The Comparison of Family Function and Related Factors in First-Child Infertile Women and Second-Child Infertile Women after “Two-Child” Policy in China

doi:10.21203/rs.3.rs-1673769/v1

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The Comparison of Family Function and Related Factors in First-Child Infertile Women and Second-Child Infertile Women after “Two-Child” Policy in China

https://doi.org/10.21203/rs.3.rs-1673769/v1

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Background: The rising prevalence of infertility rates worldwide has had a significant impact on individuals, couples, and families. This study examines how infertility affects family functions in China under the newly implemented two-child policy. We compared family function in first-child infertile (FI) and second-child infertile (SI) women.

Methods: This study included 572 infertile women of childbearing age, composed of 337 first-child infertile women and 235 second-child infertile women in a reproductive medical center in Chongqing, China, between Feb 2016 and Dec 2018. The Family Assessment Device (FAD) and Family Cohesion And Adaptability Evaluation Scale II (FACES II) scores were used to assess family perception. The Patient Health Questionnaire-9 was used to assess depression (PHQ-9).

Results: The demographic statistics of our sample showed the age of FI was 33.26±3.46, while the SI was 36.68±5.01. 46% of FI women are the only child, while 23.8% of SI women are the only child (P＜0.001). FI women had higher levels of education than SI women (P＜0.001). FI women made higher incomes than SI did (P＜0.001). The psychiatric diagnostics showed that 170(50.4%) of FI families and 157(66.8%) of SI families had a poor family function (P＜0.001). We found that infertility women with lower levels of education and family income are more likely to have an unhealthy family function (P＜0.05) based on the correlation analysis (P＜0.05). The total score of PHQ-9 is related to the family function (P＜0.05).

Conclusions: The socio-demographical statistics show SI women have lower family monthly income and lower education levels than FI individuals. SI women obtained worse scores and more family dysfunction rates regarding family functioning. The study indicated that infertile families generally have higher risks in family functioning, family cohesion, and family adaptability. Counselors and psychologists can be deployed in infertility centers to screen people with family problem risks from the beginning and perform early interventions to improve family problems.

Family functioning

Depression

Family Assessment Device

Family adaptability

Cohesion evaluation scales II

Infertility

Infertility is defined as the failure to achieve a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment in a person's ability to reproduce, either as an individual or with his/her partner¹. Infertility affects 15.5% of reproductive-age women in the United States², 24% in France³, and 25% in China⁴, according to previous studies. We define a first-child infertile female as a woman who has never been diagnosed with a clinical pregnancy and meets the infertility criteria, whereas second-child infertility applies to a woman unable to establish a clinical pregnancy but who has previously been diagnosed with a clinical pregnancy and already had a baby.

Having a child contributes significantly to a woman's family and her social life cycle in many cultures. Lack of natural reproduction can lead to feelings of shame, guilt, and low self-esteem. These negative emotions can lead to depression, anxiety, distress, and a poor quality of life in varying degrees. As a result, infertility is regarded as a major life crisis resulting in severe mental problems and a stressful experience for infertile women. In numerous studies, infertility has been linked to depression and anxiety among women as social relationships and family function is essential aspects of mental health^5,6.

The ability of a family to work together as a unit to meet the basic needs of its members is referred to as family functioning⁷. In Iran, there are more than a million infertile couples, and infertility is one of the leading causes of divorce⁸.

The first-child infertile women are considered to suffer more stress than the second-child infertile women because they do not have any babies. However, no detailed research comparing their levels of family dysfunction is conducted.

To summarize, infertile women face many problems that can strain family relationships and lead to many negative outcomes, including impairment of the infertility treatment process and a decline in their mental health. Conversely, China implemented a new universal two-child policy in 2016, allowing all Chinese couples to have a second child. According to a government-led national survey, most women covered by the policy would be 35 years and older, putting them at a higher risk of infertility. However, these studies have not compared the different family functions between FI women and SI women after China’s two-child policy implementation, although research on these families and their social relationships has been done.

Therefore, this study was designed to compare family functioning between FI and SI women and determine the possible factors attributed to their family function after the new policy implementation.

2.1 Participants

This study was carried out at the Reproductive Medical Center over 22 months, from February 2016 to December 2018.

We used an interview to determine whether the participants met the following criteria (a) willingness to participate; (b) age over 18 and under 50; (c) must be premenopausal; (d) have been unsuccessful in conceiving a baby through unprotected intercourse for more than one year; (e) be fluent in Chinese reading and writing.

