The experiences of Chinese pregnant women who have undergone fetal reduction: a qualitative study

Abstract

Pregnant women who have undergone fetal reduction may experience a series of psychological reactions, identifying those women’s experiences is helpful for improving pregnancy outcomes. However, the relevant studies and evidence are still lacking in China. This study aimed to explore the experiences of pregnant women who have undergone fetal reduction in China. A descriptive qualitative design was conducted for this study. From June to October 2025, qualitative data was collected through a semi-structured face-to-face in-depth interview from 12 pregnant women who have undergone fetal reduction in a tertiary hospital in Henan province, China. Two investigators analyzed qualitative data independently, and data was analyzed following qualitative content analysis. The experiences of pregnant women who have undergone fetal reduction were described under three themes: complex emotional experiences, multiple coping strategies, and multidimensional needs. Five sub-themes emerged from the complex emotional experiences: unacceptance and regret, distress and anxiety, ambivalence and fear, guilt, and worrying about the safety of the remaining fetus and oneself. Three sub-themes identified from multiple coping strategies: hiding inner feelings, accepting reality, and seeking help from family. Five sub-themes explained the multidimensional needs of pregnant women who have undergone fetal reduction: informational need, psychological need, accessible healthcare need, mental health service need, and financial support need. Pregnant women who have undergone fetal reduction have various psychological emotions, coping styles, and diversified needs. Screening and intervention of psychological emotions, promoting positive coping styles and addressing unmet needs based on multi-dimensional levels (e.g., policymakers, family members, professionals) are crucial for improving mental health of pregnant women who have undergone fetal reduction.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1038/s41598-026-58087-9.

Introduction

The increasing maternal age and widespread use of assisted reproductive technology for infertility treatment have led to a higher incidence of multiple pregnancies over the years^1,2. Since 1980, the incidence of multiple pregnancies has increased 76%³, with a prevalence of 0.7%~3.34% worldwide⁴. In developed countries, 1.54% of British women have multiple pregnancies, the rate of multiple pregnancies in the United States has increased from 1.89% to 3.19%^5,6. In middle- and low-income countries, the rate of multiple pregnancies has been reported to range from 0.6% to 1.8%, with an average of 13.1 twin pregnancies per 1000 births⁷. A population-based observational study found that the prevalence of multiple pregnancies in China had increased from 2.84% to 3.22%⁸.

Compared with singleton pregnancy, multiple pregnancy is associated with significantly higher rate of maternal complications (e.g., gestational hypertension, gestational diabetes, and postpartum hemorrhage), preterm delivery, fetal loss, and perinatal mortality and morbidity^9,10. Moreover, multiple pregnancy is classified as a high-risk pregnancy, women of multiple pregnancies are required more monitoring and contact with healthcare professionals, have more concerns about risk of complications during pregnancy and delivery, and experience increased parenting stress^11,12. All these unavoidable factors result in an increased prevalence of mental health problems of women who of multiple pregnancies. Therefore, focusing on the psychological condition of women with multiple pregnancies is of considerable importance.

Fetal reduction is defined as a medical procedure aimed at reducing the number of fetuses in multiple pregnancies¹³, has been used to reduce pregnancy related-complications and improve overall outcome of pregnancy^14,15. After being diagnosed as eligible for fetal reduction surgery, pregnant woman would be informed of the necessity and related risks of the fetal reduction, and then make the decision on whether to receive it. Pregnant women who need to undergo fetal reduction often have a history of infertility and assisted reproductive treatments, making it difficult for them to accept the conceive fetal reduction¹⁶. In addition, as a traumatic event, pregnant women who needed to receive fetal reduction could experience a series of complex psychological reactions, resulting in a higher incidence of psychological problems during perinatal period than ordinary women with multiple pregnancies¹⁷. Previous studies showed pregnant women who have undergone fetal reduction experienced significant stress and conflict, and doubted whether it is the right choice to receive fetal reduction¹⁸. Moreover, women with fetal reduction experience not only experienced the sorrow and guilt of the reduced fetus but also felt anxiety and fear about the prognostic outcomes of the surviving fetus¹⁹. Evidence shows that perinatal negative emotions have last and negative impacts on maternal and fetus health outcomes^20,21, therefore, more attention should be paid to the mental health of women of multiple pregnancies who have undergone fetal reduction.

