The Impact of Infant and Toddler Care Services on the Reproductive Intentions of Women of Childbearing Age in the Context of Low Fertility in China: A Cross-Sectional Survey Study

The Impact of Infant and Toddler Care Services on the Reproductive Intentions of Women of Childbearing Age in the Context of Low Fertility in China: A Cross-Sectional Survey Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Infant and Toddler Care Services on the Reproductive Intentions of Women of Childbearing Age in the Context of Low Fertility in China: A Cross-Sectional Survey Study Weiming Liu, Sisi Zhang, Mingyan Zhong, Xiaotian Pang, Zhongliang Zhu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6696383/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Infant and toddler care services are crucial fertility support measures in the context of China's low birthrate and aging population. This study aims to understand the current family care needs under existing care policies and their impact on families' intentions to have additional children, providing scientific evidence for improving social population development and care policies. Methods: A survey and interview method was employed, which included 9,699 parents of infants and toddlers from September to December 2022, along with interviews of individuals involved in infant and toddler care. Results: There is a significant regional disparity in the number of registered infant and toddler care institutions in China, with more in the eastern regions. Among the survey respondents, 54.81% of families used infant and toddler care services. Parental education level, monthly household income per capita, parental age, and employment interruptions in the family were significantly associated with the use of care services (P < 0.01). Grandparents were the primary caregivers in 54.87% of families, with most families spending between 2000–3000 yuan on childcare (45.8%). Regarding care needs, families with infants and toddlers preferred full-day care services (71.08%), favored public (61.46%) and workplace-based care (22.24%), and preferred institutions close to home (85.74%). They also preferred care costs to be between 1001–2000 yuan (51.81%), considered the optimal age for entering care to be 2–3 years (80.30%), and preferred care by professional caregivers (70.68%). Logistic regression analysis indicated that a monthly household income per capita between 3000–5000 yuan (P < 0.05), one-year maternity leave (P < 0.05), and concerns about the management, distance, fees, food, and early education in care institutions (P < 0.01) were factors influencing families' willingness to have additional children. Interviews revealed that there are few affordable care institutions, high operating costs, inconsistent industry standards, and issues with caregiver qualifications. Conclusion: China's infant and toddler care policy has deficiencies, with grandparental care being predominant. There is a significant demand for care services, and there is an urgent need to improve the quality and quantity of care institutions. Employment pressure, economic burden, and care service development affect families' reproductive intentions. 0-3 years old infant and toddler care policy care institutions fertility intentions negative population growth Figures Figure 1 1 Background China has recently opened up its fertility policy, but instead of the expected baby boom, the country has entered a low fertility phase. This reflects a generally low fertility intention among the population, driven by multiple factors. Infant and toddler care services are crucial complementary measures to fertility policies. The completeness of these services significantly affects the fertility intentions of people of childbearing age and the number of newborns. As the difficulty of infant care increases and the demand for services expands, providing reasonable care services through proactive fertility support measures can effectively enhance family fertility intentions. Currently, China's infant and toddler care system is in its early stages. In 2019, the Chinese government issued guidance on infant and toddler care, offering various forms of care services to gradually meet family needs, marking the start of state-managed infant care and changing the long-standing family care situation. In 2021, the "three-child" policy and supportive measures were introduced, emphasizing the development of a universal childcare service system. While attention to infant and toddler care in China has increased, the mismatch between service supply and demand and prominent conflicts have also received significant focus. Facing an unprecedented negative population growth in China, we can indicate an impending aging society, thus it is crucial to understand the underlying issues. Questionnaires were designed and interviews were conducted in this study, which combined online and offline methods to survey public opinion on infant and toddler care policies and the reproductive intentions of childbearing families throughout the nation. The aim is to understand the current needs of Chinese families and comprehensively improve the care system, thereby providing scientific recommendations to address the low fertility rate. 2 Methods 2.1 Data On the basis of relevant literature and expert demonstration, we designed the to investigate the current situation of infant care in Shanghai, Guangzhou, Shaanxi, Guizhou, Hubei, Anhui and Jiangxi and other provinces in China. And relevant demographic data, infant care situation and family reproductive intention were collected. Then semi-structured, direct interviews were conducted with infant care staff and some parents to understand the effects of infant care, current problems, opinions and suggestions. The questionnaire and interview guide were developed specifically for this study based on literature review and expert consultation. The English version of the questionnaire is provided in Supplementary File 1. 2.2 Measures The designed questionnaire includes the following information: General family information (age, household registration, caregiver education level, family per capital income, etc.), infant and toddler family child care expectation (care mode, service type, cost, age of child care entry, institution location, staff qualification, institution function positioning, etc.), infant and toddler care situation (infant electronic screen exposure time, number of family secretaries, access to parenting knowledge, Family care concerns, etc.), problems of infant care (management, distance, fees, diet, early education, etc.), family reproductive intention, etc. In order to ensure the quality of the questionnaire, experts were invited to conduct expert validity test before the formal survey. And before the formal investigation, the questionnaire was revised and tested several times, and the scientific and reasonable design of the questionnaire was approved. Then the families of 0–3 years old infants were selected for testing. The electronic questionnaire was designed to ensure the rationality of the data by setting the normal value range in advance, and all required questions were set to ensure the integrity of the data. During the data check period, the personnel of the project reviewed all the questionnaires in the management background in real time every day, eliminated the duplicate questionnaires in time, and verified and revised the data with obvious errors through telephone. The survey was conducted online and offline. And special QR codes were set up for different regions, and the questionnaires were distributed by uniformly trained personnel through printing posters and wechat groups of parents. As for the interview method, according to the research purpose, the interview outline was initially formulated through reviewing relevant literature and policies, and then pre-interview was conducted with 2 staff members. Then the outline was further revised, and the interview outline was determined after consulting experts again. In this study, the current situation of infant and child care was taken as the breakthrough point, and a total of 108 infant and child care related personnel and some parents received interviews to explore and pay attention to the care effect and present problems, which aims to put forward reasonable suggestions. Data was collected in the form of semi-structured, direct interviews, and the interviewers had been trained in professional qualitative research and they were familiar with interview skills. The face-to-face interview was conducted in a quiet and deserted office or conference room. Before the start of the interview, the purpose and significance of this study were informed to the respondents, and the respondents were interviewed on a voluntary basis by audio recording. The recordings were kept confidential with each interview lasting 25 to 30 minutes. The interviewers were uniformly trained, and with the consent of the interviewees, the field notes and recordings were used to ensure the integrity and accuracy of the original data. Then the interviewers excluded subjective factors to ensure the accuracy and objectivity of the data analysis results. 