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Abstract
Introduction The introduction, strict enforcement and recent exit of China’s one-child policy (OCP) resulted in China’s demographical changes, and, alongside its epidemiological transition, disproportionately impacted caregiving needs and demands on women. This study examines women’s caregiving responsibilities in contemporary China and evaluates how the OCP affected them.
Methods We simulated the female population aged 25–54 years in 2020 in China and their caregiving responsibilities based on epidemiological and demographic data for women, their parents and parents-in-law, and children under 10. Three different health states were simulated for children and the senior generation: (1) healthy, (2) end of life—decedents and (3) non-decedents in need of palliative care. We combine the care responsibility for senior family members and for children using an aggregate indicator—the Care Responsibility Score (CRS) –to compare the impact of the OCP across different generations of women.
Results Approximately 60 million working-age women are living with medium to high levels of care responsibilities (a CRS over 0.8), which is equivalent to caring for a senior family member with palliative care needs without any assistance from siblings. This includes more than one-third of the 156 million women born after the OCP and only 5% of women born before the OCP.
Conclusion For women born under the OCP, the additional responsibility generated by a lack of siblings outweighs the benefit of having four dedicated grandparents to support them in raising children.
- Health policy
- Mathematical modelling
- Child health
- Prevention strategies
- Public Health
Data availability statement
Data are available on reasonable request. Data are available on reasonable request to the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
China’s one-child policy (OCP) has created a ‘sandwich generation’, where one woman has to care for multiple senior family members and children. While public policies exist to support caregiving responsibility, professional provision of care, whether public or private, is neither sufficient, applicable, nor affordable, which hinders the job market participation of working-aged women with elderly, chronically or severely ill family members.
WHAT ARE THE NEW FINDINGS
The simulation study presented in this paper provides a quantified analysis of the size and severity of the issue, allowing us to compare the caregiving responsibilities of women born before and during the OCP. Approximately 60 million adult women currently aged 25–54 are living with medium to high levels of care responsibilities, which is equivalent to caring for a senior family member with palliative care needs without any assistance from siblings. The vast majority of them were born during the OCP’s implementation.
WHAT DO THE NEW FINDINGS IMPLY
Working-aged women born between 1981 and 1995, especially those who have multiple children, should be the primary target of policies aiming to alleviate the caregiving burden of working-aged women in China.
Introduction
China’s population is shrinking as of 2022, presenting the country with the challenge of identifying and implementing policies to slow the declining birth rate and encourage employment to support an ageing society.1 The current situation stems from a strict national family planning policy, commonly known as the ‘one-child policy’ (OCP), implemented in 1979. This policy dramatically changed China’s family structure and population pyramid. Enforcement of the policy began in the early 1980s and continued until 2014, when it was relaxed, starting from a few pilot cities.2 3 Fertility under the OCP declined dramatically from 1979 to 2014 and the population quickly aged, with the dependency ratio of old to young, defined as a total population above 64 to that between 15 and 64, increasing from 8.0 in 1981 to 17.7 in 2021.4 In response to a fertility rate below replacement—2.0—since 19925 the Chinese government amended the OCP in 2016 nationwide, allowing families to have two children and then three in 2021.6 7 There is a growing consideration for removing the child limit entirely8 to further stimulate the fertility rate given the shrinking population.1 9
Women born during the first year of the OCP will be 43 years old in 2022; women in this generation now have children and some have grandchildren. In China, women are more likely to assume the role of caregiver for older family members who fall ill, chronically ill relatives and for raising children.10 11 A report by the International Labour Organization (ILO) in 2019 showed that women in mainland China take up 71.6% of total unpaid care work and spend about three times as much on caring for other household members than men.11 Caregiving responsibilities also fall disproportionately on daughters and daughters-in-law, who care for their husbands’ parents, rather than sons and sons-in-law, who are less socially responsible for caregiving.12 Hence, this group of young women is a ‘sandwich’ generation because they care for both their children and ageing senior family members with little assistance from men.13–15 However, China’s ‘sandwich’ generation is unique, as the majority of women born under the OCP lack siblings to share caregiving responsibilities. Moreover, the senior parents’ generation is marked by extended longevity with chronic illnesses, which increases demands for care. We describe this phenomenon as a 4:2:1 caregiving structure, representing four senior family members, a young working-aged couple and their single child, which is now shifting to 8:4:2:2 or 8:4:2:n with multiple children.15
This generation of women, compared with previous generations, has equal levels of education investment with men, stemming in part from the OCP’s strict enforcement (see table 1).16 17 Simultaneously, women’s high care responsibility has negative implications for both educational attainment and labour force participation, as well as workforce productivity and gender discrimination in hiring.
