GENDER MEDICINE/VOL. 3, NO.

3, 2 0 0 6

Attitudes Toward Parenthood and Awareness of Fertility

Among Postgraduate Students in Sweden

A g n e t a S k o o g Svanberg, PhD1; Claudia Lampic, PhD2;

Per-Olov Karlstr~m, MD, PhD1; a n d Tanja Tyd6n, PhD 1,2
1Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; and 2Department of
Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden

ABSTRACT

Background: Postponing childbirth is becoming increasingly c o m m o n in Western countries,

especially among w o m e n with higher education.
Objective: The aim of the present study was to investigate female and male postgraduate students'
attitudes toward parenthood, their intentions to have children, perceived obstacles to having or rais-
ing children during postgraduate studies, and their awareness of fertility issues.
Methods: A 52-question survey was mailed to randomly selected postgraduate students attending
a Swedish university. The questionnaire was developed based on earlier research by, and the profes-
sional experience of, the authors. Three pilot studies were conducted to test the questionnaire's reli-
ability and validity. The t, x 2, and M a n n - W h i t n e y U tests were used, as appropriate, to analyze
responses.
Results: Two h u n d r e d female and 200 male postgraduate students aged _<40 years received ques-
tionnaires. The response rate was 71% (n = 141) a m o n g w o m e n and 58% (n = 116) a m o n g men. Most
childless respondents had positive attitudes toward parenthood and wanted to have 2 or 3 children,
and a majority of w o m e n wanted to have their last child after age 35. Compared with men, w o m e n
were more pessimistic about the effects of p a r e n t h o o d on their postgraduate studies, and perceived
more problems related to balancing work and family life. One of 4 respondents overestimated a
woman's ability to b e c o m e pregnant between 35 and 40 years of age, and about half had overly opti-
mistic perceptions of the chances to have a b a b y by means of in vitro fertilization.
Conclusions: Most postgraduate students wanted to have children in the future. More w o m e n
than m e n perceived that having children while completing postgraduate studies was or would be dif-
ficult, and that p a r e n t h o o d would negatively affect their status in the labor market. Because m a n y
female postgraduate students intend to have children at an age w h e n female fecundity is decreased,
information on fertility issues would help t h e m make informed decisions regarding family planning.
(Gend Med. 2006;3:187-195) Copyright © 2006 Excerpta Medica, Inc.
Key words: attitudes, fertility, parenting, universities.

Accepted for publication June 30, 2006.

Printed in the USA. Reproduction in whole or part is not permitted. 1550-8579/06/$19.00

