Abstract
Introduction
Little is known about how differences in parental contributions to childcare impact maternal postpartum psychosocial well-being, particularly in the context of global fertility decline. This study aims to explore associations of parental childcare contributions with maternal postpartum psychosocial disorders among Chinese women.
Methods
Data from the Grandmothers, Mothers and Their Children’s Health study in Huai’an, China were used. Participants were 1991 women who experienced childbirth between 2020 and 2021; follow-up survey was conducted in 2023. Parental childcare contributions were examined by care index. Maternal psychosocial disorders included mental health disorders and poor social health. Logistic regression models were conducted to assess the associations.
Results
93% mothers reported high-contribution childcare; in contrast, only 41% fathers had high-contributions. After mutual adjustment of parental childcare contributions, paternal low-contribution was associated with higher odds of maternal mental health disorders (OR=1.79, 95% CI 1.24 to 2.57) and poor social health (1.76, 1.37 to 2.24). However, these associations were not observed for maternal childcare contribution. For joint patterns of parental childcare contributions, those involving paternal low-contribution childcare were associated with higher odds of maternal psychosocial disorders, regardless of maternal contribution. The associations were consistent across different subpopulations with varied sociodemographic characteristics.
Conclusions
Parents’ contributions in childcare were imbalanced in China. Paternal low-contribution childcare was independently associated with higher odds of maternal postpartum psychosocial disorders, highlighting the potential relevance of paternal childcare contribution to maternal postpartum psychosocial well-being.
Keywords: Mental Health, Public Health, Epidemiology
WHAT IS ALREADY KNOWN ON THIS TOPIC
Postpartum psychosocial health issues have become a serious public health burden with long-term consequences for women’s lifetime health and child development. However, less is known about how parental childcare contributions impact maternal postpartum psychosocial well-being, particularly in the context of global fertility decline.
WHAT THIS STUDY ADDS
This study indicated a significant imbalance in mothers’ and fathers’ contributions to childcare in China. Low paternal childcare involvement was independently associated with higher odds of maternal postpartum psychosocial health disorders, whereas maternal childcare involvement contribution showed no significant association.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study suggests the potential relevance of paternal childcare contribution to maternal postpartum psychosocial well-being and may help inform future family-based support programmes. Further longitudinal and intervention studies are required to confirm these results.
Introduction
Postpartum psychosocial health issues, including mental health disorders (such as depression and anxiety) and poor social health (indicated by loneliness and social isolation), have become a serious public health burden with long-term consequences for women’s lifetime health and child development.1,2 Worldwide, approximately 17.2% of postnatal women are affected by depression3 and over 30% experience loneliness.4 While recognition of ‘social health’ has gained global policy traction,5 with the WHO establishing a Commission on Social Connection6 and nations such as the UK and Japan appointing ministers of loneliness.7,8 However, despite this momentum, targeted research and intervention strategies addressing the psychosocial needs of postnatal women remain lacking.
The fertility rate is continuously dropping in many countries globally9 and the direct or indirect childcare burden may be an important factor affecting women’s fertility intention.10 The importance of maternal childcare quality and quantity on their children’s development has been emphasised11,12; however, less is known about their roles in maternal postpartum psychosocial well-being. On one hand, mothers who engage in high-burden childcare may experience sleep disturbance and reduced social participation, limiting their psychosocial health13; on the other hand, more time spent interacting with children can promote positive family environments,14 which has benefits in maternal mental health. Current population-based research regarding the association between maternal childcare and postpartum mental health also failed to achieve a conclusive result. A family-based study in Germany suggested that mothers with high burden of childcare experienced greater declines in mental health15; in contrast, contrary findings existed which showed no association between maternal childcare involvement and depressive symptoms among populations from the USA.14,16
Gender inequity in childcare also exists and may influence both mothers’ and fathers’ mental health.15 Paternal involvement in childcare is a critical source of support for mothers, linked with a lower risk of maternal mental health disorders.17 However, less is known about its association with maternal social health. Moreover, most previous studies were conducted based on Western cultural settings.18,19 In some Eastern countries, fathers’ roles in childcare were traditionally absent,20 resulting in an extremely unequal distribution of parental involvements in childcare.21 Currently, the introduction of the ‘three-child’ policy in China, together with the rising employment rates in women, has led to a reduced time that mothers can devote to childcare. Against traditional gendered expectations and the changing parental roles in modern life, whether these role conflicts may affect women’s psychosocial health warrants further investigation.
