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. 2026 Feb 25;45(2):10. doi: 10.1007/s11113-026-09996-0

Women’s Reproductive Health Conditions and Fertility Goals

Karen Benjamin Guzzo 1,✉, Kathleen Broussard 2
PMCID: PMC12935700  PMID: 41769245

Abstract

There is a large body of research examining women’s fertility decision-making. Yet this work rarely considers how women’s experiences with reproductive health conditions may be linked to their fertility goals, a problematic oversight given the growing emphases on reproductive careers and childbearing biographies that highlight the need to take a life course approach to fertility. Using the 2015–2019 National Survey of Family Growth (N = 8867), this paper examines how reproductive health conditions are associated with women’s fertility goals among women who are not surgically sterile or meet the medical definition of infertility. Slightly more than one in five women report at least one reproductive health condition. Multivariable logistic regressions show that women who report a diagnosis of any reproductive health condition are 34% more likely to desire a child than their peers with no such diagnoses. However, conditional on desiring a child, women with such diagnoses are 35% less likely to intend to have a child. These findings suggest that reproductive health conditions might be perceived as barriers to fulfilling fertility goals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11113-026-09996-0.

Keywords: Fertility, Fertility goals, Reproductive health, Health conditions

Introduction

Understanding childbearing decision-making has become the focus of considerable research in demography, especially as birth rates continue to fall in the U.S. and many countries in Europe, Asia, and the Americas (Gietel-Basten et al., 2022). In the U.S., birth rates are at record lows, with the Total Fertility Rate (TFR) at 1.62 in 2023 (Osterman et al., 2025), below the previous low of 1.74 in 1983 (Livingston, 2019). The Theory of Planned Behavior (TPB) (Ajzen, 1991; Ajzen & Klobas, 2013) and the Traits-Desires-Intentions-Behavior (TDIB) (Miller, 1994) framework emphasize the formation of explicit fertility goals as necessary preconditions for fertility in industrialized countries. As such, studying fertility goals—an umbrella term for various measures of fertility ideals, desires, intentions, and attitudes—has taken on new prominence in recent years because, despite fertility rates of less than two children per woman, two-child norms at both the abstract and personal levels remain persistent in the U.S. (Brenan, 2025; Guzzo & Hayford, 2023). This suggests that many are unable to achieve their fertility goals.

The inability of standard socioeconomic measures to explain contemporary low fertility (Kearney et al., 2022) has prompted the emergence of newer theories, such as the Theory of Conjunctural Action (TCA) (Johnson-Hanks et al., 2011) and the Narratives of the Future framework (Vignoli et al., 2020). These theories highlight the role of both non-economic characteristics as well as subjective evaluations of current and future economic, situational, and relational well-being for contemporary fertility decision-making. And, indeed, there is now ample evidence that both objective and subjective statuses across a range of demographic, socioeconomic, relationship, and psychosocial characteristics are key determinants of fertility goals (Gatta et al., 2022; Ivanova & Balbo, 2024; Manning et al., 2025; Trinatopoli & Yeatman, 2018). There is also a smaller body of work demonstrating that health can influence fertility decision-making (Lazzari & Beaujouan, 2025; Sobotka & Testa, 2008). What has received virtually no attention, outside of the literature on infertility, is specific attention to the role of reproductive health conditions as a factor linked to the fertility goals of people with the capacity for pregnancy.1 This is true despite the obvious fact that childbearing is situated within a reproductive body and thus, in our view, represents a major oversight in the literature on fertility decision-making. We address this gap by exploring whether diagnoses of ovulation/menstruation problems or other specific reproductive health conditions influence the formation of fertility goals among women who are not medically infertile or surgically sterile. Further, we consider different types of goals. In the Traits-Desires-Intentions-Behavior (TDIB) framework (Miller, 1994; Miller et al., 2004), the formation of desires (what people want) precedes the formation of intentions (what people plan to do). For instance, people may wish to have a child but may not act on those desires due to potential concerns related to having reproductive health conditions, such as concerns over exacerbating conditions or an increased risk of pregnancy loss. We suggest that experiences with reproductive health problems may be an important determinant of both desires and intentions—and of the mismatch between them.

Our underlying approach is based on the life course perspective, of which a central tenet is that people’s past experiences shape their future pathways and how they see the future, including their future fertility decisions (Huinink & Kohli, 2014). This perspective has been influential for a small but growing body of work in demography that focuses on identifying the need to consider “reproductive careers” (Johnson et al., 2023) and “childbearing biographies” (Thomeer et al., 2022)—concepts that situate any particular reproductive event within women’s larger reproductive history. Much of this work focuses on concrete events: pregnancies, miscarriages, abortions, and births, but a larger set of reproductive health conditions—such as irregular periods or endometriosis—can have dramatic impacts on women’s quality of life in addition to direct impacts on fecundity and fertility (Della Corte et al., 2020). Thus, from a life course perspective, these past diagnoses (and possibly current conditions) may influence how individuals approach reproduction, including how they formulate desired fertility outcomes and form intentions (or not) to follow through on those desires.

