Sibling Availability, Sibling Sorting, and Subjective Health Among Chinese Adults.

Despite rising numbers of only children in China, little is known about their family dynamics and well-being in adulthood-for example, how often they marry other only children and whether those in siblingless families have worse or better health than others. Theoretical expectations produce opposing predictions: siblings might provide social and emotional support and reduce parental caregiving pressures, but only children might receive more support from parents and grandparents. Using the 2010 China Family Panel Study, we examine marital sorting on Chinese adults' number of siblings and test whether sibling availability and sibling sorting are associated with subjective physical and mental health. Despite general perceptions that China has an exceedingly high prevalence of adults with no siblings that might produce very small families, results demonstrate a low prevalence of siblingless couples (i.e., both spouses are only children). Married adults with no siblings or siblings-in-law have better subjective physical health but similar levels of subjective mental health relative to their counterparts with siblings. The health advantages of siblingless marital unions are greater for rural and female adults. Declining sibling prevalence in China will shape future family demographic dynamics but appears less detrimental to population health than sometimes assumed.

Limited protection of pneumococcal vaccines against emergent Streptococcus pneumoniae serotype 14/ST876 strains.

PURPOSE: Streptococcus pneumoniae (Spn) is a major cause of child death. We investigated the epidemiology of S. pneumoniae in a pediatric fever clinic and explored the genomics basis of the limited vaccine response of serotype 14 strains worldwide. METHODS: Febrile disease and pneumonia were diagnosed following criteria from the WHO at the end of 2019 at a tertiary children's hospital. Spn was isolated by culture from nasopharyngeal (NP) swabs. The density was determined by lytA-base qPCR. Isolates were serotyped by Quellung and underwent antimicrobial susceptibility testing. Whole-genome sequencing was employed for molecular serotyping, MLST, antibiotic gene determination, SNP calling, recombination prediction, and phylogenetic analysis. RESULTS: The presence of pneumococcus in the nasopharynx (87.5%, 7/8, p = 0.0227) and a high carriage (100%, 7/7, p = 0.0123) were significantly associated with pneumonia development. Living with siblings (73.7%, 14/19, p = 0.0125) and non-vaccination (56.0%, 28/50, p = 0.0377) contributed significantly to the Spn carriage. Serotype 14 was the most prevalent strain (16.67%, 5/30). The genome analysis of 1497 serotype 14 strains indicated S14/ST876 strains were only prevalent in China, presented limited vaccine responses with higher recombination activities within its cps locus, and unique variation patterns in the genes wzg and lrp. CONCLUSION: With the lifting of the one-child policy, it will be crucial for families with multiple children to get PCV vaccinations in China. Due to the highly variant cps locus and distinctive variation patterns in capsule shedding and binding proteins genes, the prevalent S14/ST876 strains have shown poor response to current vaccines. It is necessary to continue monitoring the molecular epidemiology of this vaccine escape clone.

Adult children and older people's demand for community care services in urban China.

OBJECTIVES: This paper has two objectives. First, it assesses whether the existing informal care provided by adult children has an impact on older people's propensity to demand community care services. Second, it compares the different statuses of sons and daughters in the formal/informal support trade-off. METHODS: The paper is based on an analysis of data from the 2018 wave of the China Longitudinal Ageing Social Survey, within the framework of a revised version of Andersen's model, and applies multilevel models to analyse the effects of adult children's gender, numbers and the quality of their support, on older people's willingness to purchase community care services. RESULTS: Older people who had sons as well as daughters demanded fewer services, while the number of sons increased service demand. Regarding sons, community care services compensated for economic support, daily life care and spiritual consolation, but did so only in respect of daily life care from daughters. CONCLUSIONS: Many families have only one son or one daughter as a result of the one-child policy and therefore often require support from formal care services. Moreover, there is a distinct gender division and an influential filial culture governing the impact of services on the support provided by adult children. Because ageing in place depends on both informal family support and formal services, this key policy goal is at risk if the latter provides insufficient support to the former.

How genuine are sub-replacement ideal family sizes in urban China?

