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Anorexia in China – Same, But Different

What’s on Weibo gives an overview of how anorexia nervosa is discussed in China and on Chinese social media.

Manya Koetse

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Image by Sohu.com

Although discussions on anorexia nervosa are limited in Chinese (online) media, anorexia does in fact exist in Chinese patients; some studies even suggest that levels of occurrence are not much different from Western countries. There are big differences, however, in the way anorexia is experienced and/or described in China.

“Does anorexia exist in China?” is one amongst the millions of questions recently posted on the Chinese Quora-like platform Zhihu.com. It is a question that pops up on Chinese social media every now and then, as the eating disorder is not often discussed in a Chinese context.

The empty dialogue page on Zhihu.com is telling for the general discussion of anorexia in China today. Anorexia nervosa, commonly called anorexia, is an eating disorder characterized by low weight that receives relatively little attention on Chinese online and social media compared to the English-language online environment, where there are countless support groups, discussion forums, and even the so-called unhealthy ‘Pro Ana’ communities where the behaviors related to anorexia are promoted.

Both anorexia in general, and the pro-ana communities in specific, received ample attention from Western media over the past few years. ITV recently reported about an “alarming rise in social media sites encouraging anorexic sufferers to starve themselves,” and that social media worsens the condition of people with anorexia who flock to these kinds of websites.

How come that on Chinese social media platforms, which see a different ‘skinny hype’ every year (from the ‘iPhone6 legs‘ to ‘A4 waist‘), there are few online discussions about anorexia nervosa?

 

A “WESTERN” PHENOMENON

“Eating disorders seem to be an exotic phenomenon to many Chinese, but it actually is not.”

 

General discussions of anorexia nervosa on Weibo, China’s biggest social media platform, mostly relate to cases of the disease in Western, Caucasian women. The young Australian model and performer Phoebe Combes attracted some attention on Weibo in 2017 for suffering from anorexia. “How come every time I read about [this disease] it concerns foreign women?”, one netizen wondered.

Sporadically, speculative discussions do arise on social media about Chinese celebrities who may or may not be suffering from anorexia. Talk show host Chen Luyu (陈鲁豫), for example, became a topic of discussion when netizens started worrying about her frail appearance and said she was “too thin.”

Online commenters often call talk show host Chen Luyu (陈鲁豫) “too thin.”

Talk show host Chen Luyu.

For many netizens, however, the issue is often simplified to a mere “they should just eat more.” Despite general public unawareness about anorexia in China, more doctors and specialists are stepping forward to talk about the issue.

“When a Chinese doctor raised the issue of anorexia in China some twenty years ago at an international conference, foreign experts doubted if eating disorders existed in China,” one professional support site dedicated to anorexia and bulimia in China says: “We now want to promote awareness about eating disorders to patients and their families.”

In 2017, deputy director Ma Yongchun (马永春) of a hospital in Tongde, Zhejiang, spoke out to Chinese media website AcFun.com, saying that although eating disorders seem to be an exotic phenomenon to many Chinese, it actually is not. She also warned about the negative effects of social media platforms promoting unhealthy body images or unhealthy eating patterns.

 

THE STORY OF YUN

“Her condition spiraled out of control when she spent days on end watching live streams on Chinese social media that promote unhealthy eating habits.”

 

The AcFun article featured the story of one of Ma’s patients named Yun (alias), a 33-year-old former athlete from Zhejiang who weighed only 36 pounds with a height of 160 cm when she was at her lowest point – and on the verge of death.

She told AcFun that she became anorexic after being forced to eat a restrictive diet by her grandparents during her teens. When her entire athlete team suffered from gastroenteritis, her grandmother only allowed to her to eat bean curds and rice for months on end.

The story of ‘Yun’ who suffered from severe anorexia was featured in Chinese media.

Unable to continue eating her forced diet and not allowed to eat anything else, the young Yun developed an eating disorder. At the age of 19, she was diagnosed with anorexia by doctors at the Tongde hospital – a diagnosis that was followed by years of ups and downs. Yun’s condition spiraled out of control when she spent days on end watching live streams on Chinese social media that promote unhealthy eating habits.

Weighing only 36 pounds at her low point, Yun was barely able to move. One day, when she was alone with her sister’s small baby, she found herself too weak to pick up the infant went it was desperately crying. For Yun, it was a turning point in her decision to beat the illness.

Although many doctors gave Yun low chance of survival, a team of doctors including Ma Yongchun eventually were able to give Yun the help she needed. She now maintains a healthy weight.

