Women’s Health Takes Two Steps Forward, One Step Back

Taiwan’s laws on women’s reproductive rights are an odd mix of progressive and outdated, producing widely disparate stories of joy and dejection.

Mei-chun (not her real name) was in a quandary so difficult she felt she had no choice but to call all her friends with a desperate plea: did anyone know any way she could get an abortion without the permission of her husband? “She is at her wit’s end,” her friend told me, hoping I might have a solution.

Not only could I not help this woman, but I was shocked to find out that a married woman in Taiwan – in 2022 – needs her husband’s sign-off to get an abortion, or “artificial miscarriage,” as they are euphemistically referred to here. It seemed archaic, and in the case of Mei-chun, it was excessively cruel.

Years before this incident, Mei-chun separated from her husband. Although they are no longer together, they decided not to divorce for the sake of their child, whom they co-parent on amicable terms. “For her, it would be a humiliation to have to ask him for this,” said her friend. “She’s desperate and there isn’t a way out.”

Meanwhile, Ashley Smith (her real name) is over the moon – thanks to government support, her family might be expanding soon. Smith moved from the U.S. to Taiwan more than nine years ago, where she eventually met Oscar, a Taiwanese man whom she married. The Taiwan government has contributed NT$100,000 to help her with In-Vitro-Fertilization (IVF) treatments at a provider of her choice, with more aid available if necessary.

Smith is still young at 33 but needs IVF because she suffers from Polycystic Ovary Syndrome (PCOS). With 19 eggs from her first egg retrieval, Smith and her doctor at the Dianthus Clinic are optimistic that she and her husband’s fiercely wanted children will eventually be on the way.

Ashley Smith says she is grateful for the support offered to couples undergoing IVF treatment in Taiwan.

“Of course the money is very helpful, but more than that, I feel like the government here is taking such good care of us,” says Smith. “I feel like I belong here, and my family is being supported.”

Taiwan is known not just for its comprehensive health coverage, but also for being one of the more progressive countries in the region when it comes to gender issues. From the President down, women in Taiwan occupy many positions of power.

But with healthcare experiences as disparate as Mei-chun’s and Ashley’s, are the reproductive rights and dignities of women actually respected? Mei-chun was ultimately able to get consent from her estranged husband for the termination, but what if he had said “no”? Or what if this happened to a woman in a domestic violence situation?

Lin Yi-ching, head of maternal and child health at the Health Promotion Administration under the Ministry of Health and Welfare, says that help is on the way.

“There is a proposed amendment to the Genetic Health Act that will remove the stipulation that women must seek consent from their husbands before terminating a pregnancy,” she says. “This will bring our laws in line with the UN’s Convention on the Elimination of All Forms of Discrimination Against Women.” The draft amendment, which was proposed in April, could go through the legislative process and become law as early as 2023.

Boosting health and fertility

Meanwhile, Lin’s office tries to do more to support women like Ashley who want to start families and reverse Taiwan’s dwindling population. In 2021 there were just 154,000 births in Taiwan, down from 200,000 in 2007. During that time the average maternal age for the first child went up from 28.5 to 31.2.

“Women are marrying later, having babies later – that trend is undeniable – but now more women are trying to have babies and cannot,” says Lin. “Experts say one in seven Taiwanese couples want to have children but cannot due to fertility issues.”

The government is applying a dual-track approach of gently encouraging women to take full advantage of their prime childbearing years while supporting older mothers with financial and other help. IVF assistance, which used to be means-tested, is now available to all Taiwan-registered couples, although subsidies are still more generous for low-income families. The number of covered prenatal examinations has increased from 10 to 14. Paternity leave has been put on the same legal footing as maternity leave and couples can choose if they want to take it in tandem or one parent at a time.

Improving the birth rate is a difficult task, and one that society at large must tackle – not just women, says Lin. “It is natural for more and more women to seek higher degrees, and then later on for couples to want to buy property, and with property prices so high, dual incomes are then necessary to pay the mortgage.” The creation of more public childcare centers, which is not under the remit of Lin’s office, is ongoing.

Huang Jian-Pei, secretary-general of the Taiwan Association of Obstetrics and Gynecology, does not believe the trends of delayed parenthood and fewer babies are irreversible. Although medical science has enabled women to delay motherhood, it is never going to be ideal,  and economic problems should have economic solutions, notes Huang.