Although more scholars have realized the importance and necessity of exploring the mental health of pregnant women underwent fetal reduction, the relevant studies are still lacking in China. A qualitative study focused on seven Taiwanese first pregnancy women with assisted reproductive technology’ experiences of foetal reduction found that women expressed psychological emotions (such as hesitation, ambivalence, distress, and guilt), persuaded oneself to ease guilt and wished hope in next pregnancy²². However, this study mainly focused on the first-time mothers’ experiences of fetal reduction following assisted reproductive technology in Taiwan. Moreover, there exists some differences in culture and healthcare system in Taiwan and mainland China. Based on the proportion of multiple pregnancies in China⁸, it can be estimated that the number of potential women who need to receive fetal reduction is quite large. However, to our knowledge, very limited information is available regarding the experiences of pregnant women who have undergone fetal reduction in mainland China. The implementation of China’s two-child and three-child policies has resulted in a marked increase in the incidence of multiple pregnancies²³. According to the Chinese Society for Reproductive Medicine guideline on multifetal pregnancy reduction²⁴, fetal reduction is indicated for women with triplet or higher-order multiple pregnancies, severe fetal malformations or chromosomal abnormalities, or intolerable maternal complications, so as to further reduce the risks associated with multiple pregnancies. Therefore, there still needs more evidence about experiences of women who have undergone fetal reduction to gain support to inform policy, practice and future research, which is also significant for optimizing perinatal management of pregnant women who need to receive fetal reduction. Above all, this study aims to investigate the experiences of Chinese pregnant women who have undergone fetal reduction, and further explore their needs.

Methods and procedures

Study design

Based on a descriptive approach, this qualitative study was conducted as part of mental health of fetal reduction program that was carried out in the National Regional Centre for the Development of Obstetrics and Gynecology.

Study participants

A purpose sampling strategy was used to recruit participants. We recruited participants through a sharing information poster at the obstetrics clinic of the Third Affiliated Hospital of Zhengzhou University in Zhengzhou, Henan Province, China, from June to October 2025. The eligible criteria for participants were presented as follows: (a) being 18 years or older; (b) pregnant women within 1–3 months after fetal reduction surgery; (c) voluntary participation. The exclusion criteria for participants in this study were as follows: (a) women with loss of the remaining fetus after fetal reduction; (b) women who exhibited impairment of cognitive function or serious pregnancy complications.

Data collection

An initial topic guide was developed based on literature review^22,25–27(e.g., qualitative studies on pregnant women who have undergone fetal reduction, perinatal mental health guideline, and standard descriptive qualitative literature) and expert opinions, then refined through two pilot interviews before finalizing the version used for data collection (see in Supplementary 1). Before the interviews, all women were informed of the aims and content of study and signed the informed consent. Besides, we also informed the participants that they could withdraw from the study freely, but none did. Interviews were conducted by an interviewer with training in qualitative research and medical background, data was collected through a semi-structured face-to-face in-depth interview conducted in quiet and private obstetric clinic room. Each interview lasted approximately 30–60 minutes. Interviews were digitally recorded and transcribed verbatim. Moreover, the field notes was used to record the non-verbal behaviors of the participants. Data collection ceased until reaching a saturation point, where new insights or perspectives could not be further obtained. During continuous interview coding and comparison, no new themes emerged after recruiting 12 participants, indicating that data saturation was reached.

Data analysis

Interviews were transcribed within 24h and analyzed following qualitative content analysis using NVivo 11.0 software²⁸. To obtain an understanding of the whole data, the transcribed interviews were read repeatedly. The first author (CDS) independently coded data, then two other authors (LGX and HSS) re-checked and discussed the codes to ensure the accuracy and consistency. The first author (CDS) generated initial themes and sub-themes from the data through consulting and discussing with two other authors (LGX and HSS). The final themes and sub-themes were confirmed following re-reading and re-checking codes. The authors avoided personal values and biases, all disagreements were discussed and revised until a consensus was reached. We consciously tried to exclude biases by continuously recognizing and recording pre-understandings and pre-notions, and the research method and analyse process were described and written in detail.

Ethical considerations

All methods in this study were performed in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (supplementary 2) and the Declaration of Helsinki. This study was approved by Institutional Review Board of the Affiliated Hospital of University (2024-Y106).