In this paper, we consider how reported diagnoses of ovulation/menstrual problems or reproductive health conditions are associated with women’s fertility goals among women who are not medically infertile or surgically sterile. Using the 2015–2019 National Survey of Family Growth, we examine the association between women’s reports of diagnosed reproductive health conditions and (1) fertility desires—do women want to have a(nother) child?—and, (2) conditional on wanting a child, fertility intentions—do they intend to have a(nother) child? We find that a history of such diagnoses is linked to higher odds of desiring a child but lower intentions to have a child among those who desire a child. This suggests that reproductive health conditions inhibit women’s ability to achieve their fertility goals and warrant further attention as a reproductive justice issue.

Background

There is extensive literature documenting the wide range of influences of the formation of fertility goals (Guzzo & Hayford, 2020), but this literature has generally ignored the role of reproductive health conditions. Broadening the lens to consider reproductive health seems an important new direction for research on fertility decision-making, though in many ways it harkens back to the arguments made in Miller’s (1994) and Miller et al. (2004) TDIB framework that constraints may exist between what people would like to do (desires) and what they actually plan to do (intentions). Although the reproductive career perspective emphasizes a life course approach to understand how women’s fertility at a given point is linked to other fertility events, reproductive health conditions are more common and of longer duration than fertility events. Most women have few pregnancies, and pregnancies are—by definition—a time-limited experience. As such, we consider the oversight of reproductive health experiences in the fertility goals literature is problematic.

Some reproductive health conditions can be lifelong issues that likely have both indirect and direct links to childbearing goals and behaviors. Endometriosis, which is estimated to affect more than one in ten women, can emerge in adolescence and take years before diagnosis (Agarwal et al., 2019). It can cause significant pain, digestive problems, and difficulty conceiving (Office on Women’s Health, 2021a). Uterine fibroids are estimated to affect more than 70% of women at some point during their reproductive years, though not all women are symptomatic, and can reoccur even after treatment (Stewart et al., 2017). Symptoms of uterine fibroids include heavy bleeding, abdominal discomfort, lower back pain, and pain during sex, among others (Office on Women’s Health, 2021c). Women with uterine fibroids take longer to conceive and have an elevated risk of preterm birth (Harrison et al., 2023; Karlsen et al., 2020). Although it affects only about 5% of women and is often asymptomatic, pelvic inflammatory disease (PID) is an infection (which women can get more than once) that can damage the reproductive system and reduce fecundity (Office on Women’s Health, 2021d). And, of course, many women have ovulatory or menstrual issues that do not have a formal diagnosis; irregular periods make it difficult for women to plan for, and understand, their body’s reproductive capacity (Bell & Fissell, 2021). In general, women with reproductive health conditions interface with the medical system extensively in search of diagnoses and effective treatments; some may be doing so solely for symptom relief, while others do so at least in part due to concerns over their future ability to become pregnant and carry a child to term. Further, diagnoses may be accompanied by both direct education efforts by providers as well as independent help-seeking (i.e., visiting internet forums, using WebMD) that alert those with conditions about potential difficulties related to fertility (Dinh et al., 2022; Dykstra et al., 2023).

We draw in part on studies on infertility to help guide our work, though our analyses exclude women who meet medical criteria for infertility (at least 12 months of regular unprotected penile-vaginal intercourse) and those who are surgically sterile. While there is considerable research on both fertility goals and infertility, these literatures have largely been siloed (Johnson et al., 2018). On the infertility side, there is extensive literature in medicine and medical psychology that examines experiences of infertility as well as causes and treatments (Johnson et al., 2018). Many women who meet the medical criteria for infertility engage in medical help-seeking (a clear proxy for both desires and intentions to get pregnant) but not all do so (Passet-Wittig & Greil, 2021; Wilson, 2014). Infertility medical help-seeking may also lead to women being diagnosed with reproductive health conditions (Nezhat et al., 2024), though not all infertility has an identified cause or is linked to women’s health conditions (Carson & Kallen, 2021). On the fertility goals side, most research on fertility goals excludes those who report being infertile (e.g., Hayford & Guzzo, 2013; Hiekel & Castro-Martin, 2014; Marteleto et al., 2024), largely because the underlying motivation of much of this research is to understand how people who are, in theory, capable of pregnancy are thinking about childbearing. To the best of our knowledge, only one study has directly considered infertility and fertility intentions. Shreffler et al. (2016) find that women who identify as infertile have greater desires to have a baby but lower intentions to have a child; however, they note that many women who do not meet the medical criteria for infertility still identify as such and, conversely, that many women who do meet the criteria do not identify as infertile.

