For decades, reproductive policy in China was closely tied to state objectives, with authorities first seeking to limit births through the one-child policy and now attempting to encourage larger families as the country confronts a sustained decline in births.Interviews with women across China, combined with academic research and demographic data, suggest that the legacy of the one-child era continues to influence family decisions even as government priorities have shifted.

While authorities now promote childbirth through subsidies and policy incentives, many women cite economic pressures, changing social expectations and personal autonomy as key factors shaping their choices.Since the founding of the People’s Republic of China in 1949, family planning and population management have played a significant role in public policy.

During the decades-long one-child policy, which was formally implemented in 1980 and largely ended in 2016, many families were restricted to a single child. Enforcement methods varied across regions, but reports from several parts of the country documented fines, mandatory birth-control procedures and, in some cases, forced abortions and sterilizations.

In Shen County, located on the outskirts of Liaocheng in eastern China’s Shandong province, memories of some of the most stringent enforcement measures remain vivid among older residents.One woman in her 60s, identified only by the surname Li, recalled being subjected to a tubal ligation after giving birth in 1991. According to Li, local authorities were enforcing what became known as the “childless 100 days” campaign, a policy intended to prevent births during a designated period beginning in May of that year.

Li said she was heavily pregnant when local officials transported her and other women to a hospital for procedures intended to terminate pregnancies. She said she went into labor before doctors could carry out the abortion and gave birth to a son inside the hospital.

Afterward, she was fined 6,500 yuan and ordered to undergo sterilization.The Guardian was unable to independently verify all aspects of Li’s account. However, researchers and activists familiar with the period say similar reports emerged from the region during that time.Another Shen County resident, now in her 70s, said she was one month away from giving birth when she received an injection that induced labor and ended her pregnancy.

She said women who resisted family-planning directives faced threats that included property demolition, detention and restrictions on employment.Shandong, China’s second-most populous province, has long been viewed by scholars and activists as a region where central government policies were often implemented rigorously.

Human rights activist Yang Jianli, who is originally from Shandong, described the “childless 100 days” campaign as one of the most extreme examples of one-child policy enforcement that he had encountered.The Shandong provincial government did not respond to a request for comment regarding the historical accounts.

Although comprehensive data on the campaign are unavailable, demographic analysis by Yi Fuxian, a senior scientist at the University of Wisconsin-Madison and a longtime critic of China’s population policies, indicates that birth numbers in Shen County and neighboring Guan County fell sharply during the period in question.

More than a decade after China began dismantling birth restrictions, policymakers face a different demographic challenge. China’s birth rate has continued to decline despite efforts to encourage larger families. Official data show that the birth rate fell to 5.63 births per 1,000 people last year, marking a record low.

The government has introduced a range of measures aimed at increasing births, including financial incentives and tax benefits. However, researchers say economic realities and evolving attitudes toward family life have limited the effectiveness of those initiatives.A growing body of academic research suggests that decades of restrictive family-planning policies reshaped social expectations about ideal family size.

One study published last year found that growing up as an only child contributed to a significant reduction in the number of children people expected or desired to have.For many younger Chinese adults, concerns about housing costs, education expenses and financial security appear to outweigh policy incentives.Wang Yixuan, a 26-year-old practitioner of traditional Chinese medicine, said she does not currently plan to have children.

She said achieving financial independence remains a higher priority.Jia, the filmmaker based in Beijing, said women today possess greater freedom in making decisions about reproduction than previous generations. She said many no longer view motherhood as an obligation and increasingly approach family planning as a personal choice.Recent survey data point to a significant shift in attitudes among younger women.

One study found that nearly half of women aged between 18 and 24 reported that they did not want children, compared with just 6% in 2012. The proportion of men expressing the same view also increased during the period, although at a lower rate, reaching nearly 20%.In Shen County, restaurant worker Chen Ying said economic considerations play a decisive role in family decisions.

While earlier generations faced penalties for having additional children, she said many families today are limiting family size because of the financial burden associated with raising children.Yun Zhou, a social demographer at the University of Michigan, said the one-child policy left a lasting imprint on perceptions of reproductive rights and family planning.

According to Zhou, generations of state intervention contributed to a broader understanding that reproductive decisions were subject to government influence rather than being viewed solely as personal choices.

The effects of those decades remain visible across China, where a generation raised largely as only children is now making decisions about marriage, parenthood and family size under a dramatically different demographic reality.