Considering the sensitive nature of the topic, we systematically practiced reflexivity throughout the study. Firstly, all researchers in this study had professional background in obstetric clinical nursing and maternal mental health research. Before the investigation, they sorted out pre-existing clinical perceptions and preset viewpoints, and deliberately avoided the interference of subjective prejudgments and personal experience on interview guidance and data interpretation. Secondly, all interviews were conducted in a neutral attitude without suggestive or leading questions. Besides, researchers recorded personal emotional responses, assumptions, and any unexpected dynamics throughout the research through a reflexive journal and maintained continuous self-reflection. Thirdly, we held reflexive sessions after each interview to discuss how our professional backgrounds, personal experiences, and preconceptions would influence data collection and analysis.

In this study, all interviews were conducted by a researcher with a background in obstetric clinical nursing within a tertiary hospital setting, an inherent power imbalance (researcher/clinician vs. patient) existed. This power dynamic may have discouraged participants from sharing stigmatized feelings such as regret about a reduction decision or financial motivations for reduction. To mitigate this power dynamic, the researcher explicitly stated that she acted as an independent researcher rather than clinical provider before each interview, and claimed that the interview would not affect participants’ clinical care. Besides, participants were informed that we emphasized voluntary participation, full anonymity and they could pause or skip any question. Moreover, we used semi-structured in-depth interviews and allowed participants to freely express true feelings without guidance or moral judgment, so as to encourage them to express sensitive and stigmatized experiences.

Results

The characteristics of participants

Finally, A total of 12 participants were included in the study. The ages of participants ranged from 26 to 37 years old, with an average age of 31.58. Most women had a monthly household income of over 6000 Yuan (n = 9, 75%), received fetal reduction in the second trimester (n = 8, 66.7%), presented a bachelor degree and above education (n = 8,66.7%). Half of women were multiparous (n = 6,50%) and conceived by assisted reproductive technology (n = 6,50%). More than half women employed (n = 7,58.3%). The characteristics of participants were presented in Table 1.

Table 1.

The demographic data of participants (N = 12).

Participants	Age	Education	Conception	Gravida and Para	Employment status	Monthly household income (Yuan)	Gestational week at fetal reduction	Method used for fetal reduction	Number of fetuses before fetal reduction	Number of fetuses reduced	Health status of remaining fetuses
A1	36	High school or below	Natural conception	G3P2	Unemployment	2001 ~ 4000	14	Radio-frequency ablation	2	1	Healthy
A2	33	Bachelor degree	ART	G1P0	Employment	>8000	17	Potassium chloride injection	2	1	Healthy
A3	28	High school or below	Natural conception	G2P1	Unemployment	6001 ~ 8000	10	Radio-frequency ablation	2	1	Healthy
A4	34	Bachelor degree	Natural conception	G1P0	Unemployment	6001 ~ 8000	19	Potassium chloride injection	2	1	Healthy
A5	28	High school or below	ART	G2P1	Employment	6001 ~ 8000	13	Radio-frequency ablation	3	2	Healthy
A6	37	Bachelor degree	ART	G2P1	Employment	>8000	16	Potassium chloride injection	2	1	Healthy
A7	32	Master degree or above	Natural conception	G1P0	Employment	>8000	12	Radio-frequency ablation	2	1	Healthy
A8	26	Bachelor degree	ART	G2P1	Unemployment	2001 ~ 4000	21	Potassium chloride injection	2	1	Healthy
A9	33	High school or below	Natural conception	G3P2	Unemployment	2001 ~ 4000	15	Potassium chloride injection	2	1	Healthy
A10	29	Bachelor degree	Natural conception	G1P0	Employment	>8000	14	Radio-frequency ablation	2	1	Healthy
A11	32	Bachelor degree	ART	G1P0	Employment	6001 ~ 8000	12	Radio-frequency ablation	3	1	Healthy
A12	31	Bachelor degree	ART	G1P0	Employment	6001 ~ 8000	18	Potassium chloride injection	2	1	Healthy

Themes

Analysis of qualitative data yielded three general themes: (1) complex emotional experiences; (2) multiple coping strategies, and (3) multidimensional needs. The themes and sub-themes were listed in Table 2.

Table 2.

The themes and sub-themes identified from the data analysis.