There were 337 first-child infertile women and 235 second-child infertile women among the 572 screened participants who met the research criteria and completed the questionnaires in the study. The researchers designed a demographic questionnaire to assess social demographic characteristics such as gender, age, marital status, single child or not, educational level, family history of psychosis, family monthly income, and fertility attitude, among others.

The protocol was approved by the Ethics Committee of The First Affiliated Hospital of Chongqing Medical University, Chongqing, China (2018 − 131).

2.2 Measures

2.2.1 The General Functioning Scale of the McMaster Clinical Rating Scale [FAD-GFS]

The FAD-GFS was the instrument used in this study because it provided an overall measure of the family's health or pathology. The FAD-GFS is a 12-item scale that comprises six items that describe a healthy family function, and the other six represent an unhealthy family function. Low scores indicate a healthy functioning of the family. It is highly correlated (range r = 0.48–76) with each of the six-dimensional scales⁹ and is recommended for use as a brief version of the FAD¹⁰. Miller, Epstein, Bishop, and Keitner¹¹ recommended a clinical cut-off score of 2.00 on the FAD-GFS to discriminate healthy from unhealthy family functioning based on theory and empirical evidence. They reported a diagnostic confidence rating of 0.83 for the scale¹².

2.2.2 The Family Adaptability and Cohesion Evaluation Scale, second edition, Chinese version (FACESII-CV)

FACES II is a self-report scale of 30 items that assesses two aspects of family life: family cohesion and family adaptability. Each item is scored on a 1–5 Likert scale, with a higher score indicating better family functioning. In 1992, the FACES II was translated into Chinese (FACESII-CV) and demonstrated good internal consistency (0.73∼0.85) as well as test-retest reliability (0.84∼0.91). And according to Phillips¹³, FACESII-CV has excellent psychometric properties. Typically, respondents are asked to answer the questions twice: first to assess subjects' perceptions of actual family cohesion and adaptability, and again to assess subjects' perceptions of ideal family conditions. We wanted to learn about the characteristics of family functioning among participants, so we measured both actual family cohesion and adaptability in this study. The following are the measures of dissatisfaction with family functioning: Participants answer all 30 questions twice. They rate their perception of actual family conditions for the first time and their ideal family condition for the second time. The discrepancy score, which measures participants' dissatisfaction with family functioning, is calculated as the difference between perceptions of actual and ideal conditions.

FAD-GFS and FACES II evaluate different aspects of family functioning, as they originated based on different theory systems. In this research, both FAD-GFS and FACES II are used to assess the perceived family functioning of infertile individuals to better understand the characteristics of family functioning among interfile individuals.

2.2.3 The Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is a self-report scale for detecting a major depressive disorder (MDD)¹⁴ based on diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). It refers to the previous 2-week interval and includes 9 items of depression symptoms and a functional impairment question. Each item is scored on a scale from 0 to 3, with higher scores indicating more depression (the total scores range is 0–27). Scores > = 10 suggest the possibility of depression.

2.3 Statistical analysis methods

SPSS 22 software was used for data analysis. Depending on the nature of the variable, the socio-demographic and family functioning features were described using mean values with standard deviations or frequencies with percentages. We examined the normality and homogeneity of various variables. In order to compare socio-demographic characteristics, an independent student’s t-test was used when normality assumption was held, and the Pearson chi-square test was used for categorical variables. An independent student’s t-test was also used to compare family functioning measured by FAD-GFS and FACES-II between FI and SI women. Furthermore, Pearson correlation coefficientwas calculated to investigate the possible factors of infertile family functioning. A value of P < 0.05 was considered significant in all statistical tests.

3.1 Socio-demographic characteristics of FI and SI women

The study included 572 participants, 337 of whom were first-child infertile women and 235 of whom were second-child infertile women. The age of FI was 33.26 ± 3.46, while the SI was 36.68 ± 5.01. 46% of FI women are single child, while 23.8% of SI women are single child in their families (P<0.001). FI women had a higher level of education than SI women (P<0.001). FI women made higher family monthly income than SI did (P<0.001).

The time of infertility of FI was 4.23 ± 3.29 years, while the SI was 3.87 ± 3.41 years (P = 0.37). Table 1 presents a detailed socio-demographic description of FI and SI women.

