DOI: https://doi.org/10.36004/nier.es.2025.2-07
JEL Clasification: J1, J 13, I1, I12, H51
UDC: 316.64:618.177-089.888.11](478)
PhD in sociology, National Institute of Economic Research,
Academy of Economic Studies of Moldova
https://orcid.org/0000-0002-3241-9864
Assisted reproductive technologies (ART) offer an important medical intervention for couples experiencing difficulties conceiving. This study examines the level of social acceptance of ART in Moldova and identifies key socio-demographic, economic, and cultural factors shaping public attitudes toward its use. The analysis is based on data from a quantitative exploratory study conducted between August and September 2025, using a self-administered online questionnaire completed by 375 respondents aged 20 to 50. Acceptance of ART is analysed across three contexts: personal use, use in cases of partner infertility, and willingness to encourage others to access such technologies. The findings indicate that acceptance is generally high but socially differentiated. Education, income, and place of residence are the strongest correlates of acceptance, whereas age, religiosity, and parental status exert more moderate effects. These disparities point to persistent social inequalities in attitudes toward ART and underscore the need for public policies to reduce barriers to access. At the same time, the results suggest that ART are perceived not only as medical interventions but also as instruments of broader reproductive modernisation.
Infertility represents a globally recognised public health issue, affecting 17.5% of the population over their lifetime (WHO, 2023). Other studies indicate that approximately 12% of couples face infertility, with this proportion gradually increasing (Aderaldo et al., 2023). In Moldova, the Generations and Gender Study (2020) reported that 12% of respondents aged 15–49 experienced difficulties conceiving a child in the past 12 months, and 9% reported that they could not or could no longer have children (Rosenberg et al., 2022). Fertility problems can arise at any age; however, delaying childbearing increases the risk of age-related infertility and, consequently, the need for medical assistance to conceive.
Infertility poses psychosocial challenges, affecting individual well-being and family relationships. Some analyses indicate that persistent infertility leads to long-term deterioration in mental health. Women experiencing infertility face a high incidence of anxiety and depression, associated with factors such as treatment costs, age, and the duration of infertility (Hu et al., 2025). Estimates also indicate that couples who remain infertile are more likely to divorce. Moreover, persistent infertility does not confer a “protective” long-term effect on women’s earnings. One interpretation is that, although childbirth reduces women’s earnings, the long-term burden of involuntary childlessness on women’s mental well-being may have a compensatory (negative) impact on their income (Bögl et al., 2024).
In this context, assisted reproductive technologies (ART) have become important solutions for couples facing difficulties conceiving naturally. International evidence shows that the public largely perceives infertility as a treatable medical condition and expresses strong support for universal access to ART, including willingness to contribute financially to publicly funded fertility treatment programmes (Skedgel et al., 2021). However, access to and acceptance of assisted reproductive medical technologies are not determined solely by medical need; they are influenced by socioeconomic, educational, and cultural factors, as well as the structure of public policies on funding infertility treatments.
Thus, despite major advances in fertility treatment that offer many the hope of achieving pregnancy, significant social, economic, and geographic barriers persist in many countries regarding who can access and benefit from these technologies (Imrie et al., 2023). Studies addressing this issue have identified more than one barrier to access to assisted reproductive medical technologies, with the patient’s geographic location being the most frequently reported; others were grouped thematically as psychological, financial, minority group membership, educational level, and age (Mackay et al., 2023). The acceptance and use of ART are not determined solely by medical or biological factors but are profoundly shaped by social determinants—the contextual factors that structure opportunities and constraints for individuals and groups. Understanding these aspects is important, given that assisted reproductive medical technologies have the potential to support fertility recovery in the context of delayed childbearing (Kocourková et al., 2023). Additionally, it is important to know who has access to ART, as this helps identify potential social inequities in their use (Goisis et al., 2020).
The aim of this study is to analyse the level of ART acceptance among the adult population in Moldova and to explore the socio-demographic, cultural, and economic factors associated with this acceptance. By examining acceptance at both the individual level (personal and partner-related use) and the social-normative level (willingness to encourage others), the study seeks to identify socially differentiated patterns of attitudes toward ART and to provide a basis for policy-relevant discussion.
