Introduction

Population size in each country is one of the most important determinants of economic, social, and political planning (1). The three known factors affecting the population size are fertility, mortality, and migration. Among these components, the fertility rate is the most important component affecting population growth, which with multiplier power compared to migration and mortality, can increase the population (2). The total fertility rate (TFR) is the average number of live births a woman would have throughout her life. The population of countries could decrease if TFR<2.1(3). In recent years, declining fertility rates have created global economic and social challenges for most developing countries, including Iran. According to official statistics, the total fertility rate, which was 7 children per woman in the late 1970s, declined to 1.8 in 2011 (4). Thus, the rate of the aging population is increasing and is expected to reach approximately 24% by 2050 (3).

The family planning program by the government in recent years is one of the most important factors in reducing the population rate in Iran. Economic problems, urbanization, unemployment, decreased marriage rate, increased marriage age, changes in family values, and increased level of education are the most important factors that changed the attitudes of families towards fertility and affected the fertility rate (5-7). To deal with the challenging reduction of childbearing and to create a positive attitude towards fertility, policymakers should pay special attention to these factors in their plans and strategies (6).

Attitude is an internal state that affects behaviour and selected values (8). According to the theory of planned behaviour, behaviour is the result of an intended action, and the intended action is also determined by a person's attitude towards the behaviour. According to this theory, attitude is one of the most important factors in the formation of reproductive intention (9). A negative attitude toward childbearing is the most important cause of the reduced fertility rate (10). A positive attitude towards child and childbearing not only leads to early childbearing but also leads to more fertility (11). Several studies have found a positive relationship between attitudes toward childbearing and fertility rates (6, 12-14).  A study conducted by Mousavi found that economic factors have a bigger share in young families’ negative attitudes towards fertility than other factors, such as beliefs, culture, and physical-cognitive identity (6). According to the results obtained by previous studies, women’s higher level of education, the desire for professional promotion and sexual equality, childbearing costs, personal well-being (7, 15), lifestyle changes, a high degree of individualism and poor accountability led to changes in the attitude toward childbearing (6).

Given that the attitude toward childbearing can be influenced by economic, social, and cultural factors, understanding these factors is essential. Although some studies have addressed this topic, there is no consensus on what would be the most effective way to change the attitude toward childbearing and increase fertility. So, this study aimed to find the relationship of some important demographic and socio-economic factors with fertility attitudes in married couples in Rafsanjan, Iran.

Materials and Methods

In this cross-sectional study, the statistical population was urban and rural populations covered by the comprehensive health service centers of Rafsanjan University of Medical Sciences. Inclusion Criteria was as follows: Participants must be married men aged 18 to 70 years or married women aged 15 to 45 years. They must reside in Rafsanjan, either urban or rural, for at least nine months per year. Participants must be Iranian citizens, possessing a national or identity card. Individuals with infertility issues or specific medical conditions that have been advised by a doctor to prevent pregnancy were excluded.

Sampling was done using a multi-stage stratified, cluster, and random sampling method. Stratified sampling was done according to the sections, the place of residence of people (city or village), in a proportional to size manner. This means that the number of samples in the city and village was proportional to the number of urban and rural residents in each section.

Desired sample selection was done using cluster sampling at the level of health centers and with equal cluster sizes. There should be 15 statistical units (including residents) in each cluster. To select people in each cluster at random, a list of people covered by healthcare centers was prepared. The variance of the relevant dependent variable (number of children) was 1.23, which was chosen based on a similar study that provided a suitable estimation of the investigated factors (16). The sample size for this study was calculated at 508 people (at final 512 cases filled out the questionnaire), via this formula:

To determine the accuracy (d) in quantitative variables, the rule of 5 to 10 percent standard deviation (10 percent in this study) was used. To calculate the effect of the plan, it is better to use a pilot study, but based on guesses, for such outcomes, the intra-cluster correlation is not very high and is considered 1.2.

The data was collected using a self-structured questionnaire to find the factors affecting the childbearing attitude, in the Iranian family. Independent variables in this study were gender, educational level, income, gender preference, housing, internet usage, age at marriage, optimal age distance between children, distance from marriage to the birth of the first child, and socio-economic status.

