The Effect of Family Planning on Women's Lives: The Case of The People's Republic of China Gu Baochang Xie Zhenming China Population Information and Research Center Karen Hardee Family Health International March, 1998 TABLE OF CONTENTS Acknowledgments I Executive Summary ii 1. Introduction 1 A. Background 1 B. Women’s Studies Project 2 C. Conceptual Framework 3 D. Objectives 3 2. Methods 6 A. Study Sites 6 B. Data Collection 7 C. Fieldwork 9 D. Data Analysis 10 3. Results 12 A. Life Cycle Stage and Other Personal Factors 12 B. Childbearing Experience 22 C. Contraceptive Use and Experience with Abortion 27 D. Experience with Family Planning and Reproductive Health Services 44 E. Family and Household Roles 63 F. Economic, Social and Economic Roles 96 G. Individual Physical and Psychological Factors 122 4. Summary and Recommendations 133 Bibliography 136 Attachment 1. Women’s Questionnaire, Anhui Province 140 ACKNOWLEDGMENTS Dr. Gu Baochang is deputy director of the China Population Research and Information Center (CPIRC) and Dr. Xie Zhenming is director of the Research Division of CPIRC. Dr. Karen Hardee is currently the director of research, POLICY Project, The Futures Group International. At the time of this study, she was principal research scientist, Women’s Studies Division, Family Healht International (FHI). This report and the study upon which it is based depended on the good will and active participation of the nearly 2,900 survey and focus group discussion participants. In addition, the authors would like to thank the following organizations and people for making this research possible: The State Family Planning Commission for approving the study, and the local government and family planning authorities in Jiangsu and Anhui provinces for allowing the studies to be conducted in their provinces. In the Population Research Division of the CPIRC, the authors would like to thank the following research staff for participating in the fieldwork, data analysis and report writing for the study: Gu Daping, Associate Researcher and Deputy Director; Yang Shuzhang, Research Fellow of the First Grade; Luo Binbin, Assistant Researcher; Liu Hongyan, Assistant Researcher; Feng Zhanlian, Assistant Researcher, and Tang Mengjun, Research Trainee. At FHI, we appreciate Theodore King, President Emeritus, and JoAnn Lewis, Vice President for Reproductive Health Programs, for allocating FHI corporate funds to cover part of Karen Hardee’s time to undertake this study. We would like to thank Nancy Williamson, Director of the Women’s Studies Project, for her encouragement for undertaking this study and for her review of the study, including the final report; Kathy Hinson, Contract Administrator, for administering FHI’s contract with Rockefeller Foundation; Laura Johnson, Research Assistant, for assistance with data analysis; and Barbara Barnett, Senior Writer/Editor, for editing the final report and for making helpful suggestions for recommendations. Finally, the authors would like to thank Rockefeller Foundation for its financial support to CPIRC and FHI to undertake this study. At Rockefeller, we would like to thank Evelyn Majidi, Senior Program Associate, Sara Seims, Assistant Director for Population Sciences and Steven Sinding, Director of Population Sciences. i EXECUTIVE SUMMARY Background Fertility has declined precipitously in China over the past three decades, so there are generations of Chinese women alive today who have been affected very differently by family planning. China’s total fertility rate (TFR) fell from more than six children in the 1950s to around two in 1992; virtually all couples in urban areas now have one child and most couples in rural areas have two children. In 1979, China adopted a population policy advocating one child per couple (soon thereafter, some exceptions were made, particularly in rural areas for daughter-only couples). The policy has come into conflict with a culture that has valued males over females. The legal position of women has improved, as has women’s status as measured by education and employment statistics. However, attitudes and behavior toward women suggest that gender norms and roles are slow to change. The Chinese government recognizes that the family planning program has had many beneficial effects on Chinese society but also acknowledges the program’s negative effects. While the State Family Planning Commission (SFPC) still has fertility goals and contraceptive use targets, the program is now committed to providing better quality services to clients. Most studies have looked at the status of women and the role that various factors in a woman's life play in determining her use or non-use of family planning. More recently, Family Health International (FHI), primarily with funding for the Women’s Studies Project (WSP), from the U.S. Agency for International Development, and in the case of this study, through the Rockefeller Foundation, has conducted research in a number of countries that aims instead to understand how contraceptive use and reproductive health may have affected women's lives in terms of family relations, education, employment, and quality of life. ______________________________________________________________________________ Objectives The objectives of this study were to investigate, using the WSP conceptual framework, the role family planning has played in affecting three domains of women’s lives: personal, familial and social. The study investigated women’s experiences with family planning methods and services, and with pregnancy and childbearing, and the role women attributed to family planning in the opportunities they have had in their lives. While women were of primary interest in this study, men’s perceptions and experiences were also examined. ______________________________________________________________________________ Methods This study, conducted in 1996, was undertaken jointly by the China Population Information