Participants, recruitment setting, and sampling procedure
The present descriptive-analytical, cross-sectional, web-based study was conducted on 400 married Iranian women over four months from 12 July 2020. The sample size was determined with a 95% confidence interval, 5% error, 33% P , and taking into account 10% withdrawals using This research was approved by the Ethics Committee of the Research Deputy of Shahid Beheshti University of Medical Sciences (IR.SBMU.RETECH.REC.1399.390), and sampling began after obtaining the necessary permissions from the university authorities.
Initially, married Iranian women in reproductive age (15-45 years) with reading and writing literacy were included. Then, pregnant, breastfeeding, postmenopausal, and infertile women were excluded. Given the COVID-19 pandemic, the study was conducted on the web using official online social networks popular among the public. The research poster was published on social networks to inform the public and contained a brief introduction to the research history, the study objectives, participants’ characteristics, the voluntary nature of participation in the study, the confidentiality of the data, and a link to the online questionnaire. The eligible participants willing to take part in the study first completed the informed consent form at the top of the electronic questionnaire, and then completed the questionnaires.
Data were collected using the demographic questionnaire and the childbearing intentions and related factors questionnaire.
Social and demographic variables
The demographic questionnaire was researcher-made and inquired about variables such as age, spouse’s age, duration of marriage, education, occupation, monthly household income, housing status, and household size.
Childbearing decision-making factors
The researcher-made “Factors related to childbearing intentions during the COVID-19 pandemic” questionnaire was designed according to the main constructs of the TPB [23, 32] and based on a review of literature and was validated using face and content validity methods. This questionnaire asked about the effect of the COVID-19 pandemic on childbearing intentions, the number of children, appropriate birth spacing, and the right time to have children. To assess its face validity, the questionnaire was distributed among 15 eligible women, who were asked to comment on its appearance, clarity of the chosen words, and the logical sequence of the items. The impact score was also calculated to examine the quantitative face validity, and the item was kept for the next analyses if the impact score was >1.5. To assess validity, eight experts (reproductive health experts, midwives, and epidemiologists) were invited, and the Content Validity Ratio (CVR) and Content Validity Index (CVI) were determined. The reliability of the questionnaire was assessed using the internal consistency method with Cronbach’s alpha coefficient. The “Factors related to childbearing intentions during the COVID-19 pandemic” questionnaire contained 33 items in four dimensions (supplementary 1), as follows:
Knowledge and attitude about COVID-19
This dimension included 16 items related to knowledge and three related to the attitude of couples about the decision to have children during the COVID-19 pandemic. “False” or “I don’t know” responses scored 0 in the knowledge part, and correct answers scored 1 point, and the scoring ranged from 0 to 16 in this part. The responses to the attitude questions scored one point for “agree”, two for “disagree”, and three for “no comments”, and the scores for this part ranged from 3 to 9. The reliability of this dimension was assessed with Cronbach’s alpha coefficient of 0.607 for the knowledge questions and 0.70 for the attitude part.
Subjective norms about COVID-19
This dimension of the questionnaire was assessed with four questions, including (1) People think we should have children as soon as possible; (2) I think I will be ridiculed by others if I have children; (3) Physicians (midwives) advise against childbearing during the coronavirus spread; and (4) My physician (midwife) thinks that I should have children sooner rather than later because of my fertility age limit. The scores in this dimension ranged from 1 for “totally disagree” to 7 for “totally agree”, with the minimum score of 4 for the perceived subjective norms, and a maximum of 28. The reliability of this dimension was determined with Cronbach’s alpha coefficient of 0.60.
Perceived behavioral control toward COVID-19
This dimension was assessed with four questions, including (1) I’m going to have children even if it is too expensive; (2) I shall not be deprived of the blessing of having children because of the coronavirus problems and barriers; (3) I can look after myself and my child; and (4) Financial problems, especially after the spread of the coronavirus, do not let me consider having children. The scores for this part ranged from 1 for “totally disagree” to 7 for “totally agree”, with the minimum score of 4 and a maximum of 28 for perceived behavioral control. The reliability of this dimension was determined with Cronbach’s alpha coefficient of 0.83.
Anxiety about COVID-19
This dimension included six items, and the answers to the questions ranged from 1 point for “totally disagree” to 7 for “totally agree”. (1) I am extremely worried about the spread of the coronavirus; (2) I believe I might catch the coronavirus at any given moment; (3) I’m concerned about transmitting the coronavirus to those around me; (4) My daily activities have been disrupted by coronavirus-related anxiety; (5) I’m extremely worried by thoughts of getting pregnant and visiting for prenatal care and tests during the coronavirus outbreak; and (6) Thinking about going to the hospital for childbirth during the coronavirus outbreak makes me extremely anxious. The scores in this dimension ranged from 6 to 42. The reliability of this dimension was determined with Cronbach’s alpha coefficient of 0.80.
SPSS 26 was used to summarize the demographic characteristics of the subjects. Categorical variables and continuous variables were summarized using frequencies and percentages as well as arithmetic mean and standard deviation (SD), respectively. The missing data were replaced using the mean imputation method. The relationship between the study variables (i.e. knowledge, attitude, subjective norms, perceived behavioral control and anxiety about COVID-19) and childbearing intentions were assessed through Pearson’s correlation analysis.
The present research followed the approach suggested by Hayes (2013) using PROCESS macro 3.5 to explore the research mediation model. First, the direct relationships between the four concepts including knowledge, attitude, subjective norms, and perceived behavioral control about COVID-19 and childbearing intentions without including anxiety about COVID-19 were tested (total effects model). Second, the mediator (i.e. anxiety about COVID-19) was added to the model to develop a mediation model (mediation effects model).
In this model, knowledge, attitude, subjective norms and perceived behavioral control about COVID-19 were modeled as antecedent variables influencing childbearing intentions directly and indirectly through anxiety about COVID-19 as the mediator. The model was assessed using AMOS version 24 software. All the path coefficients were estimated using the maximum likelihood method and their significance was assessed using bootstrapping with 2000 replications. Next, the standard error of the indirect relationships was estimated by the bootstrapping approach. Bootstrapping is more accurate and has a higher statistical power than the approaches proposed by Sobel (1982) and Baron and Kenny (1986). The coefficient of determination (R2) was also calculated to evaluate how well the model explained the outcome.