Copyright © 2006 ExcerptaMedica, Inc. 187

GENDERMEDICINE
INTRODUCTION
In Sweden, as in other industrialized countries,
the rise in female age at first childbirth negative-
ly affects the total fertility rate. 1 Many couples
postpone childbearing until an age w h e n female
fecundity or reproductive capacity is decreased.
Becoming pregnant m a y take twice as long for
w o m e n aged >3S years compared with w o m e n
aged <2S years. 2 Postponing childbirth to an age
w h e n female reproductive capacity is lower en-
tails the risk of involuntary childlessness. In a
2001 Swedish study, 70% of 3S-year-old child-
less w o m e n stated that difficulty with becoming
pregnant was the most important reason w h y
they did not have children)
The increasing number of y o u n g w o m e n pur-
suing higher education has contributed to the
declining fertility rate in Sweden. 4 Highly edu-
cated w o m e n embark on m o t h e r h o o d later in
life than do w o m e n with less education, s,~ and
the age of first-time mothers increases sharply
if they have >12 years of education. 7 Whereas
highly educated w o m e n have fewer children
than w o m e n with less education, <8 the situa-
tion is reversed for men. s Several studies have
shown that w o m e n and m e n regard completing
their education, holding a job, having a stable
income, and having access to proper housing as
important considerations in their decision to
become parents. 3,9 Some w o m e n report having
postponed childbearing in the interest of career
and self-actualization, which underscores the
conflict between maintaining a career and rais-
ing a family, l°,n However, Kemkes-Grottenthaler 1°
found that few female academics had actively
chosen to forgo having children.
It is possible that w o m e n and m e n postpone
childbearing without being sufficiently aware of
the age-related decline in female fertility. 12,13
Because an earlier study reported that postpon-
ing childbirth is related to higher education, 7
we were particularly interested in the attitudes
of postgraduate students, w h o tend to have a
strong work orientation and whose future ca-
reers m a y constitute--especially for w o m e n - - a n
obstacle to parenthood. The aim of the present
study was to investigate postgraduate students'
attitudes toward parenthood and intentions to
188
have children, perceived obstacles to having
and raising children during postgraduate stud-
ies, and awareness of fertility issues.
SUBJECTS AND METHODS
Respondents
The cohort consisted of 200 w o m e n and
200 m e n w h o were randomly selected from
- 2 3 0 0 registered postgraduate students at
Uppsala University in Sweden during the spring
semester in 2004. Inclusion criteria included
registration as at least a half-time active student
and age <40 years in the spring semester. The
Research Ethics Committee of the Medical Fac-
ulty at Uppsala University approved the study.
Questionnaire
Having no standardized instrument of rele-
vance for the focus of the present study, we
developed a questionnaire based on our earlier
research and professional experience. The ques-
tionnaire underwent 3 stages of pilot testing
a m o n g groups of university students. The
results from pilot tests and obtained c¢ values
indicated satisfactory reliability and validity of
the questionnaire.
Because a detailed description of the instru-
m e n t has been reported previously, 13 only 6 ad-
ditional study-specific questions are detailed
here: (1) "How confident are y o u that you will
have your desired n u m b e r of children?" Re-
sponses were given on a visual analog scale
(VAS) in millimeters, with end points of "not at
all confident" (0 mm) to "entirely confident"
(100 mm); (2) "Would y o u like to have or have
y o u had children during your postgraduate
studies?" Possible responses were "yes" or "no";
(3-6) the respondents were also requested to
report whether they considered the following
4 aspects as obstacles to having children during
postgraduate studies: e m p l o y m e n t situation,
schedule of the research project, research super-
visor's expectations, and available financial sup-
port for parental leave. Response alternatives
were "yes," "partly," "no," and "does not apply."
The final questionnaire comprised the follow-
ing topics: demographic data (5 items); inten-
tion to have children (7 items); obstacles for
 A.S. Svanberg et al.

