Background <p>In Southern Africa, Lesotho reports the highest estimated rates of depression, with women disproportionately affected. Cultural, societal, familial, and spousal pressure on women to become pregnant is a substantial public health concern linked with an increased risk of depression. However, there is limited evidence on the impact of pressure to become pregnant on depression in Lesotho using propensity score matching (PSM) analysis. Therefore, this study employed PSM to estimate the effect of pressure to become pregnant on depression among married women in Lesotho.</p> Method <p>A total of 1600 unweighted married women were included in the analysis using the recent 2023/24 Lesotho Demography and Health Survey (LDHS). The analysis used a propensity score matching analysis (PSM) with a logit model using the psmatch2 package in Stata to estimate the average treatment effect on the population (ATE), the treated (ATT), and the untreated (ATU) for the effect of pressure to become pregnant on depression. Kernel matching with a caliper width of 0.01 was used to match individuals in the two groups. The quality of the matches was evaluated statistically and graphically. Sensitivity analysis was performed to test the robustness of the PSM results, using the Mantel-Haenszel test statistics.</p> Result <p>The overall prevalence of depression among married women in Lesotho was 6.83% (95% CI: 5.68%, 8.20%). The PSM analysis showed that experiencing pressure to become pregnant increased the likelihood of depression by 6.3% (ATT = 0.063, 95% CI: 0.0138, 0.1122). The average treatment effect (ATE = 0.058, 95% CI: 0.0443, 0.0721) indicated that pressure to become pregnant significantly increased the risk of depression in the overall population by 5.8%. The average treatment effect for untreated (ATU = 0.0515) underscored that women who had not experienced pressure to become pregnant would have a 5.15% higher risk of developing depression if they had been exposed. Overall, these findings highlight that pressure to become pregnant significantly increases the risk of depression.</p> Conclusion and recommendation <p>This evaluation found that spouse or family pressure to become pregnant significantly increases the risk of depression. These findings underscore pregnancy pressure, pressing attention to reproductive coercion and community-based initiatives to mitigate its mental health consequences. Thus, policymakers and programmers should strengthen reproductive autonomy protection in mental health policies. Additionally, health care providers should screen for reproductive coercion during routine antenatal visits and offer counseling services to decrease the risk of depression. Community-based education campaigns and peer support groups involving men and families are also recommended to help reduce fertility-related pressures.</p>