Table 1

Demographic description of FI and SI Women
	first-child infertility (n = 337)	second-child infertility (n = 235)	t/X²	P
Age(mean ± SD)	33.26 ± 3.46	36.68 ± 5.01	36.41	<0.001
Only-child, number (%)	155(46%)	56(23.8%)	29.22	<0.001
Husband Only-child number (%)	141(41.8%)	45(19.1%)	32.49	<0.001
Education, number (%)			39.62	<0.001
≤High school (113,19.8%)	40(11.9%)	73(31.1%)
Middle school (75,13.1%)	39(11.6%)	36(15.3%)
Undergraduate (353,61.7%)	234(69.4%)	119(50.6%)
Graduate and above (31,5.4%)	24(7.1%)	7(3.0%)
Family monthly income (RMB), number (%)			15.85	<0.001
≤ 4500(192,33.6%)	91(27.0%)	101(43.0%)
4501–9000(253,44.2%)	164(48.7%)	89(37.9%)
>9000(127,22.21%)	82(24.3%)	45(19.1%)
Data are expressed as mean ± standard deviation (effective sample size), and number (%), as appropriate.
t value and X² were shown as appropriate.
Family monthly income was calculated in RMB.

3.2 Family functioning in the FI and SI groups

In this study, FAD-GFS and FACES II were used to assess the perceived family functioning of infertile individuals. The mean FAD-GFS scores were 1.96(SD = 0.34)for FI women and 2.07 (SD = 0.38) for SI women. According to Miller et al.¹¹, the clinical range cut-off point was used as 2: 167 (49.6%) of FI families and 78 (33.2%) of SI families scored within the clinical range. In contrast, 170 (50.4%) of FI families and 157 (66.8%) of SI families scored above the cut-off point (P<0.001), shown in Table 2.

Table 2

Comparisons of family functioning and depression between the FI women and the SI women
	first-child infertility (n = 337)	second-child infertility (n = 235)	t/X²	P
PHQ-9(mean ± SD)	4.09 ± 3.43	3.40 ± 3.14	2.32	0.13
Mean score of FAD-GFS	1.96 ± 0.34	2.07 ± 0.38	8.33	0.004
Family function according to FAD-GFS			15.14	<0.001
Healthy family function	167(49.6%)	78(33.2%)
Unhealthy family function	170(50.4%)	157(66.8%)
FACES II
Cohesion
Perceived	65.57 ± 9.35	63.38 ± 8.79	0.65	0.419
Ideal	74.99 ± 9.89	74.06 ± 8.46	10.67	0.001
Dissatisfaction	9.43 ± 5.17	10.68 ± 5.31	0.02	0.883
Adaptability
Perceived	43.78 ± 9.29	40.95 ± 8.74	2.25	0.134
Ideal	51.92 ± 6.36	51.96 ± 6.39	2.34	0.127
Dissatisfaction	8.14 ± 6.74	11.01 ± 8.77	24.53	0.001
Data are expressed as mean ± standard deviation (effective sample size), and number (%), as appropriate.
t value and X² were shown as appropriate.
Family function was defined according to the scores of FAD-GFS(cut off point = 2)

We measured the characteristics of family functioning among participants using both the (erceived and ideal dimensions. According to Table 2, there were no significant differences between FI and SI women in the dimensions of perceived family cohesion and perceived and ideal family adaptability. In contrast, SI’s report of the ideal family cohesion scale of FACES-II was significantly higher than FI women (P<0.001 for the ideal CO). There were no significant differences in family dissatisfaction cohesion between FI and SI women (P = 0.883), but there were significant differences in the dimensions of ideal family cohesion (P = 0.001).

3.3 Pearson correlation of the possible factors associated with depression of infertile women

In order to investigate the possible factors associated with depression in infertile women, a Pearson correlation coefficient was calculated, shown in Table 3. According to the analysis, infertile women with lower education levels are more likely to have a higher mean score of PHQ-9 (r=-0.108, P = 0.01).

