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BMJ Open
Maternal depression and loss of children under the one-

child family planning policy in China: a cross-sectional study
of 300,000 women
Journal: BMJ Open
Manuscript ID bmjopen-2020-048554
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Article Type: Original research
Date Submitted by the

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02-Jan-2021
Author:
Complete List of Authors: Wang, Hanyu; Tsinghua University, Vanke School of Public Health
Frasco, Eric; University College London
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Shang, Jie; George Institute for Global Health

Chen, Minne; Marie Stopes International China
Xin, Tong; Peking University Health Science Centre, Department of
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Global Health
Tang, Kun; Tsinghua University, Vanke School of Public Health
Depression & mood disorders < PSYCHIATRY, Health policy < HEALTH
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Keywords:
SERVICES ADMINISTRATION & MANAGEMENT, SOCIAL MEDICINE
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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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BMJ Open Page 2 of 24
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3 Maternal depression and loss of children under the one-child family planning policy in
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6 China: a cross-sectional study of 300,000 women
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8 Hanyu Wang1, Eric Frasco2, Jie Shang3, Minne Chen4, Tong Xin5, Kun Tang6
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10 Corresponding Author: Dr. Kun Tang
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Address: Tsinghua University, Haidian District, Beijing 100191, P.R. China
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15 Telephone Number: 86-10-82805951
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17 Corresponding Author E-mail Address：tangk@mail.tsinghua.edu.cn
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20 1 Vanke School of Public Health, Tsinghua University, Haidian District, Beijing, China. E-mail:
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22 whybest@pku.edu.cn
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24 2 University College London, Gower St, Bloomsbury, London, United Kingdom, WC1E 6BT.
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E-mail: frasco.eric@gmail.com
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29 3 The George Institute of Global Health at Peking University Health Science Center, 1801,
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31 Tower B, Horizon Tower No 6 Zhichun Rd, Beijing Haidian District, China. E-mail:
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jshang@georgeinstitute.org.cn
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36 4 Marie Stopes International China, No.172 Beiyuan Rd, Chaoyang District, Beijing, China. E-
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5 Department of Global Health, Peking University Health Science Center, No.38 Xueyuan Rd,
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43 Haidian District, Beijing, China. E-mail: xtong.katrina@gmail.com
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47 tangk@mail.tsinghua.edu.cn
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50 Manuscript word count: 3528
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60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
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3 Abstract
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6 Objectives This study aims to explore the relationship between maternal depression and the loss
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8 of the only child under the Family Planning Policy.
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10 Design, setting, and participants Baseline data from a Chinese population-based study of
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approximately 300,000 females from 10 areas were analyzed. The family-planning (FP) group was
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15 defined as women with 1 or 2 live births. In the FP group, women with at least one child alive at
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17 the time of the survey were classified into non-loss-of-only-child group, and those with no child
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left were classified into loss-of-only-child group. Non-family-planning (non-FP) group included
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22 women who had more than 2 live births. Logistic regression was used to assess the relationship
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24 between Major depression (MD) and family types, after

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26 stratification and adjustment.
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29 Primary Outcome MD was assessed using the Composite International Diagnostic Inventory.
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31 Results The odds of MD is 1.42 times higher in FP group in general (OR=1.42, 95%CI:1.28-1.57),
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33 as opposed to non-FP group. In particular, the odds of MD are 1.36 times greater in non-loss-of-
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only-child group (OR=1.36, 95%CI: 1.21-1.51) and 2.80 (OR=2.80, 95%CI: 0.88-8.94) times
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greater in the loss-of-only-child group, compared to non-FP group. The associations between FP
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40 groups and MD appeared to be stronger in the elderly population, in those who were married, less
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educated, and with higher household income. The association was found progressively stronger in
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45 those who lost their only child.
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47 Conclusions Public health interventions aiming at decreasing depression should provide mental
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49 health care and support to this vulnerable population.
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52 Key Words: Family Planning; Depression; Mental Health; China
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3 Strengths and limitations of this study
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6  It is one of the first papers that incorporates a policy dimension into the research between
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8 bereaved parents and depression.
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10  The data we used is the largest cross-sectional study in China that incorporates data on
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depression and the number of children.
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15  The study was only able to include mother’s age at the survey. Maternal age at bereavement,
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17 the child’s age at death, and other related information were not included in the survey.
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 The study is a cross-sectional study instead of a longitudinal study.
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22  The data lacks information on people’s coping mechanisms after child loss.
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1
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3 INTRODUCTION
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6 The Family Planning (FP) Policy in China - broadly known as the One-child Policy - was officially
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8 launched in 1982, a time when the country was facing the dual challenge of economic and social
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10 system breakdown after the Cultural Revolution, as well as a population size which doubled in
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only three decades.1 Most families in the city were strictly limited to one child, while some couples
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15 were allowed two if they lived in a rural area, worked in a high-risk occupation, were from minority
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17 ethnic groups, or had a disabled first child.2,3 Since then, the policy has impacted millions of
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families.4 However, changes were officially made to the policy in 2015 and all couples were
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22 permitted to have two children.1 Still, it remains a question as to what extent society and individual
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24 life have been changed under the policy. China has received credit for the effective control of
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26 population growth on one hand, but on the other, criticisms were raised regarding the deprivation
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29 of reproductive rights. Another consequence of the FP policy has been the emergence of a group
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31 of parents that lost their only child due to illness or accidents, commonly referred to as the
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33 “Shidu”.5 Since 1982, more than 1 million families have lost their only child, with the number
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expected to reach 11 million by 2050.6
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40 Major Depressive Disorder (MDD), characterised by recurrent symptoms including disrupted
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sleeping patterns, low mood, and difficulty concentrating, is a major contributor to the global
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45 burden of disease, suicide rates, and the onset of the non-communicable diseases like ischemic
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47 heart diseases.7,8 In China, more than 54 million people are estimated to suffer from MDD.9 Grief
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49 and other relevant psychological disorders, including MDD, of parents who lost their child have
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52 been an area of research in many countries. The negative emotions from the loss of bond to the
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54 child or guilt of being unable to protect the child, for example, can lead to severe psychological
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3 disorders of the bereaved parents, including depression.10-13 Using longitudinal data of 428
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6 bereaved parents in Wisconsin, Rogers et al14 show that the mental impact of child loss is long
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8 term. After an average of 18 years follow-up after a child’s death, with parent age at a mean of 53,
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10 those who lost their child report more depressive symptoms than those who did not lose their child.
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Greater risk of hospitalisation due to psychological disorders or suicidal ideation, as well as
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15 decreased social functioning, were also found in bereaved parents, especially for bereaved
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17 mothers. Additionally, depressive symptoms can lead to increased health-damaging behaviors, a
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weakened immune system, and subsequently lower physical health.15-17
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24 Studies have shown mixed evidence towards risk factors of parental depression after child
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26 bereavement. A study showed that the grief of the bereaved parents can be predicted by the child’s
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29 age at death, cause and unexpectedness of death, and the number of remaining children. Moreover,
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31 characteristics of parents themselves, including gender, religious affiliation, and professional help
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33 seeking, also play a role.18 Rogers et al.14 also found that having other children at the time of death
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might be associated with lower depression. Additionally, a recent cross-sectional study conducted
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in China found that mothers, after an only child died, rated higher on depression scales if they had
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40 low education or income, or were single .19 Another study also addressed that parents that lost an
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only child had higher scores on depression, posttraumatic stress disorder (PSTD), and worse scores
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45 on general mental health scales, when compared with parents with their only child alive.20
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49 Past research exhibits several limitations. First, there have been abundant studies about grief and
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52 related psychological outcomes of bereaved parents globally, but few that may apply to China,
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54 given the vastly different political and cultural context.21 Second, although there were a few studies
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3 conducted in China on this topic, representativeness might be limited due to sampling
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6 methodologies which were neither population-based or well-structured, producing results which
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8 cannot be extrapolated to a broader scale.19,20,22,23 Moreover, additional research is required in the
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10 Chinese context on the link between the loss of reproductive rights, subsequent involuntary
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formation of one child families, and extended grief after an only child’s death. As such, a
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15 comparison between those who lost their only child and the general population is lacking. In other
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17 words, the combined effect of losing reproductive rights and losing the only child on parent mental
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health is not shown. With reference to the issues above, this paper utilises a database of 300,000
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22 mothers in China to explore the relationship between depression and the FP policy, with the loss
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24 of an only child.
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29 METHODS
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31 Sampling
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33 The data was obtained from the baseline survey of a large cohort study conducted between 2004
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to 2008 in 10 geographically defined areas. Details of the study design and sample characteristics
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are described elsewhere.24 The regional study sites were selected carefully to retain geographic
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40 and social diversity, as well as maximise difference in disease rates and risk exposure, in order to
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better approximate representative samples. Potential participants were approached in person by
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45 community health workers in clinical settings, with over 99% consenting to participate in the
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47 baseline assessment. In total, 512,891 adults, including 302,632 (59%) women aged 30–79 years,
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49 and representing approximately 30% of the total population of the 10 regions sampled, were
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52 recruited and completed an interviewer-administered electronic questionnaire and clinic visits.
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3 As the implementation of the Family Planning Policy at a national level began in 1982, 25 female
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6 participants who had already experienced menopause in 1982 (N=10,148) were not affected by the
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8 Family Planning Policy. While the mean age for menopause in the present sample was 48 years
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10 old, we exclude females older than 48 in 1982 from the analysis. We also excluded females who
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did not present information about the live birth count or the number of children or gave
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15 contradictory information (N=5,129). The final sample size of the current study is 287,082 women
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17 aged 30-73.
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22 This study has been approved by the Institutional Review Boards at Oxford University and the
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24 China National Center for Disease Control. All the participants included in this study provided
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26 informed consent.
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31 Measurements
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33 Participants’ were asked about live birth count and the number of children alive at the time of the
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survey. In the present study, the family-planning (FP) group was defined as females with 1 or 2
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live births, as in most rural areas, some urban areas, and minority ethnic groups, the policy allowed
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40 families in which the first child was a girl to have a second child.26 In FP families, females with a
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child/children left were further classified into non-loss-of-only-child group. Females with no child
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45 left at the time of the survey were classified into loss-of-only-child group. Females who had more
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47 than 2 live births were classified into non-family-planning (Non-FP) group. Those who had no live
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49 births were categorised as childless.
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3 Outcomes
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6 Major Depressive Disorder (MD) was assessed by the Chinese version of computerised Composite
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8 International Diagnostic Inventory-Short Form (CIDI-SF), which was delivered face-to-face by
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10 trained health workers at local clinics The CIDI is a diagnostic instrument, based on criteria of the
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Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), which is proven to be
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15 moderately consistent with clinical psychiatric interviews.27,28 The Chinese version of the CIDI
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17 produces similar population estimates of MDD as the Structured Clinical Interview of the DSM.26
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In the instrument, MDD was indicated by the presence of dysphoria and/or anhedonia
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22 accompanied by a clustering of somatic, cognitive, and behavioral disturbances, including appetite
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24 or weight change, sleeping problems, feelings of guilt or worthlessness, psychomotor changes,

