A comparative study of depression, stress, and anxiety in two groups of women with and without children: a population-based study

Document Type : Original Article


1 PhD student of Reproductive Health, Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

2 Associate professor, Department of Midwifery, Midwifery and Reproductive Health Research Center, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

3 Associate professor, Department of Midwifery, Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran.

4 Assistant professor, Department of Biostatistics, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.


Introduction: Postponed childbearing is a social phenomenon in Iranian families. There is a controversy about its effect on mental health. Therefore, this study was conducted aimed to determine the role of childbearing in the rate of depression, stress, and anxiety in Iranian women of childbearing age.
Methods: This cross-sectional study was performed in 2021 on 581 eligible non-pregnant married women from 31 provinces of Iran. Non-random available sampling was performed as electronic form in virtual space. Data were analyzed by Demographic and Medical History Questionnaire, Sleep Quality (adapted from LSQ), Marital Satisfaction (EMS), Perceived Social Support (MSMPSS), Socioeconomic Status (Ghodratnama Questionnaire), and Stress-Anxiety-Depression (DASS-21). Data were analyzed by SPSS software (version 22) and Independent t-test, Chi-square, and binary logistic regression. P<0.05 was considered statistically significant.
Results: Female and spouse education (P <0.001), female employment (P = 0.004), and higher socioeconomic status (P = 0.04) were significantly higher in women without children. The marital satisfaction (P = 0.061), social support (P = 0.13), sleep quality (P = 0.58), history of chronic disease (P = 0.64), and place of residence (P = 0.058) were not significantly different between the two groups. After adjusting the data, the rate of depression in childless women is twice that of women with children (AOR=2.06 95% CI: 1.11-3.82). Stress (P = 0.38) and anxiety (P = 0.9) were not significantly different between the two groups.
Conclusion: Having children not only does not increase the rate of stress and anxiety, but also protects women against depression. Therefore, encouraging childbearing seems to promote the mental health of women in Iranian society.


