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The global decline in fertility rates is a pressing concern. The United Nations reports that the global fertility rate fell from 3.2 to 2.5 live births per woman between 1990 and 2019, with projections reaching 1.9 by 2100. Similarly, China’s 2020 census revealed a total fertility rate of 1.3, signifying a very low fertility society. Despite policy adjustments since 2013, China’s fertility rate continues to dwindle, with 1.38 million fewer newborns in 2021 compared to 2020 (1). In response, 17 government departments, including the National Health Commission and the National Development and Reform Commission, introduced 20 fertility support measures in July 2022, encompassing taxation, insurance, education, housing, and employment (2). While fertility desire is a strong predictor of actual fertility behavior, research on fertility intentions across Chinese provinces since the implementation of these 20 measures remains limited. Therefore, this study investigates whether these supportive measures have effectively stimulated fertility intentions among childbearing-age women. A cross-sectional survey of 8,002 women aged 20–49 was conducted in Shandong, Hunan, and Yunnan provinces between August and September 2023. Preliminary findings indicate higher childbearing intentions among childless women. However, the intention for a second or third child remains notably low among one-child and two-child women, respectively. The decision to have children correlates with factors such as age, education, occupation,Hukou, marital status, income, children’s gender, and childbirth expense reimbursements. Creating a more supportive fertility environment and providing preferential policies for pregnant women are crucial steps towards addressing this issue.
This cross-sectional survey was conducted in August and September 2023 in Shandong, Hunan, and Yunnan provinces. Within each province, the provincial capital (urban area) and one county under its jurisdiction (rural area) were selected as investigation sites. A multi-stage stratified random cluster sampling method was used to select women aged 20–49 years at each site. First, one street (urban) or town (rural) was randomly selected. Second, two neighborhoods (urban) or villages (rural) were randomly selected, stratified by distance from the administrative office to ensure representation of areas closer and farther away. Finally, within each selected neighborhood or village, all eligible women aged 20–49 years were recruited until the target sample size was reached. Data were collected through face-to-face interviews. Ethical approval was obtained from the Ethical Review Committee of the National Center for Women and Children’s Health, China CDC (No. FY2023-8), and all participants provided informed consent. Chi-square tests were used to compare differences between groups. A multiple logistic regression model examined factors associated with fertility intentions, with unwillingness (marked as 0) and willingness (marked as 1) as the dependent variables, and factors identified as statistically significant in the Chi-square analysis as independent variables.
This study included 8,002 women: 2,595 (32.4%) from Shandong Province, 2,767 (34.6%) from Hunan Province, and 2,819 (35.2%) from Yunnan Province. Of these, 4,410 (55.1%) resided in urban areas and 3,771 (47.1%) in rural areas. The women’s average age was 34.11±7.30 years. A total of 5,769 (72.1%) women had children, including 2,539 (31.7%) with one child and 3,051 (38.1%) with two children.
Among the 2,412 childless women, the majority were aged 25–29 (35.0%), resided in urban areas (61.0%), held non-agriculturalHukou(63.5%), had attained a college degree or higher (72.9%), and worked as professionals (e.g., doctors, teachers, engineers) (31.3%). Of the 2,539 one-child women, the largest group (25.8%) were aged 30–34, 67.3% had a college degree or higher, and 24.4% were professionals. Among the 3,051 two-child women, the largest group (32.2%) were aged 35–39. Most two-child women (69.8%) held agriculturalHukou, 74.7% had attained a senior high school diploma, and 31.5% worked as farmers. Detailed sociodemographic characteristics are presented inTable 1.
