Infertility, social pressure, and mental health: An empirical study based on a reproductive sociology framework

Abstract

BACKGROUND

Infertility affects a significant proportion of the global population, with profound implications for psychological well-being. Social mechanisms, including stigma and cultural expectations, play a critical role in shaping mental health outcomes, yet few studies have systematically examined these pathways within a reproductive sociology framework.

AIM

To investigate how infertility-related social pressure influences mental health outcomes and validate a comprehensive assessment tool for this purpose.

METHODS

In this cross-sectional study, 1200 patients with infertility were enrolled from 2023 to 2024 at Harbin Medical University in China. The Infertility Social Pressure and Mental Health Scale was developed and validated through confirmatory factor analysis and reliability testing. Structural equation modeling was used to evaluate social pressure as a mediator between infertility characteristics and mental health outcomes, while subgroup analyses explored gender, duration, and sociodemographic moderators.

RESULTS

The Infertility Social Pressure and Mental Health Scale demonstrated excellent psychometric properties (Cronbach’s α = 0.92, comparative fit index = 0.94, root mean square error of approximation = 0.06). Social pressure significantly mediated the relationship between infertility and psychological distress (β = 0.42, P < 0.001). Higher mean social pressure scores were found in women than men (3.78 vs 2.94, P < 0.001). Longer infertility duration, rural residence, and lower education were associated with greater vulnerability. Among pressure domains, self-imposed pressure showed the strongest correlation with depression and anxiety (r = 0.72, P < 0.001).

CONCLUSION

Social pressure represents a critical pathway linking infertility and adverse mental health outcomes. To improve patient outcomes, culturally sensitive psychosocial interventions, early screening, and support strategies are required.

Key Words: Infertility; Social pressure; Mental health; Reproductive sociology; Psychological distress

Core Tip: This study investigated the impact of infertility-related social pressure on mental health within a reproductive sociology framework. Using data from 1200 participants and a newly developed Infertility Social Pressure and Mental Health Scale, results showed that social pressure significantly mediated the relationship between infertility and psychological distress, with women and individuals with longer infertility duration experiencing higher burdens. Self-imposed pressure emerged as the strongest predictor of mental health outcomes. Culturally sensitive psychosocial interventions and routine psychological screening in infertility care are recommended to improve overall patient well-being.

INTRODUCTION

Infertility, defined as the inability to achieve pregnancy after 12 months of regular unprotected sexual intercourse, represents a significant global health challenge affecting approximately 17.5% of the world’s population[1]. Recent data from the World Health Organization[2] indicates that an estimated 186 million individuals worldwide experience infertility, with relatively consistent prevalence rates across different socioeconomic levels. This phenomenon extends far beyond its biomedical dimensions, encompassing complex social, cultural, and psychological factors that profoundly impact the lives of those affected[3].

The contemporary understanding of infertility has evolved from a purely medical condition to a multifaceted social issue that intersects with personal identity, family relations, and societal expectations[4]. Reproductive sociology provides a crucial theoretical framework for examining how social structures, cultural norms, and institutional practices shape the experience of infertility and its consequences for mental health[5]. This perspective recognizes that fertility and reproductive outcomes are deeply embedded within social contexts that influence individual experiences and coping mechanisms[6].

Social pressure surrounding fertility represents a particularly salient aspect of the infertility experience. Research has demonstrated that societal expectations regarding parenthood, family formation, and reproductive success create a significant psychological burden for individuals unable to conceive[7]. The social construction of motherhood and fatherhood as essential life achievements contributes to feelings of inadequacy, stigma, and social isolation among those experiencing fertility challenges[8]. These pressures are often amplified by cultural beliefs, religious expectations, and family dynamics that prioritize reproductive success as a marker of personal worth and social belonging[9].

The mental health implications of infertility are well-documented, with studies consistently reporting elevated rates of depression, anxiety, and psychological distress among affected individuals[10]. A systematic review[11] found that infertility stigma significantly impacts mental health and quality of life in women, with social pressure serving as a primary mechanism through which these effects manifest. Similarly, research has highlighted the mediating role of coping strategies in the relationship between social expectations surrounding motherhood and psychological distress among infertile women[12].

Despite growing recognition of the social dimensions of infertility, limited research has comprehensively examined the mechanisms through which social pressure influences mental health outcomes within a reproductive sociology framework. Previous studies have primarily focused on individual psychological responses or medical interventions, often overlooking the broader social context that shapes these experiences[13]. Furthermore, existing instruments for measuring infertility-related social pressure lack comprehensive validation and fail to capture the multidimensional nature of social influences on reproductive experiences[14].