Ideal family sizes remain at or above two in most low-fertility settings, but sub-replacement fertility ideals have been reported for urban China. The presence of restrictive family planning policies has led to a debate as to whether such ideals are genuine. This study exploits the ending of the one-child policy and the beginning of a universal two-child policy in October 2015 to investigate whether relaxing the restrictions led to an increase in ideal family size. We apply difference-in-differences and individual-level fixed-effect models to longitudinal data from a near-nationwide survey. For married individuals aged 20-39, relaxing the restrictions from one to two children increased the mean ideal family size by around 0.2 and the proportion who desired two or more children by around 19 percentage points. Findings suggest that although reported ideal family sizes have been reduced by policy restrictions, sub-replacement ideal family sizes in urban China appear to be genuine.

Exploring the Dynamics between Specialization and De-Specialization of Welfare Experiences: A Qualitative Study of the Special Families under the One-Child Policy in China.

The one-child policy, i.e., of having only one child per couple, was adopted as the essential family policy in China from 1979, and since the beginning of the 21st century, it has given rise to problems of special families under the one-child policy caused by the death or disability of only children. The existing research focused on the issue of special families from a macro-social level and analyzed the welfare demands and welfare policies of those families, whereas less research has been concerned with the families' individual experiences and interpretations. This study adopted a qualitative research method and conducted in-depth interviews with 33 participants to analyze the welfare experiences of special families in Jinan city, Shandong Province. The findings of the study were based on generalized analyses of the interviews, including the "specialization" dimension of welfare experiences with identity-oriented, targeted, and comprehensive characteristics, the "de-specialization" dimension of welfare experiences with identity-denied, excluded, and hidden characteristics. The dynamics between the two dimensions among different special families, different family members, and different periods in the families' lives were also examined. We present a discussion of the study's findings and their implications, categorized into the theoretical and practical domains.

Trends in female-selective abortion among Asian diasporas in the United States, United Kingdom, Canada and Australia.

Preference for sons and smaller families and, in the case of China, a one-child policy, have contributed to missing girl births in India and China over the last few decades due to sex-selective abortions. Selective abortion occurs also among Indian and Chinese diaspora, but their variability and trends over time are unknown. We examined conditional sex ratio (CSR) of girl births per 1000 boy births among second or third births following earlier daughters or sons in India, China, and their diaspora in Australia, Canada, United Kingdom (UK), and United States (US) drawing upon 18.4 million birth records from census and nationally representative surveys from 1999 to 2019. Among Indian women, the CSR in 2016 for second births following a first daughter favoured boys in India (866), similar to those in diaspora in Australia (888) and Canada (882). For third births following two earlier daughters in 2016, CSRs favoured sons in Canada (520) and Australia (653) even more than in India (769). Among women in China outside the one-child restriction, CSRs in 2015 for second order births somewhat favoured more girls after a first son (1154) but more heavily favoured boys after a first daughter (561). Third-birth CSRs generally fell over time among diaspora, except among Chinese diaspora in the UK and US. In the UK, third-birth CSRs fell among Indian but not among other South Asian diasporas. Selective abortion of girls is notable among Indian diaspora, particularly at higher-order births.

Modelling the impact of birth control policies on China's population and age: effects of delayed births and minimum birth age constraints.

We consider age-structured models with an imposed refractory period between births. These models can be used to formulate alternative population control strategies to China's one-child policy. By allowing any number of births, but with an imposed delay between births, we show how the total population can be decreased and how a relatively older age distribution can be generated. This delay represents a more 'continuous' form of population management for which the strict one-child policy is a limiting case. Such a policy approach could be more easily accepted by society. Our analyses provide an initial framework for studying demographics and how social constraints influence population structure.

The Effect of China's Two-Child Policy on the Child Sex Ratio: Evidence From Shanghai, China.

