Cultural and Gender Drivers of Fertility in Egypt’s Frontier Communities

Cultural and Gender Drivers of Fertility in Egypt’s Frontier Communities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cultural and Gender Drivers of Fertility in Egypt’s Frontier Communities Doaa Oraby, Tarek Tawfik Amin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8663771/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Egypt’s National Population Council (NPC) leads the country’s population policies and strategies. To inform its work, NPC undertakes research in governorates showing alarming fertility indicators in the 2021 Egypt Family Health Survey (EFHS). Matrouh Governorate, a frontier area with high fertility, low contraceptive prevalence, widespread child marriage, and large family size, was selected for investigation. This study explored barriers and enablers underlying local fertility practices and their sociocultural determinants. Methods A qualitative study was conducted through nine focus group discussions (FGDs) with married women, married men, mothers-in-law, and community leaders across Matrouh Governorate, complemented by a desk review of secondary sources. Data were analyzed thematically to identify perceptions and practices related to age at first pregnancy, birth spacing, and preferred family size. Results Fertility practices in Matrouh are shaped by entrenched cultural values, gender hierarchies, and misconceptions about modern contraceptive methods. Early marriage remains prevalent, particularly among Bedouin families, driven by social expectations and economic motives. Myths about contraceptive side effects, including infertility and harm to lactation, deter use. Birth spacing is idealized but rarely practiced due to male dominance and son preference. Despite awareness of health risks, women have limited agency in fertility decisions. Conclusion Deeply rooted gender norms, patriarchal decision-making, and misinformation sustain high fertility in Matrouh despite awareness of modern family planning (FP) benefits. Addressing these barriers requires gender-transformative, culturally grounded interventions that engage men, mothers-in-law, and religious leaders. Sexual & Reproductive Medicine Family planning Matrouh - Egypt unmet need birth spacing Figures Figure 1 Key Message Achieving replacement-level fertility in Egypt requires unpacking the local cultural and gendered drivers of high fertility. Tailored behavior change interventions are critical to raise awareness, correct misconceptions, and increase demand for family planning. Service availability alone is insufficient; sociocultural beliefs and gender power dynamics must be addressed through multi-level engagement. Introduction Egypt’s Family Health Survey (EFHS) conducted in 2021, marked significant progress in family planning (FP) among married women aged 15-49 years and revealed increase in the prevalence of modern FP methods rising to 64.7%, compared to 56.9% in Egypt’s Demographic and Health Survey, 2014 (EDHS). 1 However, this upward trend does not extend to younger age groups where 39% of married women aged 15-19 years use modern FP methods. 1 Early initiation of childbearing is associated with increased neonatal and maternal risks as reflected by a clear trend of increasing rates of maternal morbidity as maternal age decreases as revealed by previous research from 19 countries in Latin America and the Caribbean region. 2 Compared to mothers aged 20-24 years, mothers aged 15-19 years had 4 times increased risk of maternal death, 4.5 times increased risk for eclampsia and 3.7 times increased risk for puerperal endometritis. Additionally, infants of the youngest mothers had an increased risk for being of low birth weight, with preterm delivery, small for gestational age and fetal death. 3 Delaying of first pregnancy until women reached at least 18 years could reduce the risk of death for first-born children by 20 % on average, and may be decreased by up to 30 % in some countries. 4 The 2021 EFHS also revealed that 13.8% of married women aged 15-49 years had an unmet need for FP. 1 Unmet need for FP is a key indicator for determining the demand for contraception. Women are considered to have unmet need for FP when they want to space or limit births, but they are not using any method to prevent pregnancy. These women are at risk of unintended pregnancies which in returns imposing negative consequences on their health and well-being as they can lead to maternal morbidities and even death. Furthermore, children born from unintended pregnancies are less likely to be breastfed, more likely to be stunted, and are at higher risk of child mortality than children from wanted pregnancies. 5 The 2021 EFHS revealed a concerning rise in unintended births—from 15.7% in the five years preceding 2014 EDHS to 20.5% in the five years before the 2021 EFHS. This survey also highlighted that 20% of births occurred within just 24 months of the previous one. 1 The World Health Organization (WHO) and other international organizations recommend that individuals and couples should wait for at least 2–3 years between births in order to reduce the risks of adverse maternal and child health outcomes. 6 Women with too short intervals between births face several health risks such as puerperal endometritis, anemia, third trimester bleeding and premature rupture of membranes in addition to neonatal risks including preterm birth, low birth weight and higher infant mortality. 7 One of the main domain of the National Population Council (NPC) in Egypt is to design interventions and policies that focus on improving population characteristics, particularly in the area of family planning (FP) and broader population dynamics. To support this mandate, The NPC conducts studies to understand the underlying reasons of alarming indicators revealed by the 2021 EFHS in selected Egyptian governorates. The current study focused on Matrouh, a frontier Egyptian governorate nestled along Egypt's Mediterranean coast (see map below) 1 populated with 538,546 on January 1 st , 2023. 8 Matrouh governorate is characterized by having both Bedouins (nomadic) community and urban dwellers. The Bedouin population upholds their rich cultural traditions, with a significant emphasis on tribal values. Bedouin women typically do not work outside the home, adhering to traditional customs. Urban dwellers who have moved to Matrouh from other governorates especially the Nile Delta, bring a mix of backgrounds and skills. Uneducated women often find employment as nannies or housekeepers, while educated women take up roles in various professional entities. Matrouh economy is significantly bolstered by tourism (both internal and external) due to its natural attractions such as pristine beaches and desert safaris. The governorate's high fertility rates, low contraceptive use, prevalent early marriage and large sized families make it a critical area for understanding population dynamics in order to identify the barriers and opportunities of the local fertility practices. These practices included, initiation of the first pregnancy above the age of 18, birth spacing for 3-5 years, and adopting the concept of small family size (three children or fewer). The below table (table 1) displays total fertility rate (TFR), modern contraceptive prevalence rate (mCPR) and unmet need for FP in Matrouh per the 2021 EFHS and 2014 EDHS and percent change. 