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The International Conference on Population and Development (ICPD) held in Cairo, 1994 by 184 countries to recognize the need of population issues in a different way. Previous discussions were emphasized on the effect of population growth with regards to failures of development and poverty along with its role in environmental deterioration.
The ICPD in 1994 established a "new paradigm" in population policy with a shift from focus on effect of population growth to human rights. Demand is growing in developing countries for sexual and reproductive health programs for young women. They may face a different reproductive health risks such as sexually transmitted infections (STIs) including HIV infection, too- early pregnancy and unintended pregnancy, often leading to unsafe abortion and its complications. Sexual and reproductive health is a human right and essential to human development to achieve the Millennium Development Goals, particularly those concerned with child and maternal health, HIV/AIDS and other communicable diseases, and gender.1-3
Five priority aspects of reproductive and sexual health targeted in the 57th World Health Assembly (WHA), targeted; improving antenatal, delivery, postpartum and newborn care; providing high- quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynecological morbidities; and promoting sexual health.4 However, little scientifically based evidence exists about which program approaches are most effective in shaping healthy behaviors. The Islamic Republic (IR) of Iran was successful in some of the reproductive health domains which are discussed in this report.
Evolution of Iran’s Reproductive Health
Family planning was considered on the international agenda in ICPD conference in 1984. The target for family planning in Iran is family health promotion, and specific program followed up three goals; preventing very early pregnancies, spacing between pregnancies by three-year intervals and encouraging women not to have more than three children. As a result, family planning programs have given rise to increasing contraceptive prevalence.5 The statistics show that the Contraceptive use rate has increased from 49.9% in 1989 to 73.8% in 2000.6
Planning Studies and United Nations in Islamic Republic of Iran (2004) stated that family planning services established by the Government provide a free of charge service for contraceptive methods (pills, IUD, condoms, injections, tubal ligation, no scalpel vasectomy) throughout the Public Health Center (PHCs) network. In remote areas, these services are carried out through mobile clinics.
According to the Iranian ministry of health, the country’s total fertility rate declined from 5.6 births per woman in 1985 to 2.0 births in 2000. Iran’s fertility decline is particularly remarkable in rural areas. Between 1976 and 2000, the total fertility rate in rural areas declined from 8.1 births per woman to 2.4 births per woman. The fertility of urban women declined from 4.5 births to 1.8 births per woman during the same period.
Statistics show that the decline in fertility has mainly been due to the increased use of contraception among married women from 37% in 1976 to 74% in 2000. The change in marriage patterns has also affected fertility; women’s average age at first marriage has increased from 19.7 in 1976 to 22.4 in 1996.7,8 Although the family planning and safe motherhood programs have been successfully implemented in the past years, there still remain challenges. For instance, the unresolved need for family planning is estimated to be 8%.9 Using the traditional method is rather high.
On the other hand, quality of premarital consultation should be improved. Another aspect of family planning program is promotion of maternal health. Reports have shown a reduction of maternal mortality ratio by ¾ (three-quarters) between 1990 and 2015, which is the target of the MDG program. Maternal health was valuated by maternal mortality ratio.10
The Ministry of Health and Medical Education of Iran (2004) and WHO (2005) pointed that the maternal mortality ratio per 100,000 live births has dropped sharply to 37.4 deaths in 1997 from 91 deaths in 1989 to 26 deaths in 2005 in Iran.11 Iran’s family planning program is one of the most successful throughout the world.6
Combating HIV/AIDS
The Board of the United Nations Development Program and the United Nations Population Fund (2004) showed that there were 700,000 reported cases of sexually transmitted infections (STIs) in 2003, and more than 30,000 people are estimated to be living with HIV/AIDS in Iran. The prevalence of HIV/AIDS in the general population is less than 0.1%, and the prevalence in the 15-24 age group estimated at less than 0.01%. On the other hand, the prevalence among high-risk groups such as intravenous drug users is much higher, over 1%.12
The office of the Deputy for Social Affairs of Iran (2004) pointed out that while the prevalence of HIV/AIDS among 15-24 year old pregnant women reported cases was zero in 2003, the prevalence of the condom use rate by married women (15-49) was9.3% in urban and 5.4% in rural areas in 2000. The total number of registered HIV/AIDS infected cases in Iran was calculated to be 7,510 by late September 2004, and reached 20,130 in 2009.13 Injecting drug users accounted for 60.8% of all HIV cases reported to the Ministry of Health and Medical Education, and 94.8% of the reported cases were men.14 Injecting drug use (57.4%) is the most common way of transmission and responsible for the spread of HIV/AIDS in the country and the next common mode (6.8%) is sexual transmission. There three major factors that affect HIV/AIDS spread in the country are; human trafficking for sex in neighboring countries to the north of Iran, narcotics smuggling through eastern countries to Iran, and extra-marital sexual behaviors.11
Adolescent Reproductive Health
The Population Action International (PAI) (2002) stated that Iran had implemented national governmental programs on young people's sexual and reproductive health, such as compulsory premarital counseling programs for all couples wanting to marry.15 This program also provides a useful model that would be culturally acceptable in other countries of the region.16 Although this program was very good, but for adult people it was very late because studies show that sexual behavior initiates very soon and before marriage.17 In the past, there was no formal reproductive and sexual health in schools in Iran, because such program for young people was a taboo in schools, health units, and even amongst families. Generally, people believed that such programs and discussions have negative effects on the youth and encourage sexual risk behavior. Therefore, the youth were at risk of STIs, HIV/AIDS, and unwanted pregnancies.
