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Abstract

Background:

Over the past three decades, Iran’s fertility rate has declined sharply from 6.5 to 1.7, posing a critical demographic and public health challenge, a global trend that highlights the need to tackle multifaceted influences on childbearing intentions, including economic, social, emotional, and attitudinal factors.

This study examined the factors influencing childbearing intentions among women.

Design and Methods:

This cross-sectional study surveyed 450 reproductive-age women in Tabriz, Iran. Data were collected using self-administered questionnaires to assess sociodemographic/obstetric characteristics, attitudes toward fertility/childbearing, subjective norms, marital satisfaction, perceived social support, childbearing/parental anxiety, and hope. Data were analyzed with SPSS v24 via descriptive statistics, chi-square/Fisher’s exact tests, independent t-tests, and hierarchical multiple logistic regression to identify predictors of childbearing intention.

Results:

Only 34.2% (95% CI: 29.8–38.8) of participants intended to have children. Adjusted logistic regression identified positive associations with childbearing intention for positive attitudes (OR = 1.113, 95% CI: 1.057–1.172), subjective norms (OR = 1.458, 95% CI: 1.292–1.646), social support (OR = 1.093, 95% CI: 1.020–1.172), hope (OR = 1.165, 95% CI: 1.043–1.172), and religious beliefs (OR = 12.789, 95% CI: 1.029–158.990); conversely, negative associations for pregnancy/childbirth anxiety (OR = 0.633, 95% CI: 0.422–0.949), age > 40 years (OR = 0.01, 95% CI: 0.000–0.279), and poor financial status (OR = 0.007, 95% CI: 0.000–0.347).

Conclusion:

The findings highlight the multifaceted economic, social, emotional, and attitudinal influences on childbearing intentions among Iranian women. To promote fertility rates, targeted public health strategies are recommended, including counseling for emotional barriers, economic supports like infertility subsidies and family incentives, and community-based education on reproductive health benefits.

Keywords

childbearing intention fertility psychological factors women Iran

Introduction

Childbearing is a crucial component in demography and a topic of significant importance in the realm of social and cultural issues, as well as reproductive health.^1,2 Following the population control policies in Iran, fertility and childbearing rates have experienced a significant decline.³ Iran’s average annual population growth decreased from 3.5% in 1991 to 1.62% in 2006 and 1.3% in 2011, and further to approximately 0.7% in 2024, with a total fertility rate decline of over 50%, indicating a considerable reduction in population growth in recent years.^4–6 This has become one of the most significant challenges facing the country, a challenge shared by other regions of the world. The total global fertility rate also halved between 1975 and 2010.^3,7 This decline in fertility leads to population aging, followed by a decrease in the workforce and difficulties in meeting future employment needs. Moreover, maintaining the current levels of income, healthcare, and other social expenses by an aging population.^5,8 According to the United Nations’ projections, considering the low fertility rate, three potential scenarios for Iran’s fertility future by 2051 are possible: a negative population growth pattern, a moderate to declining population growth, or a positive population growth (approximately 0.89%). The realization of any of these three scenarios depends on the childbearing intentions and preferences of couples who will have children in the future. In recent years, numerous support measures have been implemented to increase fertility rates.⁹ However, fertility motivations and preferences are complex issues rooted in cultural, behavioral, and ideological factors, and they change within the context of demographic transition and economic and social development.¹⁰ Couples’ decisions are the most important factor in determining fertility.^11,12 Today, couples are more inclined to pursue higher education, find suitable employment, and secure stable income and housing before considering childbearing.¹¹ Numerous studies on the causes of declining fertility have emphasized economic conditions, concerns about the costs of fertility and parenting, and the increasing levels of education and employment of women.^13,14 However, childbearing is a complex process influenced by various factors, including social, economic, political, cultural norms, individual factors, and marital status, all of which can predict childbearing intentions.^15–17 According to researchers and the theory of planned behavior, the reasons associated with the desire for childbearing and fertility are numerous. These factors include psychological, social, and individual factors, such as education level, employment status, marital satisfaction, hope, social support, social pressures, anxiety about childbirth and parenthood, and ultimately, social norms.^18–20 In addition, subjective norms, which refer to perceived pressure from significant others to perform or not perform a behavior, can influence reproductive intentions.^7,21

The rapid decline in Iran’s total fertility rate (TFR) to approximately 1.7 children per woman in 2023 has accelerated population aging, projecting an elderly dependency ratio (OADR) exceeding 30% by 2050, thereby imposing a substantial public health burden through increased demand for geriatric care and chronic disease management. This demographic shift exacerbates strains on the healthcare system. Addressing these intertwined public health and economic imperatives necessitates evidence-based policies that integrate fertility promotion with sustainable aging strategies to mitigate long-term societal vulnerabilities. Because behavior change is a complex process, a comprehensive understanding of the factors associated with behavioral intentions is necessary to assist researchers and public health professionals in designing more effective programs.¹⁸ Furthermore, despite the changes and support in various societies, including Iran, understanding the status of childbearing intentions and the factors influencing them is essential not only for demographic projections, which are the basis and foundation of economic, social, and demographic planning, but also as a major and important indicator in assessing the economic and social conditions of the studied society. Therefore, this study investigated psychological factors associated with childbearing intentions. Our findings offer novel insights into how anxiety exacerbates fertility aversion. At the same time, hope fosters pronatalist attitudes, informing targeted interventions like cognitive-behavioral counseling programs to mitigate the public health burden of declining fertility rates.