Themes	Sub-themes
Complex emotional experiences	Unacceptance and regret
	Distress and anxiety
	Ambivalence and fear
	Guilt
	Worrying about the safety of the remaining fetus and oneself
Multiple coping strategies	Hiding inner feelings
	Accepting reality
Seeking help from family	Informational need
	Psychological need
	Accessible healthcare need
	Mental health service need
	Financial support need

Theme 1: Complex emotional experiences

Sub-theme 1: Unacceptance and regret

Women expressed their expectation and happiness because of multiple pregnancies. When be informed to receive fetal reduction, women were unacceptable and some of them regretted their decisions for conceiving through assisted reproductive technology.

“We already have two daughters, we wish to have the third child because the country implements three-child policy. We were very happy when the doctor told us that I was pregnant with twins, because I conceived naturally at an advanced maternal age. We just hoped that I would have a safe delivery, nobody could predict this unfortunate event, we all were in a bad mood.”(A1).

“I regret not trying to conceive naturally. I doubt that the assisted reproductive technology caused genetic abnormalities of the babies.”(A5).

“My husband and I felt so fortunate that we could have twins, because this was the first twins in our family. We excepted to raise two babies, unfortunately, the doctor informed us that I needed to consider fetal reduction because of growth restriction of one child, I didn’t accept this fact and cried when I heard this news.”(A10).

Sub-theme 2: Distress and anxiety

Anxiety was a common psychological emotion experienced by women, some women reported that they consulted doctors repeatedly so as to research for alternative options. On the other hand, women also experienced symptoms of distress because they had no choice but to accept the fetal reduction.

“Those days were absolute torture, I felt so helpless and anxiety but nobody could help me except myself, although I have consulted with many specialists from different hospitals.”(A2).

“Sorry, I couldn’t bring myself to talk about this topic, it feels like tearing open my would and rubbing salt in it, you probably wouldn’t understand.”(in tears)(A3).

“I couldn’t stop crying before going into the operating room until it was over, I don’t want to give up this fetus.”(A5).

Sub-theme 3: Ambivalence and fear

The decision-making of fetal reduction was difficult for women, because they were hard to give up their fetus and couldn’t ignore the unpredictable risks of fetal reduction surgery, which caused the hesitation and ambivalence of decision-making.

“Actually, I’ve been struggling with this decision at home for five weeks, I really didn’t want to lose this baby because I have packed double everything in my hospital bag. I constantly went to the hospital to consult doctors during this time.”(A2).

“This was an extremely difficult decision, I was not only worried about the health of babies but also couldn’t bear to part with my health. I was worried about the prognosis of babies if I refused the fetal reduction, however, I was also afraid of the risks of fetal reduction. I have been struggling with this dilemma for two weeks.”(A4).

“Although the doctors consistently reassured me that the risks of fetal reduction were low-probability events, I still couldn’t stop worrying about it.”(A5).

Sub-theme 4: Guilt

Women reported a strong guilt of reduced fetus. Even some women struggled to achieve sleep, which significantly impacted their daily lives.

“It has been one month. I was still uncomfortable and guilt when watched twin videos on TikTok.”(A9).

“I could still feel my baby’s heartbeat, but this fetus would be sentenced to death when I decide to receive the fetal reduction. Post-fetal reduction surgery, nurse told me that there was only one heartbeat. I cried and felt intense guilt so that I couldn’t sleep at night.”(A11).

Sub-theme 5: Worrying about the safety of the remaining fetus and oneself

Post-foetal reduction, women were concerned at the potential risk of infection regarding fetal reduction, and constantly stressed concerns regarding their health and the safety of the remaining fetus.

“My primary concern was whether the remaining baby or myself might be infected after surgery, because the doctor cautioned about this risk before the surgery.”(A5).

“I felt relatively calm before fetal reduction, but I was afraid of being infected post-foetal reduction although I could understand this risk.”(A12).

“I was concerned about the potential adverse effects on the surviving fetus regarding fetal reduction, therefore, I considered an early cesarean delivery to reduce risks.”(A7).

Multiple coping strategies

Sub-theme 1: Hiding inner feelings

Confronting with the trauma of fetal reduction, some women chose to hide inner feelings rather than seeking help, which may have major effects on their health.

“I refuse to revisit this memory with others, I don’t want to experience distress again because it is like reopening my old wounds.”(A1).

“I don’t want to talk about my feelings with others, because nobody could understand me from the bottom of their heart.”(A11).