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26 fatigue, concentration problems, and thoughts of suicide that lasted two weeks or more.
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31 Other co-variates
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33 Demographic and socio-economic characteristics collected in the baseline survey, specifically age
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at study date, household size, highest level of education, household income, occupation, and
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marital status, were included as co-variates in the analysis. Age at study date was collected as a
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40 continuous variable and was classified into <60 and ≥ 60 years old in the analysis. If the region
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has an average live birth count of lower than 2 per family, the region was classified as a one-child
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45 region, otherwise the region was classified as a two-children region. The household size was
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47 categorised into 1 or 2, 3 ,4, or ≥5 people. The highest level of education was categorised into
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49 primary school and below, middle and high school, and college/university graduate and above.
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52 Annual household income was classified into less than 10,000 Chinese Yuan (1 USD≈7.61
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54 Chinese Yuan in 2007); 10,000–19,999 Yuan; 20,000–34,999 Yuan; and ≥35,000 Yuan.
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3 Occupation was categorised into agriculture and related workers, factory workers, clerks (i.e.
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6 administrator/manager, professional/technical, sales and service workers, self-employed and
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8 others), and unemployed (i.e. unemployed, retired and house wife). Marital status was classified
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10 into married, widowed or divorced. Participants' health behaviors, including smoking habits and
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alcohol intake, were assessed by self-reported lifestyle status and classified as “frequent,”
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Data analysis
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22 Descriptive analysis illustrates the basic demographic, socioeconomic and lifestyle pictures
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24 by different family types. The association between family types and MDD was analysed using
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26 logistic regression. The non-family-planning group was the reference group in all models. Two
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29 types of logistic regression models were fitted: (1) unadjusted or (2) adjusted for the one/two
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31 children region, self-rated health, occupation, education, marital status, household income,
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33 smoking, and alcohol. p-values were calculated to show the significance of the association. All p-
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values refer to two-tailed tests. To understand how age, household income, education, and marital
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status potentially modify the associations between family types and MDD, a series of stratified
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40 analyses were performed using the unadjusted and adjusted models (excluding the stratification
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variable in adjustment) described above. Analyses were conducted using SAS 9.4 statistical
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45 software (SAS Institute, Cary NC).
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49 RESULTS
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52 Social-economic and lifestyle characteristics
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3 Basic characteristics of the study sample by family types are shown in Table 1. Of all 287,082
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6 participants included in the analysis, there were 196,831 FP families (68.56%), including 196,679
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8 non-loss-of-only-child (68.51%) and 152 loss-of-only-child (0.05%) families, 98,094 Non-FP
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10 families (31.03%), and 1,160 childless families (0.40%). The mean age of the study population for
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those in the non-loss-of-only-child, loss-of-only-child, non-FP, and childless group were 46.77
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15 (SD=8.10), 47.65 (SD=10.11), 58.41 (SD=9.19), and 46.43 (SD=11.19) respectively. There were
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17 more people living in urban area among childlessness group (72.46%) and less people in urban
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areas among Non-FP group (31.18%). The most common form of family composition in non-loss-
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22 of-only-child (36.73%) and loss-of-only-child group (34.93%) was a household of three people;
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24 while in Non-FP group, people commonly lived in a household of more than 5 people (46.17%).
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26 In childlessness group, people tended to live in a household with less than 2 (50.86%). The highest
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29 level of education for most people in the non-loss-of-only-child and loss-of-only-child groups were
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31 primary school and below and middle and high school, respectively. Most people in the non-FP
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33 had primary school and below education (81.54%), while people in the childless group had a higher
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percentage of college and university education (18.07%) compared to other groups. The
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distribution of participants’ household income was similar across four groups, with a higher
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40 proportion of <10,000 Yuan household income (43.48%) in the non-FP group. The most common
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type of occupation in the non-loss-of-only-child (36.96%), loss-of-only-child (42.47%), and non-
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45 FP groups (50.46%) were agriculture and related jobs. Unemployment was more common in the
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47 non-FP group (44.83%), while people in the childless group were more likely to be clerks
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49 (29.69%), compared with other groups. The distributions of marital status was similar across these
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52 four groups, with a higher percentage of widowed and divorced people in the non-FP group
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54 (16.08%). The distribution of smoking and alcohol use were similar across these four groups, but
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3 with a lower proportion of women who never used alcohol (47.42%) in the childless group and a
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6 higher proportion of women who never smoked (96.21%) in the non-loss-of-only-child group.
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10 Association between family types and MD
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Table 2 presents the prevalence and relative odds (95%CI) of MD in different family types.
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15 The prevalence of MDD in tje non-loss-of-only-child, loss-of-only-child, non-FP, and childless
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17 groups was 0.76%, 1.97%, 0.84%, and 1.29%, respectively. In the unadjusted model, non-loss-of-
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only-child and FP families in general had a decreased risk of MDD (OR=0.90, 95%CI:0.82-0.98),
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22 compared with Non-FP group. However, in the adjusted model, the odds of MDD are 1.36 times
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24 higher in non-loss-of-only-child group (OR=1.36, 95%CI: 1.21-1.51), and 1.42 times higher in the
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26 FP group in general (OR=1.42, 95%CI:1.28-1.57), as opposed to the non-FP group. For loss-of-
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29 only-child group, the odds of MD is 2.80 times greater than non-FP group, though the risk is not
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31 significant (OR=2.80, 95%CI:0.88-8.94). The childless group also had a higher risk of MD
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95%CI:1.00-2.92, p-value= 0.57).
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40 Modified association between family types and MD in different social-economic categories
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As is shown in Table 3, age, household income, highest education, and marital status appear
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45 to be effect modifiers of the associations between family types and MDD. In the fully adjusted
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47 model, the higher odds of MDD were only observed in the age ≥ 60 group (OR=1.42, 95%CI:1.11-
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49 1.82). In comparison with the reference group, the point estimate was higher in participants of
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52 above 60 years’ old for non-loss-of-only-child group (OR=3.66, 95%CI:0.49-27.68). The point
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54 estimate for the participants whose age<60 (OR=2.17, 95%CI:0.52-8.97) was also higher, though
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3 not as high as that of participants of above 60, compared to that of the reference group. The odds
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6 ratio for childlessness group were not significant in both age groups. Compared with the non-FP
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8 group, the non-loss-of-only-child group had greater odds of having MDD in both household
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10 income groups, with a slightly higher risk in people with a <10,000 Yuan household income
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(OR=1.49, 95%CI:1.27-1.75). There was a significantly increased risk of MDD observed in the
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15 loss-of-only-child group for people with a ≥10,000 Yuan household income (OR=4.45,
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17 95%CI:1.08-18.83), while no such statistically significant association was found in people with <
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10,000 Yuan household income. Compared to the reference group, people with a ≥10,000 Yuan
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22 household income showed an odds ratio of 2.30 (95%CI:1.28-4.13) in the childless group, while
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24 no association was found in people with < 10,000 Yuan household income. A higher risk of MDD
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26 was observed in people with their highest education being primary school and below (OR=1.48,
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29 95%CI:1.32-1.67) for non-loss-of-only-child group, while there was no such association in people
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31 with a highest education of junior high and above. Compared to the reference group, the point
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33 estimate of MDD risk was higher for people with their highest education being primary school and
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below (OR=3.30, 95%CI:0.79-13.74), than for people with their highest education being junior
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high and above (OR=1.99, 95%CI:0.27-14.83). Additionally, people who are married have a
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40 significantly higher risk of MDD as opposed to the reference group in both non-loss-of-only-child
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(OR=2.04, 95%CI:1.67-2.50) and loss-of-only-child groups (OR=8.81, 95%CI:1.05-74.11) than
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45 those who are widowed or divorced, in whom there was no significant risk for MDD.
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47
48
49 DISCUSSION
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52 There are three main findings in the present study. First, women in FP families in general were
53
54 found to have a higher risk of depression compared to those in non-FP families in this study.
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3 Second, within FP families and at point estimation level, greater odds of depression were found
4
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6 among females in the loss-of-only-child group compared to females in the non-loss-of-only-child
7
8 group. Third, the study found that women who lost a child under the FP policy were even more
9
10 vulnerable in terms of depression if they were older, married, with lower education level or higher
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12
13
household income.
14
15
16
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17 Women under the influence of the FP policy were found to be more susceptible to depression in
18
19
their later life in China, particularly for those who lost their only child. These findings were
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22 consistent with past literature, which suggests that bereaved mothers had 91% higher risk of mood
23
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24 disorder than those not bereaved.15 In another follow-up study, bereaved parents after child loss
25
26 experienced 40% greater risk of depression, and bereaved mothers were more likely to have severe
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27
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29 and long-lasting depression.29 While it is possible that having a lower number of children is
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31 associated with higher depression rates for mothers, we also include the notion of “biopower” as
32
iew
33 another possible explanation to elucidate our findings. Introduced by Foucault as a political