1 Table 1: Selected Fertility Indicators for Matrouh Governorate in 2014 and 2021 TFR mCPR (%) Unmet need for FP ( % ) Matrouh (EDHS 2014) 4.8 40 14.8 Matrouh (EFHS 2021) 4.38 53.7 10.4 Percent of change (%) for Matrouh - 8.75 34 -29.7 Egypt National figures 2.85 64.7 13.8 TFR=total fertility rate, mCPR=modern contraceptive prevalence rate, FP= family planning. This study sought to explore how cultural norms, gender relations, and fertility motives shape reproductive practices in Matrouh Governorate. It aimed to generate evidence for designing locally responsive interventions to improve family planning uptake. Methodology Study design: To gain insight into the respective fertility practices and their driving factors (motives), qualitative methodology was adopted in addition to desk review of relevant documents. Focus group discussions (FGDs) were used to allow group interactions and discussions among targeted audiences to assess the influence of social norms and explore the potential role of contextual factors on the respective fertility behaviors. Sampling and participants: Three FGDs were conducted with married women to explore the current practices, unmet need and potential barriers for use. Three FGDs were conducted with married men to explore fertility preferences, underlying factors and decision making. Two FGDs were conducted with mothers-in-law to explore the deeply rooted beliefs, motives and influence on fertility. One FGD was conducted with community leaders to explore their perception of the studied fertility practices and how to tackle their underlying factors. Each FGD included 8-12 participants. FGDs participants were recruited through purposive sampling technique according to predetermined criteria including being aged 18-40 for married women, 20-40 years for married men, and 40-60 for mothers -in- law, and of different sociodemographic characteristics. Additionally, those who were urban dwellers should have been based in Matrouh for at least 10 years. The study recruited community leaders of both sexes aged 25-50 years, of different backgrounds and have been in their positions for at least five years. Data collection: Separate semi-structured discussion guides were developed for each group, focusing on: age at marriage and first pregnancy; birth spacing and decision-making dynamics; desired family size and fertility motives. The FGDs were conducted in the premises of local NGOs that are accessible for the participants and provide auditory and visual privacy to allow participants to feel at ease and speak freely. Data analysis: The FGDs were transcribed then analyzed manually using thematic analysis involving coding the data and organizing it into themes that emerge from the data. The main themes focused on the current practices regarding the studied fertility behaviors, decision making, and the underlying factors of these practices. The same themes which were commonly being reflected across the participants were grouped together and divergent but relevant themes were also reported separately. Data saturation was achieved after nine FGDs when no new insights emerged. Ethical considerations: The study received IRB approval by the National Population Council. The FGDs participants provided their consent for voluntary participation in the discussions and recording of the FGDs for those who consented to participate in the study. Participants were assured that the recordings will be destroyed after the analysis and that transcripts will have no identifiers. The FGDs were conducted in venues that allow privacy of participants in addition to maintaining visual and auditory confidentiality. Anonymity was maintained and quotes were used without identifiers. Results Participants’ characteristics: The below table displays the sociodemographic characteristics of the FGDs participants. The FGDs for married men were attended by both Bedouins and urban dwellers. However, Bedouin women did not participate in the FGDs as they are not allowed to leave their homes. Studied fertility behaviors practiced by Bedouin women were reflected by participating Bedouin men and women urban dwellers who have been living in Matrouh for more than Table 2: Characteristics of FGDs Participants Participants of FGDs Participants Characteristics Married women (18-40) 21 participants: 2 illiterates - 12 elementary -3 secondary -4 commercial vocational 14 housewives - 6 workers- 1 clerk Married men (20-40) 22 participants: 1 illiterate - 2 elementary - 18 technical vocational 16 workers - 3 unemployed - 1 clerk--1 driver - 1 retired Mothers in -in-law aged (40-60 years) 18 participants:11 illiterate -1 read& write - 1 elementary – 1 secondary - 4 commercial vocational All housewives Community leaders 8 participants: 2 males (religious leader and governmental employee) - 6 females (1 religious leader – 1 NGO coordinator – 4 social workers) Age at first pregnancy: FGDs participants of both sexes stated that the ideal age for a woman to get married and have her first child is in her early twenties. They added that by this age, a woman is physically and mentally mature enough to effectively manage household chores and rear children. Marrying and having children before the age of twenty can lead to negative health consequences for the mother due to incomplete maturity of reproductive organs and the mental incapacity to rear children properly. However, many married men and women in addition to mothers-in-law and community leaders revealed that in their communities, it is common for parents to marry off their daughters as young as 16 or 17, and sometimes even at the age of 14, particularly among Bedouin families. The participants attributed the prevalence of early marriage to poverty and traditions. Parents marry off their daughters early to reduce their financial burden, and to uphold family honor which is tied to the perceived purity, reputation, and actions of female members of the family. Early marriage is viewed as a safeguard to ensure that daughters do not engage in premarital relationships, which could bring shame to the family. Furthermore, marrying daughters early is a mean to align with community expectations and avoid social exclusion, particularly among Bedouin families where early marriage is a common practice deeply rooted in cultural traditions. Few community leaders added that lack of schooling due the vast distance to travel to schools or the existence of mixed schools (girls and boys) - which is against the deeply rooted traditions- encourage parents to have their daughters drop out from school and consequently consider marriage as long as their daughters are not busy studying. “In our Bedouins’ life, from the age of 14, they get married and have babies, my father had married my mother at the age of 14, and my grandfather has married my grandmother at the age of 13, and the majority of the family is like this, they marry from this age. My wife is 16.” (A man in his twenties) The legal age of marriage in Egypt was increased to 18 following amendments of Egypt’s Child Law in 2008, which prohibits the registration of marriages before that age. Alternatively, an informal paper documenting marriage is written, yet it does not guarantee the legal rights of the girl in case of death of the husband or divorce. Some families resort to financial obligations to guarantee their daughters’ rights. Additionally, since marriage of girls before the age of 18 is not officially registered, hence, children who are born from these marriages are not registered