key: cord-0749721-vacth65z
authors: Safdari-Dehcheshmeh, Faranak; Noroozi, Mahnaz; Taleghani, Fariba; Memar, Soraya
title: Explaining the pattern of childbearing behaviors in couples: Protocol for a focused ethnographic study
date: 2022-02-26
journal: J Educ Health Promot
DOI: 10.4103/jehp.jehp_579_21
sha: 5b4044128d0ed02b78e137471f8892899222a3ee
doc_id: 749721
cord_uid: vacth65z

BACKGROUND: One of the most basic life events is fertility or reproduction, which, although known as a social phenomenon, is a complex and multidimensional concept with economic, cultural, political, and religious significance. The present study aims to explain the pattern of childbearing behaviors in couples. MATERIALS AND METHODS: This study is a focused ethnographic qualitative research. Participants of this study will be 20–35 years old couples who, using purposeful sampling method, will be selected from comprehensive health centers, ultrasound centers, laboratories, premarital counseling centers, offices of obstetricians and midwives, universities, shopping centers, cinemas, parks, restaurants, and entertainment centers in Isfahan, Iran. Sampling will continue considering the strategy of maximum variation in terms of age, occupation, education, and economic status until data saturation is reached. Data will be collected through semi-structured and in-depth individual interviews, focus group discussions, observation, field notes, daily notes, and document analysis. Simultaneous with data collection, the data will be analyzed using the thematic analysis method based on Braun and Clarke's approach. CONCLUSION: This present study is expected to lead to a deep understanding and identification of the attitudes, beliefs, and values of couples with regard to childbearing. Moreover, by understanding the pattern of childbearing behaviors of couples, useful information will be provided to the policymakers and planners for effective planning in the field of healthy childbearing. The findings can also be used in reproductive health counseling for newly married couples and community-based interventions.

O ne of the most basic life events is fertility or reproduction, which, although known as a social phenomenon, is a complex and multidimensional concept with economic, cultural, political, and religious significance. [1] Fertility can be examined not only from the biological and physiological aspects but also from behavioral perspective. [2] In any society, people may behave in a way that increases or decreases fertility. From a sociological perspective, these behavioral mechanisms often focus on the cultural norms of each society and are formed in a social context. [3] Thus, one's values, interests, and feelings with regard to childbearing are formed by confronting different environments and social resources such as family, media, educational environment, peers, that is, their world of life. [4] Fertility is one of the main components of population dynamics which plays a major role in changing the size and structure of population, [5] and is examined based on the total fertility rate (TFR) that refers to the number of live births of a woman during her reproductive period. [6] Fertility has decreased significantly in the last three decades in all areas of the world, especially in developing countries such as Iran. [7] Currently, TFR in many provinces of Iran has reached below the replacement level (2.1) . According to the studies, fertility behaviors in Iranian society have changed and delayed marriage, increased average age of marriage, and decreased desire to have children have been listed as demographic, social, and cultural issues of the country. [8] However, in the social, cultural, and religious structure of Iran, childbearing is extremely valuable and one of the main motivations for marriage and family formation as well as an important aspect of social life. [9] [10] [11] It is expected that a continuous decline in fertility rate cause economic, social, and demographic crises in the future. So that, the elderly population, the overhead index and economic dependence increase and the active labor force decreases, leading consequently to problems such as the crisis of pension organizations and the health care system for the government. [12, 13] Nonetheless, low tendency for having children is not unique to Iran but a global concern. Europe, for example, now faces childlessness on a larger scale than the United States. [14] Holton et al. conducted a study in Australia and showed that attitudes toward being a woman and motherhood were associated with women's childbearing behaviors. [15] Erfani and Beaujot in a study in Canada found that people with modern tendencies compared to those with traditional beliefs like to postpone childbearing and see the value of childbearing in meeting their personal needs and desires. [16] Seifoori et al. showed that reluctance to have children and desire to have fewer children were caused by individualism, national identity crisis, lack of welfare and perfectionist fertility, which affect women's fertility perspective. [17] In a systematic review study, Baki-Hashemi et al. divided the main factors affecting the reduction of childbearing into three general categories: (a) personal and family factors such as aging, increased age of marriage, number of current children, duration of marriage, average intervals between births, gender preferences, hope, marital satisfaction and quality of life; (b) socio-economic factors including social support, education, employment, social participation, place of residence and the impact of social networks; and (c) cultural factors including modernity, urbanization, and industrialization, change of attitudes toward the value of children, change in family values and religion. [18] Andre et al. in a qualitative research showed that Italian women's attitudes toward childbearing were influenced by financial instability and inadequate reproductive care. [19] Although a large number of studies have been conducted on reproductive behaviors, [20] [21] [22] [23] [24] many questions have remained unanswered. For example, what are the beliefs, attitudes, and values of couples about childbearing? How beliefs, attitudes, and values of couples lead to reproductive behaviors in the cultural context? Moreover, although couples' decisions for having children require their consensus, most existing studies on childbearing have focused on women's attitudes and there has been little research on men's intention to have children. [25] Based on the latest census (2016), the province (with the population of 5,120,850 people) has been 1.7. [26] The city of Isfahan, with its rich religious and cultural background, is the capital of the province and the third largest metropolis in Iran. Despite this, the city has not lagged behind in the transition to modernity, and the discourse of low childbearing is a significant social action. Over the years, couples' behaviors, especially the younger generation, have been changed in terms of childbearing and reproductive needs. The ethnographic study is one of the most accepted qualitative anthropological researches focusing on the significance of evaluating behavior in a cultural context to gain a deep understanding of common cultural laws, norms, and habits. Ethnography interprets culture and describes behavioral and social patterns and norms. [27] Given that couples' childbearing behaviors are formed based on the common values and preferences of society; it seems that ethnography is the most appropriate way to identify the culture of reproduction that influences individuals' decisions about having children. On the other hand, the present study focuses on a specific subject (childbearing), in a specific context (Isfahan city) and among a specific group of people (couples aged 20-35 years). Thus, this study will be conducted to explain the pattern of childbearing behaviors in couples.