OBJECTIVE: The bias towards males at birth has resulted in a major imbalance in the Chinese sex ratio that is often attributed to China's one-child policy. Relaxation of the one-child policy has the potential to reduce the imbalance in the sex ratio away from males. In this study, we assessed whether the bias towards males in the child sex ratio was reduced as a result of the two-child policy in China. Medical records data from one large municipal-level obstetrics hospital in Shanghai, East China. DESIGN: Matching and difference-in-differences (MDID) techniques were used to investigate the effect of the two-child policy on the imbalance in the sex ratio at birth after matching for pregnancy status and socioeconomic factors. RESULTS: Analyzing 133,358 live births suggest that the relaxation of the one-child policy had a small, but statistically significant effect in reducing the imbalance in the male to female sex ratio at birth. CONCLUSION: The results demonstrate that relaxation of the one-child policy reduced the imbalance in the male to female sex ratio at birth from 1.10 to 1.05 over the study period at one of the major obstetrics and gynecology hospitals in China.

Adult children's achievements and ageing parents' depressive symptoms in China.

This study examined the association between adult children's achievements and ageing parents' depressive symptoms in China. The research topic was examined within the contexts of one-child and multiple-children families in rural and urban China. Older adults (aged 60-113, N = 8,450; nested within 462 communities/villages) from the 2013 China Longitudinal Ageing Social Survey provided information about themselves and their adult children (N = 22,738). Adult children's achievements were assessed with educational attainment, financial status and occupational status; older parents' depressive symptoms were assessed with nine items of the Chinese version of the Center for Epidemiological Studies Depression Scale. Multilevel linear regression models were estimated separately for older parents with one child only and multiple children. For older parents with multiple children, both having one or more children with any achievement and the total number of children's achievements were associated with fewer depressive symptoms. For parents with only one child, any achievement of the child and the total number of the child's achievements were associated with fewer depressive symptoms. Our results also indicated that the association between children's achievements and parents' depressive symptoms varied by rural-urban residence and family type. Our findings contributed to the understanding of family dynamics underlying the emotional wellbeing of older adults in China.

Achieving WHO's Goal for Reducing Cesarean Section Rate in a Chinese Hospital.

Background: To address the worldwide dramatically increased Cesarean section (CS) rate in the past decades, WHO has recommended the CS rate should not be higher than 10-15%. Whether it is achievable remains unknown. Methods: We collected the data of delivery from 2008 to 2017 in two typical regional hospitals in China: Longhua Hospital (national policies rigorously implemented) and Dongguan Hospital (national policies not rigorously implemented). We compared between the two hospitals the 10 years trend in annual rate of CS, standardized by age, education level, parity, and CS history, against the time of issuing relevant national, local, and hospital policies. Results: In 10 years, 42,441 women in Longhua and 36,935 women in Dongguan have given birth. China's first national policy on CS reduction was issued in 2010 and the formal relaxation of one-child policy was issued in 2015-2016. In Longhua, the standardized annual CS rate was around 35% in 2008-2009, which declined sharply since 2010 down to 13.1% in 2016 (p < 0.001) and then leveled off. In contrast, in Dongguan, the rate stayed around 25% at the beginning, increased to 36% in 2011, decreased sharply to 27% in 2012, and leveled off until 2015 (p < 0.001), and then bounced back to 35% in 2017. The proportion of women with the history of CS increased significantly in the two hospitals (both roughly from 6% before 2010 to 20% after 2015). Analyses stratified by modified Robson classification showed that CS rates reduced in all risk classes of delivery women in Longhua but only in the Robson class 2 group in Dongguan. Major complications did not differ by hospital. Conclusion: With vigorously implementing national policies at micro levels, the WHO-recommended CS rate could be achieved without increase in major complications.

The Association Between Single-Child Status and Risk of Abdominal Obesity: Result From a Cross-Sectional Study of China.

