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2. Background
2.1 Taiwanese Fertility Transition
Taiwan has undergone a well-documented demographic reversal over the last century, transforming from an island with high fertility to low fertility in the 1950s, and from low fertility to sub-replacement levels beginning in the 1980s. Fertility decline on the island has lowered fertility from its peak TFR of 7.04 children born per woman in 1951 to a stagnant 1.75 between 1986 and 1997, decreasing again to approximately 1.12 by 2007, where it remains stable today.
Beginning in the 1920s, the decreasing death rate fast-tracked Taiwan’s population growth.
Combined with an increase in birth rate after World War II, Taiwan’s fertility peaked in the 1950s with a crude annual birth rate of over 40 children per 1000 population. The combination of a household registration system and periodic national knowledge, attitude, and practice (KAP) family planning surveys since 1965 reflects long-standing state interest in tracking population trends, making Taiwanese fertility an ideal case for exploration.
The 1950s to 1980s was generally a period of fertility reduction for Taiwanese women of childbearing age. Government introduction of the 1964 Family Planning Program, combined with increased opportunities for private economic gain, radically influenced Taiwanese childbearing preferences. The program employed civil servants as Pre-pregnancy Health
Workers (PPHWs) or part-time Village Health Education Nurses (VHENs) in each of Taiwan’s 361 townships, tasking them with traveling door-to-door to private residences to recruit women into the program (Montgomery & Casterline, 1993). Through the family planning program, PPHWs provided recruits with various contraceptives such as intrauterine devices, oral contraceptives, condoms, and distributed propaganda encouraging smaller family sizes.
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Presence of the family planning program during Taiwan’s fertility decline from the 1960s onward and high usage of contraceptives by Taiwanese women indicates the program was
successful. In their analysis of diffusion of fertility control in Taiwan, however, Montgomery and Casterline (1993) find that the actual estimate of the program impact varies dramatically
depending on statistical design. Weighted least squares regression shows the program reducing marital fertility no more than 5% from 1968-80, with increases in marital fertility in the early years of the program, while their diffusion based curves put that number somewhere between 5 and 22%. Li (1973) supports the claim that the family planning program neither induced nor increased Taiwanese fertility decline 1954-1970, pointing to evidence from Taichung (a target area of the program) to show that action programs had little appreciable effect on childbearing.
Rather, they point to decreased infant mortality as likely explanatory variable throughout the country, and rising educational levels as an important urban factor.
Nuptiality and martial fertility have also been cited as causes for Taiwanese fertility decline. Sun, Lin, and Freedman (1978) first showed that about 1/3 of the decrease in birth rate 1961-1984 was caused by changing marriage patterns, while in contrast Feeney (1991) claims that nuptiality contributed nothing to fertility change in this period. His study shows a sustained high level of marriage and motherhood for Taiwanese women throughout the 1980s, asserting contrast between his and the Chang, Freedman, and Sun (1987) study is due to methodological differences related to his focus on women’s probability of first marriage and Chang et al.
examining age specific birth rate. However, his later claim that Taiwan “may not be below replacement level after all” (in the 1990s) belies the strength of that argument (Feeney, 1991, p.
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476). Chang (2006) found that 2/3 of the decrease in birth rate 1965-1980 was attributable to declining marital fertility, and the remaining 1/3 due to nuptiality patterns.
In 1983, the combination of an extremely low death rate and large cohort of women of childbearing age resulted in a high population growth rate, which prompted the Taiwanese government to push a second wave of the family planning program. During the 1980s, statistics show fertility reduction for women under 30 years of age and a trend of delaying childbearing until the late twenties; by the 2000s the average age of mothers at first birth was into the early thirties (see Figure 1; plotted with data from R.O.C. Ministry of the Interior). Despite overall fertility decline, martial fertility actually increased between 1985 and 2007 (Luoh, 2007 as cited in Lee & Lin, 2016). Taiwan has extremely low extramarital fertility, and childbearing has been
20.0
1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 Maternal Age
Fertility Rate
Fertility change in Taiwan, 1975-2016
total fertility rate replacement rate fertility
average age of mothers at birth average age of mothers at first birth Figure 1: Fertility change in Taiwan, 1975-2016
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named as the de facto cause of marriage for many Taiwanese women (K. Chen & Yang, 2005 as cited in Lee & Lin 2016).
2.2 Pronatal Fertility Policy
Taiwanese fertility policy reflects its demographic reversal, lagged by two decades. Clear antinatalism underlies the 1964 national family planning program, which boosted contraceptive use and promoted the social and economic advantages of small families; by 1992, however, the revised Guideline for Population Policy acknowledged the need for more stable population growth in Taiwan. The “link between Taiwan’s family planning program and rapid economic progress” obstructed the state’s ability to increase Taiwanese family size, as did pressure to adopt a universal pension plan in the late 1990s (M. Lee & Lin, 2016, p. 270).
Explicit pronatal policy did not pass until the 2008 publication of a Pronatal Population Policy White Paper, due in part to backlash from feminist and environmentalist groups
throughout the 1990s and 2000s, who questioned the gendered and environmental consequences of increasing the national population. Actual quantitative fertility targets were not published until the 2013 revision of that paper, along with strategies to address low fertility. In the midst of this controversy, 1995 passage of National Health Insurance (NHI) in Taiwan included several incentives for higher fertility, such as free prenatal and neonatal care, child delivery, child health insurance, one-month cash benefit for childbirth, and complete premium coverage for low-income families. By the end of 1995, 97% of the population had registered for NHI coverage (L.
Chen, Chen, & Yang, 2008). Prior to NHI, only women covered by Government Employee Insurance had access to free prenatal care through public health insurance. Given the pronatal incentives in NHI, the present study aims to determine the effect of nationwide implementation of National Health Insurance on Taiwanese fertility.
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