Table 3

Association between depression and demographic/fertility variables among infertile women
								Cohesion			Adaptability
		Only-child	education	FMI	ToI	PHQ-9	FAD-GFS	Perceived	Ideal	Dissatisfaction	Perceived	Ideal	Dissatisfaction
Only-child	r	1	-0.189	-0.18	0.032	-0.029	0.149	-0.129	-0.099	0.048	-0.156	-0.105	0.114
Only-child	p		0.001	0.001	0.45	0.491	0.001	0.002	0.018	0.251	0.001	0.012	0.006
Education	r		1	0.311	-0.133	-0.108	-0.233	0.075	0.002	-0.108	0.108	0.052	-0.084
Education	p			0.001	0.001	0.01	0.001	0.073	0.969	0.01	0.01	0.215	0.045
FMI	r			1	-0.044	0.005	-0.112	0.074	0.08	0.032	0.071	0.081	-0.031
FMI	p				0.292	0.914	0.007	0.077	0.055	0.438	0.09	0.054	0.463
ToI	r				1	0.025	0.045	-0.09	-0.073	-0.01	-0.054	-0.046	0.036
ToI	p					0.554	0.277	0.031	0.082	0.811	0.198	0.269	0.393
PHQ-9	r					1	0.128	0.004	0.049	0.094	0.024	0.004	-0.002
PHQ-9	p						0.002	0.921	0.241	0.024	0.572	0.921	0.959
FAD-GFS	r						1	-0.142	-0.059	0.172	-0.144	-0.075	0.13
FAD-GFS	p							0.001	0.157	0.001	0.001	0.071	0.002
Cohesion
Perceived	r							1	0.865	-0.187	0.8	0.581	-0.453
Perceived	p								0.001	0.001	0.001	0.001	0.001
Ideal	r								1	0.283	0.757	0.607	-0.52
Ideal	p									0.001	0.001	0.001	0.001
Dissatisfaction	r									1	-0.042	0.078	0.099
Dissatisfaction	p										0.321	0.062	0.018
Adaptability
Perceived	r										1	0.613	-0.726
Perceived	p											0.001	0.001
Ideal	r											1	0.013
Ideal	p												0.748
Dissatisfaction	r												1
Dissatisfaction	p
Abbreviation: FMI(Family Monthly Income); ToI(Time of Infertility)
All the r values were calculated by Pearson correlation analysis.

Infertile women with a high FAD-GFS score are more likely to have a high PHQ-9 mean score (r=-0.128, P = 0.002). Infertile women who are dissatisfied with family cohesion are more likely to be depressed (r = 0.094, P = 0.024).

3.4 Pearson correlation of the possible factors associated with the family function of infertile women

We used the Pearson correlation analysis to investigate the possible factors associated with the family function of infertile women (Table 3).

In the present study, the general functioning of the subscale of FAD was used to investigate the family function of infertile women. According to the analysis, infertility women with lower levels of education and family income are more likely to have an unhealthy family function (P<0.05). Meanwhile, infertile women with a higher mean score of perceived cohesion and dissatisfaction family cohesion have more unhealthy family functions (P<0.05). In this study, we found that the family function may be better when infertile women are the only child than the non-only child. Conversely, we found that the total PHQ-9 score is related to the family function. The likelihood of suffering from depression increases as the PHQ-9 score rises, and infertile women are more likely to have an unhealthy family function (P < 0.05). According to the correlation analysis of FACES II and the potential factors associated with family functioning, the more dissatisfaction with family cohesion and adaptability in their family life, the more likely they are to have general family dysfunction.

China implemented the new universal two-child policy in 2016, allowing all Chinese couples to have a second child. According to a government-led national survey, most women included under the policy would be 35 years old and older, putting them at a higher risk of infertility. This is the first study to use the FAD and FACES II family assessment measures to assess the family functioning of infertile female patients in an infertile Chinese woman after the implementation of the two-child policy. This study is the first to explore the relationship between family functioning and mental health in first- and second-child infertile women in China.

The ability to perform domestic duties and solve problems as a family member is referred to as a family function. When faced with infertility, a major negative event, women, predictably, feel incapable of resolving the crisis. Infertile women had a low family function due to a lack of awareness of the disease, fear of complicated treatment, uncertainty about treatment outcome, and desperation when treatment failed. This study revealed that SI women performed worse on the FACES II subscales, with only two subscales showing a clear difference between FI and SI women. The findings also revealed that infertile women have poorer family functioning, including division of roles, emotional communication, and behavior control¹⁵.

In this study, the social-demographic results showed that the age of FI women was younger than SI women, and age was used as covariates when Pearson correlation was performed. Lower family income and lower education levels are more likely to attribute unhealthy family functioning. Furthermore, low-income families may not be able to afford adequate medical insurance for infertile families, resulting in couples experiencing financial stress being more likely to suffer from depression and/or anxiety¹⁶. Also, lower education levels are likely to impact the communication of the family members. Individuals with low education levels usually find it difficult to exchange information effectively and optimally among family members. All of these factors will affect family members to work together as a unit to satisfy the basic needs of the family members. In this study, FI has a higher family income and education level than SI, and the proportion of only children in FI is higher than in SI, making it easier for the first infertile women to obtain support from society and their own families. Therefore, we compared the family functions of the two groups. FI has been found to have a better general family function than SI. In the FACES II study, we found that the adaptability in SI families may be poor, related to demographic factors such as income level, education level, and poor family functions. When faced with infertility, a unique disease, patients with better family intimacy and adaptability are more organized in dealing with this crisis and thus achieve a better family function. Normalizing family function alleviates patients’ stress and allows family members to be positively involved in the treatment.

