If You Have Money You Can Make the Devil Push Your Grind Stone

Reproductive decision making under China’s family planning policies among women of low SES: Implications for maternal and child health outcomes

Kim Craig

SUNY Binghamton

ANTH 572K International Health

Dr. Deborah Schechter

May 2019

I. INTRODUCTION

Over the last four decades, China’s family planning policies have restricted family sizes, punishing those that disobey with hefty fines, job loss and mandatory abortions (Sun et al., 2018). These policies and penalties are a form of what Paul Farmer calls, structural violence, “one way of describing social arrangements that put individuals and populations in harm's way” (Farmer, Nizeye, Stulac, & Keshavjee, 2006. p. 1686). This violence is especially targeted at lower SES (socio-economic status) families that cannot afford the financial repercussions of violating the policy by having excess children. For parents that end up pregnant again after a first child, but are unable to pay the “social compensation fee” (Callick, 2007), they might choose to leave their child unregistered, thereby designating their second born to the unsavory social class of “黑孩子 hēiháizi”, literally “black child” (“black” here is referring to the illegal status) (Fong, 2015). Being unregistered impedes access to basic health and educational resources (Sykes, 2010). This essay explores how the restrictive family planning policies can lead to health disparities among low SES mothers, their heihaizi children, and the children of the heihaizi.

II. HISTORICAL BACKGROUND

During the mid-20th century, China was eager to catch up with the industrialize West, operating under the theory that more people would equate to more workers and therefore higher productivity (Sun et al., 2018). There was a push for larger families during this time and woman who had many children were celebrated in governmental campaigns (Jian, 2013). This population boom was followed by mass famine and high mortality due to governmental mismanagement and several unfortunate circumstances (Whyte, Wang, & Cai, 2015). A radical plan was devised to remedy the population growth by limiting family size which would later be called the “One-Child Policy”. The policy was implemented nationally in 1980 and was updated to a Two-Child Policy in 2015.

Although very successful at decreasing birth rates, the controversial policy has also led to a number of negative outcomes including a disproportionate gender ratio (Sun et al., 2018) and an ever rising number of heihaizi (Fong, 2015). Violators were fined up to 20% of the family’s annual salary, which some families were unable to afford, leaving them unable to register their child (Klemetti et al., 2011) or grant them a hukou. Hukou is a housing registry document that is connected to a particular province and authorizes its citizens access to all government provided services (Shi, 2017). Without a hukou, the life of a heihaizi is so limiting that in 2010, one young man, Shi Chen, sought asylum in the USA, making the case that his legal status offered no options for his future

(Sykes, 2010);

“As a member of the heihaizi, Chen asserts that he is denied access to health care and other governmental services; is excluded from higher education and many types of employment; and will be denied the right to marry and have children, the right to own property, and the right to freely travel within and outside of China.”

Financial capability has led to stratified reproductive classes where the wealthy can afford to buy their way out of the policy, suffering very little backlash from their disobedience (Shi, 2017). Meanwhile the poor have fewer options which, I argue, will lead to a lifetime of compounding health disparities that will be passed on intergenerationally.

The questions guiding this research are:

1. How has SES affected reproductive decision among Chinese families under the family planning policies?

2. What are the options for less economically-situated violators?

3. Specifically, what are the potential negative health outcomes for those children who are born in secret (黑孩子 hēiháizi) that may never have the benefits associated with citizenship?

III. METHODS

As of 2015, there were an estimated 13 million heihaizi living in China (Fong, 2015). Since this class of people is largely hidden, there have been no studies done directly from them. In this paper, I will use health data collected about populations suffering from similar structural violence to prove that an impoverished economic status coupled with strict policies has led to negative health outcomes for those who choose to flee and hide to avoid detection from birth planning officials (Shi, 2017). By imagining the history of a single unregistered person, I will address possible health risks at every stage of their lives, from gestation to adulthood. Comparing the data of other at-risk populations, I will attempt to show how a life of oppression can become embodied and then passed onto future generations.

Material used for the following research come from a number of sources. Mei Fong’s 2015 book, One Child, initially spawning my interest in the heihaizi. From there, a snowballing technique was used to gather more in-depth information about the population. For academic articles, I used Google Scholar and Find It by inputting a combination of the following keywords:

• Heihaizi

• Health

• Unregistered

• Undocumented

• Health Disparities

• Birth

• Family-Planning Policy

• One-Child Policy

• China

For a better understanding of how the Chinese report the issues surrounding the heihaizi, I used the same keywords in the China Daily Archives. Additionally, Dr. Deborah Schechter recommended a number of valuable articles and graphs.

