Maternal Mortality, Midwives, and Cesarean Sections in China, 1900S–2000S

Reproductive Modernities in Policy: Maternal Mortality, Midwives, and Cesarean Sections in China, 1900s–2000s

Suzanne Z. Gottschang

Technology and Culture, Volume 61, Number 2, April 2020, pp. 617-644 (Article)

Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/tech.2020.0055

For additional information about this article https://muse.jhu.edu/article/761578

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SPECIAL SECTION Reproductive Modernities in Policy Maternal Mortality, Midwives, and Cesarean Sections in China, 1900 s–2000s

SUZANNE Z. GOTTSCHANG

ABSTRACT : China is one of a few countries to reach the 2015 United Nations Millennium Development Goal of reducing maternal mortality by 75 percent in fifteen years. The longstanding and intractable problem of maternal mor - tality in the Global North and South makes China’s success all the more remarkable. This article examines relationships between China’s reproductive health policies aimed at reducing maternal mortality and technological changes in managing childbirth associated with them from the early twenti - eth century to the present day. Tracing technological choices to prevent maternal deaths at junctures in the history of health-based reforms makes visible China’s broader economic and political priorities in its internal moderniza - tion projects and in its interest in raising the nation’s global standing. Finally, the consequences of state reproductive priorities emerging in recent years suggest that women’s decisions to delay childbearing or to bear multiple chil - dren, may bring about circumstances increasing the risk of maternal death.

In 2010, news reports circulated that the deaths of mothers in childbirth had decreased globally by more than 40 percent since 1990. 1 A key target in the eight United Nations Millennium Development Goals (MDGs) was to en- courage member countries to change infrastructure, health care systems,

Suzanne Z. Gottschang is professor of anthropology and East Asian studies at Smith College. She would like to acknowledge the generous funding and research support pro - vided by the Research Grants Council of the Hong Kong S.A.R. (RGC CRF HKU C7011- 16G). This work was presented at a panel on reproductive technologies organized by Gonçalo Santos and the author at the Society for the History of Technology’s inaugural meeting in Asia, held June 2016 in Singapore. This article has benefitted from comments and discussions during the conference from Francesca Bray, Ruth Cowan, Gonçalo San- tos, Azumi Tsuge, Chiaki Shirai, Wu Chia-Ling, and Zhang Jun. Finally, she would like to thank Gonçalo Santos, Karen Turner, and Suzanne Moon as well as the anonymous reviewers of Technology and Culture for their helpful feedback. ©2020 by the Society for the History of Technology. All rights reserved. 0040-165X/20/6102-0009/617 –44

1. See for example in the United States: Donald G. McNeil Jr., “Maternal Deaths Plunged.”

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and practices that could bring about significant reductions in maternal mortality ratios (MMR). Global attention to maternal mortality, defined by the United Nations as any death of a woman during pregnancy, childbirth and up to six weeks postpartum, is not necessarily new. Vital statistics like maternal and infant mortality have long represented the measure of the suc - cess or failure of social and medical reforms aimed at modernizing societies APRIL and continue to serve as a measure of how well a nation cares for its women 2020 and children. 2 The Millennium Development Goal to reduce maternal mor - VOL. 61 tality represented the most ambitious effort to bring the world closer to a global aspiration of modernity in which women survive the risks of repro - duction. Yet reducing maternal deaths has proven difficult. Most countries in the Global South could not meet the MDG goal to reduce maternal mor - tality by 75 percent. Moreover, though not a signatory to the MDGs, the United States has the highest rate of maternal mortality among countries in the Global North. 3 Despite such difficulties, however, China stands out as one of only a few countries to have made significant progress. 4 China’s success in lowering MMR resulted from large-scale state efforts to improve access to hospital-based childbirth for women throughout the country with an eye to making emergency obstetrics care more widely available. Although great strides had been made in the twentieth century, since signing on to the MDGs in 2000, China has sought to make certain that every woman in the nation, no matter how remote their location and irrespective of their income, has the chance to give birth in a hospital. To date, the state has implemented this plan by expanding the number of maternity hospitals or clinics throughout the country so that by 2016 more than 95 percent of births would occur in these institutions. 5 In addition to the increase in institutionalized childbirth, the training and role of hospi - tal personnel who supervise these births also changed. Since the mid- 1990s, China abolished midwifery training and the place of midwives in overseeing childbirth, while concurrently training obstetric physicians to replace them. 6 These two widespread reforms fundamentally altered the landscape of childbirth in twenty-first-century China. Still, while decreases in MMR might be cause for celebration, increased cesarean rates in China suggest that reproduction in women’s lives may remain a potentially risky proposition. Ultimately, however, China’s successes in lowering maternal mortality represents an achievement that not only reinforces the power of

2. See Theodore M. Porter, The Rise of Statistical Thinkin g; and Michel Foucault, “Governmentality.” 3. GBD 2015 Maternal Mortality Collaborators, “National Levels of Maternal Mor- tality,” 1784. 4. World Health Organization, “The Top Ten Causes of Death.” 5. Y. Gao et al., “Progress and Challenges.” 6. Ngai Feng Cheung, Rosemary Mander, and Linan Cheng, “The Doula Midwives in Shanghai.” In some urban hospitals midwives assumed the role of a birth attendant who supports the mother during birth but is not involved in her medical care.

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the state to bring about significant health reforms for its citizens but also reminds the world of China’s increasing importance in world affairs. China’s recent efforts to prevent maternal deaths represent the culmi - nation of policies and plans spanning the twentieth century. This article follows policies and programs designed to reduce maternal mortality in China from the early twentieth century to the present day to document transformations in the spaces, technologies, and subjects of maternal gov - SPECIAL ernance. China’s modern history, in promoting maternal and child health, SECTION has been shown to reflect a dynamic process centering on the selective em- brace and adoption of Western medical and technological developments as part of efforts to modernize the nation. This focus represented a response based on the belief held by China’s reformers in the late nineteenth and early twentieth centuries that “women’s subordination was . . . explicitly linked to weaknesses in Chinese culture and the Chinese state, and moder - nity to women’s emancipation.” 7 While these trends have been well researched, as in Tina Johnson’s work on childbirth in Republican China , this article takes a longitudinal perspec - tive to make visible how technological choices reflect changing economic and political priorities in the interests of pursuing modernity. 8 With regard to childbirth, for example, Chinese medical reformers in the Republican era (1911–49) went against efforts in the West to bring birth into the purview and practice of physicians. Instead they promoted the use of trained mid - wives as a means to bring modern birthing practices to Chinese mothers. 9 Tracing maternal mortality reduction as a global and national health prior - ity through time in China’s history, this article adds to these insights as it helps makes visible the ways that programs and policies create possibilities for both adopting and discarding technologies and techniques designed to save women’s lives. For the purposes of this article, I focus on policies related to the role of hospitals, midwives, and physicians and then explore some of the technological consequences resulting from these changes. Drawing on studies of maternal mortality as well as anthropological analy - sis of policy and governance, the article demonstrates the ways that China’s efforts to reduce maternal deaths represent a form of coproduction of local circumstances and national and global agendas and interests. 10 It is important to reemphasize that at all junctures examined here we see in these changes a reflection of an aspiration to modernize China and establish its legitimate role among world powers. In the Republican era (1912–49), for example, Chinese health reformers sought to incorporate Western medical knowledge, technology, and practices to strengthen a

