Introduction

One of the serious challenges that societies are facing around the world is the desire of couples to have fewer children and delay fertility (1). The world fertility rate has decreased from more than five children per woman in 1960 to 2.5 children in 2013 (2). In the recent years, fertility behavior in Iran has also changed, and many Iranian families prefer to have fewer children than their parents now. According to statistics, 24 out of 31 provinces in Iran have fertility lower than the replacement rate (1.7 instead of 2.1 births per woman) (3). Iran currently has the lowest fertility rate in the Middle East (4). 

Studies have shown different factors affecting the fertility rate in Iran. Postponing marriage and tendency to have a single child are the main factors that reduce the fertility rate in Iran (5-7). Having a child can be considered a social fullfilment, which, has attitudinal, semantic and inter-subjective aspects in addition to the behavioral dimension. In fact, people's fertility attitudes are considered as one of the most important determinants of fertility behavior. Therefore, fertility behaviors are largely a reflection of childbearing attitudes (8). The combination of knowledge, feelings, and readiness to act toward a certain thing is called a person's attitude toward that thing (9). Fertility attitude is a person's internal desire and readiness to have a child from a social and biological point of view among families. In this regard, more effective interventions by knowing the factors must be developed to form a positive attitude toward fertility and childbearing (10). Studies emphasized the effectiveness of fertility counseling in improving the quality of the population (3, 4 and 6). Socio-economic factors including women's participation in economic issues, increasing the level of education and providing more health services the women attitude toward childbearing (11-12), empowering women in personal, family social levels, as well as religious beliefs have been proposed as the main factors affecting fertility in Iran (6). Attitude toward fertility and childbearing is a critical aspect of reproductive health that can significantly influence a person's decision to have children and reproductive process (3). It is influenced by sociocultural, economic, and psychological factors and can affect, fertility rate, childbearing time, reproductive health outcomes, and family dynamics (4). Understanding the factors affecting attitudes toward fertility and childbearing is important for developing interventions in reproductive health (5).

Premarital counseling is very important in preventing family problems and creating a healthy and stable family (13). One of the main aspects of this counseling is dealing with issues related to fertility and having children (14). Premarital counseling can help couples make informed decisions and plan for their future family by providing accurate and comprehensive information about their fertility and childbearing (7). A key goal of this counseling is to explain the various factors affecting their fertility, such as age, health, lifestyle, and environmental conditions. By understanding these factors, couples can optimize their fertility and increase their chances, when they are ready to start a family (7). Also, premarital fertility and childbearing counseling can help couples to discuss and address any fears or concerns about parenthood (14).

Knowledge about the influencing factors of childbearing can be used to develop more effective premarital counseling programs that promote positive attitudes toward these issues and improve reproductive health outcomes (1). Educational interventions and the implementation of family planning programs started in the early 1980s in Iran and caused a rapid decline in the fertility rate after 1985. Now that the population growth rate is lower than the replacement limit, the need for education to increase the fertility rate becomes more and more apparent. Considering that throughout history, the decision to have children has been left to couples, especially women (5).

There are contradictory results on the effectiveness of premarital counseling on fertility and childbearing issues, particularly women's attitude. Khadivzadeh et al (2021) and Mazloumi et al. (2016) (16) showed that fertility and childbearing counseling promoted the desire to have a child, while Haerimehrizi et al. (2017) and Chan et al. (2014) pointed out  no effect of counseling on the desire for fertility (18). Considering the decrease in the fertility rate in Iran along with economic, social, cultural and health changes, further research on women's attitude toward childbearing and studying the role of counseling in changing the attitude of women is essntial. Therefore, conducting research that measures the effectiveness of counseling on women's attitudes toward fertility and childbearing is important. Since attitudes can guide behavior, knowledge about people's attitudes allows healthcare providers to predict the health behaviors. Based on this, the present study was conducted to determinine the effect of midwife’s premarital counseling on women’s attitude towards fertility and childbearing.