IV. RESULTS FROM RESEARCH

GESTATION

Whereas the rich can use their financial positioning to side-step the policy, deemed “excess-birth nobles,” those less economically situated may choose to hide their pregnancies earning them the label “excess-birth guerillas” (Shi, 2017. p.542). While no research has been done regarding the health of heihaizi, there have been a handful of quantitative studies completed on health care utilization by their pregnant mothers. We know that prenatal care is important to the future health of the child as well as the safety of the mother (Doherty, Norton, & Veney, 2001; Jarvis et al., 2011; Oberg, 1990; Sun et al., 2018) and is a good predictor of future health outcomes of the heihaizi.

In China, once a pregnancy is registered with the government, medical expenses for prenatal care and delivery are either free or subsidized, however, without proper documentation services must be paid fully out of pocket (Doherty et al., 2001). The hefty expenses are the main reason for not obtaining medical assistance during pregnancy according to Jim Doherty’s large-scale study on pregnant women in China (2001). Unregistered mothers were also likely to avoid obstetric facilities in order to evade family planning officials who would track and report them (Doherty et al., 2001).

If caught pregnant without a legal birth permit by the local family planning officials, mothers risked forced abortions or sterilizations (Jian, 2013). In 2007, a county in Guangxi Province performed a series of mass abortions where over 17,000 fetuses were exterminated, and their mothers sterilized (Jian, 2013). In one account, a woman was seized from her home by officials who kicked her in the belly before she was taken to the hospital to have her fetus removed, after which she was made barren (Jian, 2013). In another story, a woman who was eight-months pregnant described her experience (Tasch, 2015):

"He was still alive after the nurse pulled him out from me. He was a tough little creature. He clutched the nurse's sleeve and wouldn't let go. She had to peel his fingers off her one by one before she could drop him into the bin.”

With so many such documented instances, we cannot be surprised that 71% of women with unregistered pregnancies did not deliver in hospitals (Doherty et al., 2001). These numbers correlate directly to an increased risk of maternal mortality (Sun et al., 2018). Mothers with unregistered births are 2.5 times more likely to die during delivery than those with approved births (Doherty et al., 2001).

Home deliveries performed without the aide medical professionals can be dangerous for both the mother and the child. One study researching maternal mortality rates in Guangzhou over a 9-year period found that unregistered mothers were almost 70 times more likely to die due to delivery complications than their registered counterparts (Sun et al., 2018). This number dropped to only 15 times more likely once a relaxation in policy allowed for a second child, coinciding with a smaller number of pregnancies needing to be unregistered (Sunet al., 2018).

BIRTH

Census data has revealed a profile of women who have unregistered children are likely to be married, living in rural provinces with an agricultural hukou and have less than six years of education (Zhou, 2005). As mentioned previously, most unregistered births happen at home in secret. A lack of medical attention is known to be risky for the mother and is equally perilous for the baby (Jarvis et al., 2011). Without a record of these secret home births, there is no data about the resulting children. A comparison to similar disadvantaged groups can fill in the gaps. For this we can look at other populations that may avoid seeking medical treatment for similar reasons: fear of getting caught.

A study investigating uninsured mothers in Canada, of which 58% where undocumented, found that these women were seven times more likely to have premature babies (Jarvis et al., 2011). The chronic stress experienced by the mother could cause her to have higher cortisol levels which is known to trigger labor (Carpenter, 2017). High cortisol could also restrict blood flow to the fetus impeding growth (Carpenter, 2017). This is reflected in the Canadian study which found that babies of uninsured mothers were four times more likely to be of low birth weight (Jarvis et al., 2011). A low birth weight baby is 40 times more likely to die within the first month of life (Oberg, 1990). If the baby does survive, it is more likely to suffer serious illnesses such as developmental disorders, birth defects, mental disabilities, respiratory issues, blindness, or cerebral palsy (Oberg, 1990; Ratnasiri et al., 2018). It is important to note that low birthweight can be detected in 80% of early screenings where many of the related illness can be prevented through early intervention (Oberg, 1990). Without screening or medical treatment, the outcomes of the resulting births are at severe risk.

