In recent years, considerable demographic changes have occurred around the world, among which the changes in fertility rates are one [1]. From the demographic perspective, fertility and childbearing are recognized as one of the most important determinants of population fluctuation, such that the demographic policies in most countries revolve around reducing or increasing fertility [2]. Childbearing is an important phenomenon in demographic change and the basis of sustainable development for countries with replacement fertility levels [3]. Reducing childbearing, in addition to having an impact on the population growth rate, can also affect the composition and structure of the population, such that there is a gradual shift from a younger to older age structure [4]. Iran is no exception when it comes to the process of population transition, and, in the last 30 years, the fertility rate has fallen below the succession level and progressed to a decline in childbearing [1]. The results of previous studies show that factors such as an increase in the age of marriage and that of the mother at the time of the first pregnancy, the broad coverage of contraceptive methods, gender equality, empowerment woman of low socioeconomic status, and changes in attitudes and fertility intentions have been effective in changing fertility behavior [5,6]. Attitude and fertility inclinations play a major role in childbearing [7]; positive attitudes toward childbearing can not only result in childbearing but also positive attitudes toward childbearing can not only result in timely childbearing but also elicit strong childbearing intentions [8].

In order to create positive beliefs in the community, there is a need for educational interventions tailored to existing needs. However, some scholars believe that the failure of some programs is due to the lack of attention to etiological studies and the fact that their design did not account for psychosocial models as a specific conceptual framework [9]. Therefore, the implementation of behavioral models seems to be effective in this regard; for this purpose, in this study, the beliefs, attitudes, subjective norms, and enabling factors (BASNEF) model was used (Figure 1).

This model, presented by Hubley [10] in 1988, consists of the structures of behavioral beliefs (individual beliefs about outcomes or attributes of performing the behavior), attitudes (a person’s overall favorableness or unfavorableness toward performing the behavior), subjective norms (important referent individuals approving or disapproving of performing the behavior), enabling factors (antecedents to behavioral or environmental change that allow a motivation or environmental policy to be realized), and behavioral intention (perceived likelihood of performing the behavior) [11].

This model has been derived by combining two models—PRECEDE and Reasoned Action—and has been implemented to study the behavior in question, create a design for changing it, and to determine the factors that are effective in the decision making of individuals demonstrating the behavior.

In the BASNEF model, while each intention does not necessarily lead to behavior, there are factors, such as money, skill, and existing services, connecting intention and behavior; this is the main point of departure from the Reasoned Action model [7]. In order to better understand the issue of childbearing, it is necessary to investigate women’s beliefs regarding the subject; thus, based on the BASNEF model, this study aimed to investigate the psychological and sociodemographic factors related to the childbearing intention of women referred to comprehensive health centers in Hamadan.

This was a descriptive analytical study conducted on 486 women referred to comprehensive health centers in Hamadan and selected by multi-stage sampling in 2017. For sampling, three clusters (health centers) from each of the four areas of Hamadan were randomly selected. Then, 3 days of the week were randomly chosen for visits to these health centers, where women were randomly selected. Inclusion criteria were women who were (1) 15–49 years old, (2) residing in the city, and (3) at least in the second year of marriage and with no children and those whose last child was born more than 3 years previously. The exclusion criterion was the unwillingness to participate in the study. Written informed consent was obtained from all participants. This study was also approved by the Ethics Committee of Hamadan University of Medical Sciences (approval no., IR.UMSHA.REC.1396.210).

The data collection tool was a researcher-made questionnaire based on the BASNEF model (supplement 1), divided into two parts. The first was related to demographic information (mother’s age, mother’s occupation, mother’s educational level, mother’s religion, the age at which the current marriage took place, husband’s age, husband’s occupation, husband’s educational level, husband’s income, number of pregnancies, current number of children, number of live births, sex of the children, and the number of children the mother considered ideal). The second part consisted of 50 items: 13 questions to assess attitude (“I feel happy in marital life because of the child”), 13 questions on subjective norms (“My husband encourages me to have a child”), 13 questions on motivation to comply (“My husband’s opinion about childbearing is very important to me”), four questions on behavioral intention (perceived likelihood of childbearing over a given period of time; the next few years, for example), and seven questions on enabling factors (“Have you ever participated in childbearing skills classes?”).