Background: Obesity has become a serious problem threatening the health of children and adolescents, and China's one-child policy has affected family structure and parenting practice, which may result in several adverse health outcomes. The present study aims to investigate the association between single-child status and the risk of abdominal obesity in Chinese adolescents and also to compare the differences in the risk of unideal energy-related behaviors. Methods: Data were obtained from a school-based cross-sectional survey conducted in seven provinces of China, in 2012. A total of 31,291 students aged 7-17 years were recruited in this study. Anthropometric measurements were conducted to assess height and waist circumference, and questionnaires were used to obtain information of single-child status, parental educational attainment, parental weight status, and offspring energy-related behaviors. Multivariate logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (95% CI) of single-child status and odds of childhood abdominal obesity and energy-related behaviors. Results: The prevalence of abdominal obesity was 18.2% in single children, which was higher than that of non-single children (13.7%). The prevalence was also higher in single children in different sex and residence subgroups. Logistic regression models showed that single children had 1.33 times (OR: 1.33, 95% CI: 1.24-1.43, P < 0.001) higher odds of abdominal obesity compared to non-single children. Single children had 1.08 times higher odds of physical inactivity (OR: 1.08, 95% CI: 1.03-1.14, P = 0.004), 1.13 times higher odds of excessive sugar-sweetened beverages (SSBs) consumption (OR: 1.13, 95% CI: 1.05-1.23, P = 0.002), and 1.08 times more likely to eat out (OR: 1.08, 95% CI: 1.02-1.13, P = 0.006). Those associations were more remarkable in single girls. Conclusion: Being a single child may be associated with a higher odds of childhood abdominal obesity and unhealthy energy-related behaviors. Future interventions and strategies to prevent abdominal obesity should focus on this high-risk population.

Associations Between Single-Child Status and Metabolic Syndrome in Children and Adolescents in China.

Objective: To evaluate the associations between single-child status and metabolic syndrome (MS) and to identify the highest risk group of MS among single children. Methods: Differences in participants' characteristics by sex were examined by Student's t-test for continuous variables and Pearson's chi-squared test for categorical variables. Multivariate logistic regression analysis was performed to estimate the odds ratios (OR) and 95% confidence intervals (CI) for MS and its components according to the single-child status. Radar maps were used to compare the composition of different components in MS. Results: In total, 11,784 (5,880 boys) children and adolescents were included in this study, with a mean age of (11.3 ± 3.1) years. MS was observed in 7.1% of participants, with a higher prevalence in boys (8.2%) than girls (5.9%) (P < 0.05). The prevalence of MS, elevated blood pressure and abdominal obesity in single children were higher than that in children with siblings, particularly in boys (P < 0.001). Elevated risk of abdominal obesity was observed in single children [boys (1.56, 95% CI: 1.31, 1.85), girls (1.40, 95% CI: 1.19, 1.63)], however, increased ORs of elevated blood pressure and metabolic syndrome were observed in single-child boys only (1.19, 95% CI: 1.01, 1.40 and 1.76, 95% CI: 1.34, 2.31, respectively). Results showed that a statistically significant association between single child status and MS was mainly observed in urban boys (2.04, 95% CI: 1.33, 3.12) and rural boys (1.50, 95% CI: 1.05, 2.15), but not in girls. Among all the combinations of MS, two combinations were significantly associated with the single-child status, including the combination of elevated blood pressure, abdominal and low HDL-C (1.45, 1.04, 2.04) and the combination of elevated blood pressure, abdominal obesity, low HDL-C and hypertriglyceridemia (2.04, 1.40, 3.06) (P < 0.05). Conclusions: The present study found that single children and adolescents had a higher risk of MS, elevated blood pressure and abdominal obesity. The associations were stronger in urban boys. Further attention should be directed to the prevention and control strategies targeting the high-risk population of MS.

How does the two-child policy affect the sex ratio at birth in China? A cross-sectional study.