3 Results 3.1 The situation of China's Birth Population and Registered Care Institutions China's birth rate has been declining year by year since 2016, dropping from 13.57‰ in 2016 to 6.39‰ in 2023. The number of births has shown a downward trend year by year with 9.02 million of newborns in 2023, which is a decrease of 8.84 million from 2016. The natural population growth rate has been decreasing annually, with the first occurrence of negative population growth in 2022, and the natural population growth rate in 2023 was − 1.48‰ (Fig. 1 -A). Up to January 2024, 37,303 care institutions have completed registration in the registration information system of National Health Commission's care institution. Among them, the eastern region has a larger number of registered institutions, especially in Zhejiang Province (Fig. 1 -B); in the central region, Anhui Province has a larger number of registered institutions (Fig. 1 -C); while in the western region, Sichuan Province has a larger number of registered care institutions (Fig. 1 -D), with significant disparities in the number of registered institutions among regions. 3.2 The analysis of demographic characteristics The survey respondents included 6,264 urban residents (64.58%) and 3,435 rural residents (35.42%); 1) Caregiver educational level: 792 cases of junior high school and below (8.16%), 1,758 cases of high school(18.13%), 5,862 cases of university(60.44%), 1,287 cases of master's degree and above(13.27%); 2) Average monthly household income: 1,944 cases of 3,000 and below(20.04%), 3,501 cases of 3,000–5,000 yuan(36.10%), 2,466 cases of 5,000–8,000 yuan(25.43%), 1,788 cases of more than 8,000 yuan(18.43%); 3) Age distribution: parents aged 20–29 years 2,070 cases (21.35%), 30–39 years 6,969 cases (71.85%), over 40 years 660 cases (6.80%); 4) Incidence of family employment interruption: 5,169 cases (53.29%), no family employment interruption 4,530 cases (46.71%). (Table 1 ) 3.3Analysis of Family Infant and Toddler Care Needs Among the survey respondents, the primary caregivers were grandparents in 5,322 cases (54.87%), parents in 3,849 cases (39.69%), and others in 528 cases (5.44%). Current childcare expenses were as follows: below 2,000 yuan in 3,228 cases (33.3%), 2,000–3,000 yuan in 4,446 cases (45.8%), 3,000–4,000 yuan in 1,233 cases (12.7%), and above 4,000 yuan in 792 cases (8.2%). Family needs are primarily focused on care methods, service types, care costs, age of enrollment, location of the institution, qualifications of staff, and institutional functional positioning, among other aspects. 1)Selection of care method: Parents show a strong preference for public and workplace-run institutions and they choose publicly run care (61.46%), workplace care (22.24%); full-time care services (71.08%); and 85.74% of parents hope the institution is close to home. 2)Expected care costs: Concentrated in the range of 1,001–2,000 yuan (51.81%); 80.30% of parents expect the best age for their child to start attending is 2–3 years old; 3)Parents' expectations of care institution staff: 70.68% of parents choose qualifications like pediatricians, nurses, and psychologists who are more qualified to provide care, 68.91% of parents chose "both care and education." Parents who have not chosen a care institution are most worried about child abuse and safety accidents. (Table 2 ) 3.3 Results of Interviews on Infant and Toddler Care Results of Interviews on Infant and Toddler Care Based on the grounded theory research method, the process of data analysis is divided into three stages. The coding process was assisted by Nvivo and completed through a bottom-up inductive process, and a three-level node of category relationships was formed. By organizing, coding, and refining the interview texts, the three-level nodes were summarized into two-level nodes, and then refined and integrated to obtain three primary nodes: outcomes, problems, and suggestions. (Table 3 ) In the results of the interview, the achievements of the infant and toddler care system mainly include an increase in the number of care institutions and the proportion of non-profit organizations, certain policy support, the ability of care institutions to provide basic care services, the introduction of care standards, and an increase in the number of care personnel. Related personnel pointed out problems in infant and toddler care services: institutions are primarily profit-driven and are distributed unreasonably, and policy support for multiple entities is insufficient, meanwhile, there is a large variation in care service content with many unsafe factors and inconsistent care service industry standards, and there are issues with the qualifications of care personnel. The suggestions for optimizing infant and toddler care services: Concerning the development of care institutions, management departments suggest "government authorities should clarify responsibilities, define the management mechanism for issuing business licenses and permits, and the market should conduct effective industry regulation and standardization." "Professional skill training institutions should be developed for infant and toddler care to alleviate the shortage of professional talent in infant and toddler care," suggest care institution managers, "and support for the infant and toddler care industry should be increased to reduce professional talent loss"; childbearing age parents suggest “care institutions should provide professional care, prioritizing the avoidance of high-risk factors over nurturing," "And they hope the government-run care institutions can alleviate the workplace pressure on women," "moderate competition should be formed in private and public care institutions, which would be beneficial to improving the quality of care services," "care institutions can offer some scientific parenting knowledge and skill training for new parents," etc. 3.6 Analysis of Factors That Influence the Reproductive Intentions of Families of Childbearing Age Univariate analysis showed that the factors in terms of monthly income level, parents' age, primary caregiver, concerns about care institutions, and the duration of maternal leave affect the willingness of families to have another child, with statistically significant differences ( P < 0.05). Factors with statistically significant differences in the univariate analysis were included in a logistic regression analysis. And the results showed that: the factors such as average monthly family income between 3,000–5,000 ( P < 0.05), management of care institutions, distance, fees, diet, early education ( P < 0.01), and one year of maternity leave ( P < 0.05) influenced the willingness of families to have another child. (Table 4 ) 4 Discussion Since China fully implemented the two-child policy in 2016(Communiqué of the Fifth Plenary Session of the 18th CPC Central Committee,2015), it has not achieved the expected effects. Instead, the birth rate has been declining year by year, from a birth rate of 12.07‰ shown in 2015 to the current rate of 6.39‰. The total fertility rate dropped to 1.09 in 2022, which is far below the "highly sensitive warning line" of 1.5 commonly recognized by the international community. Among the countries with a population over 100 million, this is considered a low fertility level. The sharp decline in the newborn population and the unprecedented negative population growth indicate that Chinese society will enter a state of aging development, which has attracted high attention from scholars both domestically and internationally. The care industry of China was started late, and the quality of infant and toddler care institutions and the family childcare environment are crucial to the early development of infants and toddlers (Britto et al., 2017) . Survey results show that with the liberalization of the two-child policy, there is a large demand for family care, but traditional family care is showing a trend of being unsustainable (Hong and Zhu, 2020) . The optimization of the infant and toddler care system has a significant impact on family reproductive intentions. Care for 0-3-year-old infants and toddlers in China is not managed by the government but by families. Our research particularly focuses on the gap in care for 0-3-year-olds, which include investigating the current situation of infant and toddler care institutions, differences in care between urban and rural areas, and deficiencies in care, exploring factors that affect family reproductive intentions, and providing suggestions