Background: The deliberation and decision-making involved in starting families is of growing interest because of contemporary trends showing declining fertility rates, increased maternal age at first birth and reduced family sizes. The aim of the present systematic review was to examine the reproductive decision making literature to identify which factors are important in influencing whether and when to become a parent. Methods: A search strategy was developed and tested according to Cochrane and National Institute Clinical Excellence guidelines. The search strategy included broad reproductive terms (e.g. reproduction, fertility, parenthood) that were refined through the employment of sub terms (e.g. delay, values and motivation) for the period 1990 – 2009 applied to twelve electronic databases (e.g. Medline, British humanities index, Psychinfo). Only prospective and/or cross-sectional studies employing quantitative analysis of the relationship between preconception psychosocial or other decisional drivers and childbearing intention/behaviour were included. NK and CH carried independent quality assessment of all included papers using predefined critical appraisal forms adapted from the Cochrane Handbook for Systematic Reviews of Interventions. Results: A total of 17,475 papers were identified; 4497 duplicates, 5506 unrelated papers (e.g., fertile soil) and 6628 that did not meet the inclusion criteria were removed. From the remaining 844 titles pertinent to the research, 419 abstracts were thoroughly reviewed, resulting in 186 full texts being examined. After full examination, 68 papers were included in the systematic review and subjected to full critical appraisal and data extraction. The studies assessed a total of 7 childbearing outcomes: child desire (N =8), parenting motivations (N =7), intentions (N =15), childbearing plans (N =8), timing of first birth (N =14), likelihood of first birth (N =10) and voluntary childlessness (n =16), with some articles covering more than one outcome. The results revealed that younger age, higher education, being in a stable and supportive relationship and having religious affiliations significantly predicted a greater likelihood of first birth. In contrast higher professional status and income significantly increased postponement of childbearing but a minority of studies produced other patterns of association. Only 28% of the studies focused solely on women (n =19), only 1 out of the 68 examined male only data and finally, the majority of studies (62%) were cross-sectional. Conclusion: The factors helping to initiate parenthood are more diverse (e.g., demographic, relational, social) than those causing delays in starting a family (career/socioeconomic). These findings may help explain contemporary reproductive trends. However there is a lack of studies examining other predictors of reproductive decision making and behaviour, i.e. psychological and biological factors. Further, we know little about how men deliberate about starting families. These gaps in knowledge emphasise the need for prospective research with men and women that cover psychological, social and biological drivers.

Introduction: There is limited understanding of why only 50% of people with fertility problems seek medical advice /treatment. The Theory of Planned Behaviour postulates that attitudes towards fertility treatment will influence the formulation of intentions and therefore likelihood of behaviour change. The present study assessed this hypothesis in people trying to conceive. Materials and Methods: The IFDMS was a 45-minute English survey translated into six additional languages (French, German, Italian, Spanish, Portuguese, Danish) placed online in 12 countries. Participants were asked to rate their level of agreement with 12 statements (e.g., treatment is safe) about fertility health options and to indicate their likelihood of trying 10-medical (e.g., IVF) and 9-non-medical options (e.g., seeking media information, complementary therapies) to improve their fertility. Results: The final sample consisted of 5458 people (5007 women, 451 men) from Italy (n =242), Spain (n =650), France (n =696), Germany (n =465), Denmark (n =370), United Kingdom (n =497), Canada (n =314), United States (n =291), Mexico (n =920), Brazil (n =399), India (n =95), Australia (n =164) or Other countries (n =355). The average age was 31.5 ±?5.9 years, years with partner was 5.8 ±?4.0, time trying to conceive was 2.8 years and 50.8% had received a university education. Participants’ level of agreement indicated a positive attitude to fertility treatment (e.g., medical treatment is successful and safe, not embarrassing, without long term physical effects, not inferior to adoption) but also negative attitudes to treatment (e.g., expensive, long waiting lists, scary experience, short-term physical and emotional effects). There was a significant main effect of gender (p <0.001), country (p <0.001) and an interaction between gender and country (p <0.001) on level of agreement, but in general, these differences were in strength of agreement instead of opposing opinions. About 38% of participants did not know whether fertility medical treatment was free in their country. Knowledge of treatment success rates differed significantly according to gender (p <0.05) (women believed higher rates) and country (p <0.001) with respondents from Brazil perceiving higher success rates (70.4%) and Australians lowest (50.2%). Participants had tried some options (e.g., seeking information, getting advice from general medical doctor/gynaecologist, diagnostic tests, lifestyle change) but not others (e.g., advanced forms of treatment), and there were a few they were unlikely to try (e.g., adoption, seeking advice from a traditional/spiritual healer, pharmaceutical company, pharmacist). Likelihood to try options varied greatly according to country. For example, respondents from Mexico, Brazil were more likely to seek fertility advice from a traditional healer compared to other regions, and respondents from Spain, Italy and Australia more likely to try alternative therapies compared to other regions. Of those who had yet to try advanced medical interventions, on average 66.2% stated they would likely try them (if needed). Attitudes towards medical interventions were significantly correlated with intentions to seek medical treatment (p <0.001). Conclusion: Men and women had positive attitudes towards medical treatment but their concerns and worries especially fear of treatment and their lack of knowledge about the availability of free treatment are genuine barriers to seeking medical treatment (if needed). There were no pervasive gender effects for attitudes towards treatment with the few differences between men and women about strength of opinion rather than opposing views. For example, while both men and women very much agreed that fertility treatment is expensive and can cause emotional problems, women's agreement was higher compared to men. Country variations in fertility help-seeking is mainly about which information source and treatment is utilised rather than about attitudes to it. The positive association between attitudes and intentions provide valuable insight into how best to optimise awareness and aid fertility help-seeking across different countries.