The reproductive sociology framework offers valuable insights into understanding infertility as a socially constructed phenomenon. This approach emphasizes how reproductive experiences are shaped by social institutions, cultural practices, and power structures that influence access to resources, social support, and identity formation[15]. Within this framework, infertility is understood not merely as a medical condition but as a social status that carries implications for individual identity, relationships, and social positioning[16]. The framework also highlights how social determinants of health intersect with reproductive outcomes, creating disparities in both fertility experiences and access to care[17]. This conceptualization aligns with reproductive sociology’s emphasis on understanding fertility experiences within their social context. Similarly, studies examining the social infertility cycle model have demonstrated how cultural, political, and social determinants interact to shape individual experiences of fertility challenges[18]. Cross-cultural research has revealed significant variations in how social pressure manifests across different societies. In traditional societies where motherhood is central to women’s identity and social status, the psychological impact of infertility is often more severe[19]. Thus, social pressure should be understood as a culturally specific phenomenon that is best addressed through tailored assessments and interventions[20].

To address these gaps in the existing literature, this study aims to develop and validate a comprehensive measure of infertility-related social pressure, examine its mediating role in the relationship between infertility and mental health outcomes, and identify key risk factors and protective factors that can inform targeted interventions for improving the psychological well-being of individuals experiencing infertility.

MATERIALS AND METHODS

Study design and setting

This cross-sectional study primarily employed a quantitative survey design, with qualitative interviews used only during the preliminary phase of scale development. The study was conducted from November 2023 to December 2024 at the Reproductive Medicine Center of the First Affiliated Hospital of Harbin Medical University in Heilongjiang Province, China, to examine the relationship between infertility, social pressure, and mental health outcomes. The research protocol was approved by the Institutional Review Board of Harbin Medical University, and all participants provided written informed consent.

Participants and data collection

Inclusion criteria: (1) Aged 18-45 years; (2) Had been diagnosed with infertility according to standard clinical criteria (inability to conceive after 12 months of regular unprotected intercourse); (3) Were currently seeking or had previously sought fertility treatment; (4) Demonstrated sufficient language proficiency to complete study questionnaires; and (5) Provided informed consent for participation.

Exclusion criteria: (1) Current pregnancy; (2) Severe psychiatric illness requiring immediate treatment; (3) Cognitive impairment preventing informed consent; and (4) Unwillingness to participate in follow-up assessments.

Sample size determination: Sample size calculations were performed using G*Power version 3.1.9.7 (Faul et al[21], 2009), with parameters set for multiple regression analysis. Based on an anticipated medium effect size (f² = 0.15), a significance level of α = 0.05, and statistical power of 0.90, the minimum required sample size was estimated to be approximately 1020 participants. To allow for incomplete questionnaires, data quality control, and to ensure adequate power for subgroup analyses and structural equation modeling (SEM), a final analytic sample size of 1200 participants was targeted and achieved.

Recruitment procedures: Participants were recruited through multiple strategies: (1) Direct referral from reproductive endocrinologists and fertility specialists at both urban and rural healthcare facilities; (2) Recruitment flyers posted in fertility clinics and reproductive health centers across Heilongjiang Province, including township hospitals and county-level health centers; (3) Online recruitment through fertility support groups and social media platforms; and (4) Snowball sampling through existing participants.

To enhance rural representation, we specifically partnered with eight township hospitals and four county-level maternal and child health centers in rural areas of Heilongjiang Province. Rural participants (n = 259, 21.6% of the total sample) were recruited through these partnerships, with research assistants conducting on-site recruitment during routine clinic visits. Despite these efforts, urban participants remained the majority (n = 940, 78.4%), reflecting both the concentration of fertility treatment services in urban centers and potential barriers to care access faced by rural residents.

Measures and instruments

Demographic and clinical characteristics questionnaire: A comprehensive demographic questionnaire was developed to collect information on participant characteristics, including age, gender, education level, employment status, income, relationship status, duration of infertility, previous fertility treatments, and medical history. Clinical variables included primary vs secondary infertility, specific diagnoses, treatment history, and current treatment status.

Infertility Social Pressure and Mental Health Scale: We developed a novel 34-item instrument to assess social pressure related to infertility across multiple domains. The scale development process involved: (1) Extensive literature review and theoretical conceptualization; (2) Review by a panel of experts, which included reproductive psychologists, sociologists, and fertility specialists; (3) Cognitive interviews with 25 individuals experiencing infertility; (4) Pilot testing with 150 participants; and (5) Comprehensive psychometric evaluation.