The literature indicates that the use and dissemination of ART in Europe are not determined exclusively by economic development, demographic structure, or the religious composition of the population, but are significantly influenced by the cultural and normative acceptability of these technologies (Präg & Mills, 2017). Access varies widely internationally due to religious, cultural, and political factors that affect the moral status of the embryo (Adamson, 2009). Studies show that societies in which assisted reproductive medical technologies are perceived as morally and socially legitimate exhibit higher utilisation rates, regardless of differences in GDP or total fertility. Identifying the factors that shape public attitudes towards assisted reproductive medical technologies is a crucial starting point for developing strategies to increase public acceptance (Fortin & Abele, 2016).
Delayed childbearing is recognised as one of the main factors contributing to the rising demand for assisted reproductive medical technologies in contemporary societies. At the same time, the increased availability and effectiveness of these technologies may reinforce the tendency to postpone motherhood, creating a bidirectional relationship between reproductive behaviour and the utilisation of assisted reproductive medical technologies (Kocourkova et al., 2014). This dynamic is closely linked to broader transformations in the late demographic transition, characterised by declining fertility, diversification of family forms, and the reconfiguration of life-course trajectories.
Numerous studies indicate that the use of assisted reproductive medical technologies is socially stratified, with children conceived via these technologies more likely to be born to mothers of higher socioeconomic status than those conceived naturally. Women with higher levels of education and income are more likely to access ART, both because of greater financial capacity and because of delayed childbearing, a phenomenon often associated with extended educational and professional trajectories (Imrie et al., 2023; Goisis et al., 2020). Moreover, mothers with university-level education are more likely to give birth after using assisted reproductive medical technologies than those with lower educational attainment (Goisis et al., 2024).
A frequently debated aspect in the literature is that public funding of assisted reproductive medical technologies is associated with higher utilisation rates and more favourable clinical outcomes, including higher clinical pregnancy rates in in vitro fertilisation (IVF). Health systems that include assisted reproductive medical technologies in publicly funded service packages reduce financial barriers and contribute to a more equitable distribution of access (Chambers et al., 2013; Issanov et al., 2022). The literature suggests that countries with mandatory IVF coverage have better perinatal outcomes, attributable to greater use of best IVF practices, such as single-embryo transfers (Fotovati et al., 2024).
Conversely, higher out-of-pocket costs for patients lead to a significant reduction in the use of assisted reproductive medical technologies across all population groups, suggesting that funding policies affect all social categories. Norway provides a relevant example, in which ART are largely accessible through the public healthcare system. Nevertheless, longitudinal studies show that parents conceiving through assisted reproductive medical technologies are predominantly socioeconomically advantaged: older, with higher levels of education and income, and, in most cases, married. Even in a generous system, individuals from lower socioeconomic groups may face financial barriers when seeking additional treatments in the private sector beyond the three cycles covered by the public system (Goisis et al., 2020). These findings underscore that the formal universalism of policies does not entirely eliminate social inequalities in ART use.
ART may have demographic relevance when women utilise them at an earlier age. Moreover, it has been suggested that using these technologies at a younger age increases women’s chances of achieving their reproductive goals and reduces the risk of age-related infertility and assisted reproductive medical technologies failure (Kocourkova et al., 2014). While these technologies are costly from the patient’s perspective, they are not necessarily so from a societal standpoint. Funding mechanisms should aim to maximise efficiency and equity of access while minimising the potential risks associated with multiple births (Chambers et al., 2009).
Existing literature clearly shows that access to and acceptance of ART are shaped by a complex interplay of socioeconomic, cultural, and political factors. Although there is a general understanding of the role of costs, funding systems, and cultural norms at the European level, there remains a clear need for context-specific studies.
In Moldova, both the literature and systematic empirical evidence on public attitudes toward ART remain limited. Against this background, this article provides one of the first empirical analyses of social acceptance of ART in Moldova and introduces a multidimensional approach to acceptance by distinguishing between personal, partner-related, and normative forms of support for assisted reproduction.
The study adopts an exploratory research design, which is particularly appropriate given the limited availability of systematic empirical evidence on public attitudes toward ART in Moldova. Rather than testing causal relationships, the research aims to map patterns of acceptance and to identify key social dimensions along which these attitudes vary.