and Research Center (CPIRC) and FHI. This study was carried out in two counties each in two provinces: Counties A and B are in South Jiangsu Province, an east coast province with a ii booming economy, a strong family planning program and rapid decline of fertility; Counties C and D are in North Anhui Province, representing middle China, with an agrarian economy and a less effective family planning program. The study included a survey of 1,996 women and 506 men and 56 focus group discussions (FGD) with 375 people (220 women and 155 men). The FGD were conducted with older women and older men, reproductive age women and men, unmarried women and men and woman entrepreneurs (a group of special interest in China). _____________________________________________________________________________ Results Socioeconomic and Other Personal Factors C The physical, socioeconomic and generational context of women’s and men’s lives in South Jiangsu and North Anhui differed considerably. People in South Jiangsu were more prosperous than in North Anhui. Respondents were virtually all married and were, on average, in their mid- to late 30s. Household size was, on average, 3.6 in South Jiangsu and 3.8 in North Anhui, with respondents in South Jiangsu generally living in larger and newer houses than in North Anhui. Educational attainment was higher in South Jiangsu than in North Anhui. Men tended to have more education than women and younger people had higher educational attainment than did older people. Virtually all the men and women in North Anhui worked as farmers, while only one in five respondents in South Jiangsu were farmers. The most common occupation in South Jiangsu was worker in a local enterprise. C Households were more prosperous in South Jiangsu than in North Anhui. Most households in both areas owned bicycles and televisions, but households in South Jiangsu were more likely to own other consumer goods, such as refrigerators and washing machines and means of transportation, such as motorcycles. Only ownership of tractors was more common in North Anhui than in South Jiangsu. Childbearing Experience C Knowledge of the fertility policy. People tended to know the fertility policy in their area and were, for the most part, adhering to it. A woman from South Jiangsu summed up the situation in her area: “Not many people have two children. Only the older generation had three or four.” South Jiangsu strictly enforced a one-child per couple policy with few exceptions, while North Anhui had a more relaxed one-child per couple policy in which couples whose first children were daughters were allowed to apply to have another child. Even a young man from North Anhui knew the policy . “You have to submit a report before marriage and have to go to the township to apply for a pregnancy certificate....If you have a rural residence permit, if the first child is a daughter, after several years you can have another, but I cant’ remember the spacing.” iii C Number and sex of children. Women in South Jiangsu had an average of 1.3 live births (0.7 sons and 0.6 daughters) compared to 1.8 children (1.0 sons and 0.8 daughters) in North Anhui. Contraceptive Use and Experience with Abortion C Contraceptive use in South Jiangsu and North Anhui, reported at over 90 percent among survey participants, generally followed the guidelines of the family planning policy and was based on fertility rather than on personal choice. According to one respondent from North Anhui, “everyone knows that after birth you have an IUD, but frequently the IUD drops out.” Respondents with one child used IUDs and those with two children were sterilized, particularly in North Anhui where the government has strengthened enforcement of the policy during the past decade. Method switching generally occurred with a change in parity, and around half of those who switched in North Anhui said they did so at the urging of family planning workers (compared to 10-30 percent in South Jiangsu). Over 95 percent of the women in South Jiangsu and over 80 of women in North Anhui said they were willing to accept their current method of contraception, and women expressed satisfaction with the method. The main reason noted by women and men for not using the method they deemed more suitable for themselves or their partners was the policy restriction on the method, cited by more than 70 percent of respondents. C Contraceptive failure and abortion. One-quarter of the South Jiangsu respondents said that they (or their partners) had had an abortion, compared to fewer than 10 percent in North Anhui. Most abortions were due to out-of-plan pregnancies, and more respondents in North Anhui than in South Jiangsu said the family planning cadre had compelled them to have their last abortion. In the FGD, women and men talked about the high failure rate of the steel ring IUD, used throughout China until very recently. Women noted that they worried about contraceptive failure (sometimes repeated failures); one young woman said,“ Even when women use family planning, they worry about the efficacy of the method. They worry about their sex life.” The problem of IUD failure should be ameliorated in China with the switch to copper-bearing IUDs. Experience with Family Planning and Reproductive Health Services C The context of reproductive health. This was very different for older and younger women. Many older women in the FGD characterized their lives as spent in bearing too many children and trying to raise them in poverty. One woman from South Jiangsu said, “My mother died...in the delivery of her third child of a hemorrhage. The baby was alive, but was buried with my mother. Not even the midwife came because my family had no money.” Older women wished they had had access to family planning sooner so that iv they could have limited their family size. Women of all ages agreed that younger women have a much easier time in childbearing than did older women. Most women agreed