Using data from a female population from China, this study aims to compare the contributions of parents’ involvement in childcare and to assess the independent and joint associations of parental childcare contributions on maternal postpartum psychosocial well-being.
Methods
Study design and participants
This cross-sectional study was conducted based on the Grandmothers, Mothers and Their Children’s Health (GMATCH) cohort study, which is an ongoing prospective study focusing on three generations’ women’s health in Huai’an city, Jiangsu Province, China. The initial participants were pregnant women who gave birth between July 2020 and June 2021 (n=27 923), among whom a follow-up survey was conducted in 2023 by inviting those who gave birth to daughters. Eligible and consenting participants were enrolled, along with additional recruitment of their biological mothers and daughters. A total of 2299 trios of three generations’ women were finally included in the GMATCH cohort. All participants provided informed consent. Details of the study design are available elsewhere.22,23 Baseline characteristics of participants included or not included in the GMATCH cohort were compared in online supplemental table S1. After excluding those who were widowed (n=2); gave birth again during 2021–2023 (n=269); with multiple pregnancies (n=12); diagnosed with anxiety or depression before pregnancy (n=9); and with missing covariates (n=16), 1991 postnatal women were included in the final analysis (online supplemental figure S1).
Assessment of parental childcare contribution
Maternal and paternal childcare contributions specifically to the child born during 2020–2021 were reported by postnatal women through the following questions: (1) How often do you/does the child’s father take care of the child? (Response options: every day/several times a week/once a week/every few weeks/less often); (2) How much time do you/does the child’s father spend looking after the child on each occasion? (Response options: all day and night/all day/all night/several hours at a time/1 hour/less than 1 hour). With the reference of a previous study,24 a care index was constructed by combining answers to the two questions. For the frequency of caring, responses of every day were assigned as 1; several times a week/once a week were assigned as 2; every few weeks/less often were assigned as 3. For the amount of care, responses of all day and/or all night at a time were assigned as 1; several hours at a time were assigned as 2; 1 hour or less than 1 hour were assigned as 3. The two scores were then multiplied, yielding care index values of 1, 2, 3, 4, 6 and 9; higher scores indicated lower childcare contributions. Parental care index was grouped into three categories: low (score 6 or 9; caring once per week for 1 hour at a time; or caring every few weeks for several hours at a time), medium (score 3 or 4; caring several times per week for several hours at a time; or caring every day for about an hour) and high (score 1 or 2; caring all day; several times a week; or caring every day for several hours at a time).
Assessment of maternal postpartum psychosocial disorders
Maternal postpartum psychosocial outcomes, including anxiety, depression, loneliness and social isolation, were assessed through standard questionnaires: the 7-item version of Generalised Anxiety Disorder (GAD-7) scale for anxiety;25 the 10-item version of Centre for Epidemiologic Studies Depression (CESD-10) scale for depression;26 the University of California at LosAngels (UCLA) 3-Item Loneliness Scale for loneliness27 and the Lubben Social Network Scale (LSNS-6) for social isolation.28 A GAD-7 score of ≥10 was considered as anxiety; a CESD-10 score of ≥10 was considered as depression; a Loneliness Scale score of ≥6 was considered as loneliness; a LSNS-6 score of ≤12 was considered as social isolation. Participants with either anxiety or depression were considered to have mental health disorders; those with either loneliness or social isolation were considered to have poor social health.