Questionnaire items were classified on a 5-point Likert scale (strongly disagree=1 to strongly agree=5). The content and face validity of the questionnaire were reviewed and verified by 10 health education professionals. For this purpose, the content validity ratio of 0.85 and the content validity index for the criteria of simplicity, specificity, and clarity were obtained, with an average of 0.90. Cronbach’s alpha coefficients were calculated to determine the reliability of various parts of the questionnaire: 0.70, 0.79, 0.49, 0.85, and 0.63 for the structures of attitude, subjective norms, motivation to comply, behavioral intention, and enabling factors, respectively. Data analysis was performed using IBM SPSS software ver. 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (charts, tables, and numerical indices) were used to describe the data. Inferential statistics (independent t-test, one-way analysis of variance, and linear regression) were used to determine the relationships between variables, and the significance level was set at less than 0.05.

The mean±standard deviation of the age of the participants in the study was 31.85±6.13 years and their age ranged between 16 and 49 years. Among the participants, 46.1% had university-level education and more than one-third (35.3%) had been married for 5–10 years. Of these, 34.4% of women had one child. Demographic characteristics and fertility records are depicted in Table 1.

Statistical indicators of the structures of the BASNEF model in relation to childbearing showed that positive attitudes toward childbearing, with 65.6% of the maximum achievable scores, had the highest frequency. At the other end of the spectrum, behavioral intention, with 34.1% of the maximum achievable scores, had the lowest frequency. In other words, in this study, the attitude toward childbearing was relatively favorable among mothers. However, the fertility intention was not favorable. Also, among the structures of the BASNEF model, subjective norms had the highest correlation coefficient with behavioral intention (r=0.351). As seen, there were positive (direction) relationships between all constructs of the BASNEF model and fertility intention (P<0.05) (Table 2).

There was a significant relationship between the behavioral intention of childbearing and age, education, income status, duration of marriage, and sex of the child (P<0.05). Using post hoc tests, it was detected that lower age, higher education, shorter duration of marriage, being childless, and having a daughter resulted in a greater fertility intention (Table 3).

Linear regression analysis demonstrated that the variables of motivation to comply (β=0.228), enabling factors (β=0.162), subjective norms (β=0.134), and attitude (β=0.122) were predictors of childbearing intention, in this order. Regarding the standardized values of beta, motivation to comply was the most powerful predictor compared to other structures of the model, which identified 16.8% of the variance of childbearing intention. According to the table, all the predictors had a significant positive (direct) impact on fertility intention (P<0.05). Therefore, by increasing one unit in attitude, the average of fertility intention increases by 0.122 units (Table 4).

The purpose of the present study was a BASNEF model-based investigation of the factors related to childbearing intention in women referred to comprehensive health centers in Hamadan. The results of this study demonstrated that all variables of the BASNEF model had a significant relationship with childbearing intention and were able to explain a total of 16.8% of the childbearing intention. Among the variables of the BASNEF model, the most influential predictor of childbearing intention in women was the motivation to obey. Other powerful variables were enabling factors, attitudes, and subjective norms.

In the present study, the motivation to comply was more influential for childbearing intention than other structures of the BASNEF model. Indeed, in this structure, it was determined that the opinions of important people, such as husband, father, father-in-law, mother-in-law, friends, and clerics play a very big role in a woman performing a particular behavior (such as childbearing) [10]. If a woman is exposed to the views of each of these people, her desire for childbearing will be affected. In Iranian culture, the desire for fertility, in addition to individual motivations, is also affected by social interactions, such that even if a couple is not interested in starting a family, the social pressure created by acquaintances puts them on the path to childbearing [12].