Characteristics Fertility intentions of childless women Fertility intentions to have a second child of one-child women Fertility intentions to have a third child of two-child women N n(%) P N n(%) P N n(%) P Region 0.001 0.407 0.696 Eastern 697 588 (84.4) 870 267 (30.7) 965 116 (12.0) Central 986 785 (79.6) 796 268 (33.7) 941 104 (11.1) Western 729 560 (76.8) 873 275 (31.5) 1,145 125 (10.9) Place of residence <0.001 <0.001 0.083 Urban 1,472 1,128 (76.6) 1,381 390 (28.2) 1,449 179 (12.4) Rural 940 805 (85.6) 1,158 420 (36.3) 1,602 166 (10.4) Age, years <0.001 <0.001 0.081 <25 570 379 (66.5) 1,220 21 (50.0) 921 4 (28.6) 25–29 833 654 (78.5) 1,319 168 (43.4) 2,130 26 (14.4) 30–34 386 332 (86.0) 240 (36.7) 73 (9.4) 35–39 249 230 (92.4) 2,406 143 (28.5) 2,867 108 (11) 40–44 182 159 (87.4) 133 79 (19.2) 184 78 (11.7) 45–49 192 164 (85.4) 159 (29.3) 56 (12.9) Hukou <0.001 42 <0.001 14 0.017 Non-agricultural 1,532 671 (76.3) 387 330 (27) 181 77 (8.3) Agricultural 880 1,262 (82.4) 654 480 (36.4) 773 268 (12.5) Ethnicity 0.199 502 0.382 983 0.5 Han 2,266 1,822 (80.4) 411 763 (31.7) 665 327 (11.4) Minority 146 111 (76.0) 543 47 (35.3) 435 18 (9.8) Educational level <0.001 0.498 0.625 Junior high school or below 336 310 (92.3) 323 112 (34.7) 773 90 (11.3) Senior high school 317 283 (89.3) 507 157 (31) 2,278 75 (10.4) College or higher 1,759 1,340 (76.2) 1,709 541 (31.7) 1,559 180 (11.8) Marital status <0.001 <0.001 0.118 First marriage 1,327 1,243 (93.7) 2,348 756 (32.2) 2,849 314 (11.0) Remarriage 72 65 (90.3) 89 38 (42.7) 149 26 (17.4) Single 1,013 625 (61.7) 102 16 (15.7) 53 5 (9.4) Occupation <0.001 0.001 0.046 Farmer 359 321 (89.4) 376 133 (35.4) 960 105 (10.9) Factory worker 103 87 (84.5) 148 30 (20.3) 115 10 (8.7) Civil servant 243 175 (72) 278 82 (29.5) 203 25 (12.3) Doctor/teacher/engineer 754 586 (77.7) 619 225 (36.3) 580 63 (10.9) Clerk 228 190 (83.3) 226 65 (28.8) 163 19 (11.7) Service staff 214 169 (79.0) 304 80 (26.3) 326 30 (9.2) Self-employment person 235 195 (83.0) 286 90 (31.5) 383 58 (15.1) Unemployed 155 122 (78.7) 175 67 (38.3) 209 22 (10.5) Other 121 88 (72.7) 127 38 (29.9) 112 13 (11.6) Average monthly income, CNY 0.001 0.216 0.002 <3,000 882 688 (78) 833 246 (29.5) 1,402 146 (10.4) 3,000–4,999 976 767 (78.6) 1,055 332 (31.5) 980 101 (10.3) 5,000–9,999 322 283 (87.9) 448 156 (34.8) 333 48 (14.4) 10,000–30,000 55 42 (76.4) 32 11 (34.4) 32 8 (25.0) >30,000 18 14 (77.8) 14 5 (35.7) 22 1 (4.5) No income 159 139 (87.4) 157 60 (38.2) 282 41 (14.5) Have insurance 0.261 0.084 0.176 Yes 1,776 1433 (80.7) 2,044 636 (31.1) 2,175 235 (10.8) No 636 500 (78.6) 495 174 (35.2) 876 110 (12.6) Have maternity insurance 0.398 0.296 0.086 Yes 1,410 1132 (80.3) 1,588 485 (30.5) 1,372 155 (11.3) No 366 301 (82.2) 456 151 (33.1) 803 72 (9.0) Family average monthly income, CNY <0.001 0.265 0.45 <3,000 547 406 (74.2) 414 124 (30) 798 103 (12.9) 3,000–4,999 818 646 (79.0) 732 229 (31.3) 936 105 (11.2) 5,000–9,999 691 591 (85.5) 960 300 (31.3) 928 93 (10.0) 10,000–30,000 312 255 (81.7) 401 147 (36.7) 342 38 (11.1) >30,000 44 35 (79.5) 32 10 (31.3) 47 6 (12.8) Gender of children − 0.708 <0.001 Boys − − 1,443 456 (31.6) 743 80 (10.7) Girls − − 1,096 354 (32.3) 749 108 (14.4) Boy and girl − − − − 