to improve the quality of care institutions, enhance the family childcare environment, and increase the willingness to have children. Our survey shows that the currently registered infant and toddler care institutions are far from meeting social demands, with significant regional disparities, and more institutions are located in the eastern regions. A study on China's fertility status reported that 33.2% of women of childbearing age cited "no one to take care of the child" as the main reason for their unwillingness to have children.Research on families with a second child showed that up to 86.5% of families listed "lack of caregivers" as the biggest difficulty in having a second child.A fertility intention survey by the National Health Commission also indicated that 60.5% of families expressed low fertility intentions due to the lack of childcare. Grandparents are the main force in family infant and toddler care. The biggest drawback of intergenerational care is that grandparents tend to prioritize physical health and material needs over education, often neglecting psychological and personality development. This can weaken early emotional bonds between mother and child, leading to a phenomenon known as "intergenerational indulgence" in China. Traditional childcare views of grandparents not only limit family care but also create issues when elderly caregivers fall ill, leaving the family unable to cope. This increases the childcare pressure on childbearing-aged family members. Among the survey respondents, 80.30% of parents believed that the optimal age for entering care is 2–3 years, reflecting strong care needs at this age. Kindergartens with the capacity could establish nursery classes for 2–3 year-olds to provide universal childcare services. The survey results also show that more than half of the families of childbearing age encounter employment interruptions. This is consistent with what we mentioned in our interviews about women's career breaks due to childbirth and the short maternity leave that affect mothers' willingness to have more children, and it also comply with the results of the Fourth National Survey on the Social Status of Women in China. It indicates that women's temporary career interruptions are the result of the interaction between traditional societal gender role norms, unequal sharing of family childcare responsibilities, and insufficient policy support (Brewster and Rindfuss, 2000) . A considerable number of childbearing women are exhausted from coping with the dual pressures of work and family, which affects the quality of child-rearing, suppresses the desire to have more children, and severely impacts the reserve of China's demographic dividend ( Li et al., 2017 ). In studies on childcare services for children under 3 years old abroad, it was found that under the liberal welfare system, the UK provides a variety of childcare services, such as half-day or hourly care, to respond to the social changes highlighted by the increase in female employment rate and family issues (Guo and Dong, 2021) . Abroad, Sweden offers up to 480 days of parental leave and encourages fathers to participate in childcare and provides institutional support for family care (Seward et al., 2002) ; and the French government provides childcare and early childhood education services, with government-subsidized facility fees mainly depending on family income levels. The second demographic transition theory suggests that low fertility levels may be a "temporary byproduct" of the mismatch between family life arrangements and policy systems. When the two become more compatible and well-matched, fertility levels are expected to rise ( Yang et al., 2022 ). Also, our survey results support this view. Our survey shows that parents of infants and toddlers prefer public childcare institutions for their children, but there is a current shortage of inclusive care facilities, which are predominantly privately owned thus resulting in high care costs and family upbringing expenses (Rusterholz, 2015) . The price and location of care institutions have an influence on families' choices for childcare and reproduction, which indicates that the government needs to support the construction of inclusive care institutions through special funds and targeted subsidies. And the effectiveness of national policies, incentive mechanisms, and specific measures such as tax credits are in need of improvement ( Liu T. et al., 2022 ). Meanwhile, our survey found differences between urban and rural areas in terms of infant and toddler family care, and the price and location of care institutions, with rural families facing difficulties in accessing childcare, which led to inequality in formal early childhood care and education (Michelle J, 2003) . According to international experience, addressing these disparities and developing public, professional childcare and education institutions is one of the ways to solve this problem (Hakim, 2003) . The state should provide care services through institutional arrangements to share the childcare costs and promote long-term and balanced population development in China. In surveying families' needs for infant and toddler care institutions, the quality of care institutions is another concern for families, with some parents worrying about unsafe incidents such as child abuse and accidents. High-quality childcare services have a significantly positive impact on children's short-term and long-term learning and development (OECD,2018) . In the "14th Five-Year Plan" of China in 2021, it is clearly proposed to "promote the professional and standardized development of infant and toddler care services, and improve the quality and level of care and education." Survey results show that: parents of infants and toddlers wish for further standardization and more focus on environment and safety of care institutions, besides, they hope for care that combines medical, healthcare, and education provided by qualified medical personnel. The National Health Commission should provide strong support and assurance for the sustainable development of health for infants and toddlers aged 0–3 years. In this regard, the Chinese government's issuance of guidelines for infant and toddler care, which explicitly designates the National Health Commission as the supervisory department, is also a response to public sentiment. Since the establishment of China's infant and toddler care system is still in its infancy, such problems as the current lack of standardized care quality, shortage of professional staff, uneven quality, and non-standardized care quality have increased parents' concerns about institutions ( Liu M. et al., 2022 ). To address the current shortage of professional caregivers for infants and toddlers, it is crucial to establish infant and toddler care skill training institutions and to set up specialized programs that combine care and education for children aged 0–3 years. It is also found in this study that the current Chinese community parenting service system is in need of further refinement. Meanwhile, it was discovered during interview-based research that many families with infants and toddlers have a low awareness of relevant policies and care services, and the efforts to promote these by related departments need to be intensified. It is found in a study in Zhejiang Province on care services for children under 3 years old that 20% of families had a low level of understanding of the available services, and they were unclear about the childcare resources and locations available in their vicinity, thus facing asymmetric information access. This also led to issues such as being unable to enroll their children in childcare or low enrollment rates (Investigation report on the development of infant and toddler care services under 3 years old in Zhejiang Province, 2020). When families receive support from high-quality infant and toddler care resources, they are more likely to decide to give birth to more children (Rindfuss et al., 2010). Survey results indicate that financial pressure on families is also a factor that affects their willingness to give birth to more children. In this survey, 45.8% of families reported childcare expenses concentrated between 2,000–3,000 yuan per month. Under China's current fertility situation, developing a comprehensive social support system for childbirth and creating a favorable social environment for having children, which reduces family costs, may enhance the desire to have children. Internationally, Sweden offers its citizens low-cost or free access to kindergarten; while the French government provides childbearing allowances to families with more than two children (Letablier, 2003) ; and Singapore has implemented a pro-natalist fund policy, which provides cash subsidies for each newborn (Jones and Hamid, 2015). It is shown in the research that when the marginal benefit of having children for families is less than the marginal cost (Leibenstein, 1958) , the desire to have children decreases, thereby reducing the fertility rate in society (Becker and Barro, 1988) . The model of infant and toddler care services may has an influence on the desire to have children, thereby affecting reproductive behavior. China urgently needs to establish a "mixed care" system for infants and toddlers jointly provided by the state, society, and families. Excellent nurturing and care are prerequisites for infants and toddlers to have robust physical health and achieve comprehensive and healthy development. And ensuring and promoting health is an important aspect of nurturing and care ( Kong et al., 2023 ). 