Life continuum framework on the potential influences of the OCP on women’s caregiving burden
The aim of this simulation study is to estimate the OCP’s impact on women’s care responsibilities and to compare the caregiving responsibilities of women born under the OCP to those of previous generations. In section 1, we focus on data and methods and describe the static population model we simulated using data on China’s demographic and epidemiological profiles, as well as an aggregate indicator we use to analyse care responsibility within households. In section 2, we summarise the care responsibility of women born after the OCP and are now of reproductive and working age, both in absolute terms and relative to previous generations. In section 3, we discuss the implications of our findings considering the ongoing epidemiological transition, ageing population, the COVID-19 pandemic and the recent loosening of the OCP. We discuss policy recommendations in section 4, arguing that the consequences of the OCP on caregiving and gender equity require interventions to mitigate the policy’s negative effects on women.
Panel 1: OCP: intended and unintended outcomes for women in contemporary China
Developed in 1979 and enforced from the 1980s to 2014, China’s OCP prevented most couples from having more than one child in their life; the policy effectively curtailed population growth in the world’s most populous country, with about 1.5 billion people in 2022.
The OCP was intended to limit population growth and spur economic and social development in the context of limited natural resources and resulted in a stark decrease in China’s fertility rate.18 China’s total fertility rate had already been falling before the OCP, from around 6.0 children per woman in the 1960s, to barely above 4.0 by the mid-1970s. Yet, it is the launch and continuous enforcement of the OCP that pushed the fertility rate to below 2.0 since 1992, and to approximately 1.65 in the 21st century.
The OCP introduced a variety of negative and positive influences throughout women’s life course and generated several unintended consequences, including a higher ratio of elder parents to adult children.2 China’s population is now ageing rapidly: the percentage of the population 65 and older increased from 4.6% in 1979 to 12.4% in 2021.19 Fuelled by ageing and lifestyle changes, China is facing an epidemiological transition to non-communicable and chronic illnesses. The prevalence and mortality rates of diabetes mellitus, stroke and cancer have increased steadily in the past decade.20
Further, in a society influenced by its traditional culture that prised men, the OCP led to the selective abortion of female foetuses21 and a steady increase in the male to female sex ratio at birth which peaked at 1.178 in 2004.22 After 40 years of restrictive family planning policies, China now has an excess male population of approximately 50 million among those under 55.23
By contrast, the OCP also increased families’ investments in girls born as the only child, treating them as ‘substitute sons’. This investment took the form of increased education17 and incentives for women to enter and remain in the labour market,16 that in turn stimulated women to bear their first child at older ages.23
Methods
We constructed a database of Chinese women aged 25–54 years of age in 2020. For each woman, we modelled the number of three categories of family members who determine caregiving demand. These include (1) dependents under 10, (2) elderly parents/parents-in-law and (3) siblings over 25. For categories (1) and (2), demand is also influenced by the following health-related factors: (a) serious health-related suffering (SHS), which refers to people living with conditions that generate major physical and psychological suffering as defined by the Lancet Commission on Global Access to Palliative Care and Pain Relief (LCGAPCPR)24; (b) end of life, which refers to people who died in 2022 and (c) healthy people, who are calculated by subtracting the first two categories from the total living population in each age group. Children under 10 in all three categories of health status, as well as senior family members who are either at their end of life or living with SHS, add to the care responsibility while healthy senior family members and siblings reduce women’s care responsibility (see table 2 and figure 1). Children and siblings were calculated as a function of fertility rate and mortality rate applied to respective women’s populations or their parents’ populations, using demographic data from United Nations Population Prospects (UNPP) (see table 3 and online supplemental appendix tables 1–7). SHS decedents and non-decedents were calculated following the methods of the LCGAPCPR. Each value in the simulation model represents 1000 people and each simulation was repeated 1000 times. We report the mean estimates for each simulation to avoid outliers generated by randomisation. Consequently, all results are numbers in whole thousands.