 

UNHEALTHY ONLINE TRENDS

“Vomit Bars are online forums where netizens nicknamed ‘Rabbits’ encourage each other to vomit after eating.”

 

Doctors such as Ma Yongchun are part of a growing group of specialists in China raising awareness on eating disorders in China and warning against unhealthy online trends – which are on the rise.

Over the last years, online discussion boards such as Baidu Tieba have seen the phenomenon of ‘Vomit Bars’ (催吐吧) – a phenomenon somewhat comparable to the online ‘pro-ana’ movement on English-language internet sites.

‘Vomit Bars’ are online forums where netizens nicknamed ‘Rabbits’ (兔子) encourage each other to vomit after eating. Several live streaming sites also have people promoting weird or unhealthy eating habits, such as eating non-food products or binge eating – something Dr. Ma strongly condemns.

A girl binge eating on a live stream.

On Chinese social media, organizations helping those suffering from anorexia or other eating disorders are present, but not popular.

Although the Chinese Eating Disorder Recovery Web (@进食障碍康复网) only has a weak following online, their offline mission is strong: “China’s health care system can no longer ignore the growing group of eating disorder patients in China.”

 

ANOREXIA ON THE RISE OR NOT?

“There are no official statistics on the occurrence of anorexia nervosa or other eating disorders in China in the past and present.”

 

The topic of anorexia in China has also received more attention in international media and academic publications over the past decade.

Some English-language media, such as the LA Times, suggest that with changing beauty standards, skinny trends, and more influence from Western popular culture, eating disorders are “on the rise” in China.

Whether or not this is actually true is hard to say; there are no official statistics on the occurrence of anorexia nervosa or other eating disorders in China in the past and present. A study from 2013 among Chinese female college students in Wuhan, considered one of the best estimates of national rates, however, found levels similar to Western countries (Tong et al 2014).

In Fat China: How Expanding Waistlines are Changing a Nation, the authors (French & Crabbe 2010) also suggest that eating disorders such as anorexia are indeed present in society and that an increasing number of urban Chinese, mainly young women, are suffering from it (171).

Even if anorexia were to occur as much in China as in the West – which has neither been refuted nor confirmed – the way in which the disease is described and/or experienced seems to be significantly different.

 

SAME DISEASE, DIFFERENT MANIFESTATIONS

“Chinese patients showed few, if any, of the classical concerns associated with anorexia.”

 

Various studies over the past years have established that there are differences between Western countries and China in how anorexia develops with regards to patients’ preoccupations concerning appearance and body image.

In “The Myth of Chinese Barbies: Eating Disorders in China including Hong Kong” (2014), researcher M. Getz writes that eating disorders are traditionally conceptualized as a Western mental health issue, specifically because the ‘fat phobia’ aspects of the illness are often stressed the most. According to study, this attention towards appearance seems to be less important to Chinese patients (746-747).

This idea is further strengthened by Sing Lee, an expert in eating disorders in Chinese communities, who argues that Chinese patients “showed few, if any, of the classical concerns associated with anorexia” (747).

A major way in how anorexia in China is often different than in other (Western) countries is that it is somaticized. This relates to the fact that mental illnesses in China still carry a stigma and often go undiagnosed due to the lack of mental health care institutions.

Since physical problems are more socially accepted in China than mental health issues, people who suffer from anorexia in China are more prone to talk about their problems in the form of somatic symptoms such as distaste for food and not being hungry, or abdominal problems (Getz 2014, 750).

Levels of industrialization, media influence, eating habits, societal pressure to be thin, family pressure to succeed, etc., all may play a role in the occurrence of anorexia. Especially One-Child Policy generation children allegedly experience more pressure in their lives to perform.

As the development of anorexia in China goes hand in hand with social stigmas and superstitions regarding mental health issues, a traditionally strong food culture, a general unawareness on eating disorders, and many other cultural factors that may influence the manifestation of the disease, one can see why studies have found that “eating disorders are not culture-bound or culture-specific, but rather culture-reactive.” The reasons why patients develop anorexia and how it is manifested can, therefore, radically differ per culture (Pike & Dunne 2015).

 

ONLINE DISCUSSIONS

“I simply can’t eat any food. I have no interest in food. Even if I am starving I still do not want to eat.”

 

These findings are also apparent on the various anorexia support message boards in China, where people suffering from the disease share their experiences. Rather than talking about fear of being fat, many commenters only discuss their loss of appetite and stressful lives.