The Infertility Social Pressure and Mental Health Scale (ISPMHS) assesses five primary domains: (1) Family pressure (8 items), measuring expectations and comments from family members regarding fertility and parenthood; (2) Social pressure (7 items), assessing pressure from friends, colleagues, and broader social networks; (3) Cultural pressure (6 items), evaluating cultural and religious expectations regarding reproduction; (4) Media and societal pressure (7 items), measuring the influence of media representations and societal norms; and (5) Self-imposed pressure (6 items), assessing internalized expectations and self-criticism related to fertility. Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater perceived social pressure. The scale demonstrates excellent internal consistency (Cronbach’s α = 0.92) and strong construct validity as confirmed through confirmatory factor analysis [comparative fit index (CFI) = 0.94, root mean square error of approximation (RMSEA) = 0.06, standardized root mean square residual (SRMR) = 0.05].

Mental health measures: Mental health outcomes were assessed using a brief self-report questionnaire developed specifically for this study. The questionnaire included items measuring depressive symptoms, anxiety levels, and general psychological distress experienced in relation to infertility. Items were rated on the same 5-point Likert scale as the ISPMHS to maintain consistency across measures.

This brief instrument was designed to capture infertility-specific emotional distress, and ongoing validation studies are examining its associations with established measures such as the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7.

Data collection procedures

Baseline assessment: After providing informed consent, participants completed a comprehensive baseline assessment battery either in-person at clinic sites or via a secure online platform. The assessment protocol included all primary study measures and additional questionnaires for exploratory analyses. Participants received detailed instructions, and research staff were available to address questions during completion.

Data quality assurance: The following strategies were implemented to ensure data quality: (1) Electronic questionnaires were designed with built-in validity checks; (2) Research assistants reviewed completed forms for missing or inconsistent responses; (3) Random double-entry of 10% of paper questionnaires; and (4) Systematic review of outliers with participant confirmation when appropriate. Participants with more than 20% missing data on any primary measure were excluded from analyses.

Follow-up procedures: To examine the temporal stability of primary measures and explore longitudinal relationships, a subset of participants (n = 300) was invited to complete follow-up assessments after 6 months. Follow-up participation was voluntary and incentivized through small monetary compensation.

Statistical analysis

Preliminary analyses: Data cleaning and preparation involved examining distributions, identifying outliers, and assessing missing data patterns. Missing data were handled using multiple imputation when appropriate, with sensitivity analyses conducted to evaluate the impacts of different approaches to handling missing data. Descriptive statistics were used to characterize sample demographics and primary study variables.

Primary analyses: SEM was employed to test the hypothesized model examining social pressure as a mediator of the relationship between infertility characteristics and mental health outcomes. The measurement model was first evaluated through confirmatory factor analysis, followed by testing of the structural model. Model fit was assessed using the χ² test, CFI, RMSEA, and SRMR.

Mediation analyses followed current best practices, employing bias-corrected bootstrap confidence intervals to test indirect effects. Moderation analyses examined potential differences across demographic groups using multi-group SEM approaches. Effect sizes were calculated and interpreted according to established conventions.

Secondary analyses: Additional analyses explored relationships between specific social pressure domains and mental health outcomes, cultural differences in social pressure experiences, and the role of social support as a protective factor. Exploratory profile analyses were conducted to identify subgroups at elevated risk for poor mental health outcomes based on patterns of social pressure.

RESULTS

Sample characteristics

A total of 1200 participants were enrolled in the study between November 2023 and December 2024, meeting our target sample size. The sample comprised 749 women (62.4%) and 451 men (37.6%), with a mean age of 32.8 years (SD = 5.2, range 20-45 years). Educational attainment was high, with 78.4% of participants having completed college or graduate degrees. Regarding fertility characteristics, 64.3% of participants were diagnosed with primary infertility, while 35.7% were diagnosed with secondary infertility. The mean duration of infertility was 2.7 years (SD = 1.8, range 1-8 years). Female factor infertility was identified in 41.2% of participants, male factor in 32.8%, combined factors in 18.5%, and unexplained infertility in 7.5%. At study entry, 73.2% of participants were actively pursuing fertility treatment (Table 1).

Table 1 Demographic and clinical characteristics of study participants (n = 1200), n (%).

