The Chinese saying, chi ku, literally translates as “eating bitterness,” and it is used to describe the plight of many of China’s working poor, especially women. As I boarded my plane from John F Kennedy International Airport to begin an eight week journey in China, I was unaware of how the clinical experiences I was to have there would change me. Although I had known of the social policies of communist China, I did not expect to feel the weight of government’s role in personal health—particularly in relation to family planning—and of how chi ku would be personified in the obstetrics-gynaecology clinic.
It has been nearly four decades since China’s one child policy was first introduced in 1979 as a method of population control after the 1950s post-war baby boom. Since that time, official statistics show that 336 million abortions, in addition to 196 million sterilisations of men and women, have been performed. Government researchers suggest that the high rate of abortions is primarily caused by lack of sex education; less than 10% of sexually active couples regularly use condoms, according to a recent state run survey. China Daily reported that more than 70% of callers to a pregnancy phone line at a Shanghai hospital knew almost nothing about contraception. Oral contraceptive pills are also not a culturally accepted method of birth control because many women fear the side effects of Western pills and more usually have intrauterine devices fitted—although sometimes the procedure is involuntary. For similar reasons, many women will choose surgical over medical abortions.
Doctors’ advice can be heavily influenced by social policy, and they might strongly recommend abortions to couples who already have one child. Depending on the province and family situation, the consequences of having more than one child vary. Typically, families pay a fee that is three times their annual salary when they choose to have more than one child. An abortion typically costs 300-1000 yuan (£30-100; €40-120; $50-160). The government further encourages abortions by mandating that women receive 14 days of paid sick leave for an abortion in the first trimester or 30 days’ sick leave for a termination thereafter, with abortions legalised up to six months of gestation. Sick leave is extended if a woman gets an intrauterine device placed or elects to be sterilised after an abortion.
I witnessed the differences in the doctor-patient relationship throughout my time in the clinic. Most surprisingly, the doctor provided little education to patients about family planning and contraception. He asked few questions about what methods of contraception the women had been using or if they understood the potential health risks of abortions. Little counselling was available to women. Appointments—which were often same day and rarely made in advance—were typically focused on acute care rather than prevention, unlike annual “well woman” visits in the United States. Further, women seeking abortions are often understandably nervous, yet little is done to prepare them for the procedure itself. Because women often have repeat abortions, doctors assume they know what to expect.
As a US medical student witnessing an abortion for the first time, I was surprised by the casual way that the procedure was performed; it almost felt anti-climactic because abortions have been a paralysing political and social issue in the United States. I also saw first hand the relation between social policy and personal health in China. The government still plays a direct role in reproductive behaviour and choices. This is not to say that contraceptive methods like condoms and oral contraceptive pills are not widely available over the counter—they are. Although China is the only country with a National Family Planning Commission, there remains a great need for sex education and family planning awareness because the number of women receiving abortions, both elective and forced, are at epidemic proportions.
Western medical students are taught early in our training about the importance of listening and developing strong doctor-patient relationships so that we can ultimately advocate for our patients’ health needs—part of which is ensuring that our patients can make informed decisions about their bodies. My experiences in China, whose healthcare system does not necessarily prioritise these values, highlighted this aspect of healthcare delivery and will change the way I interact with patients.
Next time I volunteer in a clinic or circulate on the wards during third year, I will remember that every patient has a story and it is our job as future doctors to develop a good history, discover the patient agenda, and adequately prepare them for their decisions. I don’t know all of the reasons why the women came to the hospital clinic that day to request abortions, but I can’t help wondering how their stories might have changed if they thought they had other alternatives besides “eating bitterness.”Ilene Tsui, second year medical student
1Pennsylvania State University College of Medicine, USA
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
- Moore M. 336 Million abortions under China’s one child policy. Telegraph 15 March 2013.
- McDonald M. Abortions surge in China; officials cite poor sex education. New York Times 30 July 2009.
- Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. Population Policy Data Bank.
Cite this as: Student BMJ 2013;21:f5822