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1 Service n Women t Women e searchong Szh osearchg Oral S Szh e Single ia Singlewomenadultservice Oral d Women i Adult istra Service isearche searche Singlewomenadultservice i Oral n.17 Even allowing for the fact that these countries are more developed and urbanized than China, the parallels are hard to ignore. It is reasonable to speculate that there would have been a further decline in China's total fertility rate had the voluntary policy of the 1970s continued. The Sex Ratio
The effect of the policy on the sex ratio has received much attention. The sex ratio at birth, defined as the proportion of male live births to female live births, ranges from 1.03 to 1.07 in industrialized countries.18 Since the onset of the one-child policy, there has been a steady increase in the reported sex ratio, from 1.06 in 1979, to 1.11 in 1988, to 1.17 in 2001.19 There are marked and well-documented local differences, with ratios of up to 1.3 in rural Anhui, Guangdong, and Qinghai provinces. Data from the 2001 National Family Planning and Reproductive Health Survey, which was carried out among a nationally representative sample of 39,600 women of reproductive age and is the most recent large-scale survey of reproductive health and fertility, show clearly that the increased sex ratio is not confined predominantly to rural China,19 as has been previously assumed20 (Table 2). There is a marked gradient across birth order: in rural areas, the sex ratio for the first birth is 1.05 (within normal limits), but it rises steeply with birth order. In urban areas, the sex ratio is 1.13 for the first birth and peaks at 1.30 for the second birth but decreases for the third and fourth births (which are rare in urban areas). The picture that emerges is that some urban Chinese make the choice to perform sex selection with the first pregnancy, since they are allowed only one child. In rural areas, most couples are permitted to have a second child, especially if the first is female. So if the second (or subsequent) child is female, the pregnancy often "disappears," allowing the couple to have another child in an attempt to have a son.
What happens to all the missing girls is a matter of speculation. Sex-selective abortion after ultrasonography undoubtedly accounts for a large proportion of the decline in female births.20,21 Actual figures are impossible to obtain, because sex-selective abortion is illegal but is known to be widely carried out, helped by a burgeoning private sector. Nonregistration of female births also contributes to the sex-ratio gap.14,15 A 1995 household survey carried out in three provinces found a normal sex ratio in the under-14 age group, with the actual number of girls exceeding the number registered by 22 percent.22 Although infanticide of girls is probably very rare now, less aggressive treatment of sick female infants is known to occur.23
The Chinese government has acknowledged the potentially disastrous social consequences of this sex imbalance. The shortage of women may have increased mental health problems and socially disruptive behavior among men and has left some men unable to marry and have a family.24 The scarcity of females has resulted in kidnapping and trafficking of women for marriage and increased numbers of commercial sex workers, with a potential resultant rise in human immunodeficiency virus infection and other sexually transmitted diseases.25 There are fears that these consequences could be a real threat to China's stability in the future.26
Although the one-child policy has been blamed for the high sex ratio, it is probably just one contributory factor. There was a high sex ratio in China in the 1930s and 1940s, mostly resulting from infanticide of girls, and then the ratio declined in the years after the Communist Revolution of 1949.27 Many other Asian countries with declining fertility rates and a traditional preference for males are also seeing sex-ratio imbalances ¡ª Taiwan, 1.19; Singapore, 1.18; South Korea, 1.12; and parts of northern India, 1.2028 ¡ª largely because of sex-selective abortion.27 In China, the marked increase in the sex ratio between the 1980s and 1990s coincided with much easier access to cheap ultrasonography and not with any substantial change in enforcement of the one-child policy. It is likely, therefore, that even in the absence of the policy, sex-selective abortion would continue, although it would probably be less common. The solution will come only with a change in attitudes toward female offspring. Publicity campaigns promoting girls are now widespread and acknowledge the importance of such change (Figure 2).
But there are some indications that the traditional preference for boys may be shifting. In the National Family Planning and Reproductive Health Survey, 37 percent of women (predominantly young, urban women) claimed to have no preference for one sex over the other, whereas 45 percent said the ideal family consisted of one boy and one girl. In fact, slightly more women expressed a preference for one girl (5.9 percent) than for one boy (5.6 percent).29 Although these expressed preferences have not yet been translated into a normalization of the sex ratio, this may happen in the near future.
Ratio of Old-age Dependency
The rapid decrease in the birth rate, combined with stable or improving life expectancy, has led to an increasing proportion of elderly people and an increase in the ratio between elderly parents and adult children.30 In China, the percentage of the population over the age of 65 years was 5 percent in 1982 and now stands at 7.5 percent but is expected to rise to more than 15 percent by 2025.28 Although these figures are lower than those in most industrialized countries (especially Japan, where the proportion of people over the age of 65 years is 20 percent), a lack of adequate pension coverage in China means that financial dependence on offspring is still necessary for approximately 70 percent of elderly people.31 Pension coverage is available only to those employed in the government sector and large companies. In China, this problem has been named the "4:2:1" phenomenon, meaning that increasing numbers of couples will be solely responsible for the care of one child and four parents.
Initiatives are under way to improve access to government pensions and to encourage saving for private pensions in an attempt to reduce the burden of the 4:2:1 phenomenon.7 In addition, a specific measure has been introduced to address the problem: in urban areas, couples who are themselves both only children are allowed to have more than one child. As only children reach reproductive age, many couples will meet these criteria, though how many will take advantage of the opportunity to have more than one child remains to be seen.
The Future of the Policy
The Chinese government is facing an important challenge: the need to balance the basic human right of reproduction with population growth, which, despite the policy's success, is still increasing at a rate of 8 per 1000, or 10 million people, per year (equivalent to the population of Belgium). In making decisions about the future, several factors must be taken into consideration.
First, relaxation of the policy can be considered only if fertility aspirations are such that a baby boom will not result. There is now good evidence that China is becoming a small-family culture. Data from the National Family Planning and Reproductive Health Survey show that 35 percent of the women questioned preferred having only one child and 57 percent preferred having two children, but very few women (an average of 5.8 percent) wanted more than two29 (Table 3). Young, urban, educated women wanted fewer children than did their counterparts in rural areas. In other studies, 75 percent of respondents in wealthy Jiangsu province were satisfied with their one child regardless of sex, whereas in poorer Yunnan province, 55 percent were satisfied with an only boy, but only 30 percent were satisfied with an only girl.8 And in Tibet, where most couples are permitted to have three children, 65 percent of the women wanted only one or two children.32 However, the survey also showed that in urban areas of China, where (with very few exceptions) only one child is allowed, 43 percent of women still preferred having two, so the one-child restriction remains unacceptable for nearly half of urban Chinese women.