In less than one generation, a unique demographic transition has taken place in Iran. A population growth rate of 4.06% in 1984 fell to 1.15% in 1993 and a total fertility rate of 6.4 births per woman in 1984 declined to 1.9 in 2010. In 2012, Iranian policymakers shifted away from a birth control policy towards a pro-natalist policy. At first glance, this may seem reasonable since its goal is to avoid the consequences of an aging population. However, we argue that the policy package raises serious public health, socioeconomic, environmental and ethical concerns and is likely to fail on its own terms.
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In 2012, in response to a significant decline in the fertility rate in Iran, policymakers performed a reversal from a birth control policy to a pro-natalist policy; however, the policy package, which includes restrictions on the flow of birth control information to the population and banning permanent sterilisation methods, raises serious concerns. To show this, we first provide an overview of the history of family planning and population control in Iran. We next explicate the content of the new pro-natalist policy package and criticise it from a public health and ethical perspective. Finally, we review design and implementation issues that will in all likelihood lead to the failure of the proposed policy package on its own terms.
History of family planning and population control in Iran
Iranian population policies have experienced many fluctuations since 1962 when the imperial government voted against governmental intervention to regulate a population of 23 million in the United Nation general assembly. This policy changed in 1967 when a census revealed a rapid growth of population that might endanger the development of the country. Therefore, the government established the first national family planning programme and made abortion legal.
When the Islamic revolution took place in Iran, starting in 1978, its population was 36 million. Two years later, Iraq attacked Iran and 8 years of military conflict began between the countries. Until 1988, the end of the war, the birth control policy was suspended, although providing fertility control services continued in public and private clinics. In fact, early marriage and repeated childbearing was encouraged by various governmental incentives; moreover, abortion became re-criminalised. After the war era, because of the socioeconomic situation of the 53 million-populated country which was perceived as precluding the government from providing the welfare services (basic education, health and food) promised by the Constitution, there was a strong political will for re-establishing population control programmes.1 In 1989, the Iranian parliament passed a development plan, which included a birth control programme. Later, the parliament removed previous incentives for high fertility; moreover, clergy bodies and the judicial system issued the authorisation for family planning and supported the policy. As a part of the programme a huge media campaign was initiated to encourage women to space their pregnancies for 3–4 years, to limit the number of children to two, and to avoid pregnancy under the age of 18 and above 35.2 ,3
This policy package was implemented for more than two decades in the Islamic Republic of Iran. During this period, Iranian population growth rate declined from 3.1% in 1989 to 1.6% in 2000 (figure 1) and total fertility rate fell to 2.1 from 6.4 children per woman in the same period4 (figure 2). The birth control programme included free access to various contraceptives, such as condoms and sterilisation, and related educational initiatives for married couples. These services were delivered through a nationwide network of urban clinics, rural centres and mobile clinics.5 This revamped public health system had a significant effect, especially on rural population fertility.6 Moreover, family planning education became a mandatory component of the curriculum for university students, last year high school female students and soldiers; in addition, participating in this education programme was mandatory to obtain a marriage certificate for all couples. As a result, in 1997, 73.8% of married women over age 15 years were using contraceptives, while the same index was 60.9% for the world4 (figure 2), 68.5% for more developed countries, and 59.4% for less developed countries.7 Although, there are some arguments that the fertility rate would have probability fallen down without the birth control programme—because of reasons that we will discuss later in this manuscript, such as, rise in literacy rate of women—a study in 2010 showed that the programme accounts for 61% of decline in fertility rate.8 Moreover, it could be argued that the magnitude of the effects of the programme might have been higher, since the study did not include the educational effects of the programme.
The new pro-natalist policy package: a critique from a public health perspective
The latest shift in population policies occurred in 2012, when population growth rate and total fertility rate fell to 1.31% and 1.9, respectively, among the population of 76 million in the country (figure 1). To address what was construed as a threat to Iran's future, which is mostly related to politics of population policy—as population growth can affect the power balance between states,9 and partly related to aging burdens, in 2012, policymakers cut the budget for the national family planning programme and discontinued all birth control education programmes for the general population, including youth. They also banned permanent sterilization methods for the general population. Moreover, the Iranian conservative parliament is currently discussing a pro-natalist bill that outlines various incentives for childbearing, including early retirement for mothers, and tax relief and child benefits for large families. The bill goes farther to gives permission to punish birth control service providers.10 However, due according to the 1994 International Conference on Population and Development's Program of Action,11 which Iran has ratified, as a member state, it should take all appropriate measures to ensure universal access to family planning and to prevent unwanted pregnancies by providing information, education and devices. Another bill, not directly part of the pro-natalist policy package, is also relevant: conditions for obtaining divorce would become harder with the objective of ‘consolidating families’; moreover, it makes finding a job more difficult for women by imposing gender quotas disadvantaging them, with the same objective.