Sub-theme 2: Accepting reality

Some women adopted positive proactive approach to accept the reality and attempted to ease psychological burden.

“I don’t want to lose my child, but I think it would be painful for this fetus if I insist on to keep this baby, I have to face reality even if I really hard to accept it.”(A1).

“There was no other way. Some doctors suggested that I could refuse fetal reduction but needed to accept the risk of premature birth. But I couldn’t accept a preterm baby who needed mechanical ventilation, because my first child was a premature baby who had to stay in the neonatal intensive care unit for a long time.”(A2).

“After becoming pregnant with twins, my body was under immense strain. My legs were severely swollen and I felt utterly exhausted. I struggled with the decision to receive the fetal reduction, but it was beyond what my body could endure. Currently, I only have one child, but I have learned to accept what happened.”(A10).

Sub-theme 3: Seeking help from family

Women expressed the positive impact of family support on their experiences. Family support served as a source of comfort and support, which could help women endure the hardships of negative experiences and keep optimistic.

“My husband comforted me and helped sort out my feelings after fetal reduction surgery, which made me feel much better.”(A4).

“I was really struggled to accept it at first. However, my husband was very supportive and had a relaxed attitude. Eventually, I tried to accept it and decided to receive the fetal reduction at 21 weeks.” (A8).

“Family support is crucial. I had a good mood with my family members’ company post-fetal reduction.”(A10).

Multidimensional needs

Sub-theme 1: Informational need

Women pointed out that some professionals were uncaring and irresponsible, this negative experience resulted that their informational and emotional needs were not met when seeking medical services. They stressed the crucial role of informational and psychological support in helping them alleviate psychological stress and integrate into shared decision-making processes.

“The doctor used so much medical jargon that I couldn’t understand. I had no choice but to search information on Rednote, but I didn’t know whose advice was reliable.”(A2).

“We made an appointment for an expert outpatient consultation previously, but the doctor was ambiguous and only advised us to continue waiting at home. We felt so helpless because we didn’t know much about this fetal reduction procedure. What we really need is that the doctor could give us a thorough explanation.”(A7).

Sub-theme 2: Psychological need

Women highlighted a strong need for psychological support from healthcare professionals. They described that some professionals were indifferent, uncaring, and judgmental, this negative interaction intensified their emotional suffering and made them feel unsupported during a traumatic experience.

“Some doctors are very detached and just brush you off with a few words, then tell you what you must do.”(A3).

“Sometimes I feel that some doctors are indifferent and don’t take fetal reduction seriously enough. Some doctors even warned me that I would have to take responsibility myself if I delayed to receive fetal reduction, which made me feel upset.”(A11).

Sub-theme 3: Accessible healthcare need

Women experienced challenges when they accessed healthcare services, such as a long waiting time for medical care and unavailability of resources. Therefore, they emphasized the significance of providing more convenient services to make it more easier for them to acquire needed treatment.

“It would be great if the waiting time for doctors could be shorter. It’s not very convenient for me to take time off from work.”(A6).

“It’s a bit challenge for us to go to the hospital due to a long distance and busy work schedules. An earlier ultrasound would be much more convenient for us.”(A9).

Sub-theme 4: Mental health service need

Some women expressed a demand for how to obtain information about seeking mental health service to manage psychological distress.

“I think it would be more helpful if there was a way to connect with medical professionals at an earlier time when I decided to receive fetal reduction.”(A6).

“I often dreamed of fetus I have lost. I felt profound sadness. I have tried everything I could think to get rid of this feeling, but nothing has worked. I don’t know where to find the professional help that I truly need.”(A3).

Sub-theme 5: Financial support need

The need for financial support was frequently requested by women. Women mentioned the importance of obtaining more financial subsidy and therapy coverage to ease family burden. Additionally, apart from medical reasons, a woman indicated that lack of sufficient financial support was also one factor prompting the decision to receive fetal reduction surgery.

“We have two children, the family financial burden is relatively heavy. I and my husband live in rural area, have a low income, and this surgery is not covered by the rural medical insurance. I have some difficulties to accept the cost of fetal reduction.” (A9).

“The doctor told me that one of the fetuses had the problem of chromosomal abnormalities. We already have one child. Raising three children is an overwhelming financial burden, especially for the cost of daily life and education. I had no choice but to reduce one fetus, raising two children would be much more easier.”(A8).