Materials and methods

Study design and participants

This research employed a descriptive-analytical cross-sectional study design. The study was conducted in healthcare centers in Tabriz, targeting all married women who attended these centers from early November to late March 2024. The inclusion criteria were as follows: married women of reproductive age residing in Tabriz, with their first marriage, and able to read and write. The exclusion criteria included pregnancy, a history of infertility, unwillingness to participate in the study, and incomplete questionnaires (more than 10% of the questions unanswered). Approximately 13 questionnaires were excluded due to these reasons, and new participants were recruited to replace them. In cases of missing data, the score of the respective variables was replaced with the mean score of the total sample.

Sampling method and sample size

Sampling was conducted in two stages. First, 25 healthcare centers (30% of the total 82 centers in the city) were randomly selected. Subsequently, participants were recruited using a convenience sampling method, while ensuring they met the inclusion criteria. Sampling continued until the calculated sample size was reached. The sample size was calculated based on the mean (standard deviation) of childbearing intentions, 5.35 (2.78), reported by Khadivzadeh et al.⁹ in Mashhad. Using the mean formula, a 95% confidence level, 80% statistical power, and a 5% margin of error around the mean, the required sample size was determined to be 408 participants. To increase the precision of the study, 10% was added to the calculated sample size, resulting in a final sample size of 450 participants. Sampling continued until the final sample size was achieved.

n = \frac{{(Z_{1} - \frac{α}{2})}^{2} \times s^{2}}{d^{2}}

The sample size was determined using prevalence estimates from a prior study conducted in Mashhad, Iran, which reported a childbearing intention rate of approximately 65% among urban women of reproductive age. This benchmark was deemed applicable to our Tabriz population due to the cities’ comparable demographic profiles as major metropolitan centers, both with populations exceeding 1.4 million, high urbanization rates (>90%), similar median ages (around 32–34 years), and socioeconomic indicators such as education and employment levels that mirror national urban averages. Furthermore, multi-city reproductive health surveys, including those encompassing both Mashhad and Tabriz, have demonstrated consistent patterns in fertility intentions and contraceptive use across these locales, supporting the generalizability of such estimates for power calculations in northwestern Iranian contexts.

Data collection method

Upon obtaining the necessary permissions to conduct the research, the researcher visited the selected healthcare centers. After screening participants based on the inclusion criteria, eligible women were selected to participate in the study. The study objectives were explained to the participants, and informed consent was obtained before providing them with the self-administered questionnaires. The researcher provided guidance and assistance if the participants encountered any difficulties or had questions while completing the questionnaires.

Data collection tools

Data were collected using a questionnaire that included the following components:

Demographic-Obstetric Characteristics Questionnaire: This included questions on age, education, and occupation of the women and their spouses; number of pregnancies; duration of marriage; child’s gender preference; ideal number of children; self-assessment of health; income (5-point Likert scale from very good to very bad); and religious status of the women, which were self-reported.

Childbearing Intention: A single question assessed childbearing intention: “Do you intend to have children in the next few years?” with response options of “Yes” or “No.”

Subjective Norms (SN): Subjective norms were assessed using six items, measuring perceived pressure from others (including spouse, parents, siblings, healthcare personnel, friends, religious figures, and mass media) to perform or not perform a certain behavior. The items were developed based on literature reviews and questions from the studies of Nakhaee and Khajeh,²² as well as Bandehelahi et al.¹⁸ A 5-point Likert scale was used. A higher score indicated greater normative pressure for childbearing. The internal consistency of the scale was assessed using Cronbach’s alpha, and it was 0.82.

Attitudes Toward Fertility and Childbearing Scale (AFCS): The AFCS was developed by Soderberg, Landgren, Christensson, and Hildingsson to assess women’s attitudes toward fertility and childbearing. The scale is based on a 5-point Likert scale. The researchers confirmed the factor structure and reported satisfactory reliability using Cronbach’s alpha. The reliability of the subscales was as follows: importance of fertility for the future, 0.9; childbearing as an obstacle, 0.91; and social identity, 0.8. The minimum and maximum scores of the questionnaire were 27 and 135, respectively, with higher scores indicating a more positive attitude toward fertility and childbearing.^23,24 This questionnaire was psychometrically evaluated in Iran by Baezzat et al., and the validity of the developed Persian version was confirmed using criterion validity and construct validity methods. The reliability of the subscales was between 0.74 and 0.86 using Cronbach’s alpha, and the reliability of the total scale was 0.79.²⁵

Anxiety Related to Childbearing and Childbirth: The questions in this questionnaire were adapted from Zhang et al.’s study in China. Anxiety was measured on a scale of 0–10. A higher score indicated greater anxiety. Subsequently, they were asked which aspects of childbearing and childbirth were associated with anxiety and what they feared.²⁶

Anxiety Related to Parenthood: The questions in this questionnaire were adapted from Zhang et al.’s study in China. The level of anxiety was measured on a scale of 0–10, with a higher score indicating greater anxiety. Participants were also asked to identify the most frightening aspect of parenthood.²⁶

The reliability of the questionnaire was assessed using the Cronbach α method in 20 women. Thus, the reliability of anxiety related to childbearing and childbirth, and anxiety related to Parenthood tools were found to be 0.82 and 0.74, respectively.

