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Knowledge about Fertility in Croatia, Measured with the Croatian Version of the Cardiff Fertility Knowledge Scale (Cfks-HR), in Relation to Attitudes toward Having a Child and Associated Factors

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17 January 2024

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Abstract
Background: Fertility is a crucial component of population maintenance and growth. A declin-ing fertility trend has been observed over the past two decades, and it continues. Objective: The aim of this research was to examine the level of fertility knowledge, factors in-fluencing fertility knowledge, and the relationship between fertility knowledge and the decision to have a child. Methods: A cross-sectional study was conducted on a sample of mothers in five hospitals on the Adriatic coast of the Republic of Croatia, involving 1541 mothers from September 2021 to De-cember 2023. The Cardiff Fertility Knowledge Scale was used for the research. Results: The participants were divided into two groups based on fertility status in women, spe-cifically the period of declining fertility in women. Group 1 included participants aged 18-31 with sustained fertility, and Group 2 included participants aged 32 and older experiencing de-clining fertility. Fertility knowledge was 58.9%. Women with higher educational status showed better results (62.3%). The most common sources of fertility knowledge were the healthcare sys-tem and the internet. Factors associated with the level of fertility knowledge included higher education, marital status, and higher economic status. Conclusion: The research results reveal a lack of fertility knowledge among participants, as well as an intention to have a child in later stages of life. The lack of formal education on this topic leads to information gathering from unreliable sources.
Keywords: 
Subject: Public Health and Healthcare  -   Nursing

1. Introduction

The decline in fertility worldwide has been evident in the last two decades. Transition changes within families, prolonged education, and new lifestyles have resulted in a reduced number of children in families and delayed childbirth of the first child. The International Conference on Population and Development emphasizes fertility as one of the most important components of population growth [1,2]. The total world fertility rate has decreased from almost 5 births per woman in 1950–1955 to 2.5 in 2010–2015 [3]. Developed countries face the reality of childbirth at a later age and declining fertility [4,5]. In these countries, fertility is lower than 2.1 children per woman, which is necessary to maintain the population [6]. This approach to fertility can be explained by the focus of individuals in reproductive age on their professional life, changes in lifestyle, and misinformation about fertility [7,8,9]. According to recent data, the birth rate in the Republic of Croatia (HR) is continuously decreasing, 1.43 (2019), 1.42 (2020), 1.41 (2021), 1.40 (2022) [10]. This fertility decline trend is not unexpected and was predicted by demographers [11]. Simultaneously, there has been an increase in the maternal age at the birth of the first child, which has risen from 26.5 (2005) to 29.7 (2021) in the European Union (EU) [12]. The lowest is in Bulgaria (26.5), and the highest in Italy and Spain (31.6) [12]. In HR, the maternal age during that period increased from 26.5 (2005) to 29.2 (2021) [13]. Research on fertility knowledge has shown that it is insufficient in many countries [14,15,16,17]. A study conducted in Canada indicated the effectiveness of online education on fertility knowledge [18]. Research conducted in HR shows that women lack specific knowledge about fertility and the impact of certain conditions on fertility [19]. Low fertility has numerous aetiologies, and it is difficult to define specific factors. Research unequivocally shows that aging leads to a decline in fertility, occurring around the age of 32 and beyond [20]. Civilizational progress has led to social development, economic advancement, and consequently, changes in lifestyle [21]. A study conducted in 79 countries showed an average fertility knowledge test score of 56.9% [22]. Participants in Italy, Japan, Germany, Sweden, and other developed countries had a low level of fertility knowledge [23,24,25,26,27]. Interestingly, even healthcare professionals, doctors, nurses, and midwives, in some cases, showed a low level of fertility knowledge [28,29,30]. This is a consequence of the low level of fertility knowledge in the student population in conducted studies [31,32,33,34]. Research has proven that a higher level of fertility knowledge leads to the decision to have a child earlier [35]. In HR, there are no recent studies assessing women's knowledge of fertility. There are only studies based on the association of education and age at the birth of the first child. A study conducted in 2022 analyzed data from 500 mothers and showed that women with a lower level of education give birth at an earlier age and have a higher number of births, while women with a higher level of education give birth at a later age and have a smaller number of births [36].
The aim of this research was to examine the level of fertility knowledge among mothers in the coastal area of Croatia, associated factors influencing fertility knowledge, and the relationship between fertility knowledge and the decision to have a child. The obtained data enable a change in educational content and a more systematic approach to the topic of fertility.

