Intention of having a second child among infertile and fertile women attending outpatient gynecology clinics in three major cities in China: a cross-sectional study.

Lau BH ，Huo R ，Wang K ，Shi L ，Li R ，Mu S ，Peng H ，Wang Y ，Chen X ，Ng EH ，Chan CH ... -  《-》

Fertility intentions to have a second or third child under China's three-child policy: a national cross-sectional study.

What proportion of people want to have a second or third child after the enactment of the three-child policy in China? Under the three-child policy, fertility intention to have a second child was ∼60% (56% of women vs 65% of men), and fertility intention to have a third child was 13% (10% of women vs 17% of men) among the Chinese population. The Chinese government announced the three-child policy on 31 May 2021, allowing all couples to have up to three children. At present, there is a lack of national surveys on the fertility intentions of women and men to have a second or third child under the three-child policy in China. In June 2021, a national cross-sectional survey including 9243 respondents aged 18-49 years was conducted online from 31 provinces in China's mainland using a random sampling method. Data on the intention to have a second or third child were collected by anonymous questionnaire. Descriptive statistics were performed to assess fertility intentions. Multivariate and multinomial logistic regression analyses were used to assess the association between fertility intentions and the investigated factors. Approximately 60% (5493/9243) of the investigated people (55.6% women vs 64.7% men) intended to have a second child, and 13.0% (1203/9243) of them (10.0% women vs 17.1% men) intended to have a third child under China's three-child policy. For non-child respondents, 46.8% of women and 60.4% of men intended to have a second child. For one-child respondents, 47.8% of women and 53.8% of men intended to have a second child. For two-child respondents, 14.4% of women and 25.9% of men intended to have a third child. The mean desired family size was 1.58 children per woman, which was lower than the 1.76 children per man. Notably, the age-specified fertility intentions of men were always higher than those of women. Women with a college or higher degree (adjusted odds ratio [aOR] 0.60, 95% CI 0.42-0.88) and a high-middle (aOR 0.71, 95% CI 0.53-0.95) or high (aOR 0.64, 95% CI 0.48-0.85) household income, as well as men living in urban areas (aOR 0.71, 95% CI 0.58-0.87) and having a high-middle household income (aOR 0.68, 95% CI 0.52-0.90), were associated with a lower intention to have a third child (all P < 0.05). In contrast, men of public service personnel had a higher intention to have a third child than factory workers (aOR 1.44, 95% CI 1.02-2.04, P < 0.05). Meanwhile, approximately one out of five two-child respondents intended to have a third child, while one out of four two-girl respondents (aOR 2.09, 95% CI 1.44-3.04) were willing to have a third child with a strong preference for boys (12.7% for boys vs 2.7% for girls). Economic and childrearing barriers were the leading barriers to having one more child. The online survey might limit the representativeness of the present study's sample. A large sample size was enrolled and a random sampling method was used to increase the sample diversity and representativeness. This study will assist in estimating the impact on population demographic of the three-child policy in China. Multiple efforts are needed to create a fertility-friendly environment for couples, thereby increasing fertility intentions to have one more child and increasing fertility rates. No funding. The authors declare no conflict of interest. N/A.

Jing W ，Liu J ，Ma Q ，Zhang S ，Li Y ，Liu M ... -  《-》

Will a government subsidy increase couples' further fertility intentions? A real-world study from a large-scale online survey in Eastern China.

