Assessing knowledge regarding fertility and attitude and intentions towards future parenthood among undergraduate medical students in Karachi

Abstract This study aimed to assess the knowledge regarding female fertility, infertility treatments and the attitudes regarding parenthood of medical students in Pakistan. Delayed childbirth among medical trainees due to extended years of medical education and training puts this population at a higher risk for involuntary childlessness later in life due to age-related decline in female fertility. A knowledge, attitude and practice study was carried out among medical students in Karachi in July 2021 using the English version of the Swedish Fertility Awareness questionnaire, which has been used in similar studies. Most participants wished to have children at some point in the future. However, a majority of students did not have sufficient knowledge regarding age-related decline in female fertility and overestimated the efficacy of infertility treatments. The results of this study indicate that despite planning to have children and placing great importance on parenthood, medical students severely overestimate female fertility and plan to start having children at an age at which female fecundity has begun to decline. These findings highlight a need for better provisions regarding fertility knowledge in the curriculum for medical students, as they are an at-risk group for involuntary childlessness due to age-related fertility decline.


Introduction
Cultural and socioeconomic shifts have played a crucial role in influencing changes in fertility rates worldwide. Multiple factors such as increased female employment, access to and education regarding contraceptives, and higher literacy rates all contribute to decreased fertility rates and increased maternal age (Khraif et al., 2017). Delaying childbirth, however, can lead to decreased fertility due to age-related fertility decline in women and is a significant cause of involuntary childlessness in the developed world (Hansen et al., 2008). A woman's ability to conceive decreases slightly in her late 20s and undergoes a significant decline between the ages of 35 and 39 (Dunson et al., 2002). Moreover, the risk of pregnancy related complications such as spontaneous abortions, pre-gestational diabetes, eclampsia (Schummers et al., 2018) and placenta previa (Jacobsson et al., 2004) also increases in women after the age of 35 years.
Studies have shown that students in higher education institutes are more likely to delay pregnancy due to educational and career demands, which puts them at a higher risk for involuntary childlessness later in life (Benzies et al., 2006;Tyd en et al., 2006). This is an even bigger concern among medical students and trainees, since the extended years of education and training induces them to delay having children more so than other highly educated professionals (Stentz et al., 2016). Medical education in Pakistan is in the form of a 5-year undergraduate programme, after which graduates can choose to enter fellowship training programmes, the length of which can vary from 4 to 5 years depending on the speciality chosen. Furthermore, certain specialities, such as gastroenterology and endocrinology, require a second fellowship of 2 or 3 years (College of Physician and Surgeons Pakistan).
Multiple studies have shown that students in higher education institutes, including those in medical colleges, overestimate the fertile period of a woman's life and the efficacy of assisted reproductive technology (Abiodun et al., 2018;Khalil et al., 2015;€ Ozerdo gan & Yilmaz, 2018;Place et al., 2022;Peterson et al., 2012;Sørensen et al., 2016;Vuj ci c et al., 2017). Furthermore, studies comparing medical and non-medical university students have shown that medical students plan to have fewer children and later than non-medical students (Nouri et al., 2014).
While the fertility rate in Pakistan, which was 3.5 in 2015-2020 (United Nations, Department of Economic and Social Affairs, Population Division, 2019), is significantly higher than the global average, there has been an increase in the median maternal age at first birth over the years (National Institute of Population Studies [Pakistan] and ICF International, 2013; National Institute of Population Studies [Pakistan] and ICF International, 2019). Moreover, a strong positive association has been noted in the Pakistani population between the educational level of women and their age at the birth of their first child. Among women who had received higher education, less than 50% had had their first child before the age of 25 (National Institute of Population Studies [Pakistan] and ICF International, 2019). In light of these statistics, current higher education students in Pakistan can be expected to continue this trend over the course of their lives.
Although no studies have been conducted regarding fertility awareness among higher education students or medical students in Pakistan, similar studies, showing results consistent with those described above, have been done on medical students in countries with fertility rates comparable to Pakistan, such as Egypt (Gamal-El Din & Saleh, 2021) and Iraq (Khalil et al., 2015), which had a fertility rate of 3.3 and 3.6 in 2015-2020 (United Nations, Department of Economic and Social Affairs, Population Division, 2019), respectively. In this study, we aimed to assess the knowledge regarding female fertility, factors affecting female fertility, infertility treatments and the attitudes and plans of both male and female medical students regarding parenthood.