5. Limitations It is important to consider the limitations of this study. The research was limited by time and area, and despite being a nationwide study, there are limitations in regional distribution and sample size. The needs based on age was not further refined, which is a direction for our future research. Secondly, due to the long time stage of family childbearing, it was not possible to track studies chronologically, and our research data are cross-sectional. Future research will be improved in this regard. Future studies will refine content and include a larger population for normative research, including providing methodological support for scientific assessment of the current situation of infant and toddler care. 6. Conclusions China's infant and toddler care policy has deficiencies, with grandparental care being predominant. There is a significant demand for care services, and there is an urgent need to improve the quality and quantity of care institutions. Employment pressure, economic burden, and care service development affect families' reproductive intentions. Declarations Ethics approval and consent to participate This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Xi’an Jiaotong University. All adult participants provided informed consent prior to participation. Informed consent for participants under the age of 16 was obtained from their parents or legal guardians. All procedures involving human participants were conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Natural Science Foundation of China (Grant No. 82372086). The funding body had no role in the design of the study, data collection, analysis, interpretation, or manuscript writing. Authors’ contributions WL: Writing – original draft, Methodology, Formal analysis SZ: Investigation, Data curation XP: Writing – original draft, Methodology ZZ: Writing – review & editing, Project administration YL: Supervision, Resources, Conceptualization HL: Funding acquisition, Writing – review & editing, Resources All authors read and approved the final manuscript. Acknowledgements The authors acknowledge gratitude to all the staff who participated in the study. Authors’ information Not applicable. 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Supplementary Files SupplementaryFile103yearsoldInfantandToddlerCareParentsQuestionnaire.docx Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Sisi","middleName":"","lastName":"Zhang","suffix":""},{"id":473102951,"identity":"a32f3f1e-7604-4474-921b-3a9759125cad","order_by":2,"name":"Mingyan Zhong","email":"","orcid":"","institution":"Jiujiang Maternal and Child Care Center","correspondingAuthor":false,"prefix":"","firstName":"Mingyan","middleName":"","lastName":"Zhong","suffix":""},{"id":473102952,"identity":"85380930-deeb-43cb-abc0-86fe7f159194","order_by":3,"name":"Xiaotian Pang","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Xiaotian","middleName":"","lastName":"Pang","suffix":""},{"id":473102953,"identity":"ab4b31ca-c567-49a1-9e17-82ab186d3257","order_by":4,"name":"Zhongliang Zhu","email":"","orcid":"","institution":"Northwest University","correspondingAuthor":false,"prefix":"","firstName":"Zhongliang","middleName":"","lastName":"Zhu","suffix":""},{"id":473102954,"identity":"472d2545-f681-4b48-8bbc-d6001f9c7e46","order_by":5,"name":"Yushan Lu","email":"","orcid":"","institution":"Jiujiang Maternal and Child Care Center","correspondingAuthor":false,"prefix":"","firstName":"Yushan","middleName":"","lastName":"Lu","suffix":""},{"id":473102955,"identity":"2a12c0a4-1205-46de-b17a-22d16af020fc","order_by":6,"name":"Hui Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYBACAwbGxgMJFQzMYB4PkVoaDiScYWDmIUELA8MBxjaoaqK0mEskNxx4OO8wu71EAuODt20M8uaEtFjOSGw4kLgtjZlHIoHZcG4bg+HOBkIOuwHWYgPSwibN28aQYHCAKC1zJEBa2H+ToKUBYgszcVrOPAQG8jGgX848bJacc07CcANBLcfTHz78UXM4mb09+eCHN2U28gRtgYFkBmCcAmkJItUDgR3xSkfBKBgFo2DEAQDupz/FKSGUmwAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Xi’an Jiaotong University","correspondingAuthor":true,"prefix":"","firstName":"Hui","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-05-19 07:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6696383/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6696383/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85180610,"identity":"cb7dc864-cf45-4588-8ab4-c0a476d20d01","added_by":"auto","created_at":"2025-06-23 07:16:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160139,"visible":true,"origin":"","legend":"\u003cp\u003eThe Situation of China's Birth Population and Registered Care Institutions in the Eastern, Central, and Western Regions\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6696383/v1/839534ee563aa1649501be31.png"},{"id":86913052,"identity":"2582ee9e-161c-4cd0-9bd6-24dc715218ae","added_by":"auto","created_at":"2025-07-17 05:39:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":831724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6696383/v1/1ad451a0-14cc-4ddd-989b-9b0e6121c4c6.pdf"},{"id":85180609,"identity":"750a2672-e137-4315-8db7-f3f060d56260","added_by":"auto","created_at":"2025-06-23 07:16:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":46629,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile103yearsoldInfantandToddlerCareParentsQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-6696383/v1/02c2bb8b4eb081ac9bf35a2b.docx"},{"id":85180608,"identity":"4ffcd4f1-bf2c-40fc-9020-80027cd02562","added_by":"auto","created_at":"2025-06-23 07:16:42","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":29183,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6696383/v1/6ab03694991ba14b806e3b16.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Infant and Toddler Care Services on the Reproductive Intentions of Women of Childbearing Age in the Context of Low Fertility in China: A Cross-Sectional Survey Study","fulltext":[{"header":"1 Background","content":"\u003cp\u003eChina has recently opened up its fertility policy, but instead of the expected baby boom, the country has entered a low fertility phase. This reflects a generally low fertility intention among the population, driven by multiple factors. Infant and toddler care services are crucial complementary measures to fertility policies. The completeness of these services significantly affects the fertility intentions of people of childbearing age and the number of newborns. As the difficulty of infant care increases and the demand for services expands, providing reasonable care services through proactive fertility support measures can effectively enhance family fertility intentions. Currently, China's infant and toddler care system is in its early stages. In 2019, the Chinese government issued guidance on infant and toddler care, offering various forms of care services to gradually meet family needs, marking the start of state-managed infant care and changing the long-standing family care situation. In 2021, the \"three-child\" policy and supportive measures were introduced, emphasizing the development of a universal childcare service system. While attention to infant and toddler care in China has increased, the mismatch between service supply and demand and prominent conflicts have also received significant focus.\u003c/p\u003e \u003cp\u003eFacing an unprecedented negative population growth in China, we can indicate an impending aging society, thus it is crucial to understand the underlying issues. Questionnaires were designed and interviews were conducted in this study, which combined online and offline methods to survey public opinion on infant and toddler care policies and the reproductive intentions of childbearing families throughout the nation. The aim is to understand the current needs of Chinese families and comprehensively improve the care system, thereby providing scientific recommendations to address the low fertility rate.