How can China tackle its declining fertility rate?

Declining fertility intention and the realities of parenthood

Over 30 years after the implementation of the one child policy in the early 1980s, China began to relax its population control measures. It introduced a selective two child policy in November 2013, followed by the universal two child policy in October 2015, and the universal three child policy in May 2021. However, the fertility intentions of Chinese couples were not stimulated as expected. The number of births per year fluctuated slightly between 2013 and 2016, and then sharply reduced from 18.83 million in 2016 to 9.02 million in 2023 (fig 2).2 The traditional notions mandating marriage and childbearing as indispensable components of life are changing radically, especially among the younger generations. In a national sample survey of marriage and fertility intentions among 14 418 college students conducted in 2021, only 49% of female respondents and 74% of male respondents reported a strong intention for marriage in their life plans, and the planned number of children was only 1.19 among women and 1.55 among men.3 Compared with their male peers, highly educated young women have lower intentions for marriage and childbearing. The 2019 national population and household dynamic monitoring survey data, including 58 538 women aged 20-49 years old (10 101 aged 20-29) reported that 59.8% of Chinese women aged 20-29 years believed that childbearing would lower their quality of life, while 52.7% considered that childbearing would affect career development.4

Fig 2

China’s demographic transition2

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Besides concerns about the potential effects on quality of life and career development, prospective parents encounter several major barriers to childbearing. In a national cross-sectional online survey of 4406 parents aged 18-49 conducted in 2021, 94.7% of Chinese parents reported encountering childbearing barriers, with the two biggest barriers being time burden (39.3%) and economic burden (36.5%).5 These barriers to parenthood are not unique to China, but extremely common to couples worldwide. Globally, in response to such barriers, governments have increasingly embraced measures to encourage child rearing, such as offering parental leave, baby bonuses, tax incentives, or housing allowances.6 However, the effect of these approaches in reversing the long term downward trends in total fertility rates remains uncertain, as fertility is declining regardless of economic, social, and cultural environments.7

Although parental leave and financial subsidies can alleviate some of the time and financial pressures on new parents, the realities of parenthood, especially for mothers, are still underestimated. First, the commitment to raising children encompasses multifaceted responsibilities, including feeding, health, education, and housing. Temporary paid leaves or financial subsidies cannot completely remove barriers to childbearing related to time and money.6 It is therefore essential to improve the affordability and equity of childcare services, healthcare services, education, and housing to ensure the wellbeing and living security of parenthood. Moreover, for new parents, especially mothers, their various losses (of sleep, freedom, quality of life, etc), interruptions (of career development and other activities), and worries (of breastfeeding, neonatal health problems, spousal relationship, etc) should also be of concern. However, support with childbearing skills and psychological counselling for parents are scarce in China.

Delayed parenthood and adverse pregnancy outcomes

Many young couples now choose to delay parenthood for personal education, career development, and other reasons. Differences between men and women in the ages at which reproductive ability falls and risks to offspring’s health increase may complicate these choices. Advanced paternal age is typically defined as age ≥45 years, whereas advanced maternal age is usually defined as ≥35 years.8 Although older parents often possess greater financial stability, more emotional maturity, and more knowledge, which could boost children’s health outcomes and development, advanced parenthood has been associated with Down’s syndrome, autism, and schizophrenia due to chromosomal variation or de novo mutations.910 Pre-pregnancy genetic counselling and prenatal genetic screening or diagnosis are therefore necessary for couples with advanced parental age. However, high costs and the shortage of staff hinder the accessibility of these services. The innovations in high throughput sequencing (also known as next generation sequencing) technologies hold promise for substantially reducing DNA sequencing costs, thereby improving the accessibility of genetic screening and diagnosis for couples.11

Advanced maternal age has also been associated with high risk maternal complications (such as gestational diabetes mellitus, hypertensive disorders of pregnancy, and postpartum haemorrhage) and adverse pregnancy outcomes (such as miscarriage, stillbirth, preterm birth, low birth weight, and birth defects).1213 Between 2013 and 2019, the proportion of pregnant women in China aged ≥35 increased from 10.7% to 15.2%, reflecting an average growth rate of 5.95% a year.14 Although the overall proportion of pregnancies in older women is not high, the growth has outpaced that in some developed countries, including Australia (1.9%), the UK (2.68%), and the US (3.32%) (fig 3).151617

