Volume 23, Issue 1 (3-2026)
J Res Dev Nurs Midw 2026, 23(1): 45-52 |
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Nazari S, Abbasi Z, Abbasi- Shavazi M J, Ebadi A, Rezaeean S M, Keshavarz Z. Understanding fertility preferences: Insights from women and experts in North Khorasan, Iran. J Res Dev Nurs Midw 2026; 23 (1) :45-52
URL: http://nmj.goums.ac.ir/article-1-2070-en.html
URL: http://nmj.goums.ac.ir/article-1-2070-en.html
Sakineh Nazari1 
, Zohreh Abbasi1 , Mohammad Jalal Abbasi- Shavazi2 , Abbas Ebadi3 , Seyedeh Mahboobeh Rezaeean4 , Zohreh Keshavarz5
, Zohreh Abbasi1 , Mohammad Jalal Abbasi- Shavazi2 , Abbas Ebadi3 , Seyedeh Mahboobeh Rezaeean4 , Zohreh Keshavarz5
1- Department of Midwifery, School of Nursing and Midwifery, North Khorasan University of Medical Sciences, Bojnurd, Iran
2- Vienna Institute of Demography, Austrian Academy of Sciences, Vienna, Austria; Department of Demography, Faculty of Social Sciences, University of Tehran, Tehran, Iran
3- Nursing Care Research Center, Clinical Sciences Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
4- Department of Midwifery, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
5- Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,keshavarzzohre57@gmail.com
2- Vienna Institute of Demography, Austrian Academy of Sciences, Vienna, Austria; Department of Demography, Faculty of Social Sciences, University of Tehran, Tehran, Iran
3- Nursing Care Research Center, Clinical Sciences Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
4- Department of Midwifery, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
5- Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,
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Discussion
This study explored two distinct fertility patterns: preferences for more than two children and preferences for fewer than two children. Among women inclined toward larger families, gaining power and social status emerged as important themes.
Based on the theory of the value of children and dignity theory, which are grounded in normative (Cultural) and rational-choice perspectives (11,12), childbearing was perceived as a source of social dignity, future security, and family support in later life (12). In traditional and religious societies, such as Iranian-Islamic culture, intergenerational family relationships and respect for the role of the mother have always been strongly emphasized (13). This finding has been confirmed in numerous studies, including those by Abassi and Khoja (14,15). Khoja (2024) reported that family and familial orientation are factors affecting childbearing (14).
Abassi (2019) also reported that reproductive preferences, expressed as receiving maternal dignity, are a factor in childbearing (15). Social acceptance was another influential factor associated with higher fertility preferences. Motherhood was regarded as a valued social role, particularly among housewives, and was linked to social recognition, role fulfillment, and cultural beliefs emphasizing childbearing as a natural aspect of womanhood (13,16). However, gendered organizations that presume a flow of support from home compete with the “motherhood mandate” that demands intensive mothering (16). Meyer-Österlund (2026) reported that motherhood is widely recognized as a profound developmental life event, encompassing physical recovery, reorganization of life and identity, and new caregiving responsibilities (17).
These findings are consistent with previous studies highlighting the contribution of maternal roles to women’s social identity and status (13,15). Broader contextual factors, such as work conditions, health status, education levels, access to healthcare, and career opportunities, have also been shown to shape fertility intentions (18,19). However, based on the study by Zarei (2025), no significant relationship was found between positive and negative childbearing motivations across different education levels (20). Religiosity has been inconsistently associated with fertility behavior in previous studies; for example, Malmir (2023), Abbasi (2022), and Amirian demonstrated a positive association between religiosity and childbearing intentions (21-23), whereas Iman (2007) and Xie D (2022) reported a limited contribution of religiosity to fertility behavior (24,25).
Lifestyle orientation also influenced preferences for larger families. Several studies have demonstrated important effects of lifestyle and parents’ childbearing behavior on their children’s childbearing preferences and behavior (26,27).
In explaining the perspectives of our study participants, it was shown that social networks and family support systems may reduce the perceived burden of childrearing and strengthen fertility intentions through social capital mechanisms. Mönkediek (2017) reported that family systems, as normative frameworks in which family processes unfold, are believed to exert a major influence on fertility. However, in their view, the question of how family systems influence fertility intentions has remained largely unexplored (28).
