What factors influence couples’ decisions to have children? Evidence from a systematic scoping review

Population and associated issues are intricate and multidimensional topics within human societies [1]. The population plays a pivotal role in any society’s economic and social dynamics, and governments must skillfully manage fertility rates to attain sustainable development effectively [2]. Fertility, a significant natural phenomenon in every society, is a vital determinant of population growth, prompting nations to devise and implement incentivizing policies to augment it [3].

Over the past three decades, one of the foremost global demographic challenges has been the considerable decline in fertility rates [4]. Across the globe, numerous families are deferring childbirth for diverse reasons, potentially leading to a decrease in desired fertility rates, prolonged population decline, and ultimately a reduction in sustainable development. Furthermore, the proportion of those opting to remain childless is rising [5, 6]. These trends have resulted in declining fertility rates in many regions worldwide, especially in developing countries, contributing to an aging population, elevated retirement rates, a dearth of human resources for employment, and diminished economic growth and productivity [5].

Understanding the influential factors on fertility has become an indispensable prerequisite for development programs, particularly for developing countries with a heightened focus on economic progress [7]. The global fertility rate has decreased from 4.5 births per woman during 1970-1975 to 2.5 during 2005-2010 [4]. As a developing nation, Iran has also experienced a rapid decline in fertility over the past decade [8]. The fertility rate in Iran has similarly dwindled in recent years, reaching 1.9 between 1978 and 2015 [9]. Confronted with this dwindling population growth, the Iranian government initiated incentivizing policies in 2012. These policies encompassed designating homemaking as an occupation with a stipulated income, implementing schemes such as “Monthly Child Incentives,” “Extended Maternity Leave,” “Mandatory Health Insurance Coverage for Mothers and Children,” “Monthly Allowance for Unemployed Women with Young Children,” and “Free Pregnancy Food Basket” [10].

Numerous factors typically influence the decision to have children. However, under the sway of incentivizing policies, Iranian families displayed a reduced inclination to have more children, leading to a cessation in population growth and a decline in fertility [10, 11]. Nevertheless, a study by Hashemzadeh and colleagues (2022) demonstrated that effectively implemented family policies can positively influence the intention of young couples to have children. These policies encompass creating a conducive environment, facilitating work-life balance for couples, executing health promotion programs, offering child-centered social support, and enhancing social and cultural ties [12].

Families’ proclivity toward childbearing is shaped by a range of factors, including societal norms, economic circumstances, cultural considerations, personal beliefs, religion, partner attributes, educational levels, and economic uncertainties such as unemployment or job opportunities, work-related stress, delayed marriage, challenging housing conditions, and similar challenges [4, 13‐15]. It could be argued that the desire for fertility in Iran is deeply intertwined with tradition, gender roles, and religious sentiments. The factors that underpin the desire for childbearing within families can ultimately lead to demographic shifts at the national level over time [9].

Parallel studies have explored the influential factors on couples’ inclination toward parenthood. In a study conducted in South Korea by Lee and Hwang (2017), the determinants of married women’s desire for parenthood were investigated. The study revealed that age, income level, and shared childcare responsibilities with spouses were pivotal factors influencing the intent for parenthood among working married women. Additionally, the findings underscored that government support for childcare significantly influences the future childbirth intentions of employed married women [13].

In another study, Rahman and colleagues (2020) identified the pivotal factors influencing fertility in developing nations. Their findings indicated that a woman’s age in developing countries significantly explains fertility outcomes. Increased education for spouses and women is associated with reduced fertility following age. Another unconventional factor influencing fertility behavior is a country’s per capita healthcare expenditure. Escalating healthcare costs per capita ultimately result in decreased fertility [16].

Similarly, a study by Soederberg and colleagues (2015) scrutinized women’s attitudes toward fertility and parenthood in Sweden. Their conclusions highlighted that age, occupation, residential area, and marital status impact attitudes toward fertility and parenthood. In light of individual differences and age, fostering awareness, dialogue, and necessary interventions in sexual and reproductive healthcare is imperative for addressing fertility concerns [17].

