Determinants of Fertility Desires and Associated Factors among Married Women Attending Comprehensive Health Centers in Iran

Abstract

Background: Iran's total fertility rate (TFR) has experienced a steep decline, from approximately 7.0 in 1960 to an estimated 1.6 in recent years (2024 - 2025), which is significantly below the replacement level, necessitating research on fertility determinants. Objectives: This study examined factors influencing childbearing reluctance among married women in Kashan. Methods: A cross-sectional study was conducted with 578 married women (aged 18 - 49 years) selected through a two-stage cluster random sampling method from five comprehensive health centers (2023). The sample size was calculated using the Cochran formula, yielding a minimum of 578 participants. Data were collected via a structured questionnaire comprising socio-demographics, a validated 15-item fertility attitude scale, and a 24-item barrier inventory. Analyses included descriptive statistics and multivariable logistic regression (SPSS v26). Results: Of the participants, the mean age was 32.5 ± 6.8 years. In total, 68.2% (n = 394) reported no fertility desire. Key deterrents were: Financial constraints (76.1%, OR = 3.2, 95% CI: 2.1 - 4.9), career conflicts [65.3%, adjusted odds ratio (aOR) = 2.7, 95% CI: 1.8 - 4.0], and marital dissatisfaction (58.9%, OR = 2.1, 95% CI: 1.4 - 3.2). Higher education (aOR = 1.9, 95% CI: 1.3 - 2.8) and employment (OR = 2.4, 95% CI: 1.6 - 3.6) significantly predicted reluctance (P < 0.001). Conclusions: Economic pressures primarily drive fertility decline. Policy interventions addressing childcare costs and workplace flexibility are urgently needed. Future policies must move beyond short-term financial incentives to address the fundamental structural and normative barriers shaping reproductive decisions.