  1. World Health Organization. Total fertility rate (per woman) Genova: World Health Organization; 2022 [cited 2022/21/05]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/123.
  2. Rotella A, Varnum ME, Sng O, Grossmann I. Increasing population densities predict decreasing fertility rates over time: A 174-nation investigation. American Psychologist 2021; 76(6):933-46.
  3. Strulik H, Vollmer S. The fertility transition around the world. Journal of Population Economics 2015; 28(1):31-44.
  4. Jalal Abbasi-Shavazi M, McDonald P. Fertility decline in the Islamic Republic of Iran: 1972–2000. Asian Population Studies 2006; 2(3):217-37.
  5. Nyoni SP, Chihoho TA, Nyoni T. Projection of Total Fertility Rate (TFR) in Iran. International Research Journal of Innovations in Engineering and Technology 2021; 5(8):244.
  6. Sobotka T. Post-transitional fertility: the role of childbearing postponement in fuelling the shift to low and unstable fertility levels. Journal of biosocial science 2017; 49(S1):S20-45.
  7. Myrskylä M, Barclay K, Goisis A. Advantages of later motherhood. Der Gynäkologe 2017; 50(10):767-72.
  8. Nasrabad HB, Abbasi-Shavazi MJ, Hosseini-Chavoshi M, Karegar-Shoraki MR. Trend and patterns of childlessness in Iran. InProceedings of the XXVII International Population Conference of the IUSSP, Busan, Korea 2013:26-31.
  9. Razeghi-Nasrabad HB, Abbasi-Shavazi MJ, Moeinifar M. Are we facing a dramatic increase in voluntary and involuntary childlessness in iran that leads to lower fertility. Crescent Journal of Medical and Biological Sciences 2020; 7(2):212-9.
  10. Avison M, Furnham A. Personality and voluntary childlessness. Journal of Population Research 2015; 32(1):45-67.
  11. Frejka T. Childlessness in the United States. InChildlessness in Europe: Contexts, causes, and consequences 2017:159-79.
  12. Nazaré PF, Fernandes Pais AS, Figueiredo-Dias M. Postponing Motherhood: A Demographic and Contemporary Issue. Current Women's Health Reviews 2022; 18(1):28-36.
  13. Yopo Díaz M. “It's hard to become mothers”: The moral economy of postponing motherhood in neoliberal Chile. The British Journal of Sociology 2021; 72(5):1214-28.
  14. Karimi M, Amani Samanai R, Hosseinia M. Meanings, Definitions and Functions of the Child. Cultural Studies & Communication 2017; 13(46):111-46.
  15. Golshani F, Mirghafourvand M, Hasanpour S, Biarag LS. The effect of cognitive behavioral therapy on anxiety and depression in Iranian infertile women: a systematic and meta-analytical review. Iranian journal of psychiatry and behavioral sciences 2020; 14(1).
  16. World Health Organization. Depression and other common mental disorders: global health estimates. World Health Organization; 2017.
  17. Lu Y, Tang C, Liow CS, Ng WW, Ho CS, Ho RC. A regressional analysis of maladaptive rumination, illness perception and negative emotional outcomes in Asian patients suffering from depressive disorder. Asian journal of psychiatry 2014; 12:69-76.
  18. Lim GY, Tam WW, Lu Y, Ho CS, Zhang MW, Ho RC. Prevalence of depression in the community from 30 countries between 1994 and 2014. Scientific reports 2018; 8(1):1-10.
  19. Katie Hurley L. Stress vs anxiety: how to tell the difference: Psycom; 2022 [cited 2022/21/05]. Available from: https://www.psycom.net/stress-vs-anxiety-difference.
  20. Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Molecular psychiatry 2022; 27(1):281-95.
  21. Widiastuti FN, Handayani D. The Impact of Socio-Economic and Gender Factors on Common Mental Disorders Among Married Women; 2019.
  22. Niemeyer H, Bieda A, Michalak J, Schneider S, Margraf J. Education and mental health: Do psychosocial resources matter?. SSM-population health 2019; 7:100392.
  23. Abdi F, Rahnemaei FA, Shojaei P, Afsahi F, Mahmoodi Z. Social determinants of mental health of women living in slum: a systematic review. Obstetrics & Gynecology Science 2021; 64(2):143-55.
  24. Akunne LI, Etele VN. Occupational Stress as a Predictor of Mental Health Status of Universities Lecturers in South-East Nigeria. Journal of Education and Practice 2021; 12(34):27-33.
  25. Batterham PJ, Brown K, Trias A, Poyser C, Kazan D, Calear AL. Systematic review of quantitative studies assessing the relationship between environment and mental health in rural areas. Australian Journal of Rural Health 2022.
  26. Khezri Z, Hassan SA, Nordin MH. Factors affecting marital satisfaction and marital communication among marital women: Literature of review. International Journal of Academic Research in Business and Social Sciences 2020; 10(16):220-36.
