Integrating reproductive health into national development strategies

Incorporating reproductive health into the national development strategy is by no means just a stop-gap measure to stimulate fertility, but a public service covering the entire population and the entire life cycle to make up for shortcomings. The essence is to achieve the dual improvement of long-term balanced development of the population and social welfare by protecting individual reproductive rights.

Last year, I went to the county with a team from a maternal and child health hospital in a western province to conduct research. I met two people in the corridor of the maternal and child hospital who left a deep impression on me: One was a 19-year-old girl from a vocational high school who accompanied her friend to have an abortion. She couldn’t even figure out the difference between condoms and emergency contraceptive pills. Physiology classes in school were basically self-study, and her parents never mentioned this to her; the other was a 38-year-old mother who did not undergo free pre-pregnancy screening when she was pregnant with her second child. Her child was found to have a neural tube defect. She sat at the door of the clinic crying, saying that "it was okay to have the first child, but there was no need to test the second child." Don’t think that this is a special case only in remote areas. According to the data released by the National Health Commission, there are more than 9 million artificial abortions in my country every year, half of which are women under the age of 25. The infertility rate among people of childbearing age has climbed to about 18%, not to mention that more than 30% of women after giving birth have varying degrees of pelvic floor dysfunction. Many people who have been leaking urine for more than ten years feel that "it is like this after giving birth, and I am embarrassed to treat it."

There was actually quite a lot of controversy over this matter in the academic circles before. One group of people holds a very realistic view. They believe that as the fertility rate continues to decline, the essence of incorporating reproductive health into the national strategy is to promote fertility. Resources should be allocated to areas directly related to fertility, such as pre-pregnancy screening, assisted reproduction, and postpartum rehabilitation, which can achieve the fastest results in increasing the number of births. The other group are scholars who study public health. They insist that reproductive health is a basic human right. Regardless of whether they have children or not, whether they are married or not, everything from sex education for teenagers, contraceptive services for unmarried people, to menopausal health care for middle-aged and elderly people, and screening for reproductive system diseases should be covered. Reproductive health cannot be narrowed down to "reproductive supporting tools."

Both statements actually have a basis in reality. Those who say they should give priority to childbearing services have seen that the medical insurance pool in many places is tight. Last year, Guangdong piloted the inclusion of assisted reproduction projects in medical insurance, and the reimbursement costs alone were nearly 200 million more than in previous years. If all reproductive-related projects were included in it at once, the medical insurance in underdeveloped areas would really not be able to bear it. When it comes to covering the entire population, there are real cases: I previously investigated a pilot village in Zhejiang, which integrated adolescent sex education, free contraceptive distribution, and menopausal women's health care into the work of the village public service station. In two years, not only did the local induced abortion rate drop by 42%, but the female labor participation rate also increased by 7 percentage points. Many middle-aged women who were afraid to go out to work because of urine leakage and gynecological diseases have now gone out to find jobs after their illnesses were cured.

To be honest, in the past, the reproductive health services in many places were really focused on "letting you give birth": if you have not given birth, you will be urged to have a pre-pregnancy check-up, and if you have given birth to a child, you will be urged to have a second child. There is no consideration at all that some people do not want to have a baby, some people are temporarily unable to give birth, and some people have already given birth and have a bunch of unsolved health problems. Now at the level of national strategy, the most obvious change is that different needs have begun to be taken into account: if you don’t want to have a baby, you can get free condoms and oral contraceptive pills in the community, and self-service contraceptive machines have begun to be installed in colleges and universities; if you want to have a baby but can’t, more than 20 provinces have now included some assisted reproductive projects in medical insurance or special subsidies; if you have already given birth or have no plans to have a baby, projects such as cancer screening and pelvic floor rehabilitation are gradually included in the list of free public services.

Of course, some people complain that the pace is still too slow. For example, unmarried people cannot cover their reproductive health expenses through medical insurance, sex education in many places is still secretive, and the coverage of male reproductive health screening is less than one-third of that of women. But if you think about it, being able to elevate this matter from "family planning package" to the position of national development strategy is a big progress in itself. In the past, when people talked about reproductive health, they were either shy or tied to "having children." Now they are finally beginning to admit that this is a basic health need that every ordinary person faces from adolescence to old age, no different from colds and fevers, high blood pressure, and diabetes.

Last month, the community hospital downstairs from my home held a free reproductive health clinic. A 62-year-old aunt came over after hiding in a plastic bag for a long time. She asked the doctor if postmenopausal bleeding was normal. She said she was afraid that others would say she was "old and immoral", so she dared not come to the hospital for half a year. She was found to be an early-stage cervical precancerous lesion, and she was fine after timely surgery. The aunt later held the nurse's hand and said that for most of her life, she knew for the first time that "women's affairs" were also matters that the state had to take care of.

In the final analysis, what is strategy or not? In the end, isn’t it just about solving practical problems for ordinary people? There is no need to step into the trap for unknown physiological knowledge, there is no need to delay the treatment of illness because of embarrassment, there is no need to afford assisted reproduction when you want to have a child, and there is no need to suffer the sequelae for the rest of your life after giving birth - if you do these things well, it will be more effective than any beautiful words.