SHANGHAI — Lying on the operating table, Qing watched as her doctor arranged the medical instruments she’d be using, piece by piece. For the first time since she decided to have an abortion, she started to panic: She had barely known anything about the procedure when she made the decision, and now the reality of the imminent surgery was sinking in. When the teen woke up an hour later, the 7-week-old embryo inside her had been removed.

Qing, whose name has been changed to protect her privacy, attends a high school in eastern China’s Fujian province that has never taught its students about sex or contraception, the 16-year-old said. Nor have her parents or other adults in her life ever broached such topics.

Although premarital sex is becoming more common in China, many do not have an accurate and comprehensive understanding of contraception, due in part to the lack of sex education. Medical experts told Sixth Tone that they are noticing an increase in unintended pregnancies among young Chinese, as well as a rise in young women seeking multiple abortions. In addition, advertisements portray abortion as an easy and painless solution, and such services are widely available.

Contraceptive education is nonsense at a school that expels a student for being in love. - Qing, 16-year-old abortion patient

In China, abortion is legal at any point during a pregnancy, though permission from local authorities is required after the third month to prevent the illegal practice of sex-selective abortion. The procedure is offered at both public and private medical institutions, typically costing between 2,000 and 20,000 yuan ($300 to $3,000). According to China’s Health and Family Planning Statistical Yearbook, more than 9 million women had abortions in 2017. Almost half of them were under the age of 25.

Gynecologist Xing Lu, who has worked for more than a decade in the family planning department at one of Shanghai’s top hospitals, said the number of young patients receiving abortions is on the rise. On average, the hospital performs more than 13 surgical abortions a day. Some of the patients who book appointments to terminate their pregnancies sob as they sign the legal forms, while others are calmer and seem well-versed in the details, even informing Xing what type of procedure they need.

Doctors in China usually recommend surgical abortion over medical abortion — which involves using pills to end a pregnancy but has a lower success rate and can have lasting side effects. Xing finds that unintended pregnancies are usually a result of patients not knowing how to use contraceptives correctly, or not using any at all.

Some have never heard of contraception, Xing said, recalling one 14-year-old girl who came to the hospital with her mother, unable to explain how she got pregnant. Last year, a survey by the All-China Women’s Federation found that 80 percent of adult respondents did not fully understand contraception. For instance, more than 36 percent said they rely on the so-called pull-out method, which is only 78 percent effective for preventing pregnancy.

A sex education class is held at a middle school in Langxi, Anhui province, Nov. 10, 2017. IC

Though the national government stipulated in 2011 that sex education be incorporated into primary and middle school curricula, in many places, such content is still missing or insufficient. Some schools use textbooks that describe the harm premarital sex inflicts on girls and the loss of respect they’ll suffer as a result, while other schools have seen strong opposition from parents who believe that sex ed will make their children more promiscuous. As a result, college students are eager to sign up for optional sex education at schools like Peking University, where they are among the most popular courses.

Qing said she learned most of what she knows about contraception from American dramas. She remembers that sex-related content came up once in her English class, but her teacher was too embarrassed to use the words “sex” and “condom,” instead skipping over them in the book. A classmate was expelled when administrators found out she was in a romantic relationship. “Contraceptive education is nonsense at a school that expels a student for being in love,” Qing said.

When Qing found out she was pregnant, she was certain of two things: First, she couldn’t continue her pregnancy, and second, her parents — who had always advised her to stay away from boys — could not find out. “I can tell others about it, but not my parents. For them, abortion means your life is ruined, and the family will be embarrassed,” she said.

Many people still believe that contraception is a woman’s responsibility, but that is incorrect. - Liu Liqing, director of Marie Stopes China

Liu Liqing, director of Marie Stopes China — the China branch of an international medical organization offering contraception and safe abortions — found that most young Chinese learn about sex and contraception through pornography and the internet. While the web does give young people more information than they would otherwise have, said Liu, much of what they find is inaccurate or incomplete.