1,559 235 (10.8) History of abortion 0.099 0.006 0.021 Yes 201 185 (92.0) 788 289 (36.7) 1,080 144 (13.3) No 1,060 933 (88.0) 1,259 388 (30.8) 1,292 126 (9.8) Complications of pregnancy − <0.001 0.115 Yes − − 365 147 (40.3) 426 55 (12.9) No − − 2,174 663 (30.5) 2,625 290 (11.0) History of abnormal delivery − 0.045 0.441 Yes − − 153 60 (39.2) 217 28 (12.9) No − − 2,386 750 (31.4) 2,834 317 (11.2) Mode of delivery − 0.915 0.687 Vaginal delivery − − 1,521 484 (31.8) 1,720 191 (11.1) Caesarean section − − 1,018 326 (32.0) 1,331 154 (11.6) Free antenatal examination − 0.035 0.693 Yes − − 962 318 (33.1) 1,388 140 (10.8) No − − 1,055 303 (28.7) 1,192 137 (11.5) Deduction or reimbursement for childbirth expenses − 0.012 0.357 Yes − − 1,575 531 (33.7) 2,151 222 (11.1) No − − 964 279 (28.9) 900 103 (11.9) Painless delivery 0.332 0.258 Yes − − 1,076 332 (30.9) 1,137 119 (10.5) No − − 1,462 478 (32.7) 1,914 226 (11.8) Note: “−” means no data.
Abbreviation: CNY=Chinese Yuan.Table 1.Univariate analysis of the association of characteristics with fertility intentions in Shandong, Hunan, and Yunnan provinces, China, 2023.
Among the 2,412 childless women, 1,933 (80.1%) intended to have at least one child, with 1,015 (42.1%) desiring one child and 918 (38.0%) desiring more than one. The remaining 479 (19.9%) reported no intention to have children. Fertility intentions for a first child varied by region: 39.2% (273/697) in the east, 45.6% (450/986) in the central region, and 40.1% (292/729) in the west. Univariate analysis revealed that childless women who were more likely to intend to have children (P<0.05) shared the following characteristics: residence in the eastern region (84.4%) or rural areas (85.6%), agriculturalHukou(82.4%), age between 35–39 years (92.4%), junior high school education or lower (92.3%), first marriage (90.3%), employment as farmers (89.4%), average monthly individual income (87.9%) or household income (85.5%) between 5,000–9,999 Yuan, sexually active (88.7%), history of pregnancy (91.9%), and presence of reproductive system diseases (84.9%) (Table 1).
Among one-child women who intended to have a second child (31.9%,n=810), univariate analysis revealed significant associations (P<0.05) with several factors. These included residing in a rural area (36.3%), having an agricultural Hukou (36.4%), being younger than 25 years old (50.0%), being remarried (42.7%), being unemployed (36.3%), and having a spouse younger than 25 years old (45.0%). Additionally, a history of abortion (36.7%), complications during first childbirth (40.3%), abnormal delivery history (39.2%), receiving free antenatal care (33.1%), and receiving childbirth expense deductions or reimbursements (33.7%) were also significantly associated with the intention to have a second child (Table 1).
Among two-child women, only 98 (11.3%) intended to have a third child. Univariate analysis revealed that the following characteristics were significantly associated with a higher likelihood of intending to have a third child (P<0.05): agriculturalHukou(12.5%), self-employment (15.1%), average monthly income of 10,000–30,000 Chinese Yuan (CNY) (25.0%), having daughters (14.4%), and a history of abortion (13.3%) (Table 1).