In this study, the FI women had a higher mean score of PHQ-9 than SI women. Among infertile women, the higher mean score of PHQ-9 is a possible risk factor associated with family function. This difference could be a reason that SI women already have a baby. They do not experience more fertility-related stress internally, or from their husbands, so their family cohesion and adaptability are more likely better than the FI family¹⁷. Having a child is considered a significant contribution to family and society associated with gender identity, as in Chinese traditional cultures. The inability to reproduce naturally can result in feelings of guilt, shame, and low self-esteem, leading to depression in varying degrees. As a result, FI women may be at a higher risk of depression. Furthermore, people suffering from depression often struggle to carry out their responsibilities in society and in their families, and some symptoms of depression have been linked to impaired communication and cognitive function in patients. All of these are likely to have an impact on how the family functions.

As a result, infertility is regarded as a bio-psycho-social crisis¹⁸. Age, social roles, and intricate family problems, in particular, contributed to a more complex re-fertility nature in patients after the full liberalization of the 'second child policy'¹⁹. Thus, the likelihood of developing psychological and family disorders in infertile patients is higher than in the other groups, and appropriate steps should be taken in this regard.

This study was the first step in investing family functioning of FI and SI families and evaluated the associated factors related to the family function of fertile individuals. The results indicated that SI women have lower family monthly income and education levels than FI individuals regarding the social-demographic subscale. Further, the SI women obtained worse scores and are more likely to have family dysfunction regarding the family functioning aspect. In general, the result indicated that infertile families face numerous challenges in terms of general family functioning, family cohesion, and family adaptability.

Authorities can use the findings of this study in future public health and social planning. Counselors and psychologists, for example, can be deployed in infertility centers to screen people with family problems from the start and provide early interventions to improve family problems. Such programs may also have long-term effects, such as improving infertile couples' mental health and reducing divorce.

first-child infertile (FI); second-child infertile (SI); the Family Assessment Device (FAD); the Family Cohesion And Adaptability Evaluation Scale II (FACES II); the Patient Health Questionnaire-9 was used to assess depression (PHQ-9); the Family Adaptability and Cohesion Evaluation Scale, second edition, Chinese version (FACESII-CV); the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV);

Ethics approval and consent to participate: This study was carried out in accordance with the Declaration of Helsinki as revised 1989. All participants or their legal representatives signed written consent forms in the survey.

Consent for publication: Not applicable

Availability of data and materials:. Not applicable

Competing interests: Not applicable

Funding: This study was supported by Chongqing Social Science Planning Project(2017YBSH057). This study was also funded by the Commission of Science and Technology of Chongqing Municipality(cstc2018jcyjAX0216).

Authors' contributions: TQ and LLW designed the research. TQ, ZM, JYT, YZ, WLW wrote the manuscript and analyzed the data. HMJ, FDW, YLC, TLH, YY contributed to the data collection. All authors have read and approved the manuscript.

Acknowledgements: The authors acknowledge the efforts of this research team and appreciate all the participants for attending this research.

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No competing interests reported.

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The Comparison of Family Function and Related Factors in First-Child Infertile Women and Second-Child Infertile Women after “Two-Child” Policy in China

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Version 1

Abstract

1 Background

2 Methods

2.1 Participants

2.2 Measures

2.2.1 The General Functioning Scale of the McMaster Clinical Rating Scale [FAD-GFS]

2.2.2 The Family Adaptability and Cohesion Evaluation Scale, second edition, Chinese version (FACESII-CV)

2.2.3 The Patient Health Questionnaire-9 (PHQ-9)

2.3 Statistical analysis methods

3 Results

3.1 Socio-demographic characteristics of FI and SI women

3.2 Family functioning in the FI and SI groups

3.3 Pearson correlation of the possible factors associated with depression of infertile women

3.4 Pearson correlation of the possible factors associated with the family function of infertile women

4 Discussion

5 Conclusions

6 Abbreviations

Declarations

References

Competing Interests

Status:

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