One netizen on Zhihu.com writes:

I am suffering from anorexia right now. The pressure at school is too much for me. I don’t have any time to relax. It’s all about studying. I simply can’t eat any food. I have no interest in food. Even if I am starving I still do not want to eat.”

Another person writes:

I think I have anorexia. But I am not sure. (..) I simply do not want to eat. If I see food, I have no desire to eat it. I only eat some breakfast and some dinner, an egg at 7.30 and some rice at 17.30.”

A new study on anorexia in China by Zaida Aguera et al (2017) confirms the idea that anorexia in Chinese patients is often experienced or communicated physical rather than psychological, as they are “culturally encouraged to use denial and minimization to cope with conditions deemed taboo” (9).

Because the way anorexia presents itself is different, researchers argue that its treatment also requires a different approach in China than in other countries that have developed own national standards on treating eating disorders.

The treatment options in China, however, are still limited. The first and only closed ward for eating disorders opened in Beijing six years ago. But the recent increased media attention raised by doctors such as Ma Yongchun and heightened focus on mental health care in China indicate that there will be more options for Chinese anorexia patients in the future.

As for the Zhihu poster who asked about anorexia in China – they are still waiting for an answer. In the meantime, they have suggested an own solution in the underline, writing: “There just is so much tasty food in China, that  anorexia in China is probably is much rarer here than in any other country in the world.” No one else responded.

By Manya Koetse

References

Agüera, Z., Brewin, N., Chen, J., Granero, R., Kang, Q., Fernandez-Aranda, F., & Arcelus, J. 2017. “Eating Symptomatology and General Psychopathology in Patients with Anorexia Nervosa from China, UK and Spain: A Crosscultural Study Examining the Role of Social Attitudes.” PLoS ONE, 12(3), 1–13.

French, Paul, and ‎Matthew Crabbe. 2010. Fat China: How Expanding Waistlines are Changing a Nation. Imprint: Anthem Press.

Getz, M.J. 2014. “The Myth of Chinese Barbies: Eating Disorders in China including Hong Kong.” Journal of Psychiatric and Mental Health Nursing 21: 746-754.

Pike, Kathleen M., and Patricia E. Dunne. 2015. “The Rise of Eating Disorders in Asia: a Review.” Journal of Eating Disorders 3:33. Available online https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-015-0070-2 [17.1.18].

Tong, J., Miao, S., Wang, J. et al. 2014. “A Two-stage Epidemiologic Study on Prevalence of Eating Disorders in Female University Students in Wuhan, China.” Social Psychiatry and Psychiatric Epidemiology 49(3): 499-505.

Are you suffering from an eating disorder and need help? For information on eating disorders and how to help if you are worried about someone, Beat (UK) or ANAD (US) has advice for sufferers, friends and family.

Spotted a mistake or want to add something? Please let us know in comments below or email us.

©2018 Whatsonweibo. All rights reserved. Do not reproduce our content without permission – you can contact us at info@whatsonweibo.com.

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Manya Koetse is the editor-in-chief of www.whatsonweibo.com. She is a writer and consultant (Sinologist, MPhil) on social trends in China, with a focus on social media and digital developments, popular culture, and gender issues. Contact at manya@whatsonweibo.com, or follow on Twitter.

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Backgrounder

“Opposing Dog Meat Consumption Is Hypocritical” – Weibo Users Respond to Anti-Dog Meat Protests in South Korea

Eating dog meat is a personal choice, many commenters argue.

Manya Koetse

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Man eating dog meat during anti-dog meat protest; image via https://udn.com/news/story/6812/3928149

Last week’s anti-dog meat protests in South Korea have triggered discussions on Chinese social media on the status quo of the dog meat industry in China. An overview of the sentiments on social media and the background of dog eating in the PRC.

South Korea’s dog meat industry made headlines on Friday after protesters in Seoul, joined by actress Kim Basinger, called for an end to the decade-old dog meat trade in the country.

Not far from the protesters were farmers who raise dogs that are sold to restaurants. They brought steamed dog meat and ate it with kimchi (featured image).

In China, where the eating of dog meat has a long history, the Seoul protests triggered some discussions on social media.

The hashtags “Hundred People Gather in South Korea to Stop the Eating of Dog Meat” (#韩国百人集会呼吁停食狗肉#) and “Big Protest in South Korea against Eating of Dog Meat” (#韩国大规模抗议吃狗肉#) received over 83 million views.

In South Korea, the overall demand for dog meat has plummeted over the years. Earlier this month, one of the largest dog meat markets in the country, the Gupo dog meat market, was shut down. In November of 2018, Seongnam city already demolished South Korea’s largest dog slaughterhouse.