7. Gail Hershatter, Women in China , 86. 8. Tina Phillips Johnson, Childbirth in Republican China . 9. Ibid. 10. Suzanne Ilcan and Lynne Phillips, “Developmentalities and Calculative Prac- tices,” 874.

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poor and war-torn country by training midwives in basic aseptic tech - niques and by establishing maternity hospitals in urban areas. With the founding of the People’s Republic of China in 1949 and throughout the 1950s, the Communist government worked to bring childbirth into the hospital and established clinics throughout rural areas. After the Cultural Revolution and with China’s economic reforms in 1978 that brought more APRIL market based approaches to the economy and to governance, hospitals 2020 started to lose essential state subsidies and the rural health care system be-

VOL. 61 came fragmented with loss of state financial support. At the same time, state oversight of women’s reproductive care increased when China imple - mented the Birth Planning Policy in 1979 limiting families to one child. By the 1990s as China began to play an ever increasing role in the global econ - omy, it adopted a number of United Nations and World Health Organiza- tion initiatives. These initiatives resulted in legal and policy changes designed to improve women and children’s health and spur changes in maternity care with the aim of decreasing maternal deaths. However, these programs brought about mixed success, as many citizens had little or no health insurance and hospitals sought profits, reflecting the disarray of China’s health system. By the twenty-first century, the convergence of China’s prosperity, the establishment of the United Nations Millennium Development Goals, and an ongoing crisis in health care access brought the CCP’s attention to the potential to improve maternal mortality by ensuring that every woman can give birth in a hospital. Its most ambitious maternal health care initiative to date, these hospitals, with their availability of technology and expertise in the event of obstetric emergencies, represent the most definitive means to prevent maternal deaths. Yet the country has witnessed a dramatic increase in cesarean sections in this period, at the same time as it is recog - nized as only one of a handful of nations to achieve MDG Five’s goal to reduce maternal mortality. Through each of these eras, I focus on policies and projects related to the role of hospitals, midwives, and physicians and the technological choices and changes that arise, and then explore some of the consequences resulting from these transformations. Drawing on stud - ies of maternal mortality as well as anthropological analysis of policy and governance, the article demonstrates the ways that China’s efforts to reduce maternal deaths represent a form of coproduction of local circum - stances and national and global agendas and interests. 11

Preventing Maternal Deaths: Beyond China

As I have noted above, healthy mothers and infants serve as key indices of a population’s well-being and have long reflected a broader sense of a nation’s strength and stability for its own people and for the outside world. 11. Ibid.

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Yet vital statistics like maternal mortality ratios have more practical uses. Since the mid-twentieth century, national governments as well as organiza - tions such as the United Nations or the World Bank have relied on statis - tics, including maternal death rates, to 1) assess the effectiveness and acces - sibility of health systems; 2) anticipate population changes that influence a nation’s economy in the near and short term, and 3) indicate how well states govern their human and other resources. 12 Before turning to the role of SPECIAL MMR in China, I first define maternal mortality, discuss its causes and SECTION means of prevention, and then turn to maternal mortality as a measure of global health in the late twentieth and early twenty-first centuries. 13 Putting together these contexts situates China’s efforts to reduce and prevent mater - nal deaths throughout time. Maternal mortality ratios measure the number of women who die during pregnancy and within forty-two days of delivery. 14 These metrics include deaths due to abortion in addition to births (including caesarean births). Causes of maternal death measured in the MMR include: hemor - rhage (27 percent), infection (11 percent), hypertensive disorders (14 percent), prolonged or obstructed labor (8 percent), and complications from abortion (13 percent). 15 What is most notable about the potential for maternal deaths due to causes from hemorrhage (the most common cause of death), is that there is no way to anticipate such complications. Hypertensive disorders may be monitored during pregnancy but can also occur unexpectedly during labor. 16 In other words, no amount of prena - tal care or screening will prevent most of these deaths from occurring. The only way to avoid death, should one of these complications arise, is to seek and receive appropriate emergency medical care within a clinical setting equipped with appropriate technology. This factor has long con - founded attempts by countries in both the Global South and North to reduce maternal deaths. “The Three Delays,” a framework developed by Thaddeus and Maine in 1994 (see fig. 1) best illustrates that in an obstet - ric emergency, seeking care, locating and reaching an adequately equipped medical facility, and receiving appropriate treatment can alter the course of complications. 17 The framework reinforces the point that ma-

12. See Ian Hacking, The Taming of Chance , 28; Vincanne Adams, Metric s; and for maternal mortality specifically, see Claire Wedland, “Estimating Death.” 13. While the causes of maternal deaths are generally agreed upon, both the classi - fication and ways of counting these deaths are complicated. See M. C. Hogan et al., “Maternal Mortality.” 14. This is the most current definition agreed upon by the International Classifications of Disease (ICD) used by the UN, WHO, and other organizations. It is by no means uncontested, however, and it has evolved over time. 15. L. D. Say et al., “Global Causes of Maternal Death,” e323. Indirect causes of maternal mortality might include parasitic infections, malaria, or anemia. 16. Lelia Duley, “Maternal Mortality Associated with Hypertensive Disorders.” 17. S. Thaddeus and D. Maine, “Too Far to Walk,” 193.

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FIG. 1 The Three Delays. (Source: S. Thaddeus and D. Maine, “Too Far to Walk,” 1093. Reprinted according to STM permissions guidlines: www.stm-assoc.org/in tellectual-property/permissions/permissions-guidelines/.)

ternal deaths can be avoided when an obstetric emergency is recognized, a medical facility is available and accessible, and equipped to offer appro - priate treatment with qualified health providers. Despite the framework’s clarity and simplicity, however, the domains identified in it reflect a com - plicated landscape. From the “black box” of socioeconomic and cultural factors determining access to receiving appropriate treatment, Thaddeus and Maine outline intersections between women, families, medical sys - tems, health professionals, cultural values and beliefs, transport, and medical technologies. Preventing maternal deaths, therefore, is not a sim - ple matter that can be remedied with a few interventions.