Characteristics	Total	Women (n = 749)	Men (n = 451)	P value
Age, mean ± SD	32.8 ± 5.2	32.3 ± 5.0	33.6 ± 5.4	< 0.001
Education level ≥ college	940 (78.4)	595 (79.6)	345 (76.5)	0.116
Employed full-time	984 (82.0)	587 (78.4)	397 (87.9)	< 0.001
Primary infertility	772 (64.3)	492 (65.8)	280 (61.9)	0.087
Infertility duration, years	2.7 (1.8)	2.8 (1.8)	2.5 (1.7)	< 0.001
Active treatment	878 (73.2)	568 (76.0)	310 (68.7)	< 0.001

Validation of ISPMHS

The ISPMHS demonstrated excellent psychometric properties across multiple validation analyses. Confirmatory factor analysis supported the hypothesized 5-factor structure, showing good model fit (χ² = 1,247.3, df = 517, CFI = 0.94, RMSEA = 0.06, SRMR = 0.05). All factor loadings exceeded 0.60, indicating strong relationships between items and their respective domains (Table 2).

Table 2 Psychometric properties of Infertility Social Pressure and Mental Health Scale subscales.

Subscale	Items	mean ± SD	Range	Cronbach’s α	Test-retest r	Factor loading range
Family pressure	8	3.45 ± 0.92	1-5	0.88	0.82	0.64-0.82
Social pressure	7	3.15 ± 0.89	1-5	0.91	0.85	0.68-0.85
Cultural pressure	6	3.28 ± 1.04	1-5	0.85	0.79	0.61-0.78
Media/societal pressure	7	2.87 ± 0.95	1-5	0.89	0.83	0.65-0.81
Self-imposed pressure	6	4.12 ± 0.78	1-5	0.87	0.86	0.70-0.84
Total scale	34	3.37 ± 0.75	1-5	0.92	0.84	-

Social pressure levels and patterns

Mean social pressure scores varied significantly across domains (F = 342.7, P < 0.001, η² = 0.15) (Table 3, Figure 1). Self-imposed pressure showed the highest level (mean = 4.12, SD = 0.78), followed by family pressure (mean = 3.45, SD = 0.92), cultural pressure (mean = 3.28, SD = 1.04), social pressure (mean = 3.15, SD = 0.89), and media and societal pressure (mean = 2.87, SD = 0.95).

Figure 1 Comparison of mean scores across 5 social pressure domains.

Table 3 Social pressure scores by demographic characteristics, mean ± SD.

Characteristics	n	Family pressure	Social pressure	Cultural pressure	Media pressure	Self-imposed	Total score
Gender
Women	749	3.68 ± 0.89a	3.32 ± 0.84a	3.45 ± 1.01a	3.02 ± 0.91a	4.28 ± 0.73a	3.78 ± 0.64a
Men	451	3.07 ± 0.87b	2.89 ± 0.89b	2.98 ± 1.03b	2.63 ± 0.94b	3.87 ± 0.81b	2.94 ± 0.71b
Infertility type
Primary	772	3.52 ± 0.91a	3.21 ± 0.87a	3.34 ± 1.02	2.91 ± 0.93a	4.21 ± 0.76a	3.48 ± 0.72a
Secondary	428	3.31 ± 0.92b	3.03 ± 0.92b	3.17 ± 1.08	2.79 ± 0.98b	3.96 ± 0.81b	3.22 ± 0.79b
Duration (years)
1-2	535	3.21 ± 0.88a	2.98 ± 0.85a	3.11 ± 1.01a	2.73 ± 0.92a	3.98 ± 0.78a	3.20 ± 0.71a
3-4	418	3.58 ± 0.91b	3.24 ± 0.87b	3.38 ± 1.03b	2.94 ± 0.94b	4.19 ± 0.76b	3.54 ± 0.73b
> 5	247	3.79 ± 0.94c	3.47 ± 0.93c	3.52 ± 1.09c	3.08 ± 0.99c	4.32 ± 0.79c	3.72 ± 0.77c

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

Values with different superscript letters within each column indicate statistically significant differences (P < 0.05) based on one-way analysis of variance followed by Tukey’s post-hoc test. Values sharing the same letter are not significantly different from each other.

Mental health outcomes

Elevated levels of psychological distress were found in the sample. Participants reported moderate levels of infertility-related psychological distress, with significant correlations between total social pressure scores and overall psychological distress (r = 0.68, P < 0.001) (Table 4).

Table 4 Mental health outcomes by gender and infertility characteristics, mean ± SD.

