Fertility and mental health: The psychological toll of childbearing.

Fertility rates have declined globally, raising concerns about demographic aging and long-term economic sustainability. In response, many governments have introduced pronatalist policies to encourage childbearing. However, these efforts often overlook the psychological toll of raising children, especially in countries with limited institutional support for families. This study estimates the effect of having more than two children on maternal mental health using data from the IPUMS National Health Interview Survey (2000-2009). To address endogeneity in fertility decisions, we use the sex composition of the first two children as an instrument. We find that having more than two children increases maternal psychological distress by 0.69 standard deviations in the full sample and by 0.61 standard deviations among married mothers. Exploring heterogeneity, we find that effects are similar across income groups, while variation by maternal education is less consistent, with larger effects observed among married mothers with a high school education.