Preventing Maternal Deaths: A Global Issue

In the international realm, in the late nineteenth and early twentieth centuries, a confluence of factors including high infant and maternal mor - tality, along with decreasing fertility rates, slowed population growth. At the same time, massive loss of life from wars, imperialist expansion, and the advent of eugenics sparked attention from historical actors with both economic and humanitarian concerns in securing future healthy genera - tions around the world. 18 The 1919 Paris Peace Conference brought about the founding of the League of Nations—an international organization (and precursor to the United Nations) designed to promote peace and interna - tional cooperation. The spirit of cooperation extended to health and resulted in the establishment of the Health Organization of the League of Na- tions (HOLN), which focused primarily on international coordination in infectious disease surveillance and management, standardizations of med - icines and vaccines, and advocated minimum nutritional requirements, 18. Valerie Fildes, Lara Marks, and Hilary Marland, eds., Women and Children First .

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especially for children. 19 By the 1930s HOLN expanded its focus from infectious disease surveillance and management to include sanitation and the welfare of mothers and infants. In the following decades, early agendas of the World Health Organization, founded in 1948, mentioned the impor - tance of improving maternal and child health but paid greatest attention to vertical programs to eradicate diseases like smallpox and malaria. 20 Most scholars mark the WHO-and-UNICEF-sponsored Alma Ata conference SPECIAL on primary health care in 1978 and the 1982 launch of the GOBI-FFF SECTION (Growth monitoring, Oral rehydration, Breastfeeding, Immunization— Female education, Family planning, and Food supplementation) to pro - mote child survival as key turning points in bringing international focus to maternal and child health. 21 However, it was not until the launch of the Safe Motherhood Initiative in 1987 by the United Nations Fund for Popu- lation Activities (UNFPA), the World Health Organization (WHO), and the World Bank that maternal mortality became a development priority, particularly in the Global South. 22 The conference on maternal mortality, held in Nairobi in 1987, included representatives from thirty-seven coun - tries: officials from UNICEF, UNFPA, the director-general of the WHO and the president of the World Bank, as well as members of fourteen non - governmental organizations and bilateral aid agencies. 23 The outcome of the meeting, The Safe Motherhood Initiative (SMI), outlined four key components to reduce maternal mortality. First, all women should have access to primary health care, adequate food, and family planning. The sec - ond component requires that during pregnancy women receive good pre - natal care, adequate nutrition, and referral to tertiary hospitals for high risk factors. Third, women should be attended, either at home or in hospital, by a trained birth attendant. Finally, all women must have access to effective obstetric emergency care. 24 In addition to outlining the means to reduce maternal deaths, the conference defined a goal to halve the maternal mor - tality ratio by 2000. Implementation of the SMI at the national level over - whelmingly focused on two of the four components: working to improve prenatal care, including screening women for potential complications, and training local traditional birth attendants. By 1997, the key action messages from the tenth anniversary assessment indicated that these approaches failed to decrease maternal deaths. 25 Participants concluded that most complications of childbirth could not be anticipated and that retraining traditional birth attendants was inadequate—these practitioners did not

19. Madsen Thorvald, “The Scientific Work of the HOLN.” 20. Allan Rosenfeld and Caroline Min, “A History of International Cooperation.” 21. Denise Roth Allen, Managing Motherhood , 49. 22. Ibid. 23. Halfdan Mahler, “The Safe Motherhood Initiative,” 688. 24. Ibid., 669. 25. Anne Starrs, “The Safe Motherhood Initiative,” 1131.

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acquire the medical skills and knowledge necessary to recognize and man - age complications and in most cases, there were no emergency obstetrics services to assist with complicated births. These lessons ultimately shaped the Millennium Development Goals targeting maternal mortality in 2000. The Millennium Development Goals (MDGs) emerged from numer - ous international conversations throughout the 1990s on topics such as APRIL improving education, the environment, and the lives of children and wom- 2020 en, and came to be known as “international development goals,” used as a 26 VOL. 61 measuring stick for development progress. With the approach of a new millennium, these goals were endorsed and later reworked for the 2000 UN Millennium Summit. 27 By 2001, development goals had been distilled into the report by the UN Secretary General, using the term “Millennium De- velopment Goals.” 28 The Millennium Development Goals, superseded in 2015 by the Sustainability Development Goals, consisted of eight goals with eighteen targets and forty-eight indicators. 29 Goal five of the MDGs required countries to improve maternal health. Maternal health in this case was measured by reducing maternal deaths and increasing the number of health professionals attending births. 30 The focus of Millennium Develop- ment Goal Five on maternal health represented a powerful shift at the global level in both emphasis on and application to preventing maternal deaths. In particular, the traditional birth attendants, who had been re- trained during the Safe Motherhood Initiative, disappeared. MDG 5 emphasized that prevention of maternal deaths required that skilled practi - tioners supervise childbirth and that emergency obstetrical services be available. As Santos shows in his research (this volume), however, they may only have disappeared in official contexts. At the end of the MDG era in 2015, in addition to China, only a hand - ful of countries had reached the target of reducing maternal mortality by 75 percent. Of the eight MDGs, the World Bank noted that the least progress had been made in reducing maternal deaths. 31 The intractability of reducing maternal mortality takes us back to the “Three Delays.” For many countries in the Global South coping with the task of improving access to the most basic of health care services, the technological, spatial, and human resources necessary to provide emergency obstetrical services to its moth - ers may be out of reach. The arrival of maternal mortality as a marker of modernity and the global-level health policies, aimed at preventing women’s deaths, that slowly emerged in its wake, have ultimately played out in pragmatic ways

26. John W. McArthur, “Own the Goals,” 154. 27. Ibid., 153. 28. United Nations, Road Map . 29. Ibid., 55–58. 30. Ibid., 56. 31. World Health Organization, UNICEF, UNFPA, and the World Bank, Trends in Maternal Mortality , 3.

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through national policy interventions. Implementation of these policies, however, relied not only on introducing technologies aimed to save women’s lives in an obstetrical emergency, but also on the nation’s ability to ap- ply these technologies across its often uneven geographic, economic, and social terrain. The remnants and legacies of war, revolution. and coloniza - tion, to name just three factors, have shaped the potential reach of policies and technologies that might prevent death in childbirth. In practice then, SPECIAL the playing field of preventing maternal deaths is not, and has not been, a SECTION level one.