Materials and methods
Medical education in Pakistan is in the form of a 5year undergraduate programme, which is divided into two preclinical and three clinical years. Only students in their clinical years were selected for this study. A cross-sectional study was conducted by circulating an online questionnaire containing demographic and KAP information through Google Forms that was distributed among 3rd-5th year students of Sindh Medical College and Dow Medical College, Karachi during August 2021-July 2022 (after IRB approval). Consent was obtained from all participants before filling the questionnaire. Both institutes have a combined student body of around 3500 students for the 5-year MBBS programme, A sample size of 217 was obtained by using an anticipated frequency of 83% from a similar study conducted by Lampic et al. (2006). The sample size was calculated by OpenEpi calculator version 3.01 with a 5% margin of error and a confidence level of 95%.
Data was collected via the English version of the validated Swedish Fertility Awareness Questionnaire developed by Lampic et al. which has been used in similar studies . Permission to use the questionnaire was obtained from the author. Relevant changes were made to adapt the questionnaire to the study population, such as the participants' year of study, and whether they had received any instruction in Gynaecology/obstetrics as part of their medical college curriculum. Quantitative data such as age is presented as mean and standard deviation. The continuous data regarding intentions of having children and awareness of fertility issues was classified into different categories of ages and percentages. Chisquare test was then used to analyze categorical data. Independent sample t-test was used to compare the mean of categorical and continuous data. The statistical analysis was conducted with a 95% confidence interval and a p-value of less than 0.05 was considered statistically significant. The data collected was analyzed by using IBM SPSS version 23.
The surveys were anonymized and students were asked to only state their age, gender and year of study. Adding email address was optional. Furthermore, the data was made accessible only to the investigators. The research protocol was reviewed and approved by the Institutional Review Board of Jinnah Sindh Medical University, Karachi (Reference number: JSMU/IRB/2021-498).

Results
A total of 217 students responded to the questionnaire, of which 180 were female and 37 were male. This is roughly representative of the student body which was included in the study, which is composed of 70% female and 30% male students. The mean age was 22 years for female participants and 21.5 years for male participants. Most students said that they had received some education regarding Gynaecology in their medical training. Very few students stated that they were in a relationship. Only 38% of men and 30% of women correctly estimated the age at which women are most fertile.
Almost half of women and more than a third of men overestimated a woman's fertile period. Both genders also overestimated the age at which women experience a slight decrease in the ability to become pregnant. Most participants believed that women do not experience a marked decrease in fecundity until the age of 45 years. Participants also overestimated the chances of conceiving by having unprotected intercourse at the time of ovulation. Both genders also had an overly optimistic view of a woman's ability to conceive by having unprotected intercourse over a period of one year, and a couple's ability to achieve a pregnancy after undergoing IVF treatment. Both genders placed equal importance on having children. 75% of female students and 62% of male students said that they wish to have children at some point. 52% of female participants responded that they would like to have 2 children, while 3 was the preferred number of children for 43% of male participants. A majority of the participants of both genders (68% of women and 55% of men) stated that they would prefer to have their first child in their mid to late twenties (24-27 years). Regarding the age to have their last child, 55% of women and 52% of men preferred the ages of 31-35 years. More than one third of women (37%), however, stated they would like to have their last child between the ages of 25 and 30 years. Most participants responded that they were likely to opt for IVF treatment (44% women; 38% men) or adoption (43% women; 46% men) if faced with problems regarding fertility. Only 16% of women and 30% of men said they would choose not to have children in case of infertility.
Among factors that impact their decision to have children, a majority of both male and female participants responded that it was important for them to have a partner with whom they could share the responsibility. Women placed a greater importance on being in a stable relationship and their work being accommodating with having children. Feeling sufficiently mature was a very important factor for around 49% of men and 76% of women. Having children before they were too old was a significant factor for 87% of women, whereas only 57% of men shared that view. More women than men felt that they would have less time to devote to their career after becoming a parent. A significant number of both men and women believed that having a child would lead them to developing as a person, having a stronger relationship with their partner and gaining a new perspective on what is important.

