The author of this article: Wang Yiqing
Recently, the National Family Planning Association issued document No. 1 "Key Points of Work of the China Family Planning Association in 2022", mentioning that "the implementation of reproductive health promotion actions, focusing on solving the outstanding problems of reproductive health of adolescents, childbearing age groups and other specific groups, carrying out special actions for artificial abortion intervention for unmarried people, reducing unintended pregnancies and abortions among adolescents, and improving the reproductive health level of the masses."
Image source: China Family Planning Association
Among them, the "special action to carry out abortion intervention for unmarried people" quickly aroused widespread concern and heated discussion in society: starting from the current situation, is this action improving the reproductive health level of the masses, or the invisible threshold of abortion?
"Abortion, it's long overdue"
From the policy and measure level, the "abortion intervention" that has attracted attention on the Internet is actually not a new concept.
Taking Shanghai As an example, in 2021, the Shanghai Family Planning Drug Administration Center has proposed a "human flow target intervention service project" and prepared a budget for this purpose. Its main purpose is to "carry out a public welfare project on intervention services for abortion recipients in the city in order to comprehensively improve the awareness of scientific contraception among the target population, reduce unintended pregnancy, reduce repeated abortions, and improve the reproductive health level of people of childbearing age".
The Outline for the Development of Chinese Women (2021-2030), the Healthy China 2030 Programme and the report of the Executive Director of the United Nations Population Fund's 2018-2021 Strategic Plan also mention measures such as "reducing abortions with non-medical needs", strengthening comprehensive interventions for people at high risk of sexual transmission, and reducing unintended pregnancies and the spread of sex-related diseases – interventions in abortion have been important tools in the past from the perspective of improving reproductive health.
Image source: United Nations
Yan Liu is the deputy chief physician of the Obstetrics Department of Tianjin First Central Hospital, and she has more than 20 years of experience in obstetrics and gynecology. "In 2010, the number of abortion surgeries reached a peak in my career, at most, I could complete 27 surgeries in 3 hours", and in recent years, the number of abortion surgeries Chinese is still high, but it has declined, and the obstetrics and gynecology department of Liu Yan's hospital can now not reach 10 such surgeries a day, "on the one hand, it is related to the country's fertility policy, on the other hand, it is also related to the current generally low willingness to have children."
According to Liu Yan's clinical observations, women who have unintended pregnancies have become the main group of abortions, and from the perspective of industry insiders, "this field is mixed". Liu Yan believes that the intervention of abortion should not only strengthen education and reduce unintended pregnancies, but also make abortion surgery more standardized.
In Liu Yan's memory, the car radio that was listened to every day ten years ago was a painless abortion advertisement, "saying that today to do surgery, tomorrow to work, in fact, these give people a lot of misleading." Liu Yan said that abortion surgery is indeed very fast, but the risk is large, "the hospital will say the operation is very simple, but the level of doctors is difficult to control."
What impressed Dr. Liu Yan was that there was once a teenage girl who had abortion surgery in other hospitals, and due to the doctor's improper operation, the uterus perforation and intestinal perforation caused intestinal necrosis, and after being transferred to the hospital, she was unconscious and was admitted to the ICU intensive care unit. In addition to safety, the price difference between abortion surgery in the market is also very large, and when seeking medical treatment, patients need to choose a formal institution as much as possible.
Therefore, due to the dual considerations of reproductive health and industry norms, abortion urgently needs intervention, but Wang Jufen, deputy director of the Women's Research Center of Fudan University, has a different attitude towards the mention of "unmarried people".
Wang Jufen has always insisted on women's and population research, and has a long-term and systematic observation of the current situation of marriage and childbirth in China, based on these experiences and judgments, she believes that in the key points of the work of the Family Planning Association, the definition of "unmarried people" is no longer scientific enough.
Wang Jufen told Lilac Garden: "In the context of the increasingly diverse concept of marriage and childbearing in today's society, people can choose to marry and divorce in a lightning way, and even if they are married, they can also form a Dink family; and with the change in the concept of marriage and childbearing, there is also the increasingly early sexual maturity age of women, before the female sexual maturity age was twelve or thirteen years old, and now it is advanced to about ten years old, and women's fertility can generally last until 45 to 49 years old."