Maternal Mortality and Midwives in the Republican Era, 191 2– 49

While unified global attempts to improve maternal mortality emerged in the late twentieth century through programs like the Millennium De- velopment Goals, nations around the world sought ways to reduce mater - nal deaths beginning in the nineteenth century. In China after the fall of the Qing dynasty in 1911, Republican-era intellectuals and reformers, responding to a confluence of forces and events, embraced maternal and child health as important markers of the nation’s path to modernity. As- pirations to create a strong, healthy citizenry as a means to modernize served to counteract longstanding internal and external perceptions of the country as weak and disorganized, especially after the humiliation of defeat in the first war with Japan (1894–95). 32 Indeed, China’s identity as “The Sick Man of Asia” brought a sense of urgency to the new nation’s efforts to improve maternal and child health. 33 At the same time, some Chinese thinkers embraced social Darwinism and eugenics; these ideas were given a material and technological outlet through the management of pregnancy and childbirth as a means to strengthen the nation. 34 Accurate counts of maternal mortality in this period do not exist, but in the 1920s the number was estimated to be 1,500/100,000. 35 For Republican government leaders and both Chinese and Western social reformers, modernizing midwifery by changing the knowledge, technology, and techniques used by lay mid - wives was a tangible way to prevent maternal deaths and produce healthy future citizens. 36 The connection between childbirth, maternal mortality, and moder - nity became visible in national and local governmental regulation of mid - 32. Nicole Barnes, “Disease in the Capital,” 286. 33. Tina Philips Johnson and Yili Wu, “Maternal and Child Health in 19th to 21st Century China,” 51. 34. Ibid., 52. Western missionaries and philanthropic organizations like the Rocke- feller Foundation also sought ways to improve maternal and child health. Jennifer Ryan, Lincoln C. Chen, and Tony Saich, eds., Philanthropy for Health in China . 35. Chongrui Yang, “Midwifery Training in China.” 36. See Johnson, Childbirth in Republican China .

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wives as well as in writings about the benefits of biomedical training for midwives in the popular press. For example, in 1913 the Guangdong mu- nicipal government, as part of its efforts to bring modern public health practices to the city, began to regulate midwifery. 37 This early attempt at regulating midwives included requirements that they complete a training program and pay a licensing fee to practice. Yet there were limited train - APRIL ing programs, and few could afford the training and licensing fees. 38 The 2020 regulations did not directly ban lay midwives—they could continue to

VOL. 61 practice but were not allowed to accept fees, advertise, or work for a gov - ernment organization. The impact of these regulations on Chinese moth - ers at the time was minimal, since most licensed midwives worked in urban areas and many families could not afford the fees of such a practitioner even if one were available. Despite the negligible influence on women and their families, instigating regulations and requirements for midwifery brought childbirth into governmental purview and set the stage for later efforts in the 1920s to reform the profession and to oversee pregnancy and childbirth. Moreover, these actions established the sense that prevention of maternal deaths required that lay midwives learn new technologies and techniques like sterilization, hand washing, use of basic medicines, and recognize signs of complicated labor—practices associated with modern, Western medicine. 39 Anxieties about the potential harm caused by traditional midwives were made real in the pages of early Republican popular magazines like Funu Shibao (The Women’s Eastern Times). Joan Judge shows how some of the regular contributors to the magazine, physicians trained in Western medicine, helped to promote modern obstetrical practices and to question the safety and efficacy of traditional midwives. 40 They argued that such changes would improve the lives of Chinese women and strengthen the nation. While some writers drew on scientific explanations about the dan - gers of infection transmitted by traditional midwives, others used firsthand accounts to appeal for a modernization of childbirth practices. One such author, Qiu Ping, cited the deaths of two friends who were attended by tra - ditional midwives and died of infection to promote the importance of modern biomedical training for midwives. Contrasting China with Japan, she described how the midwives in the latter country were trained using Western biomedical standards of care and how they made a living upon graduation. At the time of her visits in 1915, Japan had 135 midwifery schools, reflecting the country’s earlier and enthusiastic adoption of West- 37. Ibid., 56. Guangdong’s public health reforms were led by Western trained physi - cians and were some of the first to bring such reforms to a Chinese city. See Johnson, Childbirth in Republican China , 128. 38. Ibid., 128–29. 39. See Johnson, Childbirth in Republican China , for an in-depth examination of these processes. 40. Joan Judge, Republican Lens .

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ern medicine. 41 To put these numbers in perspective, in 1913, Japanese medical schools had over 15,000 graduates while China had just 500 med - ical students in training. 42 Five years later another writer, Xiaoyun, made clear that little had changed in childbearing despite calls for the reform and regulation of midwifery. She recommended that families and mothers take matters into their own hands by watching over the midwife to make sure that she followed aseptic protocols, even going so far as to describe how SPECIAL exactly to clean wounds from childbirth with sterile cotton and carbolic SECTION acid to avoid infection. 43 Despite attempts in the early years of the Republi- can period to bring modern technologies of childbirth to midwives few lasting changes were apparent to the writers and readers of Funu Shibao . Yet these types of publications made readers aware of the available tech - nology and knowledge that could prevent maternal deaths. 44 Efforts to bring modern, scientific childbirth practices to citizens in the early years of the Republic of China (ROC) beginning in 1912 mark an important turning point in the visibility of maternal mortality. However, the establishment of the Republic also brought decades of internal struggles for power among competing warlords until 1927, intermittent war with the Chinese communists until 1949, and invasion by Japan from 1937–45. 45 Despite the unstable and often decentralized reach of the ROC govern - ment, work to modernize the country persisted, albeit in piecemeal fashion over time and space. Linking modernization to improved maternal and child health continued as government and philanthropic efforts by West- ern and Chinese elites to improve maternal and child health continued throughout the country—especially in urban areas. By the late 1920s, modernizing midwifery gained a foothold at a national level through the work of Dr. Yang Chongrui (Marion Yang) and John Grant of the Rockefeller Foundation’s Peking Union Medical Center (PUMC). In its first five-year plan, the Republic’s Ministry of Health prior - itized maternal and child health and set a goal of retraining traditional mid - wives and training new ones and to establish a national maternal child health care system that included rural areas in ten years. The Ministry also established the National Midwifery Board to supervise the training and reg - ulation of midwives. These efforts were complemented by private, mission - ary, and philanthropic attempts to improve maternal and child well-being throughout China by building maternity hospitals and establishing mid - wifery schools. Despite these initiatives, most Chinese women continued to 41. Ibid., 136. 42. AnElissa Lucas, Chinese Medical Modernization , 43, cited in Johnson, Childbirth Republican China , 77. 43. Judge, Republican Lens , 138. 44. Readership of these popular magazines was limited to relatively small popula - tions of literate men and women with means to purchase such items. 45. For a comprehensive history of this period, see John K. Fairbank, ed., Republi- can China, 1912–1949 .