Supplemental material
Components of care responsibilities for women
Simplified framework for the OCP simulation. OCP, one-child policy.
Data used in the modelling
We chose 2020 because it is the most recent year with available United Nations Population Prospects data. We chose women aged 25–54 to cover most of the female population eligible for formal employment since China’s legal retirement age for women is 55. Of these groups, we focus on women born between 1981 and 1995, who fall under the OCP. Registered marriage is only permitted between a man and a woman in China, so we excluded the possibility of same-sex marriage in the calculation but acknowledge the potential for increased caregiving demands facing single individuals and those cohabiting as unmarried couples.
We combined the need of caring for senior family members and that of caring for children in an aggregate indicator: Care Responsibility Score (CRS) to capture multiple facets of the demand for care.
The CRS is a composite measure that considers the caregiving demands associated with various family members’ health conditions, each weighted to reflect the intensity of care required (equation 1). Healthy children under 10 years old 
are given a weight of 1, indicating the standard caregiving effort. Children under 10 in end-of-life care 
or experiencing SHS 
have a weight of 2, denoting a demand for care that is twice as intensive compared with caring for healthy children. In contrast, healthy senior family members 
contribute to a reduction in the caregiving score, with a weight of 0.125 applied to their number, reflecting that even if all four grandparents are involved in caring for the healthy or sick children under 10, they only relieve half (0.125×4=0.5) of the care responsibilities of the mother. Senior family members in end-of-life care (
) are assigned a weight of 1, equating their care needs to those of healthy children under 10. Senior family members with SHS 
are allocated a weight of 0.8, suggesting a slightly reduced, yet significant, caregiving responsibilities. The CRS formula is normalised for family size by including the number of siblings 
in the denominator, acknowledging that larger families may have a more distributed caregiving dynamic.
Panel 2: caregiving need and women’s time understood through vignettes
These eight vignettes illustrate examples of the CRS for each individual or household. The first vignette presents a scenario where the CRS is 0, and the last one presents a scenario where the CRS is more than 2 (see table 4).
Vignettes of Caregiving scenarios of women
We calculated the CRS for each woman in our database and summarised the CRS by age groups with 5-year intervals. We selected a few key cut-off points to represent different levels of care responsibility: (1) 0.8, which is equivalent to caring for one senior family member living with SHS without support, (2) 1.6, which is equivalent to caring for two senior family members living with SHS without support and (3) 2.0, which is equivalent to caring for two healthy children under 10, two senior family members in their last year of life, or one child under 10 who is either dying or living with SHS, without support. We then divided CRS into four categories: (1) low: less than or equal to 0.8, (2) medium: greater than 0.8 and less than or equal to 1.6, (3) high: greater than 1.6 and less than or equal to 2.0 and (4) extremely high: greater than 2.0. We then calculated the number of women (households, if married) that fall within each category, and identified significant differences between all six cohorts, using a one-way analysis of variance (ANOVA) test.
We also conducted a sensitivity analysis using a set of weights that reflect higher and lower caregiving responsibilities caused by each dependent as well as healthy senior family members and siblings over 25 providing more support versus lighter responsibility combined with less parental support. Results from the sensitivity analysis are reported in the ‘Care responsibility score and sensitivity analysis’ section.
R V.1.1.383 was used for the simulation.
Results
The number of dependents demanding care
In the constructed database, we estimated the number of dependents requiring care in each cohort. For children under 10, we report the total number requiring care, as well as those at the end of life and living with SHS. For senior family members, we report those at the end of life and living with SHS, since we did not consider healthy senior family members’ dependents as requiring care.