The reliability of the questionnaire was calculated previously by Alidousti et al. (2021) using Cronbach’s alpha coefficient, and α was reported 67.9. Also, construct validity and factor analysis have been used to measure the validity of the research tool. The Bartlett test value reported 735.575, which was significant at the p <0.001, and the coefficient KMO for this analysis was 0.741, which showed the data was appropriate for factor analysis (17).

The first part contained demographic information including age, education, employment, economic status, residence status and age at marriage, home ownership, owning a personal car, etc. The second part was the questions on attitude, which surveyed the participant's attitudes toward childbearing. This section consisted of 25 questions with a five-point Likert scale, which were answered from strongly agree to strongly disagree. Also, the questionnaire considered the attitude toward childbearing, throughout a set of 25 items in the five-point Likert scale, each person had a mean attitude number. For this purpose, there was two types of questions: questions focused on positive and negative attitudes. For each positive questions, the scoring was started from 1, and for the negative ones, from 5.

To collect data a workshop was held in order to explain and familiarize the staff involved in the program, and the related details of the plan, including the sampling method, and completing the questionnaires were given. After identifying the proper sample, the necessary explanations were given to the participants (the couples who were referred to the health center for any reason) regarding the purpose of the study. Then they were asked to complete a short questionnaire.

After collecting data from the target population, quantitative variables were described as either the mean ± standard deviation or mode, and categorical variables as the frequency and percentage. The mean of the attitudes numbers was compared across the baseline characteristics of individuals, using the Independent Sample T-test or one-way ANOVA test. All of the analyses were performed using State V.12. All p-values were two-sided, and when they were < 0.05, considered statistically significan

Results

In this study, 512 participants (men and women) completed the questionnaire. The number of women who completed the questionnaire was three times higher than the number of men. The mean age of all participants was 37.92 ± 8.00 years. Approximately 65% of the participants lived in urban areas and 43.1% were government employees (). Most had academic education between 6-12 years and more than 50% of the study population had an income of fewer than 5 million Tomans, in 2022 (The super unit of the official Iranian currency), which was in balance with their living expenses. More than 80% of cases were home-owners. The overall mean score for childbearing attitude (male and female) was 80.30± 10.32, which shows a moderate attitude toward childbearing, among the population. From it, that’s a third of the total score, which can be interpreted as a positive overall view. Nearly half of the study population had 2 children (47.5%) and also the highest percentage of cases had a girl and a boy (45.8% and 43.4% respectively). Most people wanted to have 2 children (39.1%) and the lowest percentage of people wanted to have 6 children or no children at all (0.3%). Participant felt that the optimal age for marriage was 22.83 ± 3.13 for women and 27.13 ± 3.29 for men (Table 1).

Table 2 presents responses to 25 questions regarding attitudes toward childbearing in Rafsanjan population. More than 50% of people answered totally agree with the first question, which shows that having children is very important in life (Q1). About 83% of the study’s population totally agreed and agreed with the third question, (Having children strengthens the power of responsibility of people). Ten percent of the study population preferred to live without children. About 60% of cases verified, “Life without children is cold and soulless” (Q8). Near 78% of the study`s population answered totally agree, and agree that the presence of a child strengthens the family unit (Q11). About 78 % of the study`s population believed the high cost of living was a preventing factor for childbearing (Q19). Of the participant, 52% totally agreed with this “I am worried about my child's career future” (Q26).

Table 3 compares attitudes toward childbearing based on demographic factors. The results showed that the attitude towards childbearing is higher in rural than in urban areas and this difference was significant (p = 0.028). It was also significant in women compared with men. Attitudes toward childbearing were higher in people with lower living costs. Signifying, the lower cost of living was accompanied by a greater tendency toward childbearing (p = 0.009). People with more daughters showed a positive attitude toward childbearing (r=0.120, p=0.014). Women had a greater positive attitude toward childbearing in comparison to men

(r=0.118, p=0.037). In general, the lower marital age for men (r = 0.224, p<0.001) and women (r = 0.227, p<0.001) was related to a higher attitude toward childbearing (Table 3).