Empirical data were collected through the survey “Public Perceptions of ART”, conducted between August and September 2025 using a self-administered online questionnaire. Participation was voluntary, and respondents self-selected into the study. The questionnaire was administered to individuals aged 20 to 50 years, yielding a final sample of 375 respondents. All participants provided informed consent, and the study complied with ethical standards in reproductive health research.
Given the non-probability nature of the sample, the analysis relies on descriptive and comparative statistics rather than multivariate regression techniques. This analytical strategy is consistent with the exploratory nature of the study and enables the identification of socially structured patterns of acceptance without implying statistical representativeness or causal inference.
Several limitations should be considered when interpreting the findings of this study. The data derive from a self-administered online survey with voluntary participation, which limits the sample’s representativeness and may underrepresent older, less-educated, and rural populations. The exploratory, cross-sectional design precludes causal inference, and the analysis relies on self-reported attitudes and intentions rather than observed behaviour. In addition, key explanatory mechanisms, such as medical knowledge, perceived risks, stigma, and trust in healthcare institutions, were not directly measured. Finally, the study does not differentiate among specific ART types, which may be subject to varying levels of social acceptance.
Table 1 (Annexe) presents the proportions of respondents willing (a) to use assisted reproductive medical technologies in the event of their own infertility, (b) to use these technologies if infertility concerns their partner, and (c) to encourage a person or couple in their close social network to access assisted reproductive medical technologies. Together, these three indicators capture distinct yet related dimensions of attitudes towards ART and are examined across key socio-demographic characteristics.
Overall, the results indicate relatively high levels of acceptance. A total of 76.8% of respondents report willingness to use ART in a personal infertility scenario, 75.3% in the case of partner infertility, and 80.5% express readiness to encourage others to seek such medical solutions. The remaining respondents express uncertainty or indecision, suggesting either ambivalence towards these technologies or limited information. Acceptance is slightly higher in the normative scenario of encouraging others than in self-referential situations, a pattern commonly associated with perceptions of personal risk, stigma, or financial and emotional costs. At the same time, the high level of acceptance in the partner-related scenario points to strong conjugal solidarity. Taken together, these patterns suggest a broad social consensus regarding the legitimacy of ART as a medical response to infertility.
Gender differences are evident across all three dimensions of acceptance. Women report higher acceptance than men, with the largest gap in the indicator measuring willingness to encourage others (83.5% among women versus 70.2% among men). This difference may reflect women’s greater exposure to reproductive health information and services, as well as more frequent personal or social experiences of infertility, which can foster empathy for medical reproductive solutions. Men’s lower levels of acceptance—particularly in the normative scenario—may be linked to lower engagement with reproductive health issues, gendered norms surrounding masculinity, or greater caution towards medical interventions in reproduction. Overall, women’s greater openness to ART may be understood in the context of the gendered distribution of reproductive responsibility, whereby women more often bear the social and practical burden of managing infertility, even when its causes are male or shared.
A clear social gradient in ART acceptance is evident by place of residence. The predominantly urban municipality of Chisinau shows the highest levels of firm acceptance across all three scenarios—personal use, partner-related use, and encouraging others (83% / 88.5% / 88.8%). This pattern aligns with greater exposure to modern medical practices, higher average levels of education and income, and more liberal social norms prevalent in the capital. Urban areas outside Chisinau show slightly lower acceptance than the capital but remain more favourable than rural areas (79.7% / 78.3% / 82.6%).
By contrast, respondents in rural areas report substantially lower acceptance (65.3% / 61.9% / 66.1%) and higher shares of uncertainty and opposition. These differences point to persistent inequalities in access to specialised medical services and reproductive health information, as well as to lower levels of informational and medical capital. They also reflect the continued influence of more traditional norms surrounding reproduction and medical intervention in family life, including perceptions of ART as an “external” or intrusive intervention in the private sphere of the couple.
Education is among the strongest and most consistent determinants of ART acceptance. The data show a clear, progressive rise in willingness to use or support these technologies with higher educational attainment. Acceptance is lowest among respondents with lower secondary or general education (63.5% / 64.9% / 66.2%), increases among those with vocational or specialised secondary education (75.9% / 74.7% / 78.5%), and peaks among respondents with tertiary education (81.5% / 79.7% / 86.0%). Lower levels of education are thus associated with greater ambivalence and stronger opposition across all scenarios.