Assessment of covariates
Covariates assessed in this study were self-reported by postnatal women, including maternal age at childbirth, living residence (urban/rural), marital status (married or living with partner/divorced or separated/never married), educational level (bachelor’s degree or above/vocational diploma/high school or technical secondary school/middle school or below), employment status (enterprise or public institutions/business or service sectors/workers or farmers/housewife or unemployed or others), annual household income (divided into quartiles), paternal educational level (bachelor’s degree or above/vocational diploma/high school or technical secondary school/middle school or below), paternal employment status (enterprise or public institutions/business or service sectors/workers or farmers/unemployed or others), parity (1/2/≥3), care frequency of grandparents, other family members and nanny (every day/more than one time per week/less than one time per week), and maternal anxiety and depression during pregnancy.
Statistical analysis
Baseline characteristics of participants were described as means (SD) or numbers (percentages) for continuous or categorical variables according to parental childcare contributions. Differences of baseline characteristics were compared using analysis of variance and χ2 tests when appropriate.
Linear regression models were first used to assess the associations of parental care contributions with different psychosocial disorder scale scores. Logistic regression models were conducted to examine the independent associations of parental care contributions with maternal mental health disorders and poor social health. The fully adjusted model included maternal age at childbirth, living residence, marital status, maternal educational level, maternal employment status, annual household income, paternal educational level, paternal employment status, parity, maternal anxiety and depression during pregnancy, care frequencies of grandparents, other family members and nanny. Joint associations of parental care contributions with maternal psychosocial disorders were assessed using Firth logistic regression models,29 given the sparse distributions of exposures and outcomes in the joint analysis. Additive and multiplicative interactions of parental care contributions on psychosocial disorders were examined using the delta method.30 Subgroup analyses were conducted stratified by parental sociodemographic characteristics. Sensitivity analyses were conducted to test the robustness of the results by: (1) only including participants who were married or with partner in the analysis; (2) excluding participants with anxiety or depression during pregnancy from the analysis; (3) additionally including maternal marital satisfaction (satisfied/general/dissatisfied) as a covariate in the model; (4) retaining women who have given birth again during 2020/2021–2023 in the study population and (5) assessing the association of parental care contributions with maternal postpartum psychosocial health using modified Poisson regression models.
ORs and 95% CIs were reported in this study. Significance tests were evaluated at the 0.05 level using two-sided tests. All statistical analyses were conducted using SAS (V.9.4) and R software (V.4.3.3).
Patient and public involvement
Patients and the public were not involved in the design or implementation of the study or in the interpretation or writing up of results.
Results
Baseline characteristics of participants
Among the 1991 postnatal women, the mean age (SD) at childbirth was 29.0 (4.5) years. The distribution of childcare contributions across mothers and fathers was extremely imbalanced (figure 1). About 76% mothers had the highest childcare contribution according to the care index, while only 16% fathers met the highest contribution. Only 1% mothers had the lowest childcare contribution, whereas the rate for fathers was 17%. After classifying the care index into three categories of high, medium and low care contribution, 93% mothers reported providing high-contribution childcare, while only 2% reported low-contribution childcare. In contrast, only 41% fathers provided high-contribution childcare, whereas 31% provided low-contribution childcare.
Figure 1. Proportions of maternal and paternal care contributions according to the care index. (a) Maternal and paternal care contributions according to the total score of care index. (b) Maternal and paternal care contributions according to the three classifications of care index.
At 3 years post partum, 12.0% and 32.8% women screened positive for mental health disorders and poor social health, respectively. Baseline characteristics of participants are shown in table 1, online supplemental table S2. Mothers with high childcare contribution were more likely to be partnered, lower educated, unemployed, with less help of caring from grandparents. Women whose corresponding children’s fathers with low childcare contribution were more likely to live in rural areas, unpartnered, lower educated, unemployed, with lower household income, with higher parity, with more help of caring from grandparents and other family members; and the corresponding fathers tended to be less educated and unemployed.