Multidimensional Perceived Social Support Scale (MSPSS): This 12-item, 7-point Likert scale questionnaire assesses perceived social support adequacy from family, friends, and significant others. A score of 13–48 indicates low social support, 49–68 indicates moderate social support, and 69–84 indicates high social support.²⁷ The validity was confirmed through content analysis, and reliability was established using Cronbach’s alpha coefficient (α = 0.86–0.9) for the subscales and 0.86 for the whole instrument in Iran.²⁸

The Snyder Hope Scale: The Life Hope Scale was developed by Snyder in 2005, and its purpose is to assess the level of hope in life. The questionnaire has 12 questions in 2 components. The scores range from 8 to 64. There are also four distractors and lie detector questions in this questionnaire.²⁹ This questionnaire has been psychometrically evaluated in Iran, and the Cronbach’s alpha obtained 0.66 for the agency and 0.80 for the Pathways.³⁰

Kansas Marital Satisfaction Scale: This is a three-item questionnaire. It was measured on a 7-point Likert scale. The originators of this questionnaire believe that a score of 14 or higher indicates marital satisfaction. This questionnaire was psychometrically evaluated by Arab Alidousti et al. The Cronbach’s alpha coefficient for the two questionnaires, ENRICH and Kansas, was reported as 0.74 and 0.98, respectively.³¹

The questionnaires have been formatted as a Supplemental File.

Data analysis

The research findings were analyzed statistically using SPSS version 24 software. Descriptive statistics were computed, comprising means and standard deviations for continuous variables and frequencies with percentages for categorical variables. Associations between demographic-obstetric characteristics and childbearing intention were evaluated using chi-square tests and Fisher’s exact tests, as appropriate. Additionally, independent t-tests were employed to compare the means of the main study variables (attitudes toward fertility and childbearing, subjective norms, hope, marital satisfaction, social support, and anxiety related to childbearing and parenthood) between the two groups with and without childbearing intention. Subsequently, univariate and multivariate logistic regression analyses using the enter method were conducted to identify predictors of childbearing intention. To systematically evaluate the hierarchical influence of variables, three models were employed: Model 1 assessed the unadjusted (univariate) effects of individual psychological variables (e.g., hope, anxiety) on the outcome, providing baseline associations without confounding. Model 2 then examined the combined multivariate effects of these psychological variables in isolation, isolating their independent contributions while controlling for collinearity among them. Finally, Model 3 incorporated demographic variables (e.g., age, education, income) alongside the psychological factors, enabling an assessment of adjusted effects and potential confounding or mediation by socioeconomic determinants. This staged approach facilitates a nuanced understanding of how psychological predictors maintain significance after accounting for demographic confounders, aligning with established practices in reproductive health epidemiology for dissecting multifaceted determinants. A significance level of α = 0.05 and a 95% confidence interval were considered in all analyses. Given that the skewness and kurtosis of the study’s dependent variables were between −1 and 1, the data were considered to be normally distributed.

Results

Demographic and obstetrics characteristics and their association with childbirth intention

A total of 450 women participated in this study. The mean age of the participants was 32.92 (SD = 6.73), with the majority (56%) falling within the 30–39 years age group. Approximately 52.7% of the women had a university education, and 61.1% were homemakers. Approximately 68.4% of the spouses were employed in self-employed occupations, and 84% held a diploma or higher educational qualifications. Nearly 42% of the women had one child, and 40.7% had at least one son. Approximately 55% of the women reported good health status, while 45% considered themselves moderately religious, and only 5.3% identified as highly religious. Preliminary analysis indicated that the prevalence of individuals with childbearing intentions was 34.20% (95% CI: 29.84–38.81), whereas 65.8% (95% CI: 61.19–70.16) of the participants did not intend to have children in the future. A comparative analysis of women with and without childbearing intentions identified significant differences in age, employment status, spouse’s education, number of children, health status, and religiosity. Younger women, homemakers, those with poorer health, and highly religious women were more likely to express childbearing intentions (p < 0.001). Women with spouses with higher education and those with children of both genders showed lower intentions. Most women (276) preferred two children, with 52% favoring a male child, and those desiring more children had stronger future childbearing intentions (p < 0.001). No significant difference was found in preferred child gender (p = 0.855; Table 1).

Table 1.

Participants’ demographic and obstetrics characteristics and childbearing intention (N = 450).