While couples’ inclination toward parenthood has consistently been a focal point of research, examining the influential variables on the intent for parenthood within a given society while considering its distinctive social, economic, and cultural contexts becomes highly imperative. Furthermore, grasping the factors that affect the desire and intent for fertility and parenthood through a comprehensive and all-encompassing approach can pave the way for more informed decision-making in crafting policies and initiatives to foster an increase in households’ willingness for fertility.

Consequently, the present study aims to comprehensively explore the factors influencing couples’ inclination toward parenthood through a systematic and organized review within this field.

This study was a systematic scoping review conducted in 2022. To design and conduct this scoping review, Joanna Briggs Institute’s Protocol (2015) was used [18] and the framework presented by Levac et al. [19] was also used as a guide for conducting this review [20]. The scoping review, based on the framework presented by Levac et al. and the Joanna Briggs Institute’s Protocol, consists of 6 main stages, each of which is mentioned below:

In this stage, according to the mentioned guidelines, the main research question was defined as follows: “What are the factors affecting the desire of couples to have children?” A clear research question in a scoping review serves as a guide for determining and selecting the criteria for including studies in the review process. Additionally, this clarity helps in designing a better study protocol, facilitating the search for evidence and studies, and creating a suitable structure for reporting the scoping review. The scoping review question should include the population, concept, and context (PCC) components [20].

In this study, the population (P) included all studies that studies factors affecting the desire of couples to have children. The concept (C) included the childbearing and desire to having children, and the context (C) included all countries that the couples live there.

In this stage, studies were searched in three main databases including ISI Web of Sciences, PubMed, and Scopus, using a predefined search strategy. Google Scholar was also used for complementary search. The search period was from 2002 to 2022. Table 1 shows the search strategy used for searching relevant studies in this scoping review.

The inclusion criteria for the studies were those that were in the form of original articles, reviews, or dissertations in English language, with full-text and addressed the factors affecting the couple’s desire for childbearing. The exclusion criteria were studies that lacked full-text or had non-English language or were book reviews, opinion articles, commentaries, letters to editors, or proceedings, which lacked the necessary framework for examining the specifications and evaluating the quality of the study.

In this stage, an attempt was made to access gray literature or studies that were not found in the search process by conducting a complementary search on Google Scholar and reviewing the references of the obtained studies. After searching the desired databases and removing duplicates, the studies were independently screened and reviewed by two members of the research team based on their title, abstract, and full-text in three phases. In each phase, the final decision on selecting the studies was made based on the agreement of both individuals, and in cases of disagreement, the opinion of the third member of the research team was taken.

Endnote software 8^th version was used to manage the process of systematic search and screening of studies. Moreover, the PRISMA protocol [21] was used to manage the process of selecting relevant studies and reporting this review (Fig. 1).

The process of extracting data from a scoping review is called charting the results. This process provides the reader a logical and concise summary of findings that is consistent with the objectives and questions of the scoping review. Create a charting table or form to record key source information such as authors, references, results, or findings related to the review question. Some important pieces of information that reviewers can choose to chart include author, year of publication, country of origin (published or research conducted), purpose/objectives, study population and sample size (if applicable), method, type of intervention, comparison and details (eg duration of intervention) (if applicable), intervention period (if applicable), results and related information (eg actions taken) (if applicable), and key findings related to scoping review questions. For ease of reference and tracking, reviewers are encouraged to keep careful records to identify each source [18, 20].

Therefore in present scoping review, after selecting the final studies based on the desired inclusion and exclusion criteria, data related to the factors affecting the couples’ desire to have children were extracted from the studies and entered into a study specifications table resulting from the scoping review. This table included the name of the first author, year of publication, study title, place of implementation, study design, participants, and key findings of the study. These results are presented in Table 2. Although the quality appraisal of the studies is not mandatory in the scoping review [22], the quality of the final selected studies according to the review was evaluated using specific quality assessment tools based on the each study’s type and method (Table 3). The studies obtained from the scoping review were assessed for quality using three established tools: the Critical Appraisal Skills Program (CASP) for qualitative research, the Appraisal Tool for Cross-Sectional Studies (AXIS tool), and the JBI Critical Appraisal Checklist for systematic reviews and research syntheses.

