Introduction
A country’s population policies are determined based on its socio-economic development goals [1]. Iran, a developing country, has experienced a rapid decline in fertility rates over the past few decades. Although the conventional view of declining fertility in recent years has been related to economic pressures, with the improvement of economic conditions, families have tended to maintain their children’s quality of life rather than increase their number [2, 3].
The COVID-19 pandemic has impacted various aspects of life, including social spheres and childbearing plans. After the pandemic, unemployment, economic stagnation in society, and the level of anxiety and despair regarding individuals’ future careers have risen, which has indirectly impacted the fertility rate [4, 5]. Studies have shown that negative attitudes of healthcare workers (HCW) affect mothers’ well-being and satisfaction with the services they receive. Factors that influence the attitudes and behaviors of HCW indicate that strengthening health systems and developing the workforce, including improving communication and counseling skills, are of particular importance [6]. 
Given the concern about the global fertility rate reduction to 0.8 and reaching negative growth by 2025-2030 in various countries, including Iran [7], the present study was conducted to determine the attitudes of HCW at Isfahan University of Medical Sciences towards childbearing in 2022.

Methods
This descriptive-analytical study was conducted using available samples from the Isfahan Provincial Health Center and its affiliated healthcare networks. The sample size was estimated to be 2465 according to the study by Meshkati et al. [26]. Data were collected using researcher-made questionnaires containing two parts of demographic variables (age, gender, marital status, level of education, age at marriage, number of children, work experience, and duration of cohabitation) and the Attitude toward fertility and childbearing scale, which asked questions about employees’ desire to have children. Descriptive indices (frequency, percentage, Mean±SD) were used to describe the data. chi-square, independent t-test, analysis of variance (ANOVA), and linear regression analysis were used to compare scores between groups and determine the predictive role of independent variables in the study on attitude. Data were analyzed using STATA software, version 17, with a significance level of P<0.05.

Results
Of the 2830 participants in the study, 2248(79.43%) were female and 582(20.57%) were male. The Mean±SD of the participants’ age were 38.31±7.96 years, with a minimum of 18 and a maximum of 65 years. Among them, 2358 were married, with a mean age at marriage of 25.09±4.96 years, and the minimum and maximum ages at marriage were 10 and 52 years, respectively.
The mean score of the attitude domain was 55.81±7.85 with a minimum of 25 and a maximum of 91. The ANOVA results showed that the average attitude score did not differ significantly in any of the cities (F=0.97, P=0.508). Also, the attitude score based on place of employment did not reveal a significant difference between the two groups: Headquarters (56.01±8.06) and health centers (55.73±7.71) (F=0.856, P=0.392). 
The relationship between the level of education and marital status of individuals, with the attitude score displayed that individuals with a doctoral degree and singles had higher attitude scores than those with other educational levels. The duration of cohabitation showed a significant correlation with the attitude score, and as cohabitation increased the attitude score towards childbearing also improved (P<0.005).
Based on univariate linear regression analysis, no significant relationship was observed between any of the educational levels and the attitude score (P>0.005). However, a significant relationship was observed between marital status and the duration of cohabitation, as well as the attitude score. In multivariate analysis, a significant relationship was observed only between duration of cohabitation and attitude score, meaning that a one-year increase in duration of cohabitation was associated with a decrease in the attitude score towards childbearing of 0.95 (P<0.005) (Table 1). 



Conclusion
The results of the present study showed that the attitude score was significantly related to the occupational status and marital status of the participants, with individuals in a dentist’s job and those were single reporting a higher score. Also, in the linear regression analysis, the attitude score demonstrated a significant relationship with marital status and duration of cohabitation, which means that with an increase of one year in the duration of cohabitation, the childbearing score decreased by 0.95.
In a cross-sectional study by Dundar et al. [32]. examining the effect of the COVID-19 pandemic on the attitudes of 20–30-year-old Turkish women towards childbearing, the desire to have children decreased, and the attitude of individuals towards this issue was reported to be negative. Although the Turkish study included women who had not yet become mothers, its results were consistent with ours. In the present study, the attitude towards childbearing also decreased with an increase in the duration of cohabitation. Due to the COVID-19 pandemic and fear of the disease, economic and career problems have been proposed as reasons for this issue. Due to the COVID-19 pandemic, the fear of the disease has led to a decline in people’s desire to have children, which may persist in some regions after the pandemic [9].
In this study, people had a positive attitude towards having children. The attitude score was higher in women than in men, and the attitude score increased with higher levels of education. Contrary to the present study, Chen et al. reported that the effects of the COVID-19 pandemic on fertility intentions in women of reproductive age were negative. The emergence of COVID-19 has led to an increase in mortality and a reduction in birth rates. This global crisis has had negative impacts on the society’s economy and a decrease in motivation to have children [10]. In this study, the attitude score showed a significant relationship with occupation, with dentists exhibiting a higher attitude level. These results contradicted the study by Enayat et al. [45]. They reported that the occupation of the people did not affect their attitude towards having children, which could be related to the time of the study and the sample size of the two studies [11]. The present study reported a significant relationship due to the larger sample size. 
In general, the global fertility rate has decreased over the past 50 years, and the maternal age at first pregnancy has increased [12]. Therefore, to establish a suitable population structure for the future and increase the attitudes of couples, especially health professionals, during cohabitation and in critical situations, it is necessary to implement educational and support programs as well as more effective interventions.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran (Code: IR.MUI.NUREMA.REC.1400.145).

Funding
This study was financially supported by the Deputy of Research and Technology of Isfahan University of Medical Sciences, Isfahan, Iran .

Authors contributions
Conceptualization, study design, critical revision of the manuscript and funding: Sahebjan Torkian; Data collection, data analysis and Statistical analysis: Mostafa Majidnia and Samaneh Torkian; Drafting of the manuscript: Atefeh Khoshkchali and Sahebjan Torkian; Administrative, technical support: Sahebjan Torkian, Atefeh Khoshkchali; Study supervision: All authors.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors express their gratitude to the Deputy of Research and Technology at Isfahan University of Medical Sciences and the Deputy of Health, and the HCW who participated in our study.



 

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