An important point in explaining the perspectives of our study participants is that women with lower fertility preferences described a shift from childbearing toward quality parenting. Participants emphasized the importance of providing favorable educational, emotional, and economic conditions for children rather than increasing family size (27). These findings support the theory of the quality-quantity tradeoff in fertility behavior (29), whereby parents prioritize child quality over the number of children (30). This finding has been confirmed by Hubbs (31).
Economic concerns represented another major factor influencing low fertility preferences. Participants referred to the high costs of raising children, financial insecurity, inadequate living conditions, and concerns regarding the future, which various studies have described as the hidden hardship of building a family (32). Similar research has reported the relative ineffectiveness of some current government supportive/incentive policies in increasing couples’ desire for childbearing (33).
Rethinking fertility also emerged as an important theme. Participants described changing attitudes toward motherhood, modern lifestyles, and concerns regarding restrictions on educational, occupational, and social roles. These findings reflect broader social changes in which lower fertility has become increasingly normalized. Previous studies in Iran have reported an inverse association between women’s education and fertility behavior, with higher educational attainment contributing to delayed childbearing (8). However, findings from China suggest that expanded access to higher education may, in some contexts, increase fertility rates (34,35).
One strength of this study is the simultaneous exploration of fertility preferences among women with differing childbearing patterns and expert perspectives. However, the study was conducted in a single geographical region (North Khorasan Province), which may limit the transferability of the findings. Moreover, husbands were not included in the interviews, and only women and experts were interviewed. Additionally, the findings are specific to the Iranian-Islamic cultural context and may not be generalizable to other cultural settings. Future studies involving men and diverse geographical settings could provide a more comprehensive understanding of fertility decision-making.
Conclusion
This study highlights the complex interplay of social, cultural, and personal factors shaping fertility preferences. While themes such as empowerment, passive social acceptance, inefficacy of educational and health strategies, and specific lifestyle patterns contribute to the choice of having more than two children, reconsideration of the value of children and fertility emerged as key determinants of preferring fewer than two children. These findings underscore the need for context-sensitive reproductive health policies and educational interventions that address both the motivations for larger families and evolving attitudes toward smaller family sizes. Strengthening reproductive health programs and tailoring strategies to diverse social realities can support informed decision-making and promote balanced population policies.
Considering the research findings and differences in reproductive behavior, it is recommended that similar qualitative studies be conducted in different communities and ethnic groups where differences in reproductive behavior are more evident.
Acknowledgement
This study was supported by Shahid Beheshti University of Medical Sciences. The authors extend their gratitude to the directors, reproductive health experts, and women who participated in this study.
Funding Sources
This study was funded by the Vice Chancellor for Research, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Ethical Statement
This study received approval from the Ethics Committee of Shahid Beheshti University of Medical Sciences (Approval code: IR.SBMU.PHARMACY.REC.1404.076). All ethical guidelines for research involving human participants were strictly observed, including the provision of informed consent. Permission was obtained from participants to audio-record interviews; when recording was declined, interviews were documented through written transcription. All participants were informed of the confidentiality of the data and of their right to withdraw from the interview and the study at any time without consequence.
Conflicts of Interest
The authors declared no conflicts of interest.
Author Contributions
Z.K. Z.A., S.N., conceived the main idea, designed the statistical model and computational framework, and approved the final manuscript. S.N., Z.A, SM.R, Z.K. collected the data and approved the final manuscript. A.E., MJ.A. designed the study, performed the data analysis, interpreted the results, and critically revised the manuscript. S.N. and Z.A., Z.K drafted the manuscript. all of author. contributed to the overall study conception and approved the final manuscript.
Data Availability Statement
The datasets generated during this study are not publicly available due to confidentiality constraints but can be obtained from the corresponding author upon reasonable request.
Use of Artificial Intelligence
AI-assisted tools were used to support language editing; these tools were not involved in data analysis, the writing of scientific content, the interpretation of results, or scientific decision-making.
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Introduction
One of the significant demographic and health phenomena observed in Iran over recent decades is the rapid decline in fertility. According to data from the Statistical Center of Iran, the total fertility rate (TFR) was 1.8 children per woman in 2011 (1390 in the Iranian calendar). In 2016 (1395), the TFR temporarily increased to 2.01 children per woman; however, it subsequently declined again, reaching 1.7 children per woman in 2020 (1399) (1).