As such, women’s perceptions of their infertility status do not necessarily correspond with diagnosed reproductive health conditions. Many women with reproductive health conditions do not meet the medical criteria of infertility and do not experience difficulties in becoming pregnant or carrying a child to term, perhaps because diagnoses are often accompanied by treatment. Still, infertility research and the research documenting the impacts of reproductive health conditions on health and quality of life shed some light on how reproductive health conditions and childbearing goals might be associated. There is also some qualitative research suggesting that women who report reproductive health conditions are often reluctant to make firm plans about having children due to fear of being disappointed if they could not fulfill such plans (Gomez et al. 2019). A study of 22 couples in which the female partner had endometriosis revealed that about half had experienced fertility difficulties, but even those who had not (yet) experienced actual difficulties reported that their decision-making about having children was affected by concerns related to endometriosis, with women reporting high levels of anxiety and concern (Culley et al., 2017). Further, many of these conditions affect women’s quality of life in ways that impact other life course domains. Women with endometriosis, for example, report more depression and anxiety, more problems with their social relationships and sex life, lower work productivity (and potentially lower wages) due to work absences, and more health care usage and costs (Della Corte et al., 2020), with similar quality-of-life issues for other conditions, such as uterine fibroids (Go et al., 2020).

Building on existing literature, it seems women’s fertility goals could be linked by direct concerns related to their conditions (such as whether they will be able to get pregnant or carry a pregnancy to term or that their symptoms may worsen during pregnancy) or indirect reasons (e.g., depression or difficulties in romantic/sexual relationships). Moreover, the link may vary across different measures of fertility goals. Desires represent what women want, in the absence of constraints, whereas intentions represent concrete plans (Miller, 1994). In general, there is less variation in desires to have a(nother) child across various characteristics than there is among intentions (Guzzo & Hayford, 2024); that is, many women would like to become mothers or have another child, but a subset of these do not expect to actually have a child given their current life circumstances. Still, desires are generally overlooked, even though these are sometimes more proximate to people’s mental state and worries (Miller, 2011). Although most prior work on health and fertility goals does not consider both desires and intentions, one study found that mothers with a disability were more likely to want another child but less likely to intend to do so (Shandra et al., 2014), and, as noted above, the same is true for infertility diagnoses (Shreffler et al., 2016). This is likely explained by selection—women who actively want or plan to have a child may seek out medical care as part of their childbearing journey, especially if they are worried that their reproductive health conditions may affect their ability to get pregnant or carry a pregnancy to term.

We account for several factors that are likely related to both fertility goals and reproductive health conditions. For instance, access to reproductive health care—as proxied by health insurance type and recency of pelvic exams—may influence both whether people have a diagnosis and whether they are getting the types of treatment that could limit a condition’s impact on fertility (De La Cruz & Buchanan, 2017; Giglio-Ayers et al., 2024; Shukla et al., 2025). Contraceptive use may also be important. Although contraception is generally used to manage birth timing, spacing, and quantum, many women (also) use it to manage the frequency and severity of reproductive health conditions (Jahanfar et al., 2024). Sociodemographic factors are also likely related to both diagnoses of reproductive health conditions and fertility goals. There are wide disparities in diagnoses of reproductive health conditions by race-ethnicity-nativity, education, and age (Bougie et al., 2019; Giglio-Ayers et al., 2024; Katon et al., 2023; Kreisel et al., 2021). Similarly, there is also evidence that fertility goals vary across sociodemographic characteristics such as age, education, marital status, and race-ethnicity-nativity (Guzzo, 2022; Hartnett & Gemmill, 2020; Rackin & Bachrach, 2016).

Thus, in the current study, our analyses consider how reproductive health conditions relate to fertility desires and intentions among a nationally representative sample of women who do not meet the medical definition of infertility and are not surgically sterile. Drawing on the limited prior literature, we expect that women with reproductive health conditions will have higher desires than those without such conditions. Further, we hypothesize that, among those who want to have children, intentions to have a child will be lower.

Data and Methods

The project uses 2015–2017 and 2017–2019 cycles of the National Survey of Family Growth (NSFG), a nationally representative sample of men and women aged 15–49. The data are publicly available from the National Center for Health Statistics at https://www.cdc.gov/nchs/nsfg/index.htm. The analytical sample is restricted to women2 (N = 11,695) and excludes those who are surgically sterile (or had a surgically sterile partner), meet the medical criteria for infertility of regular unprotected penile-vaginal sex without pregnancy for at least 12 months (n = 1981),3 or are currently pregnant (n = 393).