Multiple logistic regression analysis revealed distinct factors associated with the willingness to have more children. Childless women residing in rural areas, possessing an agriculturalHukou, aged 35–39 years, with a junior high school education or lower, married, and having an average monthly household income of 3,000–9,999 CNY demonstrated a higher willingness to have children. Among one-child women, factors associated with a greater willingness to have a second child included having an agriculturalHukou, being younger than 30 years old, being remarried, and having received deductions or reimbursements for childbirth expenses during their first delivery. Two-child women who were more willing to have a third child were more likely to have an agriculturalHukou, an average monthly income of 5,000–3,0000 CNY, be self-employed, and have daughters (Table 2).
Variables estimatedβ Waldχ2 P OR 95%CI Fertility intentions of childless women Place of residence Urban Ref Rural 0.421 11.034 0.001 1.52 1.19, 1.95 Hukou Non-agricultural Ref Agricultural 0.422 11.426 0.001 1.53 1.19, 1.95 Age, years <25 Ref 25–29 0.209 2.15 0.143 1.23 0.93, 1.63 30–34 0.331 2.668 0.102 1.39 0.94, 2.1 35–39 0.655 5.118 0.024 1.92 1.09, 3.39 40–44 0.092 0.102 0.750 1.10 0.62, 1.93 45–49 0.635 3.32 0.068 1.89 0.95, 3.74 Educational level College or higher Ref Senior high school 0.389 2.187 0.139 1.48 0.88, 2.5 Junior high school or below 0.472 4.683 0.030 1.60 1.05, 2.46 Marital status Single Ref First marriage 1.943 158.727 <0.001 6.98 5.16, 9.44 Remarriage 1.241 7.916 0.005 3.46 1.46, 8.21 Household average monthly income, CNY <3,000 Ref 3,000–4,999 0.595 12.406 <0.001 1.81 1.30, 2.53 5,000–9,999 0.768 15.911 <0.001 2.16 1.48, 3.14 10,000–30,000 0.433 3.119 0.077 1.54 0.95, 2.49 >30,000 0.715 2.35 0.125 2.04 0.80, 5.10 Fertility intentions to have a second child of one-child women Hukou Non-agricultural Ref Aricultural 0.317 9.685 0.002 1.37 1.13, 1.68 Marital status First marriage Ref Remarriage 0.535 4.517 0.034 1.71 1.04, 2.80 Single −0.849 6.510 0.011 0.43 0.22, 0.82 Age, years 45–49 Ref <25 0.747 4.167 0.041 2.11 1.00, 4.33 25–29 0.549 10.005 0.002 1.73 1.23, 2.44 30–34 0.184 1.390 0.238 1.20 0.89, 1.63 35–39 −0.213 1.605 0.205 0.81 0.58, 1.12 40–44 −0.547 8.573 0.003 0.58 0.40, 0.84 Deduction or reimbursement for childbirth expenses No Ref Yes 0.266 6.292 0.012 1.31 1.10, 1.61 Fertility intentions to have a third child of two-child women Hukou Non-agricultural Ref Agricultural 0.691 6.606 0.010 2.00 1.18, 3.40 Average monthly income, CNY <3,000 Ref 3,000–4,999 0.020 0.005 0.942 1.02 0.59, 1.76 5,000–9,999 0.787 5.530 0.019 2.20 1.14, 4.23 10,000–30,000 1.590 7.418 0.006 4.91 1.56, 15.40 >30,000 −17.451 0.000 0.998 0.00 No income 0.442 1.461 0.227 1.56 0.76, 3.19 Gender of children Boy Ref Girl 0.953 10.404 0.001 2.59 1.45, 4.63 Boy and girl 0.113 0.146 0.703 1.12 0.63, 2.00 Occupation Farmer Ref Factory worker −0.105 0.019 0.890 0.90 0.20, 3.97 Civil servant −1.342 1.670 0.196 0.26 0.03, 2.00 Doctor/teacher/engineer 0.540 2.421 0.120 1.72 0.87, 3.39 Clerk 0.339 0.406 0.524 1.40 0.50, 3.98 Service staff 0.243 0.312 0.577 1.28 0.54, 2.99 Self-employed 0.901 7.554 0.006 2.46 1.30, 4.68 Unemployed 0.560 1.722 0.189 1.75 0.76, 4.04 Other 0.891 2.920 0.088 2.44 0.88, 6.77 Abbreviation: CNY=Chinese Yuan;CI=confidence interval;OR=odds ratio. Table 2.Multiple logistic regression model for fertility intentions — Shandong, Hunan, and Yunnan provinces, China, 2023
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This study, the first known cross-sectional survey in China to employ a multi-stage stratified random cluster sampling method to examine fertility intentions and associated factors among women of childbearing age across different regions, revealed discrepancies in fertility intentions compared to previous research (3–6). The current study found a lower intention rate for a second child among one-child women (31.9%) than Jing’s 2022 survey (55.6%) (3) and a lower intention rate for a third child among two-child women (11.3%) than previous surveys (12.2%) (5). These differences may be attributed to the online methodology of the previous surveys, potentially attracting a higher proportion of participants who were already interested in fertility policies and having more children. Notably, this study observed higher fertility intentions for a first child among childless women (45.6%) and for a second child among one-child women (33.7%) in Hunan compared to Chen Qian’s 2022 Hunan-based study (6), which also employed a multi-stage sampling method but found that 35.9% of childless women and 29.7% of one-child women intended to have a/nother child. This suggests that the continuous adjustment of fertility policy and implementation of supportive measures may lead to a gradual realization of childbirth potential among childless and one-child women.