having children during postgraduate studies

Table I. Demographic characteristics of postgraduate
(4 items, verbal rating scale); behavioral inten-
students responding to the questionnaire.*
tions in the event of infertility (3 items, scored
using a VAS); important considerations in the Women Men
decision to b e c o m e a parent (13 items, scored Characteristic (n = 141) (n = 116)
using a verbal rating scale with response alter-
natives "unimportant," "not very important," Age group, no. (%)
"rather important," "important," "very impor- <25y 1(1) 1(1)
25-29 y 78 (55) 65 (56)
tant," and "no opinion"); perceived life changes 30-34 y 36 (26) 34 (29)
in connection to becoming a parent (16 items, 35-39 y 21 (15) 15 (13)
verbal rating scale); and awareness of fertility _>40 y 3 (2) 1 (1)
issues (4 items, open response format). Stable relationship
The questionnaire was mailed along with Yes,t % 87 76
an informational letter and a postage-paid Duration, mean, mo. 78 69
reply envelope. Two reminders were sent to Have children, %
nonrespondents. Yes 25 22
No. of children
1 13 11
Data Analyses
2 10 9
Category data of the different male and fe- 3 2 3
male groups were compared using the x 2 test.
Male and female attitudes toward parenthood *Some individuals did not respondto all questions.
tp < 0.05.
were compared with the M a n n - W h i t n e y U test
performed on raw data ranging from 1 to S. VAS
responses are reported in m m (0-100), and the born outside Sweden. Twenty-five percent of
values are presented as means and analyzed b y the respondents had >1 child (mean = 1.6; range,
t test. Continuous data regarding the perception 1-3). Most respondents (67% women, 76% men)
of fertility issues were categorized into age peri- held a temporary research position; the rest had
ods or percentages. The "correct answer," based different types of scholarships. Among the wom-
on published data 14-18 and at least 1 additional en, there was an equal distribution of students
category, is presented in segments constituting from the faculty of medicine/pharmacy (30%),
S years or 10%. The boundaries of the remain- technology (33%), and social sciences (36%).
ing categories are based on reported responses The corresponding figures a m o n g m e n were
and m a y entail larger segments. P values <0.0S medicine/pharmacy (17%), technology (S9%),
were regarded as statistically significant. All data and social sciences (24%).
were analyzed using the Statistical Package for
Social Sciences, version 11.0 (SPSS, Inc., Chicago, I n t e n t i o n s to H a v e C h i l d r e n
Illinois). For this category only, analyses were based on
data from respondents w h o were not already
RESULTS parents. Most w o m e n and m e n in this group
All analyses, except those concerning intentions wanted 2 or 3 children. The preferred mean (SD)
to have children, were based on data from all age for having the first child was 31 (2.8) years
respondents, because omission of parents or preg- for w o m e n and 32 (2.9) years for m e n (Table II).
nant respondents (n = 61) did not alter results. Of the women, 13% (n = 14) wanted their first
Of the 400 questionnaires mailed, several were child after the age of 35. For b o t h w o m e n and
returned because of incorrect postal addresses men, the desired mean age for having the last
(21 women, 12 men). The final sample consist- child was 36 (2.9 and 4.2, respectively) years.
ed of 141 w o m e n (71% response) and 116 m e n Sixty-six percent (n = 70) of the w o m e n wanted
(S8% response) (Table I). Fifteen percent were their last child after the age of 35. More than

189
GENDER MEDICINE

half of the students in this group did not want

Table II. Intention to have children among postgrad-
to have children during postgraduate studies.
uate students w h o w e r e childless.*t
W o m e n were significantly less certain about the
Women Men probability of having their desired n u m b e r of
Variable (n = 106) (n = 90) children than were m e n (P < 0.01).
There were no significant differences in be-
Age, mean (SO), y 29 (3.3) 29 (3.0) havioral intentions between w o m e n and m e n in
the event of infertility. W h e n asked what they
Want to have
children, %
would do if they or their partner could not be-
Yes 91 90 come pregnant, using a VAS of 0 to 100 (0 m m =
No 6 7 entirely unlikely to 100 m m = highly likely),
w o m e n and m e n were equally likely to pursue
Desired age at birth of
in vitro fertilization (IVF) treatment (mean [SD]
first child, %
score of 72 [27] m m for w o m e n and 70 [30] m m
25-29 y 25 17
30-34 y 41 48 for men), adoption ($9 [27] m m for w o m e n and
35-39 y 12 14 SO [29] m m for men), or to accept life without
_>40 y 1 2 children (34 [29] m m for w o m e n and 37 [28] m m
for men).
Desired age at birth of
last child, %
25-29 y 3 2
Perceived Obstacles for Having Children
30-34 y 21 18 During Postgraduate Studies
35-39 y 52 34 Of perceived obstacles, the schedule for com-
_>40 y 14 18 pleting their research project was the most
salient factor for the respondents. Employment
Total no. of children
conditions, research supervisor's expectations,
desired, %
1 5 6 and financial support during parental leave
1-2 4 6 were perceived as obstacles for having children
2 53 47 during postgraduate studies b y significantly
2-3 15 8 more w o m e n than m e n (P < 0.0S, P < 0.01, P <
3 11 15 0.0S, respectively) (Table III).
3-4 2 7

