor and midwife have the regress. This method is a powerful device for additional function of delivering the pills. achieving compliance with socially desired That is, on the proper day each month the norms. It also is very inexpensive, in the sense local practitioner arrives with either a packet that the great bulk of the work to change of 22 pills or the monthly pill. Such a prac- attitudes and enforce decisions is handled lo- tice makes it extremely difficult and embarras- 110 PAHO BULLETIN . VUE. Ix, NO. 2, 197.5 sing for the user to “forget” to take the pill. tation is 15, then interest begins to develop as There is a tinal point related to family of that time and possible frustration occurs if planning. We left China convinced of the the expectation is not fulfilled. On the other claim that there is virtually no premarital sex, hand, if the age is 25, as in the Chinese case, or that it is extremely rare. What impressed us then expectation does not develop until most in this regard was the reaction of Shan- around that time. yang medical students, who were giggling like The speaker was probably thinking of Ire- teenagers when we asked them about premari- land and Greece as two Western examples of tal sex. The dean of the school also thought places where, at least until quite recently, the this funny and explained to us that these incidence of premarital sex was low and mar- students did not even know what we were riage took place at a relatively late age. These talking about. A similar impression was made societies did not break up because of a high by difficulties encountered in trying to get level of sexual frustration. In the case of adults of various communes and neighbor- China, the idea of late marriage is reinforced hoods, including health professionals, to talk by a puritanical outlook and by a mass cul- about sexual matters directly and without ture where individuals subjugate their personal embarrassment. desires to what is believed to be the collective These impressions were reinforced by the -good of society. general structure of family planning work. If With the kind of local organizations and the hospitals and local practitioners handle all manpower resources available, China has the insertions of IUDs and control the supply of capacity to bring its population growth under pills, then it would be extraordinarily difficult control within a short period of time. The for an unmarried person to get these birth State’s extraordinary ability to make people control materials. We asked a clerk in a store change their customary thinking and practices that sold condoms whether unmarried persons has proven a highly successful tool in many could purchase condoms, and his answer was areas, including women’s rights, citizen’s par- that he would not sell any to such persons. ticipation in decision-making, and acquisition When asked how he would know whether a of hygienic habits. China’s national leaders customer was married or not, he expressed filter central policies through the intermediate considerable surprise and said “Of course I levels of provincial, city, and county govern- would know, I know everyone in this area.” ments to the communal and neighborhood Once again, we encounter this important phe- levels. Then the local leadership, to one degree nomenon of the production unit being very or another, sets family planning as a priority. local and very close. Since this type of government involves consid- In discussing the critical issues of family erable decentralization and local autonomy, planning in China before we embarked on the the big wheel and the little wheel must turn trip, one astute observer remarked that we simultaneously to effectively implement fami- should not feel that the situation with respect ly planning programs in cities and the coun- to premarital sex in China is particularly un- tryside. That is, successful family planning in usual or unique. Theoretically, the issue is at China depends on the coordination of central what point a person expects to have inter- policy and local effort. course for the first time. If the age of expec-

ACKNOWLEDGMENTS

Special acknowledgment is made to Victor national Legal Studies, Stanford Law School, H. Li, Louis Talbot Shelton Professor of Inter- who organized the trip to the People’s Re- Wang . FAMILY PLANNING IN CHINA 111 public of China and who made Iris field notes tine, Dr. Katherine NuckoIIs of the Yale available for preparation of this manuscript. School of Nursing, Dr. Ira W. Gabrielson of I am also very grateful for the assistance of the Medical College of Pennsylvania, and Dr. Dr. Lawrence W. Green of the Johns Hopkins Arlene Fonaroff of the School of Pharmacy of School of Hygiene and Public Health, Dr. Maryland University. Lowell S. Levin of the Yale School of Medi-

SUMMARY

China’s family planning efforts give the yond the teenage years. Enhancing this, a appearance of being substantial and effective, wide-ranging State publicity campaign pro- though in terms of hard data the precise motes birth control through public address degree of success achieved is hard to gauge. systems, brochures given newlyweds, classes The author’s five-week tour of China, upon and information provided to expectant par- which this article is based, showed a country ents, discussion groups designed to elicit “vol- that seemed capable of controlling its rate of untary” adoption of birth control methods, population growth, but it was unclear whether and other means. To complement this, the the desired level of growth had in fact been Government provides a nationwide network of attained. free or nearly free family planning services What was clear is that several unusual ingre- organized down to the local level and fully dients are primarily responsible for the equipped to assist with contraception, steril- marked progress made to date. Foremost ization, or termination of pregnancy upon among them is a public attitude of strict request. Although general statistics have not adherence to a moral code which effectively been made available, it seems obvious that a limits sexual relations to married couples and substantial reduction in China’s potential rate which encourages delay of marriage well be- of population growth has been achieved.

REFERENCES

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