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data\u003c/h2\u003e \u003cp\u003eOn the basis of relevant literature and expert demonstration, we designed the \u0026lt;\u0026thinsp;0\u0026ndash;3 years old Infant and Toddler Care Parents Questionnaire\u0026thinsp;\u0026gt;\u0026thinsp;to investigate the current situation of infant care in Shanghai, Guangzhou, Shaanxi, Guizhou, Hubei, Anhui and Jiangxi and other provinces in China. And relevant demographic data, infant care situation and family reproductive intention were collected. Then semi-structured, direct interviews were conducted with infant care staff and some parents to understand the effects of infant care, current problems, opinions and suggestions.\u003c/p\u003e \u003cp\u003eThe questionnaire and interview guide were developed specifically for this study based on literature review and expert consultation. The English version of the questionnaire is provided in Supplementary File 1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cp\u003eThe designed questionnaire includes the following information: General family information (age, household registration, caregiver education level, family per capital income, etc.), infant and toddler family child care expectation (care mode, service type, cost, age of child care entry, institution location, staff qualification, institution function positioning, etc.), infant and toddler care situation (infant electronic screen exposure time, number of family secretaries, access to parenting knowledge, Family care concerns, etc.), problems of infant care (management, distance, fees, diet, early education, etc.), family reproductive intention, etc.\u003c/p\u003e \u003cp\u003eIn order to ensure the quality of the questionnaire, experts were invited to conduct expert validity test before the formal survey. And before the formal investigation, the questionnaire was revised and tested several times, and the scientific and reasonable design of the questionnaire was approved. Then the families of 0\u0026ndash;3 years old infants were selected for testing. The electronic questionnaire was designed to ensure the rationality of the data by setting the normal value range in advance, and all required questions were set to ensure the integrity of the data. During the data check period, the personnel of the project reviewed all the questionnaires in the management background in real time every day, eliminated the duplicate questionnaires in time, and verified and revised the data with obvious errors through telephone. The survey was conducted online and offline. And special QR codes were set up for different regions, and the questionnaires were distributed by uniformly trained personnel through printing posters and wechat groups of parents.\u003c/p\u003e \u003cp\u003eAs for the interview method, according to the research purpose, the interview outline was initially formulated through reviewing relevant literature and policies, and then pre-interview was conducted with 2 staff members. Then the outline was further revised, and the interview outline was determined after consulting experts again. In this study, the current situation of infant and child care was taken as the breakthrough point, and a total of 108 infant and child care related personnel and some parents received interviews to explore and pay attention to the care effect and present problems, which aims to put forward reasonable suggestions. Data was collected in the form of semi-structured, direct interviews, and the interviewers had been trained in professional qualitative research and they were familiar with interview skills. The face-to-face interview was conducted in a quiet and deserted office or conference room. Before the start of the interview, the purpose and significance of this study were informed to the respondents, and the respondents were interviewed on a voluntary basis by audio recording. The recordings were kept confidential with each interview lasting 25 to 30 minutes. The interviewers were uniformly trained, and with the consent of the interviewees, the field notes and recordings were used to ensure the integrity and accuracy of the original data. Then the interviewers excluded subjective factors to ensure the accuracy and objectivity of the data analysis results.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 The situation of China\u0026apos;s Birth Population and Registered Care Institutions\u003c/h2\u003e\n \u003cp\u003eChina\u0026apos;s birth rate has been declining year by year since 2016, dropping from 13.57\u0026permil; in 2016 to 6.39\u0026permil; in 2023. The number of births has shown a downward trend year by year with 9.02\u0026nbsp;million of newborns in 2023, which is a decrease of 8.84\u0026nbsp;million from 2016. The natural population growth rate has been decreasing annually, with the first occurrence of negative population growth in 2022, and the natural population growth rate in 2023 was \u0026minus;\u0026thinsp;1.48\u0026permil; (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e-A). Up to January 2024, 37,303 care institutions have completed registration in the registration information system of National Health Commission\u0026apos;s care institution. Among them, the eastern region has a larger number of registered institutions, especially in Zhejiang Province (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e-B); in the central region, Anhui Province has a larger number of registered institutions (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e-C); while in the western region, Sichuan Province has a larger number of registered care institutions (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e-D), with significant disparities in the number of registered institutions among regions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 The analysis of demographic characteristics\u003c/h2\u003e\n \u003cp\u003eThe survey respondents included 6,264 urban residents (64.58%) and 3,435 rural residents (35.42%); 1) Caregiver educational level: 792 cases of junior high school and below (8.16%), 1,758 cases of high school(18.13%), 5,862 cases of university(60.44%), 1,287 cases of master\u0026apos;s degree and above(13.27%); 2) Average monthly household income: 1,944 cases of 3,000 and below(20.04%), 3,501 cases of 3,000\u0026ndash;5,000 yuan(36.10%), 2,466 cases of 5,000\u0026ndash;8,000 yuan(25.43%), 1,788 cases of more than 8,000 yuan(18.43%); 3) Age distribution: parents aged 20\u0026ndash;29 years 2,070 cases (21.35%), 30\u0026ndash;39 years 6,969 cases (71.85%), over 40 years 660 cases (6.80%); 4) Incidence of family employment interruption: 5,169 cases (53.29%), no family employment interruption 4,530 cases (46.71%). (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3Analysis of Family Infant and Toddler Care Needs\u003c/h2\u003e\n \u003cp\u003eAmong the survey respondents, the primary caregivers were grandparents in 5,322 cases (54.87%), parents in 3,849 cases (39.69%), and others in 528 cases (5.44%). Current childcare expenses were as follows: below 2,000 yuan in 3,228 cases (33.3%), 2,000\u0026ndash;3,000 yuan in 4,446 cases (45.8%), 3,000\u0026ndash;4,000 yuan in 1,233 cases (12.7%), and above 4,000 yuan in 792 cases (8.2%).\u003c/p\u003e\n \u003cp\u003eFamily needs are primarily focused on care methods, service types, care costs, age of enrollment, location of the institution, qualifications of staff, and institutional functional positioning, among other aspects.\u003c/p\u003e\n \u003cp\u003e1)Selection of care method: Parents show a strong preference for public and workplace-run institutions and they choose publicly run care (61.46%), workplace care (22.24%); full-time care services (71.08%); and 85.74% of parents hope the institution is close to home.\u003c/p\u003e\n \u003cp\u003e2)Expected care costs: Concentrated in the range of 1,001\u0026ndash;2,000 yuan (51.81%); 80.30% of parents expect the best age for their child to start attending is 2\u0026ndash;3 years old;\u003c/p\u003e\n \u003cp\u003e3)Parents\u0026apos; expectations of care institution staff: 70.68% of parents choose qualifications like pediatricians, nurses, and psychologists who are more qualified to provide care, 68.91% of parents chose \u0026quot;both care and education.\u0026quot; Parents who have not chosen a care institution are most worried about child abuse and safety accidents. (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Results of Interviews on Infant and Toddler Care\u003c/h2\u003e\n \u003cp\u003eResults of Interviews on Infant and Toddler Care\u003c/p\u003e\n \u003cp\u003eBased on the grounded theory research method, the process of data analysis is divided into three stages. The coding process was assisted by Nvivo and completed through a bottom-up inductive process, and a three-level node of category relationships was formed. By organizing, coding, and refining the interview texts, the three-level nodes were summarized into two-level nodes, and then refined and integrated to obtain three primary nodes: outcomes, problems, and suggestions. (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\n \u003cdiv\u003eIn the results of the interview, the achievements of the infant and toddler care system mainly include an increase in the number of care institutions and the proportion of non-profit organizations, certain policy support, the ability of care institutions to provide basic care services, the introduction of care standards, and an increase in the number of care personnel. Related personnel pointed out problems in infant and toddler care services: institutions are primarily profit-driven and are distributed unreasonably, and policy support for multiple entities is insufficient, meanwhile, there is a large variation in care service content with many unsafe factors and inconsistent care service industry standards, and there are issues with the qualifications of care personnel.