2. Materials and Methods

Research Design

A cross-sectional study was conducted on a convenience sample of mothers in five hospitals on the Adriatic coast of HR from September 2021 to December 2022.

Participants and Materials

The study included mothers who, during the research period, were in the maternity wards of five hospitals on the Adriatic coast of the Republic of Croatia. The inclusion criteria were an age of 18 years or older, the absence of psychological problems determined by reviewing medical documentation and signing an informed consent confirming voluntary participation in the study. During the specified period, we collected data from 1573 participants. Through the analysis of completed questionnaires, we identified thirty-two incorrectly filled questionnaires, which were subsequently discarded. We analyzed data from 1541 participants.

Sample Size

The sample size was calculated based on the total population of mothers in the specified hospitals over a year, considering a 95% confidence level and a 2.5 confidence interval [37]. The required sample size for the study was 1332 participants.

Questionnaire

The questionnaire used in this study is the Cardiff Fertility Knowledge Scale (CFKS), developed by Boivin and colleagues (2013) [38]. CFKS measures the level of knowledge through 13 statements in three areas: indicators of reduced fertility, fertility misconceptions, and basic facts about infertility [36]. Statements are assessed as "correct," "incorrect," or "I don't know." A correct answer is scored one point, while an incorrect or "I don't know" response is assigned 0 points. Results are presented as percentages of the maximum possible score. The CFKS has a Cronbach's α coefficient of 0.82, a test-retest reliability of 0.82, and a consistency index of 0.95. Approval for using CFKS was obtained from the authors. The questionnaire was translated into Croatian by two MA in English language and tested on a group of 106 students to confirm its clarity. Pilot data were not included in the study.

Sociodemographic Data

The questionnaire collected data on age, age at marriage, educational status, marital status, and economic status.

Childbirth Data

Participants provided information on the number of children born, age at the birth of the first child, and their intention to have more children in the future. In response to the question "Do you want to have more children in the future?" participants answered "yes" or "no."

Data on Fertility Education

Two questions focused on fertility knowledge. The question "Have you been educated about fertility so far?" required a "yes" or "no" response. If the answer was "yes," participants responded to the question "Where were you educated on fertility?" with options such as "family, friends, educational system, internet, healthcare system, other."

Data Analysis

Sociodemographic variables were presented using descriptive statistics. Categorical variables were compared using the chi-square test. T-tests and analysis of variance (ANOVA) were used to compare overall results among sociodemographic categories. Pearson's correlation was used to determine the relationship between the importance of childbirth and CFKS. Statistical significance was indicated by a p-value less than 0.05. The analysis was conducted using SPSS software (version 22.0) (IBM Corp., New York, USA).

Ethical Principles

The research was conducted in line with the Helsinki Declaration. All procedures carried out in this research were approved by the Ethics Committees of all healthcare institutions where the research was conducted. Permission to use CFKS was obtained from the authors. Participants were informed about the research by the investigators and through the informed consent, which was the first part of the survey questionnaire. By signing the informed consent, participants agreed to participate. Participation in the research was anonymous, voluntary, and confidential. To preserve anonymity, participants were asked not to provide any identification details or phone numbers on the survey questionnaire. All collected data are only accessible to the researchers.

3. Results

Sociodemographic Data

Table 1 displays the specifics of sociodemographic data. The participants were divided into two groups based on fertility status, distinguishing the period when fertility decreases in women [20]. Group 1 includes participants aged 18-31 with maintained fertility, while Group 2 comprises participants aged 32 and above experiencing a decline in fertility.