Another predictor of childbearing intention was enabling factors. According to the BASNEF model, when the attitude and subjective norms are conducive to a particular behavior, the behavioral intention leads to the desired behavior if the enabling factors serve as the mediator [10]. This has been confirmed in other studies, such that providing enabling factors like free-of-charge monthly pregnancy check-ups, free food coupons, tax cuts, paying the Bahar Azadi coin, giving student mothers more time to study, formulating plans to reduce working hours for employed mothers, providing two-week paternity leave, increasing the leave for pregnant women, implementing encouraging policies for new mothers, and raising awareness about the importance of having children, have been able to influence childbearing intention and population growth [13]. The results of a study in Russia also showed that governmental incentives had a positive effect on childbearing [14]. Therefore, it is proposed that lawmakers focus on approving policies and passing laws that enable and support childbearing.

Other findings of the present study demonstrated that attitude and subjective norms also predict the intention of childbearing among women, which is consistent with the results of similar studies [7]. In fact, if a woman has a positive attitude toward childbearing and the important people in her life encourage her in this regard, it can significantly contribute to the woman’s childbearing intention [15]. In some countries, religious beliefs regarding childbearing increase the intention to have children [16]. Therefore, it appears that this should be considered in designing interventions related to improving attitudes toward fertility in countries with a religious approach, for example, Iran.

In this study, younger women had higher childbearing intentions. While this finding is in agreement with one study [6], it contradicts another [17]. This contradiction appears to be explained by the fact that the quality of women’s encounters with the issue of childbearing varies by age group, such that younger women have more motivation and patience and, consequently, have a greater tendency to become pregnant, but, at older ages, the focus on preventing pregnancy complications leads to a reduction in childbearing intention.

In the study, women with higher educational levels had higher childbearing intentions. This finding is inconsistent with previous studies conducted in Iran [18], Oman [19], and China [20]. In the mentioned studies, the reason for the lower fertility intention in women with higher educational levels was the fact that increasing the level of education increases women’s willingness to participate in economic and social activities, which serves as a deterrent for childbearing intention. It seems that the contradiction between the present results and those of previous studies is due to the fact that although women with higher education tend to have higher childbearing intention, they may not always be able to convert it into childbearing behavior because of their various commitments, academic and otherwise.

In the present study, women with higher income had higher childbearing intention. This was consistent with the results of a previous study [21]. The evidence indicates that economic issues, including worries about providing for children and securing their future and the fear of increasing the family’s economic burden, are one of the most important reasons for women’s unwillingness to become pregnant [22]. Considering this, it seems that families with higher income have more intention to childbearing owing to greater financial security and lack of concern about the costs associated with raising children.

Another finding of this study was that childless women had higher fertility intention. The evidence shows that having no child, the probability of childbearing increases by 2.9 times and moreover, 77.7% of women with 2 or 3 children and 86% of women with more than three children did not intend to have another child. In fact, it can be said that the unwillingness to have children increases with the number of existing children [23]. It appears that fertility needs to be encouraged not only in childless women but also those who are already mothers.

In this study, higher childbearing tendencies were observed among the women with shorter marriage durations. In Iranian society, acquaintances tend to urge newly married couples to try for children and experience parenting [24]. In addition, it is a commonly held belief that having a child soon after marriage leads to greater stability in marital life [25]. It seems that such expectations and beliefs increase couples’ childbearing tendencies. In this study, childbearing intention was observed to be greater among women who had daughters. In fact, the desire to have a son can affect fertility intention. Although this finding has been confirmed in a study in Pakistan [26], it was necessary to confirm this in light of the cultural and social differences between populations [27]. Even in Iranian society, with its traditional culture, having a boy is more desirable [28].

The determination of factors related to childbearing intention among couples using the theories of health behavior is a strength of this study. Now, further studies are needed to assess the validity of other socio-psychological theories. However, the present study also had some limitations. The first limitation of the study was its cross-sectional nature; it is possible that causal relations between the variables could be further understood in a study conducted over a longer period of time. The second limitation was some eligible mothers’ refusal to participate in the study. Finally, the use of a self-report measure might have led to response bias.

The results of this study indicate that designing and implementing educational programs to improve attitudes, promote positive subjective norms, and strengthen enabling factors can play a major role in increasing women’s fertility intention.