\u003c/div\u003e\n \u003cp\u003eThe suggestions for optimizing infant and toddler care services: Concerning the development of care institutions, management departments suggest \u0026quot;government authorities should clarify responsibilities, define the management mechanism for issuing business licenses and permits, and the market should conduct effective industry regulation and standardization.\u0026quot; \u0026quot;Professional skill training institutions should be developed for infant and toddler care to alleviate the shortage of professional talent in infant and toddler care,\u0026quot; suggest care institution managers, \u0026quot;and support for the infant and toddler care industry should be increased to reduce professional talent loss\u0026quot;; childbearing age parents suggest \u0026ldquo;care institutions should provide professional care, prioritizing the avoidance of high-risk factors over nurturing,\u0026quot; \u0026quot;And they hope the government-run care institutions can alleviate the workplace pressure on women,\u0026quot; \u0026quot;moderate competition should be formed in private and public care institutions, which would be beneficial to improving the quality of care services,\u0026quot; \u0026quot;care institutions can offer some scientific parenting knowledge and skill training for new parents,\u0026quot; etc.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.6 Analysis of Factors That Influence the Reproductive Intentions of Families of Childbearing Age\u003c/h2\u003e\n \u003cp\u003eUnivariate analysis showed that the factors in terms of monthly income level, parents\u0026apos; age, primary caregiver, concerns about care institutions, and the duration of maternal leave affect the willingness of families to have another child, with statistically significant differences (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Factors with statistically significant differences in the univariate analysis were included in a logistic regression analysis. And the results showed that: the factors such as average monthly family income between 3,000\u0026ndash;5,000 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), management of care institutions, distance, fees, diet, early education (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and one year of maternity leave (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) influenced the willingness of families to have another child. (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eSince China fully implemented the two-child policy in 2016(Communiqu\u0026eacute; of the Fifth Plenary Session of the 18th CPC Central Committee,2015), it has not achieved the expected effects. Instead, the birth rate has been declining year by year, from a birth rate of 12.07\u0026permil; shown in 2015 to the current rate of 6.39\u0026permil;. The total fertility rate dropped to 1.09 in 2022, which is far below the \"highly sensitive warning line\" of 1.5 commonly recognized by the international community. Among the countries with a population over 100\u0026nbsp;million, this is considered a low fertility level. The sharp decline in the newborn population and the unprecedented negative population growth indicate that Chinese society will enter a state of aging development, which has attracted high attention from scholars both domestically and internationally.\u003c/p\u003e \u003cp\u003eThe care industry of China was started late, and the quality of infant and toddler care institutions and the family childcare environment are crucial to the early development of infants and toddlers\u003cb\u003e(Britto et al., 2017)\u003c/b\u003e. Survey results show that with the liberalization of the two-child policy, there is a large demand for family care, but traditional family care is showing a trend of being unsustainable\u003cb\u003e(Hong and Zhu, 2020)\u003c/b\u003e. The optimization of the infant and toddler care system has a significant impact on family reproductive intentions. Care for 0-3-year-old infants and toddlers in China is not managed by the government but by families. Our research particularly focuses on the gap in care for 0-3-year-olds, which include investigating the current situation of infant and toddler care institutions, differences in care between urban and rural areas, and deficiencies in care, exploring factors that affect family reproductive intentions, and providing suggestions to improve the quality of care institutions, enhance the family childcare environment, and increase the willingness to have children.\u003c/p\u003e \u003cp\u003eOur survey shows that the currently registered infant and toddler care institutions are far from meeting social demands, with significant regional disparities, and more institutions are located in the eastern regions. A study on China's fertility status reported that 33.2% of women of childbearing age cited \"no one to take care of the child\" as the main reason for their unwillingness to have children.Research on families with a second child showed that up to 86.5% of families listed \"lack of caregivers\" as the biggest difficulty in having a second child.A fertility intention survey by the National Health Commission also indicated that 60.5% of families expressed low fertility intentions due to the lack of childcare. Grandparents are the main force in family infant and toddler care. The biggest drawback of intergenerational care is that grandparents tend to prioritize physical health and material needs over education, often neglecting psychological and personality development. This can weaken early emotional bonds between mother and child, leading to a phenomenon known as \"intergenerational indulgence\" in China. Traditional childcare views of grandparents not only limit family care but also create issues when elderly caregivers fall ill, leaving the family unable to cope. This increases the childcare pressure on childbearing-aged family members. Among the survey respondents, 80.30% of parents believed that the optimal age for entering care is 2\u0026ndash;3 years, reflecting strong care needs at this age. Kindergartens with the capacity could establish nursery classes for 2\u0026ndash;3 year-olds to provide universal childcare services.\u003c/p\u003e \u003cp\u003eThe survey results also show that more than half of the families of childbearing age encounter employment interruptions. This is consistent with what we mentioned in our interviews about women's career breaks due to childbirth and the short maternity leave that affect mothers' willingness to have more children, and it also comply with the results of the Fourth National Survey on the Social Status of Women in China. It indicates that women's temporary career interruptions are the result of the interaction between traditional societal gender role norms, unequal sharing of family childcare responsibilities, and insufficient policy support\u003cb\u003e(Brewster and Rindfuss, 2000)\u003c/b\u003e. A considerable number of childbearing women are exhausted from coping with the dual pressures of work and family, which affects the quality of child-rearing, suppresses the desire to have more children, and severely impacts the reserve of China's demographic dividend\u003cb\u003e(\u003c/b\u003eLi et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In studies on childcare services for children under 3 years old abroad, it was found that under the liberal welfare system, the UK provides a variety of childcare services, such as half-day or hourly care, to respond to the social changes highlighted by the increase in female employment rate and family issues\u003cb\u003e(Guo and Dong, 2021)\u003c/b\u003e. Abroad, Sweden offers up to 480 days of parental leave and encourages fathers to participate in childcare and provides institutional support for family care\u003cb\u003e(Seward et al., 2002)\u003c/b\u003e; and the French government provides childcare and early childhood education services, with government-subsidized facility fees mainly depending on family income levels. The second demographic transition theory suggests that low fertility levels may be a \"temporary byproduct\" of the mismatch between family life arrangements and policy systems. When the two become more compatible and well-matched, fertility levels are expected to rise\u003cb\u003e(\u003c/b\u003eYang et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Also, our survey results support this view.