The hidden crisis of China’s boom in premature births
Amid China’s decline in birth rate, there has been a rise in premature births. This has proven difficult for many new parents, who sometimes do not have the necessary funds or experience to deal with the associated challenges. Thankfully, there are avenues to get help.
(By Caixin journalist Liu Xuhan)
When Yangyang was born, he was the size of his father’s palm, weighing just 0.8 kg. Born at 25 weeks and two days — just over six months — he was one of 10.6 million babies born across China that year. Today, Yangyang is four years old, a fortunate survivor in a demographic cohort where many others never made it past their first breaths.
Yangyang’s arrival brought immediate and terrifying complications for his father, Zhang Xiaojiang: neonatal respiratory distress syndrome, pulmonary hypertension and intracranial haemorrhage. For weeks, Zhang could only see his son through photographs taken by doctors inside the neonatal intensive care unit (NICU). In the images, tubes crisscrossed Yangyang’s tiny body, his ribs clearly visible beneath translucent skin.
The cost of keeping him alive in the NICU exceeded 10,000 RMB (US$1,433) a day. The financial and psychological pressure caught the family off guard, yet the sight of the fragile life they had brought into the world spurred them on. “As long as there was a glimmer of hope, we had to persist with treatment,” Zhang said.
Yangyang’s struggle is becoming more common in China, where the rate of premature births is rising even as the total number of newborns plummets. According to a study by Wu Tianchen and colleagues from the Department of Obstetrics and Gynecology at Peking University Third Hospital, published in the Chinese Journal of Perinatal Medicine in 2025, China’s preterm birth rate rose from over 5.1% in 2017 to nearly 6.6% in 2022. The rate of early preterm births rose from more than 1.3% to over 1.4% over the same period.
This rise comes against the backdrop of a deepening demographic crisis. Data from the National Bureau of Statistics shows the birth rate has fallen from 13.38 per 1,000 people in 2001 to 6.77 per 1,000 in 2024, with just over 9.5 million births recorded nationwide that year. This divergence means that while fewer babies are being born, a growing proportion of them are entering the world in a fight for survival.
Making the decision to treat is rarely simple. Families are hemmed in by limits on medical resources, financial constraints and the specter of severe complications.
There are multiple factors behind the trend, said Yang Chuanzhong, director of the neonatology department at Shenzhen Maternity and Child Healthcare Hospital, who once successfully treated a “micro-preemie” born at 21 weeks and four days. An increase in older expectant mothers, the widespread use of assisted reproductive technologies, and a higher proportion of second and third children are all driving up preterm rates, he told Caixin. High societal stress levels also play a role. For China’s medical community, prioritising the rescue of these infants has become an urgent task.
A difficult choice
Thanks to medical advances, survival is no longer an insurmountable barrier for many premature infants. Chinese Medical Association guidelines from 2024 indicate that the survival rate for ultra-premature infants born at or after 26 weeks in China now exceeds 80%, approaching levels in developed nations. However, regional disparities remain stark, and survivors often face long-term disabilities. Crucially, infants born before 28 weeks still face a high likelihood of having their treatment withdrawn.
A real-world cohort study conducted by the Department of Neonatology at the Shandong Provincial Hospital, affiliated with Shandong First Medical University, examined 1,163 live births between 24 and nearly 28 weeks gestation from 2010 to 2019. The study found that 74.1% of deaths in this group resulted from families abandoning or withdrawing medical treatment.
Making the decision to treat is rarely simple. Families are hemmed in by limits on medical resources, financial constraints and the specter of severe complications. Liu Yutong recalls the blur of her C-section, seeing doctors work on her daughter for a long time without hearing a cry. Her daughter, Ziyu, was born at 27 weeks and five days, weighing 0.86 kg with no heartbeat or spontaneous breathing.
Ziyu was diagnosed with bronchopulmonary dysplasia (BPD), a chronic lung disease common in premature babies whose lungs are undeveloped or damaged by the mechanical ventilation needed to keep them alive. Zhang Huayan, director of the Neonatology Center at Guangzhou Medical University’s Maternity and Children’s Medical Center, explained that BPD is essentially a “byproduct” of medical progress — as more fragile babies are saved, more suffer lung damage from the necessary life support.