North Khorasan Province has not been an exception to this trend and has also experienced a decline in fertility in recent years. Between 2011 and 2016 (1390-1395), along with Hamedan Province, it was one of the two provinces in Iran that experienced negative population growth. Population changes in any region are influenced by three components: fertility, migration, and mortality. Since there is no evidence of increased mortality in recent decades in the province, the negative population growth in recent years can be attributed to increased out-migration and declining fertility. The total fertility rate (TFR) in North Khorasan Province decreased from 2.8 children per woman in 2016 (1395) to 2.1 children per woman in 2019 (1398) (2).
Furthermore, population policies should be guided by robust research on fertility, as fertility represents the primary determinant of demographic transition and merits greater attention than other demographic phenomena (3,4). Although fertility is inherently a private matter within families, its consequences extend beyond the household, affecting societal structures and social interactions. Consequently, accurately measuring and understanding fertility rates across different population strata is critical for evaluating the socioeconomic conditions of a society and for developing reliable population projections, which provide the foundation for economic, social, and demographic planning (5).
Fertility encompasses not only biomedical dimensions but also complex sociocultural factors that vary across societies and contexts (6). Reproductive health, a fundamental human right essential for social, emotional, and physical well-being, may be constrained by various factors. Women play a central role in fertility, and understanding their reproductive behaviors and the motivations underlying these behaviors is crucial for achieving national objectives in economic, cultural, educational, and health planning. Such understanding also contributes to identifying the determinants that influence population growth and decline (7).
Safdari-Dehcheshmeh in a study conducted by Safdari-Dehcheshmeh (2023), the results showed that personal factors included the expansion of women’s education, participation in the labor market, personality traits, attitudes and personal preferences, fertility knowledge, and physical and psychological preparedness. Interpersonal factors included stable relationships with spouses and other important people. Macro-level factors included supportive policies, medical achievements, and sociocultural and economic factors (8).
Fertility behavior is influenced by multiple determinants, including ethnicity, cultural norms, socioeconomic conditions, and national population policies. North Khorasan, recognized as the most ethnically diverse province in Iran (Turks, Kurmanjis, Turkmens, Persians, and Tats), has not yet been the subject of studies that simultaneously examine factors influencing both low and high fertility decisions.
By identifying these determinants and informing the development of evidence-based interventions, policymakers can implement targeted programs aimed at increasing overall fertility rates while safeguarding maternal and child health. This approach is particularly important in the context of population aging and the promotion of healthy fertility practices (7). To address the existing knowledge gap, this qualitative study aimed to explore women’s fertility preferences and experts’ perspectives in North Khorasan, Iran, including those of healthcare professionals, university faculty members, and sociologists, regarding the factors shaping fertility preferences and childbearing decisions.
Methods
This qualitative study was conducted in 2025 in Bojnord, North Khorasan Province, Iran, using a conventional content analysis approach. Data were collected through in-depth, semi-structured individual interviews with 64 participants selected through purposive sampling. Participants consisted of three groups: women with two or fewer children (Low fertility preference) (n = 35), women with more than two children (High fertility preference) (n = 16), and experts in the field of childbearing (n = 13), including healthcare professionals, university faculty members, and sociologists.
Participants were recruited using purposive and snowball sampling methods based on predefined inclusion criteria and the study objectives. Inclusion criteria for women participants included being married, residing in North Khorasan Province, having experienced at least one childbirth, and being able to provide rich information regarding fertility preferences and childbearing experiences. Women were categorized into two groups: those with two or fewer children and those with more than two children.
Experts were eligible to participate if they had academic or professional experience in reproductive health, population studies, sociology, nursing, midwifery, or related disciplines and relevant work or research experience in these areas.
Data from women participants were collected through visits to health centers and, when feasible and preferred by participants, through home visits. Interviews with experts were conducted either at their workplace or in an office selected by them. Prior to each interview, participants received information regarding the study objectives, interview process, and ethical considerations, and informed consent was obtained.