Data on childbirth

Table 2 shows data on childbirth.

Source of Knowledge on Fertility

Although participants show a positive attitude toward fertility education, they tend to avoid this topic due to a sense of discomfort, which is higher among participants outside of marital partnerships.
82% of participants provided positive answers to the question "Have you been educated about fertility?" (answered yes). They were then asked, "Where have you been educated about fertility?" The next question is "Do you think fertility education is necessary?" to which participants mostly responded positively (86%). When asked, "Do you feel uncomfortable discussing this topic in an environment where there are people who are not close to you?" participants mostly answered positively (75%), and this response was mainly given by individuals not in marital partnerships (72%).
Table 3 shows the results regarding sources of knowledge on fertility.

Knowledge on fertility and related factors

Participants responded to fertility statements with an accuracy of 59.8% (SD=22.4). There was a difference in responses between the groups. The group of participants up to 31 years of age responded with an accuracy of 56.6%, while the group of older participants over 31 years responded with an accuracy of 64%. Table 4 shows the data of the CFKS scale by statements. Table 5 presents the factors associated with fertility knowledge.

4. Discussion

Knowledge on Fertility

The research we conducted on a population of women who gave birth showed a low level of knowledge about fertility. Similar results were obtained in other studies on fertility [21,27]. An international study showed that knowledge about fertility was at 59.7%, while the research we conducted showed that the level of knowledge about fertility was at 59.8%. Participants who had a high level of education in our study had better results [22]. The share of 62.3% correct answers still cannot be considered good, although this result is slightly better than the results obtained in the international research, which was 56.9 [21]. In other studies, data clearly show that a higher level of fertility knowledge is associated with a higher level of education [22,23,35,39]. Results indicating a lack of basic facts about fertility available in the literature are concerning. It is particularly important to highlight the described results based on information gathered without the need for advanced searches of professional literature. Analysis of the obtained data shows that participants do not demonstrate sufficient knowledge about the effect of diseases on fertility while at the same time thinking that having healthy habits is sufficient for preserving fertility. The attitudes of participants at this level of fertility knowledge can lead to delaying the decision to get pregnant and downplaying the importance of risk factors for reduced fertility. The described results resemble the data from a conducted study where a lack of knowledge was proven to be the main factor in incorrect health behavior [21]. Participants with higher socioeconomic status showed a higher level of fertility knowledge, as confirmed in previous studies [21,27]. Although participants express a positive attitude towards fertility education, they avoid discussing this topic due to a feeling of discomfort. The feeling of discomfort is higher among participants who are not in a marital relationship. Similar data have been found in previously conducted studies [27,32]. Previous research has proven that individuals with higher levels of education have a higher level of health literacy [40,41,42,43]. The data obtained from this research emphasize the need for engagement of the education system to raise the level of health literacy and destigmatize the topic of fertility, with a special focus on participants who show a lower level of knowledge. Promotional activities need to be designed to empower the young population for critical thinking and making informed decisions related to fertility. Such activities have already shown their potential and contributed to changes in attitudes toward fertility, as confirmed by a study in Australia [44].