Table 1. Baseline characteristics of postnatal women characterised by paternal childcare contribution.
| Overall (n=1991) | Paternal care contribution | ||||
|---|---|---|---|---|---|
| Low contribution (n=620) | Medium contribution (n=555) | High contribution (n=816) | P value | ||
| Maternal age at childbirth, year (mean (SD)) | 29.0 (4.5) | 28.9 (4.5) | 29.1 (4.2) | 29.0 (4.6) | 0.688 |
| Residence, n (%) | <0.001 | ||||
| Urban | 1465 (73.6) | 412 (66.5) | 425 (76.6) | 628 (77.0) | |
| Rural | 526 (26.4) | 208 (33.5) | 130 (23.4) | 188 (23.0) | |
| Marital status, n (%) | <0.001 | ||||
| Married or living with partner | 1961 (98.5) | 599 (96.6) | 551 (99.3) | 811 (99.4) | |
| Divorced or separated | 24 (1.2) | 18 (2.9) | 3 (0.5) | 3 (0.4) | |
| Never married | 6 (0.3) | 3 (0.5) | 1 (0.2) | 2 (0.2) | |
| Maternal educational level, n (%) | <0.001 | ||||
| Bachelor’s degree or above | 561 (28.2) | 120 (19.4) | 173 (31.2) | 268 (32.8) | |
| Vocational diploma | 429 (21.6) | 118 (19.0) | 125 (22.5) | 186 (22.8) | |
| High school or technical secondary school | 350 (17.6) | 103 (16.6) | 99 (17.8) | 148 (18.1) | |
| Middle school or below | 651 (32.7) | 279 (45.0) | 158 (28.5) | 214 (26.2) | |
| Maternal employment status, n (%) | <0.001 | ||||
| Enterprise or public institutions | 671 (33.7) | 139 (22.4) | 214 (38.6) | 318 (39.0) | |
| Business or service sectors | 337 (16.9) | 102 (16.5) | 76 (13.7) | 159 (19.5) | |
| Workers or farmers | 99 (5.0) | 41 (6.6) | 27 (4.9) | 31 (3.8) | |
| Housewife or unemployed or others | 884 (44.4) | 338 (54.5) | 238 (42.9) | 308 (37.7) | |
| Annual household income, n (%) | <0.001 | ||||
| Quartile 1 (lowest) | 449 (22.6) | 171 (27.6) | 105 (18.9) | 173 (21.2) | |
| Quartile 2 | 512 (25.7) | 165 (26.6) | 144 (25.9) | 203 (24.9) | |
| Quartile 3 | 508 (25.5) | 155 (25.0) | 131 (23.6) | 222 (27.2) | |
| Quartile 4 (highest) | 522 (26.2) | 129 (20.8) | 175 (31.5) | 218 (26.7) | |
| Paternal educational level, n (%) | <0.001 | ||||
| Bachelor’s degree or above | 477 (24.0) | 84 (13.5) | 154 (27.7) | 239 (29.3) | |
| Vocational diploma | 454 (22.8) | 130 (21.0) | 118 (21.3) | 206 (25.2) | |
| High school or technical secondary school | 432 (21.7) | 135 (21.8) | 130 (23.4) | 167 (20.5) | |
| Middle school or below | 628 (31.5) | 271 (43.7) | 153 (27.6) | 204 (25.0) | |
| Paternal employment status, n (%) | <0.001 | ||||
| Enterprise or public institutions | 697 (35.0) | 145 (23.4) | 213 (38.4) | 339 (41.5) | |
| Business or service sectors | 493 (24.8) | 144 (23.2) | 139 (25.0) | 210 (25.7) | |
| Workers or farmers | 438 (22.0) | 184 (29.7) | 115 (20.7) | 139 (17.0) | |
| Unemployed or others | 363 (18.2) | 147 (23.7) | 88 (15.9) | 128 (15.7) | |
| Parity, n (%) | 0.005 | ||||
| 1 | 848 (42.6) | 239 (38.5) | 246 (44.3) | 363 (44.5) | |
| 2 | 1024 (51.4) | 328 (52.9) | 278 (50.1) | 418 (51.2) | |
| ≥3 | 119 (6.0) | 53 (8.5) | 31 (5.6) | 35 (4.3) | |
| Care frequency of grandparents, n (%) | 0.005 | ||||
| Every day | 1204 (60.5) | 516 (63.2) | 338 (60.9) | 350 (56.5) | |
| More than one time per week | 259 (13.0) | 114 (14.0) | 72 (13.0) | 73 (11.8) | |
| Less than one time per week | 528 (26.5) | 186 (22.8) | 145 (26.1) | 197 (31.8) | |
| Care frequency of other family members, n (%) | |||||
| Every day | 121 (6.1) | 66 (8.1) | 21 (3.8) | 34 (5.5) | |
| More than one time per week | 188 (9.4) | 89 (10.9) | 50 (9.0) | 49 (7.9) | |
| Less than one time per week | 1682 (84.5) | 661 (81.0) | 484 (87.2) | 537 (86.6) | |
| Care frequency of nanny, n (%) | 0.981 | ||||
| Every day | 34 (1.7) | 14 (1.7) | 10 (1.8) | 10 (1.6) | |
| More than one time per week | 9 (0.5) | 4 (0.5) | 3 (0.5) | 2 (0.3) | |
| Less than one time per week | 1948 (97.8) | 798 (97.8) | 542 (97.7) | 608 (98.1) | |
The bold font indicates statistical significance.