Interviews were conducted using a semi-structured format with open-ended and experience-based questions tailored to each participant group. Women participants were encouraged to describe their experiences and perceptions regarding childbearing and fertility preferences through questions such as: “Please describe your experiences with childbearing,” “How did you make decisions about having children?” “What experiences or circumstances affected your decisions regarding having more children?” and “How do you perceive the advantages and challenges of having children in your current life situation?”
Experts were asked broad exploratory questions, including: “Based on your experiences and observations, how do women make decisions regarding childbearing?” and “What social, cultural, economic, or health-related factors appear to influence fertility preferences and family size?”
Follow-up and probing questions were used throughout the interviews to gain deeper insight and clarify participants’ meanings and experiences. The interviews were conducted by a faculty member experienced in qualitative research and women’s health. The interviewer maintained a neutral position throughout the interviews and documented key points to ensure the accuracy and completeness of the data.
Data collection continued until data saturation was achieved and no new concepts or categories emerged. Interviews lasted between 30 and 90 minutes. At the end of each interview, a brief summary of the main points was reviewed with participants to confirm the accuracy of the interpretations. Audio recordings and field notes were transcribed and documented immediately after each interview to ensure consistency and rigor in data management.
The data were analyzed using conventional content analysis (9), guided by the approach proposed by Graneheim and Lundman (2004). Initially, each interview transcript was read several times to achieve a sense of the whole and deepen understanding. Meaning units relevant to the research questions were then identified, condensed, and abstracted into codes. These codes were compared for similarities and differences, grouped into subcategories and categories, and subsequently organized into broader themes representing the underlying meanings in the data. Throughout the analytic process, continuous reflection and discussion among the research team ensured the credibility and trustworthiness of the findings.
Coding was conducted by two members of the research team using MAXQDA software. Final agreement on the findings was reached by three members of the team, and a qualitative research expert was also involved in the study to ensure rigor.
Finally, the data were treated as units of analysis and categorized into two groups: findings related to multiple childbearing and findings related to low childbearing.
Trustworthiness and rigor were ensured based on Lincoln and Guba’s criteria (10), including credibility, confirmability, transferability, and dependability. To enhance credibility, interview transcripts were reviewed by academic faculty members, and necessary revisions were incorporated. Participants also provided feedback on the preliminary findings to verify the accuracy of the extracted categories. Dependability and confirmability were strengthened through independent review of the interview materials and analytic decisions by members of the research team. Transferability was assessed by asking three independent reviewers-a faculty member, a homemaker, and a cultural expert (Women’s affairs consultant)-to evaluate the applicability of the findings to similar contexts.
Results
This qualitative study included 64 participants in three groups: 35 women with low childbearing intention (One or two children), 16 women with high childbearing intention (Three or more children), and 13 experts (Both male and female) in the field of childbearing (Table 1).
In the high childbearing intention group, the majority of women were 30-40 years of age (62%), had an educational level below a high school diploma (75%), were housewives (82%), and had four or more children (56%). In contrast, in the low childbearing intention group, most women were also 30-40 years old (58%), had an educational level above diploma level (65%), were employed (65%), and had two children (68%). The expert group consisted of 13 participants (9 men and 4 women) with bachelor’s degrees or higher. Their professional backgrounds included university faculty members (6 participants, including psychologists, reproductive health specialists, and healthcare professionals), 4 sociologists, and 3 individuals with seminary degrees. Experts in this study were purposefully selected from both low-child (Less than two children) and high-child (More than four children) groups (Table 1).
Analysis of the participants’ statements (From both women’s groups and experts) revealed four main themes as factors influencing the choice of having more than two children: gaining power, passive social acceptance, inefficiency of educational and health approaches, and specific lifestyle patterns (Table 2).
The theme of gaining power encompassed factors such as enhancement of social status (Receiving social respect, authority, and strengthening the woman’s position in the family), future orientation (Parent-centered foresight, child-centered foresight, and economic foresight), and role-seeking (The perception of childbearing as a feminine duty).
The theme of passive social acceptance included factors such as fertility fatalism (Religious and spiritual beliefs and behaviors) and social imitation (Dominant discursive environment, prevailing social beliefs, and the influence of historical and environmental contexts).
The theme of ineffectiveness of educational and health approaches involved factors such as educational inefficiency (Weak media performance and lack of educational resources in society) and healthcare inefficiency (Low individual self-efficacy in fertility control and weaknesses in healthcare service provision systems).