After three months in intensive care in Shanxi province, Ziyu could not be weaned off oxygen. Doctors advised Liu to give up, admitting they had “never seen such poor lungs”. But Liu refused to accept that verdict. She transferred her daughter to a hospital in Beijing. She vividly remembered holding Ziyu while she was still attached to a ventilator. Resting on Liu’s chest, Ziyu felt impossibly light and breathed with exhausted effort. Yet when Liu sang to her, the infant raised a tiny hand to cover her ear.
For others, the trouble isn’t with breathing, but feeding. Chen Hong’s son, Jiarui, born at just over 27 weeks, developed necrotising enterocolitis, a severe gastrointestinal emergency where intestinal tissue dies. While other babies consumed 10 ml of milk, Jiarui struggled with 3 ml. A 5-ml feed triggered an infection. His stomach bloated, and his skin appeared transparent.
Chen faced a grim gamble. The local maternity hospital lacked a surgical unit. She decided to transfer Jiarui to Beijing, hoping that if surgery became necessary, her son would be in the right place. It paid off. After a week of conservative treatment in the capital, Jiarui underwent a successful surgery. But the ordeal continued with readmissions for blood in the stool and hernias. Chen recalled sitting in hospital corridors in 2022, terrified that a doctor approaching her meant bad news.
“The most difficult group to save, with the highest mortality rate, is currently those under 28 weeks,” Yang said. Even if they survive, the risk of long-term sequelae like brain damage or lung disease weighs heavily on parents, often leading them to decline treatment.
China’s clinical threshold for viability has traditionally been high — 28 weeks or 1,000 grams — whereas developed nations often set the standard at 24 weeks or even 20.
Parents interviewed by Caixin confirmed that doctors often presented the option to give up. Chen recalled a doctor warning her that saving an ultra-premature baby could result in “ren cai liang kong” — a Chinese idiom meaning the loss of both the person and the wealth spent trying to save them. Despite a family income of less than 100,000 RMB a year and daily hospital bills exceeding 3,000 RMB, Chen decided to proceed. “I thought, wouldn’t it be too cruel to give up the child over money?” she said.
Sometimes, however, medical reality forces the hand of parents. Yangyang, the 4-year-old survivor, had a twin sister named Hanhan. While Yangyang fought through his complications, Hanhan’s condition deteriorated. Doctors listed a litany of defects: underdeveloped heart, meningitis, pulmonary hypertension. A severe brain bleed left her unable to breathe independently, with a prognosis of permanent paralysis.
“It wasn’t a decision made in a day,” Zhang said, his voice choking with emotion. “We struggled for a long time. In the end, we thought, rather than letting her live without quality or emotion like a vegetable, it was better to let go.” Zhang only saw his daughter three times: at birth, in the ambulance to Beijing and finally in their rental apartment where she passed away after they withdrew care.
The definition of viability also shapes these outcomes. China’s clinical threshold for viability has traditionally been high — 28 weeks or 1,000 grams — whereas developed nations often set the standard at 24 weeks or even 20.
Experts argue this higher threshold reduces the willingness of obstetricians and families to aggressively treat babies born before 28 weeks, effectively categorising them as late miscarriages. The 2024 guidelines now advocate active treatment for those born at 26 weeks or later and suggest not abandoning those between 24 and 26 weeks if the family consents.
Three fronts
For families who choose to fight, the battle is fought on three fronts: financial, practical and emotional. The Beijing Chunmiao Charity Foundation, which has funded medical care for nearly 4,000 premature infants as of June 2025, notes that economic distress is the most immediate request from parents.
A survey by the foundation and Renmin University of China found that while 41% of premature birth families had an annual income below 50,000 RMB, half faced medical bills between 100,000 RMB and 200,000 RMB. Nearly 87% of surveyed families had to pay a “catastrophic health expenditure”, which the World Health Organization defines as out-of-pocket health costs exceeding 40% of household capacity.