Introduction: Policies to enhance fertility tend to address economic (e.g., tax credits, child benefits) or work-life balance (e.g., flexitime) barriers that may delay (or even stop) people from starting families. However these have produced variable results when it comes to improving the declining fertility rates in Europe and elsewhere. One aim of the International Fertility Decision-Making Study (IFDMS) was to identify influential factors in the decision to start a family and to examine whether these differed according to gender and country with the goal of isolating potential new targets for European and international fertility policies. Materials and Methods: Theory and a systematic review of fertility decision-making generated the 45-minute English IFDMS that was translated to 6 languages and implemented in 12 countries using an online methodology (SurveyTracker) among people (18 to 49 years) currently trying to conceive. Background characteristics (e.g., education, economic hardship) and childbearing decisional factors (e.g., need of parenthood for future happiness, normative pressure to conceive) were investigated. Cronbach coefficients ranged from.72 to.88. The study received full ethical approval. Results: The sample consisted of 5458 people (5007 women, 451 men) from (n in parenthesis): Italy (242), Spain (650), France (696), Germany (465), Denmark (370), United Kingdom (497), Canada (314), United States (291), Mexico (920), Brazil (399), India (95), Australia (164) or Other (355). The average age was 31.5 years, duration of partnership 5.8 years, time trying to conceive 2.8 years and 50.8% had a university education (gender and country variations in education and economic hardship). Analyses of variance indicated that the desire for children was similar across countries (p?=n.s.) but that France, Germany, Brazil and India had a higher need of children for personal happiness than Mexico and Australia (lowest). Men had a weaker desire for children and a lower need for parenthood than women (both p<.001). However, men perceived more social pressure to have a child and were more willing to comply with these norms than women (both p<.001). In Italy, Spain and Mexico (vs North America, Western Europe) people reported less social pressure (p<.01) and willingness to comply with social norms (p<.001) to have children than other countries (India highest). Men and women ranked the influence of decisional factors similarly (p?=n.s.), but countries differed. In India the 'social status of parents' and 'good physical health' (both p<.001) were more influential than in other countries. In Italy, Spain, Mexico and Brazil personal and relationship readiness/stability was less influential (p<.001) than in other countries. Countries did not differ on the high influence of feeling economically secure. Conclusion: The results demonstrate that some decisional factors have a universal association with starting families, for example the strong desire for children or the need to be financially secure. However, the influence of others varies from country to country and between men and women: needing children for life-long happiness, experiencing social pressure to have children or wanting to conform to these social norms are not equally present in all countries. Heterogeneity in decisional factors means that policies to improve declining fertility rates need to tackle both shared barriers (e.g., European policies on economic preconditions) and decisional factors particularly present in some countries (e.g., reinforcing societal need for children in Italy). Unexpectedly, men were more aware of and more willingly to comply with family and in-law pressure to have children than women (across all countries) despite a weaker desire and need for children. A controversial interpretation of this would be that men adopt a childbearing strategy aimed at meeting social obligation rather than satisfying personal need.

Objective: Only 55% of people who meet the clinical definition for infertility seek medical advice or treatment. Research suggests this relatively low uptake (in the face of a near universal desire for children) is likely due to a complex interplay of person, relational and context factors. Design: Cross-sectional study compared participants at different levels of engagement in the medical process after one year of unsuccessful attempts to conceive: no medical involvement (NONE n=1165), medical advice only (ADVICE n=476), conventional (CONVEN n=1946), injections (INJECT n=830) or ART (n=1242). 465 were residents of the United States and 978 of Mexico with 4216 remaining from 16 other countries. Material & methods: 45-minute IFDMS English survey translated to 12 languages and implemented online in 18 countries among people currently trying to conceive. Background characteristics (e.g., education) and treatment decisional factors (e.g., treatment success rate) were investigated. Cronbach coefficients ranged from .72 to .88. Results: Average age was 31.8 ? 5.9 years, time trying to conceive was 2.8 ? 2.9 years and 33.5% had received a university education. Of the final sample, 6246 were female and 1250 male. Discriminant analysis identified four significant dimensions. ‘Norms & awareness’ (42.5% explained variance, ?2(144)=3625.1, p <.001) had highest loading items of suspecting a fertility problem (loading=.361), knowledge of availability of free treatment (.546) and ease discussing fertility issues with partner (.576), family (.386) and friends (.350). 'Readiness & Willingness' (6.3% explained variance, ?2(105)=506.1, p <.001) had factors concerning reproductive life stage (i.e., age, years married, years infertile, -.320, -.333 and -.456, respectively), attitude-to-treatment variables (i.e., treatment success rate, desire to use medical treatment, positive beliefs about treatment, need for parenthood:.511, .350, .329, .309, respectively). 'Context' (1.3% of variance, ?2(68)=68, p .001) than men. ANOVA showed that dimensional scores on ‘Norms’ did not differ between residents of US, Mexico or other countries. American and Mexican residents scored significantly higher on the ‘Readiness & Willingness’ versus others. Finally, US residents scored significantly higher on ‘Context’ than did Mexicans or people from other countries. Conclusions: Person, relational and context factors all contribute to engagement in fertility medical process but these may operate at different time points. At a minimum, people need to recognise their risk for a fertility problem and need positive support from their close network to initiate treatment. However, positive treatments attitudes (i.e., success, intentions, beliefs) and being at the ‘right’ reproductive life stage may determine whether one is willing to sustain this engagement long enough to conceive.