34
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36
technology, biopower operates through the “extension of state power over both the physical and
37
political bodies of a population, in the name of improving the life, health, and welfare of the
on
38
39
40 individual and population”.30 This view critically assesses the consequences of biopower the state
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exercised, suggesting that such power can have negative consequences.31 As an apparatus of
43
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45 biopower, the one-child policy enforced specific fertility regulation practices and behavioral
46
47 change at individual and population levels regardless of individual freedom in reproductive choice.
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49 Although there is no evidence showing clear linkage between the high prevalence of depression
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52 and the experiences of living with state-required family planning programs, some ethnographic
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54 research shows that such experiences can deprive women of sexual and reproductive health rights
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1
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3 in opposition to the interests of family, community, and local tradition.32 It is worth recognising
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6 that there was a long-standing tradition to see families with more children, and sons in particular,
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8 as blessed in China.33 Tension in families and communities are induced by the collision between
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10 one-child policy and local culture.
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15 The odds of depression were found to be higher for women aged above 60 than that of women
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17 aged below in the loss-of-only-child group, which was consistent with the finding from a
18
19
previous cross-sectional study on depression among bereaved Chinese parents in loss-of-only-
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22 child families.34 Some past studies, however, suggest that parental age does not significantly
23
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24 influence the long-term risk or pattern of depression among bereaved parents. 18,19,35.
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26
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29 In the loss-of-only-child group, higher odds of depression were observed in mothers with a lower
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31 education level. This is consistent with previous findings, which indicate that higher education is
32
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33 associated with lower severity of grief,18 risk hospitalisation for mental illness,15 and depression
34
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36
among bereaved parents. It was postulated that people with a higher education tend to have a more
37
fulfilling occupation that might distract their attention and provide them with better resources to
on
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40 cope with adverse events.36 Evidence has also shown that chronic depression was more prevalent
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in people with lower education due to socioeconomic inequality, which adds on further obstacles
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45 for people to recover from child loss.37
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49 Most previous studies have found that bereaved parents of lower income or less financial means
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52 usually experience more emotional loneliness, complicated grief, or depression.19,29,38-40. One
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54 paper has found no significant relationship between income and depression among bereaved
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1
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3 parents.35 This is contrary to our finding, which suggests that lower income may be associated with
4
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6 a smaller chance of having depression among bereaved mothers under China's family planning
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8 policy.
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13
Married women in the loss-of-only-child group were found to have an eight-fold greater risk of
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15 depression. Past research has found mixed findings regarding the effects of marital status in
16
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17 moderating the relationship between loss of child and mother’s depression. According to a recent
18
19
cross-sectional study conducted in China, marriage might protect people from depression after the
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22 loss of an only child.19 In another follow-up study, the odds of depression for parents with child
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24 loss was not associated with marital status35. However, in our study cohort, the number of divorced
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26 or widowed women was relatively small in the loss-of-only-child group, and whether the divorce
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29 took place before or after the bereavement remained unknown. Further research is needed to
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31 understand the mechanism of marital status in moderating the association between women’s risk
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33 of depression and child loss.

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37
This paper makes several important contributions. First, although the data is cross-sectional, there
on
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40 is an inherent temporal effect between the loss of child and the time of the survey. Second, it is the
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first paper that incorporates a policy dimension into the research between bereaved parents and
43
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45 depression. The results clearly show that mothers who obeyed the family planning policy tend to
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47 have a higher chance of depression than mothers who have multiple children, though whether the
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49 higher chance of depression is due to loss of reproductive rights or having a smaller number of
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52 children remains unknown. In addition, the data we used is the largest cross-sectional study in
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3 China that incorporates data on depression and the number of children. The sample was
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6 representative to infer an association at a population level.
7
8
9
10 The paper has several limitations, however. First, the study was only able to include mother’s age
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at the survey. Maternal age at bereavement, the child’s age at death, and other related information
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15 were not included in the survey. Past research suggested that the time elapsed since bereavement
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17 and child’s age at death might influence mother’s depression.15,34,37 Second, the study is a cross-
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19
sectional study instead of a longitudinal study. While people’s situation may change with the
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21
22 elapse of time, longitudinal data would allow a better understanding of different coping
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24 mechanisms and trajectories of mental health after child loss. Third, the data lacks information on
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26 people’s coping mechanisms after child loss. Past studies suggest that how people cope with the
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29 pain of child loss remains a complicated psychological pathway that permeates into multiple
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31 trajectories, and time alone may not be a reliable predictor 35,41 . However, this study focuses more
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iew
33 on the risk of depression in women that ever experienced child loss in general. Another possible
34
35
36
limitation is that the number of women with child loss was relatively undersized in this study,
37
which may result in less statistical power and less accurate estimations for some results.
on
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40 Nevertheless, the major findings of this paper are not affected.
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45 CONCLUSION
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47 In this study, we found that people in the FP group, especially those who lost their only child, were
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49 more susceptible to depression than their counterparts in the non-FP group. The susceptibility was
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52 stronger in older, less educated, wealthier, and married populations. Public health interventions
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54 that aim at decreasing depression prevalence in the population should give special care to those
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1
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3 who lost their only child, as their risk of depression is significantly higher than the rest of the
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6 population. Relevant programs should also consider the effect of family planning policy on the
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8 risk of depression, as presented in this paper. The Chinese government has announced in 2015 that
9
10 China’s one-child policy has been lifted and is to be replaced by a universal two-child policy,
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12
13
which could possibly influence people’s mental health. Further studies are needed to identify the
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15 potential positive or negative effects of the new policy on the well-being of the Chinese people.
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1
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3 ACKNOWLEDGMENTS
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6 We are grateful for Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield
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8 Department of Population Health, University of Oxford, Oxford, UK, for providing the data. CKB
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10 is supported by the Kadoorie Charitable Foundation (KCF) in Hong Kong.This manuscript was
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not prepared in collaboration with investigators of the CKB and does not necessarily reflect the
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15 opinions or views of the CKB, the KCF, or the institutions participating in the CKB.
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17 Author Contribution. H.W. and J.S. contributed to the study concept and design, statistical
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analysis, results interpretation, and drafting and revision of the manuscript. M.C. contributed to
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22 the study concept and design, drafting and revision of the manuscript. T.X., E.F., K.T. contributed
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24 to the study concept and design, and revision of the manuscript. All authors read and approved the
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26 final version of the manuscript.
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29 Data Availability. Data are available upon request
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31 Funding. This research received no specific grant from any funding agency in the public,
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33 commercial, or not-for-profit sectors.