These patterns suggest that education plays a central role in shaping attitudes towards ART by enhancing medical literacy, trust in scientific knowledge, and the ability to frame infertility as a medical condition rather than a matter of fate or moral order. Educational attainment is also closely linked to broader forms of cultural capital and higher income, which together reduce both symbolic and practical barriers to the acceptance of biomedical reproductive solutions. Differences by education are particularly pronounced in the normative scenario of encouraging others, where acceptance ranges from 66.2% among respondents with lower education to 86.0% among those with tertiary education. This indicates that education influences not only personal decision-making but also broader normative orientations towards legitimising ART for others. From a sociological perspective, education can thus be understood as a key mechanism in the rationalisation and social legitimation of biomedical intervention in reproduction.
Age is also a relevant dimension shaping attitudes toward ART. Acceptance is highest among younger, reproductively active age groups—those aged 20–29 years (79.4% for personal use; 76.5% for partner-related use; 82.4% for encouraging others) and 30–39 years (80.2%; 79.4%; 82.6%). By contrast, respondents aged 40–50 years report lower levels of acceptance across all scenarios, with the most pronounced decline in the partner-related scenario (72.1%; 62.1%; 77.6%). The sharp drop to 62.1% in this indicator indicates a pronounced age gradient in attitudes toward assisted reproduction.
These patterns indicate that ART acceptance tends to decline with age. Younger respondents may be more exposed to contemporary medical information, more pragmatically oriented toward technological solutions, and more likely to be in life-course phases in which fertility and family planning remain salient. Older cohorts may express greater caution towards reproductive medical interventions, stronger attachment to traditional norms, and heightened concern about age-related medical risks. In addition, ART may be perceived as less relevant to personal family trajectories among respondents aged 40–50, which could contribute to lower acceptance, particularly in partner-related scenarios. The pronounced age difference in the partner-related indicator may also reflect cohort-specific gender norms or differences in perceptions of medical responsibility within couples.
Household monthly income is clearly and consistently associated with acceptance of ART. Willingness to use or support these technologies increases with income, underscoring the role of economic resources in shaping reproductive attitudes. Among respondents with monthly household incomes below 10,000 MDL, acceptance remains relatively low (63.4% for personal use; 63.3% for partner-related use; 69.0% for encouraging others). Acceptance rises substantially in the middle-income categories (10,001–20,000 MDL and 20,001–30,000 MDL), reaching its highest levels among respondents with incomes above 30,001 MDL (approximately 88–89% across all three scenarios).
These findings suggest that ART are perceived not only as a medical intervention but also as an economically conditioned resource, with real or anticipated costs playing a decisive role in shaping acceptance. Income is closely intertwined with other structural factors—such as education, access to medical services, and cultural capital—that may further mediate trust in assisted reproductive medicine and access to reliable information. The strong income gradient observed in the data highlights the persistence of financial barriers and suggests that policy measures, such as subsidies or the inclusion of ART in health insurance schemes, may be important for reducing inequalities in access.
Participation in religious services is associated with meaningful variation in attitudes towards assisted reproductive medical technologies. Acceptance levels differ across categories of religious participation: respondents who attend services once a month or more report lower acceptance (69.5% for personal use; 69.2% for partner-related use; 78.0% for encouraging others), while those who attend only on major religious holidays show moderately higher levels (75.7%; 74.2%; 78.8%). The highest acceptance is observed among respondents who participate occasionally in religious services (81.7%; 80.6%; 83.5%). Individuals who report no participation in religious services occupy an intermediate position (72.8%; 72.8%; 75.7%).
These results indicate that the relationship between religiosity and ART acceptance is nonlinear. Occasional participation in religious practices is associated with the most favourable attitudes, whereas frequent religious practice is linked to greater reticence towards medical intervention in reproduction. This pattern suggests that the intensity of religious participation may reflect the degree of internalisation of traditional religious norms regarding reproduction and biomedical intervention. Frequent attendance likely reflects a more conservative normative orientation, whereas occasional participation may combine cultural or symbolic religious affiliation with more pragmatic or modern attitudes towards medical solutions. Across all categories of religious participation, acceptance is consistently higher in the normative scenario of encouraging others than in self-referential situations, indicating that religious norms appear to constrain personal decision-making more strongly than social endorsement.