Friday’s protesters hope to shut down dog meat trade in the country completely. The latest protests have put the thorny issue of the dog meat industry back in the limelight.

 

HYPOCRITICAL PROTESTS?

“I don’t eat dog meat, but I don’t oppose it.”

 

On Chinese social media site Weibo, hundreds of netizens expressed their opinion on the matter, that has been a hot topic in China for years.

According to polls from the past and present, the topic of dog meat in China is clearly a divisive one.

But over the past few days a seeming majority of commenters on Weibo spoke out about the issue in a remarkably similar way, with thousands of netizens highlighting one issue in the matter: hypocrisy.

“I won’t oppose to the eating of dog meat,” one person writes: “Because if I support the anti-dog meat movement today, then tomorrow it will turn against the eating of cows, then the eating of pigs, and then the eating of fish..”

Many people on social media agree with this point of view, arguing that no matter one’s personal ideas about dog meat, condemning the dog meat practice in specific would be hypocritical: “Pigs are so cute, why do we eat pigs then?” many say, with others arguing: “Aren’t cows also spiritual animals?”

Dog meat restaurant in Jilin.

“I also raise dogs, I also love dogs,” another commenter says: “But I think that if they legally breed dogs for the dog meat [industry], then we have no right to prevent them from doing so.”

“I don’t eat dog meat, but I don’t oppose it, as long as it’s legal it’s ok,” with others writing: “I am opposed to the eating of any living creature.”

“Eating dog is not illegal, why all this sentimental nonsense? Why don’t you also defend chickens, ducks, geese, pigs, sheep, and cows?!”

“As long as they’re not abused, I don’t see a problem with it.”

“Dog meat is tasty,” one commenter from Zhejiang writes: “I like it, although I rarely eat it. I don’t see a problem with it, it’s a personal choice.”

 

SHORT OVERVIEW OF DOG EATING IN CHINA

“To them, dog meat was just like any other meat.”

 

The tradition of dog eating in China can be traced back as far as the Shang Dynasty (ca. 1558 to 1046 BC), when dog meat was considered a delicacy for the upper class.

Later on in Chinese history, during the Han Dynasty (202 BC-220 AD), it became more and more common until the practice saw a general decline, especially in northern China, during and after the tenth century (Li et al 2017, 513-514).

Despite the rising and declining popularity of dog meat throughout China’s history, the practice of eating dog has never completely disappeared, particularly in southern China.

In a book on China from 1878 by John Henry Gray, the author notes the popularity of restaurants serving dog and cat meat in ‘Canton’ (Guangzhou):

I do not think (..) that I exaggerate in saying that there are no fewer than twenty such places in Canton. Each restaurant contains only one public apartment. The approach to this dining-room is generally through the kitchen, where cooks may be seen standing in front of slow fires over which the flesh of cats and dogs is being cooked. The flesh is cut into small pieces and fried with water chestnuts and garlic in oil. In the windows of the restaurant dogs’ carcasses are suspended, for the purpose, I suppose, of attracting the attention of passengers” (75).

He further writes:

The flesh of black dogs and cats is generally preferred because it is supposed to possess more nutriment than that of cats and dogs of any other color. At Ying-tong, a suburban district of Canton, a fair is held at which dogs are sold for food; and in one of the streets dogs and cats are daily exposed for sale. The dogs are put to death by strangling, stabbing, or felling with clubs” (76).

Something that has not changed since the days described in Gray’s book is the belief in the medicinal benefits of dog meat.

Dog meat dish, via Sohu.com.

Especially in summer, dog’s flesh is believed to serve as an antidote against summer heat, and to be nutritious and beneficial as a source to enhance male virility or to boost the liver. Even at present, Chinese media promote the eating of dog meat to boost the immune system and help stimulate better blood circulation.

It should be noted that although China has a long history of dog meat consumption, it also has a long history of dog domestication and dog-human comradery. Dogs were pets, guarded the house, used in hunting, and also used in rituals of sacrifice.

Ceramic crouching dog, excavated from Henan burial site, dating from Han Dynasty, 206BC-220AD, Henan Museum.

Most of the 20th century (1900-1978) was a tough time for people in mainland China, and it was a tough time for dogs too. In many times, there was barely enough food to eat, and under Mao’s rule, dogs were considered “parasites” and were outlawed as pets (Coren 2018; Li et al 2017, 514).