Key Variables

The dependent variables are prospective fertility desires and intentions. Fertility desires are based on the question: “Looking to the future, would you, yourself, want to have a baby at some time in the future?” with response categories of yes, no, refused, and don’t know. We dropped those who gave “don’t know” responses or refused to answer (n = 294). For fertility intentions, we use the NSFG recoded variable that incorporates information from direct questions about intentions and information on sterilization. Non-sterile (surgically or otherwise) respondents who did not have a coresidential partner were asked “Looking to the future, do you intend to have a baby at some time? (Intend refers to what you are actually going to try to do)” with categories of yes/no. Respondents with a non-sterilized coresidential partner were asked “Do you and [PARTNER] intend to have a baby at some time in the future?” We exclude respondents who did not have valid information on their fertility intentions (n = 68).

The key independent variables are the indicators of reproductive health conditions. Respondents were asked a series of separate questions of whether they had ever been diagnosed with, or treated for, the following conditions: ovulation or menstrual problems, endometriosis, uterine fibroids, or pelvic inflammatory disease. We created a dichotomous indicator of whether respondents reported any of these conditions. Women who were missing on the key reproductive health conditions were excluded (n = 22).

Covariates

Analyses account for characteristics linked to reproductive health condition diagnoses and/or fertility goals in prior work. These include age (in five-year groups given the nonlinearity between age and fertility), race-ethnicity-nativity (non-Hispanic White, non-Hispanic Black, native-born Hispanic, foreign-born Hispanic, and ‘Other’), education (less than high school, high school degree/GED/some college, Associate’s degree, Bachelor’s degree or more), marital status (married, cohabiting, previously married/not cohabiting, and never married/not cohabiting), whether the respondent has any children, insurance status (private or Medi-Gap; Medicaid, Children’s Health Insurance Program (CHIP), or state-sponsored plan; Medicare, military or other government health care; or a single-service plan, Indian Health Services, or none), last pelvic exam (within past 12 months, more than a year ago, or never), whether the respondent is currently using a contraceptive method, and self-rated health (ranging from 1 to 5, with higher scores meaning better health). Women who were missing information on one or more of the covariates (discussed below) further reduced the sample size by 70 additional cases. The final analytical sample included 8,867 women.

Analytical Plan

We begin by discussing the characteristics overall, and we compare the sample characteristics of respondents who report having ever been diagnosed with a reproductive health condition to those who have never had a reproductive condition. We then show the odds ratios (ORs) from a multivariable logistic regression predicting fertility desires. Next, among those who report desiring a(nother) child, we show ORs from a multivariable logistic regression predicting fertility intentions. In supplementary models, we examined both desires and intentions regressed on each individual condition, though we caution that there are power concerns given the small number of cases who report specific conditions.

Results

Descriptive Results

Table 1 shows the descriptive statistics for the sample. Just over one in five women report having at least one diagnosed ovulation/menstrual problem or reproductive health condition (and about 5% report having multiple conditions). For specific conditions, it ranges from 3.7% for pelvic inflammatory disease to about 15% for unspecified ovulation/menstrual problems. About 61% of the full analytical sample want to have at least one (more) child, and about 87% of those who want a child intend to have one; for a minority of women, then, there is a mismatch between desires and intentions. At the bivariate level, survey-weighted chi-square tests indicated that women who report any diagnosed reproductive health conditions have lower desires and intentions than those who do not (p < .001). This partially contradicts with our expectations.

Table 1.

Weighted descriptive statistics of analytical sample (N = 8867)

Full sample No reproductive health conditions Has a reproductive health condition p d
Reproductive health conditions
Any diagnosed ovulation/menstrual problem or reproductive condition a 22.0% – –
 Ovulation/menstrual problem 14.8% – –
 Endometriosis b 3.9% – –
 Uterine fibroids b 5.9% – –
 Pelvic inflammatory disease b 3.7% – –
Fertility Goals
Wants any (more) children 60.7% 63.1% 52.5% 0.000
Intends any (more) children, conditional on wanting any (more) children 86.8% 89.5% 75.2% 0.000
Age group 0.000
 15–19 17.5% 20.5% 7.0%
 20–24 17.3% 18.5% 13.1%
 25–29 17.4% 18.3% 14.4%
 30–34 14.8% 14.8% 14.5%
 35–39 11.7% 10.3% 16.3%
 40–44 10.6% 9.1% 15.9%
 45–49 10.8% 8.5% 19.0%
Race-ethnicity-nativity 0.002
 White (non-Hispanic) 53.5% 52.4% 57.2%
 Black (non-Hispanic) 14.9% 14.7% 15.3%
 Native-born Hispanic 14.0% 14.8% 11.4%
 Foreign-born Hispanic 7.5% 8.2% 5.3%
 Other 10.2% 10.0% 10.8%
Education 0.000
 Less than High School 18.2% 20.4% 10.3%
 High School/GED or some college 44.0% 44.1% 43.7%
 Associate’s degree 8.0% 7.1% 11.0%
 Bachelor’s degree or more 29.9% 28.4% 35.0%
Marital status 0.000
 Never married, not cohabiting 49.0% 51.5% 40.1%
 Previously married, not cohabiting 12.7% 9.9% 22.1%
 Cohabiting 12.4% 12.7% 11.3%
 Married 26.0% 25.9% 26.5%
Has children 47.6% 45.0% 56.6% 0.000
Insurance status 0.297
 Private or Medi-Gap 62.2% 62.4% 61.7%
 Public (Medicaid, CHIP, c or state-sponsored plan) 20.5% 20.7% 19.8%
 Medicare, military, or other government healthcare 4.7% 4.4% 5.9%
 Single service plan, Indian Health Service (IHS), or none 12.6% 12.6% 12.6%
Last pelvic exam 0.000
 In past 12 months 50.0% 46.2% 62.9%
 More than 1 year ago 26.7% 26.2% 28.2%
 Never 23.4% 27.5% 8.9%
Currently using contraception 57.1% 56.0% 60.6% 0.014
Mean self-rated health (SE) 3.84 (0.02) 3.93 (0.02) 3.53 (0.04) 0.000
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a5.1% of respondents reported multiple reproductive health conditions (ovulation/menstrual problems, endometriosis, uterine fibroids, or pelvic inflammatory disorder)