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give birth as they had done for centuries, in the hands of an experienced tra - ditional midwife in their local communities. 46 The years of war against the Japanese (1937–45) and the civil war with the Communists (ending in 1949) did not allow the Ministry of Health to implement its plans to create a national network of maternal and child health care. But these plans and the work of Dr. Yang Chongrui created the foundation for the development APRIL of the midwifery profession after the Communist victory in 1949. 2020 Actions taken to improve the safety of mothers during childbirth in VOL. 61 China’s Republican era offers, if only briefly here, glimpses of the inter - laced interests and agendas of China and the West. As Tina Johnson shows, missionary medical work, alongside the endeavors of local Chinese elites and philanthropic organizations like the Rockefeller Foundation’s China Medical Board, connected the future of the nation to modern, sci - entific reproduction. To do so would help the most populous country in the world shed its reputation as a disorganized and disease-ridden nation. The efforts, for example, by Chinese (Yang) and Western medical experts (Grant) based at the Rockefeller-sponsored Peking Union Medical College to train lay midwives in modern aseptic techniques illustrate these mutual interests. China’s relationship with Japan as a sometime colonizer and as an exemplar of how to modernize also complicates the China-Western medicine/science relationship. Given this complexity it may be most pro - ductive to see the efforts to prevent maternal deaths as part of the world - wide spread of scientific practices and Western medical technology in interaction with local circumstances. 47 Yet for all of their efforts, they did not bring about fundamental changes to China’s reproductive culture. Chinese women continued to give birth at home with the assistance of a midwife or an experienced female family member. The introduction of aseptic techniques and technologies used by midwives in large cities like Shanghai and Beijing reflected the influence and the presence of Western medical practices in childbirth. The uncertainties brought by war and inva - sion, along with China’s vast population and geography, made it impossi - ble to accomplish the modernization of childbirth for all mothers.

Midwifery, Hospitals, and Maternal Mortality in the People’s Republic of China

At the end of the 1960s, less than twenty years after the end of China’s civil war and the establishment of the People’s Republic of China, the Beijing Maternity Hospital oversaw the births of one-fifth of all Beijing res - idents in its delivery rooms. 48 This achievement reflected the success of the

46. Johnson, Childbirth in Republican China , 58–59. 47. Leung and Furth, Health and Hygiene in Chinese East Asia , 2; See also Ruth Ro- gaski, Hygienic Modernitie s; and Michael Shiyung Liu, “Transforming Medical Para- digms in 1950s Taiwan.” 48. Y. Liu et al., “Healthcare in China,” 32.

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efforts of the Chinese Communist Party leadership to modernize and insti - tutionalize childbirth. They rapidly expanded the training of professional and lay midwives and built hospitals and clinics throughout the country, moving childbirth into hospitals in urban areas. By 1953, every county had a hospital capable of providing basic medical and surgical services. 49 In addition to building medical institutions, the CCP relied on mass public health campaigns about sanitation, hygiene, and maternal and child health SPECIAL to improve outcomes for mothers and their infants. 50 These efforts met SECTION with success. In 1958, the maternal mortality ratio in Beijing, for example, had dropped—from 610/100,000 in 1949 to 9/100,000. 51 By 1991 the national MMR stood at 80/100,000, down from approximately 150/100,000 in 1949. In 1990, more than 70 percent of urban women gave birth in hos - pital and about 60 percent of rural women gave birth at home. 52 The Chi- nese Communist Party has long taken pride in their early success in reduc - ing maternal and child deaths and providing basic primary health care across the country. Midwives played an essential role in the decrease in maternal mortal - ity in the early years of the PRC. The CCP built on Dr. Yang Changrui’s strategy from the Republican era and trained lay midwives and a corps of professional midwives. In fact, Dr. Yang continued her work to modernize and professionalize midwifery after 1949 at the invitation of Mao Ze Dong and Zhou Enlai. She brought her longstanding expertise in establishing midwifery schools during the Republican era. Dr. Yang also gained impor - tant international perspectives and experience when she left China for fur - ther training at Johns Hopkins Medical School in 1941. Subsequently, she worked with the League of Nations, surveying the state of maternal and child health in Europe and Asia, developing training programs for medical staff under the auspices of the United Nations, and consulting for the World Health Organization during and after World War II. The CCP viewed lay midwives as important resources with experience and knowl - edge who could, with the use of some training and technology, improve the health and well-being of mothers and infants. The CCP had learned dur - ing the civil war years that local lay midwives who received training and certification in the use modern childbirth techniques and technology could best serve rural and remote areas. As government certified midwives, they acted for the first time in China’s history as state officials delivering their newest citizens. Although this transformation did not reach all lay mid - wives, as Santos’s (this volume) research in rural south China shows, wide - spread adoption of the technologies of modern childbirth began to take 49. Johnson, Childbirth in Republican Chin a; see also Michelle Renshaw, “The Evo- lution of the Hospital.” 50. Joshua Goldstein, “Scissors, Surveys, and Psycho-Prophylactics,” 155. 51. Reliable data for all of China is hard to come by in the early years of the PRC, and Beijing’s experience does not reflect what was happening throughout the country. See Renying Yan, “Maternal Mortality,” 328. 52. W. Li, Y. T. Liabsuetrakul, and B. Stray-Pedersen, “Change of Childbirth,” 185.

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hold throughout the country. These consisted of basic aseptic practices: washing hands, tying and packing the umbilical cord with sterile materials, administering silver nitrate to prevent eye infections, and identifying potential labor complications (high blood pressure or obstructions, for exam - ple). Such technologies and practices resembled those taught thirty years earlier at the First National Midwifery School established under Yang APRIL Chongrui. 53 Despite setbacks and some resistance among lay midwives and 2020 their clients in the early years of the PRC, the goal Dr. Yang and her col - VOL. 61 leagues set in the 1920s—to establish and train both lay midwives and pro - fessional midwives in modern childbirth—came to fruition. Statistical and observational data that French physician Alexander Minkowski collected during visits in 1965 and 1968 provides some per - spective on the state of maternal and child health in rural and urban China at that time. 54 Shanghai’s First Maternity Institute, for example, typically oversaw 5,000 deliveries, managed 800 cases of dystocia (obstructed labor) and performed about 250 cesarean sections every year. 55 In visits to rural/ suburban communes, Minkowski found health facilities that offered maternity care and delivery by midwives both in clinics and in peasants’ homes. 56 Minkowski notes that the expansive nature of China’s health problems and the CCP political commitment to providing adequate care to all brought pragmatic programs for training health workers in three-to- four-month programs commonly referred to as “barefoot doctors.” 57 The expansion of both health facilities and health workers brought significant changes to China’s health system. By 1981 one of China’s leading reform - ers in rural health care, Chen Zhiqian, noted that 670,000 health stations serving 85 percent of villages were staffed with 1,348,000 barefoot doctors and 500,000 midwives. 58 There is no doubt that the expansion of both health facilities and health workers brought significant improvement to maternal and child health care. Yet a mid-1970s survey showed that age- specific death rates for women between twenty-five and thirty-five years were significantly higher than that of men—indicating that death in child - birth remained a significant risk. 59 The Chinese Communist Party’s rapid success in improving maternal and child health after 1949 built on earlier efforts and emphasized provid - ing access to midwives with training in Western medicine. Their presence and the establishment of a three-level health care network to which in-