Decision on childbirth

In this study, only 11% of participants stated that they did not want a child at all, but the pregnancy occurred unplanned. Previous research on this topic has shown different data: Japan 18.0%, USA 14.2%, Sweden 4.1%, Hong Kong 19.1% [31,33,39,45]. Responses to the question of how important it is to have a child showed that participants consider it extremely important to have children during their lifetime but do not want pregnancy to occur in their twenties, which is in line with studies conducted in other areas [46]. Since we know that women decide on their first childbirth at an increasingly later age, these data are consistent with epidemiological data in Croatia [47]. The low level of fertility knowledge and the decision to have a child at a later age when fertility declines may be a consequence of economic, economic, and political changes in Croatian society, although the factors of this trend are yet to be determined. The question is whether fertility education alone will bring a positive shift in Croatia, although research on this topic shows positive experiences [48].
Women's fertility knowledge has contributed to a positive attitude towards the decision to have a child [31,33,46]. Nevertheless, despite this, the postponement of childbirth to a later age is an increasingly common decision for women [49,50]. This attitude is explained by the need for women to reconcile their maternal and professional roles [45]. Social changes have influenced women's priorities, which are increasingly dedicated to education and participation in the labor market than their mothers and grandmothers were. This attitude leads to the decision to postpone childbirth [51,52].
Although most participants answered that they had prior knowledge of fertility, their knowledge was still poor. Most participants acquired knowledge about fertility through the influence of mass media such as the internet or television, and a smaller number within the education system. The results found in other studies are somewhat similar: Japan – internet and media 41.4%; USA – education system 46%, family 19%, media 35% [33,45]. Seeking information about fertility from insufficiently accurate and quality sources is evidently present not only in Croatian but also in other social communities. The fertility problem is recognized on a global scale. Due to these facts WHO has emphasized the need to pay attention to reproductive health, which includes the field of fertility [53]. The recommendation to the health policies of individual countries is to establish an effective model of preventive activities aimed at promoting fertility. Some countries have recognized the fertility problem earlier, understood the importance of this issue, and defined a program to promote reproductive health and fertility to reduce the problem and its impact on demographic changes within society [54]. Education on fertility should be carried out in schools through existing health education topics and within the primary healthcare system. Such actions to raise the health literacy of the population are not yet carried out in Croatia, although their success has been confirmed by research [55,56]. Of course, introducing this topic into the education system and the healthcare system, due to its specificity, requires additional education of educational staff [57]. It is also necessary to consider the possibility of controlling information on this topic in the media and the internet due to forming attitudes based on unreliable information. Individuals find these sources of information desirable due to the simplicity of access and finding answers to questions that interest them. Research has shown that the inclusion of the education system in a quality way contributes to an increase in knowledge about fertility [58,59,60]. The impact of greater knowledge on this topic is not to be overlooked in unfavorable situations, when a woman, despite knowledge and a positive attitude towards fertility, cannot get pregnant, which can result in feelings of anxiety [60,61]. The results of this study confirm the results from other studies, including that mothers think that having a healthy lifestyle annuls the effect of other risk factors.
Considering the results obtained in this research, in future activities, attention should be directed towards verifying the effectiveness of education interventions and defining risk factors in forming a positive attitude towards the fertility problem.
This relevant research also has its limitations.
The study is a cross-sectional study with convenience sample conducted on participants from one part of Croatia (coastal area) and does not reflect the entire population that might offer different responses.

5. Conclusions

The research has revealed a lack of knowledge about fertility and a tendency to have the first child later in life when changes and a decrease in fertility potential are already occurring. It has been proven that the lack of formal education on fertility leads to gathering information from unreliable sources such as social media. There is a need to reorganize the educational and healthcare systems at the primary healthcare level to provide adequate education on this topic. On a broader societal level, programs need to be developed to promote reproductive health and fertility with a positive impact on individual quality of life and improvements in the overall demographic structure of society.

Author Contributions

Conceptualization, A.B. and I.JT.; project administration, A.B.; methodology, A.B. and I.JT.; validation, A.B., and I.JT.; investigation, J.J., D.Š., I.G. and M.MP.; data curation, A.B.; supervision, A.B.; visualization, A.B.; writing—original draft A.B. and I.J.T.; writing review end editing, A.B. and I.J.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by Ethics Committee of Clinical Hospital Center Rijeka, 2170-29-02/1-21-2, 31. 05. 2021.; Ethics Committee of Clinical Hospital Center Split, 2181-147/01/06/M.S.-21-02, 28.05.2021.; Ethics Committee of General Hospital Zadar, 02-23673/21-4/21, 11.06.2021.; Ethics Committee of General Hospital Šibenik, 01-8010/1-21, 28.04.2021.; Ethics Committee of General hospital Dubrovnik, 01-49/4.4-21, 07.06.2021.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data used to support the findings of this study are available from the corresponding author upon request.

Public Involvement Statement

The study included mothers who, during the research period, were in the maternity wards of five hospitals on the Adriatic coast of the Republic of Croatia.