and do not have birth certificates until the marriage is registered when the wife reaches the age of 18 which could lead to potential violation of the rights of the child in case of conflicts. When probed, almost all the study participants attending FGDs clarified that their communities do not approve of delaying the first pregnancy and that the timing of the first pregnancy is not solely up to the woman or her husband, but is more of a family, especially mother-in-law, and community decision. Families, relatives, and neighbors exert pressure on the couple to have a baby shortly after marriage as failure to get pregnant soon after marriage results in rumors about the wife's fertility status. Interviewed women and mothers-in-law added that using a contraceptive method before the first baby may cause infertility. “I gave birth to the first baby when I was 16 years, because married young woman should not take any contraceptive, contraceptives will make her sterile” (A woman in her twenties) Birth spacing: Almost all of the study participants attending FGDs stated that the ideal interval between births is 3-4 years, to enable the mother to restore her health and breastfeed her baby. However, they added that closely spaced births are preferred and practiced for different reasons among urban dwellers and Bedouins. Urban dwellers have the target to complete their families by having closely spaced pregnancies and then they can focus on their work and they can even share the clothes among siblings who are almost the same sizes. In Bedouin communities, the woman has no say as to the number and intervals between births. "A woman came to me asking: I have 7 children. I am not even 20 years old and I want to take a contraceptive, but my husband doesn't agree." (A Community Leader) Son preference to ensure the husband's family lineage is a common factor among both Bedouins and urban dwellers driving closely spaced births, especially if the first child is a girl. Consequently, some women end up giving birth to 5-6 girls without adequate intervals between births until a son is born. If a woman does not deliver a son after several closely spaced pregnancies, the husband may re-marry and divorce her. When probed, some women noted that closely spaced births are not risky for the women or the newly born. On the other hand, some women were aware of the risks associated with shorter birth intervals, particularly with respect to maternal health outcomes and added that they wanted to have break after delivering sons. "The woman doesn't see the harm in having many children one after the other in succession.” (A woman in her twenties) However, this knowledge and desire did not translate into action, mainly due to fear of side effects of modern FP methods due to concerns about side effects including bleeding, infertility and weight gain. “I don’t prefer contraceptives because it may affect the body” (A man in his twenties) An important theme that emerged from the FGDs is that lactating women largely avoid modern contraceptives mainly due to misconceptions related to FP methods including infertility and negatively affecting breastfeeding in addition to fear of side effects. Consequently, these women often rely on the lactational amenorrhea method (LAM) but fail to adhere to the necessary criteria for LAM to be used effectively as a traditional FP method. As a result, many lactating women accidentally discover their pregnancy just a few months after giving birth. This highlights a substantial knowledge gap regarding the criteria for using LAM and the availability of contraceptive methods that could be safely used by lactating women to prevent or postpone pregnancy without affecting breastfeeding. Preferred family size: Almost all study participants attending FGDs stated that the ideal number of children is three, as it allows families to provide adequate support and sustenance. "These days, 2 or 3 children at most due to rising prices. You can raise them well, educate them, dress them nicely, and take good care of them. They receive the care and attention they need in every aspect, including nurturing and affection." (A woman in her thirties) However, participants noted that among Bedouin communities, the norm is to have 8-10 children, particularly because polygamy is a common practice. Discussions revealed that the studied communities believe large families are powerful families, as having many children means they can support and care for each other, thereby reinforcing the family's strength and status within the community. " I have 18 brothers and my father is married to three ." (A man in his twenties) "What family planning are you talking about? Have 10, have 20, have 30; the most important thing is having a big family." (Community leader) The FGDs revealed that the number of children is determined by husbands being the bread winners. When probed, some of the interviewed older women stated that they may raise the issue with their husbands- if they themselves felt satisfied with the number of children they have- provided they have delivered a son, but the final say is for the husband. Some husbands added that it is the role of the wife to deliver and that she is not entitled to decide to limit births and that the husband’s decision regarding the desired number of children depends on his ability to sustain the family. However, they added that the timing of the next pregnancy could be postponed if the health status of the wife is not good provided, she has delivered a son. "The man is the decision-maker. He's the one who carries the responsibility. If the woman doesn’t want to have more children, that's not her right." (A man in his thirties) Discussions with mothers -in-law and community leaders revealed that demand for contraception is mainly for birth limiting rather birth spacing. Community leaders and mothers-in-law also added that the economic hardship is a strong barrier to raising healthy educated children which is the ultimate goal of parents. Few women referred to their inability to purchase new clothes and school bags for their children and that the sad looks of their children hardly hit them. Most of the women and few men stated that they want to have educated children, unlike themselves, and this will not be possible if they have many children. Some of the interviewed men stated that if they have enough financial resources, they can have many children. Discussions with married men highlighted that preference of large families is reinforced by a misunderstanding of religious teachings where Islam is mistakenly perceived as being non-supportive of contraceptive use, leading to a reluctance to adopt modern FP methods. “I know for sure that my wife will be pregnant if she did not use a contraceptive, but I left the matter in God’s hands” (A man in his twenties) Limitations: The exclusion of Bedouin women from FGDs limits direct gender perspectives; however, triangulation across participant groups provided insight into their lived realities. Findings are context-specific but may resonate with other frontier and tribal settings in Egypt. Discussion and Conclusion This study demonstrates that fertility behaviors in Matrouh are shaped by an interplay of knowledge, gender dynamics, and entrenched sociocultural norms . While awareness of ideal fertility practices exists, women’s agency is constrained by patriarchal decision-making, collective family pressure, and misinformation. Fertility is socially