BACKGROUND: The One-Child Policy led to the imbalance of the sex ratio at birth (SRB) in China. After that, Two-Child Policy was introduced and gradually liberalized at three stages. If both the husband and wife of one couple were the only child of their parents, they were allowed to have two children in policy (BTCP). If only one of them was the only child, they were allowed to have two children in policy (OTCP). The Universal Two-Child Policy (UTCP) allowed every couple to have two children. The objective of this study was to explore the changing trend of SRB at the stages of Two-Child Policy, to analyze the effect of population policy on SRB in terms of maternal age, delivery mode, parity, maternal education, delivery hospital, and to figure out what factors have greater impact on the SRB. METHODS: The data of the study came from Hebei Province Maternal Near Miss Surveillance System, covered the parturients delivered at 28 gestation weeks or more in 22 hospitals from January 1, 2013 to December 31, 2017. We compared the SRB at different policy stages, analyzed the relationship between the SRB and population policy by logistic regression analysis. RESULTS: Total 270,878 singleton deliveries were analyzed. The SRB, 1.084 at BTCP, 1.050 at OTCP, 1.047 at UTCP, declined rapidly (χ2 = 15.97, P < 0.01). With the introduction of Two-Child Policy, the percentage of parturients who were 30-34, ≥35 years old rose significantly, and the percentage of multiparous women increased significantly (40.7, 47.2, 56.6%). The neonatal mortality declined significantly (8.4‰, 6.7‰, 5.9‰, χ2 = 44.49, P < 0.01), the mortality rate of female infant gradually declined (48.2, 43.7, 43.9%). The logistic regression analysis showed the SRB was correlated to the three population policy stages in terms of maternal age, delivery mode, parity, maternal education, delivery hospital. CONCLUSIONS: The SRB has declined to normal level with the gradually liberalizing of Two-Child Policy in China. Advanced maternal age, cesarean delivery, multiparous women, middle level education, rural hospital are the main factors of effect on the decline of the SRB.

A Segmented Logistic Regression Approach to Evaluating Change in Caesarean Section Rate with Reform of Birth Planning Policy in Two Regions in China from 2012 to 2016.

OBJECTIVE: This study evaluated change in caesarean section rate with reform of birth planning policy in China from one-child to two-child policy. METHODS: Study data were collected from patient-level hospital records of 59,668 pregnant women who visited three major urban hospitals in Jiangsu Province and Inner Mongolia Autonomous Region of China between January 2012 and December 2016. A segmented logistic regression approach was developed to evaluate the changes in caesarean section rate in these regions with the launch of China's new partial and universal two-child policies in January 2014 and January 2016, respectively. RESULTS: Jiangsu Province had a significantly lower non-emergency caesarean rate (Jiangsu 8.15% vs Inner Mongolia 34.03%, p < 0.001) and a much lower percentage of minority population (Jiangsu 6.99% vs Inner Mongolia 21.76%, p < 0.001) than Inner Mongolia Autonomous Region. In Jiangsu Province, no change in caesarean section rate was detected with the two-child policies (all p-values > 0.05), although the unadjusted trend change (0.038, 95% confidence interval or CI: [0.016, 0.060], p < 0.001) in log odds after the implementation of the partial two-child policy was statistically significant. In Inner Mongolia Autonomous Region, an immediate jump in caesarean section rate was discovered by the segmented logistic regression with the implementation of both the partial (unadjusted level change 0.297, CI: [0.105, 0.489], p = 0.002) and universal two-child policies (unadjusted level change 1.945, CI: [1.277, 2.614], p < 0.001); but the rate reverted to the previous level thereafter. Ethnicity, maternal age, maternal reproduction history, insurance coverage type, infant weight, and infant gender were the significant factors associated with caesarean section rate (for odds ratios, all p-values < 0.05). However, the significance of infant gender may stem from the large sample size of the study and is not clinically meaningful. CONCLUSION: Change in caesarean section rate was not observed with the launch of two-child policy in China.

Effects of individual, family and community factors on the willingness of institutional elder care: a cross-sectional survey of the elderly in China.