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Competing Interest: None declared.
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Patient and public involvement Patients and/or the public were not involved in
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40 the design, or conduct, or reporting, or dissemination plans of this research.
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Licence for Publication: The Corresponding Author has the right to grant on behalf of all authors
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45 and does grant on behalf of all authors, an exclusive licence (or non exclusive for government
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47 employees) on a worldwide basis to the BMJ Publishing Group Ltd to permit this article (if
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49 accepted) to be published in JECH and any other BMJPGL products and sublicences such use and
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52 exploit all subsidiary rights, as set out in the licence.
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1
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3 Table 1 Basic characteristics of participants
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5 Family Types
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7 FP
8 Non-Loss-of- Loss-of-Only- Non-FP Childlessness
9 Only-Child Child
10 N, % 19,6679, 68.51% 152, 0.05% 89,094 31.03% 1,160, 0.40%
11 Socio-demographic characteristics
12 Mean age, years (SD) 46.77(8.10) 47.65(10.11) 58.41(9.19) 46.43(11.19)
13 Region is urban, % 50.12 45.21 31.18 72.46
14 One Child Region, % 57.21 55.92 32.00 68.45
15 Household Size, %
16 ≤2 14.24 27.40 29.70 50.86
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17 3 36.73 34.93 9.22 25.39
18 4 23.80 16.44 14.92 10.93
19 ≥5 25.23 21.23 46.17 12.82
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Socio-economic characteristics
21
Highest education, %
22
Primary school / below 44.30 49.32 81.54 28.57
23
Middle and high school 49.65 43.15 17.69 53.36
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25 College and university 6.04 7.53 0.76 18.07
26 Household income, %
<10,000yuan 22.63 36.99 43.48 26.08
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28 10,000-19,999 yuan 29.43 27.40 29.94 33.65
29 20,000-35,000 yuan 27.92 25.34 17.12 21.17
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30 >35,000 yuan 20.02 10.27 9.46 19.10

31 Occupation, %
32 Agriculture and related 36.96 42.47 50.46 15.40
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33 Factory workers 15.30 20.55 1.36 16.70

34 Clerk 17.21 15.75 3.34 29.69
35 Unemployed 30.53 21.23 44.83 38.21
36 Marital status
37 Married 95.68 93.42 83.92 93.28
on
38 Widowed/Divorced 4.32 6.58 16.08 6.72

39 Lifestyle factors
40
MET(hours/day), Mean, SD 22.08(13.08) 21.96(11.46) 17.71(11.57) 18.41(11.32)
41
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42 BMI(kg/m2), Mean, SD 23.83(3.35) 23.71(3.86) 23.84(3.64) 23.31(3.60)

43 Smoking, %
44 Never 96.21 94.52 92.96 90.10
45 Occasional 2.15 2.74 3.55 4.30
46 Regular 1.64 2.74 3.49 5.59
47 Alcohol, %
48
Never 60.64 62.33 69.47 47.42
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Occasional 35.62 35.62 27.74 43.98
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Regular 3.73 2.05 2.80 8.61
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1
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3 Table 2 Prevalence and relative odds (95%CI) of depression in different family types.
4
Depression
5 Family Types N. Total Unadjusted OR Adjusted* OR P value
Prevalence, %
6
7 Non-Loss-of-Only-Child 196,679 0.76 0.90(0.82,0.98) 1.36(1.23,1.51) <0.05
8 FP Loss-of-Only-Child 152 1.97 2.37(0.76,7.45) 2.80(0.88,8.94) 0.20
9 Total FP 196,831 0.76 0.90(0.82,0.98) 1.42(1.28,1.57) <0.05
10 Non-FP 89,094 0.84 1 1 -
11 Childlessness 1,160 1.29 1.54(0.92,2.58) 1.71(1.00,2.92) 0.57
12
13
*After adjusting for one/two children region, self-rated health, occupation, education, marital status,
14
household income, smoking, alcohol.
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3 Table 3 Relative odds (95%CI) of Family Types with Depression, stratified by age at study
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5
date, urban/rural, household income, and highest education.
6 Family Types
7
8 FP
9 Non-FP Childlessness
NLOC LOC
10
Age at study date
11
12 Age < 60
13 Unadjusted Model 0.81(0.73,0.90) 1.78(0.44,7.22) 1 1.54(0.90,2.64)
14 Adjusted Model* 1.12(0.99,1.27) 2.17(0.52,8.97) 1 1.45(0.82,2.56)
15 Age ≥ 60
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17 Adjusted Model* 1.42(1.11,1.82) 3.66(0.49,27.68) 1 0.80(0.11,5.78)
18 Household Income
19 <10,000
20
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Unadjusted Model 1.22(1.06,1.39) 1.80(0.25,13.32) 1 0.70(0.17,2.81)
21
Adjusted Model** 1.49(1.27,1.75) 1.69(0.23,12.49) 1 0.55(0.14,2.27)
22
23 ≥10,000
Unadjusted Model 0.84(0.75,0.95) 2.83(0.70,11.52) 1 2.00(1.15,3.50)
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24
25 Adjusted Model** 1.27(1.11,1.46) 4.45(1.08,18.33) 1 2.30(1.28,4.13)
26 Highest Education
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27 Primary school/below
29 Adjusted Model*** 1.48(1.32,1.67) 3.30(0.79,13.74) 1 0.73(0.18,2.96)
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30 Junior High/above
32
Adjusted Model*** 1.12(0.92,1.38) 1.99(0.27,14.83) 1 1.76(0.96,3.25)
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33
34
Marital Status
35 Married
36 Unadjusted Model 1.80(1.51,2.16) 6.55(0.83,51.89) 1 -
37 Adjusted Model**** 2.04(1.67,2.50) 8.81(1.05,74.11) 1 -
on
38 Widowed/Divorced
40 Adjusted Model**** 1.26(1.12,1.41) 2.15(0.53,8.12) 1 2.14(1.26,3.63)
41 *After adjusting for one/two children region, self-rated health, occupation, education, marital status, household
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42 income, smoking, alcohol.

43 **After adjusting for age at study date, self-rated health, occupation, education, marital status, household income,
44 smoking, alcohol.
45 *** After adjusting for age at study date, one/two children region, self-rated health, occupation, marital status,
46 household income, smoking, alcohol.
47 **** After adjusting for age at study date, one/two children region, self-rated health, education ,occupation,
48 household income, smoking, alcohol
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BMJ Open
Maternal depression and loss of children under the one-

child family planning policy in China: a cross-sectional study
of 300,000 women
Journal: BMJ Open
Manuscript ID bmjopen-2020-048554.R1
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Article Type: Original research
Date Submitted by the

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03-Apr-2021
Author:
Complete List of Authors: Wang, Hanyu; Tsinghua University, Vanke School of Public Health
Frasco, Eric; University College London
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Shang, Jie; George Institute for Global Health

Chen, Minne; Marie Stopes International China
Xin, Tong; Peking University Health Science Centre, Department of
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Global Health
Tang, Kun; Tsinghua University, Vanke School of Public Health
<b>Primary Subject
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Mental health
Heading</b>:
Secondary Subject Heading: Epidemiology, Health policy, Sociology

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Depression & mood disorders < PSYCHIATRY, Health policy < HEALTH
Keywords:
SERVICES ADMINISTRATION & MANAGEMENT, SOCIAL MEDICINE
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3 Maternal depression and loss of children under the one-child family planning policy in
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6 China: a cross-sectional study of 300,000 women
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8 Hanyu Wang1, Eric Frasco2, Jie Shang3, Minne Chen4, Tong Xin5, Kun Tang6
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10 Corresponding Author: Dr. Kun Tang
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Address: Tsinghua University, Haidian District, Beijing 100191, P.R. China
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15 Telephone Number: 86-10-82805951
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17 Corresponding Author E-mail Address：tangk@mail.tsinghua.edu.cn
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22 whybest@pku.edu.cn
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24 2 University College London, Gower St, Bloomsbury, London, United Kingdom, WC1E 6BT.
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E-mail: frasco.eric@gmail.com
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29 3 The George Institute of Global Health at Peking University Health Science Center, 1801,
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31 Tower B, Horizon Tower No 6 Zhichun Rd, Beijing Haidian District, China. E-mail:
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jshang@georgeinstitute.org.cn
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36 4 Marie Stopes International China, No.172 Beiyuan Rd, Chaoyang District, Beijing, China. E-
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5 Department of Global Health, Peking University Health Science Center, No.38 Xueyuan Rd,
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43 Haidian District, Beijing, China. E-mail: xtong.katrina@gmail.com
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47 tangk@mail.tsinghua.edu.cn
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50 Manuscript word count: 3528
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1
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3 Abstract
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6 Objectives This study aims to explore the association between maternal depression and the loss
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8 of the only child under the Family Planning Policy.
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10 Design Cross-sectional data from a Chinese population-based study were analyzed.
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Setting Population from 10 (5 rural and 5 urban) areas in China.
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15 Participants 300,000 females were included in the study. The family-planning (FP) group was
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17 defined as women with 1 or 2 live births, Those with no surviving child were classified into the
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loss-of-only-child group. The non-family-planning (non-FP) group included women who had
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22 more than 2 live births. Logistic regression was used to assess the relationship between Major
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24 Depressive Disorder (MDD) and family types, after stratification and adjustment.
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26 Outcome MDD was assessed using the Composite International Diagnostic Inventory.
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29 Results The odds of MDD are 1.42 times higher in the FP group in general (OR=1.42,
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31 95%CI:1.28-1.57), as opposed to the non-FP group. In particular, the odds of MDD are 1.36 times
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33 greater in the non-loss-of-only-child group (OR=1.36, 95%CI: 1.21-1.51) and 2.80 (OR=2.80,
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95%CI: 0.88-8.94) times greater in the loss-of-only-child group, compared to the non-FP group.
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The associations between FP groups and MDD appeared to be stronger in the elderly population,
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40 in those who were married, less educated, and those with higher household income. The
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association was found progressively stronger in those who lost their only child.
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45 Conclusions People in the FP group, especially those who lost their only child, are more
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47 susceptible to MDD than their counterparts in the non-FP group. Mental health programmes should
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49 give special care to those who lost their only child and take existing social policies and norms,
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52 such as family planning policies, into consideration.
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54 Key Words: Family Planning; Depression; Mental Health; China
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3 Strengths of this study
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6  This study is one of the first papers to incorporate a family planning policy dimension into
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8 research on the association between bereaved parents and MDD.
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10  This is the largest cross-sectional study in China that incorporates data on depression and the
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number of children
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15 Limitations of this study
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17  This study was only able to include mother’s age at the time of survey. Maternal age at
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bereavement, the child’s age at death, and other related information were not included in the
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22 survey.
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24  This study is a cross-sectional study, rather than a longitudinal study.

