Reproductive technologies as population control: how pronatalist policies harm reproductive health in South Korea

Abstract

Through the examination of pronatalist policies introduced in South Korea within the last decade, the aim of this commentary is to assess how such policies could harm women's reproductive health if they are practiced only for the purpose of population control. South Korea is a country with one of the lowest fertility rates in the world, and to increase population growth, since 2005, the Korean government has heavily regulated and promoted the use of reproductive technologies, including abortion technologies and assisted reproductive technologies (ARTs). This represents a dramatic shift from South Korea's historically antinatalist position: from the 1960s to the 1980s, abortion was widely practiced and encouraged by the government to reduce population growth, and the use of ARTs went unsupported by the government. However, when the total fertility rate reached 1.08 in 2005, the government strictly prohibited abortion and started promoting the use of ARTs to increase the nation's birthrate. Although under the current pronatalist policies, the Korean government has provided unprecedented incentives to couples seeking to have children, such as expanded maternal/paternal leave and childcare benefits, ironically, reproductive health indicators, such as maternal mortality and infant mortality, have not improved and, in some cases, have even worsened because the pronatalist policies fail to consider women's reproductive health and rights issues.

Introduction

From the antinatalist policies supported by the government in the 1960s and 1980s to the pronatalist policies of the 2000s, population control has long been a part of the political landscape in contemporary South Korea. The total fertility rate in the 1960s was 6.0 and decreased to 2.0 in the 1980s. When the total fertility rate dropped to 1.08 in 2005, a number that was reported as the lowest level in the world,¹ this trend of low fertility was widely discussed as the harbinger of a dystopian future. The Korean government projected that the labour force would decrease and the burden of caring for the elderly would increase.² Young people would pay more taxes to support the elderly and social security systems. Although there are complicated reasons to explain the low fertility rate in South Korea, including demographic changes, family structures, economic structures, and the labour market, hegemonic media discourse tends to focus on blaming individual young women for hesitating about or delaying marriage and childbirth. Increased opportunities for women in terms of higher education and employment have often been discussed as major reasons that have exacerbated the low fertility rate trend.

In 2005, the Korean government enacted The Framework Act on Low Birth Rate in an Aging Society and invested over $100 billion USD in childbirth promotion policies over the following 10 years. Policymakers and advisors determined that the low fertility rate could not be solved without changing the gendered care system and addressing the incompatibility of working and mothering in South Korea.^3,4 Childbirth promotion policies were expanded to include policies on childcare, maternal health support, and work–family balance. These pronatalist policies could be viewed as benevolent in their support and elevation of maternity and paternity.⁵ The current president, Moon Jae-in, is expected to reinforce family-friendly policies, such as the expansion of parental leave and bolstering support for single mothers. As they challenge gender inequality, the Moon administration's pronatalist policies could be interpreted as being more progressive than previous population control policies, which focused on individual women's reproductive capacity.

However, although the government has provided unprecedented incentives to couples seeking to have children, such as expanded maternal/paternal leave, financial aid for infertile couples, and childcare benefits, ironically, reproductive health indicators, such as maternal mortality and infant mortality, have barely improved. In 2014, the maternal mortality ratio was 17.2 per 100,000 live births,⁶ which is high compared to the average maternal mortality ratio (6.0) among OECD countries.⁷ Furthermore, the number of very-low-birth-weight infants has increased by five times over the last 20 years in South Korea.⁸ In a period when childbirth promotion is considered a more important political agenda item than ever before, the interpretation of different reproductive health indicators should be critically examined to determine whether the pronatalist policies can maintain women's reproductive health as a fundamental and basic human right in South Korea.

This paper aims to delineate how the Korean government regulates the use of reproductive technologies to increase the population of South Korea and analyses how pronatalist policies affect reproductive health and rights in South Korea. The focus is on the use of abortion and Assisted Reproductive Technologies (ARTs) as technologies related to reproductive health and rights. “Reproductive technologies” is defined as all the medical intervention methods related to human reproduction, which are predominantly practiced on women's bodies, including contraceptive technologies, induced abortion technologies, and ARTs. Although these technologies sometimes have opposing purposes, those for assisting pregnancy and for preventing or terminating pregnancies should be understood as existing on a continuum; this becomes particularly clear when the use, promotion, and regulation of reproductive technologies serve to support the population policies of the state. Furthermore, in terms of reproductive health and rights, abortion and ARTs should be discussed together because an individual's rights to “not have a child” and to “have a child” should both be protected as human rights, and individuals should have access to safe and legal medical services to practice their reproductive rights according to the Programme of Action from the 1994 International Conference on Population and Development (ICPD).⁹ When governments conceive of reproductive technologies as major tools to control population rather than a means by which to pursue and uphold reproductive rights, the ways in which such governments and their policies ignore and trivialise issues of reproductive health and rights become important points at which feminist activists and scholars can and must intervene.