constructed as a communal, not individual, matter, closely tied to family honor, male authority, and religious interpretations. The findings align with broader evidence from Upper Egypt and similar Middle Eastern contexts, where early marriage and son preference persist as deep-seated cultural expectations. Misunderstandings about modern FP methods, particularly fears of infertility, weight gain, or harm to breastfeeding, further reinforce non-use. The study reveals a critical knowledge–action gap , where health awareness fails to translate into behavior due to restrictive norms and limited autonomy. Addressing these barriers requires a comprehensive approach that couples gender-transformative strategies with culturally sensitive communication . Engaging men, religious and community leaders, and mothers-in-law is essential to shift attitudes toward equitable decision-making. Provider training should focus on empathetic, stigma-free counseling to rebuild community trust in FP services. Finally, to achieve replacement-level fertility, Egypt must move beyond service expansion toward social norm transformation . Efforts should focus on dismantling misconceptions, promoting informed choice, and embedding FP discussions within education, religious, and media platforms. Recommendations Behavior Change Communication: Develop sustained multi-channel campaigns grounded in local dialects and media consumption habits. Employ interpersonal communication through trained health workers and peer educators. Gender-Transformative Programming: Engage men, mothers-in-law, and community leaders as partners in shifting norms on early marriage and fertility expectations. Promote shared decision-making within couples. Religious Engagement: Partner with religious scholars to disseminate accurate interpretations of Islam supporting FP. Capacity Building and Service Integration: Train providers to address myths and deliver respectful counseling for married adolescents and women. Ensure FP services cater to lactating women and integrate LAM education. Empowerment and Equity: Empowering women in frontier and tribal communities like Matrouh to make autonomous reproductive choices is central to achieving national demographic goals and ensuring equitable development. Further Research: Conduct longitudinal qualitative and quantitative studies on fertility motives and FP outcomes among Bedouin women to inform scalable policy responses. Declarations Acknowledgements The authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. The findings and conclusions of this report are those of the authors. The authors declare that they have no conflict of interests References Central Agency for Public Mobilization and Statistics (CAPMAS) 2022. Egypt Family Health Survey 2021. Conde-Agudelo A, Belizan JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ. 2000 Nov 18;321(7271):1255-9. Conde-Agudelo A, Belizan JM, Lammers C. Maternal-perinatal morbidity and mortality. associated with adolescent pregnancy in Latin America: Cross-sectional study. American journal of obstetrics and gynecology. 2005 Feb;192(2):342-9. UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and the World Bank 2010. Facts for Life. Available at: https://www.unicef.org/reports/facts-for-life. Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception. 2008;78(1):73–8. WHO 2007. Report of a WHO Technical Consultation on Birth Spacing Geneva, Switzerland, 13–15 June 2005 USAID/ESD 2010. Healthy Timing and Spacing of Pregnancy: A Trainer’s Reference Guide. Available from: https://pdf.usaid.gov/pdf_docs/pnaec211.pdf Central Agency for Public Mobilization and Statistics. Egypt in figures 2023. Available at: https://www.capmas.gov.eg/pdf/new_Pdf/20238713628_pop2023%20-%20e.pdf Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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10:08:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":990741,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8663771/v1/5e829c44-d6d0-467a-89d3-7e8a0f082d08.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eCultural and Gender Drivers of Fertility in Egypt’s Frontier Communities\u003c/p\u003e","fulltext":[{"header":"Key Message","content":"\u003cul\u003e\n \u003cli\u003eAchieving replacement-level fertility in Egypt requires unpacking the local cultural and gendered drivers of high fertility.\u003c/li\u003e\n \u003cli\u003eTailored behavior change interventions are critical to raise awareness, correct misconceptions, and increase demand for family planning.\u003c/li\u003e\n \u003cli\u003eService availability alone is insufficient; sociocultural beliefs and gender power dynamics must be addressed through multi-level engagement.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eEgypt\u0026rsquo;s Family Health Survey (EFHS) conducted in 2021, marked significant progress in family planning (FP) among married women aged 15-49 years and revealed increase in the prevalence of modern FP methods rising to 64.7%, compared to 56.9% in Egypt\u0026rsquo;s Demographic and Health Survey, 2014 (EDHS).\u003csup\u003e1\u003c/sup\u003e However, this upward trend does not extend to younger age groups where 39% of married women aged 15-19 years use modern FP methods.\u003csup\u003e1\u003c/sup\u003e\u0026nbsp; Early initiation of childbearing is associated with increased neonatal and maternal risks as reflected by a clear trend of increasing rates of maternal morbidity as maternal age decreases as revealed by previous research from 19 countries in Latin America and the Caribbean region.\u003csup\u003e2\u003c/sup\u003e Compared to mothers aged 20-24 years, mothers aged 15-19 years had 4 times increased risk of maternal death, 4.5 times increased risk for eclampsia and 3.7 times increased risk for puerperal endometritis. Additionally, infants of the youngest mothers had an increased risk for being of low birth weight, with preterm delivery, small for gestational age and fetal death.\u003csup\u003e3\u003c/sup\u003e Delaying of first pregnancy until women reached at least 18 years could reduce the risk of death for first-born children by 20 % on average, and may be decreased by up to 30 % in some countries.\u003csup\u003e4\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 2021 EFHS also revealed that 13.8% of married women aged 15-49 years had an unmet need for FP.\u003csup\u003e1\u003c/sup\u003e Unmet need for FP is a key indicator for determining the demand for contraception. Women are considered to have unmet need for FP when they want to space or limit births, but they are not using any method to prevent pregnancy. These women are at risk of unintended pregnancies which in returns imposing negative consequences on their health and well-being as they can lead to maternal morbidities and even death. Furthermore, children born from unintended pregnancies are less likely to be breastfed, more likely to be stunted, and are at higher risk of child mortality than children from wanted pregnancies.\u003csup\u003e5\u003c/sup\u003e The 2021 EFHS revealed a concerning rise in unintended births\u0026mdash;from 15.7% in the five years preceding 2014 EDHS to 20.5% in the five years before the 2021 EFHS. This survey also highlighted that 20% of births occurred within just 24 months of the previous one.\u003csup\u003e1\u003c/sup\u003e The World Health Organization (WHO) and other international organizations recommend that individuals and couples should wait for at least 2\u0026ndash;3 years between births in order to reduce the risks of adverse maternal and child health outcomes.