OBJECTIVE: To investigate the effects of the willingness to live in elder care institutions associated with individual factors, family environment and the community environment in the elderly in China. DESIGN: Cross-sectional survey. SETTING: Heilongjiang Province, China. PARTICIPANTS: A total of 1003 elderly people were selected through multistage sampling in Heilongjiang Province. PRIMARY AND SECONDARY OUTCOME MEASURES: A multistage, stratified sampling design was employed. Differences in health status, family environment and community environment of the respondents were compared with the t-test and χ2 test. Logistic regression analysis was performed to assess key determinants of willingness to live in institutions. RESULTS: This study showed that 45.4% of respondents were willing to live in elder care institutions in the future. Factors influencing willingness to live in elder care institutions were age, house ownership, living with spouse and children, disease caregivers and availability of home healthcare services. The elders who had no property (OR=2.37, 95% CI 1.750 to 3.200, p<0.01) and those aged 80 or above (OR=2.25, 95% CI 1.490 to 3.400, p<0.01) were, respectively, 2.370 and 2.250 times more receptive to living in elder care institutions than their control groups. However, those living with a spouse (OR=0.47, 95% CI 0.287 to 0.762, p<0.01), living with children (OR=0.25, 95% CI 0.158 to 0.402, p<0.01) or living with a spouse and children (OR=0.29, 95% CI 0.160 to 0.509, p<0.01) were less willing to live in elder care institutions. CONCLUSIONS: These results suggest that the willingness to enter elder care institutions is affected by individual, family environmental and community environmental factors. We should vigorously develop community-centred intensive home-based elder care services by improving the quality and availability of home health services by expanding investment in the community.

The Chinese Postreform Generation as Caregivers: The Caregiving Intentions Toward Parents and Parents-in-Law of the One-Child Generation.

The problem of population aging in China has been widely documented. As a result of decreasing birth rates due to the Chinese one-child policy, birth rates have decreased dramatically, while life expectancy has increased. By 2040, it is expected that 24.6% of the Chinese population will be older than 65 years (United Nations, Department of Economic and Social Affairs, Population Division, 2015), with the majority of the elderly care likely to fall to their, often, singleton children. Little research has been conducted, however, with this future generation of caregivers. This article reports on a mixed-methods study comparing the attitudes of the one-child generation toward the future care of their parents and parents-in-law, in terms of gender, sibling status, and urban/rural providence. It includes the results of 26 in-depth interviews with students aged 18 to 22 years, and a survey among 351 first-year students of a semiprivate university in Zhuhai (China). No differences were found for gender, sibling status, or urban/rural providence for the intention to take care of the own parents in the future, although rural and nonsingleton participants were more likely to mention that they intended to live close to, or with their parents in the future than their urban and singleton counterparts. Concerning the care for future parents-in-law, male students in both the survey and the interviews were significantly less likely to accept responsibility for their care than female students, but no differences were found for urban/rural providence or for sibling status in this respect. Finally, female and rural students were found to be significantly much more likely to want to live in a separate house than their male and urban counterparts.

Effects of midwife-led maternity services on postpartum wellbeing and clinical outcomes in primiparous women under China's one-child policy.

BACKGROUND: The Midwife-led maternity services have been implemented in China in response to the high rates of primiparous women and Caesarean Sections (CS) which may be related to China's one-child policy. However, few studies in China have been reported on the effectiveness of Midwife-led Care at Delivery (MCD) and the Continuity of Midwife-led Care (CMC) on postpartum wellbeing and other clinical outcomes. Therefore, evidence-based clinical validation is needed to develop an optimal maternity service for childbearing women in China. METHODS: A concurrent cohort study design was conducted with 1730 pregnant women recruited from 9 hospitals in Shanghai. Among the 1730 participants at baseline, 1568 participants completed the follow-up questionnaire, with a follow-up rate of 90.6%. RESULTS: Compared with the routine Obstetrician-led Maternity Care (OMC), Midwife-led Care at Delivery (MCD) was associated with CS rate (OR were 0.16; 95%CI: 0.11 to 0.25) and a higher total score of postpartum wellbeing (ßwere 2.70; 95%CI: 0.70 to 4.70) when adjusting for the baseline differences and other confounders during delivery or postpartum period. Moreover, continuity of Midwife-led Care (CMC) was associated with CS rate (OR were 0.30; 95%CI: 0.23 to 0.41), as well as increased rate of breastfeeding within the first 24 h (OR were 2.49; 95% CI: 1.47 to 4.23), higher postpartum satisfaction (ß = 4.52; 95% CI: 1.60 to 12.68), lower anxiety (ßwere 0.66; 95% CI: 0.16 to 1.17), increased self-control (ßwere 0.39; 95% CI: 0.02 to 0.76) and a higher total score of postpartum wellbeing (ßwere 3.14; 95% CI: 1.54 to 4.75). CONCLUSION: CMC is the optimal service for low-risk primiparous women under China's one-child policy, and is worthwhile for a general implementation across China.