Importance of having
Important Considerations in the
children, VAS,* Decision to Become a Parent
mean (SO), mm 68.8 (25.8) 69.0 (24.5) Almost all respondents regarded having a sta-
ble relationship and sharing responsibility with
Confident of having
a partner as important considerations in the
the desired no. of
decision to become a parent. Compared with
children, VAS,§ II
men, w o m e n placed significantly more impor-
mean (SO), mm 39.4 (24.4) 53.4 (29.0)
tance on having access to child care (P < 0.01)
Want children during and having children before a certain age (P <
postgraduate studies, % O.OS) (Table IV).
Yes 47 36
No 51 60
Presumed or Experienced Life Changes in
*Respondents who already had children or had an ongoing Connection with Becoming a Parent
pregnancy with their partner were excluded (n = 61). Most respondents stated that becoming a par-
t Some individuals did not respond to all questions. ent would entail personal growth, being loved,
* Visual analog scale (VAS): 0 = unimportant to 100 = very important.
§P< 0.01. and being more loving. W o m e n were signifi-
IIVAS: O = not at all confident to 100 = entirely confident. cantly more pessimistic than were m e n regard-

190
 A.S. Svanberg et al.

DISCUSSION
Table III. Perceived obstacles for having children
To our knowledge, this is the first study that has
during postgraduate studies.*
investigated attitudes toward p a r e n t h o o d and
% Women % Men fertility awareness a m o n g postgraduate stu-
Obstacle (n = 141) (n = 116) P dents. One interesting finding was that post-
graduate students on average wanted to have a
Employment conditions <0.05 higher n u m b e r of children compared with the
Yes 23 14
current fertility rate of 1.75 in Swedish women.1
Partly 25 17
No 48 65 Childless female respondents wanted to have
their first child at age 31, which is 2 years older
Schedule of research
project than the mean age for Swedish first-time moth-
Yes 29 23 ers in 2004,1 and two thirds of the w o m e n
Partly 33 27 wanted their last child after the age of 35. Thus,
No 33 46 m a n y female postgraduate students are post-
Research supervisor's poning their childbearing until an age w h e n fe-
expectations <0.01 male reproductive capacity is decreased, which
Yes 16 3 jeopardizes their ability to have 2 or 3 children.
Partly 24 14
No 54 78 Women appeared aware of this dilemma, judging
by their relatively low confidence about having
Financial support for
parental leave <0.05 the desired number of children.
Yes 26 12 About half of the respondents regarded the
Partly 21 18 schedule of their research project as an obstacle
No 48 61 and did not want to have children during their
studies. This finding is comparable to that of a
*Some individualsdid not respond to all questions.
previous report on 1200 postgraduate students
in Sweden, 40% of w h o m stated they had post-
ing the impact of p a r e n t h o o d on their work life. p o n e d the decision to have children until com-
Sixty-two percent of w o m e n and 49% of m e n pletion of their studies. 19 Our findings showed
strongly agreed that p a r e n t h o o d would imply that more w o m e n than m e n considered em-
less time for work and career (P < 0.01). Whereas p l o y m e n t conditions, financial support for
38% of w o m e n strongly agreed that p a r e n t h o o d parental leave, and research supervisor's expec-
would imply poorer status in the labor market, tations as obstacles to having children during
this was true for only 9% of m e n (P < 0.001). postgraduate studies.
Parental-leave benefits in Sweden are based
Awareness of Fertility Issues on annual income from the preceding year and
One of 4 w o m e n and 1 of 3 m e n believed that the lowest a m o u n t per day is ~20 ¢ (~$25 US).
women's ability to b e c o m e pregnant decreases Postgraduate students on scholarships receive
markedly after the age of 40 (Table V). Only a the lowest a m o u n t of parental-leave benefits,
minority of respondents had realistic percep- whereas students with temporary research posi-
tions of women's fecundity at different ages. tions receive 80% of their regular salary during
About half of the w o m e n and m e n overestimat- parental leave. In the present study, w o m e n and
ed a y o u n g woman's chances of becoming preg- m e n had similar e m p l o y m e n t situations, which
nant in 1 year. In contrast, half of the respon- therefore does not contribute to our under-
dents had overly pessimistic perceptions standing of reported gender differences in per-
regarding older w o m e n ' s fertility. Further- ceived obstacles. One possible explanation for
more, approximately half of the w o m e n and these findings is that w o m e n and m e n differ in
m e n overestimated the chances of having a their perceptions of what practical impact par-
child b y means of IVE e n t h o o d has had or would have on their studies

