Modern societies are characterised by “refined” demographic and family planning behaviour regarding low fertility and mortality [ 1]. These types of societies are the ones desired by many developing countries since they exhibit stable population sizes relative to economic growth. Increasing population size means a continuous drain of the limited resources of a nation. Population control is an essential step without which the economic development of a country may be difficult to attain [ 1]. Population control practices have increased with the development of science and technology and these have contributed to changes in women’s attitudes towards pregnancy and childbirth [ 1]. These changes in attitude, to an extent, may be attributed to urbanization modernization and increased female education. These have set the pace for the emergence of new lifestyles such as the desire for smaller family sizes and increased contraceptive usage [ 2]. The extent to which women in their reproductive ages accept family limitations and practice has an influence on the prevailing fertility levels of a society [ 3].

Efforts aimed at reducing fertility levels in Ghana began after the attainment of independence and the country is considered a pioneer in promoting fertility decline since the 1980s [ 4]. This fertility decline has happened in the face of low levels of contraceptive use [ 4,5]. The total fertility rate (TFR) declined between 1988 and 2008; moving from 6.4 to 4.0 which translates into a decline of 2.4 children per woman within 20 years [ 5]. Yet, contraceptive prevalence hovers around 27 per cent for all methods and 22 per cent for modern methods among currently married women [ 6].

This picture in Ghana is quite different from that seen in Eastern and Southern African countries with similar rates of fertility decline, where the driving force has been attributed to increased modern contraceptive use [ 7]. Explanations other than contraceptive use have been proposed for Ghana’s fertility decline. These include underreporting of contraceptive use by women and the control of fertility through reduced coital frequency [ 5]. Widespread use of induced abortion may also be a major contributing factor in fertility decline in Ghana [ 5]. This study, using qualitative methods, explores some of the nuances accounting for fertility behaviours among better-educated women in Cape Coast.

The education of women usually increases their interest in a particular contraceptive method to regulate their fertility [ 8]. A study on contraception and induced abortion in rural Ghana found a positive association between higher education level and preference for traditional method use [ 9]. A similar study in southern Cameroon where educated women preferred periodic abstinence, withdrawal, and abortion to modern contraceptive use because it conforms to norms of modernity and self-discipline [ 10]. These findings suggest that continuous refusal to use hormonal methods may influence the educated group to adopt periodic abstinence or reduced coital frequency as an alternative way of reducing the risk of pregnancy [ 10]. The main objective of the study was to explore fertility control behaviours among educated urban women in the Cape Coast Metropolis. The study sought to answer the research question - What are the factors influencing fertility control among educated urban women?

A number of profound factors have, over the years, influenced individuals to achieve desired fertility goals. Among these are socioeconomic factors. The high rising labour force participation rates and earnings of women over the past few decades are a reflection of the changing economic status which mostly contributes to fertility decline. That is, women are less dependent on men for economic security. Organization for Economic Cooperation and Development (OECD) in 2012 argued that the skills and abilities of women in the labour market have made them become more economically empowered like men; therefore, they are able to better provide for themselves [ 11]. Though studies have not fully supported this argument, reasonably, women’s higher levels of education, income, and employment have been connected to low fertility. Studies show that women’s fertility rates are low in communities where females’ economic opportunities are on the increase [ 12].

Women’s economic empowerment helps stabilize fertility levels since they have a voice on fertility sizes especially if the man does not earn much [ 12]. A study on the impact of female employment on fertility in Dakar and Lome, Senegal and Togo respectively suggests that men now express a strong desire for economically active spouses with steady employment [ 13]. The implication of this is that highly educated women are more likely than less educated women to negotiate with their spouses on the number of children they desire. Studies show that better and improved socio-economic circumstances of couples are associated with a greater likelihood of realizing the desired birth size [ 14]. Again, a study supports the assumption that decisions regarding fertility control are affected by women’s opportunities for work, having spouses who work, and the neighbourhood conditions in which women find themselves [ 12]. However, the effects of male employment opportunities on the rate of fertility size are minimal. This means that the employment opportunities of men do not completely explain declines or rises in marital fertility [ 15]. Researchers point out that living in a resource-rich neighbourhood is linked with low incidences of sexual intercourse that may lead to unplanned pregnancy due to economic empowerment and availability of all forms of contraceptive methods and abortion [ 16]. They conclude that the increasing number of poor persons within extremely deprived communities may help explain the high birth rates that occur among couples in poor neighbourhoods [ 16].