Fortunately, IR Iran agreed to teach adolescents health and even sexual health as a result of negotiation between academics and religious leaders in New York ICPD+5 1999, provided that its content is suitable on youth conditions is done with parental supervision. A number of educational programs have been developed and executed providing information on adolescent health, family planning, STD, HIV/AIDS, and even sex issues to girls and boys based on their age and understanding. These programs are welcomed by families and the authorities.18 Due to the sensitivity of adolescent reproductive health, efforts are being delegated to formal and no formal education channels such as Parents/Teacher Associations. This channel seems to be appropriate and culturally accepted, though it should be further strengthened. Couples receive information on reproductive health, family planning, sexually transmitted infections, safe pregnancy and delivery, as well as referral procedures in case of any complications.9
Management of Unsafe Abortion and Sexually Transmitted Infections
It is estimated that 100,000 young women resort to illegal or induced abortion every year worldwide.16 Another study stated an estimated 73,000 abortions per year, according to a recent analysis of nationally representative data. Because abortions are difficult to obtain in Iran and are often performed illegally, accurate data on the procedure's incidence are unavailable.19
The Statistical Center of Iran (2000-001) pointed out that abortion is illegal in Iran, except to save the mother’s life,7 and termination pregnancy related to fetus malformation or retardation, but post abortion care is provided as part of primary health care.20
The Office of the Deputy for Social Affairs of Iran (2004) stated that information on illegal abortion is inadequate. The Ministry of Health and Medical Education (MOHME) believe that high-quality counseling together with reliable, effective, modern contraceptive methods will reduce the number of unwanted pregnancies, and hence illegal abortions. On the other hand, there is a shortage of data on the prevalence of STIs due to a lack of reporting, especially from the private sector clinics. The Government supports free provision of condoms for unmarried clients and no charges should be imposed in STI clinics.9 But it seems that this service is very weak for adolescents and teenagers, because there are insufficient trained health workers to provide this service and the service delivery is usually a few hours when the pupils are at school. More programs should stress the importance of abstinence of sexual behavior pre-marriage. There is insufficient statistical data on pre-marital relationships and it is better to focus on these issues because a significant portion of the Iranian populations are young.
Discussion
Every year, an estimated 210 million women suffer from pregnancy complications, often leading to serious disability, and a further half a million women die as a result of pregnancies worldwide. Three million babies die in the first week of life and about 3.3 million infants are stillborn every year.21,22
More than 120 million couples have an unresolved issues concerning contraception,23 and 80 million women have unwanted or unintended pregnancies each year, 45 million of which are terminated.24 WHO (2000) reported that of these 45 million abortions, 19 million are unsafe, 40% of them are done on women aged under 25, and around 68,000 women die every year from complications of unsafe abortions.25 WHO (2000) also reported that an estimated 340 million new cases of four common sexually transmitted bacterial and protozoa infections are acquired each year, at least a third of which affect people under the age of 25.26 Such infections contribute to the global problem of infertility, which affects more than 180 million couples in developing countries.27
Nearly five million new HIV infections and 257,000 deaths from cervical cancer are reported each year.26,28 The risk of physical and sexual violence is thought to be between one in six women, which is a risk factor for many of these sexual and reproductive health problems.29 The honor victory of the Islamic Revolution (1979) particularly in the last decade has taken major steps in health status, especially reproductive health. The highest population rate (4% a year) occurred between 1967 and 1986, when the government faced great demands for food, health care, education and employment. Therefore, they decided to implement the population and family planning program in the government's five-year development plan.30
Some of the well-known political and religious figures in the country advocated having more children, to increase the population of Muslims but, after the war in 1988, the Plan and Budget Organization alerted head government leaders that the nation’s resources could not support the high cost of reconstruction, hence the Population and Development congress held in Mashad September 1988 by the ministry of health and medical education emphasized the importance of family planning and long discussions with religious leaders and policy makers convinced them to implement family planning programs in IR Iran. The program was approved by Ayatollah Ruhollah Khamene'i, which meant that there was agreement from both the top religious leaders and the policy makers. This also ensured acceptance of family planning by the people of Iran from the point of view of religion.30-33
Furthermore, after the revolution, public health systems rapidly improved. In Iran, public health systems consist of three levels, namely; District, Regional and National levels. Executive units such as health houses and Rural, Urban Health Centers, and District Hospital, as well as District Health Directorates are located at District levels. In the Regional level, the chancellors of the Universities of Medical Sciences supervise the activities in the district level. While at the national level, the Ministry of health and Education is in charge of policy-making, planning, goal setting of health lead and supervise the activities of the lower levels. Nowadays, in rural areas, the government has established