In 2020, there were 95 000 children under 10 at the end of life for women born between 1991 and 1995, with an additional 107 000 children living with SHS. Those two figures decrease steadily as women’s age increases: for women born between 1986 and 1990, the number of children under 10 at the end of their life is 57 000, and the number of children under 10 living with SHS is 95 000. For women born between 1981 and 1985, the two figures are 23 000 and 33 000, for women born between 1976 and 1980, 5000, and 7000, and women born before that have 1000 or fewer children under 10 in either condition. The number of children under 10 in either condition per 100 000 women also decreases as women’s age increases, with women born between 1991 and 1995 having the highest number of children under 10 at the end of life per 100 000 women (204), and living with SHS per 100 000 women (230).
In contrast, the number of senior family members requiring care increased with women’s age. In 2020, Chinese women born between 1991 and 1995 had a total of 490 000 senior family members (parents or parents in-law) at the end of life and an additional 351 000 of them living with SHS. Senior family members at the end of life and living with SHS were 1055 and 755 per 100 000 women, respectively. For Chinese women born between 1966 and 1970, there are 1 700 000 senior family members at the end of life (2786 per 100 000 women) and 777 000 (1272 per 100 000) living with SHS. Senior family members as dependents increased less drastically as the number of children under 10 decreased: from the first cohort of women born between 1991 and 1995 to the last cohort of women born between 1966 and 1970, the number of senior family members as dependents increased by roughly three times, but the number of children under 10 dropped by almost 100% (table 5).
Average number of dependents requiring caregiving by age and level of dependency/intensity of caregiving
We also summarised the number of siblings and healthy senior family members as potential supporters to share women’s caregiving responsibilities. Not surprisingly, the number of siblings over the age of 25 increases as women’s age increases: women born between 1991 and 1995 average 0.7 siblings while women born between 1966 and 1970 average 2.9 siblings. The number of healthy senior family members per woman decreases as women’s age increases from 2.7 per woman for those born between 1991 and 1995 to 0.2 per woman for those born between 1966 and 1970 (table 6).
Care support from siblings and healthy senior family members by age group
Overall, women born after 1981 have high levels of caregiving responsibility for children under 10, and fewer senior family members living with SHSs or at the end of their lives. In terms of resources to support their caregiving responsibilities, women born after 1981 have fewer healthy siblings over 25 years old to assist with caring for senior family members when they are dying or living with SHS but more healthy senior family members to assist with caregiving for children under 10 than previous generations.
CRS and sensitivity analysis
The CRSs for three cohorts born under the OCP vary widely: for the 46 million Chinese women born between 1991 and 1995, ~28 million have a low CRS of less than or equal to 0.8, ~12 million have a medium CRS between 0.8 and 1.6, 3 million with a high CRS between 1.6 and 2.0, and another 3 million with an extremely high CRS over 2.0. For the 62 million born between 1986 and 1990, 37 million have a CRS less than or equal to 0.8 (low), 17 million between 0.8 and 1.6 (medium), 5 million between 1.6 and 2.0 (high), and 3 million over 2.0 (extremely high). Of the 48 million born between 1981 and 1985, 38 million have a CRS less than or equal to 0.8 (low), 8 million between 0.8 and 1.6 (medium), 2 million between 1.6 and 2.0 (high), and only 3000 over 2.0 (extremely high) (table 7).
Number of people (in thousands) and proportion of people (%) with different categories of care responsibility score by age group
Comparing across different cohorts (figure 2), the proportion of women with medium to extremely high CRS (over 0.8) drops significantly as women’s age increases, from 38% of women born between 1991 and 1995 and 40% of women born between 1986 and 1990 to 21% of women born between 1981 and 1985, 11% of women born between 1976 and 1980, 3% of women born between 1971 and 1975, and only 1% of all women born between 1966 and 1970. This reflects a total of 60 million women with medium, high or extremely high CRS (over 0.8), of which 53 million were born under the OCP. Among the 60 million, 16 million women have high or extremely high CRS (over 1.6), almost all of whom were born under the OCP. ANOVA tests show that the differences among the six cohorts are statistically significant, with a p<0.0001.
Number of women across CRS categories by cohort. CRS, Care Responsibility Score.
Sensitivity analyses resulted in changes in CRS, but not in the relative relationships between age groups. Regardless of the weights used, women born after 1981 have a significantly higher CRS than their counterparts born before 1980 (table 8).