Guidelines and Standards Statement

This manuscript was drafted against the STROBE criteria for reporting cross-sectional studies.

Conflicts of Interest

The authors declare no conflict of interest.

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Table 1. Sociodemographic Characteristics of Participants (N=1573).
Table 1. Sociodemographic Characteristics of Participants (N=1573).
Age N (%)
<32 892 (57)
=32> 681 (43)
Range 18-41
Age of marriage Mean (SD)
<32 26,5 (3,41)
=32> 25,7 (2,75)
N (%)
Educational status <32 =32>
Elementary school or less 181 (21) 142 (21)
High school 547 (61) 352 (52)
Higher education 164 (18) 187 (27)
Marital status <32 =32>
Single parent 72(8) 69 (10)
Married 820 (92) 613 (90)
Economic status
551 - 1000 € 455 (51) 293 (43)
1001-1500 € 348 (39) 286 (42)
1501-2000 € 80 (9) 82 (12)
>2001 € 10 (1) 20 (3)
Table 2. Data on childbirth.
Table 2. Data on childbirth.
Age at the birth of the first child
Mean (SD) 28,8 (3,6)
Range 18-41 (23)
Number of children born N (%)
First childbirth 802 (51)
Second childbirth 503 (32)
Third childbirth or more 267 (17)
Do you want to have more children in the future? N (%)
Da Ne
First childbirth 1279 (83) 262 (17)
Second childbirth 647 (42) 894 (58)
Third childbirth or more 169 (11) 1372 (89)
Table 3. Sources of Knowledge on Fertility.
Table 3. Sources of Knowledge on Fertility.
Source of Knowledge N, %
Educational System 123 (8)
Family, friends 345 (22)
Television, newspapers 46 (3)
Healthcare system 521 (33)
Internet 491 (31)
Not sure 46 (3)
Table 4. Fertility knowledge.
Table 4. Fertility knowledge.
<32 =32>
Statements (T-true; F-false) T (%) T (%)
A woman is less fertile after the age of 36 years. (T) 69,5 72,3
A couple would be classified as infertile is they did not achieve a pregnancy after 1 year of regular sexual intercourse (without using contraception). (T) 45,6 48,2
Smoking decreases female fertility. (T) 74,2 86,4
Smoking decreases male fertility. (T) 71,6 75,3
About 1 in 10 couples are infertile. (T) 34,7 52,6
If a man produces sperm, he is fertile. (F) 67,2 66,5
These days a woman in her 40s has a similar chance of getting pregnant as a woman in her 30s. (F) 74,5 82,4
Having a healthy lifestyle makes you fertile. (F) 24,3 32,4
If a man has had mumps after puberty, he is more likely to later have a fertility problem. (T) 86,4 88,4
A woman who never menstruates is still fertile. (F) 36,3 45,2
If a woman is overweight by more than 13 kg then she may not be able to get pregnant. (T) 45,2 56,8
If a man can achieve an erection, it is an indication that he is fertile. (F) 67,7 78,6
People who have had a sexually transmitted disease are likely to have reduced fertility. (T) 38,5 46,6
Table 5. Factors Associated with Fertility Knowledge.
Table 5. Factors Associated with Fertility Knowledge.
<31 =32>
AS(SD) p AS (SD) p
Educational status
Elementary school or less 41.5 (21.3) 0,42 42.8 (23.2) 0,54
High school 43.7 (22.9) 45.5 (21.6)
Higher education 47.7 (23.4) 48.4 (23.1)
Marital status
Single parent 41,5 (22,4) <0,05 46,2 (23,3) 0,04
Married 47,6 (23,2) 47, 8 (22,4)
Economic status
551 - 1000 € 42,3 (22,1) <0,05 46,7 (23,4) 0,09
1001-1500 € 44,5 (23,4) 47,6 (22,3)
1501-2000 € 44,8 (23,2) 49,4 (21,4)
>2001 € 47,7 (21,2) 51,2 (22,7)
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