“We hope the government could provide more annual subsidy for each child. Furthermore, the fetal reduction surgery often increases the risk of premature birth, we also hope that a greater portion of the associated medical costs could be covered by insurance.”(A12).

Discussion

This study highlighted the experiences of Chinese pregnant women who have undergone fetal reduction, which is significant for the development of targeted strategies aimed at improving their mental health. Our results underscored that pregnant women who have undergone fetal reduction reported high level psychological burdens and different unmet needs.

Our study found that pregnant women who have undergone fetal reduction experienced a series of complex emotional experiences, such as unacceptance and regret, distress and anxiety, ambivalence and fear, guilt, worrying about the safety of the remaining fetus and oneself, this finding was consistent with previous results^18,29,30. In our study, we found that there existed some differences in women’s emotional responses at different time points. When decided to receive fetal reduction, due to the lack of knowledge about fetal reduction surgery and being forced to accept the decision of fetal reduction, unacceptance and regret, distress and anxiety, ambivalence and fear were the most common emotional responses experienced by women. If women couldn’t effectively cope with those psychological distress, they would choose to refuse or delay to receive fetal reduction surgery, which may led to miss the optimal time for receiving treatment and increase the risks of adverse pregnancy outcomes²⁵. This suggests that when professionals inform women the decision of the fetal reduction, professionals should assess women’s psychological state, identify high-risk groups and formulate targeted intervention measures based on women’s psychological development trend. Furthermore, professionals should explain the necessity and possible issues of fetal reduction surgery to ease women’s tension, which is helpful to strengthen women’s confidence and compliance about the surgery, improve the success rate of the surgery and reduce perioperative complications. The guilt and worrying about the safety of the remaining fetus and oneself were women’s the most common emotional responses after fetal reduction surgery, this could be explained by being forced to end one fetus’ life and worrying about the potential risks of fetal reduction. It has been proven that those emotional responses were positively more higher risks of anxiety and depression^31,32. Therefore, more health education programs should be conducted to enhance women’s sense of control over the safety of the fetus and themselves, including the status of the retained fetus, key points of postoperative care, abnormal symptoms and response methods. Moreover, previous studies showed group psychological counseling and peer education were helpful for women to reconstruct cognition and actively share emotional experiences^33,34. However, only a limited studies have focused on psychological interventions for pregnant women underwent fetal reduction and the intervention effect is still lack of valid evidence. Above all, our study found that the emotional experiences of women who have undergone fetal reduction surgery were complex and dynamic. This suggests that more longitudinal studies are still needed to clarify the specific incidence of various psychological health problems and explore the trajectory of emotional changes and influencing factors among pregnant women who undergoing fetal reduction.

Our study found that women taken negative and positive coping styles to cope with emotions. Coping style is defined as the personalized strategies and methods to manage the internal and external demands of stressful events³⁵. Preliminary evidence demonstrated that there was a positive association between coping styles and mental health³⁶. The positive coping style could effectively relieve the psychological pressure brought by negative events, reducing the prevalence of mental health problems³⁷. However, individuals who adopted the negative coping style may suffer more emotional distress, enhancing the incidence of mental health³⁸. In this study, some women chose to hide inner feelings or rejected seek help from others, which may be a sign of negative coping style. It is necessary timely to recognize and eliminate women’s negative coping strategies, and strengthen guidance and assist about coping styles related to mental health education for women who have undergone fetal reduction surgery, improving women’s coping strategies and positive attitudes toward fetal reduction. Some women chose positive coping styles such as accepting reality and seeking psychological help-seeking in this study. Women emphasized that family support, especially the partner support, was the most important pillar, could positively impact their mental health and coping styles. Some of them indicated the partners often served as primary caregivers, providing emotional support and suggestions of medical decisions, which played a crucial role in whether women decided to receive fetal reduction surgery and alleviate negative emotions. This finding suggests that creating support networks and promoting open communication and understanding between women and their families is necessary. Additionally, studies focus on women’s help-seeking preferences should be explored and leveraged for early mental health interventions.