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26  The data lacks information on people’s coping mechanisms after child loss.
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1
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3 INTRODUCTION
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6 The Family Planning (FP) Policy in China - broadly known as the one-child policy - was officially
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8 launched in 1982, a time when the country was facing the dual challenge of economic and social
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10 system breakdown after the Cultural Revolution, as well as a population size which doubled in
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only three decades.1 Most families in the city were strictly limited to one child, while some couples
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15 were allowed two if they lived in a rural area, worked in a high-risk occupation, were from minority
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17 ethnic groups, or had a first child born with a disability.2,3 Since then, the policy has impacted
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millions of families.4 However, changes were officially made to the policy in 2015 and all couples
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22 were permitted to have two children.1 Still, it remains a question as to what extent society and
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24 individual life have been changed under the policy. China has received credit for the effective
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26 control of population growth on one hand, but on the other, criticisms were raised regarding the
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29 deprivation of reproductive rights. Another consequence of the FP policy has been the emergence
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31 of a group of parents that lost their only child due to illness or accidents, commonly referred to as
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33 the “Shidu”.5 Since 1982, more than 1 million families have lost their only child, with the number
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expected to reach 11 million by 2050.6
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40 Major Depressive Disorder (MDD), characterised by recurrent symptoms including disrupted
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sleeping patterns, low mood, and difficulty concentrating, is a major contributor to the global
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45 burden of disease, suicide rates, and the onset of the non-communicable diseases like ischemic
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47 heart diseases.7,8 In China, more than 54 million people are estimated to suffer from MDD.9 Grief
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49 and other relevant psychological disorders, including MDD, of parents who lost their child have
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52 been an area of research in many countries. The negative emotions from the loss of bond to the
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54 child or guilt of being unable to protect the child, for example, can lead to severe psychological
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3 disorders of the bereaved parents, including MDD.10-13 Using longitudinal data of 428 bereaved
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6 parents in Wisconsin, Rogers et al14 showed that the mental impact of child loss is long term. After
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8 an average of 18 years follow-up after a child’s death, with parent age at a mean of 53, those who
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10 lost their child report more depressive symptoms than those who did not lose their child. Greater
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risk of hospitalisation due to psychological disorders or suicidal ideation, as well as decreased
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15 social functioning, were also found in bereaved parents, especially for bereaved mothers.
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17 Additionally, depressive symptoms can lead to increased health-damaging behaviours, a weakened
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immune system, and subsequently lower physical health.15-17
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24 Studies have shown mixed evidence towards risk factors of parental depression after child
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26 bereavement. A study showed that the grief of the bereaved parents can be predicted by the child’s
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29 age at death, cause and unexpectedness of death, and the number of remaining children. Moreover,
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31 characteristics of parents themselves, including gender, religious affiliation, and professional help-
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33 seeking, also play a role.18 Rogers et al.14 also found that having other children at the time of death
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might be associated with lower depression. Additionally, a recent cross-sectional study conducted
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in China found that mothers, after an only child died, rated higher on depression scales if they had
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40 low education or income, or were single.19 Another study also addressed that parents that lost an
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only child had higher scores on depression, posttraumatic stress disorder (PTSD), and worse scores
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45 on general mental health scales, when compared with parents with their only child alive.20
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49 Past research exhibits several limitations. First, there have been abundant studies about grief and
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52 related psychological outcomes of bereaved parents globally, but few that may apply to China,
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54 given the vastly different political and cultural context.21 Second, although there were a few studies
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3 conducted in China on this topic, representativeness might be limited due to sampling
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6 methodologies which were neither population-based nor well-structured, producing results that
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8 cannot be extrapolated to a broader scale.19,20,22,23 Moreover, additional research is required in the
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10 Chinese context on the link between the loss of reproductive rights, subsequent involuntary
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formation of one-child families, and extended grief after an only child’s death. As such, a
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15 comparison between those who lost their only child, and the general population is lacking. In other
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17 words, the combined effect of losing reproductive rights and losing the only child on parent mental
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health is not shown. With reference to the issues above, this paper utilises a database of 300,000
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22 mothers in China to explore quantitatively the association between depression and the FP policy,
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24 with the loss of an only child.

