China’s fertility rate falls to an all-time low

In the face of population decline, a three-child policy has replaced China’s infamous one-child per couple edict. A new cross-sectional study has now reviewed parental intentions and found – as in other countries – that many couples are no longer keen on large families.

In July the UN’s population project forecast a decline in China’s population – from a present high of 1.43 billion to around 1.3 billion by mid-century.(1) The projection is accompanied – and apparently explained – by a dramatic decline in fertility rate, as well as increasing life expectancy. Indeed, although China relaxed its infamous one-child per couple policy in 2014 in favour of a three-child policy in 2021, it is now in the midst of its weakest population growth for decades.

In response to the population figures, China’s National Health Commission reported that total fertility rate had dropped to 1.3 in 2020, a rate well below the notional 2.1 needed to maintain population levels. Other reports put present TFR as low as 1.16, with catastrophic implications for economic growth, healthcare and living costs. One report said China was ‘facing a demographic timebomb’.

Now, adding more fuel to this smouldering fire is a new report in Human Reproduction of a cross-sectional survey from China (9243 respondents aged 18-49 years) showing that adoption of the three-child policy appears to be making only a modest difference to the parenthood intentions of Chinese people: intention to have a second child was found to be around 60% (56% of women vs 65% of men), and to have a third child only 13% (10% women vs 17% men).(2) Overall, the mean desired family size for women was 1.58 children (and 1.76 for men). As in previous studies – and in other countries – men and women with higher education and income had lower parental intentions.

The principal ‘barriers’ inhibiting these intentions were found to be economic (the ‘critical painpoint’) and childrearing. The authors note that ‘the government would need to address these barriers first’ in supporting its three-child policy, which presently cannot alone ‘effectively alleviate the declining trend of fertility’. That, as in other countries of low TFR, ‘is an inevitable result of economic and social development’, say the authors, which to resolve will require ‘multiple efforts’ to create a fertility-friendly environment. Such efforts might include arrangements for three-generation living (given the importance of family support for children).

What about fertility treatment? This study report makes no such mention, but, according to preliminary world IVF data presented at ESHRE’s Milan annual meeting, China is now by far the world’s most prolific ART nation, with more than 1 million cycles reported for 2018, way more than Japan (452,000 cycles) and USA (180,000 cycles).

There was no hint of any such data before 2020, when an unexpected report from China’s National Health Commission published its registry figures for 2016, with the not unexpected total of 900,000+ cycles (around one-third of which were FET).(3) The report described a steep escalation in ART activity since China’s first IVF baby (in 1988) – but especially so over recent years. For example, as a mark of availability there were 360 cycles performed per million inhabitants in 2013, yet 657 cycles per million in 2016 (with concentrations in the Eastern provinces of China). There were 311,309 ART babies born in 2016, which accounted for 1.69% of total births, a rate, said the authors, almost the same as reported by the CDC for the USA that same year.

Yet both the availability and population rates were lower in China (and USA) than in those countries where ART does indeed seem to make a difference to population rates. In her EIM presentation in Milan, Christine Wyns reported that availability in Czech Republic was around 3500 cycles per million population, followed closely by Belgium, Denmark, Estonia, Slovenia and Iceland.

The 2020 paper also indicated that ART services in China have not been covered by any national medical insurance system, although local reimbursement schemes for families with no child were said to be available in certain provinces. When China’s two-child policy was introduced and ‘fully implemented’ in 2016, ART was then recognised as ‘a necessary and beneficial complementary technology in maternal and child health services for couples with infertility’. Thus, as a safe and effective technology for infertility, ART ‘remains the focus of Chinese government regulation’. However, it remains to be seen if as part of a population policy (and a three-child family policy) state-supported ART can address a TFR which seems in a cascade beyond recall. Moreover, demographers remain sceptical about the benefits of ART as part of a population policy, even if in countries like Denmark and Australia more than 5% of all babies born are conceived by ART.

1. See https://www.weforum.org/agenda/2022/07/china-population-shrink-60-years-world/
2. Jing W, Liu J, Ma Q, et al. Fertility intentions to have a second or third child under China’s three-child policy: a national cross-sectional study. Hum Reprod 2022; doi.org/10.1093/humrep/deac101
3. Bai F, Wang DY, Qiu J, et al. Assisted reproductive technology service availability, efficacy and safety in mainland China: 2016. Hum Reprod 2020; 35: 446-452. doi:10.1093/humrep/dez245.