The need for knowledgeable and compassionate professionals was viewed by women as an important area of concern in this study. Some women experienced negative interactions that occurred with professionals, complaining that unmet information needs regarding fetal reduction and their concerns were not taken seriously when accessing healthcare services. This could be attributed to the lack of communication skills of professionals. Healthcare providers play a critical role in womens’ decisions-making process of fetal reduction. Previous studies have shown that if professionals who were judgemental and uncaring of women’s accounts of their feelings and experiences, and couldn’t provide an adequate communication, the important information may be missed or misunderstood, resulting in women felt unsupported and made unreliable decisions about therapy process²⁵. On the contrary, perinatal women who had adequate information about fetal reduction and perceived positive interactions with professionals, could promote women’s positive treatment decisions-making^25,39. Therefore, implementing communication skills training programs for professionals, including the technical to provide accessible and reliable information, and relational skills and the ability to demonstrate a culture of closeness, respect, and understanding, could positively impact the well-being of pregnant women underwent fetal reduction.

It was not surprising that another need was identified from our study was hospital convenience services. Henan is a province with a large population and shortage healthcare resources, this leading to the inconvenience of patients’ access to healthcare and adverse healthcare experiences, such as long waiting times, inadequate communication of medical information. Some women also expressed that they had limited access to advanced medical resources, suggesting that there is a need to facilitate the sharing of resources and personnel between advanced hospitals and underserved healthcare institutions. On the other hand, the internet hospitals could be a good choice to address this conflict⁴⁰. Currently, China is engaged in the active promotion fertility-friendly society, based on the rapid development of internet hospitals to improve the medical environment, we recommend that hospitals should constantly optimize processes and apply convenient services based on women’s suggestions.

The women emphasized their desires for a timely mental health services, highlighting that women had limited access to mental health services, as reported in prior studies^41,42. The ACOG recommended that professionals should complete a full assessment of mood and emotional well-being for perinatal women, and provide referral services^43,44. In recent years, the Chinese government has gradually increased emphasis on perinatal women’s mental health, requiring medical institutions to provide mental health screening and professional psychological support for perinatal women⁴⁵. However, only a few tertiary hospitals have established perinatal psychological counseling clinics and the majority of perinatal women self-reported they didn’t receive screen of mental health, resulting in the actual provision of mental health services is still insufficient⁴⁶. In this study, all women reported not receiving screen of mental health during the hospitalization. This finding underscores the need for more science popularization and educational work of perinatal mental health and psychological help-seeking resource, and tailores interventions to improve the promotion of perinatal mental health services in medical institutions.

Our study also identified the financial support as a strong need for pregnant women underwent fetal reduction, particularly for those with a low income or coming from rural areas. Except for medical reasons, one participant mentioned that financial burden served as an additional contributing factor for the decision of fetal reduction. Besides, participants also explicitly expressed an urge need that fetal reduction should be covered by medical insurance. These findings reveal that financial constraints mainly act on two levels: the cost of raising multiple children and inadequate medical insurance. Although China have unveiled the three-child policy⁴⁷, this policy mainly focuses on the number of children rather than providing targeted financial support for families who raising multiple children from a single pregnancy. To alleviate the parenting stress, the Chinese government has provided childcare subsidies since 2025⁴⁸. However, compared with singletons, multiple births usually face with prohibitive costs (e.g., prenatal checkup, neonatal intensive care, and childcare) that could not be adequately covered by existing public subsidies. Although not observed in our study (all reductions were medically indicated), our findings also suggest that financial barriers could hypothetically influence such decisions in the absence of medical indications. Therefore, we suggest that government should implement comprehensive support policies for multiple pregnancies, such as providing additional prenatal tests subsidies and neonatal care coverage, multiple birth care vouchers, childcare priority and cost relief. On the other hand, some developed counties have incorporated fetal reduction into medical insurance coverage. However, fetal reduction surgery covered by medical insurance still lacks a centralized policy in China, resulting in that fetal reduction has not covered by medical insurance in most provinces. Additionally, it is also necessary that policymakers should extend the new rural cooperative medical insurance or the basic medical insurance to cover fetal reduction, set reasonable reimbursement rates and out-of-pocket caps based on regional economic development levels, and provide additional exemptions for low-income rural families.