53. Johnson and Wu, “Maternal and Child Health in 19th to 21st Century China,” 61. 54. Alexander Minkowski, “Care of the Mother and Child.” 55. Ibid., 218. 56. Ibid., 229. 57. Ibid., 231. 58. Zhiqian Chen, Medicine in Rural China , 160, quoted in Arif Dirlik, “Global Mo- dernity,” 103. 59. See Penny Kane, “Assessment of Chinese Health Care” in Johnson and Wu, “Maternal and Child Health in 19th to 21st Century China,” 63.

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creasing numbers of women could turn in cases of obstetric emergencies in rural and urban China provided the conditions under which maternal mortality rates could decline as dramatically and quickly as they did. These achievements also served as a key indicator not only to the Chinese people but to the world that the CCP’s socialist modernization project was work - ing. Socialist modernity was manifested in obstetrics care by combining the mobilization of the state’s greatest resource—its people who trained as SPECIAL barefoot doctors/midwives—and a pragmatic system of health care insti - SECTION tutions—local clinics and hospitals, along with tertiary hospitals. These institutional changes did not change the location of childbirth for most rural women and the many urban women who gave birth in the home. However, these women were now more likely to be attended by a midwife trained in aseptic techniques who could also detect complications during birth. Women were also now embedded in a health care system that had the potential to care for them should an emergency arise. These changes helped to cultivate a reproductive culture in which birth was viewed as an event that required care from experienced midwives at home. At the same time, women in many areas of China had better access to the biomedical expertise of physicians situated in hospitals. For rural women, this birthing culture remained entrenched well into the twenty-first century. While drawing on Western science and medicine to develop a maternal and child health system, reproductive modernity in the Mao years reflected the prag - matism and focus of the CCP’s modernization agenda, with its attention to reorganizing society from the bottom up and drawing on its citizenry as a resource to bring about such changes.

Market Reforms, Birth Planning, and Maternity Care

The late 1970s to mid-1990s brought significant transformations to modernizing China’s reproductive health landscape in four key ways. First, the state sought to extricate itself from financially supporting hospitals and clinics and from health care provision more generally by dismantling or reducing health insurance for rural and urban citizens to better focus on implementing economic reforms. It implemented the Birth Planning Policy, which limited families to one child, creating increased family focus on gestating, birthing, and rearing a healthy child. The state also began to train increasing numbers of physicians to meet China’s health care needs after the interruption of the Cultural Revolution from 1966–76. Finally, the admission of the PRC government to the WHO in 1972 and establishment of the WHO Representative office in 1981 brought China firmly into the international health community. Together these policies and events resulted in significant changes in the availability and use of reproductive technologies and practices to prevent maternal deaths. As part of the economic reforms beginning in 1978, state entities like

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hospitals were required to increase their revenues as the state decreased subsidies. While urban residents may have been covered by insurance, beginning in 1985 hospitals and clinics shifted to a fee-for-service model, and most insurance only partially covered these expenses. The earlier Cooper- ative Medical scheme available to rural residents disintegrated with the dis - mantling of the commune system as the state focused its energies on eco - APRIL nomic reform and developing a market economy. 60 In urban, coastal areas, 2020 rapid migration increased the population living in cities and put pressure

VOL. 61 on an already unstable health care system. Additionally, many physicians and other health personnel left rural areas for the cities, creating a shortage of medical professionals in rural and interior parts of China. 61 By the 1990s, increasing numbers of urban employers stopped offering health insurance so that less than 40 percent of urban workers had health insurance. As a result, China’s citizens paid for health care out of pocket using savings and loans from friends and family to pay for costly treatments. 62 Though the state did retreat from subsidizing health care, the implementation of the Birth Planning Policy in 1979 brought new forms of oversight to repro - duction and sharpened family interests in ensuring the birth of a healthy child. The policy reflected the government’s hopes of “achieving wealth, modernity, and global power through selective absorption of Western sci - ence and technology.” 63 Under increasing pressure to give birth to only one child, urban and rural women’s reproductive health came fully under both state scrutiny and medical supervision. Although the state’s primary goal was to slow China’s population growth in pursuit of economic development, an unintended outcome was that maternal mortality rates declined. Women were simply having fewer children. From this perspective, then, the availability of con - traceptive technologies from birth control pills and IUDs to tubal ligation, vasectomy, and abortion represented an important intervention in lower - ing a woman’s risk of dying in childbirth. This came at cost, however. Women and their families had little say in the type of contraception they used, and they did not have the freedom to determine family size on their own. National repercussions of these choices are evident in the skewed sex ratios that favor the birth of boys and have now resulted in an excess of over 30 million men. 64 In addition to these population-based consequences, research indicates that 75 percent of women who decided to have a second child outside of the plan were much less likely to seek prenatal care, to seek medical professional help, or to give birth in a clinic or hospital. 60. Liu et al., “Healthcare in China.” 61. Y. Gong and A. Wilkes, “Reforming Rural Health Care,” quoted in Daemmrich, “Healthcare Reform,” 7. 62. Winnie Yip and Ajay Mahal, “The Health Care Systems of China and India,” 922. 63. Greenhalgh, “Science, Modernity, and the Making of China’s One-Child Pol- icy,” 164. 64. Yi Zeng and Therese Hesketh, “The Effects of China’s Universal Two Child Pol- icy,” 3.