Sensitivity analysis of weights used to calculate Care Responsibility Score
Discussion
The OCP drastically shifted China’s demographic structure and accelerated the ageing process for China’s population. The Chinese government abolished the OCP in recognition of its ageing population and developed different proposals to encourage reproduction. However, the social, economic and political effects of the OCP remain, as the generation born under the policy constitutes most of China’s working and reproductive class and will continue to do so for the next 20–30 years. In this paper, we examined one potential consequence of the OCP: the excess care responsibility created for first-generation women born as the only child to care for sick senior family members and additional children.
We estimated that 60 million women in contemporary China have a CRS of more than 0.8, which is equivalent to caring for one senior family member living with SHS without sibling support. This finding underscores the severe care burden placed on many women, which might hamper their employment opportunities, and create social issues such as abuses and abandonment surrounding childcare, senior care and the quest for gender equity. Despite improved educational opportunities for women, between 1990 and 2010, China’s gender employment gap expanded (14%–20%) and the ratio of women’s wages to men’s declined (78%–67%).25
Our study supports that women born under the OCP have high caregiving responsibilities; these responsibilities are much higher than for the generation born before the OCP. Both the absolute number and proportion of women facing a high CRS are much smaller among women born before the OCP. For example, we estimate that only 300 000 women born before the OCP had either ‘high’ or ‘extremely high’ caregiving responsibility, which is less than 1% of this age group. This means that for the female generation born under the OCP, the extra responsibility created by fewer siblings and more children outweighs any benefits associated with healthy and dedicated senior family members who could potentially help with child-rearing.
The Chinese government introduced private sector caregiving in the late 1970s, which has grown since its implementation. Our analysis shows that mothers born under the OCP require much more support than women from previous generations; these mothers are now also working outside of the home, increasingly in urban settings removed from traditional family support networks. There is a need for government intervention to address this gap through either direct service provision, financial subsidies or more supportive work environments to ensure that women born under the OCP can translate economic opportunities into economic productivity and enhanced well-being.
Early childhood education and day care services are two areas where reforms could substantially improve women’s lives.26 The Reform and Opening Up launched in 1978 gradually led to the elimination of a series of public services that provided affordable day care across the country, including infant care and prekindergarten care.27 The private market has not filled the caregiving gap, and recent news on child abuse in private kindergartens has further intensified fear and mistrust of private facilities.28 Moreover, most private childcare facilities do not accept children below 2; families with resources hire a nanny while others rely on the mother and grandparents for care.
The Chinese government implemented several recent policies to encourage private investment in the senior care industry and standardise service provision. In 2016, 2017 and 2019, policies fully opened the market for services, improved the quality of senior care29 and more rapidly developed the commercial insurance market for senior care.30 31 The impact of these policies has yet to be observed, as the market provision of professional care for the senior generation continues to fall short of demand. Further, sending senior family members to nursing facilities instead of caring for them at home is thought to violate traditional Chinese values, especially in rural areas where nursing facilities are minimal.32 33 We, therefore, note multiple policy, market and cultural impediments to caring for seniors professionally, which reforms have yet to address.
According to the LCGAPCPR, the majority of China’s palliative care need comes from the older population and from chronic illnesses such as cancer, cerebrovascular disease and dementia.24 As China’s population continues to age and the incidence and prevalence of chronic illnesses grow, subsequent caregiving needs will also rise, placing even more pressure on families—mainly women, government and society at large. While China has made great progress in health system performance, current health expenditure is still low, at only 5% of GDP.34 More public investment is needed to meet the growing demand for caregiving, both for the general healthcare industry and senior care in particular.