bAs defined by the U.S. Department of Health & Human Services, Office on Women’s Health, endometriosis occurs when tissue similar to the lining of the uterus (womb) grows outside of the uterus; uterine fibroids are muscular tumors that grow in the wall of the uterus; pelvic inflammatory disease is an infection of a woman’s reproductive organs

cChildren’s Health Insurance Program

dp-values reflect Chi-square tests comparing respondents with and without a reproductive health condition across all variables except mean self-rated health, which we compared means using survey-weighted linear regression

The overall sample is skewed slightly towards younger ages, but this is more so the case for those without diagnosed reproductive health conditions, whereas those who reported diagnosed reproductive health conditions tend to be older (p < .001). For instance, 20.5% of those without a diagnosed condition are ages 15–19 but only 7% of those with a condition are in that same age group. Conversely, 19% of those with reproductive health conditions are ages 45–49 but only 8.5% of those with no reproductive health conditions are in that same age group. Slightly more than half of the sample (54%) is non-Hispanic White, with about 15% non-Hispanic Black, 14% native-born Hispanic, 7.5% foreign-born Hispanic, and 10% ‘Other.’ Both native-born and foreign-born Hispanic women are slightly under-represented among those with diagnosed reproductive health conditions. Looking at education, the modal category is a high school degree, GED, or some college for the full sample, but educational distribution varies by reproductive health issue diagnoses (p < .001). The share without a high school or equivalent degree is twice as high among those with no conditions (20%) than those with conditions (10%), and those with a Bachelor’s degree or more is higher among those with conditions (35%) than among those without (28%). Just under half of the overall analytical sample has never married and is not cohabiting, though only 40% of those with reproductive health conditions fall into this category (p < .001). The sample is split fairly evenly among those with and without children, but those with a diagnosed condition are more likely to have children (p < .001). Many of the sociodemographic differences likely reflect age differences in the two groups. There are no substantive differences in insurance type between those with and without diagnosed health conditions (p = .297). Finally, looking at other health characteristics, half of the overall sample has had a pelvic exam in the past 12 months, but the share is much higher among those with a health condition (63%) than those without (46%; p < .001). Just under six in ten (57%) women in the analytical sample are using contraception, with the share slightly higher among those with reproductive health conditions (61%) than without (56%; (p = .014). Mean self-rated health is higher among those without reproductive health conditions (3.9) than those without (3.5; p < .001).

Multivariable results

Table 2 shows odds ratios (ORs) from multivariable analyses regressing fertility desires on our indicator of reproductive health conditions. As hypothesized (and unlike in the bivariate results), in the presence of full controls, women who report any diagnosed ovulation/menstrual problems or other reproductive health conditions are about 34% more likely to desire a(nother) child (p = .005). In models not shown in which we added covariates independently, we identified age as driving the reversal relative to what was observed in the bivariate results. The full model shows large age differences in the desire for a(nother) child, with higher ORs among women at younger ages and lower ORs at older ages relative to women 30–34.4 Non-Hispanic Black and native-born Hispanic women are more likely to desire a(nother) child relative to non-Hispanic White women (OR = 1.31, p = .012 and OR = 1.36, p = .007 respectively). There are no educational differences in fertility desires, but we do see differences by marital status and parenthood status. Women who are cohabiting or married have an elevated risk of wanting at least one (more) child (OR = 1.47, p = .016 and 1.33, p = .021, respectively) relative to never-married, non-cohabiting women. Childless women are 2.8 times (p < .001) as likely to desire children than women who have children.5 Finally, looking at health characteristics, there are no differences in fertility desires by insurance status or self-rated health. However, there are significant differences in fertility desires for reproductive health-specific measures. Compared to women who never had a pelvic exam, women who ever had an exam (including those in the past year) are 1.83 times as likely to desire a(nother) child (p = .001), and women using contraceptives are about a third (OR = 0.65, p < .001) less likely to desire a(nother) child than women who are not using any contraceptive method.