Zhang Xiaojiang, a farmer from Hebei province, spent over 500,000 RMB on his twins, with 200,000 RMB coming out of pocket — more than three times his household’s annual income. Chen Hong and her husband, working in tourism, saw their income evaporate during the pandemic just as Jiarui was born. “At our hardest moment, we had practically nothing in our pockets and ate instant noodles for a week,” she said.
... systemic support is scarce. Only about 15% of families feel they receive adequate social support.
The pressure did not end at discharge. When Liu Yutong brought Ziyu home after 180 days in the hospital, she realised the hospital had been a safety net she no longer had. Ziyu required home oxygen and a feeding tube. Once, while cleaning the ventilator, Liu removed the nasal mask only to see her daughter turn purple from hypoxia. “For a young person with no medical knowledge, it was a terrifying scene,” she said.
Many parents are ill-equipped for this level of care. The Chunmiao Charity Foundation’s research indicates that roughly one-third of parents feel overwhelmed by medical terminology and lack sufficient time to communicate with doctors. Without professional guidance, mistakes happen. One family hired a nanny who used feeding volumes appropriate for a full-term baby, causing the premature infant to suffer gastrointestinal bleeding.
To bridge this gap, some hospitals are establishing family integrated care NICU allowing parents to enter the ward, provide skin-to-skin contact, and learn nursing skills. However, these facilities, along with transitional wards designed to prepare families for discharge, are not yet widespread in China.
Premature infants require monitoring for years to track development, but that can be difficult in China. Rural families often cannot afford the travel costs to return to city hospitals, and local county hospitals frequently lack paediatric departments...
Through it all runs a current of emotional trauma. Ren Ruohui, a medical social worker, describes the journey as a psychological struggle for parents, marked by panic, guilt and a desperate need for certainty. Yet, systemic support is scarce. Only about 15% of families feel they receive adequate social support. While policies encourage the integration of social workers into hospitals to provide psychological and resource aid, actual implementation lags. Social workers are rare, and charitable organisations like the Chunmiao Charity Foundation cannot meet the overwhelming demand alone.
Building a rescue network
Creating a safety net for these fragile lives requires a coordinated system connecting prenatal care, high-level hospital intervention and community support.
Experts advocate for a tiered diagnosis and treatment model similar to that in Japan. Ideally, high-risk deliveries should occur in hospitals equipped with provincial-level neonatal centres. When that isn’t possible, rapid transfer networks are vital. However, China’s referral system remains largely based on guidelines rather than mandatory protocols, and many grassroots hospitals still attempt to treat high-risk cases beyond their capabilities.
Fujian province offers a model for what might be possible. The Fujian Children’s Hospital has established a provincewide emergency transfer network that has moved over 4,000 critically ill children in five years. Crucially, strictly for Fujian residents or permit holders, the transfer is free. “This way, parents don’t have to make decisions based on money,” said Lin Yunfeng, director of the neonatology department. “They only need to consider if the child can be saved.”
The challenge extends to follow-up care. Premature infants require monitoring for years to track development, but that can be difficult in China. Rural families often cannot afford the travel costs to return to city hospitals, and local county hospitals frequently lack paediatric departments, leaving these children in a medical void after discharge.
Social organisations are attempting to fill in the cracks. Between 2015 and 2025, the Chunmiao Charity Foundation worked together with 68 hospitals and seven social organisations to build a preliminary rescue network. If a social work agency in Kunming receives resources but lacks local cases, it offers help to families in neighbouring Guizhou province or the Xizang Autonomous Region.
South China’s Guangdong province has established social work stations in every township and street, allowing medical social workers to connect discharged families with community-level support. Yet, Wen Dongbao, a project director at a social work resource centre in Guangzhou, noted that funding remains a bottleneck. “Most policies encourage hospitals to develop medical social work,” Wen said, “but who pays for it? The hospital, the civil affairs department, or the health system? We need more specific systemic support.”
This article was first published by Caixin Global as “In Depth: The Hidden Crisis of China’s Boom in Premature Births”. Caixin Global is one of the most respected sources for macroeconomic, financial and business news and information about China.
