Introduction

The drastic decline in fertility rate is taken into account as one of the significant changes throughout the world (1). Over the past 25 years, Iran has also faced a sharp fall in fertility indices. In this respect, the census statistics have shown that the total fertility rate in Iran has reached lower than that of replacement (2). The World Bank estimates that Iran’s population growth rate will reach 1.32%, 1.13%, and
1% during 2015-2019, 2020-2024, and 2025, respectively (3).

Prolongation of this fertility trend can lead to some serious problems, especially regarding economy, such as workforce reduction, which can have negative impacts on investments and consumption. Moreover, the society will confront an aging population in a near future (4) imposing the heavy undertaking costs on the society. From the social aspect, a generation gap and a change in family structure will be created (5).

Therefore, the diminished tendency for having children has also been added to the list of nationwide issues which are in need of solutions (3). The previous studies investigated some of the influential factors, including childbearing motivations (2, 6), religious beliefs (7), pressure exerted by others (8), the spouses’ interactions (9), empowering of women (10) as well as education levels, counseling centers, and other services provided by health care providers (11, 12). 

In depth recognition of childbearing behaviors’ determinants helps the fertility control counsellors to provide the couples with more suitable recommendations and practices. It seems that changes in couples’ fertility behaviors might result from major variations in their attitudes toward childbearing (13). Attitudes are a complex mode of feelings, desires, ideas, or tendencies which can lead to a kind of preparedness to behave based on various experiences (14). Attitudes are also considered as the most important elements of behavior (15). As a result, investigating the attitudes of young people at the onset of their marital life can help with predicting their behavior in the future to some extent. Negative opinions about childbearing can be reformed through correct planning and timely interventions.

While most studies conducted in Iran have focused on identifying different factors affecting failure in childbearing as well as desirable number and gender of children, few studies have shed light on the attitudes of people to having children. In the study performed by Kearny et al. (2016) on 358 women aged 18-30 years, opinions and pressures exerted by key people around them were noted as a remarkable factor contributing to delays in childbearing in Australia (16).

The best time to assess the attitudes, take essential measures, and educate the youngs about the risks of pregnancy in older ages is during their visits at premarital counseling units as their first referral to health centers. Likewise, Tough et al. (2007) investigated the Canadian couples awareness about the prenatal hazards. They found that 70% of these couples knew that aging was directly linked with pregnancy problems, but less than half of them had knowledge about augmented risks of preterm delivery and caesarean section with increased age at the pregnancy (17). Tyden et al. (2006) also notes giving awareness to young women as one of the tasks of health staffs (18).

In other words, fertility within each community is affected by the attitudes and norms governing fertility and childbearing. Therefore, it is necessary to design questionnaires based on the cultural, social, and religious conditions to better identify fertility problems and delineate solutions. It should be noted that questionnaires employed in most studies in this domain are derived from the western ones. With this background in mind, this study aimed to measure the attitudes towards childbearing, using a culture-based questionnaire among men and women on the verge of marriage attending health centers of Mashhad, Iran in 2016.

Materials and Methods

This cross-sectional study was performed on 170 women and 100 men on the verge of marriage, referring to premarital counseling clinics of Mashhad, Iran. The sample size was calculated according to the study performed by Khadivzadeh et al. (2014) on opinions about governmental incentives for childbearing and their relationship with fertility preferences in Mashhad (119). According to their study, the standard deviation of tendency for fertility in couples was 2.88. Therefore, considering α=0.05, d=0.4, σ=2.88, and z_1-α/2=1.96 a total of 200 individuals (100 people for each gender) were calculated using the following equation:

14n=z1-خ±2أ—دƒd2 =1.96*2.880.42 ≈200">

Given the higher availability and cooperation by women, 170 women were recruited to present a more precise study. As a result, the 170 women and 100 men attending premarital counseling clinics of health centers were selected through multistage convenient sampling. Eighteen women and ten men failed to complete the questionnaire and were excluded leading to the final 152 women and 90 men participants.

The inclusion criteria entailed: 1) being Iranian and living in Mashhad or the surrounding villages, 2) getting married for the first time, 3) having reading and writing ability, and 4) expressing willingness to participate in the study. The exclusion criteria encompassed incomplete responses to the questionnaire or refusing to cooperate. The study locations were premarital counseling clinics of Danesh Amooz and Vahdat health centers which were randomly selected out of the four premarital counseling clinics of Mashhad.

After explaining the research objectives to the participants and obtaining their consent, the questionnaires were submitted to them. The data were collected using the demographic questionnaire in addition to a scale based on cultural attitudes towards childbearing (47 items) developed in 2013 by Khadivzadeh et al. (20). It should be noted that the content and face validity were confirmed in another study (21). To score the questionnaire, a five-point Likert scale ranging from totally agree (score 5) to totally disagree (score 1) was used. 

The questionnaire was submitted to
10 members of the nursing, midwifery, reproductive health, and medical education staff at Mashhad University of Medical Sciences. The internal consistency of the questionnaire was calculated using Cronbach’s alpha coefficient, which was obtained as 0.49. Results of the two-weeks test-retest revealed the reliability of this questionnaire to be desirable (r=0.97 and P˂0.001).