\u003csup\u003e6\u003c/sup\u003e Women with too short intervals between births face several health risks such as puerperal endometritis, anemia, third trimester bleeding and premature rupture of membranes in addition to neonatal risks including preterm birth, low birth weight and higher infant mortality.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOne of the main domain of the National Population Council (NPC) in Egypt is to design interventions and policies that focus on improving population characteristics, particularly in the area of family planning (FP) and broader population dynamics. To support this mandate, The NPC conducts studies to understand the underlying reasons of alarming indicators revealed by the 2021 EFHS in selected Egyptian governorates.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current study focused on Matrouh, a frontier Egyptian governorate nestled along Egypt\u0026apos;s Mediterranean coast (see map below) \u003ca href=\"#_ftn1\" name=\"_ftnref1\" title=\"\"\u003e\u003c/a\u003e\u003csup\u003e1\u003c/sup\u003e populated with 538,546 on January 1\u003csup\u003est\u003c/sup\u003e, 2023.\u003csup\u003e8\u003c/sup\u003e Matrouh governorate is characterized by having both Bedouins (nomadic) community and urban dwellers. The Bedouin population upholds their rich cultural traditions, with a significant emphasis on tribal values. Bedouin women typically do not work outside the home, adhering to traditional customs. Urban dwellers who have moved to Matrouh from other governorates especially the Nile Delta, bring a mix of backgrounds and skills. Uneducated women often find employment as nannies or housekeepers, while educated women take up roles in various professional entities. Matrouh economy is significantly bolstered by tourism (both internal and external) due to its natural attractions such as pristine beaches and desert safaris.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe governorate\u0026apos;s high fertility rates, low contraceptive use, prevalent early marriage and large sized families make it a critical area for understanding population dynamics in order to identify the barriers and opportunities of the local fertility practices. These practices included, initiation of the first pregnancy above the age of 18, birth spacing for 3-5 years, and adopting the concept of small family size (three children or fewer). The below table (table 1) displays total fertility rate (TFR), modern contraceptive prevalence rate (mCPR)\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003eand unmet need for FP in Matrouh per the 2021 EFHS and 2014 EDHS and percent change.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"588\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 588px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1: Selected Fertility Indicators for Matrouh Governorate in 2014 and 2021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTFR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emCPR (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnmet need for FP (\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e%\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatrouh (EDHS 2014)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e40\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMatrouh (EFHS 2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.38\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e53.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent of change (%) for Matrouh\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e- 8.75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-29.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEgypt National figures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.85\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e64.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTFR=total fertility rate, mCPR=modern contraceptive prevalence rate, FP= family planning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study sought to explore how cultural norms, gender relations, and fertility motives shape reproductive practices in Matrouh Governorate. It aimed to generate evidence for designing locally responsive interventions to improve family planning uptake.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy design:\u003c/strong\u003e To gain insight into the respective fertility practices and their driving factors (motives), qualitative methodology was adopted in addition to desk review of relevant documents. Focus group discussions (FGDs) were used to allow group interactions and discussions among targeted audiences to assess the influence of social norms and explore the potential role of contextual factors on the respective fertility behaviors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and participants:\u003c/strong\u003e Three FGDs were conducted with married women to explore the current practices, unmet need and potential barriers for use. Three FGDs were conducted with married men to explore fertility preferences, underlying factors and decision making. Two FGDs were conducted with mothers-in-law to explore the deeply rooted beliefs, motives and influence on fertility. One FGD was conducted with community leaders to explore their perception of the studied fertility practices and how to tackle their underlying factors. Each FGD included 8-12 participants. FGDs participants were recruited through purposive sampling technique according to predetermined criteria including being aged 18-40 for married women, 20-40 years for married men, and 40-60 for mothers -in- law, and of different sociodemographic characteristics. Additionally, those who were urban dwellers should have been based in Matrouh for at least 10 years. The study recruited community leaders of both sexes aged 25-50 years, of different backgrounds and have been in their positions for at least five years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection:\u003c/strong\u003e Separate semi-structured discussion guides were developed for each group, focusing on: age at marriage and first pregnancy; birth spacing and decision-making dynamics; desired family size and fertility motives. The FGDs were conducted in the premises of local NGOs that are accessible for the participants and provide auditory and visual privacy to allow participants to feel at ease and speak freely.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis:\u003c/strong\u003e The FGDs were transcribed then analyzed manually using thematic analysis involving coding the data and organizing it into themes that emerge from the data. The main themes focused on the current practices regarding the studied fertility behaviors, decision making, and the underlying factors of these practices. The same themes which were commonly being reflected across the participants were grouped together and divergent but relevant themes were also reported separately. Data saturation was achieved after nine FGDs when no new insights emerged.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u0026nbsp;\u003c/strong\u003eThe study received IRB approval by the National Population Council. The FGDs participants provided their consent for voluntary participation in the discussions and recording of the FGDs for those who consented to participate in the study. Participants were assured that the recordings will be destroyed after the analysis and that transcripts will have no identifiers. The FGDs were conducted in venues that allow privacy of participants in addition to maintaining visual and auditory confidentiality. Anonymity was maintained and quotes were used without identifiers.