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29 METHODS
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31 Sampling
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33 The data was obtained from the baseline survey of a large cohort study conducted between 2004
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to 2008 in 10 defined areas (5 urban and 5 rural) in China. Details of the study design and sample
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characteristics are described elsewhere.24 The regional study sites were selected carefully to retain
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40 geographic and social diversity, as well as maximise differences in disease rates and risk exposure,
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in order to better approximate representative samples. Potential participants were approached in
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45 person by community health workers in clinical settings, with over 99% consenting to participate
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47 in the baseline assessment. In total, 512,891 adults, including 302,632 (59%) women aged 30–79
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49 years, and representing approximately 30% of the total population of the 10 regions sampled, were
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52 recruited and completed an interviewer-administered electronic questionnaire and clinic visits.
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3 We only included female participants in the current study. As the implementation of the Family
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6 Planning Policy at a national level began in 1982,25 female participants who had already
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8 experienced menopause in 1982 (N=10,148) were not affected by the Family Planning Policy.
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10 While the mean age for menopause in the present sample was 48 years old, we exclude females
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older than 48 in 1982 from the analysis. We also excluded females who did not present information
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15 about the live birth count or the number of children or gave contradictory information (N=5,129).
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17 The final sample size of the current study is 287,082 women aged 30-73.
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22 This study has been approved by the Institutional Review Boards at Oxford University and the
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24 China National Center for Disease Control. All the participants included in this study provided
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26 informed consent.
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31 Measurements
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33 Participants were asked about their live birth count and the number of children alive at the time of
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the survey. In the present study, the family-planning (FP) group was defined as females with 1 or
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2 live births, as in most rural areas, some urban areas, and minority ethnic groups, the policy
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40 allowed families in which the first child was a girl to have a second child.26 In FP families, females
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with a child/children left were further classified into non-loss-of-only-child group. Females with
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45 no child left at the time of the survey were classified into loss-of-only-child group. Females who
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47 had more than 2 live births were classified into the non-family-planning (Non-FP) group. Those
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49 who had no live births were categorised as childless.
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3 Outcomes
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6 Major Depressive Disorder (MDD) was assessed by the Chinese version of the computerised
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8 Composite International Diagnostic Inventory-Short Form (CIDI-SF), which was delivered face-
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10 to-face by trained health workers at local clinics. The CIDI is a diagnostic instrument, based on
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the criteria of the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), which is
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15 considered to be moderately consistent with psychiatric interviews in clinical settings.27,28 The
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17 Chinese version of the CIDI produces similar population estimates of MDD as the Structured
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Clinical Interview of the DSM.26 Briefly, participants were asked a set of questions and were
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22 defined as MDD cases if, during the past 12 months, they had felt “sad, blue, or depressed” for
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24 more than two weeks. An additional set of symptoms were also considered when making the
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26 diagnosis, including the presence of dysphoria and/or anhedonia accompanied by clustering of
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29 somatic, cognitive, and behavioral disturbances, including appetite or weight change, sleeping
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31 problems, feelings of guilt or worthlessness, psychomotor changes, fatigue, concentration
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33 problems, and thoughts of suicide. Details on logistics and scoring can be found elsewhere.26
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Other co-variates
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40 Demographic and socio-economic characteristics collected in the baseline survey, specifically age
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at study date, household size, highest level of education, household income, occupation, and
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45 marital status, were included as co-variates in the analysis. Age at study date was collected as a
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47 continuous variable and was classified into <60 and ≥ 60 years old in the analysis. If the region
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49 has an average live birth count of lower than 2 per family, the region was classified as a one-child
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52 region, otherwise the region was classified as a two-children region. The household size was
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54 categorised into 1 or 2, 3 ,4, or ≥5 people. The highest level of education was categorised into
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3 primary school and below, middle and high school, and college/university graduate and above.
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6 Annual household income was classified into less than 10,000 Chinese Yuan (1 USD≈7.61
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8 Chinese Yuan in 2007); 10,000–19,999 Yuan; 20,000–34,999 Yuan; and ≥35,000 Yuan.
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10 Occupation was categorised into agriculture and related workers, factory workers, clerks (i.e.
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administrator/manager, professional/technical, sales and service workers, self-employed and
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15 others), and unemployed (i.e. unemployed, retired and housewife). Marital status was classified
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17 into married, widowed or divorced. Participants' health behaviours, including smoking habits and
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alcohol intake, were assessed by self-reported lifestyle status and classified as “frequent,”
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22 “occasional,” and “non” smoker/drinker.
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26 Data analysis
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29 Descriptive analysis illustrated the basic demographic, socioeconomic and lifestyle characteristics
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31 by different family types. The association between family types and MDD was analysed using
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33 logistic regression. The non-family-planning group was the reference group in all models. Two
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types of logistic regression models were fitted: (1) unadjusted or (2) adjusted for the one/two
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children region, self-rated health, occupation, education, marital status, household income,
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40 smoking, and alcohol. The adjusted model selected variables based on previous literature.19,29-31
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Socioeconomic factors, including region, occupation, education, marital status, and household
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45 income have been considered as associated with both family type and MDD.19,29-37 Smoking and
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47 alcohol use have long been associated with MDD,33 Number of offspring and family structure has
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49 also been associated with lifestyle factors.34,35 Thus, smoking and alcohol were included in the
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52 model. Similarly, self-rated health was associated with both MDD and family structure and was
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54 included in the model.36,37 p-values were calculated to show the significance of the association.
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3 All p-values refer to two-tailed tests. To understand how age, household income, education, and
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6 marital status potentially modify the associations between family types and MDD, a series of
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8 stratified analyses were performed using the unadjusted and adjusted models (excluding the
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10 stratification variable in adjustment) described above. Analyses were conducted using SAS 9.4
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statistical software (SAS Institute, Cary NC).
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17 RESULTS
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Social-economic and lifestyle characteristics
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22 Basic characteristics of the study sample by family types are shown in Table 1. Of all 287,082
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24 participants included in the analysis, 68.56% are FP families, 98,094 Non-FP families (31.03%),
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26 and 1,160 childless families (0.40%). Participants in the Non-FP group tended to be older (mean
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29 age: 58.41, SD: 9.19) compared with other groups. The majority of participants in the childlessness
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31 group were living in urban areas (72.46%). Participants in the non-FP group tended to have lower
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33 education, with most of them having primary school or below education (81.54%) compared to
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other groups. The distribution of participants’ household income was similar across four groups.
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Unemployment was more common in the non-FP group (44.83%). The distribution of marital
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40 status was similar across these four groups, with a higher percentage of widowed and divorced
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people in the non-FP group (16.08%). The distribution of smoking and alcohol use were similar
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45 across these four groups, but with a lower proportion of women who never used alcohol (47.42%)
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47 in the childless group and a higher proportion of women who never smoked (96.21%) in the non-
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49 loss-of-only-child group. Due to the large sample size, ANOVA and t test all produced significant
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52 p values and thus the results from ANOVA and t test were not displayed.
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3 Association between family types and MDD
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6 Table 2 presents the prevalence and ORs (95%CI) of MDD in different family types. The
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8 prevalence of MDD in the non-loss-of-only-child, loss-of-only-child, non-FP, and childless groups
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10 was 0.76%, 1.97%, 0.84%, and 1.29%, respectively. In the unadjusted model, non-loss-of-only-
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child and FP families in general had decreased odds of MDD (OR=0.90, 95%CI:0.82-0.98),
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17 higher in non-loss-of-only-child group (OR=1.36, 95%CI: 1.21-1.51), and 1.42 times higher in the
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FP group in general (OR=1.42, 95%CI:1.28-1.57), as opposed to the non-FP group. For the loss-
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22 of-only-child group, the odds of MDD are 2.80 times greater than the non-FP group, though odds
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24 are not significant (OR=2.80, 95%CI:0.88-8.94). The childless group also had higher odds of
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26 MDD compared to non-FP group, though the result was not significant in terms of p-value
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29 (OR=1.71, 95%CI:1.00-2.92, p-value= 0.57).
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33 Modified association between family types and MDD in different social-economic categories
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As is shown in Table 3, we explored possible effect modification of some adjusted variables,
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including age, household income, highest education, and marital status. In the fully adjusted
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40 model, the higher odds of MDD for non-loss-of-only-child group were only observed in the age ≥
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60 group (OR=1.42, 95%CI:1.11-1.82). Compared with the non-FP group, the non-loss-of-only-
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45 child group had greater odds of having MDD in both household income groups, with slightly
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47 higher odds in people with a <10,000 Yuan household income (OR=1.49, 95%CI:1.27-1.75).
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49 There were significantly increased odds of MDD observed in the loss-of-only-child group
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52 (OR=4.45, 95%CI: 1.08-18.83) and childless group (OR: 2.30, 95%CI:1.28-4.13) for people with
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54 a ≥10,000 Yuan household income. Higher odds of MDD were observed in people with their
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3 highest education being primary school and below for non-loss-of-only-child group (OR=1.48,
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6 95%CI:1.32-1.67), while there was no such association in people with a highest education of junior
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8 high and above. Additionally, people who are married have significantly higher odds of MDD as
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10 opposed to the reference group in both the non-loss-of-only-child (OR=2.04, 95%CI:1.67-2.50)
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and loss-of-only-child groups (OR=8.81, 95%CI:1.05-74.11).
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17 DISCUSSION
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There are three main findings in the present study. First, women in FP families in general were
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22 found to have higher odds of depression compared to those in non-FP families in this study.
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24 Second, within FP families and at point estimation level, greater odds of depression were found
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26 among females in the loss-of-only-child group compared to females in the non-loss-of-only-child
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29 group. However, the result was not statistically significant. Third, the study found that women who
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31 lost a child under the FP policy were even more vulnerable in terms of depression if they were
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33 older, married, with lower education level or higher household income.

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The overall prevalence of MDD was 0.76% among participants under the family planning policy
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40 and 0.84% among participants who did not follow the policy in this study. This is consistent with
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recent studies using the same database, in which they also reported a MDD prevalence under
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45 1%.38,39 However, the prevalence was lower than the global estimates and other estimates in
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47 China.40,41 Estimates using the global burden of disease in 2010 found that the global prevalence
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49 of MDD was 4.4% in 2010.41 A study found that the 12-month prevalence MDD was 2.3% from
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52 2001-2010 in China.40 The difference could be attributed to the measurement tool, selection bias,
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54 and cultural influences.38,42 CIDI-SF, which is a valid and widely-used tool and is employed in this
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3 study, was found to generate different results from other tools.42 The current study recruit
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6 participants who were voluntarily involved in the survey and it is possible that people with MDD
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8 were less likely to participate in a survey. Besides, in China, depression may be stigmatised and
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10 people may tend to deny their mental condition due to the stigmas.38 The interpretation of the
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current study should consider the lower than usual MDD prevalence in the study database.
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17 Women under the influence of the FP policy were found to be more susceptible to depression in
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their later life in China. While it is possible that having a lower number of children is associated
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22 with higher depression rates for mothers, we also include the notion of “biopower” as another
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24 possible explanation to elucidate our findings. Introduced by Foucault as a political technology,

