A nuanced reading of "reduce non-medically necessary abortions"

Attempting to paint a more complete picture

China's State Council, the government cabinet, published the 23,562-character 中国妇女发展纲要（2021—2030年）Chinese Women's Development Guidelines for 2021-2030 at the end of September.

One brief sentence mentioning abortion in it has triggered both domestic and foreign attention, leading to renewed criticism that "China's government still treats women's bodies as tools for its economic development goals," and made onto dedicated reports in The New York Times and The Economist.

This is the paragraph that includes the highlighted sentence

提高妇女生殖健康水平。普及生殖道感染、性传播疾病等疾病防控知识。在学校教育不同阶段以多种形式开展科学、实用的健康教育，促进学生掌握生殖健康知识，提高自我保护能力。增强男女两性性道德、性健康、性安全意识，倡导共担避孕责任。将生殖健康服务融入妇女健康管理全过程，保障妇女享有避孕节育知情自主选择权。落实基本避孕服务项目，加强产后和流产后避孕节育服务，提高服务可及性，预防非意愿妊娠。推进婚前医学检查、孕前优生健康检查、增补叶酸等婚前孕前保健服务更加公平可及。减少非医学需要的人工流产。加强对女性健康安全用品产品的质量保障。规范不孕不育症诊疗服务。规范人类辅助生殖技术应用。

We shall improve women's reproductive health. We shall popularize the knowledge in prevention and control of reproductive tract infections, sexually transmitted diseases, and etc.. Scientific health education shall be carried out practically in various forms at different stages of school education to promote students to master reproductive health knowledge and improve their self-protection ability. We shall promote the awareness of sexual morality, sexual health, and sexual safety between men and women, and advocate sharing contraceptive responsibility. We shall integrate reproductive health services into the whole process of health management for women, and ensure that women enjoy the right to know and choose contraception on their own. Basic contraceptive services shall be implemented, and postpartum and post-abortion contraceptive and birth control services shall be strengthened to improve service accessibility and prevent unplanned pregnancy. We shall promote pre-marital medical examination, pre-pregnancy health examination for good births, folic acid supplementation, and other pre-marital and pre-pregnancy health care services to be fairer and more accessible. We shall reduce non-medically necessary abortions. We shall strengthen the quality assurance of women's health and safety products. We shall regulate the diagnosis and treatment services for infertility as well as the application of human assisted reproductive technology.

China’s fertility rate may become the “world’s lowest” without strong intervention policy, the Global Times reported in May, quoting demographers. Anhui, a central province, said at the end of September 2011 that newborns could drop from 984,000 in 2017 to the estimated 530,000 in 2021.

The state has officially instituted a three-child-per-couple policy, and the repealing of the 社会抚养费 “social maintenance fee” in effect means there are no fines on the books for having even more babies.

In light of the background, one reason in singling out the highlighted sentence is, as narrated, China is desperate for more babies, so now the government seems to have its sights set on curbing abortion.

A more recent article on The Atlantic said hoping, probably vainly, to reverse the trend, Xi’s government is moving to limit abortions, a typically heavy-handed approach to the country’s demographics.

Given that such a narrative dominates Western mainstream media's coverage on this issue - and fully acknowledging China’s strict enforcement of family planning policies in the past had its consequences, here are a few points that attempt to paint a more complete picture.

First, the same paragraph that says 减少非医学需要的人工流产 We shall reduce non-medically necessary abortions also says 

落实基本避孕服务项目，加强产后和流产后避孕节育服务，提高服务可及性，预防非意愿妊娠。

Basic contraceptive services shall be implemented, and postpartum and post-abortion contraceptive and birth control services shall be strengthened to improve service accessibility and prevent unplanned pregnancy. 

If reducing non-medically necessary abortions is for more babies, then the quoted sentence above could only result in fewer babies. Unfortunately, despite in the same paragraph, it went largely unmentioned in the press coverage.

Second, as the press coverage, including The New York Times and The Economist, rightly noted, reducing non-medically necessary abortions is not new for a document like the Chinese Women's Development Guidelines.

Ten years ago, the Chinese Women's Development Guidelines for 2011-2020 says

主要目标：

Main objectives:

7.保障妇女享有避孕节育知情选择权，减少非意愿妊娠，降低人工流产率。

7. We shall protect women's right to know and choose contraception on their own, reduce unplanned pregnancy and the rate of induced abortions.

策略措施：

Measures:

8.保障妇女享有计划生育优质服务。研究推广安全、有效、适宜的避孕节育新技术和新方法，推行避孕节育知情选择，提供避孕节育优质服务。加大避孕知识宣传力度，提高妇女自我保护意识和选择科学合理避孕方式的能力，预防和控制非意愿妊娠和人工流产。强化男女共同承担避孕节育的责任意识，开发、研制男性避孕节育产品，动员男性采取节育措施，提高男性避孕方法使用比重。

8. We shall ensure women's access to quality family planning services. We shall study and promote safe, effective, and appropriate new contraceptive technologies and methods, promote informed choice of contraception and provide high-quality contraceptive services. We shall intensify the publicity of knowledge on contraceptions, improve women's awareness of self-protection and their ability to choose scientific and reasonable contraceptive methods, and prevent and control unplanned pregnancy and induced abortions. 

We shall strengthen the awareness of men and women in sharing the responsibility of contraception, develop male contraceptive products, mobilize men to take contraceptive measures, and increase the proportion of male contraceptive methods.

Twenty years ago, the Chinese Women's Development Guidelines for 2001-2010 says

研究推广安全、有效的避孕节育新技术、新方法，提供避孕节育的优质服务。节育手术并发症发生率控制在1‰以下。预防意外妊娠，降低人工流产率。

We shall study and popularize new, safe and effective contraceptive techniques and methods to provide quality contraceptive services. The incidence of complications from birth control operation shall be controlled below 1 ‰. We shall prevent accidental pregnancy and reduce the rate of induced abortions.