Discussion

Based on our results, the total childbearing attitude score, in the population under study was 80.30± 10.32, and since it gets nearly 75% of the total number, it can be concluded that the Rafsanjan population has a positive attitude toward childbearing. On the other hand, the TFR (of 1.74) in Rafsanjan, a small city in Iran (electronic health record (EHR)) compared to 1.59 (in 2010–2015) in Iran, according to official statistics (18), can also confirm this positive attitude, in this city.

A high proportion (83%) agreed that having children strengthens the power of responsibility of people, showed in couples with family responsibility; childbearing was an important parameter to elevate their responsibility (Q3). One reason may be that Rafsanjan is a less industrialized city, and in a research study, it was approved that industrialization influences fertility attitude, because of women`s social status, in their work and at home. The emergence of new conceptions of women`s role in society and egalitarian attitudes in the family was created through work opportunities. Such attitudes and patterns of husband and wife interaction are associated with smaller family sizes and lower fertility (19).

The attitudes toward childbearing were significantly higher in rural than in urban areas. Urbanization and industrial life have negative effects on childbearing tendencies (20). In developing countries, regional context (urban/rural) is an effective factor in childbearing (21). The result by Araban and her colleagues (2020) was similar to our findings which reported higher childbearing intention in rural than in urban areas (21). Unfortunately, migration of the rural population to industrial cities increased since in rural regions agriculture is the main job, and recently agriculture cannot be responsible for the basic requirements of a new generation in a rural region. Despite migration from the rural region to cities, rural residents have a higher fertility rate and tend to childbearing (22). This can be justified in several ways, firs the urban population spends time elevating education and does not have free time to tend to childbearing (23). The second housing market and high costs of homes in cities changed family behaviors. When couples must live in a small apartment, tend to have a child significantly will be decreased (24). Third, in the rural population, religious status is higher than urban population, and studies showed higher fertility rates among the religious population (25, 26).

Based on the results of the present study, families with lower living costs tended to have more children. According to the research reports, several factors such as rising costs, economic pressure on families, and poor welfare facilities are responsible for decreasing childbearing (6, 27).  In a study by Abbasi Shavazi et al. (2006) the main parameters connected to fertility reduction and demographic changes in Iran were related to socioeconomic factors and political changes (28).

Numerous studies indicated that education, especially in woman, have an important role in the fertility pattern (29). According to the present study results, the empowerment of women in socio-economic parameters, especially increasing the education level, can decrease fertility rates but in the present study, there was no correlation between education level and attitude toward childbearing. In other words, on average all cases in our study (low to high education level) had the same attitude relative to childbearing. Education is one of the main factors in the development of all aspects of life. Now education is linked to fertility planning (30). Recently in 2021, Utomo et al. reported high-level educated women have later pregnancies and often have fewer children than non-educated or low-educated women. Some highly educated women continue childless life (31). Acharya (2010) in a study evaluated the main demographic factors on fertility behaviour in Nepal and concluded that different variables affected the fertility rate, but education was the most important variable. He also reported job status and income ratio were negatively correlated with the fertility rate (32). One of the reasons for this controversy, between our finding and previous studies, may be the fact that highly educated people constituted a small population of the participants (16.5%), besides the overall attitude in the study`s population was positive, while about 78% of this population believed that the presence of a child strengthens the family unit, therefore, this positive attitude might have influenced less by the education level.  The results of the present study showed participants were concerned regarding the high cost of living (78%). It shows economic factors were the important preventing factor for childbearing (Q19). As well, they were worried about the child's career future (Q26). Various studies have been conducted on the impact of economic status on the fertility rate and family planning. Good economic status is another parameter that plays an important role in the fertility rate (33). According to scientific reports, there was a positive correlation between economic status in families and the trend of childbearing (34, 35).

In addition, the results of the present study showed a positive correlation between low living costs and the trend of childbearing. In other words, in families with lower living costs, there was a greater tendency to childbearing, so if the economic pressure reduces, the childbearing tendency will increase. Kim et al. (2005) evaluated the effective parameters for rapidly declining fertility in Korea. They marked key factors for population decline including socioeconomic change, globalization, fluctuations in childbirth costs (income problems), family formation, and the orientation toward gender equality (36). In another study, Weeden (2006) reported higher income in men had a positive relation with fertility. The results of the present study are close to the mentioned studies (37).