Variable	Depression score	Anxiety score	Psychological distress
Total sample	3.42 ± 0.98	3.56 ± 0.92	3.49 ± 0.87
Gender
Women	3.68 ± 0.94a	3.82 ± 0.88a	3.75 ± 0.82a
Men	2.99 ± 0.92b	3.13 ± 0.87b	3.06 ± 0.81b
Infertility type
Primary	3.51 ± 0.96a	3.65 ± 0.91a	3.58 ± 0.86a
Secondary	3.26 ± 0.99b	3.40 ± 0.92b	3.33 ± 0.87b
Duration
1-2 years	3.18 ± 0.93a	3.32 ± 0.89a	3.25 ± 0.83a
3-4 years	3.48 ± 0.97b	3.62 ± 0.91b	3.55 ± 0.86b
5+ years	3.74 ± 0.99c	3.88 ± 0.93c	3.81 ± 0.88c
Treatment status
Active treatment	3.51 ± 0.97a	3.65 ± 0.91a	3.58 ± 0.86a
No treatment	3.19 ± 0.95b	3.33 ± 0.90b	3.26 ± 0.85b

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

Within each variable category, means with different superscript letters are significantly different (P < 0.05) based on one-way analysis of variance followed by Tukey’s post-hoc test. For example, in the Duration category, the 1-2 years (a) and 3-4 years (b) groups did not differ significantly from each other but were both significantly lower than the 5+ years (c) group, indicating a significant progressive increase.

Correlation analyses

Social pressure and psychological distress showed strong correlations for self-imposed pressure (r = 0.72, P < 0.001) and family pressure (r = 0.65, P < 0.001) domains (Table 5).

Table 5 Correlation matrix of social pressure domains and mental health outcomes.

Variable	Family pressure	Social pressure	Cultural pressure	Media pressure	Self-imposed	Depression	Anxiety	Psychological distress
Family pressure	-	-	-	-	-	-	-	-
Social pressure	0.68a	-	-	-	-	-	-	-
Cultural pressure	0.61a	0.59a	-	-	-	-	-	-
Media pressure	0.54a	0.62a	0.57a	-	-	-	-	-
Self-imposed	0.71a	0.66a	0.63a	.58a	-	-	-	-
Depression	0.65a	0.58a	0.54a	0.49a	0.72a	-	-	-
Anxiety	0.62a	0.56a	0.52a	0.47a	0.69a	0.78a	-	-
Psychological distress	0.64a	0.57a	0.53a	0.48a	0.71a	0.91a	0.89a	-

^aP < 0.001.

Regression and mediation analyses

Multiple regression analyses showed that social pressure significantly predicted mental health outcomes, explaining 42% of the variance in psychological distress scores (R² = 0.42, F (5, 1194) = 296.8, P < 0.001) (Table 6).

Table 6 Multiple regression analysis predicting psychological distress.

Predictor	B	SE	β	t	P value	95%CI
Constant	0.82	0.09	-	9.11	< 0.001	0.64-1.00
Family pressure	0.27	0.03	0.28	9.00	< 0.001	0.21-0.33
Social pressure	0.14	0.03	0.14	4.67	< 0.001	0.08-0.20
Cultural pressure	0.18	0.02	0.21	9.00	< 0.001	0.14-0.22
Media pressure	0.09	0.02	0.10	4.50	< 0.001	0.05-0.13
Self-imposed pressure	0.38	0.03	0.34	12.67	< 0.001	0.32-0.44

R² = 0.42, Adjusted R² = 0.42, F (5, 1194) = 296.8, P < 0.001. CI: Confidence interval.

Gender and sociodemographic moderation effects

Multi-group SEM analyses revealed significant gender differences, with higher social pressure found among women across all domains (Cohen’s d = 1.18) and stronger pressure-mental health associations than men (depression: β = 0.52 vs 0.38; anxiety: β = 0.49 vs 0.35; χ² diff = 67.3, P < 0.001).

Urban or rural residence moderated family pressure effects, with rural residents showing stronger indirect effects on depression (β = 0.19 vs 0.11, P < 0.05), reflecting traditional family values in rural Chinese communities. Educational background also moderated outcomes, with lower education associated with stronger pressure-distress relationships (β difference = 0.14 for depression, 0.13 for anxiety, both P < 0.01), suggesting that education provides protective resources (Table 7, Figure 2).

Figure 2 Social pressure scores by gender and infertility type. CI: Confidence interval.

Table 7 Social pressure mediation analysis.