It is worth noting that more detailed clinical information of participants allows for a more nuanced ethical discussion in this study. Fetal reduction involves complex ethical dilemmas, such as fetal selection, balancing maternal and fetal risks, and upholding principles of beneficence and non-maleficence. Firstly, fetal reduction decision should strictly follow standardized clinical guidelines, priority for reduction should be given to fetuses with structural malformations, abnormal growth trajectories, or unfavorable intrauterine positions rather than non-medical factors. Secondly, informed consent is critical and requires clinicians to fully disclose risks, benefits, outcomes, and alternatives of the chosen reduction method, including its potential impact on the ongoing pregnancy and the possible psychological consequences. Thirdly, healthcare professionals should acknowledge that pregnant women who have undergone fetal reduction may experience a series of psychological emotions, therefore, adequate perioperative psychological interventions should be provided for women.

Strengths and limitations

To our knowledge, this was a study that explained the experiences of pregnant women who have undergone fetal reduction in mainland China, which has not been extensively researched. This study also had some limitations. Firstly, the sample size was small and participants were recruited only from one tertiary hospital in Henan province, which restricted the representation and generalizability of results. More multi-center and large-sample studies should be conducted in the future. Secondly, some participants may hide their inner feelings because of the sensitivity of topic, we attempted to manage this limitation by building trust. Thirdly, owing to the restrict of time and manpower, we were not able to follow up the participants’ feelings to multiple available times. There is a need to conduct a longitudinal study to assess women’s psychological feelings at multiple time points. Finally, our findings only apply to women undergoing selective reduction for medical reasons, however, the psychological experiences of women undergoing selective reduction (due to medical reasons) and multifetal pregnancy reduction (due to fetal number) are fundamentally different. Therefore, future research is needed to compare psychological experiences between these two groups.

Implications

Our study has significant implications for improving well-beings of pregnant women who have undergone fetal reduction. First, the negative psychological experiences of women undergoing fetal reduction constitute a dynamically changing process. However, current routine perinatal care system usually lacks of standardized psychological assessment tools for this vulnerable group. Therefore, we suggest that standardized psychological screening assessment scales and long-term mental health follow-up mechanisms tailored for women undergoing fetal reduction should be established and incorporated into routine perinatal healthcare system, so as to identify women at high risk of mental health. On the other hand, professionals should develop interventions based on further exploring the actual needs of women undergoing fetal reduction and establishing multidisciplinary teams (including obstetricians, nurses, and psychiatrists), which is beneficial to provide effective and continuous psychological support. Moreover, as the most common endorsed help-seeking source of pregnant women underwent fetal reduction, exploring the partner’s role in the decision-making of fetal reduction and women’s psychological emotions coping is a much-needed focus area in the future, which may help for professionals to facilitate the development of the design and delivery of effective intervention strategies. Finally, a few previous studies have reported psychological responses relation to fetal reduction, more studies focused on maternal decision-making process of fetal reduction should be conducted to contribute to the existing knowledge in this area.

Conclusions

Pregnant women who have undergone fetal reduction have various psychological emotions, coping styles, and diversified needs. To improve healthcare providers’ communication and psychological support during women’s decision-making process, we suggest that they should: (1) use open-ended, non-judgmental questions to explore women’s concerns, values, and reasons for considering reduction; (2) provide balanced information about medical indications, procedure details, potential emotional consequences, and alternatives; (3) offer immediate emotional support and diversified health education models. On the other hand, promoting positive coping styles and addressing unmet needs based on multi-dimensional levels (e.g., policymakers, family members, professionals) are also crucial to improve mental health of pregnant women who have undergone fetal reduction.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

All authors contributed to this manuscript. DC: Data curation, Methodology, Supervision, Formal analysis, Writing- original draft. GL: Data curation, Methodology, Supervision, Formal analysis, Writing- original draft. HC: Data curation, Validation, Resources, Writing-review & editing. MF: Investigation, Data curation, Validation, Writing-review & editing. LY: Investigation, Data curation, Validation, Writing-review & editing. SZ: Investigation, Validation, Resources, Writing-review & editing. PZ: Investigation, Validation, Resources, Writing-review & editing. NY and GD: Resources, Visualization, Writing-review & editing. SH: Conceptualization, Investigation, Formal.

Funding

This work was supported by Henan Provincial Medical Science and Technique Program of China (LHGJ20240346).

Data availability

The datasets are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study has been reviewed and approved by the Ethics Committee of The Third Affiliated Hospital of Zhengzhou University(2024-Y106). Informed consent was obtained by all participants.

Competing interests

The authors declare no competing interests.