Historical and social background

Historically, South Korea was one of the countries that worked to reduce its fertility rate as part of its economic development under authoritarian governments from the 1960s to the 1980s. Since 1953, Criminal Law (Articles 269 and 270) has strictly prohibited abortion on any grounds in South Korea, and abortion remains illegal except in very limited circumstances, such as if the pregnant woman was raped or if the foetus has a genetic disease. Despite this, from the 1960s to the 1980s, abortion was widely accepted and recommended as part of antinatalist policies that were included in the Five-Year Plan for Economic Development. Thus, abortion has been practiced without any restriction or prosecution for the last 50 years, in part because the Korean government, following the recommendations of international development organisations, worked to reduce the total fertility rate in order to receive international aid in the 1960s and 1970s.¹⁰ This means that abortion technologies have historically functioned as birth control technologies in South Korea, contributing to the reduction of its fertility rate. As a result, South Korea's family planning project has been evaluated as the most successful example of a population control project.¹¹ In other words, unlike many countries in “the West”, abortion has long been a political and economic consideration for the Korean government rather than one tied to religious belief or morality.

While the use of abortion technologies was widely encouraged from the 1960s to the 1980s, South Korea's government policies dramatically shifted in the early 2000s as Korea moved toward a low fertility rate. To boost fertility, the South Korean government revived the criminal code on abortion, and in 2005, the government set up The Master Plan for the Prevention of Illegal Abortion.¹² An interview with the Minister of Health and Welfare suggested that the reason the government established abortion prevention policies was to increase population growth rather than to address reproductive health concerns.¹³ In this interview, the minister mentioned that if they could reduce abortion rates by half, it would significantly help increase the total birth rate of the country. In 2018, the South Korean government amended the Medical Service Act to increase the penalties enacted on abortion service providers to include the suspension of their licences for a month.* In response to these changes in the law, the Korean College of Obstetrics and Gynaecology decided to stop performing illegal abortions from August 2018—a commitment they have continued to uphold—and feminist activists have engaged regularly in mass rallies to advocate for safe and legal abortion in South Korea.¹⁴

On the other end of the reproductive technologies spectrum, since 1985 when the first in-vitro fertilisation (IVF) baby was born in South Korea, the demand for ARTs has been steadily climbing along with the growing number of couples who were diagnosed as infertile, which in 2010 reached approximately 200,000 diagnoses annually.¹⁵ Although IVF was used successfully as early as the mid-1980s, the use of ARTs was not widely accepted throughout the 1980s and 1990s. During that period, the major discourse about the use of ARTs tended to focus on how the new technologies were potentially dangerous because they challenged traditional family systems, values, and gender roles. Thus, when ARTs were introduced to Korean society, the mass media villainised the infertile women who were using them because they believed that their use was related to incest and “bastards”, and they expressed concern that such technologies would one day pave the way for the creation of human factories.¹⁶ Furthermore, from the 1970s to 1980s, infertility was not considered a social problem in South Korea because sterilisation, contraceptive technologies, and abortions were considered more important as they served to help reduce the total fertility rate.¹⁷

Since the 2000s, the demand for ARTs in South Korea has been increasing rapidly as people delay marriage and childbearing (delayed pregnancy is one of the major factors that causes infertility). During the last 26 years, the average age of a woman's first marriage in South Korea has increased from 24.8 in 1990 to 32.7 in 2016.¹⁸ The delayed marriage trend is closely connected to delayed childbearing because marriage is considered a precondition for conceiving a baby in South Korea, where only 1.9% of births occur in single mothers.¹⁹ When South Korea's fertility rate dropped to the lowest level in the world in 2005, infertile women's requests for government assistance were finally recognised,²⁰ and as previously noted, in 2006, the government launched the Infertile Couple Support Policy. To explain their rationale for supporting IVF treatments for infertile couples, the Ministry of Health and Welfare highlighted that the success rate of infertility treatment is over 50%, and if half of the infertile couples in the country, who comprise 10–15% of couples within fertile age groups, succeed in conceiving, tens of thousands of IVF babies would be born.²¹

Although the eligibilities and ranges of covered treatments have changed between 2006 and 2016, in 2016, infertile couples could receive approximately $1,900 USD for each IVF cycle. In 2015, a total of approximately $80 million USD was invested in the ART subsidy programme. The budget of The Infertile Couple Support Policy makes up over 50% of the total budget for the government's childbirth-promotion-related policies, including provisions for childcare costs. As a result, the total number of infertile patients who used ARTs in South Korea increased from 58,754 in 2000 to 209,319 in 2014, and the number of IVF babies was estimated at 6% of total births in 2017, possibly an underestimate as this figure only includes government-supported IVF.²² In 2017, The Infertile Couple Support Policy was extended so that all types of ARTs are covered by the national health insurance.