Path	Direct effect	Indirect effect	Total effect	95%CI (indirect)
Women
Infertility characteristics → depression	0.18a	0.34c	0.52c	0.29-0.39
Infertility characteristics → anxiety	0.16a	0.33c	0.49c	0.28-0.38
Men
Infertility characteristics → depression	0.15a	0.23c	0.38c	0.18-0.28
Infertility characteristics → anxiety	0.14	0.21c	0.35c	0.16-0.26
Urban residents
Family pressure → depression	0.24c	0.11a	0.35c	0.05-0.17
Family pressure → anxiety	0.22b	0.10a	0.32c	0.04-0.16
Rural residents
Family pressure → depression	0.36c	0.19b	0.55c	0.13-0.25
Family pressure → anxiety	0.34c	0.22c	0.56c	0.16-0.28
Higher education (≥ college)
Social pressure → depression	0.26c	0.12a	0.38c	0.06-0.18
Social pressure → anxiety	0.24c	0.11a	0.35c	0.05-0.17
Lower education (< college)
Social pressure → depression	0.32c	0.20b	0.52c	0.14-0.26
Social pressure → anxiety	0.30c	0.18b	0.48c	0.12-0.24

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

CI: Confidence interval.

Clinical thresholds and risk profiles

Using receiver operating characteristic analysis, we identified optimal cut-off scores for predicting clinically significant psychological distress using the ISPMHS (Table 8). Duration and treatment effects showed a dose-response relationship with social pressure levels. Participants with 5+ years of infertility reported significantly higher social pressure across all domains compared to those with shorter durations [F (2, 1197) = 98.7, P < 0.001, η² = 0.09]. Current treatment status also influenced social pressure experiences, with participants actively undergoing fertility treatment reporting higher levels of social pressure (mean = 3.47, SD = 0.74) compared to those not in treatment [mean = 3.19, SD = 0.81; t (1198) = 6.8, P < 0.001, d = 0.36] (Figure 3).

Figure 3 Mental health outcomes by infertility duration and treatment status. CI: Confidence interval.

Table 8 Risk profile analysis for groups at high risk for psychological distress.

Risk profile	n (%)	ISPMHS score, mean ± SD	Distress prevalence	OR (95%CI)
Lowest risk
Men, secondary, < 2 years, low family pressure	85 (7.1)	2.43 ± 0.52	18.3%	1.00 (reference)
Moderate risk
Men, primary, 2-4 years, moderate pressure	161 (13.4)	3.12 ± 0.61	42.5%	3.31 (2.14-5.12)
Women, secondary, < 3 years, moderate pressure	214 (17.8)	3.28 ± 0.68	48.9%	4.26 (2.82-6.44)
High risk
Women, primary, 3-5 years, high family pressure	293 (24.4)	3.89 ± 0.73	71.3%	10.84 (7.26-16.18)
Highest risk
Women, primary, 5+ years, high family pressure, low support	107 (8.9)	4.32 ± 0.65	89.3%	38.26 (23.47-62.37)

Odds ratio for clinically significant psychological distress (score ≥ 3.5). CI: Confidence interval; OR: Odds ratio; ISPMHS: Infertility Social Pressure and Mental Health Scale.

DISCUSSION

This study provides comprehensive evidence for the critical role of social pressure in mediating the relationship between infertility experiences and mental health outcomes. Our findings demonstrate that social pressure serves as a primary pathway through which infertility impacts psychological well-being, accounting for approximately half of the variance in depression and anxiety symptoms among individuals seeking fertility care. These results have important implications for understanding the social determinants of reproductive mental health and developing targeted interventions to support individuals experiencing fertility challenges.

The development and validation of the ISPMHS significantly contribute to reproductive health research methodology[22]. This instrument provides a comprehensive, psychometrically sound measure of infertility-related social pressure across multiple domains, thereby filling a critical gap in available assessment tools[23]. The strong factor structure and excellent reliability of the ISPMHS support its utility for both research and clinical applications. The identification of five distinct domains of social pressure provides a nuanced understanding of how different social influences contribute to psychological distress, enabling more targeted assessment and intervention approaches.

We found that self-imposed pressure represents the highest level of social pressure. This finding aligns with theoretical frameworks emphasizing the internalization of social norms and expectations and suggests that individuals experiencing infertility face external pressures from family, friends, and society and also develop internal pressure through the adoption of cultural scripts regarding fertility and parenthood. This internalization process may be particularly problematic because it creates ongoing psychological stress that persists even when external pressures are reduced. The high levels of self-imposed pressure observed in our sample underscore the need for interventions that address cognitive and emotional responses to infertility rather than focusing solely on external social factors.