Independent associations of parental childcare with maternal psychosocial disorders
When mutually adjusted for parental childcare contributions in the model, we observed no significant association between maternal care contribution and postnatal psychosocial disorders (figure 2). In contrast, paternal low care contribution was associated with higher odds of maternal mental health disorders (OR=1.79, 95% CI 1.24 to 2.57) and poor social health (OR=1.76, 95% CI 1.37 to 2.24), compared with high care contribution. The associations between paternal low care contribution and maternal psychosocial disorders were consistent across different subpopulations with varied sociodemographic characteristics (figure 3).
Figure 2. Independent and joint associations of maternal and paternal childcare contributions with maternal psychosocial disorders. (a) Independent and joint associations of maternal and paternal care contributions with maternal mental health disorders. (b) Independent and joint associations of maternal and paternal care contributions with maternal poor social health. The independent associations of maternal and paternal care contributions with maternal psychosocial disorders were assessed using logistic regression models. The joint associations of maternal and paternal care contributions with maternal psychosocial disorders were assessed using Firth logistic regression models. The models were adjusted for maternal age at childbirth, residence, marital status, maternal educational level, maternal employment status, annual household income, paternal educational level, paternal employment status, parity, maternal anxiety and depression during pregnancy, care frequencies of grandparents, other family members and nanny. For models of independent associations of maternal and paternal care contributions, they were mutually adjusted.
Figure 3. Subgroup analyses of the association between paternal childcare contribution and maternal psychosocial disorders. The models were adjusted for maternal age at childbirth, residence, marital status, maternal educational level, maternal employment status, annual household income, paternal educational level, paternal employment status, parity, maternal anxiety and depression during pregnancy, care frequencies of grandparents, other family members, and nanny, and maternal childcare contribution.
These associations were consistently observed when assessing maternal anxiety, depression, loneliness and social isolation, separately (table 2, online supplemental table S3 and S4). We only observed an association between maternal low care contribution with a higher odds of loneliness (OR=2.42, 95% CI 1.07 to 5.48); however, the association was no longer statistically significant after adjustment for multiple comparisons using the Benjamini-Hochberg false discovery rate procedure (online supplemental table S4). In contrast, paternal low care contribution was associated with higher odds of maternal depression (OR=1.86, 95% CI 1.28 to 2.70), loneliness (OR=2.47, 95% CI 1.71 to 3.57) and social isolation (OR=1.50, 95% CI 1.16 to 1.94).