By contrast, parental status is associated with only modest differences in attitudes towards ART. Respondents with children report acceptance of 76.3% for personal use, 75.2% for partner-related use, and 81.4% for encouraging others, while respondents without children report comparable levels (78.2%; 77.3%; and 78.3%, respectively). These small differences do not indicate a strong effect of parental status on ART acceptance.
Nevertheless, subtle variations in the response pattern can be observed. Respondents without children are slightly more willing to consider ART for themselves or their partner, possibly reflecting unmet reproductive aspirations or future-oriented family plans. In contrast, respondents with children show somewhat higher levels of willingness to encourage others, which may reflect greater empathy toward infertile couples or an appreciation of the social and personal value of parenthood. Overall, these findings suggest that acceptance of ART functions primarily as a general normative attitude rather than as a response driven by personal parental experience. Parental status thus appears to be a secondary factor, relative to structural resources and cultural norms, in shaping attitudes toward ART.
Intentions to give birth or conceive in the future are also associated with attitudes toward assisted reproductive medical technologies. Respondents who report an intention to conceive (“definitely/probably yes”) express relatively high levels of acceptance across all three scenarios: 77.8% for personal use, 79.0% for partner-related use, and 83.9% for encouraging others. The highest levels of acceptance, however, are observed among respondents who are undecided about future childbearing (“I am not sure”), with 85.8% indicating willingness to use ART themselves, 82.8% in the partner-related scenario, and 85.7% when encouraging others.
Respondents who state that they do not or will no longer wish to have children (“probably no/definitely no”) display acceptance levels similar to those who intend to conceive (77.2%; 76.1%; 83.5%), while those who find it difficult to answer report the lowest levels of acceptance across all scenarios (66.7%; 66.7%; 75.0%). This pattern suggests that firm reproductive intentions—whether positive or negative—are associated with relatively stable and moderate levels of acceptance, whereas uncertainty plays a more decisive role in shaping openness to ART.
Higher acceptance among undecided respondents may reflect a perception of ART as a means of preserving or extending future reproductive options. Individuals who intend to conceive appear to adopt a pragmatic approach to medical interventions that facilitate family planning. At the same time, respondents who do not plan to have children often continue to express normative support for ART, as reflected in their willingness to encourage others, indicating a separation between personal reproductive preferences and broader social acceptance of medical intervention in reproduction. By contrast, difficulty in articulating future reproductive intentions may signal limited information, moral ambivalence, or anxiety regarding potential consequences, which in turn translates into lower acceptance of ART.
This study demonstrates that ART are widely socially accepted in Moldova, and reveals a clear social structure underlying this acceptance. Education, place of residence, income, gender, and religiosity emerge as key factors shaping attitudes towards ART. Overall, the findings support the interpretation that acceptance of these technologies reflects broader processes of the modernisation of reproductive values rather than merely individual reactions to infertility.
The results indicate that factors linked to human capital and modernisation, particularly higher educational attainment, urban residence, and greater economic resources, are positively associated with openness to ART. These associations likely operate through greater medical literacy, trust in scientific knowledge, and improved access to healthcare services. By contrast, more traditional normative contexts, such as rural settings and frequent religious practice, are associated with greater reticence toward biomedical interventions in reproduction, reflecting enduring cultural understandings of the “naturalness” of reproduction and the moral boundaries of medical involvement in family life. Gender differences further highlight the role of social structure in shaping attitudes: women tend to be more favourable toward ART than men, possibly due to greater exposure to reproductive healthcare and a disproportionate responsibility for managing infertility within couples.
A consistent finding across the analysis is the distinction between normative support for ART and personal willingness to use it. Acceptance is systematically higher in scenarios involving others’ encouragement than in self-referential situations, suggesting that perceptions of financial cost, medical risk, and social stigma continue to shape individual decision-making. This pattern indicates a form of generalised normative acceptance accompanied by individual caution, consistent with sociological perspectives that emphasise that moral approval of a technology often precedes its widespread personal adoption.