How many couples with at least one child under 3 years would like to have another one or more child(ren) in Eastern China and will an in-cash subsidy be conducive to couple's fertility intentions? In sum, only 15.1% of respondents had further fertility intentions (FFI) before learning about the subsidy, and the planned in-cash subsidy policy increased respondents' overall FFI by 8.5%. Fertility has been declining globally and has reached a new low in China. The reasons why the Chinese three-child policy was under-realized, and how couples will react to a planned monthly ¥1000 (€141.2) subsidy policy, are not fully understood. During January and February 2022, a cross-sectional online survey aiming to understand families' expenses of raising a child under 3 years old, and couples' FFI, was conducted. During the survey period, 272 510 respondents scanned the QR code. This study reports the findings pertaining to questions on respondents' sociodemographic characteristics, household factors, FFI, and changes in intention from negative to positive after learning about the planned in-cash subsidy. After exclusion, 144 893 eligible responses were included. Respondents' FFI, the effect of a planned ¥1000/month*36 months' in-cash subsidy (€5083.2 in total) on people with a negative FFI before the subsidy, and potential reasons for persistent negative FFI after learning about the subsidy were collected through an anonymous online survey. Stepwise binary logistic regression models were used to select associated factors. The potential fertility rate change and government costs were estimated. A stratified analysis by current child number and sensitivity analysis were also conducted. In sum, 15.7% (22 804/144 893) of respondents were male, 15.1% of respondents reported a positive FFI, and 10.0% (12 288/123 051) without an FFI at first changed their intention after learning about the planned in-cash subsidy policy. For those who still said 'no FFI', 46.5%, 20.6%, and 14.7% chose pressure on housing status, expenses on children's education, and lack of time or energy for caring for another child as their first reasons. FFI was strongest in participants receiving the most financial support from their parents, i.e. grandparents (OR = 1.73, 95% CI = 1.63-1.84 for the >¥100 000/year group), and weakest in those already having two children (OR = 0.23, 95% CI = 0.22-0.24). For those with no FFI before learning about the subsidy policy, respondents with the highest house loan/rent (>¥120 000/year, OR = 1.27, 95% CI = 1.18-1.36) were more likely to change their FFI from 'No' to 'Yes', and those with the highest household income (>¥300 000/year, OR = 0.65, 95% CI = 0.60-0.71) were least susceptible to the policy. In our study population, about 1843 more births every year and an additional 0.3 children per woman were projected under a conservative estimation. Annual estimated cost at the provincial scale would be ¥817.7 (€115.5) million, about 1.02‰ of the total General Public Budget Revenue in 2022. The findings were generally robust in the stratified analysis and sensitivity analysis. Selection bias and information errors may exist in the online survey responses. The large sample size and detailed further analysis were used to minimize such biases. Fertility intentions in Eastern China are rather low. Policymakers should focus more on financial and childcare burdens for a better realization of the three-child policy, including housing, education and childcare services. An in-cash subsidy, which has never been used in China previously, shows promising potential for increasing FFI. However, the application of such policy should be in line with local conditions for better cost-effectiveness regarding fertility-boosting and fiscal sustainability for the government in the long run. This work was supported by the National Key Research and Development Plan of China (2019YFC0840702). The authors declare no conflict of interests. N/A.

Dong WH ，Wang X ，Yuan F ，Wang L ，Gu TM ，Zhu BQ ，Shao J ... -  《-》

Psychosocial experiences of involuntary definitive childless women: a comparative study based on reproductive status.

Do involuntary definitive childless women have lower psychosocial adjustment levels than women with infertility diagnoses actively trying to conceive and presumably fertile women? Involuntary definitive childless women have lower levels of sexual functioning than infertile women actively trying to conceive and presumably fertile women, and higher levels of depression than presumably fertile women. Involuntary definitive childless defines those who wanted to become parents but were unable to do so. Studies have provided evidence about infertility and its psychosocial consequences, but there is a lack of knowledge about the impact of involuntary definitive childlessness, namely on sexual function, social support, marital satisfaction, and psychological adjustment. This associative study was conducted between July 2021 and January 2022 for involuntary definitive childless women and between July 2016 and February 2018 for women with an infertility diagnosis actively trying to conceive as well as presumably fertile women. An online questionnaire announced in social media and gynaecology and fertility clinics was used. The inclusion criteria for all participants were being childless, in a heterosexual relationship and cohabiting for at least 2 years. Specific inclusion criteria for involuntary definitive childless women were: trying to conceive for at least 2 years; not achieving pregnancy because of biological and medical constraints; and not undergoing fertility treatment or being a candidate for adopting a child at time of the study. For women with an infertility diagnosis the inclusion criteria were: actively trying to conceive (naturally or through fertility treatments); having a primary fertility diagnosis; and aged between 22 and 42 years old. For presumably fertile women, the inclusion criteria were: having a parenthood wish in the future; and not knowing of any condition that could prevent them from conceiving. Out of 360 women completing the survey, only 203 were eligible for this study (60 involuntary definitive childless women, 78 women with an infertility diagnosis actively trying to conceive, and 65 presumably fertile women). All participants completed a questionnaire including sociodemographic and clinical data, the Female Sexual Function Index, the 2-Way Social Support Scale, the Relationship Assessment Scale, and Hospital Anxiety and Depression Scale. Binary logistic regression was performed to assess the relation between sexual function, social support, marital satisfaction, anxiety, depression, and reproductive status, adjusting for age, and cohabitation length. Presumably fertile women were used as a reference group. Women were 34.31 years old (SD = 5.89) and cohabited with their partners for 6.55 years (SD = 4.57). The odds ratio (OR) showed that involuntary definitive childless women had significantly lower sexual function than infertile women actively trying to conceive (OR = 0.88, 95% CI = 0.79-0.99) and presumably fertile women (OR = 34.89, 95% CI = 1.98-614.03), and higher depression levels than presumably fertile women (OR = 99.89, 95% CI = 3.29-3037.87). Women with an infertility diagnosis actively trying to conceive did not differ from presumably fertile women in sexual function, social support, marital satisfaction, anxiety, and depression. The majority of childless women underwent fertility treatments, and childlessness for circumstantial reasons owing to lack of a partner was not included, therefore these results may not reflect the experiences of all women with an involuntary childless lifestyle. There was a time gap in the recruitment process, and only the definitive childlessness group filled out the questionnaire after the coronavirus disease 2019 pandemic. We did not ask participants if they self-identified themselves with the groups' terminology they were assigned to. Our results emphasize the importance of future research to provide a more comprehensive understanding of the adjustment experiences of childless women and an awareness of the poor adjustment they might experience, highlighting the need to keep following women after unsuccessful treatments. Clinical practitioners must attend to these dimensions when consulting involuntary definitive childless women who might not have gone through treatments but also experience these adverse outcomes. This study was partially supported by the Portuguese Foundation for Science and Technology. The authors declare that they have no conflict of interest. N/A.

