Chain mediation of rumination and negative coping styles in the relationship between fertility stress and psychological distress among Chinese infertile women: a cross-sectional study

Background: Infertility affects approximately 48.5 million couples worldwide, with infertile women experiencing significantly higher rates of psychological distress (27-40%) compared to the general population. While fertility stress has been identified as a primary contributor to psychological distress, the underlying mechanisms remain poorly understood. Objective: This cross-sectional study examined the mediating roles of rumination and negative coping styles in the relationship between fertility stress and psychological distress among Chinese infertile women. We hypothesized that fertility stress would influence psychological distress through three indirect pathways: (1) rumination alone, (2) negative coping styles alone, and (3) a sequential chain from rumination to negative coping styles. Methods: A total of 608 infertile women (mean age 33.5 ± 4.8 years) were recruited from three tertiary hospitals in Heilongjiang Province, China. Participants completed standardized measures including the Fertility Problem Inventory (FPI), Event-Related Rumination Inventory (ERRI), Trait Coping Style Questionnaire (TCSQ), and the Chinese version of the Infertility Distress Scale (IDS). Chain mediation analysis was conducted using the PROCESS macro (Model 6) with 5,000 bootstrap samples. Results: = 0.20 (95% CI [0.16, 0.23]). The direct effect accounted for 45% of this relationship, while indirect effects accounted for 55%. Three significant mediation pathways were identified: through rumination alone (30% of total effect), through negative coping styles alone (20% of total effect), and through the sequential chain from rumination to negative coping styles (5% of total effect). Conclusion: Fertility stress influences psychological distress in infertile women through direct and indirect pathways. A theoretically-derived sequential chain model suggests a potential vulnerability mechanism, though the cross-sectional design does not permit verification of causal temporal ordering. Longitudinal research is needed to confirm the hypothesized sequence. These findings suggest rumination may represent a key intervention target. However, given the cross-sectional design, further longitudinal and intervention research is needed to establish whether rumination-focused approaches effectively reduce psychological distress. Potential clinical implications should be considered preliminary and warrant testing through randomized controlled trials.