		Desire for childbearing		p-Value
Variable	Total N (%)	Yes (N = 154)	No (N = 296)	p-Value
Women’s age groups (year)
>20	16 (3.6)	11 (7.1)	5 (1.7)	<0.001^a
20–29	108 (24.0)	77 (50.0)	31 (10.5)
30–39	252 (56.0)	64 (41.6)	188 (63.5)
40–49	74 (16.4)	2 (1.3)	72 (24.3)
Women’s educational status				0.465^b
Primary & secondary school	35 (7.8)	10 (6.5)	25 (8.4)
High school	178 (39.6)	57 (37.0)	121 (40.9)
University	237 (52.7)	87 (56.5)	150 (50.7)
Women’s employment status				0.039
Housewife	275 (61.1)	84 (54.5)	191 (64.5)
Employed	175 (38.9)	70 (45.5)	105 (35.5)
Husband’s education				0.001^b
Primary & secondary school	58 (12.9)	6 (3.9)	52 (17.6)
High school	194 (43.1)	73 (47.4)	121 (40.9)
University	198 (44.0)	75 (48.7)	123 (41.6)
Husband’s employment status				0.504^a
Jobless	3 (0.7)	0 (0)	3 (1.0)
Employed	139 (30.9)	51 (33.1)	88 (29.7)
Self-employed	308 (68.4)	103 (66.9)	205 (69.3)
Gravid				<0.001^b
No pregnancy	62 (13.8)	52 (33.8)	10 (3.4)
1	188 (41.8)	70 (45.5)	118 (39.9)
2	105 (23.3)	8 (5.2)	97 (32.8)
≥3	95 (21.1)	24 (15.6)	71 (24.0)
Gender of children				<0.001^b
Boy	183 (40.7)	43 (27.9)	140 (47.3)
Girl	126 (28.0)	52 (33.8)	74 (25.0)
Boy and girl	79 (17.6)	8 (5.2)	74 (25.0)
No children	62 (13.8)	51 (33.1)	11 (3.7)
Income status				<0.001^a
Very good	45 (10.0)	18 (11.7)	27 (9.1)
Good	162 (36.0)	86 (55.8)	76 (25.7)
Moderate	233 (51.8)	49 931.8)	184 (62.2)
Bad	10 (2.2)	1 (0.6)	9 (3.0)
Self-reported health status				0.467^a
Very good	103 (22.9)	31 (20.1)	72 (24.3)
Good	246 (54.7)	86 (55.8)	160 (42.1)
Moderate/poor	98 (21.8)	37 (24.0)	61 (20.6)
High	3 (0.7)	0 (0)	3 (1.0)
Self-reported religion status				<0.001^b
I’m not religious at all	62 (13.8)	26 (41.9)	36 (12.2)
I’m a little religious	162 (36.0)	40 (26.0)	122 (41.2)
I’m somewhat religious	202 (44.9)	70 (45.5)	132 (44.6)
I’m very religious	24 (5.3)	18 (11.7)	6 (2.0)
The desired number of children				<0.001^a
0	15 (3.3)	2 (1.3)	13 (4.4)
1	87 (19.3)	10 (6.5)	77 (26.0)
2	276 (61.3)	110 (71.4)	166 (56.1)
3	49 (10.9)	24 (15.6)	25 (8.4)
≥4	23 (5.1)	8 (5.2)	15 (5.1)
The desired gender of children				0.855^a
Boy	234 (52.0)	81 (52.6)	153 (51.7)
Girl	216 (48.0)	73 (47.4)	143 (48.3)

Fisher’s exact test.

Chi-square.

Comparison of the main study variables in the two groups

Preliminary analysis of the main variables revealed that the mean total scores for attitude toward fertility and childbearing, perceived social norms, and perceived social support were 101.86, 16.50, and 63.69, respectively. The mean scores for childbearing anxiety and parenting anxiety were calculated as 6.24 and 6.56, respectively. Additionally, the mean total scores for hope and marital satisfaction were found to be 29.56 and 16.50, respectively. An independent samples t-test indicated statistically significant differences between women with and without childbearing intentions in terms of mean scores on attitude toward fertility and childbearing, perceived social norms, perceived social support, hope, and marital satisfaction (p < 0.001). Specifically, women who expressed childbearing intentions had higher mean scores in attitude toward fertility and childbearing, perceived social norms, perceived social support, and marital satisfaction compared to those without such intentions. Similarly, the mean score for perceived social norms was also higher among women with childbearing intentions.

The independent samples t-test also showed a significant difference between the two groups regarding childbearing anxiety and parenting anxiety, such that the group without childbearing intentions had higher mean scores in both domains (Table 2).

Table 2.

Comparison of the total main variable scores in the two groups.

Variable	All	Min–Max	Intention to have a child during the next		p-Value^a	Effect size (Cohen’s d)
	N = 450		Yes (N = 154)	No (N = 296)
	Mean (SD)		Yes (N = 154)	No (N = 296)
AFCS	101.86 (13.38)	72–140	113.60 (10.44)	95.76 (10.33)	<0.001	1.717
SN (subject’s norms)	16.50 (4.23)	7–60	20.86 (6.56)	14.94 (6.08)	<0.001	0.936
MSPSS	63.69 (12.53)	24–84	70.92 (9.47)	59.93 (12.28)	<0.001	1.002
Childbearing and childbirth anxiety	6.24 (2.17)	0–10	4.92 (1.76)	6.93 (2.04)	<0.001	1.055
Parenthood anxiety	6.12 (2.19)	0–10	4.73 (1.98)	6.83 (1.94)	<0.001	1.071
hope	29.56 (5.24)	19–45	32.51 (5.91)	28.02 (4.10)	<0.001	0.882
Marital satisfaction	16.50 (4.23)	3–21	18.92 (2.30)	15.24 (4.45)	<0.001	1.038

t-test.

Correlation between the main study variables

As presented in Table 3, the Pearson correlation analysis revealed significant positive correlations between attitude toward fertility and childbearing and several variables: perceived social norms (i.e. pressure from family and society; r = 0.224, p < 0.001, small effect), perceived social support (r = 0.434, p < 0.001, medium effect), hope (r = 0.402, p < 0.001, medium effect), and marital satisfaction (r = 0.401, p < 0.001, medium effect). This indicates that as scores on these variables increased, so did the mean score for attitude toward fertility and childbearing. Additionally, statistically significant negative correlations were observed between the attitude toward fertility and childbearing and both childbearing anxiety (r = –0.384, p < 0.001, small effect) and parenting anxiety (r = –0.333, p < 0.001, small effect).