1500 health houses, and more than 4000 health centers in rural and urban areas,32,33 which offer PHC services, family planning and reproductive health free of charge. Each health house serves around 1,500 people, usually covering the people of one central village and those of satellite villages, who are within an hour’s walk from the central village. Each health house is generally controlled by health providers, entitled as Behvarzes, who are trained for two years.34
The other successful program related to the health development program is curriculum of population and family planning education at all levels for university students. In public education, couples who are planning to marry must participate in consultation of family planning classes before receiving their marriage certificate. The program’s goal is to increase male involvement and responsibility in family planning.31 Empowerment of women such as promotion of education at all levels, women’s participation in all areas of social life, women’s active involvement in the health sector, are considered another important aspect of the overall policies of the Iranian Government, which have contributed significantly to the success of the policy on family planning.34
On the other hand, the Islamic Republic of Iran has created a program for HIV prevention, care and support for injecting drug users, such as clinics for HIV prevention. A large number of triangular clinics providing services deal with drug users, sexually transmitted infection services, and care/support for people living with HIV/AIDS. Needle syringe programs, Methadone maintenance treatment in order to reduce the harm related to injecting drug use and education to prevent the spread of HIV/ AIDS have been implemented in triangular clinics.14
The Islamic Republic of Iran has successfully met many of its commitments under the program of action of the International Conference of Population and Development.35,36 However, a national strategy is needed to reach reproductive health-care goals.7,8 Since 50% benign young age-group (<17) in Iran's population pyramid, supplying reproductive health is a fundamental strategy for the Iranian people, which is a point of consideration also mentioned by United Population Fund.37,38
It seems that advocating policy such as distributing modern contraception free of charge for couples, information/education/ communication programs (IEC), and empowering women are important factors for the accomplishment of positive quality of family planning in Iran.10 In terms of maternal health, five major reasons directly affect the decline in maternal mortality including; decreased fertility rate, an increase in late marriages and childbirths, improved rural women’s literacy, better access to emergency health (especially obstetric) services, and a broad availability of maternal and childbirth care due to expanded health networks and centers.
For instance, the contraceptive prevalence rate jumped from 49.6% in 1989 to 73.8% in 2000. Moreover, the adolescent (15-19) fertility rate almost halved from 54 children per 1000 women in 1996 to 26.8 children per 1000 women in 2000. Furthermore, increasing literacy of women plays an important role in improving maternal health because liberate women postpone childbearing and increase the gap between children.
Another cause which reduced maternal mortality is the accessibility of network service through the establishment of nearly 12,000 (15000 or 12000) health houses and 4,000 health centers. At the present time, health care networks cover 75% of rural villages and most of the urban areas.39 The office of the Deputy for Social Affairs of Iran (2004) reported that to further create a comprehensive national system to prevent maternal death requires an appropriate establishment or system to monitor maternal care programs, which is an important matter. Also, the proportion of births assisted by skilled attendants has increased from 70% in 1989 to around 90% in 2000.
HIV programs, combating narcotics smuggling, education attainment and accessibility to knowledge around HIV also have an important role in HIV prevention. On the other hand, international development cooperation to face the challenges are equally important.9 Iran will consolidate its efforts to promote culturally sensitive training on gender and reproductive health in schools, particularly with regard to reproductive rights. Regarding adolescent reproductive health access to information and educational programs in schools, universities and premarital classes also play a pivotal role in achieving adolescent health goals.
Conclusion
While the country has gained significant achievements towards ICPD targets, it still faces notable challenges which need systematic efforts in order to attain the recommended targets by 2015. Some of the recommendations include:
- Improving the role of NGOs in service provision particularly when there is insufficient supportive policy on reproductive health.
- Improving community-based programs and participation of all people would be effective. Male involvement in reproductive programs is vital.
- Developing teenage-friendly and male-friendly services is recommended to help accomplish reproductive health as earlier as possible.
- The need to combat AIDs is an important priority and consists of; (a) Introducing new methods of identifying HIV-positive people, (b) Establishing a comprehensive data bank on HIV/ AIDS Surveillance, (c) Modifying cultural and legal approaches that adversely influence the spread of HIV/AIDS, (d) Establishing regional cooperation with the aim of preventing drug trafficking, and (e) Providing high quality Anti Retro-Viral medicines (ARVs) and Rapid Diagnostic Kits at a low price to those who need it.
- Establishing surveillance systems for sexual transmission (Diagnosis, counseling and treatment) and promoting prevention of sexually transmitted infections.
- Quality assurance systems for assessing comprehensive quality public health centers.
- Eliminating unsafe abortions and providing comprehensive care for women who seek abortions; safe abortion services where legal and post-abortion care everywhere, including counseling on family planning to help avoid repeat abortion.
Acknowledgements
The authors reported no conflict of interest and no funding was received on this work.
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