Those who kept pets were seen as part of the ‘bourgeoisie,’ and during the Cultural Revolution, pet dogs were reportedly seized and beaten to death in front of their owners (Coren 2008, ch. 21).

Much has changed since those days. Although (stray) dogs, as carriers of diseases and potentially aggressive, are often still considered a drain on society, having a dog as a pet has become much more commonplace in China since the late 1980s and early 1990s.

Eating dog meat has become less popular, especially among young people in China, who have grown up very differently from their parents and have different perceptions of dogs.

Chinese writer Bang Xiao looks back on the first time his mother served him dog meat during Chinese New Year, writing:

For them, dog meat was just like any of the other meats, and coming from a generation who lived through famine and the Cultural Revolution, I was told I should be grateful. For me though, it meant I was eating my own pet Duo Duo. I cried.”

Later on, he writes about his parents:

They weren’t “dog eaters”. They were just people that happened to have a different history that led to different animals being on the menu.

 

THE YULIN DOG MEAT FESTIVAL

“Don’t go, don’t eat it, don’t pay attention to it.”

 

Despite the general unpopularity of dog meat in China, there is one time of the year when the discussions on the practice of dog eating flare up again, and that is during the Yulin Lychee & Dog Meat Festival, an annual event that’s been held over the past decade in the Chinese city of Yulin intended to generate income from tourism (Brown 2018).

Some 10,000 to 15,000 dogs and cats are slaughtered during the 10-day event that starts on June 21st every year. The event attracts hundreds of people every day. There is a restaurant strip and a market where dozens of vendors cook various dog meat dishes in large woks and where live dogs are sold and slaughtered.

Yulin, image via 轉角國際udn Global

Although the voices of those people protesting the festival seem to grow louder year on year, the dog meat festival continues. It is not illegal, and its economic benefits have become of crucial importance for many in the city of Yulin.

Vendor selling dog meat at the Yulin festival.

A 2016 media survey held among 2000 people from various ages and places in China found that 64% of the people opposed to the festival, 52% thinks that dog meat should be banned in China, and 70% said they had never had dog meat themselves.

“Don’t go, don’t eat it, don’t pay attention to it. When there’s no business, the killing will stop,” one Weibo commenter suggests.

 

A MURKY MARKET

“There does not seem to be a Chinese dog meat market that is both cruel-free and completely legal.”

 

Apart from Yulin, the eating of dog meat is barely a celebrated tradition in China anymore.

For a What’s on Weibo article from 2015, we could still find 122 restaurants listed as ‘dog meat’ specialty restaurants in the city of Beijing on restaurant site Dianping. But at present, Dianping no longer publicly lists any restaurants when searching for ‘dog meat’ specialty places (note that there still are restaurants serving dog meat, but they might not be listed due to controversy or for fear for activists).

China’s biggest e-commerce websites sell different herb mixes for dog stews or dog meat hotpots (see tweet below), but the market could hardly be called thriving.

Yet, despite all those people on Chinese social media saying that eating dog meat should not be a problem for those who still want to eat it, China’s dog meat market does actually have a problem.

China has no law that bans the eating of dogs; eating dog meat is a personal freedom. But what makes the issue murky and troublesome is that China actually has no large-scale legal dog farms, nor legal dog slaughterhouses.

The very few dog farms in existence in China would never be adequate to provide the meat for the industry in southern China, let alone for the estimated 10,000+ dogs slaughtered in Yulin every year.

It is therefore not clear where the dogs that are used for their meat in China come from. Are they stray dogs? Are they stolen from the streets? And if so, would this not be considered illegal (Brown 2018; Cao 2014; Yan 2015, 46)?

Every now and then scandals appear in the media of restaurants slaughtering and killing dogs that were actually people’s pets (for example, this scandal in Jilin in 2018 or in Chengdu this year).

Another issue making the dog meat market a problematic one is the cruel treatment of the dogs.

China has seen countless of food scandals over the years, and some of them involve the selling of poisoned dog meat. As a result, many people have a general distrust in (frozen) meat products and want to make sure they are consuming good quality meat.

Dog meat markets such as Yulin, therefore, often sell living dogs. They are virtually like ‘wet markets’ for dogs, where those who want to eat dog meat can do so with the assurance that the meat they are eating is fresh and safe. The dogs are slaughtered at the spot or are sold alive for home consumption (Brown 2018).

Image via BBC.com.

The process of being transported, being displayed in tiny cases in the summer heat, and being killed in often cruel ways all add to the enormous stress and pain the animals at the live dog market are suffering.

