Are Higher Medical Benefits Associated with Fertility Intentions?-A Survey Study from the Yangtze River Delta Region

Objectives: The aging population problem caused by low fertility intentions has already emerged worldwide and is expected to become more severe in the future. Despite the gradual implementation of welfare policies, there has been no substantial improvement in individuals' intentions to have more children. It has therefore become increasingly important to examine the factors that correlate with individuals' intentions in relation to fertility policy. Methods: The data used in this study were drawn from the 2023 Health Life Satisfaction Survey of the Yangtze River Delta Phase II conducted by Shanghai Jiao Tong University. The primary analysis employed binary logistic regression to examine the association between medical insurance type and fertility intentions, with healthcare accessibility operationalized as a moderating variable. Gender and parity-stratified analyses were conducted as pre-specified exploratory secondary analyses to examine potential heterogeneity in these associations. Results: A total of 8789 citizens were included in the analysis, of whom 18.42 percent reported fertility intentions. Individuals enrolled in the Basic Medical Insurance System for Urban Employees exhibited significantly higher odds of having fertility intentions compared with those enrolled in the Basic Medical Insurance System for Urban and Rural Residents (OR = 1.2154, 95% CI = 1.0626-1.3901, p < 0.001). Moreover, individuals covered by the Basic Medical Insurance System for Urban Employees and residing near secondary hospitals showed significantly higher odds of fertility intentions (OR = 1.6727, 95% CI = 1.1273-2.4821, p < 0.05) than those covered by the Basic Medical Insurance System for Urban and Rural Residents and living near primary hospitals. Conclusions: Medical insurance benefit levels, as well as the quality and accessibility of healthcare resources, are positively associated with individuals' fertility intentions, suggesting that welfare design and service delivery may jointly shape the institutional context for reproductive decision-making.