Subsequently, the collected data underwent iterative qualitative analysis to ensure comprehensive coverage of complex topics and concepts relevant to the review’s context. This method facilitated the identification and summarization of various aspects concerning factors influencing couples’ desire to have children and enabled accurate interpretation of the study texts. Unforeseen data discovered during interpretation were continuously incorporated into the evolving results, with the graphical table being regularly updated. It is advisable for the review team to familiarize themselves with the original results and test the data extraction format in a few studies to ensure comprehensive extraction. This approach is commonly favored by practitioners conducting scoping reviews [18].

The summary of findings elucidates the objectives of the included articles, the underlying concepts and approaches, and the results pertaining to the review questions. Extracted results were categorized into broader theoretical groupings aligned with the review’s focus [20]. In this stage, two authors independently screened and reviewed the text and results of each selected study in the review and extracted related meaningful codes according to the review purpose. Then they integrated and summarized the data obtained from the studies’ texts to reach the sub-themes related to the factors affecting the couples’ desire to have children. In cases of possible disagreements, a third person in research team would help to reach a consensus. Finally, the main themes related to the topic were defined, clarified, and categorized as a comprehensive set of factors affecting the couples’ desire to have children (Table 4).

This step is optional in some scoping review guidelines, but in the framework provided by Levac [19], getting experts’ opinions regarding the obtained items through consultation is emphasized. Therefore, it tried to use some experts’ suggested viewpoints in this field to finalize the research findings.

Through a meticulous search, 5,346 studies were identified across 3 primary databases. After eliminating duplicates, 2,756 studies proceeded to the title screening phase. Subsequently, studies with irrelevant titles were excluded, leaving 1,134 studies for abstract review. From this, 336 studies were identified as suitable for full-text assessment. Also, 23 studies were added to this screening phase due to experts’ suggestion or by checking the references’ lists. After a comprehensive evaluation of the complete texts, 46 articles met the criteria for inclusion in the scoping review and subsequent data extraction.

The majority of the studies were conducted in 2021 (19.5%), followed by 2017 (15%), 2022 (13%), and 2019 (13%). The predominant focus of the final studies derived from the scoping review was Iran (65%). However, within the scoping review, four selected studies explored factors influencing couples’ fertility preferences across a range of countries spanning from three to seventy-nine nations. Additionally, the selected studies in the scoping review employed diverse methodological approaches: cross-sectional and observational studies constituted 78%, qualitative studies comprised 11%, and systematic reviews constituted 9%. An overview of the chosen final studies based on the systematic scoping review is presented in Table 2.

Also, Table 3 presents the results of the quality assessment of the final studies derived from the scoping review, utilizing various quality assessment tools categorized by study type.

Through qualitative data analysis extracted from the selected studies in the systematic scoping review, factors influencing households’ fertility preferences were categorized into 8 primary themes and 101 sub-themes. The primary themes about factors affecting households’ fertility preferences encompassed individual factors, demographic and familial factors, cultural factors, social factors, health-related factors, economic factors, insurance-related factors, and issues related to governmental support and encouragement policies (as detailed in Table 4).

Based on the findings of the present study conducted through a systematic review framework, influential factors affecting couples’ inclination towards parenthood have been grouped into eight domains: individual factors, demographic and familial factors, cultural factors, social factors, health-related factors, economic factors, insurance-related factors, and government policies supporting or encouraging parenthood.

Drawing from the insights of this research, it becomes evident that governments and policymakers must bestow comprehensive and well-directed attention to the myriad of factors influencing households’ intentions and behaviors related to childbearing. Furthermore, given the comparatively limited effectiveness of specific existing government incentive policies in stimulating couples’ aspirations for childbearing, a reassessment and reformulation of these policies seem indispensable. Particularly crucial is addressing paramount challenges and factors contributing to couples’ concerns about childbearing or reinforcing elements that could significantly enhance fertility desires and intentions for childbearing.