One of the significant demographic and health phenomena observed in Iran over recent decades is the rapid decline in fertility. According to data from the Statistical Center of Iran, the total fertility rate (TFR) was 1.8 children per woman in 2011 (1390 in the Iranian calendar). In 2016 (1395), the TFR temporarily increased to 2.01 children per woman; however, it subsequently declined again, reaching 1.7 children per woman in 2020 (1399) (1).
North Khorasan Province has not been an exception to this trend and has also experienced a decline in fertility in recent years. Between 2011 and 2016 (1390-1395), along with Hamedan Province, it was one of the two provinces in Iran that experienced negative population growth. Population changes in any region are influenced by three components: fertility, migration, and mortality. Since there is no evidence of increased mortality in recent decades in the province, the negative population growth in recent years can be attributed to increased out-migration and declining fertility. The total fertility rate (TFR) in North Khorasan Province decreased from 2.8 children per woman in 2016 (1395) to 2.1 children per woman in 2019 (1398) (2).
Furthermore, population policies should be guided by robust research on fertility, as fertility represents the primary determinant of demographic transition and merits greater attention than other demographic phenomena (3,4). Although fertility is inherently a private matter within families, its consequences extend beyond the household, affecting societal structures and social interactions. Consequently, accurately measuring and understanding fertility rates across different population strata is critical for evaluating the socioeconomic conditions of a society and for developing reliable population projections, which provide the foundation for economic, social, and demographic planning (5).
Fertility encompasses not only biomedical dimensions but also complex sociocultural factors that vary across societies and contexts (6). Reproductive health, a fundamental human right essential for social, emotional, and physical well-being, may be constrained by various factors. Women play a central role in fertility, and understanding their reproductive behaviors and the motivations underlying these behaviors is crucial for achieving national objectives in economic, cultural, educational, and health planning. Such understanding also contributes to identifying the determinants that influence population growth and decline (7).
Safdari-Dehcheshmeh in a study conducted by Safdari-Dehcheshmeh (2023), the results showed that personal factors included the expansion of women’s education, participation in the labor market, personality traits, attitudes and personal preferences, fertility knowledge, and physical and psychological preparedness. Interpersonal factors included stable relationships with spouses and other important people. Macro-level factors included supportive policies, medical achievements, and sociocultural and economic factors (8).
Fertility behavior is influenced by multiple determinants, including ethnicity, cultural norms, socioeconomic conditions, and national population policies. North Khorasan, recognized as the most ethnically diverse province in Iran (Turks, Kurmanjis, Turkmens, Persians, and Tats), has not yet been the subject of studies that simultaneously examine factors influencing both low and high fertility decisions.
By identifying these determinants and informing the development of evidence-based interventions, policymakers can implement targeted programs aimed at increasing overall fertility rates while safeguarding maternal and child health. This approach is particularly important in the context of population aging and the promotion of healthy fertility practices (7). To address the existing knowledge gap, this qualitative study aimed to explore women’s fertility preferences and experts’ perspectives in North Khorasan, Iran, including those of healthcare professionals, university faculty members, and sociologists, regarding the factors shaping fertility preferences and childbearing decisions.
Methods
This qualitative study was conducted in 2025 in Bojnord, North Khorasan Province, Iran, using a conventional content analysis approach. Data were collected through in-depth, semi-structured individual interviews with 64 participants selected through purposive sampling. Participants consisted of three groups: women with two or fewer children (Low fertility preference) (n = 35), women with more than two children (High fertility preference) (n = 16), and experts in the field of childbearing (n = 13), including healthcare professionals, university faculty members, and sociologists.
Participants were recruited using purposive and snowball sampling methods based on predefined inclusion criteria and the study objectives. Inclusion criteria for women participants included being married, residing in North Khorasan Province, having experienced at least one childbirth, and being able to provide rich information regarding fertility preferences and childbearing experiences. Women were categorized into two groups: those with two or fewer children and those with more than two children.
Experts were eligible to participate if they had academic or professional experience in reproductive health, population studies, sociology, nursing, midwifery, or related disciplines and relevant work or research experience in these areas.
Data from women participants were collected through visits to health centers and, when feasible and preferred by participants, through home visits. Interviews with experts were conducted either at their workplace or in an office selected by them. Prior to each interview, participants received information regarding the study objectives, interview process, and ethical considerations, and informed consent was obtained.