All the data was analyzed using the SPSS version 16. In order to compare the results between the two gender groups and to compare the scores of questionnaire items, independent t-test and Mann-Whitney U test were used.
In addition, the correlation between the demographic variables and opinions about childbearing were assessed using Pearson correlation. P-value < 0.05 was considered as significant. 

Results

Our findings demonstrated that the mean and the standard deviation of women’s age was 24.42±5.23 years with a minimum of 15 and maximum of 38 years old. Regarding the place of residence, 98.7% of the female participants lived in urban areas and 1.3% in villages. Moreover, 0.7, 5.9, 21, and 72.4% of the women respondents had elementary school, middle school, high school, and academic education, respectively. In terms of occupation, 20.4% of the female participants were employees, 34.7% were students, 31.3% were housewives, and 13.6% had other jobs. Only 5.3% and 14.1% of these women had mothers and fathers with academic degrees, respectively. Considering the level of income, 77.9% of the participants had adequate income, while 12.5% had income of lower than the adequate, and 9.6% had an income of higher than adequate.

Furthermore, the mean and standard deviation of men’s age was found to be 27.06±4.3 years with a minimum of 19 and maximum of 39 years old. Our results also revealed that 99.1% of the male participants were living in urban areas and 0.9% of them were from villages. It should be noted that 90% of men were holding a high school diploma and higher degrees. In terms of occupation, 30% of the men were employees, while 66.7% of them were self-employed, and 3.3% were university students. Only 4.1% and 12.08% of them had mothers and fathers with academic degrees, respectively. Considering the income, 76.4% of the participants had adequate income, 16.5% had income of lower than adequate, and 7.1% had an income of higher than adequate.

Attitude Difference between Women and Men

The mean score of opinions about childbearing was 164.03±21.62 (out of 235) and 158.86±24.91 in women and men, respectively. The results of independent t-test did not indicate any significant difference in the attitudes to childbearing between the women and men (P=0.11).

According to the results of Mann-Whitney U test, there was a significant difference between the opinions of women and men regarding the items 1, 33, and 38. Men agreed more with item 1 which states that generation continuity is one of the important purposes of human creation (P=0.04). In addition, women approved item 33 (i.e., having a lower number of children can increase the quality of their upbringing) more than men (P=0.002). Considering item 38
(i.e., pregnancy and childbirth reduce the attractiveness of the women’s body and lead to their premature aging), men agreed more in comparison with women (P=0.01). Table 1 demonstrates the mean of attitude score for women and men towards various questionnaire items.

Table 1. Mean and standard deviation for each item of the childbearing attitude questionnaire in women (n=152) and men (n=90)

Childbearing Tendencies

The mean and the standard deviation of the desired number of children in women was 2.32±1.01 with a minimum and maximum of zero and five, respectively. The mentioned number was 2.14±0.9 in men with a minimum of zero and a maximum of three children (Figure 1).

In women’s opinion, the mean of ideal number of daughters was 1.07±0.61 with a minimum of zero and a maximum of two and the mean of ideal number of sons was 1.16±0.69 with a minimum of zero and a maximum of three.

                              Percent of the desired number of children in women

                              Percent of the desired number of children in men

Figure 1. Relative frequency of the desired number of children among the participants

In this respect, 15.5% of women had no desire to have daughters, 61.5% of them had tendency to have one daughter, and 23% wanted to have two daughters. Moreover, 13.5, 60.1, 23, and 3.4% of the women had no predisposition to have sons, had desire to have one son, tended to have two sons, and were willing to have three sons, respectively.

The mean of ideal number of daughters among men was 1.02±0.52 with a minimum and maximum of zero and two, respectively. On the other hand, the mean of desired number of sons in men’s opinion was 1.28±1.4 with a minimum of one and a maximum of three. Furthermore, 24% of men had no desire to have daughters and 76% of them tended to have one daughter. In addition, 18, 56, and 26% of men tended to have one, two, and three sons, respectively.

Relationships between the Attitudes and Demographic Variables

In this study, a significant relationship was observed between the attitudes towards childbearing among women and men on the verge of marriage and the number of their desired children. However, no significant relationship was found between the attitudes with age, birth order, level of education, parental education, level of income, the number of sisters and brothers (Table 2), place of residence (urban or rural areas), and the occupational status.

Table 2. Relationship between attitudes towards childbearing and demographic variables

 r_s=Spearman’s correlation, r_p=Pearson correlation       

Relationship between Ideal Child Number and other Variables

The ideal number of children among women on the verge of marriage had a significant relationship with birth order, number of sisters, as well as the number of sister’s daughters and sons. The ideal number of children among men on the verge of marriage was also correlated with birth order and the number of brother’s sons.

Moreover, our results showed that the ideal number of daughters among women had a relationship with birth order, number of sisters, and number of sister’s daughters and sons. Likewise, the ideal number of sons was significantly correlated with birth order and the number of sisters’ sons.

Furthermore, the ideal number of sons among men was correlated only with the number of brother’s sons; while the ideal number of daughters had no relationship with any of the variables (Table 3).

Table 3. Relationship between ideal number of children in participants’ opinion and other variables

 r_s=Spearman’s correlation  

Discussion