Another significant factor in this discussion is the role of education. Education provides people with the knowledge and skills that can lead individuals to a better quality of life. Education is linked to the health of mothers and their children. The level of education of women is a factor which can play a significant role in reducing fertility. Educated women postpone their first marriage and prefer smaller family sizes, are usually aware of and use contraception and have better negotiation skills on reproductive issues [ 12]. In many countries, women’s education has been established to have a significant effect on fertility. Education brings in a new viewpoint on life as well as skills for taking advantage of new opportunities. An increase in the level of women’s education leads to a rise in age at first marriage and age at first birth and consequently, a decline in fertility. For instance, in Latin America, studies have shown that education is probably the most important socio-economic variable related to greater occupational differences and social mobility which can both affect marriage and reproductive behaviour in various ways [ 17].

Women with higher educational levels are more likely to break traditional arrangements including early marriage and childbearing. Education indirectly influences age at first birth and changes in the traditional work role. Women with gainful employment may be more likely to postpone marriage and even childbearing within marriage [ 17]. For example, researchers reported that the median age at first birth for women with secondary education was 25 years as compared with 19 years for the middle and primary school leavers [ 18]. Similar studies on education and fertility in Kenya confirm that post-primary schooling, especially for 9 or more years has a strong effect on postponing the beginning of fertility often by three to four years [ 19].

The spread of education and literacy among women is believed to be fundamental to changes in their reproductive behaviours. The effect of women’s education on fertility in less developed countries is found to rise with no education and then decrease sharply once a certain level of education is attained [ 12]. The implications are that education is positively linked to improved health, lower level of fertility, disregard of traditional constraints upon sexual behaviours and practice of breastfeeding. All these are identified as increasing fertility levels. As the educational level increases, marriage tends to be postponed which causes negative effects on fertility and offsets the initial effect of fertility increase. Moreover, educated women desire relatively fewer children. They have high contraceptive knowledge and a high chance of working or engaging in economic activities in or outside their locality. All of these factors are known to lower fertility levels [ 12]. However, it is also possible that initiation of child-bearing can lead to the termination of education of an individual [ 12].

One other area that requires consideration is location or residence. Place of residence is a useful indicator of the degree of change from traditional or rural behaviour to modern or urban behaviour. Significant rural-urban differences in marriage and fertility timing are partly the result of the greater impact of education on age at first marriage and the incidence of cohabitation and first birth in urban areas in comparison with those in rural [ 20]. Urban marriage, cohabitation and first birth distribution appear to be more dispersed than the rural distributions. Urban women have greater heterogeneity in their marriage and fertility arrangements. Generally, fertility is higher for women residing in rural areas compared with those residing in urban areas. Higher levels of education, occupation, a more modern environment, and aspirations for higher levels of living are among the factors which affect fertility among urban women [ 20]. Also, it is assumed that urban women have a better knowledge of and access to modern contraception than women in rural areas [ 21]. A recent demonstration has shown that rural fertility is substantially higher than urban fertility in every African country. Studies have also indicated the powerful effect of urban residence on lower fertility levels. Urban residence may occur in the early stages of a woman’s life or at later times; hence, the length of exposure or living in an area may also be of critical consideration.

Occupation is also a critical area that needs to be looked at. Studies suggest that non-agricultural labour force participation interferes with economic development and fertility. Economic development is associated with an increase in education and occupational opportunities for women that compete with fertility-inhibiting factors to influence fertility. This relationship between female employment and fertility holds in developing countries although there are regional variations [ 22]. Together with other aspects of the development process such as migration, these opportunities are expected to affect fertility through the proximate determinants like education. Labour force participation and work status can be used in assessing fertility and migration jointly although research findings on these variables have failed to point to a clear and consistent relation among them [ 23]. This is large because of differences in definitions used in different places, especially between the developing and developed areas, and because even when definitions are similar, they may have assumed that similarly categorised activities are, in fact, comparable in different perspectives [ 23].