Discussion
The aim of this study was to assess medical students' knowledge regarding female fertility (particularly agerelated decline in female fertility) and their attitudes and intentions regarding parenthood. Our findings showed that most students have a generally positive view regarding parenthood and wanted to have children at some point in the future. The ideal number of children was two for female participants, and three for male participants. This is lower than the fertility rate for Pakistan (3.6 in 2018) and is also in contrast to the ideal number of children according to the general Pakistani population, which is 3.9 among women and 4.3 among men (National Institute of Population Studies [Pakistan] and ICF International, 2019). A similar pattern was observed in studies conducted in Iraq (Khalil et al., 2015) and Egypt (Gamal-El Din & Saleh, 2021), in which medical students planned to have fewer children than the general population of their respective countries.
The recommended age for a woman to conceive depends on the number of children a couple wants to have, and whether they would be willing to consider IVF in the case they are unable to achieve a spontaneous pregnancy. For a 90% chance of realizing the desired family size, the maximum recommended age of a woman at conception for those couples who do not wish to consider IVF is 27 years for a two-child family and 23 years for a three-child family (Habbema et al., 2015). In our study, the participants' preferred age for having a first child was between 24 and 27 years, which is higher than the median age at first birth among women in Pakistan (22.8 years), and also higher than the recommended maximum age for people who wish to have 3 children (26% female and 43% male participants). Most female participants, however, stated that they wish to have two children, and their desired age to commence childbearing falls within the recommended age limit of 27 years for realizing a two-child family.
Regarding the age at which to have their last child, most female participants preferred the ages of 31-35 years, a period in which a woman's fertility has already started to undergo a decline. This is consistent with studies conducted on medical students in other countries (Alfaraj et al., 2019;Khalil et al., 2015;Vuj ci c et al., 2017). Both genders placed equal importance on having children and displayed similar likelihood of opting for IVF treatment or adoption in case of infertility. Interestingly, in contrast to studies from other countries (Khalil et al., 2015;Vuj ci c et al., 2017), medical students in Pakistan were less likely to opt for IVF treatment. Whether that is due to limited availability, increased cost (Assisted Reproductive Technology is not subsidized in Pakistan) or lack of awareness is not clear, as little data exists about ART in Pakistan (Irshad & Werner-Felmayer, 2016). One study conducted among the adult population of outpatient centres of two tertiary care hospitals in Karachi revealed that most participants were unfamiliar with IVF, and among 55% of those who were aware of it considered it unacceptable due to religious reasons (S. Ali et al., 2011). Medical students can be expected to be more aware regarding IVF and other Assisted Reproductive Technologies due to the nature of their education and training. However, it is unclear whether cultural or religious factors play a role in their response regarding IVF, since no study regarding the perception of IVF or ART has been conducted on medical students or healthcare professionals in Pakistan.
Participants' awareness of age-related fertility decline and efficacy of IVF treatments was not satisfactory. This is consistent with studies done in Iraq (Khalil et al., 2015), Egypt (Gamal-El Din & Saleh, 2021) and America (Kudesia et al., 2017). This highlights a need for better provisions regarding fertility knowledge in the curriculum for medical students.
Women placed greater importance on being able to balance their job with having children, suggesting that women are more concerned with childcare than men. This can be attributed, at least to some extent, to cultural practices regarding gender roles with respect to parenthood (Ali et al., 2022). The lack of appropriate maternity benefits and childcare facilities may also play a role in delaying childbirth among women in the workforce. Maternity benefit laws in Pakistan entitle women to 12 weeks of paid leave (16 weeks in Sindh) (The Sindh Maternity Benefits Act, Provincial Assembly of Sindh, 2018). Only the province of Sindh, however, has mandated organizations with 10% or more female employees to establish daycare facilities within their premises (The Sindh Maternity Benefits Act, Provincial Assembly of Sindh, 2018). Also, little data is available on the enforcement of these laws, and even the most progressive legislation     includes no safeguards to prevent discrimination against pregnant employees.
The present results indicate that despite planning to have children and placing great importance on parenthood, medical students of both genders do not have sufficient knowledge regarding age-related decline in female fertility. They also plan to start having their children at an age at which female fertility begins to decline. It is therefore imperative for people to have sufficient, accurate knowledge about fertility in order to make informed decisions regarding parenthood. Educational and counselling sessions on reproductive health and fertility could be used for this purpose. Tools like the Reproductive Life Plan when used in such sessions have proven to be useful . Online educational interventions have also shown an increase in participants' knowledge about fertility and ART treatments. Caregivers, especially those working with family planning and contraceptive counselling, can also play a role in increasing awareness regarding the influence of age on fertility (Daniluk & Koert, 2015).
We hereby acknowledge that the small sample size can be a limitation of our study. A larger sample size, from a more diverse pool of medical students from multiple universities, might have further reduced any sampling error. In addition, while the ratio of male to female respondents roughly corresponds to that in the study population, another limitation can be the smaller number of male respondents. Furthermore, since few students stated that they were in a relationship, had significant personal obstetric history, or had not yet received any instruction in gynaecology or obstetrics as part of their medical curriculum, the possible associations or implications of these variables on knowledge regarding fertility and attitude towards parenthood could not be explored. Out of all the participants who stated that they wish to have children at some point, 10% and 14.5% did not answer the questions regarding the ideal age to have their first and last child, respectively. Any resulting bias that these missing values might have caused in the findings could be another limitation of the study.

Disclosure statement
No potential conflict of interest was reported by the author(s).