Zhu Ru, an experienced obstetrician and artificial reproductive technology expert in Anqing, Anhui province, has witnessed firsthand China's shrinking birthrate.

"Some women fail to conceive because of inflammation in the reproductive system such as salpingitis, which is an inflammation of the fallopian tubes caused by a bacterial infection. Others suffer from ovulation disorders due to obesity or excessive weight loss," Zhu told China Daily after a busy morning of consultations with dozens of patients last month.

Zhu is a deputy director in the obstetrics and gynecology department of Anqing Municipal Hospital, a leading local medical facility in the eastern province.

He and his colleagues believe that many young couples are not simply unwilling to have a child, but instead are intimidated and frustrated by physical obstacles, pain, fear and lack of support. Financial incentives proposed by some economists and demographers are not a panacea to encourage births, they added.

In 2021, the rate of infertility among Chinese men and women of childbearing age was 7 to 10 percent, National Health Commission statistics showed. Of those dealing with infertility, an estimated 20 percent could benefit from artificial reproductive technology treatment.

Multiple factors

Zhu has also witnessed a growing number of older women who have trouble having a second or third child because of factors such as age and a declining ability to ovulate.

"Premature ovarian failure — the early cessation of ovulation under the age of 40 — is increasingly prevalent among women of childbearing age, which can be attributed to pressure brought about by supporting their family, irregular work and rest, unhealthy diet and declining immunity," he said.

For the majority of women, menstruation ends in their 50s. However, Zhu has seen some women who stop having their period at the age of 40, or even as young as 36.

Delayed preparation for pregnancy is one of the major factors behind infertility, he said.

"This is why we recommend people do what their age permits; get married and have a child early. Don't wait until your career is a major success," he said, adding that the functioning of a woman's ovaries won't wait for her job.

Another major impediment to fertility lies with men. "The average quality of sperm is declining and there is a rising occurrence of erectile dysfunction," Zhu said.

Preventing infertility is a topic that should not exclude teenagers, he added. The obstetrician has encountered cases of female students aged 16 to 17 coming to his clinic to seek an abortion. "One of the youngest was even younger than 14 years old," he said.

The hospital strictly sticks to the policy of reporting pregnancies involving girls under the age of 18 to police in order "to step up teenager protection and supervision," Zhu added.

He urged boosting sex education for junior and senior high students so they learn how to behave sensibly and to protect themselves.

"Pregnancy at too young an age and a subsequent abortion impacts fertility in the long run. A low birthrate is not necessarily solely related to a willingness for parenting, but also the physical and medical conditions of the young parents-to-be," he added.

Zhu is also the head of his hospital's reproductive medical center, which was established in April.

The center has conducted close to 80 cycles of intrauterine insemination — a technique that boosts the chances of pregnancy by placing specially prepared sperm directly in the uterus. The success rate is above 20 percent.

Now the hospital is preparing to establish an in vitro fertilization center.

"Although we are a third-tier town in the country, there is huge demand for assisted reproductive technology," Zhu said."Currently, our hospital is actively preparing for rolling out in vitro fertilization and embryo transfers to bring hope to those unable to bear a child."

Family sizes

China witnessed a quick uptick in birthrates after restrictions on having a second child were lifted in 2015. But statistics point to the cooling of the second-child boom in recent years.

Echoing the nation's shrinking birthrates, the annual new births in Anqing saw consecutive drops from 2020 to 2022, falling from 37,000 in 2020 to 28,000 in 2021, and 25,000 in 2022.

The total number of the city's registered residents in 2022 was 4.156 million, a year-on-year drop of 0.36 percent, the city's statistics office said.

Tong Chen, a physician at Anqing Municipal Hospital's obstetrics and gynecology department, said despite shrinking overall birth numbers, most married couples in smaller towns like Anqing have a strong desire to have a child. However, the desire to have a second child is weaker.

"Cities like Anqing are not like big metropolises. Some people working and living in bigger cities are more willing to live alone and have a freer lifestyle. If young people get married here, they usually try to have a child as soon as they can," she said.

Tong joined the hospital's medical staff in 2010 and has two children.