that in general the reproductive health of younger women is better than that of older women. There was also a sense that people -- including male cadres -- have a better understanding of women’s health. C Family planning information and reproductive health services. There has long been acceptance of family planning in South Jiangsu and until recently, resignation toward it in North Anhui. Now, particularly among younger women and men, family planning use is the norm. Messages about family planning are reinforced by family planning cadres and community leaders. In South Jiangsu, women received family planning and other health services at the township level, either in health clinics or Maternal and Child Health (MCH) hospitals while in North Anhui most women got their services from the township family planning service station. Typical services received included pregnancy tests, family planning consulting and services, and maternal and child health (MCH) services. Fewer than one in five women had complaints about their current service delivery point (SDP), although the percentages varied by county. The main complaints included long waiting lines, crowded clinics, the distance from home to clinic and the cost of services. C Women’s tests . In order to make contraceptive use more effective and to reduce the abortion rate, the family planning program has instituted a system of quarterly “women’s tests” (pregnancy tests and IUD checks) which are mandatory for women of reproductive age who are not sterilized. A woman from North Anhui said, “Some service stations require 100 percent participation -- even from young married women.” In addition, for a small fee, women can receive a gynecological exam. When they were first instituted, many women considered the tests an imposition on their time, but once the women were “educated” about the “importance” of the tests (some were fined for not participating), they became resigned to coming to the family planning clinic four times a year. Some women expressed appreciation for the tests, indicating that the tests provided needed gynecological care for rural women. C Men and family planning. In the FGD, men noted that family planning use is usually the responsibility of women. According to a middle-aged man from South Jiangsu, “Males take less responsibility for family planning....Men are important and should be protected. Women should use family planning.” In the survey, women and men in North Anhui were more likely than those in South Jiangsu to say that men should have vasectomies and that they should use condoms. Unease about both men and women receiving services at family planning clinics at the same time does not appear to be a significant barrier to male involvement in contraceptive use. In China, a bigger barrier to male use of contraception appears to be a defacto emphasis in the program advocating use of female methods, namely female sterilization and the IUD. A young man from South Jiangsu said, “I wish v we had better methods for males.” C Reproductive health information and services for young adults. The Chinese government is concerned about controlling young adults’ fertility and meeting their reproductive health needs. Abortions for unmarried women, particularly in cities, are quite prevalent. There is a gap in coverage for young people between school and marriage. In the FGD, young people said that the information they received on sex and reproductive health was quite general. One young woman from South Jiangsu said, “Because of the ideology in rural areas, people are shy to ask such questions.” Some said that such subjects are taboo in rural areas. A young woman from North Anhui noted, “Our family will oppose. We need to avoid such topics.” Young people said they usually have to wait until marriage to learn details of sex and family planning. Family and Household Roles C Gender and generational roles in households in South Jiangsu and North Anhui are changing, although for the most part, women are still considered primarily responsible for household work such as cooking and cleaning. In the FGD, women and men agreed that as more women work outside the home, men are slowly increasing (although sometimes reluctantly) their contribution to domestic work. Women have been more involved in household decision-making and as women increasingly work outside the home for an income, they are accorded more say in matters with parents-in-law. According to a man from North Anhui, “Women have become important in decision-making in the family.” A woman from South Jiangsu noted, “My position is equal to my husband. I can spend money and discuss with my husband.” A young man from North Anhui commented, “Nowadays, whoever is more capable, with more education and more income, that person will be in charge.” Some older people lamented the lack of respect among the young for their elders -- and the lack of work and child rearing ability among the young. A woman from North Anhui complained, “My daughter-in-law has one child. She walked away and left the baby for the grandmother to look after. She is not home the whole day.” C Satisfaction with family size and sex composition of children. Women and men tended to say they had the right number of children for their circumstances. The most satisfied were those who had one son and one daughter. Those who were not satisfied tended to say they had too few children, rather than too many. In the FGD, some women and men stated a preference for daughters because they are easier and less expensive to raise and are nicer to their parents in old age. One woman from North Anhui noted, “I have two sons -- thats’ too much burden. They have to go to school and get married. Thats’ going to be expensive.” Furthermore, women and men in one county in South Jiangsu had an economic reason for wanting daughters -- for their embroidery skills. Still, desire for sons remained strong. According to a woman from vi South