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26 biopower operates through the “extension of state power over both the physical and political bodies
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29 of a population, in the name of improving the life, health, and welfare of the individual and
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31 population”.43 This view critically assesses the consequences of biopower the state exercised,
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33 suggesting that such power can have negative consequences.44 As an apparatus of biopower, the
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one-child policy enforced specific fertility regulation practices and behavioural change at
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individual and population levels regardless of individual freedom in reproductive choice. Although
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40 there is no evidence showing a clear linkage between the high prevalence of depression and the
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experiences of living with state-required family planning programmes, some ethnographic
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45 research shows that such experiences can deprive women of sexual and reproductive health rights
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47 in opposition to the interests of family, community, and local tradition.45
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52 The point estimate of MDD odds for those who lost their only child was high, though the result
53
54 was not significant. These findings were consistent with past literature, which suggests that
55
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1
2
3 bereaved mothers had 91% higher risk of mood disorder than those not bereaved.15 In another
4
5
6 follow-up study, bereaved parents after child loss experienced 40% greater risk of depression, and
7
8 bereaved mothers were more likely to have severe and long-lasting depression.46 It is worth
9
10 recognising that there was a long-standing tradition to see families with more children, and sons
11
12
13
in particular, as blessed in China.47 Families may desire more children, especially sons, based on
14
15 this tradition, which was in opposition to the policy. Tension in families and communities might
16
Fo
17 be induced by the collision between one-child policy and local culture. This might contribute to
18
19
the high depression prevalence among bereaved mothers because in local culture, communities
20
rp
21
22 could be regarded as unfortunate by others. Besides, it is important to note that the aggregated
23
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24 odds of MDD among participants who lost their only child were not statistically significant. We
25
26 maintained that the non-significant result was mainly due to the small sample size in this group,
rr
27
28
29 but it could be that the result is due to chance. The interpretation should be made with consideration
ev
30
31 of the statistical significance, sample size, and the point estimate.
32
iew
33
34
35
36
The odds of depression were found to be higher for women aged above 60 than that of women
37
aged below in the loss-of-only-child group, which was consistent with the finding from a previous
on
38
39
40 cross-sectional study on depression among bereaved Chinese parents in loss-of-only-child
41
ly
42
families.29 Some past studies, however, suggest that parental age does not significantly influence
43
44
45 the long-term risk or pattern of depression among bereaved parents. 18,19,48.
46
47
48
49 In the loss-of-only-child group, higher odds of depression were observed in mothers with a lower
50
51
52 education level. This is consistent with previous findings, which indicate that higher education is
53
54 associated with lower severity of grief,18 risks of hospitalisation for mental illness,15 and
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1
2
3 depression among bereaved parents. It was postulated that people with a higher education tend to
4
5
6 have a more fulfilling occupation that might distract their attention and provide them with better
7
8 resources to cope with adverse events.49 Evidence has also shown that chronic depression was
9
10 more prevalent in people with lower education due to socioeconomic inequality, which adds on
11
12
13
further obstacles for people to recover from child loss.50
14
15
16
Fo
17 Most previous studies have found that bereaved parents of lower income or less financial means
18
19
usually experience more emotional loneliness, complicated grief, or depression.19,30,46,51,52. One
20
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21
22 paper has found no significant relationship between income and depression among bereaved
23
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24 parents.48 This is contrary to our finding, which suggests that lower income may be associated with
25
26 a smaller chance of having depression among bereaved mothers under China's family planning
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27
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29 policy.
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30
31
32
iew
33 Married women in the loss-of-only-child group were found to have eight-fold greater odds of
34
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36
depression. Past research has found mixed findings regarding the effects of marital status in
37
moderating the relationship between loss of child and mother’s depression. According to a recent
on
38
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40 cross-sectional study conducted in China, marriage might protect people from depression after the
41
ly
42
loss of an only child.19 In another follow-up study, the odds of depression for parents with child
43
44
45 loss was not associated with marital status48. However, in our study cohort, the number of divorced
46
47 or widowed women was relatively small in the loss-of-only-child group, and whether the divorce
48
49 took place before or after the bereavement remained unknown. Further research is needed to
50
51
52 understand the mechanism of marital status in moderating the association between women’s risk
53
54 of depression and child loss.
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1
2
3
4
5
6 This paper makes several important contributions. First, although the data is cross-sectional, there
7
8 is an inherent temporal effect between the loss of child and the time of the survey. Second, it is the
9
10 first paper that incorporates a policy dimension into the research between bereaved parents and
11
12
13
depression. The results clearly show that mothers who obeyed the family planning policy tend to
14
15 have a higher chance of depression than mothers who have multiple children, though whether the
16
Fo
17 higher chance of depression is due to loss of reproductive rights or having a smaller number of
18
19
children remains unknown. In addition, the data we used is the largest cross-sectional study in
20
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21
22 China that incorporates data on depression and the number of children. The sample was
23
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24 representative to infer an association at a population level.

25
26
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29 The paper has several limitations, however. First, the study was only able to include mother’s age
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30
31 at the time of the survey. Maternal age at bereavement, the child’s age at death, and other related
32
iew
33 information were not included in the survey. Past research suggested that the time elapsed since
34
35
36
bereavement and child’s age at death might influence mother’s depression.15,29,50 Second, the study
37
is a cross-sectional study instead of a longitudinal study. While people’s situations may change
on
38
39
40 with the elapse of time, longitudinal data would allow a better understanding of different coping
41
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42
mechanisms and trajectories of mental health after child loss. Third, the data lacks information on
43
44
45 people’s coping mechanisms after child loss. Past studies suggest that how people cope with the
46
47 pain of child loss remains a complicated psychological pathway that permeates into multiple
48
49 trajectories, and time alone may not be a reliable predictor 31,48 . However, this study focuses more
50
51
52 on the risk of depression in women that ever experienced child loss in general. Another possible
53
54 limitation is that the number of women with child loss was relatively undersized in this study,
55
56
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1
2
3 which may result in less statistical power and less accurate estimations for some results.
4
5
6 Nevertheless, the major findings of this paper are not affected.
7
8
9
10 CONCLUSION
11
12
13
In this study, we found that people in the FP group, especially those who lost their only child, were
14
15 more susceptible to depression than their counterparts in the non-FP group. The susceptibility was
16
Fo
17 stronger in older, less educated, wealthier, and married populations. Several potential public health
18
19
implications could be inferred from this paper. First, mental health interventions should give
20
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21
22 special care to those who lost their only child, as their risk of developing depression is significantly
23
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24 higher than the rest of the population. Second, relevant programmes should also consider the effect
25
26 of family planning policy on the risk of depression, as presented in this paper. Third, when
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27
28
29 designing mental health programmes, existing social policies and norms should be considered as
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30
31 they could impact mental health at a population level. The Chinese government has announced in
32
iew
33 2015 that China’s one-child policy has been lifted and is to be replaced by a universal two-child
34
35
36
policy, which could possibly influence people’s mental health. Further studies are needed to
37
identify the potential positive or negative effects of the new policy on the well-being of the Chinese
on
38
39
40 people.
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1
2
3 ACKNOWLEDGMENTS
4
5
6 We are grateful for Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield
7
8 Department of Population Health, University of Oxford, Oxford, UK, for providing the data.
9
10 Author Contribution. H.W. and J.S. contributed to the study concept and design, statistical
11
12
13
analysis, results interpretation, and drafting and revision of the manuscript. M.C. contributed to
14
15 the study concept and design, drafting and revision of the manuscript. T.X., E.F., K.T. contributed
16
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17 to the study concept and design, and revision of the manuscript. All authors read and approved the
18
19
final version of the manuscript.
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22 Data Availability. Data are available upon request
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24 Funding. This research received no specific grant from any funding agency in the public,
25
26 commercial, or not-for-profit sectors.
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27
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29 Competing Interest: None declared.
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30
31 Patient and public involvement Patients and/or the public were not involved in
32
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33 the design, or conduct, or reporting, or dissemination plans of this research.

34
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36
Licence for Publication: The Corresponding Author has the right to grant on behalf of all authors
37
and does grant on behalf of all authors, an exclusive licence (or non-exclusive for government
on
38
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40 employees) on a worldwide basis to the BMJ Publishing Group Ltd to permit this article (if
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accepted) to be published in JECH and any other BMJPGL products and sublicences such use and
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45 exploit all subsidiary rights, as set out in the licence.
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47 Ethics approval: Not applicable
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4
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47
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1
2
3 Table 1 Basic characteristics of participants
4
5 Family Types
6
7 FP
8 Non-Loss-of- Loss-of-Only- Non-FP Childlessness
9 Only-Child Child
10 N, % 19,6679, 68.51% 152, 0.05% 89,094 31.03% 1,160, 0.40%
11 Socio-demographic characteristics
12 Mean age, years (SD) 46.77(8.10) 47.65(10.11) 58.41(9.19) 46.43(11.19)
13 Region is urban, % 50.12 45.21 31.18 72.46
14 One Child Region, % 57.21 55.92 32.00 68.45
15 Household Size, %
16 ≤2 14.24 27.40 29.70 50.86
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17 3 36.73 34.93 9.22 25.39
18 4 23.80 16.44 14.92 10.93
19 ≥5 25.23 21.23 46.17 12.82
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Socio-economic characteristics
21
Highest education, %
22
Primary school / below 44.30 49.32 81.54 28.57
23
Middle and high school 49.65 43.15 17.69 53.36
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24
25 College and university 6.04 7.53 0.76 18.07
26 Household income, %
<10,000yuan 22.63 36.99 43.48 26.08
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27
28 10,000-19,999 yuan 29.43 27.40 29.94 33.65
29 20,000-35,000 yuan 27.92 25.34 17.12 21.17
ev
30 >35,000 yuan 20.02 10.27 9.46 19.10

31 Occupation, %
32 Agriculture and related 36.96 42.47 50.46 15.40
iew
33 Factory workers 15.30 20.55 1.36 16.70

34 Clerk 17.21 15.75 3.34 29.69
35 Unemployed 30.53 21.23 44.83 38.21
36 Marital status
37 Married 95.68 93.42 83.92 93.28
on
38 Widowed/Divorced 4.32 6.58 16.08 6.72

39 Lifestyle factors
40
MET(hours/day), Mean, SD 22.08(13.08) 21.96(11.46) 17.71(11.57) 18.41(11.32)
41
ly
42 BMI(kg/m2), Mean, SD 23.83(3.35) 23.71(3.86) 23.84(3.64) 23.31(3.60)