Table 2.

Odds ratios from multivariable logistic regression predicting desire for a(nother) child

Odds Ratio SE
Any diagnosed ovulation/menstrual problem or reproductive condition 1.34** 0.14
Age category
 15–19 4.26*** 0.98
 20–24 2.94*** 0.48
 25–29 1.78*** 0.22
 30–34 Ref
 35–39 0.34*** 0.04
 40–44 0.14*** 0.02
 45–49 0.08*** 0.02
Race-ethnicity-nativity
 White (non-Hispanic) Ref
 Black (non-Hispanic) 1.31* 0.14
 Native-born Hispanic 1.36** 0.15
 Foreign-born Hispanic 1.33 0.21
 Other 1.12 0.19
Marital status
 Never married, not cohabiting Ref
 Previously married, not cohabiting 1.07 0.14
 Cohabiting 1.47* 0.23
 Married 1.33* 0.16
Education
 Less than High School Ref
 High School/GED or some college 1.14 0.16
 Associate’s degree 1.10 0.21
 Bachelor’s degree or more 1.16 0.21
 Has children 2.81*** 0.28
Insurance status
 Private or Medi-Gap Ref
 Public (Medicaid, CHIP,a or state-sponsored plan) 0.89 0.09
 Medicare, military, or other government healthcare 0.73 0.14
 Single service plan, Indian Health Service (IHS), or none 1.09 0.16
Last pelvic exam
 Never Ref
 A year ago or more 1.83** 0.33
 In past 12 months 1.83*** 0.32
Currently using contraception 0.65*** 0.05
Self-rated health 1.08 0.06
Constant 0.43** 0.14
N 8867
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Ref = reference category

a Children’s Health Insurance Program

* p < .05, ** p < .01, *** p < .001

Looking next at fertility intentions among women who desired a child (Table 3), the association between reproductive health conditions and intentions is in the opposite direction as desires. Among those who want at least one child, women who report a diagnosis of an ovulation/menstrual problem or specific reproductive health condition are about a third less likely (OR = 0.65, p = .002) to intend to have a child relative to those without any diagnosed reproductive health conditions even when controlling for the full set of covariates. This is consistent with our hypothesis.

Table 3.

Odds ratios from multivariable logistic regression predicting intentions for a(nother) child, among women who desire a(nother) child

Odds Ratio SE
Any diagnosed ovulation/menstrual problem or reproductive condition 0.65** 0.09
Age category
 15–19 12.64*** 5.91
 20–24 3.98*** 0.90
 25–29 2.19*** 0.37
 30–34 Ref
 35–39 0.56* 0.13
 40–44 0.16*** 0.04
 45–49 0.04*** 0.02
Race-ethnicity-nativity
 White (non-Hispanic) Ref
 Black (non-Hispanic) 2.42*** 0.52
 Native-born Hispanic 2.38*** 0.50
 Foreign-born Hispanic 2.54*** 0.62
 Other 1.48 0.34
Marital status
 Never married, not cohabiting Ref
 Previously married, not cohabiting 0.72 0.15
 Cohabiting 1.12 0.28
 Married 1.59* 0.33
Education
 Less than High School Ref
 High School/GED or some college 1.31 0.33
 Associate’s degree 1.15 0.38
 Bachelor’s degree or more 2.10* 0.70
 Has children 2.39*** 0.52
Insurance status
 Private or Medi-Gap Ref
 Public (Medicaid, CHIP, a or state-sponsored plan) 0.79 0.14
 Medicare, military, or other government healthcare 1.06 0.34
 Single service plan, Indian Health Service (IHS), or none 0.76 0.19
Last pelvic exam
 Never Ref
 A year ago or more 0.95 0.31
 In past 12 months 1.04 0.34
Currently using contraception 0.59*** 0.08
Self-rated health 1.24** 0.09
Constant 0.84 0.38
N 5433
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Ref = reference category