191
GENDER MEDICINE

Table IV. Important considerations for postgraduate students' decision to have children.*t

% Women % Men % Women % Men

Criteria (n = 141) (n = 116) Criteria (n = 141) (n = 116

That live in a stable That want to have

relationship children before I become
Very important 80 84 "too old"~
Important 14 12 Very important 18 11
Important 30 31
That l have a partner That l have a home
with whom I can share suitable for children
the responsibility Very important 14 16
Very important 74 66 Important 29 34
Important 18 26 That l have completed
my studies
That l feel sufficiently Very important 11 15
mature Important 19 14
Very important 55 49
That l have a
Important 25 35
permanent position
Very important 16 20
That I have a job which Important 17 24
allows me to balance
work and family life That l have advanced
Very important 28 23 in my profession
Important 30 36 Very important 7 8
Important 20 12
That I/we have a good That I have had time to
financial situation at the travel and do other things
family level that can be difficult with
Very important 18 15 children
Important 38 38 Very important 9 4
Important 13 18
That I have access to That my friends have or
child cares are expecting children
Very important 28 12 Very important 1 0
Important 28 32 Important 3 1

*A comparison using the Mann-Whitney U test was performed on raw data from a response scale ranging from 1 to 5, where 1 = not
important and 5 = very important.
tTo illustrate the participants' main responses, only percentages for the response alternatives indicating high importance are presented.
:~P< 0.01.
§P < 0.05.

with regard to parental leave, for example. Al-
t h o u g h b o t h parents in Sweden are entitled to
the same n u m b e r of cash-benefit days, fathers
in 2004 only used 17% of the cash-benefit days
available to a couple w h e n they have a baby. 2°
Both w o m e n and m e n considered having a
stable relationship and having a partner with
w h o m they could share the responsibility of
p a r e n t h o o d as very important to attain before
having children. Similar to findings in other
studies, 3,12,13 having a sufficient income, proper
housing, and a stable relationship were salient
factors w h e n starting a family. In a previous
study, ~70% of undergraduate students believed
that completing their studies was an important
condition for parenthood. 13 In contrast, only
30% of postgraduate students in the present
study emphasized this condition. An explana-
tion for this m a y be the older m e a n age of the
postgraduate students and the fact that a major-

192
 A.S. Svanberg et al.

Table V. Postgraduate students' awareness of fertility issues.*t

% Women % Men
Question (n = 141) (n = 116)

At what age is there a marked decrease in women's ability to become pregnant?

25-34 y 24 24
35-39 y$ 48 35
40-44 y 23 28
45-59 y 4 12
If a woman and a man regularly have unprotected intercourse during a period of 1 year...
How large is the chance that she will become pregnant if she is 25-30 years old?
0-69% 26 24
70-79%~ 21 21
80-89% 34 34
90-100% 19 20
How large is the chance that she will become pregnant if she is 35-40 years old?
0-49% 49 49
50-59%~ 28 28
60-69% 9 18
70-100% 14 11
For couples that undergo treatment with in vitro fertilization, what is their chance,
on average, of having a child?
0-19% 18 25
20-29%$ 23 22
30-39% 31 14
40-100% 28 35