\u003c/p\u003e \u003cp\u003eOur survey shows that parents of infants and toddlers prefer public childcare institutions for their children, but there is a current shortage of inclusive care facilities, which are predominantly privately owned thus resulting in high care costs and family upbringing expenses\u003cb\u003e(Rusterholz, 2015)\u003c/b\u003e. The price and location of care institutions have an influence on families' choices for childcare and reproduction, which indicates that the government needs to support the construction of inclusive care institutions through special funds and targeted subsidies. And the effectiveness of national policies, incentive mechanisms, and specific measures such as tax credits are in need of improvement\u003cb\u003e(\u003c/b\u003eLiu T. et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Meanwhile, our survey found differences between urban and rural areas in terms of infant and toddler family care, and the price and location of care institutions, with rural families facing difficulties in accessing childcare, which led to inequality in formal early childhood care and education\u003cb\u003e(Michelle J, 2003)\u003c/b\u003e. According to international experience, addressing these disparities and developing public, professional childcare and education institutions is one of the ways to solve this problem\u003cb\u003e(Hakim, 2003)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe state should provide care services through institutional arrangements to share the childcare costs and promote long-term and balanced population development in China.\u003c/p\u003e \u003cp\u003eIn surveying families' needs for infant and toddler care institutions, the quality of care institutions is another concern for families, with some parents worrying about unsafe incidents such as child abuse and accidents. High-quality childcare services have a significantly positive impact on children's short-term and long-term learning and development\u003cb\u003e(OECD,2018)\u003c/b\u003e. In the \"14th Five-Year Plan\" of China in 2021, it is clearly proposed to \"promote the professional and standardized development of infant and toddler care services, and improve the quality and level of care and education.\" Survey results show that: parents of infants and toddlers wish for further standardization and more focus on environment and safety of care institutions, besides, they hope for care that combines medical, healthcare, and education provided by qualified medical personnel. The National Health Commission should provide strong support and assurance for the sustainable development of health for infants and toddlers aged 0\u0026ndash;3 years. In this regard, the Chinese government's issuance of guidelines for infant and toddler care, which explicitly designates the National Health Commission as the supervisory department, is also a response to public sentiment. Since the establishment of China's infant and toddler care system is still in its infancy, such problems as the current lack of standardized care quality, shortage of professional staff, uneven quality, and non-standardized care quality have increased parents' concerns about institutions\u003cb\u003e(\u003c/b\u003eLiu M. et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). To address the current shortage of professional caregivers for infants and toddlers, it is crucial to establish infant and toddler care skill training institutions and to set up specialized programs that combine care and education for children aged 0\u0026ndash;3 years.\u003c/p\u003e \u003cp\u003eIt is also found in this study that the current Chinese community parenting service system is in need of further refinement.\u003c/p\u003e \u003cp\u003eMeanwhile, it was discovered during interview-based research that many families with infants and toddlers have a low awareness of relevant policies and care services, and the efforts to promote these by related departments need to be intensified. It is found in a study in Zhejiang Province on care services for children under 3 years old that 20% of families had a low level of understanding of the available services, and they were unclear about the childcare resources and locations available in their vicinity, thus facing asymmetric information access. This also led to issues such as being unable to enroll their children in childcare or low enrollment rates\u003cb\u003e(Investigation report on the development of infant and toddler care services under 3 years old in Zhejiang Province, 2020).\u003c/b\u003e When families receive support from high-quality infant and toddler care resources, they are more likely to decide to give birth to more children\u003cb\u003e(Rindfuss et al., 2010).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSurvey results indicate that financial pressure on families is also a factor that affects their willingness to give birth to more children. In this survey, 45.8% of families reported childcare expenses concentrated between 2,000\u0026ndash;3,000 yuan per month. Under China's current fertility situation, developing a comprehensive social support system for childbirth and creating a favorable social environment for having children, which reduces family costs, may enhance the desire to have children. Internationally, Sweden offers its citizens low-cost or free access to kindergarten; while the French government provides childbearing allowances to families with more than two children\u003cb\u003e(Letablier, 2003)\u003c/b\u003e; and Singapore has implemented a pro-natalist fund policy, which provides cash subsidies for each newborn\u003cb\u003e(Jones and Hamid, 2015).\u003c/b\u003e It is shown in the research that when the marginal benefit of having children for families is less than the marginal cost\u003cb\u003e(Leibenstein, 1958)\u003c/b\u003e, the desire to have children decreases, thereby reducing the fertility rate in society\u003cb\u003e(Becker and Barro, 1988)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eThe model of infant and toddler care services may has an influence on the desire to have children, thereby affecting reproductive behavior. China urgently needs to establish a \"mixed care\" system for infants and toddlers jointly provided by the state, society, and families. Excellent nurturing and care are prerequisites for infants and toddlers to have robust physical health and achieve comprehensive and healthy development. And ensuring and promoting health is an important aspect of nurturing and care\u003cb\u003e(\u003c/b\u003eKong et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eIt is important to consider the limitations of this study. The research was limited by time and area, and despite being a nationwide study, there are limitations in regional distribution and sample size. The needs based on age was not further refined, which is a direction for our future research. Secondly, due to the long time stage of family childbearing, it was not possible to track studies chronologically, and our research data are cross-sectional. Future research will be improved in this regard. Future studies will refine content and include a larger population for normative research, including providing methodological support for scientific assessment of the current situation of infant and toddler care.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eChina's infant and toddler care policy has deficiencies, with grandparental care being predominant. There is a significant demand for care services, and there is an urgent need to improve the quality and quantity of care institutions. Employment pressure, economic burden, and care service development affect families' reproductive intentions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Xi\u0026rsquo;an Jiaotong University. All adult participants provided informed consent prior to participation. Informed consent for participants under the age of 16 was obtained from their parents or legal guardians. All procedures involving human participants were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003cbr\u003e\u0026nbsp;This work was supported by the National Natural Science Foundation of China (Grant No. 82372086). The funding body had no role in the design of the study, data collection, analysis, interpretation, or manuscript writing.