Gender differences observed in experiences of social pressure reflect broader societal patterns regarding reproduction and gender roles. The higher levels of social pressure across all domains experienced by women likely reflect cultural expectations that place primary responsibility for reproduction on women, even though male factors contribute to approximately one-third of infertility cases. These findings are consistent with previous research demonstrating that women bear disproportionate psychological burdens in fertility challenges, regardless of the underlying medical cause. The stronger relationship between social pressure and mental health outcomes for women suggests that gender-specific interventions may be necessary to address the unique challenges faced by women experiencing infertility. Our finding of elevated social pressure among Chinese infertility patients aligns with patterns observed internationally, though with notable cultural variations. In Western individualistic cultures, self-imposed pressure and personal goal disruption predominate[24], whereas in collectivistic Asian cultures, family and societal expectations play a more dominant role[25]. Cross-cultural studies have confirmed that pronatalist contexts generate particularly intense social pressure[26], with even higher stigma levels in some regions, such as sub-Saharan Africa, than in our sample from China[27]. In addition, the urban-rural differences observed in this study align with findings of international research showing stronger fertility expectations in traditional communities. Unlike those of Western studies, which have indicated reduced stigma among younger cohorts[28], our data suggest persistent pressure across age groups in China, reflecting the endurance of traditional values despite modernization. These cross-cultural variations underscore the necessity of culturally adapted assessment tools and interventions. Even though infertility-related distress appears universal, these variations furthermore highlight that the pathways whereby social pressure operates are culturally contingent.

Urban-rural differences point to the importance of considering sociodemographic context in Chinese infertility care. Rural residents experience stronger family pressure effects due to traditional family structures where reproductive success remains tied to family honor. This suggests that interventions should be tailored to locations, with rural healthcare providers requiring particular sensitivity to family pressures and potentially involving family members in counseling.

Education emerged as a protective factor, offering cognitive resources for reframing expectations, exposure to diverse life models, and economic independence. These findings suggest psychoeducational interventions enhancing health literacy may particularly benefit individuals with lower educational backgrounds, providing alternative frameworks for understanding fertility beyond traditional parenthood models.

The dose-response relationship between infertility duration and social pressure levels provides important insights into the temporal dynamics of social influences on fertility experiences. The progressive increase in social pressure over time suggests that prolonged infertility may lead to cumulative social stress that compounds the psychological impact of the medical condition itself. This pattern has important implications for the timing of psychological interventions. Early intervention may be particularly beneficial in preventing the escalation of social pressure and its associated mental health consequences.

The role of social pressure in the infertility-mental health relationship challenges prevailing biomedical approaches that focus primarily on medical interventions. Our findings suggest that addressing social factors may be as important as medical treatment in improving overall well-being for individuals experiencing fertility challenges. This perspective mirrors the growing recognition of the social determinants of health and the need for comprehensive, biopsychosocial approaches to healthcare delivery. Healthcare systems must consider how to integrate social and psychological support into routine fertility care to address the full spectrum of patient needs.

The protective effects of social support observed in our study provide important guidance for the development of interventions. Strong social support networks appear to buffer the negative psychological effects of infertility-related social pressure, suggesting that interventions focused on building and strengthening support systems may be particularly beneficial. This finding supports the development of peer support programs, support groups, and family-based interventions that enhance social resources for individuals experiencing fertility challenges. Healthcare providers should assess social support as part of routine care and facilitate connections to appropriate support resources when deficits are identified.

Our findings further indicate that coping strategies are crucial in helping individuals develop adaptive responses to social pressure[29]. Whereas emotion-focused coping strategies amplify the negative effects of social pressure, problem-focused strategies ameliorate its effects[30]. Cognitive behavioral approaches that help individuals develop effective coping skills, challenge unrealistic social expectations, and manage emotional responses to social pressure may be particularly beneficial. These interventions should be integrated into comprehensive fertility care programs to address both the medical and psychological aspects of treatment[31].

The clinical implications of our findings extend beyond individual patient care to broader healthcare policy and system design. The high prevalence of clinically significant depression and anxiety in our sample underscores the need for routine mental health screening in fertility care settings. The ISPMHS cut-off scores identified in our study provide practical tools for identifying individuals at risk for psychological distress and requiring referral to appropriate support services[32]. Healthcare systems should implement systematic screening protocols and ensure that adequate mental health resources are available to support fertility patients[33].

Our results also have important implications for healthcare provider training and education. For grassroots and resource-constrained settings, we recommend training primary care providers to identify high-risk individuals using simplified ISPMHS screening, establishing referral networks connecting rural clinics with urban psychological services, and utilizing digital technologies such as mobile-based counseling and online peer support platforms to overcome geographical barriers to mental health care. Furthermore, fertility specialists, nurses, and other healthcare providers working with infertility patients should receive training on recognizing and addressing social factors that contribute to psychological distress. Training should include awareness of cultural differences in social pressure experiences, gender-specific considerations, and evidence-based approaches for addressing social and psychological aspects of infertility care. Professional education programs should integrate social and psychological perspectives into fertility care training to equip providers for more comprehensive patient care.

