Focus on family planning

The Islamic Republic of Iran is often perceived by the outside world as a very conservative, closed society when it comes to social issues. However, the country boasts one of the best family planning programmes in the region. With the average size of a family at 4.6 - rural five, urban 4.4, according to official statistics compared to seven/eight in the neighbouring countries of Pakistan and Afghanistan, Iran is the most progressive country in the region when it comes to family planning. In this report IRIN looks at how attitudes towards family planning and health issues have changed since the 1979 revolution, and where its success lies. FAMILY PLANNING POLICIES IN THE PAST Prior to the revolution, there was virtually no family planning programme. "We had population control in the system, but people did not accept it," Dr Malek Afzali, Iran's deputy minister for research and technology in the Ministry of Health, told IRIN in the capital, Tehran. Between 1976 and 1986, Iran's population had increased by an average annual rate of 3.4 percent from 33 million to 49.4 million, and the government faced great demands for food, health care, education and employment. So it decided to implement the population and family planning programme in the government's first five-year development plan. However, for the first decade after the revolution there was no family planning programme, as the authorities enforced Islamic laws and the interpretation or misinterpretation then was that Islam did not encourage people to practise family planning. Following the start of the eight-year war between Iran and Iraq in 1980, population programmes were neglected. Some of the well-known political and religious people in the country advocated having more children, to increase the population of Muslims. The universal rationing programme introduced after the beginning of the war also provided incentives for larger families. A baby meant an additional share of rationed goods, which were not only of food, but also modern consumer goods. According to Afzali, during the first 10 years that followed the revolution, there was a very good primary health-care system in the country, which offered very basic services to the rural population and deprived areas. This resulted in a reduction in the infant mortality rate from 90 to 50 per 100,000 live births. So for the 10 years that followed the revolution, emphasis was placed on strengthening the health-care system and lowering the infant mortality rate. In 1988, the growth rate in the country stood at 3.9 percent. The birth rate had also increased due to immigration and encouragement to have more children. This was when medical experts began lobbying for a family planning policy to be put into place. At the end of 1989, the government did just this, with three main goals: women were encouraged to space their pregnancies, to discourage pregnancies under 18 and over 35, and to limit family size to two to three children. "We had long discussions with our leaders and pushed for a comprehensive family planning programme that would work," Afzali said. The programme was approved by Ayatollah Ruhollah Khamene'i (Iran's Wali Faqih or religious leader), which meant that there was agreement from both the top religious leaders and from the policy makers. This also ensured acceptance of family planning by the people of Iran from the point of view of religion. Another problem fuelling the debate on acceptance were educational levels among women. However, this changed over time with the literacy movement department, established within the government to promote education, especially for women and girls, precisely for this reason. In 1991, a Department of Population and Family Planning was set up. Its responsibility was to deliver family planning services through the primary health-care network. In the following years, family planning services were widely made available to the population through the extensive primary health-care system. Afzali remarked that the success of the family planning programme was evident, saying that the number of unwanted pregnancies now stood at 20 percent, down from 25 percent in 1980. "To start with, we only had approval for contraception such as the pill, condoms and IUCDs [intrauterine contraception devices]. But we were later given a fatwa [religious decree] for vasectomies to be carried out," he added. Another fatwa was also issued calling for consent by couples on family planning issues, thereby ensuring that there were no major side effects, that the method of family planning should be reversible, and should be based on Islamic rules. "We trained people in carrying out reversible operations," he said. FAMILY PLANNING TODAY The overall average annual population growth rate of 3.4 per cent between 1976 and 1986 dropped to just under 2 percent between 1986 and 1996, according to government statistics. Regardless of its quality and coverage, the 1996 census revealed a decline in the growth rate of the Iranian population. In the absence of any evidence of massive out-migration or a rise in mortality rates since 1986, it is obvious that the observed drop in growth rate is mainly due to a sharp fall in fertility. The average household size for the country as a whole had increased steadily to 5.21 by 1991, with the increase being more consistent and higher from 4.77 to 5.62 in rural areas. However, it has dropped noticeably since then in both rural [from 5.62 to 5.18] and urban [from 4.88 to 4.64] areas. According to health experts, there is now demand from Iranians for family planning. "People want to be able to provide for their children properly, and are reconsidering the number of children per household. This is not just in the cities, but in the villages too," Afzali said. Today, 76 percent of Iranian women are using contraception; 56 percent opting for modern contraception, with 20 percent on the pill, 9 percent using condoms, 10 percent having IUCDs fitted, 17 percent opting for sterilisation, and 2 percent using the withdrawal method. Targeting adolescents with this issue is seen as one of the main aims by the ministry. "We were worried about adolescent health, so we asked for adolescent health education to be introduced," Afzali explained. This was approved under several conditions. Firstly, that the content should be relevant to the age of the child, and that fully fledged health education would only be given to married couples, and also under the supervision of parents. It was eventually introduced in schools in 1996. "I believe that the most important thing is that family planning is introduced in the community, because it is more sustainable," he said. A few years back, the health ministry carried out a survey and project within a community in Semnan in which millions of people took part and was initially supported by the World Health Organisation. Key women in communities were chosen by parents to be trained to educate girls, which resulted in a very good response, according to Afzali. "The women found it easier to talk about it, but it was more difficult with the men, so we resorted to using our health workers to educate them." THE ROLE OF RELIGION With the Islamic clerics still holding a tight reign in the government, convincing them was one challenge faced by those trying to promote family planning. "The mullahs in Iran are not only here to preach religion. They have much more responsibility and are answerable to the people. This has helped to change attitudes on family planning," Afzali maintained. "We have strong support from the parliament and religious leaders these days," the head of the health ministry's population family planning programme, Dr Safiea Shahriari, told IRIN in Tehran. She explained that there had been consent from the highest levels. "We have received fatwas from Ayatollah Khamene'i about family planning contraception, vasectomies." Only two months ago, the ministry received a fatwa on abortion. Previously abortion had only been possible if the mother's life was in danger. However, Shahriari explained that a new fatwa had been released from the Ayatollah, which laid down that the a foetus could be aborted if there was a problem with it. "We hope this will eventually be incorporated into the law," she said.

More and more couples are opting for smaller families

Although there had been many misconceptions over the role religion plays in family planning, there was now considerable support. "The religious policy makers have accepted our recommendations," she noted. CHALLENGES AHEAD One of the greatest challenges ahead for the Iranian health ministry is the cooperation of men in family planning. "There is not as much male participation as we would like. Only two to three percent of men opt for a vasectomy, of whom nine percent use condoms. We have some programmes targeting them," Shahriari said. Adolescent health is also one issue needing to be addressed. "The younger generation do not talk to the older generation about their health problems due to cultural reasons," Afzali said. He added that they were often misinformed and that this could pose problems in the future with the threat of HIV/AIDS. There are still problems in giving women more of a say in family planning, as culturally men are dominant in these issues. "We need to upgrade the position of women," he said. He explained that Iranians being Shi'ah Muslims, there was greater latitude in making changes under Islamic law, as they had more freedom to interpretation. "We have made a good start on family planning and we hope to continue in keeping our nation fit and healthy," he added.