Ribeiro S ，Pedro J ，Martins MV 《-》

The ABC of reproductive intentions: a mixed-methods study exploring the spectrum of attitudes towards family building.

What are the intentions of men and women of reproductive age in the UK regarding reproduction and family building? We identified six main categories of people; Avoiders, Betweeners, Completers, Desirers, Expectants and Flexers, for whom reproduction education strategies should be tailored differently to suit intentions. Several studies have highlighted poor fertility awareness across men and women of reproductive age. As the average age of first-time parents continues to rise, there has been a concerted effort from educators, healthcare professionals, charities, reproductive health groups and government policymakers, to improve fertility awareness. In order to ensure that these messages are effective and to deploy the best strategies, it is important to understand people's reproductive health needs. This study therefore aimed to explore different reproductive intentions to aid tailoring of information to help individuals and couples achieve their family building desires. We conducted a mixed-method study via a UK-wide cross-sectional survey with 1082 participants and semi-structured interviews of 20 women and 15 men who agreed to follow-up interviews. Interviews lasted an hour on average. Ethics approval from UCL Research Ethics Committee. Survey participants were recruited nationwide via online newspaper and social media adverts. Interviewees were purposely sampled to include men and women from the reproductive age range (18-45 years), varying ethnicity and education background. Survey data were analysed using the Minitab statistical software package. Interview data were transcribed and analysed using the framework method. From the survey and interviews, we identified six key categories of people, grouped alphabetically, in a user-friendly manner to highlight a spectrum of reproductive intentions: Avoiders describes respondents who have no children and do not want to have children in the future; Betweeners describes those who already have child(ren) and want more in the future but are not actively trying to conceive; Completers describes those who have child(ren) but do not want more; Desirers describes those who are actively trying to conceive or plan to have child(ren) in the future; Expectants describes those who were pregnant at the time of the study; and Flexers describes those who may or may not already have and are unsure but or open to having child(ren) in the future. Analysis of survey data identified the following proportions in our study: Avoiders, 4.7%; Betweeners, 11.3%; Completers, 13.6%; Desirers, 36.9%; Expectants, 4.1%; and Flexers 28.4% and 2.4% preferring not to answer. There was one 'other' group from qualitative analysis, who would like to have children in the future but were unsure whether they could or had changing views. We recommend classifying as 'Desirers' or 'Flexers' for the purposes of fertility education. A majority of the survey population were trying to get pregnant; were pregnant; or planning to have a child in the future-whether actively, passively or simply open to the idea, with interviews providing deep insights into their family building decision-making. Due to the online recruitment method, there may be a bias towards more educated respondents. We developed a user-friendly, alphabetical categorization of reproductive intentions, which may be used by individuals, healthcare professionals, educators, special interest groups, charities and policymakers to support and enable individuals and couples in making informed choices to achieve their desired intentions, if and when they choose to start a family. There was no external funding for this study. The authors report no competing interests. N/A.

Grace B ，Shawe J ，Johnson S ，Usman NO ，Stephenson J ... -  《-》