Panel 3: COVID-19 and the demand for caregiving by women
China was put under strict COVID-19 control measures for the past 3 years, until recently. From early 2020, many businesses and public affairs were operated under various rules for prevention and virus containment. Many kindergartens had not been allowed to re-open until late 2022,35 and many elementary schools created online courses for students to remain at home.36 In February 2021, the Beijing government issued a notice to allow one working parent to stay home to care for children with protection from firing. Most applicants for this programme are mothers rather than fathers, which risks setting them back in their careers, permanent departures from the workforce and reversing progress on gender equality in the Chinese economy.37 COVID-19 control measures in China came to an abrupt end in early December 2022, causing a sudden increased demand for healthcare resources. As the COVID-19 pandemic hits China the same way it did the rest of the world, women in China would suffer more negative consequences from the pandemic than men due to existing gender inequities and the ways the virus has exposed them to new vulnerabilities such as compounded economic impacts and gender-based violence,38 just as has been approved elsewhere. Women also already represent the majority of healthcare providers in both paid and unpaid industries in China, which are facing increased demand both in professional facilities and at home. The overwhelming care responsibilities have pushed women away from equitable access to the job market,39 and further disadvantaged them in their households and society. As a result, policies targeting and supporting women by alleviating their care responsibilities are crucial for a smooth and sustainable rebound from the global COVID-19 pandemic and ensuing economic recession.38
Note that our calculation did not include China’s urban/rural divide, which affects caregiving responsibilities. According to China’s National Bureau of Statistics, China had 260 million internal migrants in 2011.40 Many migrants are young parents who left their senior family members and young children to seek better job opportunities.41 In recent years, migrants’ demographic profiles have changed, with women and adolescents increasingly coming from rural areas to cities for education or employment.42 The effects of the rural–urban divide are multifaceted; on one hand, the distance between parents and their families might prevent young couples from caring for their children and senior family members. Yet, on the other hand, young couples who move to cities with their children will not have senior family members to support them in child rearing. More research is needed to further understand the care responsibility of migrant workers in China.
This study has several additional limitations: first, our database was constructed using the demographic data of the female population in China. Thus, households with single men were not included in our database. This exclusion reflects a lack of data: males born under the OCP may also actively partake in child-rearing and care for sick parents in contemporary China and may experience an associated CRS. However, we did not find sufficient quantitative data to measure the proportion of men providing care or the extent to which care is shared within households. Many previous studies have identified that women are the primary caregivers in households in mainland China and that married women are the main caretakers of their parents-in-law.10 12 Based on a 2008 Time Use Survey, the ILO estimated that women in China conduct approximately 72% of unpaid work in the home.11 43 A time-use study conducted in 2019 in a small city of 200 000 residents in mainland China also found that over one-third of women reported spending more than 3 hours on childcare daily, vs only 8% of men.44 Second and subsequently, we also excluded husbands’ illnesses in caregiving estimates, where the wife is the primary caregiver. Third, with the assumption that women spend more time than men helping with the family, we did not differentiate caregiving roles between grandmothers vs grandfathers. Rather, we assumed that a healthy grandfather shares the same proportion of child-rearing responsibility as a healthy grandmother. In addition, we assume that the age-specific mortality rate and age-specific fertility rate follow a Poisson distribution with equal probabilities for everyone, independent of other factors that might play a role in affecting those two rates, such as marital status. Finally, in this study, we first constructed data on household composition and then, by applying the epidemiological data, generated data on care responsibility, or demand for care, within each household. Although we were able to identify literature to support our assumption that those care responsibilities are primarily faced by women, our data do not provide insights into the actual provision of care. A recent review revealed that only 20% of China’s child care needs are met by private institutions, at a price considered ‘much higher than expected’ for most families,14 so it is reasonable to believe that the majority of those care responsibilities are being fulfilled by women with unpaid work. This study thus represents only the first step toward estimating the caregiving impact of China’s OCP.
Conclusions and policy recommendations
In 2021, the government launched a series of policies to support the abolishment of the OCP and to stimulate fertility.45 While some of these policies focus on ensuring easy and affordable access to quality child care, the overall strategy needs to be reviewed, assessed and evaluated from the perspective of Chinese women’s needs throughout the life cycle and using a gender equity lens. The Lancet Commission on Women and Health proposed a framework and set of recommendations that can be useful for this process and these are focused on valuing, counting, compensating and being accountable to women.39
Specifically, it behoves the Chinese government to examine the short-term and long-term effect of child-care responsibilities and employment opportunities for all parents. This will require better data and research on gender differentials in unpaid healthcare work in China, to estimate the value of time and productivity that is invested in promoting and supporting health, yet not well accounted for in current health system planning efforts. Careful review of the policies that have been applied in other countries to promote gender equity in child care and in labour markets may uncover strategies that can be adapted for China.