Finally, sociocultural factors can affect the fertility levels of individuals. Culture may be defined simply as the total way of life of a human society. It includes, in a complex integrated whole, all learned and shared behaviours stemming from values within an emotional environment. With improved economic conditions, societies will experience different demographic forms due to varying cultural influences. The value placed on large families, especially among less developed countries who benefit from the process of development, the assurance of security for the elderly, sex preference, the ability of women to control fertility, and the status of women within families and society are among important cultural factors affecting family size and the demand for family planning services. Studies have indicated that large numbers in a family may be the only guarantee of security in disorganised traditional societies where there is no social safety net put in place by the government as a protective cover for the aged. For instance, having a big family is important because it will help during old age and has implications for family prestige [ 24]. The study further explained that the primary cause of high fertility, especially in sub-Saharan Africa, can be found in social and family patterns. Central cultural principles include the idea that many descendants must be produced to ensure the survival of lineage, the issue of female virtue with the production of a large number of children, the stronger influence of the lineage than the nuclear family, and a belief in the power of ancestral spirits [ 24]. Factors believed to contribute to lower fertility size, particularly in developed countries, are high costs of child raising and the negative impact of large family size on the standard of living in the family [ 24].

The Theory of Planned Behaviour (TPB) was developed to reflect the expansion of the Theory of Reason Action (TRA). The TPB predicts an individual's intention to engage in a behaviour at a specific time and place. The expansion was the addition of the variable Perceived Behaviour Control (PBC) to fill the gap in TRA [ 25]. The TPB is a theory which predicts deliberate behaviour because behaviour can be predictive and planned. The theory of planned behaviour assumes three conceptual independent elements of intention. The first element of the theory is the attitude (beliefs and values about the outcome of the behaviour) towards the behaviour. It refers to the degree to which a person has an unfavourable evaluation of the behaviour in question. A person’s judgment of performing the behaviour is good or bad is in favour of or against performing the behaviour. Attitude is, also, believed to be the first antecedent of behavioural intentions. An individual will intend to perform certain behaviours when he or she evaluates them positively [ 25]. Studies suggest that intentions are based on attitudes and predict behaviour that is based on subjective norms [ 26]. For example, attitudes towards fertility control behaviour are different in each life span. Educated urban women may positively evaluate their fertility because they are exposed to information and conditions about the essence of achieving a desirable fertility size.

The second element is a social factor called subjective norm (beliefs about what other people think the person should do). It refers to the perceived social pressure to perform or not to perform the behaviour. It is, normally, assumed to be a function of silent normative belief where the underlying normative belief is concerned with the likelihood that specific individuals are motivated to comply with, approve or disapprove of behaviour. In relation to fertility control behaviour, social relations or family members are the most influential people with regard to fertility control. Such significant people can be helpful in one’s attempt to perform a behaviour. It can be said that a person’s fertility control behaviours can be influenced by other people (family members or relations) who may advise that one increases or decreases his/her fertility.

The third antecedent of intention is the perceived behavioural control. This includes the external factors that may directly or indirectly affect fertility control behaviour; that is, factors that predict intentions to regulate fertility for a healthy life. Perceived behavioural control refers to people’s perception or ease in performing a behaviour of interest and it is assumed to reflect past experiences as well as anticipated impediments and obstacles [ 27]. By this, people are likely to perform a behaviour they feel they have control over and desist from carrying out behaviours they fail to have control over.

The central feature of TRA and the TPB is the intention towards behaviour. It is the individual’s intention to perform a given behaviour. Intention is assumed to capture the motivational factors that influence behaviour and indicate how individuals are willing to try or how much effort they would exert in performing behaviour [ 25]. They suggested that intention is the appropriate feature to predict and understand fertility control behaviour. As a conventional rule, the more favourable the attitude and subjective norms with respect to behaviour are, the greater the perceived behavioural control. The stronger should be an individual’s intention to perform the behaviour under consideration. The relative importance of attitude, subjective norm, and perceived behavioural control in the prediction of intention is expected to vary across behaviours and situations [ 25].