*An open response format was used; respondents were requested to state what they believed.
tpercentages may not equal 100 due to rounding.
:~lndicates the category that contains the "correct answer" according to published data.14-18

ity have e m p l o y m e n t in the form of a tempo- revealed that m a n y childless w o m e n merely

rary research position, which t h e y m a y perceive
as regular employment. Both w o m e n and m e n
stated that the greatest impact of p a r e n t h o o d is
on personal growth, followed by being loved
and being more loving. This observation is con-
sistent with previous reports about attitudes
toward p a r e n t h o o d a m o n g graduate stu-
dents 12,13,21 and infertile couples. 22
The w o m e n in our study were more pessimistic
t h a n were m e n regarding the effect of parent-
h o o d on their status in the labor market and on
the a m o u n t of time available for work and
career. These findings are comparable to those
of an earlier study of Swedish undergraduates 13
as well as those of an American study indicating
that most female medical students believed
their career progress had been slowed by having
children. 23 Another survey of female academics
m e a n t to postpone m o t h e r h o o d until their
careers were established. 1° Our findings indicate
that w o m e n are more concerned about the
practical issues involved in balancing work and
parenthood t h a n are men.
In the present as well as in a previous study of
undergraduate students, 13 about half of the
respondents had overly optimistic perceptions
of a woman's chances of becoming pregnant in
her late 20s. Half of undergraduate students also
believed that female fertility decreases marked-
ly after the age of 40.13 Our findings indicate a
more realistic understanding of the age-related
decline in women's ability to become pregnant.
This m a y be due to the fact that the present
study group was older and more highly educat-
ed. However, the term marked decrease is rather
subjective, and the correlation between medical

193
GENDERMEDICINE
facts 14-18 and the respondents' answers should
be interpreted with caution. Interestingly, half
of the postgraduate students underestimated
a woman's chances of becoming pregnant be-
tween the ages of 35 and 40, which is surpris-
ing, considering that most female respondents
wanted to have their last child during that age
period. This overly pessimistic belief is in con-
trast to the overestimation of the chances of
having a child by means of IVE a m e t h o d that
was generally considered a viable solution in
the event of infertility.
Previous research has f o u n d that primary
infertility was related to higher levels of educa-
tion, 24 and that female university students
tended to postpone childbirth until they earned
their degree. 3 W o m e n and m e n need to be well
informed about the declining rates of concep-
tion for w o m e n in their 30s and the limitations
of success using assisted reproduction. In most
public IVF clinics in Sweden, w o m e n can under-
go treatment up to age 40, and in private clin-
ics, up to age 43. It is essential that w o m e n
u n d e r s t a n d this reality so t h e y can make
informed decisions regarding their plans for
childbearing. An argument can also be made for
public policy intervention in terms of health
education about fertility levels.
Because we lacked a standardized instrument
of relevance for the focus of the present study,
we developed our own questionnaire. No back-
ground data were available for nonresponders,
but the percentage of respondents born outside
Sweden corresponds well with the national
percentage of immigrants in Sweden in 2004
(12%). 1 However, the relatively low response
rate a m o n g m e n limits the conclusions that can
be drawn about the male sample.
CONCLUSIONS
The findings of the present study show that
although most postgraduate students have posi-
tive attitudes toward having children, t h e y tend
to postpone childbearing. In comparison to men,
w o m e n perceived more obstacles to h a v i n g
children during their postgraduate studies and
appeared to have more doubts about whether
t h e y would have their desired n u m b e r of chil-
194
dren. W o m e n also expressed more concerns
about future problems with balancing work and
family life. Because a substantial n u m b e r of
w o m e n overestimate not only their fertility in
the late 30s but also the success rate of IVF, they
m a y delay childbearing w i t h o u t knowing they
risk childlessness. To address this current public
health and social problem, we suggest that in-
f o r m a t i o n about the age-related decline in
fecundity be provided to women, especially
those who embark on a long academic path. A
preferable m e t h o d of educating w o m e n engaged
in lengthy university studies might be leaflets
and/or through student-oriented magazines.
Our findings have clinical implications for
family p l a n n i n g staff w h o have the responsibil-
ity of educating patients about the influence of
age on fertility. Moreover, we believe that our
findings illustrate the need to assist w o m e n in
their efforts to combine family life with higher
education and career.
ACKNOWLEDGMENT
This study was supported by the Foundation of
Family Planning in Uppsala, Sweden.
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