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By the early 1990s, the widespread negative consequences of China’s laissez-faire approach to the provision of health care beginning in 1978 became visible. Problems ranged from rising rates of preventable diseases and mounting health care cost burdens on citizens to increasingly poor quality health care came to the fore in the mid-1990s. It was clear to the state and indeed the world that substantial changes in the system were nec - essary. 65 The mid- to late 1990s mark a period in China’s efforts to mini - SPECIAL mize maternal deaths that stands in significant contrast to earlier periods SECTION sketched above. The Chinese government’s adoption and implementation of United Nations conventions on women’s health and child welfare and the formulation and adoption in 1995 of the Law on Health Protection of Mothers and Infants made visible national concerns about the role of mothers as reproducers of the nation and transmitters of Chinese “spiri - tual civilization.” 66 More practically, pregnant women gained access to special maternity insurance and subsidies to cover the costs of their med - ical care—though these were largely urban-based and therefore not neces - sarily available to all women. 67 The laws and directives, however, brought substantive changes to maternity care in China’s hospitals and clinics and signified a turn towards cooperation and collaboration with the global health community. Efforts to collaborate with global institutions like the WHO were not new, as the PRC had gained entrance to the WHO in 1972. China’s bare - foot doctors had also served as a model for the WHO’s emphasis on low- cost primary care to improve health in countries in the Global South in 1981 (Alma Ata Declaration). In 1991 Premier Li Peng signed the “World Declaration on the Survival, Protection and Development of Children” as well as the “Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children” after China partici - pated in the 1990 United Nations World Summit for Children. In addition, China co-sponsored the draft resolution for the United Nations Conven- tion on the Rights of Children, which was formally approved in 1991 and adopted by the Chinese government in 1992. 68 In 1991, China also partic - ipated in the UNICEF-WHO Baby Friendly Hospital Initiative to increase breastfeeding. By 1997 it led the world in reorganizing more than 7,000 hospitals to improve declines in breastfeeding that began in the 1970s. 69 Such state-sponsored actions mark important instances when the Chinese government embraced and helped to shape international stan - dards and goals regarding maternal and child health. 70 China’s active par - ticipation in such initiatives partly stemmed from leaders’ understanding

65. Dale Huntington et al., Improving Maternal Health , 1. 66. Ann Anagnost, “A Surfeit of Bodies,” 24. 67. Liu and Sun, “Maternity Insurance,” 31. 68. Xinhua News Agency, “Maternal and Infant Law,” 192. 69. Suzanne Gottschang, Formulas for Motherhood , 23. 70. China’s bid and eventual entrance into the WTO is a well-known example of this.

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that to be considered on par and to compete with other developed coun - tries, the nation must raise its living standards and improve the health and well-being of its citizens. Healthy mothers produce infants who become sturdy citizens of a strong state—all signs of a modern nation that echoes China’s aspirations beginning in 1912. 71 Despite the initiatives described above, by the mid-1990s China found APRIL itself seeking assistance from the United Nations, WHO, and the World 2020 Bank to rebuild its failing health care system. The 1998 Basic Health Ser- VOL. 61 vices Project, which focused on reducing maternal mortality in poor areas of China, was funded by the Chinese government, the World Bank, and the UK Department of International Development. Aiming to bring compre - hensive but more localized and relevant solutions to the rural health care system, the project was implemented in ninety-seven of the poorest coun - ties in ten provinces. It included actions to implement new health insur - ance schemes, coordinate health services, improve access to affordable care, and provide better training for health professionals. 72 The project’s success can be measured in reductions of MMR from 125.5 to 68.2 in seven years. These changes may have resulted from improved access to profes - sional medical care and hospital deliveries, which increased from 20 per - cent in 1998 to 70 percent in 2006. 73 One important change in the early 1990s entailed shifting the supervi - sion of low-risk hospital births from midwives to physicians, a change implemented primarily in urban areas. Professional midwifery was ultimately dismantled when the state began closing midwifery training programs in 1993. 74 Practicing midwives were offered the option of training to become physicians or returning to nursing in another part of the hospital. 75 The justification for the removal of midwives from the delivery room centered on two factors. First, more physicians than midwives had been trained since the 1970s, and second, midwives, especially those in rural areas, were blamed for high infant and maternal mortality rates (for anecdotal evi - dence to the contrary, see Santos in this issue). 76 The eradication of mid - wifery continued throughout the 1990s, eventually reaching rural areas in the twenty-first century. Technological changes that would come to shape maternal mortality in China also occurred outside the realm of childbirth. In 1989 the Chinese Ministry of Health implemented a national maternal and child mortality

71. These aspirations began in the late nineteenth century, but became more con - crete with the establishment of the Republic of China. 72. Huntingdon et al., “Improving Maternal Health,” 1. 73. Ibid. 74. Ngai Feng Cheung et al., “Clinical Outcomes of the First Midwife-Led Normal Birth Unit.” 75. Ibid. 76. Ngai Feng Cheung, “History Midwives China,” 235; See also H. Jiang et al., “Towards Universal Access to Skilled Birth Attendance.”

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surveillance system (NMCMSS) to collect population-level data on maternal mortality. Covering thirty-one provinces as well as autonomous re- gions, the system reaches every county and has established numerous strategies to ensure the reliability of the data. In addition, provinces throughout China have, at various times beginning in the 1990s, established their own maternal mortality surveillance systems. The key difference between these two ways of counting maternal deaths is that the NMCMSS SPECIAL represents a 5 percent sample of all maternal deaths, while provincial level SECTION surveys account for all maternal deaths. While efforts were made to gather such statistics during the Republican and Mao eras, only intermittent and spotty data could be collected.7 7 Such mechanisms for making visible Chi- na’s vital statistics serve as a technological marker of modern governance. The convergence in the 1980s and 1990s of the one-child policy, the retreat of the state from health care, and the state’s active participation in mul- tilateral UNICEF and WHO programs designed to improve maternal and child health resulted in a number of changes in the technologies and practices associated with maternal mortality. In urban areas, with the birth of a precious single child, the stakes for ensuring a healthy delivery for mothers and infants increased. Bringing normal birth into the purview of physicians rather than midwives in hospitals may be considered a response to such pressure. Ultimately, the role of midwives as protectors of maternal and child health began to diminish as the role of hospitals and clinics expanded, bringing possibilities for the increased use of technologies like cesarean sections. For rural Chinese mothers, providing affordable access to medical care during pregnancy and supervision of childbirth by biomedically trained personnel at home or in a hospital also brought these women to a modern biomedical ideal of childbirth that had begun only sixty years earlier.

Twenty-first-century China, Maternal Mortality, and Modernity

The turn of the twenty-first century brought about significant changes to the maternal and child health care system which built on policy changes from the 1990s. By 2003 policy makers in China, as part of their commitment to meeting the United Nations Millennium Development Goal 5 to decrease maternal mortality by 75 percent in 2015, implemented plans to ensure that every woman gave birth in a hospital. To guarantee access, the state expedited reforms in insurance and instituted a “facility birth subsidy” in rural China based on the success of the 1998 Basic Health Services Project. These changes resulted in more rural women giving birth in the newly strengthened network of hospitals and clinics with physician oversight.7 8 In

77. Johnson, Childbirth in Republican China , 143. 78. Ministry of Foreign Affairs, China’s Progress Toward the Millennium Develop- ment Goals , 31.

