China’s universal two-child policy appears to have coincided with an unexpected rise in depressive symptoms among many married women of reproductive age, a new analysis suggests. The study found that women exposed to the policy faced a higher risk of moderate to severe depression, particularly when confronted with conflicting family pressures or financial constraints, and it was published in Epidemiology and Psychiatric Sciences.
The period between ages 20 and 40 is a time of heightened vulnerability to mental health challenges for women, the researchers note. Biological changes, career development and shifting social identities intersect to shape psychological well-being, making fertility decisions especially stressful.
China has long regulated family planning. The original one-child policy began in 1979 to curb fears of overpopulation, and its legacy included a skewed sex ratio and an aging population despite reductions in maternal mortality.
To address these demographic imbalances, the government introduced a partial two-child policy in 2013, allowing a second child if either parent was an only child. By late 2015, the formal universal two-child policy was announced, with all families allowed to have two children from 2016 onward.
Most public health research beforehand focused on physical birth outcomes and economic trends stemming from policy shifts. Psychological consequences, by contrast, received less attention, though relaxation of fertility restrictions could both ease and complicate women’s stress.
A possible shift back to larger families might raise the physical demands of childcare and limit career flexibility for women. It could also fuel disagreements within couples or across generations about reproductive choices, prompting the study led by Ruoxi Ding of Peking University Sixth Hospital and corresponding author Chao Guo to examine potential mental health effects.
The researchers drew on the China Family Panel Study, a nationwide biennial survey, extracting data from 2012, 2014, 2016, 2018 and 2020. The final sample included 7,481 married women aged 20 to 40, making this a sizeable analysis.
They employed a difference-in-difference design, a quasi-experimental method that compares changes over time between groups affected by a policy and those not affected.
Women who were restricted to one child before 2016 were treated as the exposed group, defined as neither partner being an only child and having only one child at the time. The control group consisted of women who were already eligible to have two children under previous rules or who already had two or more children.
Mental health was assessed with established psychiatric questionnaires. In some survey years, participants completed the Kessler 6 Rating Scale, while in others the Center for Epidemiologic Studies Depression Scale items were used to track negative emotions over the prior period.
After the universal two-child policy took effect, the exposed group showed a marked rise in depressive symptoms. The researchers found a 45 per cent higher odds of moderate to severe depressive symptoms for these women compared with the pre-policy period.
The data were further broken down by social and demographic factors. The increase in depressive symptoms was most pronounced among women aged 30 to 40, while younger women did not exhibit the same negative mental health impact.
The authors suggest that older women may have less flexibility in career planning and face higher physiological risks associated with pregnancy, contributing to elevated psychological stress when faced with the prospect of a second child.
Income and education also shaped the outcomes. Women with only primary-level education or below and those living in households with middle-range incomes showed notable rises in depression scores, highlighting how empowerment and the ability to negotiate reproductive decisions can influence mental health.
Gender-preference pressures around sons emerged as a major factor. The adverse effect was especially apparent among women whose first child was a boy; women who had only daughters before the policy did not show the same uptick in depressive symptoms.
The researchers note that traditional expectations for male heirs can carry heavy financial burdens, such as helping sons purchase a home for marriage, which may intensify fears about having two sons.
Conversely, for women who previously had only girls, the relaxed policy could relieve stress by offering a sanctioned chance to try for a boy, underscoring how cultural norms interact with policy to shape mental health outcomes.
The rise in depressive symptoms was heavily concentrated among women who did not go on to have a second child after the policy change, suggesting distress may stem from an inability to conceive or ongoing family disputes over whether to expand the family against a mother’s wishes.
The study acknowledges several limitations. It relies on self-reported measures of depressive symptoms rather than formal clinical diagnoses, which can be affected by memory or social desirability biases.
Additionally, the specific psychological scales used in the surveys changed across years. While the researchers adjusted for these shifts and cross-validated findings with a consistent subset of questions, they note that longitudinal work benefits from a single, stable measurement tool.
Future work could track subjective experiences such as marital satisfaction and fertility desires, to map more precisely how policy shifts translate into emotional distress. Monitoring the mental health impacts of newer pronatalist initiatives, including more recent three-child policies, may help public health officials design better support for parents.
The study is titled “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,” and was authored by Ruoxi Ding, Dianqi Yuan, Xiaohan Zhu, Yushan Du and Chao Guo.