So reducing the rate of induced abortions was present in the same documents in 2001 and 2011, and the latest 2021 document basically inherited the same thing but added the word “unnecessary”.

Tying the latest developments together is how journalism works, so it’s understandable that the press coverage has all brought up the recent sea changes in China’s family planning policy. But, as shown above, it’s not something new.

Third, China has one of the highest induced abortion rates in the world and it was still rising.

Statistics from the United Nations Statistics Division show China’s induced abortion rate is far higher than those in the developed world.

According to the latest《中国生殖健康报告》 "2020 Report on Reproductive Health in China" published in January 2021, the rate of induced abortions rose from 25.9 out of 1,000 women in 2014 to 28.3 in 2018.

In comparison, the United States CDC reported its abortion rate was 11.3 abortions per 1,000 women aged 15–44 years in 2018.

In August 2018, China’s National Health Commission published a technical guideline 《人工流产后避孕服务规范》 emphasizing providing contraception services to prevent induced abortions, which it believes is detrimental to women’s health.

The 《人工流产后避孕服务规范（2018版）》文件解读 Q&A accompanying the technical guideline says

近年来我国人工流产数量大，每年约900多万例。接受人工流产手术的女性中低龄者、未育者占比大，重复人流比例高。

In recent years, the number of abortions in China is large, about 9 million cases per year. A large proportion of women who undergo abortions are of a low age or have yet to give births, and the proportion of repeat abortions is high.

In comparison, a total of 619,591 abortions for 2018 were reported to the United States CDC from 49 reporting areas.

The Q&A went on to say

人工流产对女性健康和生育能力损害严重，可能引发输卵管阻塞、宫腔粘连、子宫内膜异位症等并发症，还可能导致女性继发不孕，多次重复人工流产导致并发症及继发不孕的风险更高。有人工流产史特别是多次人工流产的妇女即使得以怀孕，也会增加自然流产、早产、胎盘异常及低体重儿等不良妊娠结局的发生风险，危害母婴安全。人工流产对于低龄者、未育者影响更大，不仅危害身心健康，由此引发的继发不孕还将影响家庭和谐幸福。当前人工流产高发原因主要有两方面。一是育龄人群缺乏避孕节育科学知识，避孕措施缺失，导致意外妊娠。二是避孕方法咨询指导不到位，育龄人群采用高效避孕方法不足，避孕失败率高。

Abortion can cause serious damage to women's health and fertility and may lead to complications such as tubal obstruction, uterine adhesions, endometriosis, etc.

It may also lead to secondary infertility, and the risk of complications and secondary infertility is higher with repeated abortions. Even if a woman with a history of abortion, especially multiple abortions, is able to conceive, there is an increased risk of adverse pregnancy outcomes such as spontaneous abortion, preterm delivery, placental abnormalities, and low birth weight babies, endangering the safety of the mother and child. The impact of abortion is even greater for those who are young and infertile, which not only endangers physical and mental health but also affects family harmony and happiness by causing secondary infertility.

There are two main reasons for the current high incidence of abortion. First, the lack of scientific knowledge of contraception and birth control for people of childbearing age and the lack of contraceptive measures result in unintended pregnancy. The second is the lack of guidance on contraceptive methods leading to the lack of efficient contraceptive methods for people of childbearing age and the high rate of contraceptive failure.

Lastly, if you go back to the paragraph that includes the sentence, reducing non-medically necessary abortions is placed in the paragraph that started with the sentence 提高妇女生殖健康水平 We shall improve women's reproductive health.

So, from purely a textual analysis point of view and in line with some points made above, reducing non-medically necessary abortions is seen, at least in the 中国妇女发展纲要（2021—2030年）Chinese Women's Development Guidelines for 2021-2030, within the framework of improving women’s reproductive health.

提高妇女生殖健康水平。普及生殖道感染、性传播疾病等疾病防控知识。在学校教育不同阶段以多种形式开展科学、实用的健康教育，促进学生掌握生殖健康知识，提高自我保护能力。增强男女两性性道德、性健康、性安全意识，倡导共担避孕责任。将生殖健康服务融入妇女健康管理全过程，保障妇女享有避孕节育知情自主选择权。落实基本避孕服务项目，加强产后和流产后避孕节育服务，提高服务可及性，预防非意愿妊娠。推进婚前医学检查、孕前优生健康检查、增补叶酸等婚前孕前保健服务更加公平可及。减少非医学需要的人工流产。加强对女性健康安全用品产品的质量保障。规范不孕不育症诊疗服务。规范人类辅助生殖技术应用。

We shall improve women's reproductive health. We shall popularize the knowledge in prevention and control of reproductive tract infections, sexually transmitted diseases, and etc.. Scientific health education shall be carried out practically in various forms at different stages of school education to promote students to master reproductive health knowledge and improve their self-protection ability. We shall promote the awareness of sexual morality, sexual health, and sexual safety between men and women, and advocate sharing contraceptive responsibility. We shall integrate reproductive health services into the whole process of health management for women, and ensure that women enjoy the right to know and choose contraception on their own. Basic contraceptive services shall be implemented, and postpartum and post-abortion contraceptive and birth control services shall be strengthened to improve service accessibility and prevent unplanned pregnancy. We shall promote pre-marital medical examination, pre-pregnancy health examination for good births, folic acid supplementation, and other pre-marital and pre-pregnancy health care services to be fairer and more accessible. We shall reduce non-medically necessary abortions. We shall strengthen the quality assurance of women's health and safety products. We shall regulate the diagnosis and treatment services for infertility as well as the application of human assisted reproductive technology.