Table 2. Association of maternal and paternal childcare contributions with maternal individual psychosocial disorders.
| Cases (%) | Model 1 | Model 2 | Model 3 | ||||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | OR (95% CI) | P value | ||
| Maternal care contribution | |||||||
| Anxiety | |||||||
| High | 53 (0.03) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 4 (0.04) | 1.57 (0.55 to 4.43) | 0.397 | 1.78 (0.55 to 5.80) | 0.337 | 1.79 (0.55 to 5.80) | 0.335 |
| Low | 2 (0.05) | 1.75 (0.41 to 7.43) | 0.450 | 2.62 (0.49 to 13.91) | 0.258 | 2.16 (0.42 to 11.25) | 0.358 |
| Depression | |||||||
| High | 207 (0.11) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 14 (0.15) | 1.45 (0.81 to 2.61) | 0.214 | 1.40 (0.72 to 2.73) | 0.318 | 1.22 (0.62 to 2.38) | 0.566 |
| Low | 7 (0.17) | 1.64 (0.72 to 3.75) | 0.239 | 1.77 (0.67 to 4.63) | 0.246 | 1.41 (0.54 to 3.70) | 0.485 |
| Loneliness | |||||||
| High | 215 (0.12) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 13 (0.14) | 1.27 (0.70 to 2.33) | 0.431 | 1.39 (0.72 to 2.67) | 0.326 | 1.14 (0.59 to 2.21) | 0.701 |
| Low | 11 (0.27) | 2.80 (1.38 to 5.68) | 0.004 | 3.33 (1.48 to 7.49) | 0.004 | 2.42 (1.07 to 5.48) | 0.034 |
| Social isolation | |||||||
| High | 495 (0.27) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 24 (0.26) | 0.99 (0.61 to 1.59) | 0.957 | 1.22 (0.74 to 2.02) | 0.442 | 1.13 (0.68 to 1.87) | 0.646 |
| Low | 17 (0.41) | 1.95 (1.04 to 3.66) | 0.037 | 1.73 (0.87 to 3.42) | 0.117 | 1.47 (0.74 to 2.92) | 0.276 |
| Paternal care contribution | |||||||
| Anxiety | |||||||
| High | 16 (0.02) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 9 (0.02) | 0.82 (0.36 to 1.88) | 0.645 | 0.65 (0.27 to 1.54) | 0.328 | 0.61 (0.25 to 1.46) | 0.268 |
| Low | 34 (0.05) | 2.90 (1.59 to 5.31) | <0.001 | 2.00 (1.02 to 3.92) | 0.043 | 1.89 (0.96 to 3.72) | 0.067 |
| Depression | |||||||
| High | 66 (0.08) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 55 (0.10) | 1.25 (0.86 to 1.82) | 0.244 | 1.19 (0.80 to 1.78) | 0.387 | 1.17 (0.78 to 1.76) | 0.436 |
| Low | 107 (0.17) | 2.37 (1.71 to 3.29) | <0.001 | 1.92 (1.33 to 2.76) | <0.001 | 1.86 (1.28 to 2.70) | 0.001 |
| Loneliness | |||||||
| High | 58 (0.07) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 58 (0.10) | 1.53 (1.04 to 2.23) | 0.030 | 1.38 (0.93 to 2.07) | 0.113 | 1.36 (0.91 to 2.04) | 0.136 |
| Low | 123 (0.20) | 3.23 (2.32 to 4.51) | <0.001 | 2.60 (1.81 to 3.73) | <0.001 | 2.47 (1.71 to 3.57) | <0.001 |
| Social isolation | |||||||
| High | 177 (0.22) | 1.00 (reference) | 1.00 (reference) | 1.00 (reference) | |||
| Medium | 133 (0.24) | 1.14 (0.88 to 1.47) | 0.324 | 1.07 (0.82 to 1.40) | 0.637 | 1.06 (0.81 to 1.38) | 0.695 |
| Low | 226 (0.36) | 2.07 (1.64 to 2.62) | <0.001 | 1.54 (1.20 to 1.98) | <0.001 | 1.50 (1.16 to 1.94) | 0.002 |
Model 1: Unadjusted.
Model 2: Adjusted for maternal age at childbirth, residence, marital status, maternal educational level, maternal employment status, annual household income, paternal educational level, paternal employment status, parity, maternal anxiety and depression during pregnancy, care frequencies of grandparents, other family members and nanny.