“Look at Germany, look at Singapore – the countries that are actually having some success in reversing the demographic trend are investing massively, much more than Taiwan,” he says. “What if I told you we can double our birth rate right away? I believe we can if we give a NT$4 million subsidy per child.” Given the high cost of raising a child, Huang believes a generous subsidy would encourage more people to have children.

“When I started practicing, around 5% of my patients who are expecting would be considered advanced maternal age (older than 34),” he says. “Now it’s over a third.”

Women’s health in Taiwan has generally made tremendous strides, says Huang, who practices as an OB/GYN at Mackay Memorial Hospital in Taipei. Rates of cervical cancer have come down by more than 70% from when he first started practicing more than two decades ago.

“We were at 30 incidences of cervical cancer (per 100,000),” says Huang. “Now we are below eight, and we are aiming for four within a decade.” Taiwan has achieved this through aggressively promoting free annual pap smear tests, which are available to women from the age of 30 (although the World Health Organization recommends women start testing at the age of 25).

Pap smear tests can detect cervical cells that have been changed by the Human Papillomavirus (HPV) before it develops into cancer. The HPV vaccine is offered free of charge to young women of high-school age, although Huang thinks it should be universally available. “Men also suffer from HPV and vaccines are always more effective when they are universally given.” 

The funds for preventive health measures come from various departments within the government, but not as a part of the National Health Insurance (NHI), which focuses on treatment rather than prevention. While Huang is in favor of more coverage, he says the real problem is that not enough women are taking advantage of the free or low-cost tests.

“We have free breast cancer screenings every two years for women above the age of 45 and free pap smears annually,” he says. “Bone density screening is not covered but is very low-cost at NT$1,000. But too many women just don’t do it.”

Termination of pregnancy is legal for up to 24 weeks in Taiwan. Beyond that, a strong case needs to be made for an abortion to be approved. Typically accepted arguments include health of the mother, lack of viability of the fetus, or incest.

“The survival rate for babies born prematurely at 24 weeks is already 60-70%,” notes Huang. “At 28 weeks, it is 90%, so after 24 weeks you have to balance the desire of the mother with the rights of the baby.”

Like Lin, Huang is confident that needing the spouse’s consent before terminating a pregnancy will soon be a thing of the past. “It seems like at long last we have consensus on all sides that we need to rectify this,” he says. “As a practitioner it will be a welcome change indeed.”

No time for complacency

“Consensus? Consensus among whom? Certainly not the religious groups!”

That was the riposte by former legislator and current Chairwoman of the women’s advocacy non-profit organization Taiwan Women’s Link Huang Shu-ying, who has been fighting the spousal consent rule for over a decade – first as a legislator, then as an activist.

After endless battles with anti-abortion forces in Taiwan, led by Christian, Buddhist, and even Daoist activists, Huang says nothing about the proposed amendment can be taken for granted.

“People are being way too optimistic, and they don’t seem to understand the extreme tactics of the anti-abortion groups,” she says. “If anything, I am worried that the amendment process will open a Pandora’s box, and anti-abortion activists will use it as an opportunity to make reproductive rights less accessible than before in Taiwan.”

Huang is well-versed in the high-octane tactics combined with innocuous wordsmithing that anti-abortion groups use; the same playbook that worked well in the United States to strip women of their reproductive rights.

“They’ve called me ‘murderer’ and protested outside my office showing terrible videos,” she says. “Meanwhile they’ll advocate for ‘more time to think and more counseling to support women,’ which sounds harmless but are tactics to make it harder for women to control their own bodies.”

“These groups are well-resourced – they count legislators in both major parties as their members and they are emboldened seeing the success of similar groups in the United States,” she says. “Do not underestimate their ability to mobilize.” Huang notes that the 2024 elections might make even neutral or pro-choice politicians unwilling to get entangled in a contentious issue in 2023, when  amendment of the Genetic Health Act is slated to go before the legislature.

Huang is also bothered by the assumption that reversing the birth rate slump is necessary for Taiwan to thrive as a nation. “All this talk about ‘why aren’t women having more babies’ and ‘how can we make women have more babies’ is seriously annoying. What if women just want to have other achievements, careers, and goals?”

A growing population is not necessary to support the economy as technology replaces labor, says Huang.

“Look how many people we used to need to tend a field, and how AI is going to completely change our world. There are so many ways to solve Taiwan’s economic problems that don’t put the burden on women, and it will probably be better for the planet.”