Table 3.

Descriptive statistics and correlations between the main variables of the study.

Variable	1	2	3	4	5	6	7
1. AFCS	1	0.224*	0.434*	−0.384*	−0.333*	0.402*	0.401*
2. SN (subject’s norms)		1	−0.259	0.097**	0.067	−0.011	0.061
3. MSPSS			1	−0.567*	−0.553*	0.391*	0.378*
4. Childbearing and childbirth anxiety				1	0.784*	−0.296	−0.231
5. Parenthood anxiety					1	−0.365*	−0.286*
6. Hope						1	0.356*
7. Marital satisfaction							1

p < 0.001. **p < 0.05.

Predictors of childbearing intention

Model 1 of the logistic regression analysis showed that all variables significantly influenced childbearing intentions. According to the results, for every one-unit increase in attitude toward fertility and childbearing, perceived social norms, perceived social support, hope, and marital satisfaction, the probability of having childbearing intentions increased by 20.1% (OR = 1.201, p < 0.001), 15.1% (OR = 1.151, p < 0.001), 10% (OR = 1.100, p < 0.001), 21.1% (OR = 1.211, p < 0.001), and 36.9% (OR = 1.369, p < 0.001), respectively.

Significant negative relationships were also found between childbearing intention and both childbearing anxiety and parenting anxiety. That is, as levels of childbearing anxiety or parenting anxiety increased, the likelihood of having childbearing intentions decreased by 41.7% (OR = 0.583, p < 0.001) and 48.2% (OR = 0.518, p < 0.001), respectively.

In Model 2, which used multiple logistic regression without controlling for demographic factors, all primary variables were entered into the model simultaneously. The results showed that some variables remained statistically significant predictors of childbearing intention, although their coefficients changed slightly. Attitude toward fertility and childbearing remained significant, with a one-unit increase associated with a 13.7% increase in the likelihood of childbearing intention (OR = 1.137, p < 0.001). Perceived social norms demonstrated an even stronger effect than in Model 1, showing a 43.2% increase in the probability of childbearing intention (OR = 1.432, p < 0.001). Moreover, increases in perceived social support (MSPSS score) and marital satisfaction were associated with a 9.1% (OR = 1.091, p = 0.002) and 24.3% (OR = 1.243, p < 0.001) increase in the likelihood of childbearing intention, respectively. However, childbearing anxiety remained a significant negative predictor, reducing the probability of childbearing intention by 35.3% (OR = 0.647, p = 0.008). In contrast, parenting anxiety no longer showed a statistically significant relationship with childbearing intention (OR = 0.769, p = 0.076). Similarly, although hope showed a positive trend, it was not statistically significant in this model (OR = 1.073, p = 0.101). Finally, in Model 3, demographic variables including women’s age, employment status, spouse’s education level, income status, and religious beliefs were added to the model. The results of the multiple logistic regression (Model 3) indicated that several factors significantly influenced childbearing intention. Positive attitudes toward pregnancy (OR = 1.11), perceived social norms (OR = 1.46), perceived social support (OR = 1.09), feelings of hope (OR = 1.17), and being more religious (OR = 12.79) were all significantly associated with increased odds of childbearing intention. Conversely, childbearing anxiety (OR = 0.63), being over 40 years of age (OR = 0.01), and poor income status (OR = 0.007) were associated with reduced childbearing intentions. Marital satisfaction, employment status, and spouse’s educational level did not show statistically significant effects on childbearing intention in this final model (Table 4).

Table 4.

Results of the univariate and multiple logistic regression analysis of the study’s main variables and demographic factors on childbearing intention.

Variables		Unadjusted OR	Adjusted OR (95% confidence Interval)	p-Value
Model 1	AFCS	0.183	1.201 (1.160–1.244)	<0.001
	SN (subject’s norms)	0.140	1.151 (1.112–1.190)	<0.001
	MSPSS	0.095	1.100 (1.075–1.126)	<0.001
	Childbearing and childbirth anxiety	−0.540	0.583 (0.513–0.662)	<0.001
	Parenthood anxiety	−0.544	0.518 (0.513–0.0658)	<0.001
	hope	0.192	1.211 (1.153–1.273)	<0.001
	Marital satisfaction	0.314	1.369 (1.267–1.479)	<0.001
Model 2	Constant	−27.645	0.520	<0.001
	AFCS	0.128	1.137 (1.088–1.189)	<0.001
	SN (subject’s norms)	0.359	1.432 (1.296–1.581)	<0.001
	MSPSS	0.087	1.091 (1.033–1.152)	0.002
	Childbearing and childbirth anxiety	−0.435	0.647 (0.469–0.892)	0.008
	Parenthood anxiety	−0.263	0.769 (0.575–1.028)	0.076
	hope	0.071	1.073 (0.986–1.168)	0.101
	Marital satisfaction	0.218	1.243 (1.079–1.433)	0.003
Model 3	Constant	−0.653	0.520	<0.001
	AFCS	0.107	1.113 (1.057–1.172)	<0.001
	SN (subject’s norms)	0.377	1.458 (1.292–1.646)	<0.001
	MSPSS	0.089	1.093 (1.020–1.1172)	0.012
	Childbearing and childbirth anxiety	−0.457	0.633 (0.422–0.949)	0.027
	Parenthood anxiety	−0.276	0.759 (0.519–1.110)	0.155
	hope	0.153	1.165 (1.043–1.172)	0.007
	Marital satisfaction	0.112	1.118 (0.953–1.313)	0.172
	Women’s age groups (year)
	>20	Ref
	20–29	−0.194	0.824 (0.078–8.697)	0.872
	30–39	−1.913	0.148 (10.017–1.311)	0.086
	40–49	−4.575	0.010 (0.000–0.279)	0.007
	Women’s employment status
	Housewife	Ref
	Employed	−0.810	0.445 (0.121–1.640)	0.224
	Husband’s education
	Primary & secondary school	Ref
	High school	0.688	1.990 (0.442–8.963)	0.370
	University	−0.062	0.940 (0.170–5.187)	0.943
	Income status
	Very good	Ref
	Good	1.591	4.910 (0.940–25.638)	0.059
	Moderate	−0.412	0.662 (0.112–3.924)	0.650
	Bad	−5.025	0.007 (0.000–0.347)	0.013
	Self-reported religion status
	I’m not religious at all	Ref
	I’m a little religious	−0.037	0.964 (0.185–5.035)	0.965
	I’m somewhat religious	0.318	1.374 (0.292–6.481)	0.688
	I’m very religious	2.549	12.789 (1.029–158.990)	0.047