  27. Wang Q, Zhang J, Wang R, Wang C, Wang Y, Chen X, et al. Sleep quality as a mediator of the association between coping styles and mental health: a population-based ten-year comparative study in a Chinese population. Journal of Affective Disorders 2021; 283:147-55.
  28. Karami J, Momeni K, Alimoradi F. Prediction of sleep quality based on stress, depression and anxiety with role of mediator cognitive emotion regulation strategies in pregnant women. Iran J Obstet Gynecol Infertil 2016; 19(9):1-10.
  29. Binder MR. The neuronal excitability spectrum: A new paradigm in the diagnosis, treatment, and prevention of mental illness and its relation to chronic disease. American Journal of Clinical and Experimental Medicine 2021; 9(6):187-203.
  30. Giesselmann M, Hagen M, Schunck R. Motherhood and mental well-being in Germany: Linking a longitudinal life course design and the gender perspective on motherhood. Advances in Life Course Research 2018; 37:31-41.
  31. Donath O. Regretting motherhood: A sociopolitical analysis. Signs: Journal of Women in Culture and Society 2015; 40(2):343-67.
  32. Henderson A, Harmon S, Newman H. The price mothers pay, even when they are not buying it: Mental health consequences of idealized motherhood. Sex Roles 2016; 74(11):512-26.
  33. Peterson H. Fifty shades of freedom. Voluntary childlessness as women's ultimate liberation. InWomen's studies international forum 2015; 53:182-91.
  34. Gouni O, Jarašiūnaitė-Fedosejeva G, Kömürcü Akik B, Holopainen A, Calleja-Agius J. Childlessness: Concept Analysis. International Journal of Environmental Research and Public Health 2022; 19(3):1464.
  35. Center IPR. Rejuvenate the population and support the family. Tehran 2021.
  36. Mirzaei M, Ardekani SM, Mirzaei M, Dehghani A. Prevalence of depression, anxiety and stress among adult population: Results of Yazd health study. Iranian journal of psychiatry 2019; 14(2):137.
  37. Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour research and therapy 1995; 33(3):335-43.
  38. Norton PJ. Depression Anxiety and Stress Scales (DASS-21): Psychometric analysis across four racial groups. Anxiety, stress, and coping 2007; 20(3):253-65.
  39. Bener A, Alsulaiman R, Doodson LG, El Ayoubi HR. Comparison of Reliability and Validity of the Breast Cancer depression anxiety stress scales (DASS-21) with the Beck Depression Inventory-(BDI-II) and Hospital Anxiety and Depression Scale (HADS). Int J Behav Res Psychol 2016; 4(4):197-203.
  40. Sahebi A, Asghari MJ, Salari RS. Validation of depression anxiety and stress scale (DASS-21) for an Iranian population. Journal of Iranian Psychologists 2005; 1(4):36-54.
  41. Beaufort IN, De Weert-Van Oene GH, Buwalda VA, de Leeuw JR, Goudriaan AE. The depression, anxiety and stress scale (DASS-21) as a screener for depression in substance use disorder inpatients: a pilot study. European addiction research 2017; 23(5):260-8.
  42. Tran TD, Tran T, Fisher J. Validation of the depression anxiety stress scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women. BMC psychiatry 2013; 13(1):1-7.
  43. Ghodratnama A, Heidarinejad S, Davoodi I. The relationship between socio–economic status and the rate of physical activity in Shahid Chamran University Students of Ahwaz. Journal of Sport Management 2013; 5(16):5-20.
  44. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. Journal of personality assessment 1988; 52(1):30-41.
  45. Salimi A, Jokar B, Nikpour R. Internet communication in life: The role of perceived social support and loneliness in the use of the internet. Psychological studies 2009; 5(3):81-102.
  46. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. Journal of personality assessment 1988; 52(1):30-41.
  47. Canty-Mitchell J, Zimet GD. Psychometric properties of the Multidimensional Scale of Perceived Social Support in urban adolescents. American journal of community psychology 2000; 28(3):391-400.
  48. Bagherian-Sararoudi R, Hajian A, Ehsan HB, Sarafraz MR, Zimet GD. Psychometric properties of the Persian version of the multidimensional scale of perceived social support in Iran. International journal of preventive medicine 2013; 4(11):1277.
  49. Fowers BJ, Olson DH. ENRICH Marital Inventory: A discriminant validity and cross‐validation assessment. Journal of marital and family therapy 1989; 15(1):65-79.
  50. Arab Alidousti A, Nakhaee N, Khanjani N. Reliability and validity of the Persian versions of the ENRICH marital satisfaction (brief version) and Kansas Marital Satisfaction Scales. Health and Development Journal 2015; 4(2):158-67.
  51. Lali M, Abedi A, Kajbaf MB. Construction and validation of the lifestyle questionnaire (LSQ). Psychological Research 2012; 15(1).