a Children’s Health Insurance Program

* p < .05, ** p < .01, *** p < .001

As with fertility desires, several sociodemographic and health covariates are significantly associated with fertility intentions among those who desire a(nother) child. Younger women have higher intentions, and older women lower intentions, than women aged 30–34. Relative to non-Hispanic White women who want a child, non-Hispanic Black (OR = 2.42, p < .001), native-born Hispanic (OR = 2.38, p < .001), and foreign-born Hispanic (OR = 2.54, p < .001) women are all more than twice as likely to intend to have a(nother) child. Although education was not related to desires, it is related to intentions among those with positive desires—women with at least a Bachelor’s degree are twice as likely as those without a high school degree to intend to have a child (OR = 2.10, p = .029). Married women are about 60% more likely to intend a(nother) child than non-cohabiting never-married women (p = .029), and women without children are 2.4 times as likely to intend to have a child than those who already have children (p < .001). There are no differences in fertility intentions among those who desire (more) children by insurance status or pelvic exam history, but women who are using contraception are about 40% less likely to intend to have a child (OR = 0.59, p < .001). Finally, women’s self-rated health is positively associated with greater intentions to have a child (OR = 1.24, p = .006) among those who desire a child.

Supplementary Models

We explored each specific reproductive health condition and its association with desires and intentions separately. Note that we also include polycystic ovary syndrome (PCOS), which is also linked to both fertility issues and quality of life issues (Gibson-Helm et al., 2017; Office on Women’s Health, 2021b). Data about PCOS was only collected in the 2017–2019 NSFG and so was not included as part of our overall measure, and results shown here for PCOS are for a smaller analytical sample. Supplemental Table S1 shows the results for fertility desires for models that include each condition separately, and Supplemental Table S2 repeats this for fertility intentions among those who desire at least one (more) child; all analyses include the covariates in the main models. The findings are similar to the binary combined indicator. Each condition is associated with an elevated risk of desiring a child compared to those without that specific condition, though not each one reaches statistical significance. Similarly, among those who desire at least one (more) child, each specific condition is associated a lower risk of intending a child relative to those without that condition.

Discussion and Conclusion

As fertility rates in the U.S. and elsewhere have declined (Gietel-Basten et al., 2022), attention to the factors that influence fertility decision-making has grown. Longstanding demographic theories argue that fertility results from a childbearing decision-making process in which individuals formulate clear desires to have children and then develop plans to follow through (or not) on those desires (Miller, 1994; Miller et al., 2004). As such, there is a rich literature on fertility goals, though much of this work has focused solely on intentions, to the neglect of desires (Miller, 2011). In recent years, this body of work has grown as scholars try to understand why birth rates are at record lows in many contexts in the Americas, Europe, and Asia. Research that has focused on traditional economic factors does not seem able to explain these declines (Kearney et al., 2022), leading to the development of theories focusing on potentially new factors, particularly subjective evaluations of economic and relational well-being (Manning et al., 2025; Vignoli et al., 2020). While these new theories and approaches have identified a broader range of factors to incorporate into models of fertility decision-making, one aspect continues to be overlooked: reproductive health.

There is a small body of literature that examines the role of health in fertility decision-making, finding that poorer physical and mental health are negatively linked to fertility intentions (Lazzari & Beaujouan, 2025; Sobokta & Testa, 2008). However, attention specifically to reproductive health is lacking. One reason this is problematic is that there is increased recognition that any given reproductive event or situation is nested within women’s longer reproductive history (Johnson et al., 2023; Thomeer, Reczek, & Stacy, 2022). Unfortunately, the notion of reproductive histories or careers has generally focused on measurable, distinct fertility events (births, abortions, miscarriages) even though women’s more general reproductive health is almost certainly relevant given that having a child involves one’s entire reproductive system. Another reason the oversight of women’s reproductive health for fertility goals research is problematic is that there is a large literature in medicine and medical psychology on infertility that has been largely neglected in demographic studies of fertility behavior (Johnson et al., 2018). This literature shows that many women with infertility clearly desire and intend to have a child, as evidenced by medical help-seeking for infertility, yet not everyone who has infertility seeks help (Passet-Wittig & Greil, 2021; Wilson, 2014), and not everyone who has reproductive health conditions would meet medical definitions of infertility. Thus, we fill the gap in the literature by considering women’s reproductive health experiences among those who are not infertile or sterile and studying potential linkages between health conditions and both fertility desires and intentions.

Although diagnoses of specific conditions are relatively rare in our analytical sample, one in five women report at least one diagnosed ovulation/menstrual problem or specific reproductive health condition. These conditions, which can persist throughout the reproductive years, often have substantial impacts not only on fertility directly but potentially also indirectly by impacting women’s quality of life, their intimate relationships, their ability to maintain employment, and their interactions with healthcare professionals (Castelo-Branco & Naumova, 2020; Della Corte et al., 2020; Go et al., 2020). As such, they may influence how women formulate fertility goals, including impacts on how women view their ability to act on their desires. Among the women analyzed here, about 60% desired to have at least one (more) child, but about 13% of those who desired a child did not intend to have one.