Discussion

In this study, we aimed to evaluate some of the key factors influencing childbearing intention. A comprehensive analysis indicates that positive attitudes toward childbearing, supportive subjective norms, perceived social support, hope, and strong religious beliefs are associated with an increased inclination toward childbearing. In contrast, anxiety related to pregnancy and childbirth, advanced age (over 40 years), and low financial status are linked to a reduced intention to have children.

First, according to our findings, only about 34% of the women surveyed reported having an intention to give birth in the next few years, which aligns with national surveys indicating sub-replacement fertility levels, underscoring a critical public health concern amid Iran’s total fertility rate (TFR) decline to 1.7, which signals heightened risks of population aging and strained healthcare resources. Posing immediate public health challenges such as increased infertility prevalence and maternal health disparities, necessitating proactive strategies like subsidized reproductive counseling. Similarly, a study by Lampic et al.³² in Sweden reported a childbearing intention rate of 96.5%, while studies from Italy and China found rates of approximately 28% and 26.6%, respectively.^26,33 These results are inconsistent with previous studies conducted in Iran, which reported childbearing intentions at 62%,⁷ 59%,³⁴ and 41%.³⁵ This discrepancy in findings may be attributed to differences in how “childbearing intention” was defined across studies and variations in the time frames considered, for example, whether the focus was on childbearing plans within the next 2 years or over a more general period. Moreover, the demographic characteristics of the study populations can also influence responses. For instance, the Swedish study focused on male and female university students, nearly half of whom were unmarried, suggesting that childbearing intentions might be higher among younger, single individuals.³² In contrast, all participants in our study were married women, and we assessed their intention toward future childbearing. Additionally, differences in the timing and context of the studies may have contributed to the variation in results. In Iran, fertility rates have declined over time, particularly in large urban areas. These findings align with the global trend of declining childbearing intentions in many developing countries and even some developed nations,^36–38 indicating a profound transformation in family formation patterns, gender roles, and reproductive decision-making in contemporary societies.

The role of psychological and demographic factors in childbearing intention

This study identifies psychological factors as key determinants of childbearing intentions. Positive attitudes toward fertility, subjective norms, perceived social support, and hope significantly predict childbearing desire, while childbearing and parenting anxiety negatively influence it, aligning with the Theory of Planned Behavior (TPB) and the Interactive Socio-Cultural Model.^19,39 TPB posits that intentions are shaped by personal attitudes, subjective norms, and perceived behavioral control, while the socio-cultural model emphasizes the role of social interactions and cultural expectations.^40,41

Positive attitudes toward fertility were strongly associated with increased childbearing intention, even after controlling for other variables, consistent with prior research.^11,42 Literature reviews further emphasize the central role of attitude as a powerful construct in predicting human behavior.

Additionally, subjective norms emerged as the strongest predictor of childbearing intention, highlighting the strong influence of social pressures and surrounding expectations on reproductive decisions. This finding aligns with previous studies conducted in Iran and other Islamic countries.^43,44 Likewise, numerous other studies have emphasized the pivotal role of subjective norms in the domain of fertility.^11,43,44 For example, Araban et al.⁷ demonstrated that subjective norms and societal pressures are positively correlated with women’s childbearing intentions.

Perceived social support also positively influenced childbearing intention, with supported women showing greater desire for childbearing, corroborated by national and international studies^45–47 A review of the literature further supports the view that social support is a key social determinant of health and plays a significant role in improving overall quality of life. According to researchers, interpersonal relationships are not inherently considered sources of social support unless individuals perceive them as accessible resources to fulfill their needs.^48,49 In a study conducted by Ghahremani et al., perceived social support acted as a mediating factor by increasing feelings of security and reducing stress, thereby enhancing childbearing intentions.