Abortion and contraceptive technologies

Between the 1960s and 1980s, many Korean women were encouraged to use abortion and contraception for the purpose of reducing fertility rates. The accessibility of these reproductive technologies, however, did not guarantee women's reproductive health and rights because the main target of The Family Planning Programme was, in fact, women's bodies. Although vasectomies were more convenient and effective, only tubal ligation was widely practiced as a surgical sterilisation method.²³ The Lippes Loop, an early version of an intrauterine device (IUD), was still at the stage of experimentation in the United States with several side effects reported, yet it was used by the Korean government in over 100,000 cases annually in the mid-1960s.²⁴ Induced abortion was widely accessible before the population policy turned in the pronatalist direction; nevertheless, women who needed abortions could not expect the best medical treatment or appropriate information because abortion remained illegal de jure.

Since 2005, when abortion was framed by the government as a demographic challenge, many Korean women have been forced to engage in unsafe abortions. As maternal mortality is closely related to unsafe abortion in many countries,²⁵ the serious crackdown on illegal abortions starting in 2010 could be considered one of the reasons contributing to the increase in South Korea's maternal mortality, which rose from 12.0 in 2008 to 17.2 per 100,000 live births in 2011 (Statistic Korea, 2015),²⁶ although it would be difficult to prove a direct correlation. Between 2008 and 2010, the cost of having an abortion in a clinic skyrocketed to 10 times its previous amount, and fake medical abortion pills were traded on black markets. A teenager died as a result of her late-term abortion surgery because she was not able to find an abortion clinic earlier on in her pregnancy.²⁷ However, tragic situations like this continue to be repeated. Gynaecologists have refused to perform abortions because of the government's decision to strengthen its punishment of abortion providers even though the Constitutional Court is currently reviewing the abortion ban.

If the government wants to reduce abortion rates, a reasonable approach might be to reduce unwanted pregnancies. However, from 2004, the use of contraceptive technologies, including sterilisation surgeries, oral contraceptive pills, and emergency contraceptive pills, was not covered by the national health insurance because the government announced that if they supported contraceptive methods, it would be in conflict with their pronatalist policies. Thus, while IUDs and vasectomy surgeries were covered by the national health insurance until 2004, from 2005, vasectomy reversals and IUD removals became eligible for insurance coverage instead. Furthermore, the government's official response to the national petition for the decriminalisation of abortion in 2017 was that they would reinforce support for single mothers and promote adoption. As many empirical studies have shown, there is no relationship between abortion regulation and fertility rates; as such, the current antiabortion policies in South Korea will likely not be effective in boosting the country's population. More importantly, though, such restrictive policies could contribute to an increase in the number of unsafe abortion procedures.

Assisted reproductive technologies

The current accessibility of ARTs for infertility has increased through governmental support, with 70% coverage under the national health insurance. Such accessibility does not necessarily promote or ensure women's reproductive health. Preterm births and multiple pregnancies are more common. In South Korea, the preterm birth rate has increased from 2.5% in 1995 to 6.3% in 2012, closely related to the increasing number of multiple pregnancies. Among individuals using IVF, the multiple pregnancy rate was 51.2% in South Korea in 2006²⁸ and 30% worldwide,²⁹ and the Korean government has revised laws about maternity leave to provide additional support for mothers who give birth to twins or triplets (e.g. extended maternity leave). As twins become a “normalised” phenomenon, some couples are known to use IVF to have twins even though they are not infertile as a kind of “planned parenting” so that the couples can have two children but avoid taking maternity leave twice. In 2015, the government finally made guidelines to regulate the number of transplanted embryos (which results in multiple pregnancies and preterm births), but the dangers are discussed in terms of the harmful effects on foetuses or newborn babies rather than on the pregnant women themselves. The government guidelines are seen by IVF clinics as recommendations, and many ignore them because a clinic's success rate is the most important factor used to show the quality of their technologies and services. Under these circumstances, the use of ARTs has simply functioned as a means to increase the number of newborn babies, and the medical and health risks for infertile women are both overlooked and trivialised.

As the number of multiple pregnancies grows, the number of selective abortions has also increased (i.e. procedures that reduce the number of foetuses in a pregnancy). When used as a supplementary technology that supports ARTs, the South Korean government has allowed the practice of selective abortion even though, under general circumstances, abortion is strictly prohibited in South Korea.³⁰ This ironic situation reveals a lack of consistent direction of government pronatalist policies which, rather than ensuring and promoting women's reproductive health, have other concerns of population control.

Conclusion

The policies outlined above represent a critical point for reproductive health and rights in South Korea. When pronatalist policies are practiced as a tool for manipulating population, women's reproductive health and rights can be threatened. Korean feminist activists, reproductive rights groups, and social movement activists have called for the abolition of the criminal codes of South Korea's abortion law since 2017, arguing that individual women should decide whether they have a child or not and that women's reproductive rights should not be determined or regulated based on population policies. If abortion were legalised in South Korea, access to safe and legal abortion would only be one step toward supporting and upholding individuals’ reproductive rights. Conceptualising reproductive rights as a basic human right should not be affected by government politics following demographic changes. The right to have a child and the right to not have a child should both be respected and protected by the government, and the use of reproductive technologies to uphold these rights should contribute to the promotion of individuals’ reproductive health.

Disclosure statement

No potential conflict of interest was reported by the author.

ORCID

Sunhye Kim http://orcid.org/0000-0002-2265-5804