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003cbr\u003e\u0026nbsp;WL: Writing \u0026ndash; original draft, Methodology, Formal analysis\u003cbr\u003e\u0026nbsp;SZ: Investigation, Data curation\u003cbr\u003e\u0026nbsp;XP: Writing \u0026ndash; original draft, Methodology\u003cbr\u003e\u0026nbsp;ZZ: Writing \u0026ndash; review \u0026amp; editing, Project administration\u003cbr\u003e\u0026nbsp;YL: Supervision, Resources, Conceptualization\u003cbr\u003e\u0026nbsp;HL: Funding acquisition, Writing \u0026ndash; review \u0026amp; editing, Resources\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;The authors acknowledge gratitude to all the staff who participated in the study.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; information\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCentral Committee of the Communist Party of China. Communiqu\u0026eacute; of the Fifth Plenary Session of the 18th CPC Central Committee. Zhongguo Chan Jing. 2015;12:14\u0026ndash;21. Chinese.\u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics of China. http:// www.stats.gov.cn/.\u003c/li\u003e\n\u003cli\u003eWang J, Li XM. The low fertility trend under China\u0026apos;s three-child policy: dilemmas and solutions. Qingnian Tansuo. 2021;(04):50\u0026ndash;61. Chinese.\u003c/li\u003e\n\u003cli\u003eSong J. Fertility motivations and intentions among reproductive-aged population in China. Renkou yu Jingji. 2022;6:1\u0026ndash;16. Chinese.\u003c/li\u003e\n\u003cli\u003eSP Y. The status and strategies of early family education in central China[J]. Studies in Early Childhood Education, 2019,3(291): 85-88.\u003c/li\u003e\n\u003cli\u003eJ L. Research progress on the influence of family nurturing environment on early childhood development[J]. 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Zhongguo Qingnian Shehui Kexue. 2022;41(6):86\u0026ndash;94. Chinese.\u003c/li\u003e\n\u003cli\u003eYang JH, Du SH. Fertility support policies in several countries and their implications for China. Tansuo. 2017;(02):137\u0026ndash;146. Chinese.\u003c/li\u003e\n\u003cli\u003eC R. costs of children and models of parenthood：comparative evident from two swiss cities[Z]. 2015: 40(2)：208-229.\u003c/li\u003e\n\u003cli\u003eH L. Economic Backwardness and Economic Growth:Studies in the Theory of Economic Development[M][J]. New York:Wiley Press, 1957.\u003c/li\u003e\n\u003cli\u003eBECKER G S B R J A. A reformulation of the economic theory of fertility[J]. The quarterly journal of economics, 1988(103(1): 1-25).\u003c/li\u003e\n\u003cli\u003eBUDIG M J. Are Women\u0026apos;s Employment and Fertility Histories Interdependent? An Examination of Causal Order Using Event History Analysis[J]. Social Science Research, 2003,3(32): 376-401.\u003c/li\u003e\n\u003cli\u003eHAKIM C. A New Approach to Explaining Fertility Patterns: Preference Theory[J]. Population and Development Review, 2003,29(3): 349-374.\u003c/li\u003e\n\u003cli\u003eLiu T, Li JH, Song Y. Policy implementation conditions for care services for children under 3 years old in China: A multi-stream perspective. Nanjing Med Univ J Soc Sci Ed. 2022;22(5):443\u0026ndash;448. Chinese.\u003c/li\u003e\n\u003cli\u003eLiu M, Shen ZQ, Hong BX, et al. Analysis of care services for children under 3 in Sichuan Province based on supply-demand matching theory. Sichuan Univ J Med Sci. 2022;53(4):663\u0026ndash;669. Chinese.\u003c/li\u003e\n\u003cli\u003eR R R, K G D, M K S P. Child-Care availability and fertility in norway[J]. Population and Development Review, 2010: 34-36.\u003c/li\u003e\n\u003cli\u003eCHASSIAKOS. Children and adolescents and digital media[J]. Pediatrics, 2016,5(138).\u003c/li\u003e\n\u003cli\u003eMY O. The influence of perceived parenting styles on socio-emotional development from pre-puberty into puberty[J]. Eur Child Adolesc, 2018,1(27): 37-46.\u003c/li\u003e\n\u003cli\u003eJ L. From early family systems to internalizing symptoms: the role of emotion regulation and peer relations[J]. J Fam Psychol, 2017,31(3): 316-326.\u003c/li\u003e\n\u003cli\u003eBEACH COPELAND D H B. Early maternal-efficacy and competence in first-time,low-income mothers[J]. Compr Child Adoles Nurs, 2017: 40-41.\u003c/li\u003e\n\u003cli\u003eYang J, Li HY, Yang CH. Status and development strategies of inclusive infant and toddler care services in communities: A survey of 48 communities in X City, Jiangsu Province. 2022. Chinese.\u003c/li\u003e\n\u003cli\u003eBREWSTER K L R R. Fertility and Women\u0026apos;s Employment in Industrialized Nations[J]. Annual Revies of Sociology, 2000(271-296): 26.\u003c/li\u003e\n\u003cli\u003eLiu LC. Social childcare services: welfare for working mothers\u0026mdash;A comparison of Nordic and East Asian countries. Renkou yu Shehui. 2015;31(04):97\u0026ndash;105. Chinese.\u003c/li\u003e\n\u003cli\u003eLi MY, Qimu T, Zhang Q, et al. Comparative analysis of parenting stress and social support between Chinese and Japanese parents in the low fertility era. Xueqian Jiaoyu Yanjiu. 2017;(03):46\u0026ndash;54. Chinese.\u003c/li\u003e\n\u003cli\u003eTang ZY, Liu KC. Impact of family support on second-child fertility intentions among rural migrant workers: Evidence from CFPS 2020. 2024:1\u0026ndash;10. Chinese.\u003c/li\u003e\n\u003cli\u003eKong WR, Xu MX, Jia N, et al. Parenting and care capacity of parents with 0\u0026ndash;3-year-old children in Beijing and its influencing factors. Chin J Child Health Care. 2023;31(07):741\u0026ndash;745. Chinese.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"0-3 years old infant and toddler care policy, care institutions, fertility intentions, negative population growth","lastPublishedDoi":"10.21203/rs.3.rs-6696383/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6696383/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: Infant and toddler care services are crucial fertility support measures in the context of China's low birthrate and aging population. This study aims to understand the current family care needs under existing care policies and their impact on families' intentions to have additional children, providing scientific evidence for improving social population development and care policies.\u003c/p\u003e\n\u003cp\u003eMethods: A survey and interview method was employed, which included 9,699 parents of infants and toddlers from September to December 2022, along with interviews of individuals involved in infant and toddler care.\u003c/p\u003e\n\u003cp\u003eResults: There is a significant regional disparity in the number of registered infant and toddler care institutions in China, with more in the eastern regions. Among the survey respondents, 54.81% of families used infant and toddler care services. Parental education level, monthly household income per capita, parental age, and employment interruptions in the family were significantly associated with the use of care services (P \u0026lt; 0.01). Grandparents were the primary caregivers in 54.87% of families, with most families spending between 2000–3000 yuan on childcare (45.8%). Regarding care needs, families with infants and toddlers preferred full-day care services (71.08%), favored public (61.46%) and workplace-based care (22.24%), and preferred institutions close to home (85.74%). They also preferred care costs to be between 1001–2000 yuan (51.81%), considered the optimal age for entering care to be 2–3 years (80.30%), and preferred care by professional caregivers (70.68%). Logistic regression analysis indicated that a monthly household income per capita between 3000–5000 yuan (P \u0026lt; 0.05), one-year maternity leave (P \u0026lt; 0.05), and concerns about the management, distance, fees, food, and early education in care institutions (P \u0026lt; 0.01) were factors influencing families' willingness to have additional children. Interviews revealed that there are few affordable care institutions, high operating costs, inconsistent industry standards, and issues with caregiver qualifications.\u003c/p\u003e\n\u003cp\u003eConclusion: China's infant and toddler care policy has deficiencies, with grandparental care being predominant. There is a significant demand for care services, and there is an urgent need to improve the quality and quantity of care institutions. Employment pressure, economic burden, and care service development affect families' reproductive intentions.\u003c/p\u003e","manuscriptTitle":"The Impact of Infant and Toddler Care Services on the Reproductive Intentions of Women of Childbearing Age in the Context of Low Fertility in China: A Cross-Sectional Survey Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 07:16:37","doi":"10.21203/rs.3.rs-6696383/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81a05efa-a635-4e1d-95c3-6df2dcedec83","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-17T05:39:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-23 07:16:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6696383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6696383","identity":"rs-6696383","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}