This present study is a focused ethnographic qualitative study. The eligible participants will be selected from comprehensive health centers, ultrasound centers, laboratories, premarital counseling centers, offices of obstetricians and midwives, universities, shopping centers, cinemas, parks, restaurants, and entertainment centers in Isfahan, Iran.

The participants (couples) will be selected using a purposeful sampling method and, then, sampling will continue considering the strategy of maximum variation in terms of age, education, occupation, and economic status to enrich the data. In the present study, sampling will continue until the data are repeated and data saturation is reached, and this is when all the codes and categories are completed, the main categories are sufficiently developed in-depth and breadth, and no new information is obtained during the analysis and coding process. Inclusion criteria consist of being legally and religiously married, Shiite (Shia) couples whose age ranges between 20 and 35 years (healthy reproductive age range), the first-time married couples who have married over the past 5 years, Iranian citizenship, ability to speak Persian, willingness to participate in the study, informed consent for providing information, the ability to express their feelings and emotions and the ability to convey concepts. In the present study, couples with a history of infertility, couples with known mental illnesses, those who have a child or children with special problems (genetic abnormalities, epilepsy, severe disabilities, etc.,) as well as those who live in Isfahan because of education, temporary work or uncertain status will not enter the study.

In this study, interview is the main method of data collection. In-depth individual and semi-structured interviews will be conducted in a quiet and private setting and, to minimize the impact of couples on each other, they will be interviewed separately. Interview questions will be descriptive, structural, and comparative. The interviews will begin with descriptive questions and, to this end, the participants will be asked to describe their beliefs, attitudes, opinions, or experiences about childbearing. As the interviews continue, structural questions will be asked based on the outcome of the initial interviews. Finally, the interviews will end with questions which reveal discrepancies and differences. For instance, the interviews can begin with the following questions: What is your idea about the issue of childbearing and parenting? What do you think about this? Please explain it. Depending on the participants' responses and to expand and understand the findings more deeply, the following probing questions will be asked: What do you mean by this phrase or sentence? Can you explain more? Can you give an example? During the interviews, the researcher will record the nonverbal behaviors of the participants (the way they communicate, facial expressions, tone of voice, emotional reactions and emotions, etc.), environmental conditions and events, and important points of each session as field notes. These notes can help the researcher to remember the events, actions, and interactions during data analysis. For data collection in the present study, the nonparticipatory observation method with the proposed Spradley model will be used, in which nine main dimensions are observed, which are: Space, actors, activities, objects, act, event, time, goal, and the record of the expressed feelings and emotions. [28] In this regard, behaviors and interactions of people and couples will be observed in the comprehensive health centers, ultrasound centers, laboratories, premarital counseling centers, offices of obstetricians and midwives, universities, shopping centers, cinemas, parks, restaurants, and entertainment centers of the city. Immediately after the observations or during them, the researcher will record them as field notes as soon as possible. In the present study, focus group discussions (FGDs) will also be used for data collection. FGDs sessions will be held with the presence of six up to 10-12 couples. These sessions will be held with an emphasis on the interactions of the participants with each other to access the perceptions, attitudes, views, and beliefs of the couple in the field of childbearing. In group discussion sessions, the researcher will be the facilitator and director of the discussions, and another person will be present to take notes. In this