Even those who do know about contraception often aren’t aware of how to use it properly. Xing has met pregnant patients who only began using a condom halfway through intercourse. Also, few Chinese people use or even know about birth control pills, one of the most common methods in most Western countries. Instead, they prefer over-the-counter emergency contraceptive pills — also known as the morning-after pill — which can be taken after unprotected sex, though frequent use can result in increased side effects like menstrual disorders and nausea. According to a report by pharmaceutical market research institute Sinohealth CMH, emergency contraceptive pills account for 70 percent of the birth control pill market in China.

In fact, contraception has long been promoted among the nation’s married couples; for years, the government would send free contraceptive products to families for optional use. But in the ’80s, under the now-defunct one-child policy, birth control became a political duty, and women were forced to get intrauterine devices (IUDs) to prevent pregnancy after giving birth to their first child. Alternatively, their husbands could undergo a vasectomy.

Since the mid-1990s, mandatory abortion and contraceptive measures have been relaxed. But as the government’s contraception policies have mainly targeted married couples, unmarried young people are still largely overlooked by reproductive health and family planning services, both at the cultural and policy levels, according to the United Nations Population Fund China. For example, though the government distributes free condoms at clinics and health centers, they are only given to adults who can prove that they are over 18. There are also limited sexual and reproductive health counseling services available for young people.

A volunteer demonstrates how to use a condom during a university class in Zhengzhou, Henan province, Jan. 16, 2010. Sha Lang/VCG

Sex is still seen as a taboo topic, which makes it more difficult to raise awareness about contraception. Restrictions on advertising sex-related products, including condoms, were only lifted in 2014 when rising HIV infection rates became a concern.

Advertisements for surgical abortions, however, did not fall under these regulations and are frequently seen splashed across billboards and TV screens. Private hospitals often promote their abortion services using pastel colors and dreamy pictures alongside slogans such as “Goodbye, pain; welcome back, happiness!” and “Painless abortion: the safest guarantee for love.”

Marie Stopes China has been dedicated to promoting contraceptive education for years. The organization holds talks on contraception at public venues, including universities. “We often see students’ eyes light up, and they listen carefully when we start talking about contraception,” said Zhou Anqin, director of the organization’s center in Xi’an, the capital of northwestern China’s Shaanxi province.

Some colleges are seeing a rise in dropouts due to unintended pregnancy, said Zhou, prompting a more active approach to teaching students about contraception. Last year, Zhou was invited to hold a talk on contraception at a vocational college shortly after a newborn baby was found abandoned on the school’s sports field.

Photographer’s Choice/VCG

When young women go to Marie Stopes for abortions, Zhou tries to explain the advantages of long-term birth control options like IUDs. Yet many reject these methods, associating them with the previous generation and the nation’s former one-child policy.

Some of the women Zhou treats are not first-time patients. More than 55 percent of women getting an abortion have undergone the procedure before, according to a report by the National Research Institute for Family Planning and the Chinese Academy of Medical Sciences & Peking Union Medical College. Zhou recalls one patient who had her first surgical abortion at 16 and returned five times for the same procedure in less than two years. “She even praised our surgical technique when she came back,” said Zhou.

To effectively address the issue of unintended pregnancy, Liu of Marie Stopes China told Sixth Tone, attitudes toward sex, contraception, and gender roles need to change. After learning about contraceptive methods during information sessions, some girls say they need to first check whether their boyfriends agree. When Liu’s organization promotes contraception at public events, oftentimes the only attendees are women. “Many people still believe that contraception is a woman’s responsibility, but that is incorrect,” said Liu. “Men also need to assume responsibility when it comes to contraception.”

After her abortion, Qing was left with a feeling of guilt — toward the embryo, as well as toward her mother, whom she felt she had disappointed. “All we learn from our parents and in school is to stay away from romantic relationships. But we are not taught how to protect ourselves,” Qing said. “Sex is beautiful, and it should be accepted with proper education and protection.”

Editor: Denise Hruby.

(Header image: Nicolas Asfouri/VCG)