She has witnessed instances of couples having one child but disagreeing on having a second child, as was the case with one of her female colleagues.

"After giving birth to the first child, she wanted to have another one, but her husband did not support her," Tong recalled. "He said:'I have a child and I am a father already. It's enough to know what it is like to be a dad. I can't handle more children.'"

Jiang Xihuan, the head nurse of Tong's department, said: "Young fathers-to-be should also get more involved in learning about childbirth and parenting. Based on our experience, some pregnant women are easily distracted when attending pregnancy classes due to pregnancy discomfort and tiredness."

Jiang, 55, specializes in the use of music therapy and meditation to help relieve the pain of pregnancy and childbirth.

She is also a certified fertility instructor with the International Childbirth Education Association and last year offered free classes and workshops for pregnant women in local communities.

Some fathers-to-be undergo simulated labor pain to understand what their partner is going through, but Jiang believes this is "far from enough"."Although it can make a young father feel sympathetic, it produces no immediate effects on easing the wife's various pains," she said.

The husband, the entire family and even society should consider ways to help pregnant women eliminate psychological pain and deal with challenges, she said.

Relieving pain

Many medical experts in Anqing pointed to the disparities between big cities, smaller towns and rural areas when it comes to childbirth-related resources and public awareness, which deserves far greater attention and input.

For many women, their concerns about childbearing are not only related to a lack of support from their spouse and family, but also to labor and potential birth defects of infants.

Dong Jinchun, an associate chief physician at Anqing Municipal Hospital's anesthesiology department, is a keen advocate of analgesics to diminish labor pain.

Only 20 to 30 percent of women who give birth vaginally in his hospital have an analgesic during labor, lagging way behind richer cities and municipalities such as Shanghai and Chongqing, Dong said. In many European and North American countries the number is above 80 percent.

He noted that analgesics relieve pain without loss of feeling or muscle movement, yet "public awareness of science in this regard is far from enough".

"In cases where the pain of vaginal delivery is severe, the young mother's family members also have to agree as long as (the mother) herself has agreed to receive an analgesic during labor," he said.

He said he had found that younger first-time mothers are more likely to receive a labor analgesic."Most of the time, giving birth to the first child is more painful than for the second child," he said.

Jiang, the head nurse, said China also needs to urgently improve education on childbirth, "especially in third- and fourth-tier cities, where there are a lack of childbearing and parenting classes."

"Nowadays, it is a prominent problem that some smaller cities have trouble setting up workshops for pregnant women and midwife clinics," she added.

Jiang said for a small family it is essential to be on the same page when it comes to understanding appropriate knowledge rather than "superficial details".

Free checkups

Wangjiang county, which is affiliated to Anqing, provided free pre-pregnancy health checkups to 2,764 married couples over the past year as part of a nationwide drive to address birth defects.

A total of 4,436 people also completed free premarital physical checkups, which means that 96.02 percent of the people who registered for marriage in the county last year underwent such examinations.

"We are providing local women and children with full-process and full-cycle health services to continuously enhance their happiness and security," Hu Ting, head of Wangjiang County Maternal and Child Health Hospital, said in a Chinese New Year message issued this month.

Zhang Jun, an ultrasound physician with Anqing Municipal Hospital's ultrasound imaging department, has a good awareness of how birthrates have changed in recent years.

"In the past, for example, of every 100 people who got married, about 50 of them planned to have children. But now, only about 20 or 30 people plan to have children."

He added that the number of checkups for a third child now accounts for only a small fraction of the total checkups.

In the eight counties affiliated to Anqing, the accuracy and efficiency of pregnancy checkups vary across community-level medical institutions.

In recent years, Zhang's ultrasound imaging department has sent medical staff to rural communities and townships for training and guidance and to boost the standardization of such screening at local medical institutions.

"The birthrate is already low. What we do is save a pregnant woman the trouble of traveling from the countryside to the city for a regular checkup," Zhang said.

This year, the department will continue promoting advanced screening technology in rural communities to improve the level of standardization.

"We need to go back to check where they have been. What we do is to enable more babies to be born healthy," Zhang said.

He Jiang and Zhang Bing contributed to this story.