study, document analysis will be used to collect data. In this regard, instructions, circulars, pictures, and billboards in the city, posters existing in comprehensive health centers, news published in newspapers and websites, texts published in newspapers, and reports on childbearing will be examples of the evaluated documents. The daily notes of the participants will also be used in this study. To this end, the participants are asked to immediately write down their conversation when they talk to their spouse or others about childbearing or provide their past memories to the researcher at an appropriate time. Due to the COVID-19 epidemics in Iran and the continuation of this disease and therefore the continuation of home quarantine (which is necessary to control the disease), [29] access to participants will be difficult. In this regard, interviews will be conducted in the participants preferred locations (preferably outdoors) in full compliance with health protocols and social distance.

For data analysis, the six-step thematic analysis method of Braun and Clarke will be used. [30] These six steps include getting familiar with the data, generating the initial codes, searching for themes, reviewing the themes, defining and naming the themes and, finally, producing the report. Data analysis will be performed throughout the data collection period and the data are analyzed simultaneously with the data collection and a cyclical process is repeated.

Rigor and trustworthiness of the data will be based on the four criteria of Lincoln and Guba including credibility, dependability, confirmability, and transferability. [31] In the present study, in order to increase the credibility of data various methods such as continuous and long-term involvement of the researcher in the research process and spending enough time for data collection, maximum variation in the selection of the participants (in terms of age, education, occupation, and economic status), review by the participants (member checking), and combination of various data collection methods such as observation, interview, FGDs, document analysis, daily notes, and field notes will be used. To ensure the dependability of the data, the researcher will explain the details of the research context, the stages of analysis and extraction of the study results, and provide the possibility of auditing and evaluation of the study by external supervisors so that they can carefully review the data and decision process of the researcher. To this end, initial codes extracted from the interpretation of the participants' experiences, examples of how to extract the themes and excerpts from the text of the interviews for each of the themes will be provided to the supervisors. In this study, with regard to transferability of the data, the research results will be offered to a number of people with the features of the research participants, who were not present in the research, so that they can judge the similarity of the research results with their own experiences. In this study, the researcher will contribute to the confirmability of the data by providing complete details of the research phases. In addition, the text of some interviews, codes, and extracted themes will be provided to some faculty members who are familiar with the analysis of qualitative studies and interview, but are not a member of the research team, to test the accuracy of the coding and theme extraction process and their complementary opinions will be used. Moreover, in order to avoid personal bias in judgment, the researcher will use reflexivity. [32] In fact, the researcher does not ignore her thoughts; by contrast, she is aware of them and tries to reveal them through reflexivity. As such, the researcher's previous assumptions cannot lead to bias in the research.

This study has been approved by the Ethics Committee of Isfahan University of Medical Sciences (ethics code: IR.MUI.RESEARCH.REC.1399.610). The researcher will provide complete explanations about the objectives and process of the research as well as the confidentiality and protection of data to the participants and ask them to participate in the research. Also, she will obtain their informed written consent for recording their voices during the interview and the sessions. The participants will also be given the option to withdraw and leave the study at any stage they wish. The rights, reverence and dignity of the participants will be observed in this study.

