Kidding the system
Qiao Jie sinks her slim frame onto a large, black sofa in a small meeting room at Peking University Third Hospital's reproductive-health centre. It's late on a Friday afternoon and the director of the mainland's leading fertility clinic, still wearing her round, light-blue surgical hat, has had a busy week creating life.
Today, though, her usual peppy mood has deserted her. Qiao has just come from doing something she hates: reducing the number of foetuses in a woman's womb. Critics would say 'killing' is a better word. Whatever you call it - and in this case it involved two of triplets - it's a soul-destroying thing to do, says Qiao.
'These are lives and we hate to take life. I give life!' she says, clasping her hands in prayer. 'I prayed before I did it. How do you decide which one to keep? Plus, one of them was an identical twin and that made it much harder. But the mother knew that for her health, she had to do it.'
The mainland is in the grip of a craze for multiple births that is alarming doctors and health authorities, as families try to outwit the country's tough population policies by taking a cheap and widely available fertility drug. Designed for women with ovulation problems, the drug - clomifene citrate - is approved around the world for use by couples experiencing certain types of infertility.
Yet ingenious minds are putting it to use for different reasons in China, principally among those kicking against the mainland's 26-year-old one-child policy, which decrees urban couples can have one child, rural couples can sometimes have two and non-Han peoples also can have two. The government is tinkering with the policy - with the first generation born after 1980 now entering reproductive age, single children marrying each other may have two offspring - but essentially, it is holding firm.
Less likely than white or black people to conceive twins naturally, the Chinese have seen rates for multiple births soar over the past decade. In a sign of growing awareness of the phenomenon, China celebrated its first ever Twins Festival in Beijing in October 2004. About 500 pairs of twins aged from just a few months to nearly 70 sang, danced, made friends and took part in games. The festival was a huge success, with a repeat last year that drew about 600 pairs.
While there are no reliable nationwide figures, birth rates at a busy maternity hospital in Nanjing, Jiangsu province, give an idea of the trend. Last year, 90 of 6,900 women giving birth at the Nanjing Maternal and Child Health Hospital had multiples - mostly twins - compared to just 45 from a similar number of pregnancies in 1995; the rate jumped from 0.65 per cent to 1.3 per cent - a 100 per cent increase. In terms of the percentage of births that are multiple, Nanjing is now roughly on par with Britain, although lags behind the United States, where the rate stands at around three in 100.
Like everywhere else in the world, the spike is partly accounted for by the introduction of artificial reproduction techniques, such as in-vitro fertilisation (IVF), which lead to a higher incidence of multiple births. Yet in China, a more complex brew of politics, tradition and economics is at work, as information about new, cheap drugs spreads rapidly and feeds into strongly held desires for bigger families and, above all, sons. In a country where people wish each other 'double happiness' when they marry, parents-to-be hope to conceive multiples in order to bypass fines for an 'out of plan' child that can amount to tens of thousands of yuan. Multiple births are exempt.
Some people, such as Xiao Hua, Qiao's Friday afternoon patient, want to do all they can to conceive
a boy. For the Xiaos (not their real name), a farming family from Beijing's rural outskirts, the birth of their first baby a few years ago was a mixed blessing - it was a girl. Xiao knew she'd have to try again. Thousands of years of tradition dictated each family must have at least one son to carry on the ancestral line.
The couple also knew that China's rigorous one-child policy allowed farmers whose first child was a girl to have a second. But what if that child was also a girl? Having a third is not permitted and would bring heavy fines that could beggar the Xiaos, who make a modest living tending a plot of the tall, yellow corn typical of northern China.
So in March, Xiao went to the local pharmacy and asked for the 'multi-kid pills' she'd heard about in the village. At the small but well-stocked shop, they asked no questions, handing over a little, white plastic bottle for 10 yuan, plus a little change. Inside was a three-month supply of clomifene, which stimulates ovaries to produce several eggs instead of the usual one per month. Following the instructions printed on the bottle, Xiao, in her late 20s, swallowed one pill daily for five days. She also took traditional herbal medicine to strengthen her health.
The drug worked; Xiao conceived triplets in the first month. But the thought of carrying three frightened her, so 13 weeks into her pregnancy - far too late in Qiao's opinion - Xiao came looking for help and took the doctor's advice, which was to abort two foetuses in order to maximise her chances of bearing a healthy child.