CHILDHOOD + ADOLESCENCE

In the event that the heihaizi makes it past the first year of life, the child will not be eligible to receive medical attention for even the most basic care without risk of being outed for their unregistered status as a hukou would be needed to prove their identity. Any medical treatment would not be covered by insurance and would be priced at full cost (Doherty et al., 2001). Most Chinese families of low SES would struggle to afford this. To understand the health disparities that might be faced during this time, we can look to other uninsured children who are also unlikely to receive regular medical treatment. One study in the US found that these populations are less likely to be immunized which has led to historical outbreaks of preventable diseases such as measles, mumps and pertussis (Oberg, 1990).

Without regular screening, small issues can grow into catastrophic problems if left untreated. Missed early detections of problems with vision, hearing, dental, anemia, lead poisoning and recurrent infections can have detrimental outcomes without medical intervention (Oberg, 1990).

But not all of the potential health risks are physical. Once the child realizes their legal status, the pressure of maintaining their secret can have a deleterious effect on their mental and emotional health (Gonzales, Suárez-Orozco, & Dedios- Sanguineti, 2013). A study, led by Roberto Gonzales, examined undocumented children in the US and found that many of them realized their status when they were unable to participate in the same rites of passages as their peers due to their lack of documentation (2013). This led to anxiety, frustration and stress and provoked a social distancing out of fear of being discovered (Gonzales et al., 2013). Substance abuse, self-harm and suicide attempts were higher than their native and documented peers and the mental anguish of chronic stress became physical embodied in the form of higher blood pressure, headaches, decreased cognitive performance, and decreased impulse control (Gonzales et al., 2013).

ADULTHOOD

As these unregistered children reach adulthood, finding work can be complicated. We see in parallel populations of undocumented workers that without identity papers, they are obligated to work illegally, excluding them from benefits or job security (Li & Rose, 2017). They are more likely to take physically demanding, “dirty jobs” which places them at higher risk of injury and casualty (Pikhart, Drbohlav, & Dzurova, 2010). In addition to the constant stress of the working conditions and uncertain job security, they have a underlying fear of being caught or exposed (Pikhart et al., 2010).

The generalized stress experienced through the heihaizi’s life can wear down the cardiovascular, metabolic and immune systems. The long term “weathering” of these important systems can “fuel the progression of chronic diseases” such as cardiovascular disease, diabetes, an increased susceptibility to infection and accelerated aging (Geronimus, 2001. p. 135).

PARENTHOOD

Now that the first generation of heihaizi (those born between 1980-2000) are well into their childbearing years, it is important to consider what will become of their kids. When a heihaizi has children, their children will be burdened by the same social status and health disparities as their parents. Without their parent’s documentation, they will also be unable to obtain the documents that prove personhood (Fong, 2015). The struggles become heightened for this new generation where, unlike their parents who could rely on the previous generation’s hukous, they must rely on parents with no legal documentation or associated benefits whatsoever. What will happen when the parents of the first generation heihaizi are gone? Who will they rely on? Will this destiny be continued into the third and fourth generations of heihaizi?

Legal status won’t be the only limiting factor that future generations of heihaizi will inherit. Many studies show that embodied health can be passed intergenerationally (Carpenter, 2017; Kuzawa & Sweet, 2009; Ratnasiri et al., 2018; Walters et al., 2011). One of which, led by Karina Walters (2011), found that “powerful stress environmental conditions can leave an imprint of mark on the epigenome that can be carried into future generations with devastating consequence” (p.184). With the immense number of stressors and health risks the first generation of heihaizi is liable to be exposed to over their lifetime, there is great danger of passing some on.

V. CONCLUSION

As of now, there is no pathway to citizenship for the heihaizi who are unable to pay their fines (Fong, 2015). Despite the recent changes in policy allowing families to have more children, the fines are still applied retroactively. Even if a heihaizi’s family does manage to pay their debts, post-factum documents like birth certificates, which would be needed to obtain a hukou, are difficult to create without any proof of personhood (Radiolab, 2016). As we see in the results of Shi Chen’s appeal for asylum, there is no luck looking to the outside for help (Sykes, 2010). Without an internal change to China’s policy allowing forgiveness for past fines, the heihaizi’s futures are bleak.