43 Smoking, %
44 Never 96.21 94.52 92.96 90.10
45 Occasional 2.15 2.74 3.55 4.30
46 Regular 1.64 2.74 3.49 5.59
47 Alcohol, %
48
Never 60.64 62.33 69.47 47.42
49
Occasional 35.62 35.62 27.74 43.98
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Regular 3.73 2.05 2.80 8.61
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1
2
3 Table 2 Prevalence and relative odds (95%CI) of depression in different family types.
4
5 Family Types N. Total Depressed % Unadjusted OR Adjusted* OR P value
6 FP Non-Loss-of-Only-Child 196,679 0.76 0.90(0.82,0.98) 1.36(1.23,1.51) <0.05
7
Loss-of-Only-Child 152 1.97 2.37(0.76,7.45) 2.80(0.88,8.94) 0.20
8
9
Total FP 196,831 0.76 0.90(0.82,0.98) 1.42(1.28,1.57) <0.05
10 Non-FP 89,094 0.84 1 1 -
11 Childlessness 1,160 1.29 1.54(0.92,2.58) 1.71(1.00,2.92) 0.57
12
13 *After adjusting for one/two children region, self-rated health, occupation, education, marital status,
14 household income, smoking, alcohol.
15
16
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18
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20
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22
23
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24
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26
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29
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32
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37
on
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1
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3 Table 3 Adjusted ORs (95%CI) of family types with depression, stratified by age at study
4
5
date, urban/rural, household income, and highest education.
6 Family Types
7
8 FP
9 Non-FP Childlessness
NLOC LOC
10
Age at study date
11
12 Age < 60* 1.12(0.99,1.27) 2.17(0.52,8.97) 1 1.45(0.82,2.56)
13 Age ≥ 60* 1.42(1.11,1.82) 3.66(0.49,27.68) 1 0.80(0.11,5.78)
14 Household Income
15 <10,000** 1.49(1.27,1.75) 1.69(0.23,12.49) 1 0.55(0.14,2.27)
16 ≥10,000** 1.27(1.11,1.46) 4.45(1.08,18.33) 1 2.30(1.28,4.13)
Fo
17 Highest Education
18 Primary 1.48(1.32,1.67) 3.30(0.79,13.74) 1 0.73(0.18,2.96)
19 school/below***
20
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Junior High/above*** 1.12(0.92,1.38) 1.99(0.27,14.83) 1 1.76(0.96,3.25)
21
Marital Status
22
23
Married**** 2.04(1.67,2.50) 8.81(1.05,74.11) 1 -
Widowed/Divorced**** 1.26(1.12,1.41) 2.15(0.53,8.12) 1 2.14(1.26,3.63)
ee
24
25 *After adjusting for one/two children region, self-rated health, occupation, education, marital status, household
26 income, smoking, alcohol.
**After adjusting for age at study date, self-rated health, occupation, education, marital status, household income,
rr
27
28 smoking, alcohol.
29 *** After adjusting for age at study date, one/two children region, self-rated health, occupation, marital status,
ev
household income, smoking, alcohol.

30
**** After adjusting for age at study date, one/two children region, self-rated health, education, occupation,
31
household income, smoking, alcohol
32
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2 STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies
3
4 Item Page
5 No Recommendation No
6 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or 3
7 the abstract
8 (b) Provide in the abstract an informative and balanced summary of what 3
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10 was done and what was found
11 Introduction
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Background/rationale 2 Explain the scientific background and rationale for the investigation being 5
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14 reported
15 Objectives 3 State specific objectives, including any prespecified hypotheses 7
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Methods
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18 Study design 4 Present key elements of study design early in the paper 7
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19 Setting 5 Describe the setting, locations, and relevant dates, including periods of 7-8
20 recruitment, exposure, follow-up, and data collection
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Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection 7-8
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23 of participants
24 Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, 9-10
25 and effect modifiers. Give diagnostic criteria, if applicable
ee
26
27 Data sources/ 8* For each variable of interest, give sources of data and details of methods 8
28 measurement of assessment (measurement). Describe comparability of assessment
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29 methods if there is more than one group

30
Bias 9 Describe any efforts to address potential sources of bias 8-10
31
ev
32 Study size 10 Explain how the study size was arrived at 8

33 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If 8-10
34 applicable, describe which groupings were chosen and why
iew
35
36 Statistical methods 12 (a) Describe all statistical methods, including those used to control for 10
37 confounding
38 (b) Describe any methods used to examine subgroups and interactions 10
39
(c) Explain how missing data were addressed 10
40
on
41 (d) If applicable, describe analytical methods taking account of sampling 10-

42 strategy 11
43 (e) Describe any sensitivity analyses 10-
ly
44
11
45
46 Results
47 Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers 11
48
potentially eligible, examined for eligibility, confirmed eligible, included
49
50 in the study, completing follow-up, and analysed
51 (b) Give reasons for non-participation at each stage
52 (c) Consider use of a flow diagram
53
54 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, 11
55 social) and information on exposures and potential confounders
56 (b) Indicate number of participants with missing data for each variable of 11
57
interest
58
59 Outcome data 15* Report numbers of outcome events or summary measures 11-
60 12
1
1
2 Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted 12
3
estimates and their precision (eg, 95% confidence interval). Make clear
4
5 which confounders were adjusted for and why they were included
6 (b) Report category boundaries when continuous variables were 12-
7 categorized 13
8
(c) If relevant, consider translating estimates of relative risk into absolute 12-
9
10 risk for a meaningful time period 13
11 Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, 12-
12 and sensitivity analyses 13
13
14 Discussion
15 Key results 18 Summarise key results with reference to study objectives 13
16 Limitations 19 Discuss limitations of the study, taking into account sources of potential 17
17
18 bias or imprecision. Discuss both direction and magnitude of any potential
Fo
19 bias
20 Interpretation 20 Give a cautious overall interpretation of results considering objectives, 14-
21
limitations, multiplicity of analyses, results from similar studies, and other 16
rp
22
23 relevant evidence
24 Generalisability 21 Discuss the generalisability (external validity) of the study results 16-
25 17
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26
27 Other information
28 Funding 22 Give the source of funding and the role of the funders for the present study 19
rr
29 and, if applicable, for the original study on which the present article is
30
based
31
ev
32
33 *Give information separately for exposed and unexposed groups.
34
iew
35
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and
36
37 published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely
38 available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
39 http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is
40
on
available at www.strobe-statement.org.
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ly
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BMJ Open is committed to open peer review.

As part of this commitment we make the peer review

Maternal depression and loss of children under the one-

Journal: BMJ Open

Article Type: Original research

Date Submitted by the

Shang, Jie; George Institute for Global Health

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

24 between Major depression (MD) and family types, after

24 or weight change, sleeping problems, feelings of guilt or worthlessness, psychomotor changes,

33 another possible explanation to elucidate our findings. Introduced by Foucault as a political

33 of depression and child loss.

33 commercial, or not-for-profit sectors.

21 5. Wei Y, Jiang Q, Basten S. The Wellbeing of Bereaved Parents in an Only-child Society.

24 Bureau of Statistics of China; 2018.

30 American Psychiatric Pub; 2013.

30 epidemiology: a review. International Review of Psychiatry. 2007;19(5):497-507.

33 International journal of methods in psychiatric research. 1998;7(4):171-185.

30 >35,000 yuan 20.02 10.27 9.46 19.10

33 Factory workers 15.30 20.55 1.36 16.70

38 Widowed/Divorced 4.32 6.58 16.08 6.72

42 BMI(kg/m2), Mean, SD 23.83(3.35) 23.71(3.86) 23.84(3.64) 23.31(3.60)

42 income, smoking, alcohol.

Maternal depression and loss of children under the one-

Journal: BMJ Open

Article Type: Original research

Date Submitted by the

Shang, Jie; George Institute for Global Health

Secondary Subject Heading: Epidemiology, Health policy, Sociology

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

24  This study is a cross-sectional study, rather than a longitudinal study.

24 with the loss of an only child.

33 older, married, with lower education level or higher household income.

24 possible explanation to elucidate our findings. Introduced by Foucault as a political technology,

24 representative to infer an association at a population level.

33 the design, or conduct, or reporting, or dissemination plans of this research.

21 Bureau of Statistics of China; 2018.

30 Basic Books; 1980.

24 methods in psychiatric research. 2004;13(2):122-139.

30 International journal of methods in psychiatric research. 1998;7(4):171-185.

24 biopolitics. Stanford University Press; 2005.

33 48. Kreicbergs U, Valdimarsdóttir U, Onelöv E, Henter J-I, Steineck G. Anxiety and

30 >35,000 yuan 20.02 10.27 9.46 19.10

33 Factory workers 15.30 20.55 1.36 16.70

38 Widowed/Divorced 4.32 6.58 16.08 6.72

42 BMI(kg/m2), Mean, SD 23.83(3.35) 23.71(3.86) 23.84(3.64) 23.31(3.60)

household income, smoking, alcohol.

29 methods if there is more than one group

32 Study size 10 Explain how the study size was arrived at 8

41 (d) If applicable, describe analytical methods taking account of sampling 10-

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