Model 3: Additional mutually adjusted for maternal and paternal care contributions.
Joint associations of parental childcare with maternal psychosocial disorders
Maternal and paternal childcare contribution scores were positively but very weakly correlated (Spearman’s ρ=0.10, p<0.001). When examining joint patterns of parental care contributions (figure 2), we found that regardless of maternal care contribution, patterns involving low paternal care contribution were associated with higher odds of maternal psychosocial disorders. Patterns of ‘maternal high and paternal low care contributions’ and ‘maternal medium/low and paternal low care contributions’ were associated with 1.73-fold (95% CI 1.20 to 2.51) and 2.88-fold (95% CI 1.43 to 5.57) increased odds of mental health disorders, and 1.83-fold (95% CI 1.43 to 2.35) and 1.78-fold (95% CI to 1.04 to 3.00) increased odds of poor social health, respectively, compared with the pattern of ‘maternal high and paternal high care contributions’. Similar results were observed for maternal anxiety, depression, loneliness and social isolation (online supplemental figure S2 and S3). We observed no additive or multiplicative interactions between maternal and paternal care contributions on maternal psychosocial disorders (online supplemental table S5). Sensitivity analyses presented similar results to the main findings (online supplemental table S6).
Discussion
This cross-sectional study found that mothers’ and fathers’ contributions in childcare were disproportionately distributed in China, with over three-quarters of mothers but only one-quarter of fathers providing high-contribution childcare. Paternal low childcare contribution, even after adjustment for maternal childcare contribution, was associated with higher odds of maternal postpartum psychosocial disorders; while such association was not observed for maternal childcare contribution. When assessing the joint patterns of parental childcare contributions, regardless of maternal childcare contribution, patterns involving low paternal care contribution were associated with higher odds of maternal psychosocial disorders. These associations were consistently observed in subpopulations with different socioeconomic backgrounds.
The observed unequal contribution of mothers and fathers in childcare in this study has also been reported in previous studies based on the Chinese population.20,21,31,32 For example, a nationwide cohort study based on the China Health and Nutrition Survey suggested that mothers spent about twice as many hours with children as their husbands; and mothers’ childcare time increased over time from 2004 to 2011 whereas no significant change was observed in fathers.31 Another study combining two data sources from the Chinese General Social Survey and the China Education Panel Survey also revealed significant gender inequality among caregiving activities.21 In contrast, evidence from some Western countries showed that the gender differences in childcare were relatively smaller, although mothers still devote more time to childcare than fathers.33 One of the possible reasons may be the influence of the Confucian culture, under which men are expected to engage in work while women are responsible for taking care of families.34 The observed differences in educational levels, employment status, and household income in various childcare contribution groups can also support this hypothesis. Other possible reasons may include the involvement of grandparents, the employment rate of mothers and the time of parental leave.20,35
Maternal childcare contribution was not associated with postpartum psychosocial disorders in our study. Similar results were also reported according to a US birth cohort study, revealing that the childcare instability was not associated with maternal depressive symptoms.16 Another study using data from the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development also found no association between maternal childcare quality and postpartum depression.14 In the current study, this result may partly be explained by the high proportion (76%) of women providing high contribution of childcare, leaving too little variation to detect associations. Besides, women providing lower contributions of childcare tended to be more highly educated or employed. The engagement in professional activities and related social engagement may attenuate the risks of psychosocial disorders in these women.34
Regardless of maternal childcare contribution, paternal low care contribution was consistently associated with higher odds of maternal psychosocial disorders both in independent and joint analyses. Such results were consistently reported in previous studies based on populations from both Western and Eastern countries.34,36–39 For example, a nationwide survey in England found that paternal support during the postnatal period was important for ensuring maternal emotional health.39 Another study based on populations from Japan suggested that fathers’ childcare behaviours were associated with less maternal psychological distress.38 These beneficial effects of paternal involvement in childcare can be explained by increased maternal perception of instrumental support and sense of security, therefore alleviating maternal risks of psychosocial disorders.34 In addition, paternal childcare contribution was associated with socioeconomic status, as those providing higher levels of childcare were more likely to be higher educated, employed and in higher income households. Spousal socioeconomic status also emerged as an important factor influencing maternal psychosocial well-being.