Interviews were conducted using a semi-structured format with open-ended and experience-based questions tailored to each participant group. Women participants were encouraged to describe their experiences and perceptions regarding childbearing and fertility preferences through questions such as: “Please describe your experiences with childbearing,” “How did you make decisions about having children?” “What experiences or circumstances affected your decisions regarding having more children?” and “How do you perceive the advantages and challenges of having children in your current life situation?”
Experts were asked broad exploratory questions, including: “Based on your experiences and observations, how do women make decisions regarding childbearing?” and “What social, cultural, economic, or health-related factors appear to influence fertility preferences and family size?”
Follow-up and probing questions were used throughout the interviews to gain deeper insight and clarify participants’ meanings and experiences. The interviews were conducted by a faculty member experienced in qualitative research and women’s health. The interviewer maintained a neutral position throughout the interviews and documented key points to ensure the accuracy and completeness of the data.
Data collection continued until data saturation was achieved and no new concepts or categories emerged. Interviews lasted between 30 and 90 minutes. At the end of each interview, a brief summary of the main points was reviewed with participants to confirm the accuracy of the interpretations. Audio recordings and field notes were transcribed and documented immediately after each interview to ensure consistency and rigor in data management.
The data were analyzed using conventional content analysis (9), guided by the approach proposed by Graneheim and Lundman (2004). Initially, each interview transcript was read several times to achieve a sense of the whole and deepen understanding. Meaning units relevant to the research questions were then identified, condensed, and abstracted into codes. These codes were compared for similarities and differences, grouped into subcategories and categories, and subsequently organized into broader themes representing the underlying meanings in the data. Throughout the analytic process, continuous reflection and discussion among the research team ensured the credibility and trustworthiness of the findings.
Coding was conducted by two members of the research team using MAXQDA software. Final agreement on the findings was reached by three members of the team, and a qualitative research expert was also involved in the study to ensure rigor.
Finally, the data were treated as units of analysis and categorized into two groups: findings related to multiple childbearing and findings related to low childbearing.
Trustworthiness and rigor were ensured based on Lincoln and Guba’s criteria (10), including credibility, confirmability, transferability, and dependability. To enhance credibility, interview transcripts were reviewed by academic faculty members, and necessary revisions were incorporated. Participants also provided feedback on the preliminary findings to verify the accuracy of the extracted categories. Dependability and confirmability were strengthened through independent review of the interview materials and analytic decisions by members of the research team. Transferability was assessed by asking three independent reviewers-a faculty member, a homemaker, and a cultural expert (Women’s affairs consultant)-to evaluate the applicability of the findings to similar contexts.
Results
This qualitative study included 64 participants in three groups: 35 women with low childbearing intention (One or two children), 16 women with high childbearing intention (Three or more children), and 13 experts (Both male and female) in the field of childbearing (Table 1).
In the high childbearing intention group, the majority of women were 30-40 years of age (62%), had an educational level below a high school diploma (75%), were housewives (82%), and had four or more children (56%). In contrast, in the low childbearing intention group, most women were also 30-40 years old (58%), had an educational level above diploma level (65%), were employed (65%), and had two children (68%). The expert group consisted of 13 participants (9 men and 4 women) with bachelor’s degrees or higher. Their professional backgrounds included university faculty members (6 participants, including psychologists, reproductive health specialists, and healthcare professionals), 4 sociologists, and 3 individuals with seminary degrees. Experts in this study were purposefully selected from both low-child (Less than two children) and high-child (More than four children) groups (Table 1).
Analysis of the participants’ statements (From both women’s groups and experts) revealed four main themes as factors influencing the choice of having more than two children: gaining power, passive social acceptance, inefficiency of educational and health approaches, and specific lifestyle patterns (Table 2).
The theme of gaining power encompassed factors such as enhancement of social status (Receiving social respect, authority, and strengthening the woman’s position in the family), future orientation (Parent-centered foresight, child-centered foresight, and economic foresight), and role-seeking (The perception of childbearing as a feminine duty).
The theme of passive social acceptance included factors such as fertility fatalism (Religious and spiritual beliefs and behaviors) and social imitation (Dominant discursive environment, prevailing social beliefs, and the influence of historical and environmental contexts).