China currently has no laws from the perspective of animal welfare to minimize the pain and suffering during transport, the selling, or at the point of slaughter (Brown 2018).

For the aforementioned reasons and more, festivals such as the Yulin Dog Meat one are getting more controversial year on year, with more and more Chinese calling for a boycott and a ban.

 

DISTORTED DISCUSSIONS

“If you eat dog meat of unknown origin, you might be participating in the killing of someone else’s pet.”

 

As the discussions on dog meat in China are ongoing following the South Korea protests, one blogger posted a survey asking netizens if they support the eating of dog meat.

Despite the many commenters who also defend the practice of dog eating, a majority of 67% percent among the 32.000 participants said they do not support it as “dogs are our friends.”

A recurring sentiment expressed on Chinese social media on the issue is that there essentially is nothing wrong with eating dog meat – and that it would be hypocritical to only oppose to eating dog without also opposing eating sheep, cows, chickens, and so on – as long as it is legal, and as long as the dogs are not stolen, poisoned, or abused.

But that’s the whole issue at hand: all those things are in fact happening in the dog meat industry today. It is difficult to discuss the eating of dogs based on the hypothetical assumption that these things are not occurring.

Consumers are not buying (frozen) meat from legal dog farms and certified dog slaughterhouses, they are mostly buying living dogs or dog meat from unknown origins, and the process of selling and slaughtering often goes hand in hand with cruel treatment.

“I don’t oppose to eating dog, but I hate the dog trafficking market,” one person says. Another commenter agrees, writing: “I don’t oppose to the eating [of dogs] that are bred for it, but I do oppose to those who steal other people’s dogs. Most of the dog meat I’ve seen comes from unknown origins. (..) If you eat dog meat that you don’t know the origin of, you might be participating in the killing of someone else’s pet.”

For now, China and South Korea are very different when it comes to their dog meat industries and their (legal) changes. The countries do seem to have one thing in common, which is that the practice of eating dog meat is no longer popular among the younger generations.

This might suggest that as sales are dropping, the dog meat market will shrink and might eventually disappear altogether if there is no interest in it.

“Don’t hype the dog meat festival,” one Weibo commenter writes: “It’s the hype that made it big and that led to more dogs being killed.

This basically reiterates the advice of one of the aforementioned commenters: don’t go, don’t eat it, don’t pay attention to it, and the business will, eventually, die out.

Want to read more? Also see:

20 Facts About Dogs & Dog-Eating in China
The Yulin Dog Meat Festival: 10 Views From Chinese Netizens
Tradition or Abuse? Chinese Views on the Yulin Dog Meat Festival

By Manya Koetse

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References

Brown. Hannah. 2018. “Yulin Lychee and Dog Meat Festival: A Shift in Focus.” In: Tourism Experiences and Animal Consumption: Contested Values, Morality and Ethics, Carol Kline (eds), Chapter 15. London: Routledge.

Cao Yin. 2014. “Experts: Dog Meat Festival ‘Illegal’.” China Daily (June 16). Online at http://www.chinadaily.com.cn/china/2014-06/16/content_17589087.htm [6.23.16].

Coren, Stanley. 2008. The Modern Dog: A Joyful Exploration of How We Live with Dogs Today. New York: Free Press.

–. 2018. “What Is China’s Current Attitude Concerning Dogs?” Psychology Today, Feb 21 https://www.psychologytoday.com/us/blog/canine-corner/201802/what-is-chinas-current-attitude-concerning-dogs [7.15.19].

Gray, John Henry. 1878. China: A History of the Laws, Manners, and Customs of the People (Volume II). London: MacMillan & Co.

Li, P. J., Sun, J., & Yu, D. 2017. “Dog “Meat” Consumption in China: A Survey of the Controversial Eating Habit in Two Cities.” Society and Animals, 25(6), 513–532. http://doi.org/10.1163/15685306-12341471

Xiao, Bang. 2018. “Chinese New Year: Remembering how I first ate dog meat, and how differences bring us together.” ABC, February 17 https://www.abc.net.au/news/2018-02-17/chinese-dog-meat-eating-linked-to-history-of-famine/9454394 [7.15.19].

Yan Wei. 2015. “Dog Meat Festival: Traditional Custom or Abuse?” Beijing Review (29): 46-47.

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Over a Third of China’s Babies Are Delivered via C-Section – The National Health Commission Wants to Change That

Fear of pain is a major reason for nonmedical cesarian deliveries on maternal request.