Hope was another significant positive factor, with hopeful individuals more open to parenthood, though its effect was not statistically significant in the final model.^7,50 Researchers have also demonstrated that individuals with greater hope tend to perform better in maintaining and improving their health and coping with personal challenges. Our results similarly showed that women with childbearing intentions reported higher levels of hope, although the mean score difference between the two groups was not statistically significant in the final model. However, other studies^37,51 have shown that hope significantly influences reproductive decision-making and timing, indicating that hopeful women are more inclined toward childbearing, findings that align with prior research conducted on diverse populations.⁵²

Marital satisfaction showed a positive but non-significant effect on childbearing intention after adjusting for demographic variables, contrasting with some studies where it was influential.^7,53,54 This discrepancy suggests that its role may vary depending on sociodemographic and psychological contexts.⁵⁵ In Model 3, adjusting for psychological and demographic covariates, marital satisfaction became non-significant. This is likely due to: (1) confounding by demographic factors (e.g. age, education, income), which may account for variance in childbearing intention previously attributed to marital satisfaction, consistent with studies noting its non-linear relationship with fertility desire ^7,53; (2) overlap with stronger predictors like perceived social support and subjective norms, where supportive marital relationships contribute to social support ^43,44; and (3) context-specific dynamics in Iran, where social pressures dominate reproductive decisions, diminishing marital satisfaction.⁷

Analysis revealed that childbearing and parenting anxieties negatively impact future childbearing intentions, with childbearing-related anxiety significantly reducing the likelihood by fostering fears of pregnancy and childbirth as major barriers. These findings align with prior studies linking such anxieties to earlier reproductive decisions.^26,47 Moreover, anxieties related to parenting negatively affected decision-making by generating deep concerns about post-childbirth responsibilities. However, in the final model, after controlling for demographic and psychological variables, the effect of parenting anxiety on childbearing intention was no longer statistically significant. Zhang et al.²⁶ similarly reported high levels of childbearing and childbirth-related anxiety among young women, identifying the birthing process as a primary source of underlying anxiety. Therefore, early interventions aimed at mitigating these negative emotions hold considerable potential for influencing fertility behavior. Similar results have been found in other studies, highlighting the prevalence of fear or anxiety regarding childbirth and pregnancy^56,57 which not only affects fertility behaviors and intentions but may also significantly impact pregnancy outcomes.^58,59 Psychological and educational interventions aimed at reducing childbearing anxiety in women⁶⁰ could potentially be effective in alleviating such fears. Based on recent studies, childbirth-related anxiety (e.g., fear of childbirth) acts as a negative mediator in women’s fertility intentions, potentially reducing the desire for childbearing, particularly in societies with low fertility rates.⁶¹ Psychological interventions, such as counseling, psychoeducation, and mindfulness-based therapies, can mitigate this anxiety, thereby enhancing fertility intentions.⁶² A recent systematic review underscores that non-pharmacological interventions, including group or individual counseling, not only alleviate anxiety but also increase preparedness for childbirth and can be integrated into family-oriented policies.⁶³ In this context, policymakers could incorporate pre-pregnancy counseling programs into public health systems to target anxiety and boost fertility rates. Moreover, combining non-pharmacological interventions with supportive economic policies (e.g., alleviating financial pressures of child-rearing) could enhance effectiveness. Additionally, implementing fertility incentive policies could play a significant role in improving fertility intentions.

Finally, an examination of demographic characteristics and their effects on childbearing intention revealed that age had a significant negative association with childbearing intention. This finding aligns with existing evidence demonstrating age’s substantial impact on fertility.^64,65 For example, a study by Kodzi et al.⁶⁶ showed that for each additional year of age at first birth, fertility decreased by approximately 3%. In our study, being over 40 years of age was strongly associated with a drastic decline in childbearing desire. This result can be well explained by physiological changes, limited biological opportunities, and cognitive-emotional shifts that occur during midlife.⁹ Also, it can be attributed to heightened awareness of age-related fertility decline, elevated obstetric risks, and shifting life priorities toward career stability and existing familial responsibilities, thereby diminishing the perceived feasibility and desirability of additional pregnancies.

Additionally, low-income status, as a structural-social factor, significantly reduced the likelihood of childbearing intention. This finding is consistent with studies showing that economic factors play a prominent role in reproductive decision-making.^37,67 Notably, religious belief had a very strong positive effect on childbearing intention. Women who identified as “highly religious” were 12.8 times more likely to express a desire for childbearing. This result aligns with studies showing that religion, as a source of moral and ethical values, can significantly influence personal life decisions.⁶⁸ Based on recent studies, the role of religion in Iran has been reported to have a predominantly positive effect on women’s fertility intentions; religious women exhibit a greater inclination toward childbearing, as religious beliefs, such as the value placed on family and ethical-value-driven motivations, promote fertility.⁶⁹ In comparison to secular societies, such as European countries, fertility intentions in Iran are higher, as secularism is associated with a reduced desire for childbearing, even among religious individuals, with economic and social factors predominating in such contexts.^69,70 In Western societies, the costs of child-rearing significantly diminish fertility intentions.⁷¹

Lastly, employment status did not show a statistically significant effect on childbearing intention in this study, although employed women tended to express lower fertility desires. This finding is partially consistent with studies indicating that work conditions, work-life balance, and occupational stress can serve as barriers to fertility.^1,72

In the fully adjusted Model 3, which incorporated demographic confounders such as age, employment, spouse’s education, income, and religiosity, several psychological and socioeconomic factors emerged as robust predictors of childbearing intention. Positive attitudes toward pregnancy, perceived social norms, social support, and hope significantly bolstered intentions, highlighting the protective role of supportive psychosocial environments. Conversely, childbearing anxiety, age over 40, and poor income status markedly diminished odds, underscoring barriers tied to emotional distress and economic precarity. Notably, marital satisfaction, employment status, and spouse’s education level did not retain significance post-adjustment, suggesting their effects may be mediated by these dominant factors. These findings reveal profound public health implications for Iran’s fertility crisis, where psychological barriers like childbearing anxiety undermine intentions amid socioeconomic pressures. To counter this, actionable strategies include integrating pre-pregnancy counseling programs in primary care to alleviate anxiety and foster hope through cognitive-behavioral techniques, alongside nationwide stigma reduction campaigns addressing cultural taboos around delayed childbearing, potentially increasing intentions by 20%–30% as evidenced in similar interventions. Such measures, if scaled via community health workers, could mitigate population aging risks and bolster maternal health equity.