Reproductive health conditions did indeed turn out to be linked to both desires and intentions among women who are not surgically sterile or meet the medical criteria for infertility. Women who reported a diagnosis of ovulation/menstruation problems or one of three specific reproductive health conditions (endometriosis, uterine fibroids, or pelvic inflammatory disease) were about a third more likely to desire a child than their counterparts who did not report any such diagnoses. Further, and as hypothesized, women who desired to have at least one (more) child were about third less likely to intend to have a child if they reported a diagnosis of a reproductive health issue. These results were robust to controls for women’s health insurance status, contraceptive use, pelvic exam history, and general self-rated health, along with sociodemographic controls. As such, it appears that reproductive health conditions act as a constraint on women’s ability to achieve their fertility desires even among women who are not sterile or infertile. Women might feel as if they will be unable to conceive or carry a pregnancy to term and preemptively decide not to try to have a child. This interpretation would align with work by Gomez et al. (2019), who found that women with reproductive health conditions expressed ambivalence about future childbearing as a form of self-protection against disappointment and emotional pain. Our results demonstrate that reproductive health conditions are indeed salient for reproduction and should be incorporated into measures of reproductive careers/biographies and into research examining the link between reproductive careers/biographies and other demographic outcomes.

Limitations

The NSFG is a cross-sectional dataset and does not include information on women’s age at diagnosis or how long they have had their condition, nor is there information on severity, treatment, or other aspects of their condition that could impact fertility and quality of life. This precludes identifying specific experiences related to reproductive health conditions that could be impacting fertility decision-making, such as severe pain, frustration with providers, or difficulty in maintaining intimacy in relations. Information about reproductive health conditions is based on women’s self-reports and thus are likely to be underestimates of the true prevalence of such conditions. Further, as a cross-sectional survey, fertility goals are measured at only a single point in time and may change over the life course; they may also differ before and after being diagnosed with a reproductive health condition. Finally, we are unable to observe which women go on to fulfill their fertility goals.

Conclusion

Reproductive health conditions have largely been overlooked in the literature on fertility decision-making. The results here suggest that, among women who are not surgically sterile and who do not meet the medical criteria for infertility, reproductive health conditions are not uncommon. These conditions are, in turn, linked to women’s fertility goals in ways that merit additional consideration. Some women may be proactively seeking medical attention if they worry about their ability to have a successful pregnancy, while others could find that their goals change or become clearer when faced with potential barriers to childbearing. It could also be that quality-of-life issues related to reproductive health conditions drive some of the associations. These findings suggest, in any case, patients with reproductive health conditions may need additional support and counseling in a clinical setting to help them better understand how their condition may impact childbearing. Changes in how insurance providers define eligibility for infertility treatments may also be warranted; if reproductive health conditions are known to impact conception, requiring women to have 12 or more months of unprotected penile-vaginal sex before covering infertility treatment seems to present an unnecessary barrier. Additionally, as emphasized in the reproductive justice literature, understanding how women interact with family planning systems as they pursue their childbearing goals remains important. Finally, we note that demographic research increasingly focuses on health, yet measurement of reproductive health remains scant in major data collections. This is especially problematic given that fertility—one of the three core demographic foci—is inherently situated within a reproductive body.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1 (41.5KB, docx)

Acknowledgements

This research was supported by a center grant from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development to the University of North Carolina at Chapel Hill’s Carolina Population Center (P2C-HD050924). A prior version of this paper was presented at the 2024 annual meeting of the Population Association of America, Columbus, OH.

Ethics declarations

Competing interests

The authors have no competing interests to declare that are relevant to the content of this article.

Footnotes

1

For brevity’s sake, and for data reasons discussed in the Data and Methods section of the paper, we use the term “women” throughout the manuscript but acknowledge that not all people who identify as women have the capacity for pregnancy and not all people who identify as something other than a woman lack the capacity for pregnancy.

2

The 2015–2019 NSFG does not collect information on gender identity; the screener identifies whether respondents are male or female and then funnels them into the “male” or “female” survey accordingly. Within each survey, and in reports using the data from the sex-specific surveys, the NSFG uses gender terms to describe the analytical population and findings. We acknowledge that our data may include people who do not identify as women, but we use gender terms consistent with NSFG usage.

3

Alternative specifications where we included women who did not report being medically infertile did not change the main results.

4

We tested whether the association between fertility desires and reproductive health issues varied by age by interacting the age categories with our indicator of health issues, but the interaction was not significant (not shown). The same was true for intentions, suggesting that while age and reproductive health issues are independently linked with fertility goals, the association between reproductive health issues and desires/intentions does not vary by age.

5

We tested whether the association between fertility desires and reproductive health issues varied by parenthood status by interacting parenthood and reproductive health issues, but the interaction was not significant (not shown). The same was true for intentions, suggesting that while parenthood status and reproductive health issues are independently associated with fertility goals, the relationship between reproductive health issues and desires/intentions does not vary by whether one has children or not.

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