Jiangsu, “My mother-in-law said it is inferior to have daughters. If you have a son, even your house will look higher.” Some women from North Anhui agreed: “If you have a son, you will be seen as a strong family relative to families that have no son, which is regarded as weak.” A woman from North Anhui said, “There is very much discrimination against [women with two daughters and no sons] by the mother-in-law and the family. They lead miserable lives, especially if they are sterilized. Then there is no hope. You have terminated your family line.” FGD participants talked about the lengths women would go to have a son. All cities and many villages have ultrasound machines available to check if IUDs are in place. The practice of detecting the sex of the fetus and having a sex-selective abortion is illegal, but, as noted by FGD participants, continues. According to some women from North Anhui, “People use an ultrasound B machine. If it is a female fetus, they dont’ want it. People will usually go elsewhere to check....No matter how much money they have to spend, they think it is worth it.” It is possible, however, that if sex-selective abortion is effectively banned, infanticide may increase, unless the causes of the problem, namely the status of women in China, are addressed. C Out-of-plan births. Out-of-plan births can include births not in accordance with the local family planning regulations in terms of either parity or spacing. One-third of the respondents in North Anhui had out-of-plan births compared to 2 percent in South Jiangsu. Out-of-plan children were twice as likely to be sons as daughters. People noted being fined for out-of-plan children. One woman from North Anhui said ,“In our rural areas, family planning only allows people not to have babies, but does so by relying on fines.” Although the government has said out-of-plan children will not be given preference for social services, out-of-plan children were not likely to be school dropouts and they were likely to have received medical treatment and immunizations. C Family planning and marital relationships. Family planning use appeared to have little effect on marital and sexual relationships. In addition, women and men reported little couple disagreement about family size; when disagreements occurred, couples generally discussed the situation and reached a joint decision. The congruence of the views of women and men in this study (particularly in the survey) implies that women and men do communicate about issues surrounding family planning and reproductive health. C Desired attributes in spouses among young adults. While people of all generations noted the changing status of women, including women’s role in decision-making in the household, young women and men still reverted to prevailing gender norms and roles when they talked about their desired attributes in a spouse. They said that the husbands would be the primary breadwinners and the wives would be responsible for household chores. One woman from South Jiangsu said, “...to support the family depends mostly on vii the husbands’ salary.” A young woman from North Anhui said, “I want a career before marriage. After marriage there is so much housework to worry about.” No young men mentioned being worried about not finding a wife due to the unbalanced sex ratio. One woman in North Anhui did say that “even ugly boys can find wives now” because her village was rich. Young people in both South Jiangsu and North Anhui seemed to think that premarital sex and cohabitation were uncommon in their communities. Few said they would engage in such behavior, although they could understand young couples who did. Economic, Social and Community Roles C Economic roles for women. Younger women in both provinces had more exposure to education and work opportunities than older women. Said one older woman from North Anhui: “...young women are in heaven and we are on the ground. We arent’ even 10 percent as good as them” A woman from South Jiangsu noted, “Womens’ status has improved. When it comes time for bonuses and promotions...I dont’ see men way ahead and women behind in my school.” However, women in South Jiangsu had wider choices for work than did women in North Anhui, who were virtually all farmers. C Income and spending. Nearly three-quarters of the women and men in South Jiangsu received a wage for their work, compared to fewer than eight percent in North Anhui. Income from household economic activities was also common in both provinces. Some respondents had multiple sources of income. Many women in both provinces said they work to earn money for their children (for education, weddings and building houses--for their sons) and for their own old age support. One woman from North Anhui said, “I just want to get rich to have a house for my son. I think all the time about how to do business.” A woman from North Anhui agreed, saying “Although we now have fewer children and the economic burden is lighter, we still want to make more money. As long as we have enough to spend, wer’e all right.” Average family income in 1995 was significantly higher in South Jiangsu than in North Anhui (about 21,000 Yuan compared to 1 4,000 Yuan ). Housing and children took up the largest portion of income for families in South Jiangsu and North Anhui. C Social welfare benefits. Since the beginning of the new economic responsibility system initiated in the early 1980, State support for people’s incomes and welfare has been reduced. Workers in the formal sector receive an array of social welfare benefits not available to rural agricultural workers. Such benefits include paid sick leave, maternity leave, old age, health, life, hazard and disability insurance, and housing allowance. There was a vast difference in the social welfare benefit net between the two provinces. With the exception of sick leave, between 40-75 percent of the respondents in South Jiangsu 1 In January, 1995, US$1 equaled 8.4 yuan. viii