Limitations

Several limitations should be considered when interpreting the findings of this study. First, the results cannot be generalized to women in other cities or to those visiting private clinics and healthcare centers, as these populations were not included in the sample. Additionally, unmarried women did not participate in this study, limiting the generalizability of the findings to this demographic group. Moreover, the data were collected through a cross-sectional study, which means that causal relationships cannot be inferred. The use of convenience sampling is a key limitation, as it introduces potential selection bias, which may engender selection bias by disproportionately including health-conscious women who are more inclined to participate in fertility-related surveys, potentially skewing results toward higher reported childbearing intentions or optimism regarding psychological factors like hope. Our sample, drawn from health center attendees, likely overrepresents women with greater health awareness and engagement with preventive care, better access to services, and potentially skewing socioeconomic status, and specific health intentions (e.g., seeking family planning counsel), which directly influence the very attitudes and anxieties we measured. Consequently, our findings may not be generalizable to the broader population, as we have likely underrepresented women who do not access health centers due to barriers like lack of access, distrust, or cultural reasons. In addition, Childbearing intention was assessed using a single-item measure. This approach, which is common in demographic and reproductive health research, has demonstrated satisfactory reliability and predictive validity in predicting actual reproductive behavior over recent years, comparable to multiple-item scales. However, future studies may benefit from multidimensional measures to examine underlying affective components. The notably wide 95% confidence interval for the association between religious beliefs and childbearing intention (1.029–158.990) reflects substantial imprecision in the estimate, likely attributable to limited sample size or high variability in responses, thereby constraining the interpretability and generalizability of this result. Future studies are recommended to include both men and women to explore fertility intentions at the couple level and to better understand the predictive factors influencing reproductive decision-making. Furthermore, qualitative research is suggested to provide deeper insights into the various factors influencing fertility intentions.

Conclusion

The findings of this study indicate that childbearing intentions are influenced by multiple psychological, social, and demographic factors. Therefore, comprehensive and multifaceted strategies are essential to promote fertility motivation in society. These should include: strengthening social support through family, community, and government policies; managing anxiety related to pregnancy and childbirth; promoting hope and psychological well-being; supporting women in low-income situations; and providing premarital counseling and ongoing marital guidance. Additionally, access to accurate information regarding the impact of each factor, whether positive or negative, is essential for demographers, policymakers, and planners to design effective interventions tailored to the specific needs of their populations.

Supplemental Material

sj-docx-1-phj-10.1177_22799036251410258 – Supplemental material for Determinants of childbearing intention among Iranian women: Integrating psychological, demographic, and socioeconomic factors

Supplemental material, sj-docx-1-phj-10.1177_22799036251410258 for Determinants of childbearing intention among Iranian women: Integrating psychological, demographic, and socioeconomic factors by Asal Rahbar-Zeraati, Azita Fathnezhad-Kazemi and Atefeh Velayati in Journal of Public Health Research

Footnotes

Acknowledgements

We thank the women who participated in the study. We also appreciate the support from the Islamic Azad University of Tabriz Medical Sciences.

ORCID iD

Azita Fathnezhad-Kazemi

Ethical considerations

Written informed consent was obtained from each participant before the completion of the survey. This study was approved by the Ethics Committee of the Islamic Azad University of Tabriz Medical Sciences, Iran (code number: IR.IAU.TABRIZ.REC.1402.246). All the methods were carried out following relevant guidelines and regulations.

Consent for publication

Not applicable.

Author contributions

Asal Rahbar-Zeraati: methodology, writing, review, and editing, writing–original draft. Atefeh Velayati: formal analysis, writing, review, and editing. Azita Fathnezhad-Kazemi: writing–original draft, writing–review and editing, supervision, methodology.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets are available from the corresponding authors on request.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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Determinants of childbearing intention among Iranian women: Integrating psychological,demographic,and socioeconomic factors

Abstract

Background:

Design and Methods:

Results:

Conclusion:

Keywords

Introduction

Materials and methods

Study design and participants

Sampling method and sample size

Data collection method

Data collection tools

Data analysis

Results

Demographic and obstetrics characteristics and their association with childbirth intention

Comparison of the main study variables in the two groups

Correlation between the main study variables

Predictors of childbearing intention

Discussion

The role of psychological and demographic factors in childbearing intention

Limitations

Conclusion

Supplemental Material

sj-docx-1-phj-10.1177_22799036251410258 – Supplemental material for Determinants of childbearing intention among Iranian women: Integrating psychological, demographic, and socioeconomic factors

Footnotes

Acknowledgements

ORCID iD

Ethical considerations

Consent for publication

Author contributions

Funding

Declaration of conflicting interests

Data availability statement

Supplemental material

References

Supplementary Material