The prevalence of barriers to rearing children aged 0–3 years following China’s new three-child policy: a national cross-sectional study

A national anonymous cross-sectional survey was conducted online in June 2021 using a random sampling method on the largest online survey platform in China: Wen Juan Xing (Changsha Ranxing Information Technology Co., Ltd., Hunan, China). A sample database covering over 2.6 million respondents was established by this online platform, whose personal information was confirmed to ensure an authentic, diverse and representative sample [15]. A sample size of 4200 people was indicated to be sufficient to estimate the prevalence of 87.5% (as previously reported in China [12]) with 1% margin of error and 95% confidence level using the formula: \(n=\frac{Z_{\alpha /2}^2\times p\left(1-p\right)}{d^2}\)[16]. The participants completed the questionnaires online by mobile phone.

A total of 5491 potentially eligible respondents were randomly selected and invited to participate in the survey. After quality control and manual check procedures to exclude ineligible, incomplete, and invalid questionnaires, the final sample consisted of 4406 respondents (80.2%) (flowchart presented in Supplemental Fig. 1).

A self-administered questionnaire was designed to collect information from the participants, including 12 questions about sociodemographic characteristics, 4 questions about reproductive status, 5 questions about fertility intentions and one question about childrearing barriers. The primary outcome was the prevalence of barriers to rearing children aged 0–3 years, which was defined as the proportion of respondents who self-reported childrearing barriers. Fertility intention refers to the unwillingness or willingness to have a second or third child. The only-child situation of parents includes parents neither of whom is only child, parents one of whom is only child, and parents both of whom are only child.

Sociodemographic characteristics included gender, ethnicity (Han and minority), age, residence (rural and urban), educational level (Junior high school or below, Senior high school or equivalent, and College or higher), annual household income (< 30,000, 30,000–80,000, 80,000–120,000, > 120,000 Chinses yuan (CNY)), number of children (1, ≥2), province, and occupation (factory worker, farmer, clerk, public servant, employee, and others). According to the economic development level, the provinces and municipalities were divided into 3 regions, including eastern (Beijing, Tianjin, Hebei, Liaoning, Shanghai, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, and Hainan), central (Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, and Hunan) and western (Inner Mongolia, Chongqing, Guangxi, Sichuan, Guizhou, Yunnan, Tibet, Shaanxi, Gansu, Qinghai, Ningxia, and Xinjiang) region [17].

Barriers to rearing children aged 0–3 years was investigated with the question “What do you think is the biggest barrier to rearing 0 to 3-year-old children?” (Answer options: high time cost, high childrearing cost, high education cost, physical factors, others, and no barriers). We defined the respondents who chose the first five options as parents with childrearing barriers. For the biggest barrier, “high time cost” referred to the lack of time to raise children. “High childrearing cost” referred to the heavy economic burden of rearing children. “High education cost” referred to the great pressure to satisfy the education of young children. “Physical factor” referred to the factors related to personal health status.

Patients and the public were not involved in the design and conduct of the study.

Of the 4406 Chinese parents included in our study, 57.9% were women, 95.3% were the Han nationality, 65.5% were urban, 70.9% had a college degree or above, 62.1% had an annual household income of over 80,000 CNY, 68.9% had one child, 31.1% had at least two children, 58.1% lived in the eastern region, and 47.3% were employees (Table 1). 53.0% of the respondents were parents neither of whom is only child, 62.6% intended to have a second child, and 14.8% intended to have a third child.

94.7% of the 4406 respondents self-reported barriers to rearing children aged 0–3 years, of which 39.3% reported high time cost, 36.5% reported high childrearing cost, 13.5% reported high education cost, and 5.0% reported physical factors as the biggest barriers (Table 2). High time cost and high childrearing cost were also major barriers among respondents intended to have a second child (75.7%) and those intended to have a third child (66.7%) (Fig. 1).

Women (aOR 1.49, 95%CI 1.13, 1.96) and people with college degree or above (aOR 3.46, 95%CI 2.08, 5.75) were associated with higher prevalence of childrearing barriers, whereas farmers (aOR 0.48, 95%CI 0.26, 0.87) were associated with lower prevalence (Table 1). Women (aOR 1.17, 95%CI 1.03, 1.33), and people having an annual household income of over 80,000 CNY (aOR 1.50–2.08, all P < 0.05) were more likely to report high time cost as the biggest barrier. People having at least 2 children (aOR 1.16, 95%CI 1.00, 1.35) tended to report high childrearing cost, while people with an annual household income of over 120,000 CNY (aOR 0.60, 95%CI 0.48, 0.75) did not. Women (aOR 1.22, 95%CI 1.02, 1.47) and people aged 40–49 years (aOR 1.96, 95%CI 1.02, 3.77) reported high education cost more often, while people having an annual household income of over 80,000 CNY (aOR 0.52–0.63, P < 0.05) reported less often (Supplemental Table 1, Supplemental Fig. 2).

Multivariate logistic regression models showed that people who intended to have a second child (aOR 0.58, 95%CI 0.40, 0.83) and people who intended to have a third child (aOR 0.51,95%CI 0.37, 0.71) were associated with less childrearing barriers (Table 2). People who intended to have a second child (aOR 1.21, 95%CI 1.04, 1.42) and parents one of whom is only child (aOR1.21, 95%CI 1.03, 1.42) were more likely to report high time cost as the biggest barrier, while people who intended to have a third child (aOR 0.77, 95%CI 0.64, 0.93) were less likely to report (Table 2). Parents one of whom is only child (aOR 0.81, 95%CI 0.69, 0.96) were related to less reported high childrearing cost. People who intended to have a third child (aOR 1.59, 95%CI 1.07, 2.36) and parents both of whom are only child (aOR 1.56, 95%CI 1.08, 2.26) were more likely to report physical factors, while people who intended to have a second child (aOR 0.61, 95%CI 0.42, 0.87) were less likely to report. In subgroup analysis, the association between fertility intention and childrearing barriers were stable (Table 3).

The main strength of our study is that it is the first to understand the barriers to rearing children aged 0–3 years and the association between fertility intention and childrearing barriers among Chinese parents following the new three-child policy. The estimated prevalence of barriers could provide scientific evidence for the need of making childrearing policies and supporting measures, and the analysis of related factors could help formulate targeted policies and measures for people with different sociodemographic characteristics and fertility intention, thereby reducing childrearing barriers and guaranteeing child health. However, there are some limitations. First, we collected data using online questionnaire, so that people who were not internet users were not included in our study. Nevertheless, there were 989 million internet users in China by December 2020, and 99.7% of them surf the internet by mobile phone [45]. Additionally, internet use was more prevalent in people of childbearing age than in other age groups. Second, our study was cross-sectional and could not demonstrate causal association. Third, because of lacking occupation option like “immigrant workers” in our questionnaire, we could not measure the barriers among immigrant Chinese who face more childrearing difficulties [46]. Last, the coronavirus disease 2019 (COVID-19) pandemic might have an impact on our results [42].