The theory of planned behaviour has some limitations. TPB exclusively focuses on rational reasoning without considering unconscious influences on behaviour and the role of feelings beyond expected affective consequences [ 28]. The subjective norm construct has also been challenged as not being a strong predictor of intentions [ 29]. This is partly ascribed to a combination of measurement and the need for expansion of the normative components. A study, however, used TPB to identify the factors influencing the breastfeeding intention of postpartum women. It was also applied in studying workplace dishonesty behaviour intentions [ 31].

The study adopted the interpretivist (qualitative) philosophy in social research. Phenomenological designs employed in qualitative research. A significant assumption underlying descriptive phenomenology is the trust that it is essential for the researcher to shed all previous personal knowledge to hold the essential lived experiences of the participants being studied. This implies that the researcher must actively keep his or her awareness of all previous expert knowledge in addition to personal biases [ 32]. Descriptive phenomenology design is flexible and allows for more freedom during interviews to explore the essence of others’ experiences [ 33]. The population for the study comprised women who have at least secondary-level education, are married or in a stable union and are between the ages of 18 and 49 years. This age range was chosen because it reflects women of different ages, who are at different stages in their reproductive lives and, may have different views on fertility and family planning. A snowball sampling technique was used to select thirty-two (32) respondents for the study. The respondents constituted the number that provided the required information at saturation. The main instrument for data collection was a semi-structured interview guide. Data was collected from educated women within the Cape Coast Metropolis. Five items open-ended questions under the heading Factors influencing fertility control among highly-educated urban women in the Cape Coast Metropolis. All transcribed data were then imported into NVivo 11, a computer-aided qualitative data analysis package with each transcript coded sentence by sentence. The codes were determined and constructed based on the content of the data. After the coding process, each code was described and memos attached as ideas about the themes emerged from social-cultural, economic to educational factors.

Women control their fertility for reasons ranging from social-cultural, and economic to educational factors. The following section presents reasons mentioned by participants as capable of or having influenced their decision to control their fertility.

Generally, almost all the participants talked about the demand for many children from family members expressing support for a large family. Most of the participants claimed that culturally, family members put a premium on large families for varied reasons which eventually affect women’s fertility levels. The participants said family pressure usually emanated from parents, in-laws, and relatives. One of the participants explained her experience:

Pressure from family can severely affect one’s fertility. I think extended family issue because I think if my father were alive I would have gone in for a third child even at the age of 35. He was insisting that I should add one more to the two I already have. He was saying at least I should give him the “Father, Son and the Holy Ghost”. Sometimes too the family wanted a particular sex which could push you to try, try and try. At the end of the day, if you’re not lucky, you will end up giving birth to children more than you planned. I have a colleague worker here who is going through a similar situation. Her decision is to give birth to three children but her mother-in-law is always on her to add two more to it. The mother-in-law wants her son to name two children after her two daughters. (Interviewee 18, tertiary level, 44 years)

However, some participants reported that they were not in any way going to succumb to the demands of family members against their desired number of children. They said family members would always bring their demands for more children but that was not going to sway them from their plans. A respondent said:

As for the family members, they will come but one thing is that their opinions will not take care of the child. My mother-in-law used to tell me that she expects nothing less than six children. I kept asking myself whether this woman was serious with what she said or if they were just jokes. How can my husband and I raise six children to the standard we have set for ourselves? So as for the family members, they will come with their “funny” proposals but I believe that the final decision rests on us. My husband even jokes with such things that, having many children is not a problem but money for “koko” [porridge] is the big issue. (Interviewee 22, tertiary level, 27 years)

Another participant also said:

My mother usually tells me that she expects me to bring five children to the family because according to her our family is not large. But I think this belongs to the past because those days, the economy was not as “hard” as it is today. I believe the kinds of food that were available then were more nutritious than today. It is her wish but I can’t go beyond what I’m looking for. It is my decision and I have to go by that. Nobody will take care of them for me. Family members will have their say but we will have our way. (Interviewee 25, tertiary level, 32 years)

The accounts of a number of participants indicated that education delays the beginning of childbearing for many women. Some of the respondents said that because of their continuous schooling, they did not start childbirth early. They explained that the late start of childbearing may reduce their chances of raising a large family size. This was because, to the women, few years may be left for them to enter menopause. A participant noted:

The time you start childbirth determines a lot. I’m 25 years old now and I have not started because of continuous education. I may start at say age 28 or 30, in that sense age may not be on my side to give more birth. As a woman, at a certain age, I can’t give birth again. (Interviewee 10, tertiary level, 25 years)

Based on the remarks about the reduced fertility size as a result of education, probing was necessary to find out the benefits of educated persons having a small family size. Two key issues relating to quality human capital development emerged from the data. The first was that, with a small family size, one could ensure good health and training of the children which would help them to develop well. A participant said:

The health of any human being cannot be compromised. Without good health, you can’t do anything in life. It is my responsibility to ensure that my children receive quality health. With good health, coupled with sound training and education, the sky will be the limit for the children in future. I can’t do this when the children are more than what my resources can actually cater for. (Interviewee 9, tertiary level, 28 years)

The second issue that emerged had to do with the social respect and recognition that one enjoys as a result of providing good care for one’s children. The participants who held this view believed that every society accords a certain level of respect to people with higher education. They indicated that such individuals educate their children and ensure their proper upbringing. Some women concluded that educated people are recognised as influential people in society. One participant observed:

I have realised that giving birth to many children does not determine one’s respect in society. But providing quality care to one’s children shows the respect and recognition people have for you. With a small family, you can take care of the children with the little that you have. (Interviewee 24, SHS level, 25 years)

Another factor that came out strongly was economic status. From the responses, it emerged that the general economic situation does not support large family sizes. Participants indicated that the cost of raising a child from the day of conception to the day they leave home runs into millions of Ghana cedis. They said that can take a large proportion of the family budget as the prices of goods are rising and may not be commensurate with their financial level. One participant said:

The economic situation these days is hard. My husband and I are working but we believe with our financial level, we may put the children into problems if I raise more kids. Now the cost of feeding the kids with good food alone is not a joke. When your child is crying for food at the time you don’t have money and your neighbour asks why the child is crying like that, that is when you will realise that you have given birth. (Interviewee 23, tertiary level, 31 years).

On occupation, two views emerged as reasons for controlling fertility. One was the nature of the job. Some participants indicated that in some jobs, work schedules give mothers little or no time to manage their homes, particularly caring for the children. According to them, caregiving is often placed in the hands of house-helps as an alternative means. This would allow mothers to meet job demands and concentrate on their careers. Notwithstanding that, participants viewed fertility control as a way of creating space to manage their homes and, at the same time, concentrate on their profession. A participant noted:

I think it is a big factor for me. Sometimes I leave for work even before the kids wake up from bed and close around 4:30 pm. As a married woman, I’m supposed to go home and take care of the kids, cook for the family and do other housework. You will realise that the whole day you might not even have time to rest. Here, for instance, if you are not at the ward, your situation is even worse. You do teaching, supervising, marking, case studies, and attending to referral cases before adding home management. If you’re not careful you may even break down. When you leave the children in the hands of caregivers it is another problem. An example is what happened in Uganda or Kenya about how a maid badly treated a baby in the absence of the parents. With few kids, I can concentrate on my job to raise money to support the family budget. (Interviewee 4, tertiary level, 32 years)

The second viewpoint was about rules and regulations governing the workplace. Participants indicated that some jobs do not entertain children within the work environment during working hours. Two respondents, for instance, said they had received caution some few days preceding the interview for bringing their children to their workplace. The women described such conditions as unfavourable for raising a large family size. This situation places a limitation on women’s fertility levels. One participant had this to say:

The kind of job you do can also influence the number of children you will like to have. For instance, if I’m a pure water seller, I can carry my child along. But if you found yourself in an institution like banking where rules and regulations are strictly enforced, you can’t go to work with a child. For now, here is a little flexible. If we get a new coordinator who is a strict person, I can’t come to work with my child. It means I have to hire someone to take care of him when I’m at work. If I hire someone to do that, I’ll have to pay the person so additional cost is going to be incurred. In some companies or institutions, they look for all these before you are even employed. (Interviewee 24, SHS level, 25 years)