Different from our results, Sabermahani et al. 2017 evaluated several factors that affected the fertility rate in Iran, from 1966 to 2013. They reported a decrease in total income and economic status of families not having any relationship with fertility rate. They concluded their reports are different from society’s acceptance, that economic factors and income status are important parameters for fertility rate. In addition, they evaluated the effects of the cash subsidy policy on the fertility rate and showed cash subsidy does not have a significant effect on the fertility rate. They suggested that cash subsidy may be the payment for the costs of current children and not for childbearing planning (5). The difference between the results of the Sabermahani study and the present study regarding the role of economic status in childbearing planning can be explained in two ways: First, a person with good economic status can have more children and provide welfare and quality of life for all of them (38). Second, with high economic status, especially in families with highly educated women, the views on life and special cultural conditions will be changed, and the tendency toward childbearing significantly will be decreased (39).

Our findings showed that attitude to suitable marital age in men and women was significantly and negatively associated with childbearing intention. In recent decades in developed and developing countries, people got married later and the main factor for this delay is the need for education and employment in women (40). The results of several demographic studies recommend that life changes such as an increase in marital age, a decrease in favourable intentions to have a child, and starting increase in the need for a job spatially in women are associated with decreased levels of fertility rate (41, 42). For example, in a study researchers suggested that women’s educational and occupational status may be the main parameter for the delay in marital status and childbearing (43). Regarding gender, women had a more positive attitude toward fertility. This is in line with the other studies which found that having children is of great importance for women, rather than men (44, 45). This was interpreted as the traditional differences in concepts between men and women (45). The positive attitude toward childbearing in the present study participants with more daughters indicates the study population wished to have a son. This finding also can be considered as a cultural category; have more tendency for childbearing among families with more daughters. However, the reason was not asked, but from the cultural characteristics of the studied population, it could easily be interpreted that a wish to have a son was the reason. There was a historical tendency to the child`s sex-determining with the economic, cultural-social, religious, and medical background (46).  

The rapid decline in fertility rates and the disruption of the age pyramid balance could cause irreparable economic and social damage to the country. The population policy perspective should focus on the direct and indirect factors of increasing fertility. This approach will not be achieved except by increasing studies on population axes and determining the components affecting fertility. Couples and their attitudes are the most important factor, which must be considered as the target of intervention, to increase the fertility rate. This aim will not be achieved unless focusing on planning, policy-making, and demographic-economic interventions related to these basic determining factors, which are assessed in this study. It is suggested that in future studies, social factors (more broadly) and the quality-of-life parameters get to be evaluated in relation to couples' attitudes toward childbearing.

The strength of the current study was that several factors related to fertility rate as well as the attitude of the participants were investigated. Another positive point was the large number of participants, which increases the validity of findings and could increase the generalizability of the findings to the society.

One of our limitations was data collection from couples attended public health centers, which may not be representative of the general population.

Conclusion

From this study, it can be concluded that the majority of respondents wanted to have children, but other conditions also must be provided, such as higher economy and income, and future job opportunities for children. Therefore, obliterating documents related to contraceptive methods or advertising alone cannot help to achieve an increase in the fertility rate. In addition, government intervention alone cannot get away from the current problem (fertility rate decline), but public acceptance and couples’ and families' cooperation can play an important role, as those are the main determinants.

Since more details regarding couples’ attitude toward childbearing have been discussed, the results may help to take steps in line with the new demographic policies, with encouraging couples toward childbearing.

Declarations:

Acknowledgments

The Authors would like to thank the Health Department and health centers’ staff, at Rafsanjan University of Medical Sciences, Rafsanjan, Iran, for their collaboration.  We express our deepest appreciation to the couples who participated in our study. 

Conflicts of interest

The authors declared no conflicts of interest.

Funding

There is no funding.

Ethical considerations

This study was done after obtaining the ethical approval of the ethics committee of Rafsanjan University. Also, informed consent was obtained from all participants.The participants’ data was kept confidential.

Authors' contribution

SP designing the study, writing the manuscript. FA analysis of data, drawing the tables, writing the manuscript. PKh designing the study, analysis of data. MKD and ZJ data collection. Shk questionnaire preparation. MV designing the study, writing the manuscript. All authors reviewed the results and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.