The theme of ineffectiveness of educational and health approaches involved factors such as educational inefficiency (Weak media performance and lack of educational resources in society) and healthcare inefficiency (Low individual self-efficacy in fertility control and weaknesses in healthcare service provision systems).
|
Table 2 (Continued)
  |
The theme of specific lifestyle patterns incorporated factors such as the absence of a need-generating attitude (Simplicity and contentment), differences in family and kinship structures (Patriarchal mindsets, traditional and early marriage patterns, and prioritization of marriage over girls’ education), and confidence in marital cohesion (Strength of family foundations and lower divorce rates).
Analysis of participants’ statements (Including women from both groups and experts) yielded two main themes influencing the choice of having fewer than two children: rethinking the value of children and rethinking fertility (Table 3).
The theme of rethinking the value of children encompassed factors such as a shift in perspective from childbearing to childrearing (Emphasizing quality over quantity) and a cost-benefit attitude (Concerns about child-centrism; emotional, economic, physical, and psychological burdens; and threats to social well-being).
The theme of rethinking fertility included factors such as modernism (The social desirability of having fewer children and women’s shifting priorities toward pursuing education and employment) and desire management (Compensating for lost opportunities and the aspiration to enjoy life).
Analysis of participants’ statements (Including women from both groups and experts) yielded two main themes influencing the choice of having fewer than two children: rethinking the value of children and rethinking fertility (Table 3).
The theme of rethinking the value of children encompassed factors such as a shift in perspective from childbearing to childrearing (Emphasizing quality over quantity) and a cost-benefit attitude (Concerns about child-centrism; emotional, economic, physical, and psychological burdens; and threats to social well-being).
The theme of rethinking fertility included factors such as modernism (The social desirability of having fewer children and women’s shifting priorities toward pursuing education and employment) and desire management (Compensating for lost opportunities and the aspiration to enjoy life).
|
Table 3. Extracted themes from participants’ opinions regarding factors affecting the choice to have fewer children
  |
Discussion
This study explored two distinct fertility patterns: preferences for more than two children and preferences for fewer than two children. Among women inclined toward larger families, gaining power and social status emerged as important themes.
Based on the theory of the value of children and dignity theory, which are grounded in normative (Cultural) and rational-choice perspectives (11,12), childbearing was perceived as a source of social dignity, future security, and family support in later life (12). In traditional and religious societies, such as Iranian-Islamic culture, intergenerational family relationships and respect for the role of the mother have always been strongly emphasized (13). This finding has been confirmed in numerous studies, including those by Abassi and Khoja (14,15). Khoja (2024) reported that family and familial orientation are factors affecting childbearing (14).
Abassi (2019) also reported that reproductive preferences, expressed as receiving maternal dignity, are a factor in childbearing (15). Social acceptance was another influential factor associated with higher fertility preferences. Motherhood was regarded as a valued social role, particularly among housewives, and was linked to social recognition, role fulfillment, and cultural beliefs emphasizing childbearing as a natural aspect of womanhood (13,16). However, gendered organizations that presume a flow of support from home compete with the “motherhood mandate” that demands intensive mothering (16). Meyer-Österlund (2026) reported that motherhood is widely recognized as a profound developmental life event, encompassing physical recovery, reorganization of life and identity, and new caregiving responsibilities (17).
These findings are consistent with previous studies highlighting the contribution of maternal roles to women’s social identity and status (13,15). Broader contextual factors, such as work conditions, health status, education levels, access to healthcare, and career opportunities, have also been shown to shape fertility intentions (18,19). However, based on the study by Zarei (2025), no significant relationship was found between positive and negative childbearing motivations across different education levels (20). Religiosity has been inconsistently associated with fertility behavior in previous studies; for example, Malmir (2023), Abbasi (2022), and Amirian demonstrated a positive association between religiosity and childbearing intentions (21-23), whereas Iman (2007) and Xie D (2022) reported a limited contribution of religiosity to fertility behavior (24,25).
Lifestyle orientation also influenced preferences for larger families. Several studies have demonstrated important effects of lifestyle and parents’ childbearing behavior on their children’s childbearing preferences and behavior (26,27).