  52. Nomaguchi KM, Milkie MA. Costs and rewards of children: The effects of becoming a parent on adults' lives. Journal of marriage and family 2003; 65(2):356-74.
  53. Kravdal Ø, Grundy E, Skirbekk V. Fertility history and use of antidepressant medication in late mid-life: a register-based analysis of Norwegian women and men. Aging & Mental Health 2017; 21(5):477-86.
  54. Nelson SK, Kushlev K, English T, Dunn EW, Lyubomirsky S. In defense of parenthood: Children are associated with more joy than misery. Psychological science 2013; 24(1):3-10.
  55. van den Broek T. Is having more children beneficial for mothers’ mental health in later life? Causal evidence from the national health and aging trends study. Aging & Mental Health 2021; 25(10):1950-8.
  56. Graham M. Is being childless detrimental to a woman's health and well-being across her life course?. Women's health issues 2015; 25(2):176-84.
  57. Ashburn-Nardo L. Parenthood as a moral imperative? Moral outrage and the stigmatization of voluntarily childfree women and men. Sex roles 2017; 76(5):393-401.
  58. Hintz EA, Brown CL. Childfree and “bingoed”: A relational dialectics theory analysis of meaning creation in online narratives about voluntary childlessness. Communication Monographs 2020; 87(2):244-66.
  59. Holton S, Fisher J, Rowe H. Motherhood: is it good for women's mental health?. Journal of Reproductive and Infant Psychology 2010; 28(3):223-39.
  60. Kuipers YJ, van Beeck E, Cijsouw A, van Gils Y. The impact of motherhood on the course of women's psychological wellbeing. Journal of Affective Disorders Reports 2021; 6:100216.
  61. Huijts T, Kraaykamp G, Subramanian SV. Childlessness and psychological well-being in context: A multilevel study on 24 European countries. European Sociological Review 2013; 29(1):32-47.
  62. Hamidifar M, Kanani MA, Abdollahi Chanzanaq H. Voluntary childless' sight on childbearing: A study in Rasht. Sociological Cultural Studies 2017; 8(3):25-50.
  63. Klinefelter K. Positive Rituals for Motherhood: Pain Points and Practices for Maternal Well-Being 2021
  64. Tahmassian K, Anari MA, Fathabadi M. The influencing factors of parenting stress in Iranian mothers. European Psychiatry 2011; 26(1):19-24.
  65. Mobasheri M, Alidosti M, Heidari Soureshjani S, Khosravi F, Khalafeyan P, Jalilian M. Determination of the most important factors influencing the fertility patterns of single child and without child families in Shahr-e-kord city in 2013. Scientific Journal of Ilam University of Medical Sciences 2013; 21(6).
  66. Rizzo KM, Schiffrin HH, Liss M. Insight into the parenthood paradox: Mental health outcomes of intensive mothering. Journal of Child and Family Studies 2013; 22(5):614-20.
  67. Alinaghian S, Rafat Jah M, Vedadhir A. What we talk about when we talk about Mothering: Social Construction of Mothering in Tehran. Women's Studies Sociological and Psychological 2020; 18(3):107-44.
  68. Hashemi F, Rajabi M, Ahmadi A. Study of women's attitude toward value of children (case study: women 15-49 years old of Shiraz City). Journal of Applied Sociology 2017; 28(3):61-78.
  69. Molina-García L, Hidalgo-Ruiz M, Cocera-Ruíz EM, Conde-Puertas E, Delgado-Rodríguez M, Martínez-Galiano JM. The delay of motherhood: Reasons, determinants, time used to achieve pregnancy, and maternal anxiety level. PLoS One 2019; 14(12):e0227063.
  70. Abma JC, Martinez GM. Childlessness among older women in the United States: Trends and profiles. Journal of Marriage and Family 2006; 68(4):1045-56.
  71. Modiri F. Different Types of Family Values and Their Socio-Economic Correlates in Tehran City. Journal of Applied Sociology 2018; 29(1):147-66.
  72. Dijkstra-Kersten SM, Biesheuvel-Leliefeld KE, van der Wouden JC, Penninx BW, van Marwijk HW. Associations of financial strain and income with depressive and anxiety disorders. J Epidemiol Community Health 2015; 69(7):660-5.
  73. Razzak HA, Harbi A, Ahli S. Depression: prevalence and associated risk factors in the United Arab Emirates. Oman Medical Journal 2019; 34(4):274.
  74. Maselko J, Bates L, Bhalotra S, Gallis JA, O’Donnell K, Sikander S, et al. Socioeconomic status indicators and common mental disorders: evidence from a study of prenatal depression in Pakistan. SSM-population health 2018; 4:1-9.
  75. Nunes JC, Carroll MK, Mahaffey KW, Califf RM, Doraiswamy PM, Short S, et al. General Anxiety Disorder-7 Questionnaire as a marker of low socioeconomic status and inequity. medRxiv 2021.
  76. Jamali S, Poornowrooz N, Mosallanezhad Z, Alborzi M. Correlation Between Sexual Satisfaction and Self-Esteem and Stress in Women of Reproductive Age. Journal of Clinical & Diagnostic Research 2018; 12(10).