Ultimately, the heihaizi are being punished for their parent’s poverty. While Chinese celebrities like film director, Zhang Yimou, could manage to pay his 7.48 million yuan ($1.2 million) social compensation fee that allow his five excess children to enjoy a legal status, not everyone can afford such luxury (Shi, 2017). Zhang’s children will have access to healthcare, education, and the opportunity for their future children to acquire the same benefits. Meanwhile the circumstances of excess births among lower income Chinese have the potential to put the health of multiple generations at risk: the mother who does not seek prenatal care, the heihaizi who will be ineligible to receive healthcare throughout their lives, and the children of the heihaizi who will inherit all the embodied health disparities amassed through the daily stresses of living as a stigmatized person.

VI. LIMITATIONS

Though there are a handful of studies documenting health information on mothers of unregistered children in China, I was unable to locate research on the children of those women. For this reason, I used data from populations that share similar social exclusion and legal constraints. However, these other groups live in different countries under different legal systems with slight differences to their sources of stress. While the two groups may have comparable experiences, we cannot assume that the same outcomes should apply to the heihaizis unilaterally. The health disparities from which the heihaizi suffer are based on issues of class, where most of the comparison groups that I have used suffer based on difference of cultural and national identity.

Similarly, due to the hidden nature of heihaizi, it is very possible that the limited data that we have on them are sorely under-reported. For instance, census data including unregistered births have been contested (Fong, 2015) and the numbers may be much higher.

It’s easy to imagine how and why these numbers would be difficult to cultivate, but why they are reported with such variety is confounding. Naomi Weisbrook Hauser (2011) wrote a compelling thesis on publication bias by outside sources reporting on China. In her paper she argues that the West, especially the US, tends to vilify China with respect to family planning policies, whereas China deflects statements that would stain its image (Weisbrook Hauser, 2011). While academic papers should aim to maintain unbiased standings when reporting research data, the ingrained cultural attitudes have the potential to permeate unconsciously. If unchecked, this could lead to under or over reporting of certain numbers depending on the framing of questions and their source.

VII. FUTURE RESEARCH

Though it would be extremely difficult to be granted permission to research let alone locate sufficient numbers of heihaizis, I feel a great deal could be learned by such an effort. This population is extremely vulnerable due to factors that are out of their control. While the limited research we have on mothers is a starting point, I propose that more research should be done on the heihaizis themselves.

I intend to focus on this group in my dissertation research but will need to find a clever way to frame it in order to be granted permission by the Chinese government. I will conduct a small qualitative study on the social worlds of several of these unregistered individuals and learn how they are navigating their adult lives, with the goal of using my film background to create a feature length documentary to report my findings.

While health disparities would be addressed, I do not aim to make it the central point of my research. I propose that someone better suited should look into long term health consequences of living a stigmatized life of social exclusion and no legal status in the People’s Republic of China. Such research could provide data proving the structural violence that lead to their embodied health disparities which could then strengthen arguments for policy reform.

VIII. REFERENCES

• Callick, R. (2007). China relaxes its one-child policy. The Australian. Retrieved from http://www.theaustralian.com.au/news/world/china-relaxes-its-one- child-policy/story-e6frg6so-1111112880730

• Carpenter, Z. (2017, February). What’s Killing America’s Black Infants? | The Nation. The Nation. Retrieved from https://www.thenation.com/article/whats-killing-americas-black-infants/

• Doherty, J. P., Norton, E. C., & Veney, J. E. (2001). China’s one-child policy: The economic choices and consequences faced by pregnant women. Social Science and Medicine, 52(5), 745–761. https://doi.org/10.1016/S0277-9536(00)00175-1

• Farmer, P. E., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural Violence and Clinical Medicine. PLoS Medicine, 3(10), e449. https://doi.org/10.1371/journal.pmed.0030449

• Fong, M. (2015). One child : the story of China’s most radical experiment. Houghton Mifflin Harcourt.

• Geronimus, A. T. (2001). Understanding and eliminating racial inequalities in women’s health in the United States. JAMWA, 56(4).