These findings align with international research showing generally favourable public attitudes toward ART, alongside persistent inequalities in access related to socioeconomic status and cultural context (Fauser et al., 2019; Passet-Wittig et al., 2025). As in other countries, higher-income groups in Moldova display more positive attitudes, underscoring the continued importance of financial resources in shaping both acceptance and potential use. At the same time, international evidence highlights that awareness gaps, financial barriers, and cultural considerations remain significant obstacles to equitable access, even in contexts where public support for assisted reproduction is high (Adamson et al., 2025).
Importantly, the results suggest that positive attitudes toward ART coexist with limited or uneven knowledge about their procedures, costs, and risks. Previous studies indicate that individuals often overestimate their understanding of assisted reproductive medicine, while lacking accurate information about success rates, age limits, and potential health risks (Szalma & Bitó, 2021). The present findings, particularly regarding the roles of religiosity and uncertainty, indicate a similar pattern in Moldova and underscore the importance of targeted public education.
Taken together, the study shows that assisted reproductive medical technologies are perceived as legitimate and effective responses to infertility, but that acceptance is unevenly distributed across social groups. Structural inequalities related to education, income, and place of residence continue to shape how these technologies are valued and understood, indicating that processes of medical modernisation are not uniformly diffused across society.
From a policy perspective, these results highlight the need for a dual approach that combines efforts to improve equitable access to ART with initiatives to increase public knowledge and support informed decision-making. Expanding financial support mechanisms, improving access to specialised services outside major urban centres, and developing evidence-based information programs could help reduce social disparities and strengthen reproductive health outcomes in Moldova.
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| If your health condition would prevent you from having children by natural conception, would you be willing to resort to ART? | If your spouse’s or partner’s health condition would prevent the conception of a child by natural means, would you be willing to resort to ART? | If a person or couple in your close circle were to face infertility, would you encourage them to access ART? | ||
| Total | 76.8 | 75.3 | 80.5 | |
| Sex | Female | 78 | 77.3 | 83.5 |
| Male | 72.6 | 70.3 | 70.2 | |
| Place of residence | Chisinau Municipality | 83 | 88.5 | 88.8 |
| Other cities | 79.7 | 78.3 | 82.6 | |
| Rural areas | 65.3 | 61.9 | 66.1 | |
| Education level | Lower secondary / General | 63.5 | 64.9 | 66.2 |
| Vocational / Specialised secondary | 75.9 | 74.7 | 78.5 | |
| Higher education | 81.5 | 79.7 | 86 | |
| Age | 20-29 years | 79.4 | 76.5 | 82.4 |
| 30-39 years | 80.2 | 79.4 | 82.6 | |
| 40-50 years | 72.1 | 62.1 | 77.6 | |
| Monthly family income | < 10.000 MDL | 63.4 | 63.3 | 69.0 |
| 10.001 - 20.000 MDL | 79.8 | 79.9 | 82.4 | |
| 20.001 - 30.000 MDL | 76.2 | 73.8 | 79.7 | |
| ≥ 30.001 MDL | 89.4 | 87.9 | 89.4 | |
| Religious participation | Once a month or more | 69.5 | 69.2 | 78 |
| Only on major holidays | 75.7 | 74.2 | 78.8 | |
| Occasionally. family events or holidays | 81.7 | 80.6 | 83.5 | |
| Never | 72.8 | 72.8 | 75.7 | |
| Parental status | Yes | 76.3 | 75.2 | 81.4 |
| No | 78.2 | 77.3 | 78.3 | |
| Intention to (further) have/ conceive a child in the future? | Definitely yes / Probably yes | 77.8 | 79.0 | 83.9 |
| Not sure | 85.8 | 82.8 | 85.7 | |
| Probably no / Definitely no | 77.2 | 76.1 | 83.5 | |
| Difficult to answer | 66.7 | 66.7 | 75.0 | |
This article was prepared within the framework of research subprogram 030102: Demographic Transition in the Republic of Moldova: Specificities, Socioeconomic Implications, and the Strengthening of Demographic Resilience (2024–2027).