Materials and Methods

This Quasi-experimental study with one-group pretest-posttest design was conducted in Ardabil from March to May 2023. The study population was women who referred to the premarital counseling center. The sample size was calculated approximately 111 women using the following formula; based on an average attitude score of 24.66±5.54 from previous studies (19), and considering the effect size of 1.5, power of 80%, and alpha of 5%.

The inclusion criteria were women with age of 18-45 years old, getting married for the first time and being able to read and write in Farsi. The exclusion criteria were incomplete filing of the questionnaire and unwillingness to continue the study. Sampling was performed using a convenience sampling method.

The data collection tool was a two-part questionnaire including demographic information (age, education, job, income, childbearing tendency, desire to have children, intensity of desire to have a child, number of children, child gender preference) and the Attitudes to Fertility and Childbearing Scale (AFCS). The AFCS questionnaire is a useful and standardized tool for understanding people's attitudes toward fertility and childbearing (20). It is a self-report tool with 20 questions, which are arranged in the form of a five-point Likert scale (completely agree to completely disagree). The score range of this tool is (20-100). This tool has three components as follows: a) the first field, “the importance of children for the future”, includes six questions (1-6). The range of scores in this area was 6-30. b) The second field, “Childbearing as a hindrance at present”: contains 10 questions (9-18) and their scores range was 10-50. c) The third field “social identity”: contains 4 questions (7-8-19-20). The range of scores in this area was 4-20. Söderberg et al (2013) have confirmed the validity and reliability of the tool (20). This instrument has also been psychometrically evaluated in Iran by Kurd Zangeneh et al (2019) the validity of the instrument in the Iranian version was confirmed by the content validity technique and its reliability was also reported using Cronbach's alpha 0.88 (21). In the present study, validity of the instrument was confirmed by the content validity technique and the reliability of the tool was obtained at 0.87 by Cronbach alpha.

To collect data, a written letter of introduction was presented to the authorities of the premarital counseling center, and then the researcher started sampling. Ardabil has only one premarital counseling center. Thus, the researcher referred to the premarital counseling center every day for six weeks. At first, the study objectives and methods were explained for participants and written informed consent was obtained. They were assured that their information would remain confidential. Then, women were asked to complete the demographic questionnaire as well as the Attitudes to Fertility and Childbearing Scale (AFCS). Thereafter, an experienced counselor offered counselling to the participants using face-to-face approach with questions and answers to discuss different aspects of fertility and childbearing according to the content that met the Ministry of Health recomendation (Table 1. In this study, a trained midwife counselor did counselling for all participants.

The duration of the sessions was 90 minutes. The researcher succeeded in achieving her estimated sample in 18 sessions.The number of participants in each session was varied between five and eight.

Two weeks after counseling,  participants were agin asked to fill AFCS.

Data were analyzed using SPSS software version 15. Demographic data was analyzed descriptively (frequency, mean, and standard deviation). The Kolmogorov–Smirnov statistic test was used to check the normality of data distribution. Chi-square was used for categorical variables. For comparison befor and after intervention, paired t-test was used. The P < 0.05 was considered significant.

Results

The study was conducted with 111 women referred to the premarital counseling center, and all participants completed the study protocol. The demographic data of the participants is shown in Table 2. The average age of women was 23.09±7.12 and their future husbands’ was 28.18±6.12 years.

The score of the AFCS questionnaire before and after childbearing marriage counseling was compared by T-test based on Table 3. The differences of 16 statements out of 20 were significant. This means that childbearing counseling changed the participant's attitude.

According to Table 4, the effect of childbearing counseling was significant in “The Importance of children for the future” and “Childbearing as a hindrance at present” domains, while in the domain of “Social Identity” was not significant.

In Table 5, the childbearing tendency consists of desire to have children, the intensity of desire to have a child, and the number of children scores were compared before and after childbearing marriage counseling. Childbearing marriage counseling significantly increased intensity of desire to have a child. Despite a change in the desire to have children among 5 participants, the effect of childbearing marriage counseling on desire to have children was not significant. Gender preference of the child in 28 (25.2%) participants were girl, 28 (25.2%) were boy, and 55(49.5%) participants reported that the gender of the child was not different.

There was no correlation between the scores of the AFCS questionnaire with demographic data.