According to the Oriental Network, the average age of marriage for both sexes in Shanghai is close to 30 years old. This means that more people choose to marry later and have children later – in a situation where social attitudes and public physiological conditions are constantly changing, a single focus on unintended pregnancies and abortions among unmarried and adolescent groups may simplify the problem and not have the universal significance of keeping pace with the times."
"The society's attention to abortion should include all women of childbearing age, and no longer distinguish between married and unmarried", which is also the view of Wang Jufen and their research group when they participated in the formulation of the "14th Five-Year Plan for the Development of Women in Shanghai", she believes that for women's health services, their entire life cycle should be included, and if you want to improve the reproductive health of the public more scientifically and effectively, you should do clearer background research and propose more universal care measures before the policy is proposed.
Drug abortion cannot be allowed
Walking into the pharmacy, the family planning counter is always the most eye-catching, and the red and yellow contrasting "Viagra has arrived" is posted in front of each window.
However, what has recently caused discussion has become a reminder card in front of the cash register with the words "no sale of drugs for the termination of pregnancy", combined with the fifth batch of national collections in 2021, mifepristone and cabetin were kicked out, which also made some netizens worry that "the difficulty of abortion may be further improved" in the future.
Image source: Visual China
However, at the level of market supervision, there have long been restrictions on drugs for the termination of pregnancy.
"Regulating the sale and use of drugs for the termination of pregnancy is mainly to cooperate with the national policy of rectifying the two Non-Africans", Wang Ding, deputy director of the Market Supervision and Administration Bureau of Nanyang City, Henan Province, introduced that the so-called "two non-africans" refers to the non-medical need to identify the sex of the fetus, and the non-medical need to artificially terminate pregnancy, the background of this policy is the domestic gender ratio that has been unbalanced for many years.
On the other hand, in 2020, the "Printing and Distribution of the National Shortage Drug List" and the "Opinions of the General Office of the State Council on Further Improving the Supply and Price Stabilization of Shortage Drugs" were issued, and oxytocin was included in the national clinically necessary shortage drug key monitoring list. This means that if there is no enterprise hanging on the provincial centralized drug procurement platform or not listed in the centralized procurement directory of the province, medical institutions can put forward procurement needs, search for pharmaceutical manufacturers offline, and negotiate directly with drug supply enterprises.
Wang Ding told Lilac Garden: "In the continuous improvement of the centralized procurement of drugs in public hospitals, the state has further emphasized the implementation of drug classification procurement. Among them, for non-patent drugs in women's and children's specialties, the implementation of centralized hanging nets, direct procurement by hospitals, the reason is that the demand for such drugs is limited, in order to improve the production enthusiasm of pharmaceutical companies, to ensure the supply of drugs, starting from the fifth batch of collection catalogues issued by the state, mifepristone and cabetonin will be withdrawn from the collection sequence."
From a clinical point of view, Dr. Liu Yan also said that the scope of application of medical abortion is limited: "From a professional point of view, we do not recommend self-medication for abortion; although we also do abortion, it must be in a regular hospital, under the judgment and observation of professionals."
"Pregnancy termination drugs are basically by causing the uterus to contract and causing the embryo to come out under pressure, but in this case, the embryo may not come out completely, resulting in dripping bleeding, which is more dangerous." For abortion surgery, the risk of heavy bleeding in the flow of medicine is already high, if such drugs are not controlled, let the patient operate on their own, the risk of heavy bleeding will be very large."
Wang Ding, who has been engaged in drug supervision for more than 20 years, said that taking Henan Province as an example, the implementation of the "Regulations on the Administration of Drugs for the Termination of Pregnancy in Henan Province" began in 2005, and the relevant regulations of other provinces on such drugs were also implemented in this period of time. In the implementation of management, "mainly from the sales channels and use of norms to supervise such drugs", specifically, at the sales level, the production and wholesale enterprises of terminated pregnancy drugs can only sell such drugs to qualified institutions, while drug retail enterprises prohibit the sale of such drugs; at the use level, qualified institutions need to establish a complete record of the purchase and use of drugs for the termination of pregnancy, and keep them for more than 3 years.