It was revealed that there are diverse factors that may influence women’s fertility control. The women I studied expressed strong convictions that the opinion of family members could influence fertility size, particularly, with their preference for large families. It was seen that more children were demanded from the participants to either increase the size of their extended family or to satisfy cultural demands. A similar study reported that having a big family is important because it illustrates the preservation of cultural values and enhances family prestige [ 24]. This, therefore, suggests that a key cause of high fertility, especially among sub-Saharan Africans could be traced to the social and family systems [ 34]. However, participants were clear in their minds that no amount of family forces could sway them from their plans. They intimate that the days when large family sizes were the preferred option apparently because children were typically seen as economic assets in households are over. Reasons commonly given were that the high cost of raising children does not support large families. These appear to suggest that increasing economic burdens influence fertility. A previous study revealed that factors believed to contribute to lower fertility size are high costs of child care and the negative impact of large family size on the standard of living in that family [ 24].

Another prominent factor affecting fertility size was the educational level of individuals. In general, education is believed to impart values, aspirations and skills to people which encourage and facilitate their social development. An earlier study asserted that women’s education is the most important factor influencing fertility levels and fertility decline. This may be due to the fact that higher education levels open up greater opportunities for women that often conflict with repeated childbearing. Generally, the participants indicated that the quest to seek academic and professional development does not allow them to start childbearing early [ 17].

As a result, it emerged that the knowledge respondents had acquired through education had made them aware of the negative outcomes of large family sizes. Previous studies supported the findings of this current study that the educational status of women can shape their overall fertility levels due to their knowledge and use of contraceptives coupled with their better negotiation skills on reproductive matters [ 12]. Further, society expects some participants to educate their children with stories that are based on the knowledge they have acquired through education. Increasing labour force participation rates and earnings of women are the reflection of the changing economic status which mostly contributes to a fertility decline [ 11]. The profession of women was frequently mentioned as a factor that can influence fertility. It emerged that the kind of work women do and the rules and regulations governing the workplace have strong implications on fertility desires. For instance, some respondents were of the view that a strict application of workplace rules could pose a problem for women. They particularly mentioned financial institutions where employees could not have their babies around the premises during working hours. They conclude that women in such situations may not be able to raise many children because they may not have time to train the children the way they want. This is an indication that the more women are engaged in the labour market, the more they tend to minimize their fertility. This supports the findings made by similar studies that fertility rates are low in settings where women are increasingly participating in the labour market [ 11,12]. This seems to suggest that there is a seeming conflict between women’s occupations and fertility levels. Perhaps the conflict is stronger when there is less institutional support for employed women.

The study underscores the adequate involvement of male partners in women’s fertility control practices, especially women’s contraceptive preferences. This demonstrates the authority of men over women in the domain of the family. Recognising that men have enormous powers regarding fertility issues tend to appreciate the need to promote and advance family needs and welfare. Also, the results indicate that other close associates or relatives are involved in women’s contraceptive lives. These close relations are what describes as a social network in his social-ecological framework [ 35]. Besides, there are multiple socio-cultural and economic obstacles that could work against achieving desired fertility levels. Some women act individually in their fertility control practices because of the non-supportive attitudes of partners, which may have a negative effect on their reproductive lives. It is recommended that family planning programmes should not focus on only women, but include male partners to enhance a change in behaviour and norms regarding power and gender roles that do not make them supportive partners. There is a need for a high-level promotion through civil society to encourage men to get involved in family planning matters. This will help women or couples to freely adopt their desired fertility control methods without hindrance.

Author’s Contributions: Conceptualization JB; methodology JB and LJT; validation JB and LJT; formal analysis JB; investigation JB and LJT; resources JB and LJT; data curation JB and LJT; writing—original draft preparation JB; writing—review and editing JB; visualization JB and LJT; supervision JB; project administration JB and LJT. All authors have read and agreed to the published version of the manuscript.

Funding: “This research received no external funding”

Data Availability Statement: Data is available on request from the corresponding author.

Acknowledgements: We acknowledge the respondents for their time and patience.

Conflicts of Interest: “The authors declare no conflict of interest.” “No funders had any role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results”.