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2011, more than 90 percent of all births in China took place in a medical facility supervised by physicians. 79 While the MMR declined from 59/ 100,000 in 2000 to 36/100,000 in 2011, these remarkable changes have brought about unintended consequences: a 2010 report from the WHO found that China also had one of the world’s highest cesarean section rates, averaging 46 percent and reaching 80 percent in some urban hospitals be- APRIL tween 2007 and 2008. 80 It is an understatement to suggest that childbirth in 2020 twenty-first-century China has become increasingly medicalized and, in VOL. 61 many cases, is considered a matter for surgical intervention. China’s high cesarean rates could result from women’s exposure to the potential of cesarean sections by giving birth in hospitals. But social sci - ence research on the determinants of the use of cesarean sections shows that birthing in a hospital is but one of a constellation of factors that might influence surgical intervention. For example, a 2007 study suggests that the broader context of technological intervention in pregnancy may play a role in the mode of childbirth. Researchers in China found that the risk of a cesarean section was 1.6 times higher among those women who received an ultrasound scan at a prenatal visit than among those who did not receive one. The same study found, however, that those mothers who had no prenatal care at all were also more likely to deliver by cesarean section. When considering technological intervention in birthing practices, then, the field of influence may extend outside of the birth itself. 81 Economic, cultural, and social forces may also play a role and reflect changing reproductive cultures (see Santos, this issue). This dynamic be- comes clear in some studies that find women and their families requesting a cesarean section as a way to ensure an auspicious birthday or to avoid the pain and potential physical injuries that can be associated with vaginal delivery. 82 A recent prospective study found that as women progressed through pregnancy, their desire for a cesarean section or vaginal delivery evolved. The percentage of women who desired a cesarean section in the second trimester increased from 13 percent to 17 percent during the third trimester. The study also found that physician suggestion of a cesarean sec - tion, in situations where there were no medical indications, accounted for 29 percent of all cesareans performed during the study. Of the 523 women in the sample, 58 percent underwent a cesarean section. 83 These findings, along with other research in China on the cesarean section rate, point to a convergence of factors that might explain the rise of this practice. In addi - tion to maternal request, some research suggests that the recent privatiza - tion of more medical care creates a financial incentive for the physician

79. Sufang Guo et al., “Delivery Settings,” 757. 80. Pisake Lumbiganon et al., “Method of Delivery and Pregnancy Outcomes,” 492. 81. Guo et al., “Delivery Settings,” 758. 82. X. L. Feng et al., “Factors Influencing Rising Caesarean Section Rates,” 36. 83. Honglei Ji et al., “Factors Contributing to the Rapid Rise,” 4.

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and hospital to perform cesarean sections. Further, there is increased pres - sure on physicians as a result of the one-child policy to avoid exposing women and their infants to the risks of childbirth, thus encouraging them to perform unnecessary cesarean sections to prevent complications for the infant. 84 It is clear that in addition to the near ubiquitous hospital delivery for women, a number of economic, social, cultural, and political/legal fac - tors contribute to China’s cesarean section rate. Taken together, these fac - SPECIAL tors reflect changes in the reproductive culture more generally and speak SECTION to the complexity of these changes as an array of actors—from the state to pregnant mothers—and circumstances—from the economic to the social —shape birth practices. Perhaps more experience will help acculturate health professionals and citizens to the idea of cesarean sections as an intervention reserved for spe - cific conditions and situations. One recent experiment with reinstated midwives on a normal birth unit in a Hangzhou hospital offers some hope. Researchers found that births overseen by midwives resulted in 88 percent vaginal deliveries compared to 58 percent of deliveries supervised by physicians and nurses in the same hospital. 85 These results, alongside indi - cators from countries in which midwives deliver most low-risk mothers, could bring back midwifery to China’s hospitals. 86 Childbirth in China’s twenty-first century, then, might reframe reproductive modernity as a bal - ance between the highly medicalized cesarean section and the assistance of trained birth attendants.

Conclusion: Cesarean Sections, Maternal Mortality, and Reproductive Modernities

Ultimately, the medicalization of childbirth may be seen to represent the pinnacle of China’s efforts to modernize the nation: women are giving birth in hospitals—themselves a modern institution—and availing them - selves of modern surgical technology instead of undergoing the physical duress of childbirth. Yet the conundrum presented by efforts to both reduce maternal mortality and minimize cesarean sections in China repre - sents a confluence of factors that can be traced back to the Republican era. China’s great strides in reducing maternal mortality coincide with the rapid creation of a hospital-based birth system for the entire country. The most significant change in technologies of childbirth—the cesarean section— however, does not necessarily improve maternal mortality ratios. Whether the policies designed to decrease maternal deaths have any bearing on these rates is beyond the scope of this article. It is possible that the future of

84. Ibid., 8. 85. Cheung et al., “Clinical Outcomes of the First Midwife-Led Normal Birth Unit,” 584. 86. Ibid., 586.

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China’s maternal mortality ratio will rest on two recent policy changes, both of which relate to the demographic consequences of the one-child policy. In 2015, China registered the lowest total fertility rate in the world, at 1.05, and the country now faces a complex demographic future with an increase in its aging population and skewed sex ratios. 87 The official relaxation of the one- child policy to a two-child policy to offset these demographic changes could APRIL potentially increase risk of death due to pregnancy or childbirth among 2020 those who choose to have an additional child. Alternatively, China could VOL. 61 follow in Korea and Japan’s footsteps as a very low-fertility country for the foreseeable future, as women are having children later in life. For example in 2009, 15.8 percent of Japanese women giving birth to their first child were over thirty-five years old. Studies show that Japanese women in this age group are at a significantly higher risk for cesarean section than younger women. 88 One study noted that despite hospital policies prohibiting elective cesarean sections, Japanese obstetricians have been inclined to perform sur - gery on anxious, first-time, older mothers who had undergone IVF treat - ment. 89 The precarious nature of reproduction is perhaps highlighted when pregnancy itself requires technical assistance, and as a result, the bodily driven timeline of childbirth seems risky. Evidence of similar patterns in urban China is already apparent. The average age of marriage for women in China is twenty-six, and in cities like Shanghai, women are marrying at an average age of thirty. 90 In light of trends in other East Asian nations, these changes in China could portend a future in which cesarean sections might well represent a nation’s best chance of ensuring the health and longevity of mothers and their infant-citizens.

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