Currently, there is no evidence to show that there will be a net benefit for the community from this policy package. In fact, this package has many obvious, expectable disadvantages for public health.
First, it is most probable that the new policy will increase the current 33% rate of unintended pregnancies,12 especially in low socioeconomic populations and subgroups living in remote areas. In the early years of the Islamic revolution, when the family planning programme was abandoned due to a pro-natalist policy, total fertility rate escalated to 10 births per woman in Sistan and Baluchistan province—one of the most remote and less developed provinces—although there was no significant rise in fertility rate in central provinces.13 In addition, in most rural areas, contraceptive use is still dependent on distribution of means through the national family planning programme. In fact, even in the pro-population control era, some subgroups, such as slum-dwellers, did not have sufficient access to the primary healthcare, including family planning.14 According to a recent report by government officials, 18 million people, around one-third of population, live in unofficial housings and slums.15 Moreover, even among the general population, there is an unmet need for family planning counselling and education.16 For instance, in 2004 only 59% of the service receivers in the capital city had sufficient knowledge of the family planning method they were using.17
The overall picture is that the most important reproductive concerns, such as the rate of unwanted pregnancy and use of reliable contraception methods, are not satisfactorily addressed yet18 and the new policy package would only worsen the situation, especially by banning permanent sterilisation methods. These methods were the second most common method of contraception in Iran, with a prevalence of 14.15% in women19 (see figure 3).
The second disadvantage of the new policy is a probable rise in incidence of illegal abortions. Illegal abortions pose a clear threat to women's physical and mental health. In Iran, since 1979, abortion is illegal except in special circumstances, such as when the mother's health is at risk or both the life of the mother and the life of the fetus are at risk. As a result of restrictive abortion laws, around 6000 legal abortions are performed yearly, according to the health ministry reports,20 and illegal abortions are estimated to reach 219 000 (CI 95%, 176 673 to 288 538).21 In addition, Iran's 2000 Demographic and Health Survey showed that 26% of married women had an abortion in their lifetime and that abortion rates were higher in provinces where contraceptive usage was lower.22 When abortion is considered an illegal act, the risk of morbidity is higher since help-seeking may be restricted. These facts, besides women's limited knowledge about complications of unwanted pregnancies and induced abortion,23 indicate that if the incidence of unwanted pregnancies increases, so will illegal abortions.
The third disadvantage is a high chance for dissemination of sexually transmitted diseases due to the lack of sexual health education and free condom distribution, especially among the youth. Studies indicate that youth do not have enough sexual health knowledge and that they use condoms inconsistently.24 Moreover, HIV-infected individuals are estimated around 126 000 in Iran; two-thirds of them are not aware that they are carrying the virus (Response to Inquiry from the Research Team Conducting the Study “HIV Infection Frequency in Iran: Modeling for the years 2009–2015;” Center for Communicable Disease Management, Regional Knowledge Hub for HIV/AIDS Surveillance at Kerman University of Medical Sciences, UNAIDS, February 2012 (Response to Inquiry from the Research Team Conducting the Study, unpublished)). As a sexual route is the most prevalent route of HIV-transmission, education and condom usage should be promoted, but in fact condom usage has decreased after cutting the budget and increasing the prices, according to Non-Governmental Organisations active in Iran.25
The fourth disadvantage is that a poorly planned increase in population would undermine of social determinants of health.26 If the new policy package is effective, it will probably increase population mostly in low socioeconomic populations, which suffer from poverty, high unemployment rates, illiteracy, etc. It is not clear that current policies (given current economic growth estimates) will improve the condition of existing populations. It is therefore even more uncertain that the additional population will lead a better life than their parents. We are more likely to witness an increase in the incidence of poverty, unemployment, illiteracy and inappropriate distribution of population. A more numerous population with a low socioeconomic status would negatively impact physical and mental health indicators.11 According to an unofficial report published in 2011, 44.5–55% of Iran’s urban population lived under the poverty line.27 Populations vulnerable on multiple fronts may be negatively affected by the new policy. Children, in particular, are vulnerable, especially those who live in poverty. Data released by the Iranian Census Center in 2006 shows that 1.7 million of children are engaged in child labour28 and 3.5 million were deprived of education, their number reached 4.5 million in 2012.29 Moreover, the unemployed form another vulnerable population likely to be negatively affected by the new fertility policy, since they do not have the means to purchase contraceptives and may not be able to support large families. Currently, total unemployment rate is 10–20% and youth unemployment is 24%.4 It is estimated that 60% of the population is under the age of 30; it would hence be expected that unemployment would be a central challenge for government in the foreseeable future.
