Healthy debate over premarital checks

Growing calls for potential couples to take tests, report Yang Wanli and Li Yingqing from Yunnan.

'If you found any health problems that might affect whether or not you can have a child, would you still get married?" asked Xue Peng.

The 32-year-old engineer from Beijing, who married in 2006 after dating his wife for three years, was commenting on the rise in the number of calls for compulsory premarital health checks.

For Xue, the checks impose unnecessary external factors on prospective brides and grooms, factors that may affect the relationship: "Marriage is all about love, which means you are willing to spend your whole life with the other person, in sickness and in health."

Only 7 percent of couples that married in Beijing in 2011 underwent a premarital medical check, but the figure was closer to 100 percent a decade ago.

Compared with rates in other cities or provincial areas, Beijing is at the bottom.

In days gone by, people in China were not allowed to marry without permission from their work units, which insisted on premarital health checks, but the requirement was scrapped when new marriage registration rules came into force on Oct 1, 2003 and the decision was left to the individual.

A few days after those regulations came into force, the Ministry of Health issued a statement emphasizing that premarital physical checks were still helpful because they could identify hereditary and communicable diseases and mental health issues.

The ministry said it would continue to encourage couples to undertake the examination before tying the knot.

However, some misunderstood the new regulations and mistakenly assumed that the checkup no longer existed. Statistics from the Ministry of Health show that the number of people who took the checkup nosedived to 3 percent in 2004 from 80 percent the previous year.

Birth defects

The incidence of birth defects has increased across China in recent decades. The Ministry of Health said in September that three out of every 200 babies born in 2011 had a birth defect, double the rate in 1996.

Those calling for the reinstatement of mandatory premarital health checks blame the phasing out of the procedure for the rise in the number of birth defects.

Most happen in the first three months of pregnancy and can be caused by genetic factors or even a prepregnancy infection. Other factors are at play too. Some defects result from exposure to medicines or chemicals - for example, alcohol abuse can cause fetal alcohol syndrome, which affects growth patterns and can sometimes result in mental health issues.

Birth defects can affect physical appearance or bodily functions, or both. Some, such as a cleft palate, are structural and easily identifiable. Many can be prevented through premarital checkups, and later examinations performed before and during pregnancy.

Ji Lianmei, a doctor at Beijing United Family Healthcare, said that the checkups provide better knowledge of a couple's health and can identify potential birth defects. Every year, around 800,000 to 1 million babies are born with defects or illnesses, such as cardiac problems in China.

"The statistics only record defects in very early infancy. But some defects don't show up until the child is aged 5 or 6 years, so the real number is likely to be even higher than that indicated by the official statistics," said Ji.

Most people in Beijing have a free physical checkup every year, which they believe plays the same role as the premarital checkup, said Ji, to explain the low rate of premarital checks in the city. She added that heavy workloads mean many people are unwilling to spend their free time on the checks.

The rise in the number of birth defects has resulted in calls for the reinstatement of mandatory premarital checks. Some municipal health authorities have decided to promote a one-stop premarital medical checkup to encourage more people to voluntarily undergo the examinations.

Earlier this year, it was reported that Guangzhou, the capital of Guangdong province, had resumed mandatory testing. Although the reports turned out to be untrue, they helped trigger a heated debate. Seventy-two percent of those who responded to an opinion poll conducted by Sina Weibo, China's most prominent microblogging site, were in favor of a return to mandatory testing.

To encourage more young couples to take the test, the Beijing health bureau has provided free checkups for residents since 2009. With Beijing hukou - the permanent residence permit - couples can get the checkup in any of the 19 clinics or hospitals in the city that provide it.

A number of other cities and provincial areas also provide free premarital examinations. Wuhan, in Hubei province, has done so since 2008 and Dalian in Liaoning province started in 2007.

The rate of premarital checkups has risen as a result of the policy, but many people still mistakenly believe that a prepregnancy test plays the same role as the premarital checkup.

"My husband and I undertook the prepregnancy physical checkup and it has even more items than the premarital checkup," said Xu Fang, who refused to have a premarital checkup because of her conviction that marriage is about love not health.

Xu said the free health check provided by the State-run institution where she works guarantees her basic health. "Checkups relating to fertility can be left for the prepregnancy test," said Xu, who underwent the test three months before she became pregnant. She gave birth to a boy in November 2011.

