China’s declining fertility rate
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q1000 (Published 09 May 2024) Cite this as: BMJ 2024;385:q1000- 1Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University School of Public Health, Beijing, China
- 2Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong Province, China
- 3State Key Laboratory of Female Fertility Promotion, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Peking University Third Hospital, Beijing, China
- Correspondence to: J Qiao jie.qiao{at}263.net
China had the largest population in the world for many decades. Its total fertility rate (the average number of children a woman is expected to have in her lifetime) was as high as 6.0 before 1970, then decreased to 1.5-1.7 by the late 1990s. The rate remained stable until the early 2010s and then fell again.1
In an attempt to increase birth rates, China replaced its one child policy—introduced in 1979— with a universal two child policy from 2015. However, the total fertility rate continued to fall, reaching 1.3 by 2020.2 Additional pronatalist measures followed in 2021 but did not reverse the trend. In 2023, just 9.02 million babies were born in China, half the number born in 2016.
As societies become more prosperous and women achieve greater equality in education and employment, a falling birth rate seems unavoidable. In addition to rapid socioeconomic development and urbanisation, China’s family planning policies (including policies encouraging later childbearing, longer intervals between children, and fewer children in the 1970s, before the one child policy) have been a major contributor to falling fertility rates, although the exact number of births that they prevented or delayed remains a matter of debate.1 The covid-19 pandemic may have further exacerbated China’s low birth rate by delaying marriage and childbearing among young people.3
Social and health implications
A persistently low fertility rate will have substantial social implications and affect both population health and the organisation of health services. Clinical services for women and children may be reduced or closed because of falling demand. The number of women discharged from China’s obstetrics and gynaecology departments fell by 23% between 2016 and 2021, while discharges from paediatric departments decreased by 8%.45 China has a hierarchical maternal and child health system, with clinical services arranged top down from provincial to prefectural level and then further to county level.6 Healthcare providers operate in competition with one another, so relatively small obstetric and paediatric departments in county public and private hospitals are at the greatest risk of downsizing or closure.
The number of obstetricians and gynaecologists in China increased from 300 000 to 370 000 between 2016 and 2021 despite a falling birth rate,45 almost doubling the ratio of doctors to births. To adapt, obstetricians—particularly those in small county facilities—may switch to clinical services such as reproductive counselling and fertility treatment, for which demand is likely to rise.7 Obstetricians in higher level facilities may have to manage increasing numbers of older women with complex pregnancies and a higher demand for caesarean sections. The proportion of caesarean deliveries increased from 28.8% of all births in 2008 to 36.7% in 20188 and is expected to rise further.
Any extra resources arising from fewer births should be used to improve both the quality of maternity services and the outcomes for women and their babies. Importantly, these resources should be diverted to strengthen preventive services for women and children, including paying more attention to the social determinants of health, as emphasised in the Healthy China 2030 Plan.
Reforms to improve health services for older adults are also becoming increasingly urgent in China. Fewer births and population ageing have resulted in the proportion of people aged 65 or older rising from 10.8% to 15.4% between 2016 and 2023.910 In 2022, deaths outnumbered births for the first time (by 0.85 million), and this deficit increased to 2.08 million a year later.10
To meet the growing demand for healthcare among older adults, the Department of Ageing and Health, established in 2018 under China’s National Health Commission, has been promoting the establishment of elderly care departments in hospitals, strengthening palliative care services, and encouraging cooperation between health facilities and nursing homes to make better use of available services. China’s successful maternal and child health system6 may be a good model for care of older adults: both services require a high degree of integration between public health and clinical teams and close collaboration across facilities at different levels to provide primary care and more complex clinical services.
China’s population challenges and their implications are shared by many high income countries globally. Since falling fertility rates are driven largely by social progress rather than policy failure, reversing the overall trend is challenging. However, early introduction of policies such as economic support for families and strengthening parental rights in the workplace, while still protecting women’s rights and their educational and career advancement goals, may help slow the pace of decline. These kinds of policies are credited with helping France maintain its relatively high and stable fertility rate (around 1.8-2.0).11 Countries with fast growing economies should prepare well in advance for falling fertility rates.
Acknowledgments
We thank Jian-meng Liu for his valuable comments.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: JT is The BMJ’s China editor. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Commissioned; not externally peer reviewed.
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