In explaining the perspectives of our study participants, it was shown that social networks and family support systems may reduce the perceived burden of childrearing and strengthen fertility intentions through social capital mechanisms. Mönkediek (2017) reported that family systems, as normative frameworks in which family processes unfold, are believed to exert a major influence on fertility. However, in their view, the question of how family systems influence fertility intentions has remained largely unexplored (28).
An important point in explaining the perspectives of our study participants is that women with lower fertility preferences described a shift from childbearing toward quality parenting. Participants emphasized the importance of providing favorable educational, emotional, and economic conditions for children rather than increasing family size (27). These findings support the theory of the quality-quantity tradeoff in fertility behavior (29), whereby parents prioritize child quality over the number of children (30). This finding has been confirmed by Hubbs (31).
Economic concerns represented another major factor influencing low fertility preferences. Participants referred to the high costs of raising children, financial insecurity, inadequate living conditions, and concerns regarding the future, which various studies have described as the hidden hardship of building a family (32). Similar research has reported the relative ineffectiveness of some current government supportive/incentive policies in increasing couples’ desire for childbearing (33).
Rethinking fertility also emerged as an important theme. Participants described changing attitudes toward motherhood, modern lifestyles, and concerns regarding restrictions on educational, occupational, and social roles. These findings reflect broader social changes in which lower fertility has become increasingly normalized. Previous studies in Iran have reported an inverse association between women’s education and fertility behavior, with higher educational attainment contributing to delayed childbearing (8). However, findings from China suggest that expanded access to higher education may, in some contexts, increase fertility rates (34,35).
One strength of this study is the simultaneous exploration of fertility preferences among women with differing childbearing patterns and expert perspectives. However, the study was conducted in a single geographical region (North Khorasan Province), which may limit the transferability of the findings. Moreover, husbands were not included in the interviews, and only women and experts were interviewed. Additionally, the findings are specific to the Iranian-Islamic cultural context and may not be generalizable to other cultural settings. Future studies involving men and diverse geographical settings could provide a more comprehensive understanding of fertility decision-making.
Conclusion
This study highlights the complex interplay of social, cultural, and personal factors shaping fertility preferences. While themes such as empowerment, passive social acceptance, inefficacy of educational and health strategies, and specific lifestyle patterns contribute to the choice of having more than two children, reconsideration of the value of children and fertility emerged as key determinants of preferring fewer than two children. These findings underscore the need for context-sensitive reproductive health policies and educational interventions that address both the motivations for larger families and evolving attitudes toward smaller family sizes. Strengthening reproductive health programs and tailoring strategies to diverse social realities can support informed decision-making and promote balanced population policies.
Considering the research findings and differences in reproductive behavior, it is recommended that similar qualitative studies be conducted in different communities and ethnic groups where differences in reproductive behavior are more evident.
Acknowledgement
This study was supported by Shahid Beheshti University of Medical Sciences. The authors extend their gratitude to the directors, reproductive health experts, and women who participated in this study.
Funding Sources
This study was funded by the Vice Chancellor for Research, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Ethical Statement
This study received approval from the Ethics Committee of Shahid Beheshti University of Medical Sciences (Approval code: IR.SBMU.PHARMACY.REC.1404.076). All ethical guidelines for research involving human participants were strictly observed, including the provision of informed consent. Permission was obtained from participants to audio-record interviews; when recording was declined, interviews were documented through written transcription. All participants were informed of the confidentiality of the data and of their right to withdraw from the interview and the study at any time without consequence.
Conflicts of Interest
The authors declared no conflicts of interest.
Author Contributions
Z.K. Z.A., S.N., conceived the main idea, designed the statistical model and computational framework, and approved the final manuscript. S.N., Z.A, SM.R, Z.K. collected the data and approved the final manuscript. A.E., MJ.A. designed the study, performed the data analysis, interpreted the results, and critically revised the manuscript. S.N. and Z.A., Z.K drafted the manuscript. all of author. contributed to the overall study conception and approved the final manuscript.
Data Availability Statement
The datasets generated during this study are not publicly available due to confidentiality constraints but can be obtained from the corresponding author upon reasonable request.
Use of Artificial Intelligence
AI-assisted tools were used to support language editing; these tools were not involved in data analysis, the writing of scientific content, the interpretation of results, or scientific decision-making.
Type of study: Original Article |
Subject:
Midwifery
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