• Gonzales, R. G., Suárez-Orozco, C., & Dedios-Sanguineti, M. C. (2013). No Place to Belong. American Behavioral Scientist, 57(8), 1174–1199. https://doi.org/10.1177/0002764213487349

• Jarvis, C., Munoz, M., Graves, L., Stephenson, R., Souza, V. D’, & Jimenez, V. (2011). Retrospective Review of Prenatal Care and Perinatal Outcomes in a Group of Uninsured Pregnant Women. Retrieved from https://illiad.lib.binghamton.edu/illiad/pdf/966476.pdf

• Jian, M. (2013, May). China’s barbaric one-child policy. The Guardian. Retrieved from https://www.theguardian.com/books/2013/may/06/chinas-barbaric-one-child-policy

• Klemetti, R., Regushevskaya, E., Zhang, W. H., Wu, Z., Yan, H., Wang, Y., & Hemminki, E. (2011). Unauthorised pregnancies and use of maternity care in rural China. European Journal of Contraception and Reproductive Health Care, 16(5), 359–368. https://doi.org/10.3109/13625187.2011.596233

• Kuzawa, C. W., & Sweet, E. (2009). Epigenetics and the embodiment of race: Developmental origins of US racial disparities in cardiovascular health. American Journal of Human Biology, 21(1), 2–15. https://doi.org/10.1002/ajhb.20822

• Li, J., & Rose, N. (2017, November 1). Urban social exclusion and mental health of China’s rural-urban migrants – A review and call for research. Health and Place, Vol. 48, pp. 20–30. https://doi.org/10.1016/j.healthplace.2017.08.009

• Oberg, C. N. (1990). Medically Uninsured Children in the United States: A Challenge to Public Policy. Journal of School Health, 60(10), 493–500. https://doi.org/10.1111/j.1746-1561.1990.tb05888.x

• Pikhart, H., Drbohlav, D., & Dzurova, D. (2010). The self-reported health of legal and illegal/irregular immigrants in the Czech Republic. International Journal of Public Health, 55(5), 401–411. https://doi.org/10.1007/s00038-010-0156-1

• Radiolab. (2016). The Girl Who Doesn’t Exist | Radiolab | WNYC Studios. Retrieved from https://www.wnycstudios.org/story/invisible-girl

• Ratnasiri, A. W. G., Parry, S. S., Arief, V. N., DeLacy, I. H., Halliday, L. A., DiLibero, R. J., & Basford, K. E. (2018). Recent trends, risk factors, and disparities in low birth weight in California, 2005–2014: a retrospective study. Maternal Health, Neonatology and Perinatology, 4(1), 15. https://doi.org/10.1186/s40748-018-0084-2

• Shi, L. (2017). The New Rich and Their Unplanned Births: Stratified Reproduction under China’s Birth-planning Policy. Medical Anthropology Quarterly, 31(4), 537–554. https://doi.org/10.1111/maq.12352

• Sun, W., Liu, S., He, F., Du, L., Guo, Y., El-Chaar, D., ... Chen, D. (2018). Impact of relaxation of the one-child policy on maternal mortality in Guangzhou, China. International Journal of Gynecology and Obstetrics, 141(3), 378–383. https://doi.org/10.1002/ijgo.12445

• Sykes, C. J. (2010). CHEN v. HOLDER | FindLaw. Retrieved from https://caselaw.findlaw.com/us-7th-circuit/1520012.html

• Tasch, B. (2015, October). What happened when people violated the one-child policy. Business Insider. Retrieved from https://www.businessinsider.com/what-happened-when-people-violated-the-one-child-policy-2015-10

• Walters, K. L., Mohammed, S. A., Evans-Campbell, T., Beltrán, R. E., Chae, D. H., & Duran, B. (2011). Bodies don’t just tell stories, they tell histories: Embodiment of Historical Trauma among American Indians and Alaska Natives. Du Bois Review, 8(1), 179–189. https://doi.org/10.1017/S1742058X1100018X

• Weisbrook Hauser, N. (2011). AMERICAN DISCOURSE ON CHINA: A CROSS-TIME COMPARISON OF (University of Missouri). Retrieved from https://search-proquest-com.proxy.binghamton.edu/docview/1114902821?pq-origsite=primo

• Whyte, M. K., Wang, F., & Cai, Y. (2015). Challenging Myths about China’s One-Child Policy. The China Journal. Retrieved from http://scholar.harvard.edu/files/martinwhyte/files/challenging_myths_published_version.pdf

• Zhou, Y. (2005). Uncovering Children in Marginalization: Explaining Unregistered Children in China.