According to Wang Ding, the most common pregnancy termination drugs on the market are mifepristone tablets, in addition to misoprostol tablets, oxytocin injection, etc. are within the scope of supervision of pregnancy termination drugs, while ordinary contraceptives do not belong to the list of pregnancy termination drugs, which can be purchased in retail pharmacies.
"In the years after the implementation of the regulations in 2005, the phenomenon of illegal sales in the market is still difficult to put an end, because retail pharmacies and wholesale enterprises have a process of gradually accepting the new policies, and the regulatory authorities have also gradually strengthened the process of supervision," Wang Ding said, "In recent years, the phenomenon of illegal sales has become uncommon, for pharmaceutical retail enterprises, the illegal cost of selling such drugs is very high, for production and wholesale enterprises, this is not a bulk sale of drugs, not a lot of profit margins."
Taking Henan Province as an example, the penalty for illegally selling such drugs by pharmaceutical retail enterprises is to confiscate drugs and illegal gains, and impose fines of more than 3,000 yuan and less than 20,000 yuan, which will be registered in the records of their business specifications.
For the supervision of drugs for the termination of pregnancy, in addition to the routine inspection of the drug regulatory department, there are special inspections jointly conducted by the health administrative department, the family planning management department and the drug supervision department, and the scope of inspection includes medical institutions, family planning service agencies, drug wholesale enterprises, and drug retail enterprises, "For example, we will check the purchase, sale and use records of drug wholesale enterprises and hospitals, and check whether there is any illegal loss of drugs for the termination of pregnancy by comparing the purchase volume, use and inventory quantity", Wang Ding said.
Speaking of the future trend of drug management for the termination of pregnancy, Wang Ding believes that the management regulations will be more stringent and perfect in the continuous revision, which is related to the life safety of drug users and the safety of the country's population, "so drug abortion will not be allowed, nor can it be allowed."
No one is an outsider
From abortion surgery to pregnancy termination medications, the risk and burden of pregnancy act more directly on the woman herself, which is not a healthy reproductive concept in terms of both a single pregnancy cycle and the long-term development of the population.
"With 9.5 million abortions a year in mainland China and less than 11 million births, it is a pity that these children have been aborted," wang Jufen lamented, adding that in addition to her tenure at Fudan University, she also has a heavy identity as a volunteer on the 12338 Women's Rights Protection Public Service Hotline, providing monthly counseling services to callers.
"A few years ago, there was a girl who was pregnant, her boyfriend was scared away, afraid of taking responsibility, the caller told that the miscarriage cost more than 1,000 yuan, she was pregnant for 4 months, the doctor said that if she did not miscarry, she would not be able to flow, but she had no money", talking about this matter, Wang Jufen is still difficult to let go.
"Shouldn't our society provide more services, more appropriate scientific education and more correct concepts of marriage and childbearing?" Pregnancy should not be a single responsibility for women", Wang Jufen believes that for the public who are not ready to become pregnant, they should have sufficient sexual health knowledge and scientific contraceptive measures to avoid unintended pregnancies.
"The experience of many countries tells us that the spread of knowledge about reproductive health may be more effective than direct intervention in pregnancy, and that in cases where a pregnancy has already been unintended, if both parties are genuinely in love, our society should provide them with the necessary help and conditions to continue to develop and start a family, perhaps not necessarily to the point of miscarriage."
Wang Jufen said that we can refer to the cooling-off period for abortion set up by some countries to give full counseling and possible help to the parties; for women who have an unexpected pregnancy but decide to have children, or pregnant women who are missing a man but still have the courage to continue to have children, the society should provide these women with training in employment guidance and other aspects, reduce the burden on these women, and provide a suitable environment for the birth of these children, which is also in line with the principle of "maximizing the interests of children".
In the case of the number of abortions is still huge, the number of births continues to decline, and the infertility rate is increasing, it is the increasingly diversified concept of marriage and childbearing and the more complex demographic structure of society, how to provide more universal, more up-to-date, more warm and caring policies, how to improve supporting education and services, may need further exploration.
On the issue of taking on reproductive responsibilities and improving reproductive health, no one is an outsider, regardless of gender or age. (Planner: Leu.)
Title image source: Visual China