This study found that residing in rural areas or having an agriculturalHukouwas associated with higher fertility intentions, consistent with previous research (7–9). Notably,Hukouwas the only factor influencing childbearing desires across all three groups: childless, one-child, and two-child women. This aligns with previous findings (8) suggesting that traditional cultural influences contribute to a stronger desire for larger families among rural women. Furthermore, the differential impact of the one-child policy — imposing looser restrictions on women with agriculturalHukouand stricter ones on those with non-agriculturalHukou— might explain the slower increase in childbearing desires among urban women following the policy’s relaxation.
This study revealed that childless women aged 35–39 exhibited the strongest desire for children. This finding may be attributed to younger women prioritizing educational attainment and career advancement, leading to delayed marriage and childbearing. By ages 35–39, with increased career stability, the desire for children may become more pronounced. Additionally, advancements in Chinese medical technology and reproductive policies likely contribute to this trend. These improvements offer greater support for high-risk pregnancies, potentially boosting the confidence of older women considering childbearing.
Consistent with previous studies, women with middle or higher household incomes were more likely to intend to have children than those with lower incomes (10). This suggests that financial stability, which allows families to meet both childcare and daily expenses, may increase the desire for children. However, while higher individual income was positively correlated with birth intentions, a large majority (77.7%) of self-employed women also reported intending to have a child. Furthermore, among women with two children, professional women constituted the largest group intending to have a third child. These findings suggest that flexible work schedules, often available to self-employed and professional women, may mitigate the negative career impacts associated with larger families.
Contrary to previous studies, this study found no association between education level and the intention to have more children. Instead, maternity subsidies, such as free antenatal examinations and hospital delivery subsidies, emerged as major influencing factors. This suggests that effectively implemented fertility support measures could further increase desired family size. Additionally, univariate analysis revealed that women with a history of miscarriage or previous pregnancy complications were more likely to have a second child, highlighting the need for targeted support for this demographic.
This study reveals a low intention to have second or third children among Chinese women. To effectively increase birth rates, China must cultivate a more supportive fertility environment. This includes implementing measures to eliminate employment barriers for mothers and alleviate work-family conflict. Additionally, expanding access to preferential fertility policies, particularly those supporting pregnant women, is crucial to enhancing reproductive desires.
This study benefits from its multi-stage stratified random cluster sampling method across diverse regions. Furthermore, it uniquely examines the influence of socio-demographic characteristics, pregnancy history, and service utilization during pregnancy on fertility intentions.
There were some limitations in this study. First, the geographic limitation to six counties/districts within three provinces may restrict the generalizability of findings to regional and national levels. Second, factors like childcare and children’s education were not considered in this study.
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No conflicts of interest.
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All the women who participated in the study. We also express our thanks to the efforts of all staff in the data collection areas in Shandong, Hunan and Yunnan provinces.
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