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u0026rsquo; characteristics:\u003c/strong\u003e The below table displays the sociodemographic characteristics of the FGDs participants. The FGDs for married men were attended by both Bedouins and urban dwellers. However, Bedouin women did not participate in the FGDs as they are not allowed to leave their homes. Studied fertility behaviors practiced by Bedouin women were reflected by participating Bedouin men and women urban dwellers who have been living in Matrouh for more than\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 575px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Characteristics of FGDs Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants of FGDs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003eParticipants Characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried women (18-40)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003e21 participants: 2 illiterates - 12 elementary -3 secondary -4 commercial vocational\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 housewives - 6 workers- 1 clerk\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarried men (20-40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003e22 participants: 1 illiterate - 2 elementary - 18 technical vocational\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;16 workers - 3 unemployed - 1 clerk--1 driver - 1 retired\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMothers in -in-law aged (40-60 years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003e18 participants:11 illiterate -1 read\u0026amp; write - 1 elementary \u0026ndash; 1 secondary - 4 commercial vocational\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAll housewives\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity leaders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003e8 participants: 2 males (religious leader and governmental employee) - 6 females (1 religious leader \u0026ndash; 1 NGO coordinator \u0026ndash; 4 social workers)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAge at first pregnancy:\u003c/strong\u003e FGDs participants of both sexes stated that the ideal age for a woman to get married and have her first child is in her early twenties. They added that by this age, a woman is physically and mentally mature enough to effectively manage household chores and rear children. Marrying and having children before the age of twenty can lead to negative health consequences for the mother due to incomplete maturity of reproductive organs and the mental incapacity to rear children properly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, many married men and women in addition to mothers-in-law and community leaders revealed that in their communities, it is common for parents to marry off their daughters as young as 16 or 17, and sometimes even at the age of 14, particularly among Bedouin families. The participants attributed the prevalence of early marriage to poverty and traditions. Parents marry off their daughters early to reduce their financial burden, and to uphold family honor which is tied to the perceived purity, reputation, and actions of female members of the family. Early marriage is viewed as a safeguard to ensure that daughters do not engage in premarital relationships, which could bring shame to the family. Furthermore, marrying daughters early is a mean to align with community expectations and avoid social exclusion, particularly among Bedouin families where early marriage is a common practice deeply rooted in cultural traditions. Few community leaders added that lack of schooling due the vast distance to travel to schools or the existence of mixed schools (girls and boys) - which is against the deeply rooted traditions- encourage parents to have their daughters drop out from school and consequently consider marriage as long as their daughters are not busy studying.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In our Bedouins\u0026rsquo; life, from the age of 14, they get married and have babies, my father had married my mother at the age of 14, and my grandfather has married my grandmother at the age of 13, and the majority of the family is like this, they marry from this age. My wife is 16.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(A man in his twenties)\u003c/p\u003e\n\u003cp\u003eThe legal age of marriage in Egypt was increased to 18 following amendments of Egypt\u0026rsquo;s Child Law in 2008, which prohibits the registration of marriages before that age. \u0026nbsp;Alternatively, an informal paper documenting marriage is written, yet it does not guarantee the legal rights of the girl in case of death of the husband or divorce. \u0026nbsp; Some families resort to financial obligations to guarantee their daughters\u0026rsquo; rights. Additionally, since marriage of girls before the age of 18 is not officially registered, hence, children who are born from these marriages are not registered and do not have birth certificates until the marriage is registered when the wife reaches the age of 18 which could lead to potential violation of the rights of the child in case of conflicts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen probed, almost all the study participants attending FGDs clarified that their communities do not approve of delaying the first pregnancy and that the timing of the first pregnancy is not solely up to the woman or her husband, but is more of a family, especially mother-in-law, and community decision. \u0026nbsp;Families, relatives, and neighbors exert pressure on the couple to have a baby shortly after marriage as failure to get pregnant soon after marriage results in rumors about the wife\u0026apos;s fertility status. Interviewed women and mothers-in-law added that using a contraceptive method before the first baby may cause infertility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I gave birth to the first baby when I was 16 years, because married young woman should not take any contraceptive, contraceptives will make her sterile\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e(A woman in her twenties)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBirth spacing:\u003c/strong\u003e Almost all of the study participants attending FGDs stated that the ideal interval between births is 3-4 years, to enable the mother to restore her health and breastfeed her baby. However, they added that closely spaced births are preferred and practiced for different reasons among urban dwellers and Bedouins. Urban dwellers have the target to complete their families by having closely spaced pregnancies and then they can focus on their work and they can even share the clothes among siblings who are almost the same sizes. In Bedouin communities, the woman has no say as to the number and intervals between births. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;A woman came to me asking: I have 7 children. I am not even 20 years old and I want to take a contraceptive, but my husband doesn\u0026apos;t agree.