"The list of questions and tests was longer than for the premarital checkup and even included a check on the quality of my husband's sperm. I think it is more meaningful," she said.

"It (the premarital check) cannot be replaced by checkups during pregnancy. If the baby is shown to have a severe health problem, the parents will have to decide whether to have an abortion, which can bring great harm to the mother and also the family," said Li Huajun, director of the obstetrics and gynecology department at the China-Japan Friendship Hospital in Beijing.

He added that the rate of birth defects in China is 10 times higher than in the US and some European countries.

An important aim of the premarital check is to gather basic knowledge about a patient before pregnancy, because the information it provides can be crucial. One of the advantages is that the check can provide clues about whether a woman should take preventive measures, such as using folic acid which can prevent defects such as spina bifida.

A paper written by experts from Peking University's Institute of Reproductive and Child Health shows that 80 percent of women took folic acid when the premarital checkup was compulsory, but the rate fell to 30 percent when the tests became voluntary. Moreover, the number of women taking folic acid in early pregnancy dropped by 20 percent once the checkups ceased to be mandatory.

The paper also indicated that the number of women exposed to risks, including x-rays and alcohol and illegal drugs, in early pregnancy doubled after the publication of the new marriage regulations in 2003.

The premarital checkup also includes a test for HIV and can identify potential problems with the reproductive organs, neither of which can be isolated by regular health checks. If problems are suspected, the doctor will give the prospective parents a checklist of things to watch for during pregnancy.

Free checkups

Standing outside the Xishan district center for women and children's health in Kunming, Yunnan province, 50-year-old Han Lingjie waited for her niece to finish the premarital checkup. Han is a firm believer in the efficacy of the premarital checkup and said it should be mandatory once again.

She said the younger generation is more open about sexual matters and the number of people reporting cases of contagious disease has increased during the past 10 years. For Han, this simply underscores her conviction that the checks must again become compulsory. "When I was young, syphilis and HIV/AIDS were almost unheard of," she said, recalling that 30 years ago lovers often did not even dare to kiss before marriage.

Han said she would not allow her 21-year-old daughter to marry a man with a contagious disease, even if effective treatment was available. "Some people may hide their health problems, so premarital checkups are essential," she said.

But for her niece, 22-year-old Tan Mingyi, the checkup is simply a way of learning more about her health rather than an "entrance exam" for marriage.

"We have known each other for years and even if the checkup suggests health problems, we will still get married," said Tan. She said most of her friends were alerted to the importance of the checkup by their parents and they were positive about it.

"All my friends had the checkup before their marriage registration. We are confident and know that marriage has pros and cons," said Deng Weigang, Tan's fiancee. "We were surprised to discover that the checkup is free. That's great."

Simplified procedures

The Xishan district center has provided free premarital checkups since September 2010. If payment were compulsory, the tests would cost around 300 yuan ($48) per couple. To simplify the procedure, the center has established branch offices in the same buildings as the civil affairs bureau where couples apply for marriage registration.

"The whole process only takes an hour and it's free. So the number of people having the checkups increased sharply last year. People simply said 'Why not?'" said Shan Wenhua, the director of the center.

In autumn 2009, the center tested the use of free checkups. At the time, the civil affairs bureau and checkup office were 5 km apart. Shan said the staff had difficulty persuading people to have the checkup, even though free transportation was provided between the offices.

"They thought it would take half a day. Some people got into the car and then got out again. The distance put them off," he said. "But the premarital checkup is voluntary, so we can only encourage people to take it, we can't force them."

When the new marriage regulations were introduced in 2003, the number of people that had the premarital checkup in Xishan plummeted to less than 2 percent annually. However, the introduction of free checks helped reverse the decline and in 2011, roughly eight in 10 registered couples had the examination. Between January and August this year, the number hit 100 percent.

However, despite the benefits provided by the checks, it seems that some old, romantic attitudes take precedence.

"Marriage is only about love. We are not pigs that need to be screened and tested before being turned into canned meat," said Xue Peng.

Tang Yue contributed to this story.

Contact the reporter at yangwanli@chinadaily.com.cn

(China Daily 11/26/2012 page6)