Discussion

The results of this study indicate that premarital counseling towards fertility and childbearing improved women’s attitudes in the domains of 'importance of fertility for the future' and 'childbearing as a hindrance at present'. According to Khadivzadeh et al (2021) study, counseling has an important place in education in promoting awareness and attitude toward healthy fertility (15). Khodakarmi et al. (2020) (19), and Mazloumi et al. (2016) (16) showed a positive relationship between the desire to have a child after similar counseling with our study which was in line with our results. For instance,, Haerimehrizi et al. (2017) reported no effect of counseling on fertility desire, citing economic issues as the primary reason for reluctance to have children (17). Even, Chan et al. (2014) reported a negative effect of counseling on the desire for fertility, despite their awareness of infertility problems (18). The desire of human beings to have a child is inherent. In the same way, the fertility of couples is usually not to the extent of their biological ability. There is a huge difference in terms of the size of the family, between developing and developed countries. Various cultural, social, economic factors and common norms in the society play an effective role in different societies in different ways (22). Therefore, childbearing education may have different results in different societies.

According to the results, counseling did not change attitudes toward fertility and childbearing scores in the “Social Identity” domain. This result is in accordance with Dorahaki et al (2023), who declared that “women don't summarize their identity as in the past in the family, the motherhood role and having children” (23), so that even counseling cannot change it. In our study intensity of desire to have a child was significantly increased after counseling. Nafisi et al. (2017) observed a positive relationship between the intensity of the desire to have children and the desired number of children (24), and this attitude was seen more among husbands than among women. Also, the results of Khairollahi et al. (2017) indicated a significant relationship between the desired numbers of children in the future after the intervention (25). However, Mahmoudian et al. (2014) in the survey research reported a negative relationship in the number of desired children in the future (26), which was inconsistent with our results. Islamlou et al. (2014) reported the lack of positive intervention in fertility promotion policies in Iran (27). According to the results of Moodi et al. (2013) no significant relationship was observed between the awareness score and the couple's attitude after the intervention (23) the low quality of the classes that authors mentioned in the limitations of the study might be the reason for this. However, Rahmati et al. (2020) observed a positive relationship between the awareness level and attitude toward fertility after the intervention (28). Abulfotouh et al. (2013) stated that couples did not show any desire for fertility after the intervention (29). Ozjan and Topatnep (2023) observed a positive relationship between the levels of attitude toward fertility after the intervention (30), which was consistent with the results of the present study. The variable results of these consultations can be caused by the difference in the content of the class and shows that these programs need to be fundamentally modified and the most important principle in improving the quality of these classes is the selection of comprehensive educational content based on educational needs assessment and considering  the couples problems before marriage.

Participants in this study did not declare any gender preference, but practically although a societal preference for male children was observed (26, 31).

One of the limitations of the study was the reluctance of some women to fill out the questionnaire due to the fear of information disclosure. To solve this problem, participants were assured that the information would remain confidential. Since this study was conducted in the marriage counseling center of Ardabil, therefore, caution should be exercised in generalizing the findings to other settings.

Conclusion

Participating in premarital counseling sessions improved women's attitudes toward fertility and childbearing. Counseling in the field by midwives affects the awareness of couples about fertility and helps the population growth and the health of future generations. Considering the effectiveness of these counselling approach in changing women's attitudes, it is suggested to increase the frequency and hours of its sessions.

Declarations

Acknowledgements

The present study was the master’s thesis of a midwifery student. We hereby appreciate all the people involved in this study. 

Conflicts of interest

The authors declared no conflict of interest.

Ethical approval

At the beginning of the study, the objectives of the study were explained to the participants and an informed consent form was obtained. Participants were assured that there is no obligation to participate in the study. Also, they were informed that the questionnaires are anonymous, the information related to the questionnaires are confidential and the results will be published only as a group.

Authors’ contribution

SSh, MM, AG, and PA participated in the design of the study, analysis, and draft of the manuscript. AG carried out the data collection; MM interpreted the data; SSh drafted the manuscript. All authors read and approved the final manuscript.