Manya Koetse

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Image by Sohu News

China’s National Health Commission wants to lower the nation’s high C-section rates. On Chinese social media, many women argue it should be up to the mother to decide how she wants to give birth.

In 2018 the percentage of deliveries by cesarean was 36.7% in mainland China, according to the latest Report on Women’s & Children’s Health (中国妇幼健康事业发展报告) that was launched by the National Health Commission on May 27.

This means that together with Hong Kong, Taiwan, Brazil, Egypt, and Turkey, the People’s Republic of China (PRC) now has the highest C-section rates in the world.

A World Health Organization report from 2010 estimated that 46% of Chinese babies were delivered via C-section. In 2017, another study found that this percentage was incorrect, although some urban and wealthier regions in China, such as Shanghai, did see C-section (CS) rates as a high as 68% (Black & Bhattacharya 2018, 1; McNeil 2017).

China’s CS rates have recently become a hot topic in Chinese newspapers and on social media. On May 27, the National Health Commission of the People’s Republic of China held a Beijing news conference in which Qin Geng (秦耕), the director, announced that more actions will be taken to encourage natural childbirth among Chinese women.

Qin Geng during the press conference on May 27.

These actions will, among others, include stricter regulation of cesarian section operations and the provision of more support and pain relief for laboring women, as well as a higher hospital income for natural births. The National Health Comission hopes to significantly reduce the number of unneccesssary C-sections without medical indication in this way (Beijing News 2019; Caijing 2019).

Since 1985, the international healthcare community has considered 10-15% to be “the ideal rate” for C-sections, of which the highest percentage are those CS deliveries with medical indications that can actually save the lives of mothers and babies.

Although the worldwide rates for CS deliveries have increased throughout the years, there is no evidence for the benefits of nonmedically indicated C-sections for women or children, according to the World Health Organization.

This is not the first time Chinese authorities try to combat the country’s high CS rates. After reports by the World Health Organization from 2010 and 2015 pointing out the potential hazards of unnecessary C-sections, there have been various state efforts to reduce the number of nonmedical cesarian surgeries.

Besides the introduction of free prenatal education classes, these efforts included monitoring public hospital CS rates and removing bonuses or cutting portions of a hospital’s income once their CS rates reached a certain threshold (e.g. 40%) (Wang 2017, 3). These government initiatives seem to have had effect: the country’s C-section growth rates have slowed down, but were not decreasing yet.

Since the Chinese government announced an end to its one-child policy in 2015, lowering cesarean sections rates has become a more urgent matter, as Chinese couples are now allowed to have a second child.

Although various studies from mainland China and beyond challenge the idea that nonmedical C-sections are less ‘safe’ than vaginal births for single deliveries, this risk changes when a woman who previously had a CS section plans another pregnancy: multiple cesarean sections are associated with additional risks including CS scar rupture and abnormal placental invasion (Biler et al 2017, 1074; Black & Bhattacharya 2018, 2; Liu et al 2015, 817).

 

Why So Many C-sections in China?

 

But why does China have such a high cesarian delivery rate at all? Since the early 1990s, mainland China saw a more dramatic rise in CS rates than, for example, the USA; from less than 10% (with only 3.4% in 1988), China went to one of the highest in the world (Hellerstein 2011; Wolf 2018, 13).

The answer to why this is, is not so straightforward and relates to socio-economic changes as well as cultural factors that come into play.

One reason is that there is a general belief in the ‘safety’ of cesarian births that influence women’s choices for a (nonmedical and planned) C-section (Black & Bhattacharya 2017, 2).

An insightful study into this matter is that of researcher Eileen Wang (2017), who found that anxiety about giving birth and fear of pain is also a major reason for nonmedical cesarian deliveries on maternal request, especially considering that only a minority of Chinese women are given any form of pain relief during labor. Besides traditional concepts, this is also because China faces a shortage of anesthetists and because obstetricians are not always well-informed to prescribe other forms of pain medication (2017, 5).

As noted by Wang, epidurals are denied to laboring women not just because anesthesiologists are too busy, but also because of various other factors: different from a scheduled C-section on their agenda, they are not always available during nighttimes and in weekends to administer anesthesia to women in labor, do not have the time to monitor a patient for hours during labor (whereas a cesarean could be done in an hour), or were not even trained to administer epidurals (2017, 5).

“Giving labor without pain: removing mom’s fear for giving birth” – image by Chinese website http://www.8bb.com/huaiyun/1381.html.

According to Wang, the concerns about labor pain result in more requests for C-sections, both before and during labor. With relatively low awareness and availability of labor pain relief methods many Chinese women simply opt for a C-section as a way to control their pain.