\u0026quot;\u0026nbsp;\u003c/em\u003e(A Community Leader)\u003c/p\u003e\n\u003cp\u003eSon preference to ensure the husband\u0026apos;s family lineage is a common factor among both Bedouins and urban dwellers driving closely spaced births, especially if the first child is a girl. Consequently, some women end up giving birth to 5-6 girls without adequate intervals between births until a son is born. If a woman does not deliver a son after several closely spaced pregnancies, the husband may re-marry and divorce her.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen probed, some women noted that closely spaced births are not risky for the women or the newly born. On the other hand, some women were aware of the risks associated with shorter birth intervals, particularly with respect to maternal health outcomes and added that they wanted to have break after delivering sons.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The woman doesn\u0026apos;t see the harm in having many children one after the other in succession.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(A woman in her twenties)\u003c/p\u003e\n\u003cp\u003eHowever, this knowledge and desire did not translate into action, mainly due to fear\u0026nbsp;of side effects of modern FP methods due to concerns about side effects including bleeding, infertility and weight gain.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t prefer contraceptives because it may affect the body\u0026rdquo;\u0026nbsp;\u003c/em\u003e(A man in his twenties)\u003c/p\u003e\n\u003cp\u003eAn important theme that emerged from the FGDs is that lactating women largely avoid modern contraceptives mainly due to misconceptions related to FP methods including infertility and negatively affecting breastfeeding in addition to fear of side effects. Consequently, these women often rely on the lactational amenorrhea method (LAM) but fail to adhere to the necessary criteria for LAM to be used effectively as a traditional FP method. As a result, many lactating women accidentally discover their pregnancy just a few months after giving birth. This highlights a substantial knowledge gap regarding the criteria for using LAM and the availability of contraceptive methods that could be safely used by lactating women to prevent or postpone pregnancy without affecting breastfeeding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreferred family size:\u003c/strong\u003e Almost all study participants attending FGDs stated that the ideal number of children is three, as it allows families to provide adequate support and sustenance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;These days, 2 or 3 children at most due to rising prices. You can raise them well, educate them, dress them nicely, and take good care of them. They receive the care and attention they need in every aspect, including nurturing and affection.\u0026quot;\u0026nbsp;\u003c/em\u003e(A woman in her thirties)\u003c/p\u003e\n\u003cp\u003eHowever, participants noted that among Bedouin communities, the norm is to have 8-10 children, particularly because polygamy is a common practice. Discussions revealed that the studied communities believe large families are powerful families, as having many children means they can support and care for each other, thereby reinforcing the family\u0026apos;s strength and status within the community.\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eI have 18 brothers and my father is married to three\u003c/em\u003e.\u0026quot; \u0026nbsp;(A man in his twenties)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;What family planning are you talking about? Have 10, have 20, have 30; the most important thing is having a big family.\u0026quot;\u003c/em\u003e (Community leader)\u003c/p\u003e\n\u003cp\u003eThe FGDs revealed that the number of children is determined by husbands being the bread winners. When probed, some of the interviewed older women stated that they may raise the issue with their husbands- if they themselves felt satisfied with the number of children they have- provided they have delivered a son, but the final say is for the husband. Some husbands added that it is the role of the wife to deliver and that she is not entitled to decide to limit births and that the husband\u0026rsquo;s decision regarding the desired number of children depends on his ability to sustain the family. However, they added that the timing of the next pregnancy could be postponed if the health status of the wife is not good provided, she has delivered a son. \u0026nbsp;\u003cem\u003e\u0026quot;The man is the decision-maker. He\u0026apos;s the one who carries the responsibility. If the woman doesn\u0026rsquo;t want to have more children, that\u0026apos;s not her right.\u0026quot;\u0026nbsp;\u003c/em\u003e(A man in his thirties)\u003c/p\u003e\n\u003cp\u003eDiscussions with mothers -in-law and community leaders revealed that demand for contraception is mainly for birth limiting rather birth spacing. Community leaders and mothers-in-law also added that the economic hardship is a strong barrier to raising healthy educated children which is the ultimate goal of parents. Few women referred to their inability to purchase new clothes and school bags for their children and that the sad looks of their children hardly hit them. Most of the women and few men stated that they want to have educated children, unlike themselves, and this will not be possible if they have many children. Some of the interviewed men stated that if they have enough financial resources, they can have many children. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiscussions with married men highlighted that preference of large families is reinforced by a misunderstanding of religious teachings where Islam is mistakenly perceived as being non-supportive of contraceptive use, leading to a reluctance to adopt modern FP methods.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I know for sure that my wife will be pregnant if she did not use a contraceptive, but I left the matter in God\u0026rsquo;s hands\u0026rdquo;\u003c/em\u003e (A man in his twenties)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations:\u0026nbsp;\u003c/strong\u003eThe exclusion of Bedouin women from FGDs limits direct gender perspectives; however, triangulation across participant groups provided insight into their lived realities. Findings are context-specific but may resonate with other frontier and tribal settings in Egypt.\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eThis study demonstrates that fertility behaviors in Matrouh are shaped by an interplay of \u003cstrong\u003eknowledge, gender dynamics, and entrenched sociocultural norms\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e While awareness of ideal fertility practices exists, women\u0026rsquo;s agency is constrained by patriarchal decision-making, collective family pressure, and misinformation. Fertility is socially constructed as a communal, not individual, matter, closely tied to family honor, male authority, and religious interpretations.\u003c/p\u003e\n\u003cp\u003eThe findings align with broader evidence from Upper Egypt and similar Middle Eastern contexts, where early marriage and son preference persist as deep-seated cultural expectations. Misunderstandings about modern FP methods, particularly fears of infertility, weight gain, or harm to breastfeeding, further reinforce non-use. The study reveals a critical \u003cstrong\u003eknowledge\u0026ndash;action gap\u003c/strong\u003e, where health awareness fails to translate into behavior due to restrictive norms and limited autonomy.