At Jemo Health Centre on the outskirts of Addis Ababa, health worker Tewodros Tibebu says social stigma and limited awareness continue to delay access to comprehensive abortion care, despite Ethiopia legalizing broad abortion services more than two decades ago.

Tibebu, who has worked in comprehensive abortion care for four years, is among only three trained providers currently delivering the service at the facility. According to his account, many patients arrive after significant delays, often seeking help only after complications emerge from procedures carried out elsewhere.

“The biggest challenge is stigma,” Tibebu said in a feature published by the World Health Organization on May 5. “Many women are afraid someone will recognize them when they come here. Others do not even know the service exists.”Comprehensive abortion care has reportedly been available at Jemo Health Centre for nearly a decade.

However, Tibebu said access barriers remain widespread, particularly for women seeking confidential and medically supervised treatment.According to his account, many patients first visit private clinics where procedures may be carried out by practitioners lacking formal training in abortion care. By the time some women reach public facilities such as Jemo, they are already suffering from infections or sepsis that could have been prevented through earlier medical intervention.

Ethiopia expanded legal access to abortion in 2005 under revised provisions that allowed the procedure under broader circumstances than previously permitted. Despite the legal framework, health care providers and reproductive health organizations have continued to report uneven access across regions, driven by social stigma, provider shortages and gaps in public awareness.

Tibebu said the stigma surrounding abortion services affects providers as well as patients. “Some coworkers oppose the comprehensive abortion care department,” he said. “Some people in my community do not know what I do.”The social pressures attached to abortion care are a recurring issue in reproductive health systems globally, particularly in countries where legal reforms have outpaced shifts in public attitudes or health infrastructure.

Health workers often face professional isolation, ethical scrutiny and personal criticism while providing services that remain politically and culturally contested.Tibebu said professional training helped him better understand both the clinical and ethical dimensions of abortion care. “Before, it was difficult,” he said.

“After I received specific training, I understood the work differently and could provide the care women need.”The experiences described by Tibebu formed part of a broader announcement by the Human Reproduction Programme, known as HRP, regarding a new international training initiative on comprehensive abortion care.

The programme, launched through the WHO Academy platform, combines four separate learning modules focused on medical abortion, surgical abortion, post-abortion care and human rights integration in comprehensive abortion care. According to HRP, the courses are designed to provide modular and interactive learning environments that simulate real clinical decision-making scenarios encountered by frontline health workers.

WHO said the training initiative is intended to strengthen evidence-based care and improve consistency in abortion services across different health systems. The programme also places emphasis on privacy, non-discrimination and accountability within clinical practice.

The human rights integration component links medical treatment with broader principles related to patient dignity and access to care, according to WHO. Together, the courses are intended to establish a standardized framework for providers working in comprehensive abortion care settings.The launch reflects continuing international efforts by global health organizations to reduce preventable maternal complications associated with unsafe abortion procedures.

WHO has repeatedly stated in policy guidance that access to trained providers, accurate information and safe clinical environments are central to reducing maternal morbidity and mortality.At facilities such as Jemo Health Centre, providers say the gap between legal availability and practical access remains significant.

Tibebu noted that many patients learn about the service only through informal networks and word-of-mouth referrals rather than official health campaigns or referrals from primary care systems.That reliance on informal communication channels, he said, contributes to delays that can worsen medical outcomes.

The WHO feature also highlighted the operational pressures facing providers in facilities with limited staffing. With only three trained workers handling abortion care services at Jemo, workloads remain concentrated among a small number of clinicians.

Training programmes such as the one launched by HRP are intended in part to address those shortages by expanding provider knowledge and strengthening clinical capacity. WHO said the interactive nature of the courses allows health workers to engage with practical decision points similar to those encountered during patient care.

The organization has increasingly used digital and modular learning systems to expand access to specialized medical training, particularly in lower-resource health settings where formal clinical education opportunities may be limited.Tibebu said the training reinforced his understanding of abortion care not only as a technical medical service but also as direct patient support during periods of vulnerability and medical risk.

“People may not understand what we do,” he said. “But when you think about the woman in front of you, the decision is clear. You are helping someone.”WHO separately announced a webinar linked to the comprehensive abortion care learning programme scheduled for April 28, 2026.

The organization also published updated abortion-related fact sheets in December 2025 as part of its broader reproductive health guidance materials.The HRP programme operates jointly under the United Nations Development Programme, the United Nations Population Fund, the United Nations Children’s Fund, WHO and the World Bank, focusing on research, policy development and training in human reproduction and reproductive health services.