The study findings contribute to broader discussions about reproductive justice and healthcare equity. The significant impact of social pressure on mental health outcomes highlights how social determinants create additional barriers to reproductive well-being beyond medical factors. These findings support arguments for comprehensive reproductive healthcare policies that not solely focus on medical interventions but also address social and psychological aspects of fertility care. Policies should envisage a reduction of social stigma surrounding infertility, improve access to psychological support services, and address cultural factors that contribute to social pressure.

From a public health perspective, our findings suggest the need for community-level interventions to address social attitudes and norms surrounding fertility and parenthood. Public education campaigns that increase awareness of infertility prevalence, challenge myths and misconceptions, and promote supportive attitudes toward individuals experiencing fertility challenges could help reduce social pressure at the population level. These efforts should be culturally-tailored and include messaging that addresses the specific sources of social pressure identified in this study.

These findings have substantial implications for future research. Longitudinal studies should examine the evolution of social pressure over time and its long-term effects on mental health and treatment outcomes. Intervention studies testing approaches to reduce social pressure and enhance social support are needed to establish evidence-based treatments. Cross-cultural research that compares social pressure experiences across different societies and cultural groups is necessary to inform the development of culturally-adapted interventions. Additionally, research examining social pressure in specific populations could provide insights into unique challenges faced by diverse groups.

The study has several limitations that should be considered when interpreting results. First, the cross-sectional design fundamentally limits our ability to establish causal relationships between social pressure and mental health outcomes. While our theoretical framework and statistical modeling support the mediating role of social pressure, we cannot determine temporal precedence or rule out reverse causality. Longitudinal studies with multiple assessment points are required to confirm these relationships over time and capture the dynamic trajectory of how social pressure evolves throughout the infertility journey. Secondly, participants were mainly recruited from urban fertility clinics. As a result, the generalizability of our findings may be limited for rural populations or individuals not seeking medical fertility treatment. Although we included rural participants, the urban clinic recruitment strategy may have systematically excluded individuals with limited healthcare access.

Thirdly, participants in our sample demonstrated notably high educational attainment, with 78.4% having completed college or graduate degrees. This educational profile likely underrepresents the experiences and vulnerabilities of individuals with lower educational backgrounds who may face compounded social pressures due to limited cognitive resources for reframing expectations, reduced exposure to diverse life models, and lower economic independence. The protective effects of education observed in our moderation analyses suggest that our findings may actually underestimate the severity of social pressure impacts in less educated populations. Future research should deliberately oversample individuals with lower educational attainment to better understand their unique challenges and inform tailored interventions for this particularly vulnerable group. Fourthly, although the ISPMHS demonstrated strong psychometric properties, we did not conduct criterion validation against gold-standard mental health measures such as the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 screening tools. This limits direct comparability with studies using these established instruments and leaves questions about the clinical sensitivity and specificity of our mental health assessments. Ongoing validation studies are examining correlations between ISPMHS scores and these standardized measures to establish criterion validity.

Despite these limitations, this study provides robust evidence for the central role of social pressure in shaping mental health outcomes in individuals experiencing infertility. The ISPMHS offers a valuable tool for assessment and research, while our findings provide clear recommendations for intervention development and policy reform. Future research should build upon these findings to develop and test interventions that address social pressure as a key mechanism linking infertility to psychological distress[34]. Furthermore, longitudinal studies are needed to examine the temporal dynamics of social pressure and its long-term effects on both mental health and treatment outcomes[35]. Research should also explore how digital technologies and social media influence infertility-related social pressure in contemporary society[36]. Finally, implementation science approaches are needed to translate these findings into effective clinical practices and health policies[37]. The comprehensive understanding of social pressure mechanisms provided by this study offers a foundation for developing more effective, holistic approaches to infertility care that address both medical and psychosocial dimensions of the fertility journey[38].

CONCLUSION

This study demonstrates that social pressure is a critical mediator between infertility and mental health outcomes, with the newly developed ISPMHS providing a reliable tool for assessment. Women, individuals with longer infertility duration, and those from rural areas experience higher social pressure, particularly self-imposed pressure. These findings emphasize the need to integrate psychosocial interventions into routine fertility care, including culturally-sensitive counseling, social support enhancement, and cognitive-behavioral strategies to address internalized pressures. Healthcare systems should implement routine screening using the ISPMHS to identify at-risk individuals and provide timely psychological support alongside medical treatment, ultimately improving the overall well-being of those experiencing infertility.