Universal two-child policy linked to increased depression among Chinese women

China’s transition to a universal two-child policy was associated with an unexpected increase in depressive symptoms among many married women of reproductive age. A recent analysis found that women exposed to the new policy faced a higher risk of moderate to severe depression, especially if they encountered conflicting family pressures or financial constraints. The research was published in the journal Epidemiology and Psychiatric Sciences.

The childbearing years between ages 20 and 40 represent a period of elevated vulnerability to mental health challenges for women. During this time, biological changes, career development, and shifting social identities can act as major stressors. The decision to have a child, or the inability to do so, deeply influences a person’s psychological well-being.

In China, the government has heavily regulated family planning for decades. The original one-child policy began in 1979 to curb fears of overpopulation. While it reduced maternal mortality, it also led to a skewed sex ratio and an aging population.

To address these demographic challenges, the government introduced a partial two-child policy in 2013. This specific rule allowed couples to have a second child if either parent was an only child. By late 2015, the government announced the universal two-child policy, granting all families the right to have two children starting in 2016.

Most prior public health research focused on how these policy shifts affected physical birth outcomes and economic trends. Less attention was given to the psychological consequences of the transition. While the relaxed rules might alleviate the stress of suppressed fertility desires, they could also introduce new burdens.

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A return to multi-child families might increase the physical demands of childcare and reduce a woman’s career flexibility. It could also spark new disagreements between spouses or across generations regarding reproductive choices. Ruoxi Ding of Peking University Sixth Hospital and corresponding author Chao Guo led a team of researchers to investigate these potential mental health impacts.

The researchers analyzed data from the China Family Panel Study, a nationwide biennial survey. They extracted information from the 2012, 2014, 2016, 2018, and 2020 survey waves. The final dataset included 7,481 married women aged 20 to 40, making this a large study.

To isolate the effect of the policy change, the team used a quasi-experimental approach called a difference-in-difference analysis. This method compares changes over time between a group affected by a new event and a control group that remains unaffected.

The researchers categorized women who were restricted to one child before 2016 as the exposed group. This meant neither the woman nor her husband was an only child, and they only had one child at the time. The control group consisted of women who already qualified to have two children under the previous rules, or who already had two or more children.

To measure mental health, the surveys utilized established psychiatric questionnaires. In some years, participants answered the Kessler 6 Rating Scale, which asks how often a person experienced nervousness, agitation, or psychological fatigue over the past month. In other years, the surveys used items from the Center for Epidemiologic Studies Depression Scale, which tracks negative emotions over the past week.

Following the implementation of the universal two-child policy, women in the exposed group experienced a marked increase in depressive symptoms. The researchers calculated that these women faced a 45 percent higher odds of having moderate to severe depressive symptoms compared to the years before the policy took effect.

The team then separated the data by social and demographic factors to identify which groups were most affected. They found that the increase in depressive symptoms was prominent among women aged 30 to 40. Younger women did not show the same negative mental health impact.

The researchers suggest that older women might experience less flexibility in career planning and face higher physiological risks associated with pregnancy. This combination of factors could elevate their psychological stress when confronted with the sudden possibility of a second child.

Income and education also influenced the outcomes. Women with low educational backgrounds (primary school or below) and those living in households with a medium family income displayed a notable rise in depression scores. Education often correlates with personal empowerment and the ability to negotiate reproductive decisions or household duties with a spouse.

High-income families can often afford the costs of raising multiple children, and low-income families might view children as future economic support. Middle-income families, conversely, face the highest proportional financial strain when balancing childcare costs against their available resources.

Cultural pressures regarding the gender of children played a major role in the findings. The negative mental health impact was highly visible among women whose first child was a boy. In contrast, women who only had daughters prior to the policy did not show a similar increase in depression.

Traditional preferences for male heirs are common in many parts of the country, but raising sons often carries heavy financial expectations, such as helping them purchase a home for marriage. The researchers note that many women now experience a fear of having two sons because of these economic burdens.

The new policy may have created intense friction between a woman’s desire to avoid a second son and older generations’ traditional preference for more grandsons. For women who previously had only girls, the relaxed policy may have actually relieved stress by giving them a sanctioned opportunity to try for a boy.

The rise in depressive symptoms was heavily concentrated among women who did not actually give birth to a second child after the policy changed. This suggests that the distress may stem from an inability to conceive, or from ongoing family disputes over whether to expand the family against the mother’s wishes.

The study has several limitations regarding its data collection. The surveys relied on self-reported questionnaires to track depressive symptoms rather than formal clinical diagnoses by medical professionals. Self-reported responses can be influenced by a participant’s memory or a desire to avoid embarrassment.

The specific psychological scales used in the survey occasionally changed from year to year. While the researchers adjusted for this mathematically and verified their results with a consistent subset of questions, continuous use of a single measurement tool is generally preferred in longitudinal studies.

Future investigations will need to track subjective experiences, such as marital satisfaction and individual fertility desires, to map exactly how policy shifts translate into emotional distress. Tracking the mental health impacts of newer pronatalist initiatives, such as the more recent three-child policy, will help public health officials design better psychological support systems for parents.

The study, “China’s universal two-child policy and depressive symptoms among women at childbearing age: a difference-in-difference analysis based on the China Family Panel Study,” was authored by Ruoxi Ding, Dianqi Yuan, Xiaohan Zhu, Yushan Du, and Chao Guo.