\u003c/p\u003e\n\u003cp\u003eAddressing these barriers requires a comprehensive approach that couples \u003cstrong\u003egender-transformative strategies\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewith\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eculturally sensitive communication\u003c/strong\u003e\u003c/strong\u003e. Engaging men, religious and community leaders, and mothers-in-law is essential to shift attitudes toward equitable decision-making. Provider training should focus on empathetic, stigma-free counseling to rebuild community trust in FP services.\u003c/p\u003e\n\u003cp\u003eFinally, to achieve replacement-level fertility, Egypt must move beyond service expansion toward \u003cstrong\u003esocial norm transformation\u003c/strong\u003e. Efforts should focus on dismantling misconceptions, promoting informed choice, and embedding FP discussions within education, religious, and media platforms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eBehavior Change Communication:\u003c/strong\u003e\n \u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eDevelop sustained multi-channel campaigns grounded in local dialects and media consumption habits.\u003c/li\u003e\n \u003cli\u003eEmploy interpersonal communication through trained health workers and peer educators.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGender-Transformative Programming:\u003c/strong\u003e\n \u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eEngage men, mothers-in-law, and community leaders as partners in shifting norms on early marriage and fertility expectations.\u003c/li\u003e\n \u003cli\u003ePromote shared decision-making within couples.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReligious Engagement:\u003c/strong\u003e\n \u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003ePartner with religious scholars to disseminate accurate interpretations of Islam supporting FP.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCapacity Building and Service Integration:\u003c/strong\u003e\n \u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eTrain providers to address myths and deliver respectful counseling for married adolescents and women.\u003c/li\u003e\n \u003cli\u003eEnsure FP services cater to lactating women and integrate LAM education.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEmpowerment and Equity:\u003c/strong\u003e\n \u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003e\u003cstrong\u003eEmpowering women in frontier and tribal communities like Matrouh to make autonomous reproductive choices is central to achieving national demographic goals and ensuring equitable development.\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFurther Research:\u003c/strong\u003e\n \u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eConduct longitudinal qualitative and quantitative studies on fertility motives and FP outcomes among Bedouin women to inform scalable policy responses.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. The findings and conclusions of this report are those of the authors. The authors declare that they have no conflict of interests\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eCentral Agency for Public Mobilization and Statistics (CAPMAS) 2022. Egypt Family Health Survey 2021.\u003c/li\u003e\n\u003cli\u003eConde-Agudelo A, Belizan JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ. 2000 Nov 18;321(7271):1255-9.\u003c/li\u003e\n\u003cli\u003eConde-Agudelo A, Belizan JM, Lammers C. Maternal-perinatal morbidity and mortality. associated with adolescent pregnancy in Latin America: Cross-sectional study. American journal of obstetrics and gynecology. 2005 Feb;192(2):342-9.\u003c/li\u003e\n\u003cli\u003eUNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and the World Bank 2010. Facts for Life. Available at: https://www.unicef.org/reports/facts-for-life. \u003c/li\u003e\n\u003cli\u003eHubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception. 2008;78(1):73\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eWHO 2007. Report of a WHO Technical Consultation on Birth Spacing Geneva, Switzerland, 13\u0026ndash;15 June 2005\u003c/li\u003e\n\u003cli\u003eUSAID/ESD 2010. Healthy Timing and Spacing of Pregnancy: A Trainer\u0026rsquo;s Reference Guide. Available from: https://pdf.usaid.gov/pdf_docs/pnaec211.pdf \u003c/li\u003e\n\u003cli\u003eCentral Agency for Public Mobilization and Statistics. Egypt in figures 2023. Available at: https://www.capmas.gov.eg/pdf/new_Pdf/20238713628_pop2023%20-%20e.pdf \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"National Population Council","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Family planning, Matrouh - Egypt, unmet need, birth spacing","lastPublishedDoi":"10.21203/rs.3.rs-8663771/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8663771/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEgypt\u0026rsquo;s National Population Council (NPC) leads the country\u0026rsquo;s population policies and strategies. To inform its work, NPC undertakes research in governorates showing alarming fertility indicators in the 2021 Egypt Family Health Survey (EFHS). Matrouh Governorate, a frontier area with high fertility, low contraceptive prevalence, widespread child marriage, and large family size, was selected for investigation. This study explored barriers and enablers underlying local fertility practices and their sociocultural determinants.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study was conducted through nine focus group discussions (FGDs) with married women, married men, mothers-in-law, and community leaders across Matrouh Governorate, complemented by a desk review of secondary sources. Data were analyzed thematically to identify perceptions and practices related to age at first pregnancy, birth spacing, and preferred family size.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFertility practices in Matrouh are shaped by entrenched cultural values, gender hierarchies, and misconceptions about modern contraceptive methods. Early marriage remains prevalent, particularly among Bedouin families, driven by social expectations and economic motives. Myths about contraceptive side effects, including infertility and harm to lactation, deter use. Birth spacing is idealized but rarely practiced due to male dominance and son preference. Despite awareness of health risks, women have limited agency in fertility decisions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDeeply rooted gender norms, patriarchal decision-making, and misinformation sustain high fertility in Matrouh despite awareness of modern family planning (FP) benefits. Addressing these barriers requires gender-transformative, culturally grounded interventions that engage men, mothers-in-law, and religious leaders.\u003c/p\u003e","manuscriptTitle":"Cultural and Gender Drivers of Fertility in Egypt’s Frontier Communities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-24 00:40:36","doi":"10.21203/rs.3.rs-8663771/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed9f2961-3286-46a7-a02b-e728d30c1d63","owner":[],"postedDate":"January 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61540389,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2026-01-24T00:40:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-24 00:40:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8663771","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8663771","identity":"rs-8663771","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}