Fertility is considered to be an important event during a couple's life and is supposed to be a necessary, optimal, and ultimate goal of life almost in all cultures around the world. [1] People's fertility-related decisions are strongly influenced by their feelings, interests, beliefs, values, and opinions. [4] Like other behaviors, reproductive behavior is also context dependent. [33] Thus, social and cultural factors lead to different reproductive behaviors. [34] In Iran, as a Muslim country, having children is a virtue and one of the main motivations for marriage and family formation. It is a common expectation for couples to give birth to their first child shortly after the start of their married life. [35] However, in recent years, childbearing behaviors have changed and late marriage and reduced desire to have children are among the country's demographic, social and cultural problems. [8, 9] Studies show that women's employment or education, which prevents couples from having children, is on the rise. [36] Delaying the first delivery and increasing the age of women in the first pregnancy will have medical and demographic consequences. [37] According to studies, changes in reproductive behaviors and reduction of fertility rates are, on the one hand, due to structural, political, and economic changes, social development and health promotion and, on the other hand, they are caused by changes in values and attitudes of society. [17, 22] Attitude is the main determinant of fertility intention as well as the adoption of reproductive strategies and reproductive behavior, [38] and culture has the greatest impact on the formation of attitudes toward behavior. A closer look at childbearing and its complexity show the role of culture as a guide to decision-making processes as well as behavioral patterns. [39] Because within each culture, some patterns emerge that persist over time and gradually become the cultural norms of the people living in society. [40] Ethnography emphasizes the significance of evaluating one's behavior in a cultural context to gain a deep understanding of common cultural laws, norms, and habits, and describes behavioral and social patterns and norms. [27] Accordingly, ethnographic study is the most appropriate method for determining reproductive culture which influences people's decisions for having children. In other words, in this method, the researcher reveals the internal factors affecting the real life of a cultural group and tries to focus on understanding the beliefs, attitudes, and behaviors of a culture. For this reason, this method is suitable for taking any action to improve health conditions. [29] the present focused ethnographic study by providing a comprehensive and in-depth explaining of the couples' reproductive behaviors and their determinants as well as a rich description of the fertility culture, not only contributes to the better understanding of the needs of people in society, but it also can be used as an important resource to solve the problems or challenges of the society. Thus, by understanding the pattern of childbearing behaviors of couples, it can provide the country's policymakers and planners with useful information for effective planning in the field of healthy childbearing. The findings of this study are expected to be used by policymakers as a basis for the design of policies and appropriate, enlightened, and useful strategies and solutions to provide the most desirable services with appropriate quality and culture for increasing fertility or preventing further fertility decline at the national level. Furthermore, the findings of this study can be used in reproductive health counseling for newly married couples and community-based interventions in this area. The results of this study can also be used as a guide and starting point for designing and conducting further studies in areas related to reproductive behavior through using various quantitative and qualitative methods.

One of the limitations of this study is COVID-19 epidemics in a way that can affect the psychological health of participants and their attitudes and behaviors about childbearing. Quarantine and social distancing also make access to participants difficult. It is suggested that further studies are conducted in a situation where COVID-19 epidemics in the country have been controlled. Also, although qualitative studies have no claim about the generalizability of their results, they might seem important from the viewpoint of the individuals who are willing to apply the results of these studies and so it will be considered as a limitation. In this regard, efforts will be made to increase the rigor and trustworthiness of the findings by selecting participants with maximum variation, guidance, and supervision of experts and external review.

Fertility decline as a social, demographic, and political issue needs to be thoroughly investigated. According to studies, if low fertility persists, various economic problems (reduction of labor force), demographic (population aging), and social (damage to the kinship system) will occur. Since attitudes, beliefs, values, and norms play an essential role in couples' childbearing behaviors; this study tries to discover the culture of couples' childbearing. Therefore, policymakers with a correct understanding of the couple's childbearing culture can take the necessary planning and actions in this regard. Furthermore, the findings can be used in reproductive health counseling for newly married couples and community-based interventions.

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We should thank the Vice-chancellor for Research of Isfahan University of Medical Sciences for the financial support. Moreover, we appreciate all women and men who participate in this study.

This study will be supported by Isfahan University of Medical Sciences. This article is related to the dissertation of Ph. D. in reproductive health that approved by Isfahan 

There are no conflicts of interest.