The authorities began to grow suspicious about the spike in multiples in 2004, when Henan province reported the birth of quadruplets and then quintuplets; in February of that year, a woman from the countryside surrounding Xinmi city delivered four babies then, in December, five were produced by a mother from the same area. Just five years earlier, the district had recorded its first ever quadruplets.
Last month, local health authorities launched a three-week investigation, vowing to 'keep in check the flourishing phenomenon of multiple births'. Their target was medical facilities illegally offering fertility treatment. Just 65 hospitals in China are authorised to offer such treatment, although doctors estimate about 200 do so in reality.
A spokesman for the Henan health department refused to comment but a circular issued last month shows authorities believe the problem is widespread. 'Artificial reproduction techniques are legal ... but right now, in Henan province, many health facilities are offering the technology without being permitted to and that is leading to many multiple births and many social problems,' it read.
Worried about the surge in unmonitored drug taking, the nationwide State Food and Drug Administration banned the over-the-counter sale of clomifene in December. The ban isn't working.
On a recent midweek afternoon, a visitor bought the drug without a prescription from a Xidan district branch of Beijing's Golden Elephant pharmacy chain, one of the capital's biggest. The saleslady, friendly and sympathetic, did not dispense any warnings along with the drug, which can cause side effects such as headaches and nausea. Women who take clomifene for longer than the three months prescribed by doctors could develop ovarian or breast cancer. There is also a slight risk of ovarian hyperstimulation syndrome.
'How long have you been trying [to conceive]?' she asked. 'Two years is not long. Take your time. Don't worry too much. Why are there so many twins now? It's all because of taking this medicine,' she said, before selling it for a little over nine yuan.
While many women are taking clomifene without any medical supervision, others are treading the borderline between legality and illegality by begging doctors to help them have twins through IVF.
China's first test-tube baby was born at Qiao's hospital on March 10, 1988. Since then, IVF has
been in heavy demand. Doctors say infertility is on the rise and affects one in 10 couples in China, pushed upwards principally by stress, infections and the country's catastrophic pollution levels.
'In the mornings, the waiting room is so crowded I can hardly squeeze by,' says Qiao.
The whitewashed, three-floor building, which stands on a crowded, run-down campus undergoing renovation, carries out a high 2,000 IVFs each year. About 30,000 are provided annually throughout China. Supply does not meet demand, says Qiao, although it's not far off. And while the couples crowding her hallways genuinely need help to get pregnant, some quietly ask their doctors to help them have more than one while they're at it.
'There are women who come to us and tell us they want twins. But we tell them that even if they do IVF, their chances of having a single baby are still 70 per cent,' says Qiao.
Others, like the Xiaos, medicate below the radar. Often they are poor farmers attracted by clomifene's low cost. 'We get a lot of mothers up from the country,' says Liu Xiaomei, head of obstetrics and gynaecology at Nanjing's Maternal and Child Health Hospital. The poor who take clomifene without medical supervision often cannot afford antenatal care. Some present at hospital only when they develop health problems such as high blood pressure or a premature labour. 'By the time they get here, they are often very far along,' says Liu.
A stocky 50-year-old, Liu has monitored women's health and delivered babies for 23 years. Her hospital is the biggest maternity unit in Nanjing. In an average year, 7,000 babies are born here.
Inside the newborn intensive-care unit it's quiet, with about 15 babies lying in incubators and a team of young nurses monitoring them.
Outside, the corridors and waiting rooms of the plain, white-tile-and-whitewash buildings of the large hospital complex are packed with women in various stages of pregnancy. In the antenatal check-up centre - a giant room with a balcony running around a large indoor atrium - hundreds wait to see the doctor, sitting uncomfortably on light-blue plastic chairs bolted together. Some are huge, with bulging bellies and swollen ankles, uncomfortable in Nanjing's summer heat; others, though still slim, are decked out in pastel maternity frocks. While most have conceived naturally, some were helped by the hospital's IVF clinic ... and some by clomifene.
'Some of our patients only half-understand the effect of the drug and take it for more months than we allow. That can be dangerous,' says one of the centre's employees. 'Often it's the ones who live farther away, in the countryside. They feel it's easier this way.'
And like Xiao, they might end up having to reduce.
It's nearly time to head home but today Qiao will do so with a heavy heart. Still, she's sure she did the right thing. 'It's the safest [way],' she says.