Implications
The different roles of parental childcare contribution in maternal postpartum psychosocial well-being observed in this study have implications for health policy and practice. This study shows a significant imbalance in the time that parents spend in childcare, highlighting the need to address this issue through more comprehensive family or labour policies in China, such as extending paternal leave, promoting flexible work and affordable childcare services.35,40 The associations of mothers’ and fathers’ involvement in childcare with maternal postpartum psychosocial disorders also differed, with the association being driven primarily by paternal, rather than maternal, childcare contribution. This suggests the potential relevance of paternal childcare contribution to maternal postpartum psychosocial well-being and may help inform future family-based support programmes. Further longitudinal and intervention studies are required to confirm these results.
Strength and limitations
The strengths of this study include the comparison of maternal and paternal contributions in childcare and the consideration of multiple socioeconomic factors. Several limitations should be acknowledged. First, both maternal and paternal childcare contributions were based on mothers’ reports and may therefore be vulnerable to reporting bias, particularly because objective measures of paternal childcare were unavailable. In addition, there is currently no validated instrument for assessing parental childcare contributions. Therefore, the care index adapted from the ALSWH cohort was intended to capture relative childcare intensity by combining reported frequency and duration,24 rather than to serve as a formally validated scale. Second, the cross-sectional study design may limit the inference of causal relationships and raise the possibility of reverse causation, as maternal psychosocial status may influence mothers’ perceptions and reporting of fathers’ childcare involvement. Third, the relatively small sample size and highly skewed distribution of maternal childcare contribution, with 93% of mothers reporting high contribution, limited exposure variability and reduced the statistical power to detect associations with maternal psychosocial outcomes. Thus, the null findings for maternal contribution should be interpreted cautiously. Fourth, although we considered multiple confounders, residual confounding cannot be excluded, such as paternal mental health. We used the E-value methodology to assess the robustness of the observed associations of unmeasured confounding, which indicated that an unmeasured confounder would need to be associated with both low paternal childcare contribution and the corresponding maternal outcome by risk ratios of at least 2.98 for mental health disorder and 1.98 for poor social health, above and beyond the measured covariates, to fully explain away the observed associations. Fifth, selection bias would exist as the follow-up was restricted to women who had given birth to a daughter due to the cohort study design. Baseline comparisons showed differences in several socioeconomic and reproductive factors between included and non-included women. Therefore, the analytic sample may not fully represent the original population of postpartum women, which may limit the generalisability of our findings. Finally, this study may be culturally specific to Chinese people, as fathers tend to be more frequently involved in family activities and childcare in Western countries. Future studies are warranted to compare the results across different social backgrounds.
Conclusions
This study indicated a significant imbalance in mothers’ and fathers’ contributions to childcare. Low paternal childcare involvement was independently associated with higher odds of maternal postpartum psychosocial health disorders, whereas maternal childcare contribution showed no significant association. These findings highlight the potential relevance of paternal childcare contribution to maternal postpartum psychosocial well-being.
Supplementary material
Acknowledgements
We thank all women and their babies who participated in the study, and all the members and staff in Huai’an Maternal and Child Health Care Hospital Affiliated to Yangzhou University who contributed to the data collection of this study
Footnotes
Funding: XX was supported by China Medical Board (21-416), Natural Science Foundation of China (72474197) and Zhejiang University Fundamental Research Fund for the Central Universities (Grant no–NA). WD was supported by Huai’an Science and Technology Program (HAB2024039). XZ was supported by Key Medical Program of Jiangsu Health Commission (ZD2021044).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study has ethical approval from the Ethics Committee of Huai’an Maternal and Child Health Care Hospital Affiliated to Yangzhou University (Approval Number: 2019056 and 2023030). Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available on reasonable request.
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Associated Data
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Supplementary Materials
Data Availability Statement
Data are available on reasonable request.