Table 2 Main factors contributing to the decline of TFR in the MENA region

Health care-related

Improved primary care services and integration of family planning programs [12, 16, 18, 22, 23], greater confidence of parents in the survival of their children [21], reduced rate of infant/child/maternal mortality [11, 17, 22, 24,25,26], increased rate of modern contraceptive use [7, 10, 11, 17, 19,20,21,22,23], promoted maternal-child health services [17], increased beds/hospitals relative to population size [15], increased men’s participation in reproductive/sexual health practices [23]

Cultural

Changes in women’s attitudes towards employment [12], weakening of traditional values and norms of MENA societies concerning parenting and child-raising, and strengthening of their tendencies to the norms of Western cultures [14, 16, 21], increased women’s tendency to get married at older ages [10, 21, 23], changes in people’s beliefs about marriage and parenting [18], increased tendency to form smaller families [21, 23]

Economic

High costs of marriage and child-raising [12, 13, 21, 23], inflation [18], housing and employment problems [11, 13, 23], economic development and improved living standards [20], increased countries’ per capita income [15, 24], youth’s economic expectations, increased GDP per capita [20]

Social

Increased urbanization [7, 10, 12, 14, 17, 20,21,22], increased educational levels (especially of women) [7, 10,11,12,13, 15,16,17, 19,20,21,22,23,24], women’s empowerment [7, 17], increased rate of migration (especially to foreign countries) [21], reduced rate of early marriage [23]

Political

Governments’ direct support policies for family planning [11, 13,14,15, 20, 21, 23], abolishment of restrictions to the realization of women’s rights (e.g., revision of divorce laws) increased legal age of marriage [21, 23], the establishment of restrictions for polygamy [21], attempts to reduce people’s tendency to have male children [23]