A balanced investment in both direct public provision of care, as well as regulation and management of private services would improve quality of care and reduce abuses.28 An equity lens is also required to meet the needs of women and families in rural areas. Although efforts are being made to reduce the uneven distribution of health resources between urban and rural areas,46 the urban–rural gap is likely to persist across multiple aspects of the health system in the near future, which puts more demand for care at home in rural areas. Individuals in rural China are more likely to work informally and tend to forgo employment when child care or senior care responsibilities increase as private sector caregiving alternatives are not viable.25 In addition, families in rural areas are also more heavily influenced by traditional values that emphasise women’s roles as caregivers at home.47 48 While our study did not distinguish between rural and urban women in our data, the authors do acknowledge that rural women born during the OCP are among the subgroups needing the most policy support.
While child care demand might decrease in the future as the fertility rate continues to fall, especially in urban areas, senior care demand has been projected to increase as China’s population ages and suffers from non-communicable and chronic illnesses. In addition to improving access to child and elder caregiving supports, addressing the NCD disease burden stands to not only lessen the demand for elder caregiving but also create opportunities for healthy older adults to potentially support younger generations. The healthy longevity agenda49 promotes greater investment in preventative health and social supports throughout the life course to allow individuals to age well. This agenda aligns with the Healthy China 2030 strategy50 and also provides opportunities to re-envision the ways in which the policy infrastructure can address the caregiving burden and transitions that fall disproportionately on women. A healthy longevity agenda can also help to redress gender inequities in China’s caregiving burden.
Government messaging, education and incentives that support both men and women to take on unpaid care are necessary to improve gender equity in the workforce and reduce women’s unequal caregiving burden. In addition, employers can cultivate gender-equitable and transformative workplace environments, subsidise family care options and ensure that leave policies are sensitive to caregiving needs for all employees.
The Chinese government is faced with the challenge of a shrinking population. Going forward, policy strategies to curb the declining birth rate must take a life course perspective to redress the short-term, medium-term and long-term adverse consequences of the OCP on contemporary women. This necessitates a holistic approach that prizes gender equity and encompasses incentives for higher education and professional development, employment policies and working conditions, care giving and healthy ageing while incorporating cultural considerations in the context of a rapidly evolving and complex society.
Data availability statement
Data are available on reasonable request. Data are available on reasonable request to the corresponding author.
Ethics statements
Patient consent for publication
Acknowledgments
The authors are grateful to Julia Olson for her work which contributed to the conceptual framework used to develop the model, to Oscar Mendez Carniado for his assistance in the data reparation and to Valentina Vargas for her research support that made this manuscript much stronger. We also thank The Tecnológico de Monterrey (Challenge-Based Research Funding Program, I036-IOR005-
C5-T3-T) and the The Ibero-American General Secretariat (SEGIB) and the European Union (Memorandum of Cooperation: DJ-TM-GSL/ITESM-INV/2024-030) for financial support.
References
Supplementary materials
Supplementary Data
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Footnotes
Handling editor John Lee
X @harreolao
Contributors XK, FMK and BE developed the ideas for this work. XK devised the methodology for the simulation. HA-O provided part of the databases—age group-specific data on SHS—used in the analysis and XK collected other data and conducted the analysis with RC-A. XK and RSN completed the data presentation and produced the graphics. XK, FMK, BE and MT drafted the manuscript with guidance from AL. All authors reviewed, improved and approved the manuscript. XK is the author responsible for the overall content as the guarantor.
Funding Two research grants from EMD Serono and Merck KGaA funded this study (reference numbers: AWD-003776, AWD-006650 and AWD-008501); the sponsor is not involved in the study design, data analysis or writing of this paper.
Competing interests FMK reports two research grants from EMD Serono and Merck KGaA related to measuring the economic value of women’s paid and unpaid contributions to the health sector. XK, BE and RC-A report research consulting payments from EMD Serono and Merck KGaA via the University of Miami Institute for the Advanced Studies of the Americas. Other coauthors declare no competing interests.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.