But there are also other factors that contribute to the relatively high rate of women requesting C-sections for nonmedical reasons. One of them is the importance placed in the astrological calendar: having a baby on that one ‘lucky day’ or within that ‘lucky year’ is considered enough reason to plan a cesarian birth for many Chinese families.

In early 2015, ahead of the Chinese New Year, many women rushed to the hospital to make sure their baby was born in the Year of the Horse (2014) as the Year of the Goat (2015) was coming up. There is an old Chinese saying that nine out of ten people born in the Year of the Goat are incomplete and will suffer from great misfortune throughout their life (“十羊九不全”).

Another factor that leads to more cesareans on maternal request relates to the existing concerns among women that vaginal delivery will affect their figure or sex life (Wang 2017, 2).

 

Responses on Chinese Social Media

 

Since the Beijing news conference of May 27, the hashtag “Reducing Unnecessary Cesarean Section Surgery” (#减少非必需剖宫产手术#) has taken off on Chinese social media.

On Weibo, the hashtag page received 340 million views at time of writing. One thread about this topic even received over 28400 comments.

“What do you call ‘unnecessary cesarian’?” one of the most popular comments said: “Isn’t it that so many women in labor choose to have a C-section because natural childbirth is too painful?”

Other commenters also called for a normalization of pain relief in labor, saying that the high percentage of C-sections lies in the fact that Chinese women lack access to “wútòng fēnmiǎn” (无痛分娩) or “painless birth,” meaning vaginal delivery with pain relief.

Some Weibo users also stress that women should have the freedom of choice on how they wish to give birth, saying: “C-section or natural should be my own choice” and “If you leave me no choice I might as well not give birth at all.”

Multiple commenters write: “The lower the C-section rate, the higher the suicides,” referring to an incident that occurred in Shaanxi in 2017 when a pregnant woman committed suicide by jumping from the fifth floor of the hospital after she was allegedly denied a CS delivery.

Other Chinese netizens also complain about the fact that it seems to be men who are promoting the new policies to combat the high C-section rates, writing: “Isn’t there a way to have them suffer the pain of labor instead?”

In her study, scholar Eileen Wang also argues that the lack of pain relief is one of the major issues that should be addressed by policymakers who are hoping to reduce the number of C-sections in China. Further improving the childbirth experience by, for example, integrating a midwifery model, is also essential in making natural childbirth more attractive for Chinese women, Wang argues.

For now, many hospitals in China are still offering C-section “packages”: some prices start at RMB 5800 ($840) for a C-section, other hospitals have packages that start from RMB 88,000 ($12,741) including a three-day hospital stay in a private room.

“It’s a pregnant’s woman body, so she should decide how she wants to deliver her baby,” one commenter on Weibo writes: “It should be a woman’s right to decide.”

By Manya Koetse

References

Biler, A., Ekin, A., Ozcan, A., Inan, A. H., Vural, T., & Toz, E. 2017. “Is It Safe to Have Multiple Repeat Cesarean Sections? A High Volume Tertiary Care Center Experience.” Pakistan Journal of Medical Sciences 33(5): 1074–1079.

Black, Mairead & Sohinee Bhattacharya. 2018. “Cesarean Section in China, Taiwan, and Hong Kong— A Safe Choice for Women and Clinicians?” PLOS Medicine 15(10): 1-3.

Caijing. 2019. “卫健委:全国剖宫产率为36.7% 积极推广分娩镇痛.” Caijing , May 27 http://economy.caijing.com.cn/20190527/4591594.shtml [5.31.19].

Hellerstein, Susan Celia. 2011. “Cesarean Delivery in China Analysis of Cesarean Deliveries Without Indication.” The American College of Obstetricians and Gynecologists: 20s.

McNeil, Donald. 2017. “Study Finds Lower, but Still High, Rate of C-Sections in China.” New York Times, Jan 9 https://www.nytimes.com/2017/01/09/health/c-section-births-china.html [6.2.19].

Wang, Eileen. 2017. “Requests for Cesarean Deliveries: The Politics of Labor Pain and Pain Relief in Shanghai, China.” Social Science and Medicine (173): 1–8.

WHO. 2015. “WHO statement on caesarean section rates.” World Health Organization, April https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/ [6.2.19].

Wolf, Jacqueline H. 2018. Cesarean Section – An American History of Risk, Technology, and Consequence. Baltimore, Maryland: Johns Hopkins University Press.

Featured image by Sohu News.

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