Fig 3

Proportion of births to women aged ≥35 in selected countries compared with proportion of pregnancies among older women in China14151617

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Such a rapid growth of births among women aged ≥35 poses a substantial burden on the maternal and child health services system. Enhancing the capability of health services and management of high risk pregnant women and newborns is challenging, especially in low resource settings. Multiple approaches will be required. First, the fragmentation of maternal and child health services and management between maternity institutions and communities should be addressed. Second, reinforcing remote medical education and services systems can effectively improve access to high quality services in low resource settings. Third, establishing a robust referral network of maternal and neonatal intensive care units (MICUs and NICUs) across institutions and regions is an effective measure to save the lives of mothers and newborns.

Declining fecundity and assisted reproductive technologies

Declining fecundity is an incontrovertible reality in both men and women, stemming from myriad diverse and intricate causes. Ability to conceive is more age dependent in women than in men. Several indicators of female fertility (anti-müllerian hormone, antral follicle count, oocyte quality, etc) fall rapidly with increasing maternal age.181920 Notably, in China the prevalence of infertility among couples of reproductive ages rose from 11.9% in 2007 to 18% in 2020; the annual number of assisted reproductive technology cycles reached over 1 million, with over 0.3 million babies born through assisted reproduction each year.212223 Currently, China has 517 assisted reproduction centres and 27 sperm banks.2122

The intricate mechanisms underpinning reproductive ageing remain elusive, making treatment of infertility challenging. The mechanisms may include genetic factors, environmental exposures, gametic senescence, diseases of the reproductive system (ovary, fallopian tube, uterus, etc), and systemic diseases (immunological diseases, cancers, etc). Further research is needed to delve into the nuanced pathogeneses and develop new therapeutic approaches. The shortage of evidence based guidelines in China has resulted in the overuse of some methods of assisted reproduction, such as use of intracytoplasmic sperm injection rather than conventional in vitro fertilisation in couples with non-severe male infertility.24

The high costs of treatment (around ¥25 000 (£2500; €3200; $3500) per cycle) are a further barrier for many infertile couples. Only a few provinces (such as Beijing, Liaoning, and Guangxi) include infertility treatments in social health insurance, and even these have limited cover. A comprehensive cost effectiveness analysis at both individual and societal levels and evaluation of the feasibility of expanding insurance coverage across the country is imperative.

Furthermore, elective egg freezing (for social rather than medical reasons) is currently illegal and controversial in China. Opponents challenge the notion that egg freezing is a foolproof insurance policy, emphasising the risks associated with delayed childbearing (failure of egg thawing or embryo implantation, systematic ageing of the body, etc). Conversely, proponents argue for the fulfilment of single women’s reproductive autonomy and that prohibition may foster illicit underground markets, jeopardising women’s health and rights. In modern societies, delayed childbearing or having a child alone is increasingly common for professional women, who must balance career aspirations and family planning. Egg freezing allows women to preserve their oocytes at younger ages and increases their chances of conceiving through fertility treatments later in life.

In the past two decades, substantial improvements in the effectiveness and safety of oocyte cryopreservation have made egg freezing a viable strategy to tackle age related infertility. According to the International Federation of Fertility Societies (IFFS) Surveillance 2019, 56 countries (including the US, UK, Canada, and Brazil) permit oocyte freezing for fertility preservation in non-medical indications.25 In the book Career And Family: Women’s Century-Long Journey Toward Equity, the 2023 Nobel laureate Claudia Goldin traces how generations of women have grappled with balancing career and family.26 In the US, college educated women who graduated in the 1960s and 1970s delayed childbirth for careers but struggled with infertility due to advanced age. However, the most recent cohort who graduated after the 1980s achieved a better work-life balance as advancements in fertility treatments (including egg freezing) allowed them to have children later in life.26 Currently, many career oriented women in China similarly delay childbirth to pursue professional goals but face challenges conceiving at older ages. Lifting the restriction on elective egg freezing could help some women to conceive, although they should be fully informed that it does not guarantee a successful live birth because of the risks of failure of egg thawing and declining endometrial receptivity at advanced ages.27

Policy priorities to reverse declining fertility rates

Building on the challenges described, we suggest policy priorities to reinforce the government’s pronatalist measures, the maternal and child health services system, and assisted reproductive technology services to address declining fertility intention and fecundity in China (table 1).