Finally, human consumption has already excessively strained natural resources.30 This phenomenon is particularly critical in Iran because of additive consequences of climate change and human mismanagements, and it clearly affects public health. At this moment, more than 500 cities around the country are already facing drinking water shortage.31 According to the Ministry of Energy, this drought condition will continue for 20 years all over the country. Thus, there is a mismatch between the number of people and available water resources and there is no plan as to how sustainably manage natural resources for a much larger population. In addition, Iran is ranked as the eighth most air-polluted country globally with four of the most polluted cities in the world.32 These environmental conditions, besides a high migration rate from rural areas to cities and from smaller cities to larger ones, make large cities less livable and less sustainable even for the current population, not to speak of an increased population.
Intertwined with these public health and environmental concerns, the new policy package brings up ethical concerns. First, basic considerations of social justice in public health and health policy have not been adequately considered.33 The new policies would entrench unequal access to primary healthcare in Iran. In particular, they would undermine the welfare of rural and lower socioeconomic populations by drastically limiting their access to birth control services. Social justice requires policies that enable each individual to exert a sufficient degree of control over the broad shape of their lives,34 yet the new policies fail to acknowledge this by undermining reproductive choices. Additionally, the cost of the new policies’ financial incentives is an enormous economic burden. Allocating scarce resources to pro-natalist policies, rather than improving basic infrastructure and needs, is incompatible with broadly shared principles of distributive justice. According to the minister of Health, the country experiences a shortage in physicians and dentists, lacks 200 000 nurses and 100 000 hospital beds to satisfy the medical needs of its current population.35
In addition, the new policies undermine the autonomy of individuals. Deprived of essential birth control information necessary for empowering them, many will no longer be in a position to autonomously choose certain procedures and services or even be aware of their existence. This is in contradiction with the right to be informed and to have access to safe, effective, affordable and acceptable methods of family planning. To ensure these rights, healthcare workers should be authorised and enabled to provide all relevant information and services. Although no public policy can be expected to address all moral concerns, it needs to acknowledge the most basic demands of public health and health policy ethics.
A policy package with low probability OF success: design and implementation issues
Even if the public health, environmental and ethical concerns we have raised could be addressed, the policy package faces design and implementation challenges that severely undermine the probability of success in sustainably increasing a healthy and productive population in the country, at the moment. Four reasons support this claim.
First, implementation of costly incentive programmes does not seem economically feasible and sustainable. The World Bank's forecast for economic growth in Iran is not optimistic and the State's revenues depend on fluctuating prices of oil and lifting international economic sanctions.
Second, it seems that the majority of women would not increase their fertility even if the government provided economic incentives. The 2002 Fertility Transition Survey indicated that women desired up to two children.36 This trend could be the result of several long-term factors, such as two decades of advertisement for small families and important institutional and social changes after the Islamic revolution, including rise in women's literacy rate. Women's literacy rate increased from 25% in 1970s to 56.1% in 1991 and to 79.2% in 2012 through universal education (figure 4); in 2012, the ratio of young literate females to males (ages 15–24 years) was 99%.4 In addition, in December 2010, the government performed a major economic reform, replacing indirect subsidies with a direct cash transfer programme to all Iranian households. Since monthly cash transfers are payable to the head of family in proportion to the number of children, this programme could be considered a governmental incentive for population growth. However, according to the available data, no significant growth in the population has taken place (figure 2).
Moreover, even with removing the birth control programme, other causes of low fertility rate are still present and considered responsible for the current low fertility rate. These causes are not taken into account in the design of the current policy package, undermining its probability of success on its own terms. For instance, a tempo effect could explain a transient reduction in fertility rate in Iran. The tempo effect, which is a delay of the first birth, is attributed to increased age at marriage (15%) and to use of contraception after marriage (85%).13 Gender equity as a result of increasing literacy rates and education levels of women could lead to delay in the initiation of pregnancy and rise of age at marriage. If the current low fertility rate is in part due to the tempo effect, we could expect it to rise without the introduction of pro-natalist policies. Moreover, from a broader view, changes in cultural beliefs have been mentioned as an effective factor13 and it is not clear that the current policy package would significantly influence those beliefs. Finally, rise in health standards, including decline in infant mortality rate is another contributing factor to population size. It could lessen the demand for more children.1
Finally, the policy package's likelihood of success is undermined by the lack of support among independent medical and academic professionals for the pro-natalist policy. Their cooperation cannot be obtained just by decree, but only by demonstrating through studies and reliable data that the proposed policies will be overall beneficial.
To conclude, there is an unmet need for family planning in Iran and the new pro-natalist policy package, will probably create a huge burden on public health including increase in unintended pregnancies, illegal abortions, sexually transmitted diseases and poverty. Moreover, the new package brings up crucial and unaddressed ethical concerns. It also faces design and implementation problems that undermine its likelihood of success on its own terms.
The authors would like to thank Ms Amelia Hood for her assistance in language editing of the manuscript.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
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