Do only children have poor vision? Evidence from China's One-Child Policy.

This paper examines whether only children have poor vision by exploiting the quasinatural experiment generated by the Chinese One-Child Policy. The results suggest that being an only child increases the incidence of myopia by 9.1 percentage points. We further investigate the mechanisms through which being an only child affects the myopia and find that only children, as the only hope in a household, receive higher expectations in terms of academic performance and future educational attainment and pressure to succeed in life from parents, which contribute to the increased myopia. We also find that the school quality of only children is significantly higher than that of non-only children. This study provides new insights into an important health consequence of One-Child Policy in China.

Impact of relaxation of the one-child policy on maternal mortality in Guangzhou, China.

OBJECTIVE: To assess the impact of the one-child policy in China on maternal mortality. METHODS: The present retrospective study included maternal death data from Guangdong, China, from January 1, 2006, to December 31, 2015; data from 2013 were excluded because they were not available. Maternal deaths were divided into legal and illegal pregnancies based on adherence to the one-child policy. The maternal mortality ratio (MMR) was compared between the groups, temporal trends in the MMR were examined, and comparisons were made of the causes of death and access to maternity care. RESULTS: The final analysis included 847 520 live deliveries and 383 maternal deaths. The MMR among legal pregnancies declined moderately from 18.5 deaths per 100 000 live deliveries in 2006 to 12.2 deaths per 100 000 live deliveries in 2015 (P=0.029), whereas the MMR among illegal pregnancies declined dramatically from 1268.4 deaths per 100 000 live deliveries to 177.5 deaths per 100 000 live deliveries (P<0.001). The proportion of avoidable maternal deaths decreased and access to quality maternity care improved among illegal pregnancies during the study period. CONCLUSIONS: Maternal mortality among illegal pregnancies declined with relaxation of the one-child policy in China.

Increased obesity risks for being an only child in China: findings from a nationally representative study of 19,487 children.

OBJECTIVES: Given the rapid demographic transition and obesity growth in China, it is important to study how the large only-child population (≈100 million) might contribute to the obesity epidemic. This study evaluated associations of only-child status with weight and energy expenditure-related behaviors in China and examined how the associations may vary by sex and urbanicity. STUDY DESIGN: Secondary analyses of nationally representative cross-sectional data from China Education Panel Survey: Junior Cohorts 2013-14, which included 19,487 students from 112 middle schools in 28 regions across China. METHODS: We used propensity-score-weighted multilevel models to test associations between only-child status and weight outcomes. RESULTS: Compared with sibling-sons, only-sons had higher body mass index (BMI) (Beta = 0.32, P < 0.05) and higher risks of overweight (OR = 1.24, 95% CI = [1.07-1.45]) and obesity (OR = 1.29, 95% CI = [1.02-1.64]); and spent less time on TV watching (Incidence rate ratio (IRR) = 0.89, 95% CI = [0.81-0.98]), internet use (IRR = 0.87, 95% CI = [0.79-0.96]), after-school sports (IRR = 0.91, 95% CI = [0.83-0.99]), and household chores (IRR = 0.85, 95% CI = [0.80-0.92]). Overweight/obesity risks for only-sons were particularly pronounced in urban China, where only-sons were 36% more likely to be overweight and 43% more likely to be obese than sibling-sons. Only-daughters had a higher risk of obesity (OR = 1.43, 95% CI = [1.01-2.04]) than sibling-daughters. However, the association was not significant for either urban girls or rural girls examined separately. Only-daughters in rural areas spent less time helping with household chores (IRR = 0.88, 95% CI = [0.80-0.97]) than sibling-daughters. CONCLUSIONS: Future childhood obesity interventions should pay special attention targeting the large young only-child population in China.