Recent population policy developments in Iran

The population policies of Iran have been formulated and legislated as part of a 5-year Socio-Economic and Cultural Development Program law (SECDP). In the first SECDP law, legislated by the Islamic Parliament of Iran (Majles) on 31 January 1990, population policy goals were set at reducing the TFR from 6.4 children per woman in 1986 to 4.0 in 2011, and reducing the rate of the natural increase in population from 3.2% to 2.3% within the same period.13 However, evidence from national censuses and demographic surveys showed that Iran surpassed these population policy goals within less than a decade after the approval of the law. In fact, the TFR dropped to 2.1 children in 2000 and 1.8 children in 2011, and the rate of natural increase in population plunged to 1.5% and 1.3% in 1996 and 2011, respectively.2 ,3 Such unprecedented declines in fertility and population growth rate created a fear of population decline among Iranian leaders, particularly the conservative figures who viewed declining population as a threat to national security. Consequently, they began to speak about a need for a shift from an antinatalist to a pronatalist population policy.

The recent debate on rising population in the country can be traced back to the former President Ahmadinejad, who frequently spoke about the need to prevent population decline by encouraging families to have more than two children. As an example, in March 2011 (the Iranian New Year) he announced that the government would grant a one-time cash incentive of one million Toman (equivalent to an average monthly salary) and a monthly payment of 100 000 Toman to any child born in that year, a promise which has never been fulfilled.14 However, his pronatalist debates and slogans paved the way for the Leader to officially announce the end of the population control policy legislated in 1989.

In a speech given to public citizens in September 2012, Iran's Supreme Leader, Ayatollah Ali Khamenei, stated that “one of the mistakes that we [state officials] made (I myself also share in making this mistake), was that the population control must have been stopped from the mid-1990s and afterward, though the population control policy was good at the time it was legislated”.9 He added, “If our population follows the current trends, we will have an aging country. So, families and young population should increase their reproduction”. Then, he added that “the antinatalist policy must be put to an end”.

Subsequently, the then Health Minister, Dr Marzieh Dastjerdi, declared that “the former population control policy has been removed and is no longer funded by the government, but we have asked the government to fund a new population program, known as ‘Reproductive Health’, with the amount of 190 billion Rials that fosters maternal and child health and deals with infertility”.12 Later, she clarified that “the production, supply, and delivery of contraceptive methods continues as before, but we have only changed the direction of family planning toward reproductive health, focusing on proper birth spacing, maternal and child health, nutrition of healthy infants and children, and curing infertility”.15 According to the then Director General of Family Health in the Ministry of Health, the new reproductive health programme will continue delivering publicly-funded family planning services and training to women living in regions with fertility rates at or above the replacement level to prevent unintended pregnancies, and to poor women and those who have high sexual and reproductive health risks. However, women who live in low fertility settings will not be entitled to free contraceptive services, as before, but they will be trained and informed about proper birth spacing, and healthy childbearing before, during, and after pregnancy.16

Though the government adopted a co-operative approach to women's reproductive needs, legislative organisations attempted to curb access to family planning services and knowledge, with the intention of raising fertility. For instance, the Supreme Council of the Cultural Revolution approved the removal of the ‘Population and Family Planning’ course from the post-secondary curriculum, and replaced it with a new course entitled ‘Knowledge of Family and Population’. Therefore, since September 2013, university and college students have been taking the new course that focuses on marriage and family formation, spousal emotional relationships, and childbearing and rearing rather than sexual and reproductive health risks and contraceptive methods that was taught to students taking the former course.10 Moreover, the Parliament of Iran proposed Bill 446 in 2014 that bans any medical surgeries aiming to permanently prevent fertility, except in cases where a pregnancy presents a risk to women's physical and mental health. According to this bill, medical practitioners who defy this law will be fined.11

Such political turmoil surrounding the new evolving pronatalist population policy continued until the Leader, Ayatollah Ali Khamenei, officially announced 14 general policies on population with the purpose of making up for population decreases in recent years.17 According to two of these 14 policies, maternal and child health cannot be compromised by any pronatalist decision-making and programmes. This is why the Guardian Council of Iran returned Bill 446 to the Parliament for further revisions as it was seen to be inconsistent with the policies stated by the Leader. Since the bill is still alive and under review in Parliament, and there is the potential for proposing similar bills in the future, this study aimed to answer the question: If the provision of publicly-funded contraceptive methods, especially vasectomy, tubectomy and IUDs that are delivered by healthcare practitioners are limited, which groups of women are most likely to be at risk of unwanted pregnancies and therefore seek clandestine abortions, leading to maternal morbidity and mortality? Currently the government delivers free contraceptive methods, including sterilisation, IUDs, injections, pills and condoms, to vulnerable women, including those who are living in deprived settings with a large number of children and those who will risk their health and their fetus if they were to become pregnant.18 Only pills and condoms are additionally accessible via drugstores at an affordable price for the majority of the population.

Data and methods

This study used data from the 2014 Tehran Survey of Fertility, designed by the author and administered face-to-face, by a team of female interviewers trained by the author, among a representative sample of 3012 married women aged 15–49 years residing in Tehran's 22 residential districts. A wide range of data was collected by the survey, including complete histories of live births, contraceptive use, and induced abortions. The samples were selected by the author based on a three-stage stratified cluster random sampling design. In the first stage, enumeration areas were selected in each residential district, and in the second stage residential clusters were chosen in each selected enumeration area. The selections in both stages were done based on the probability proportion to population size. The sampling frame for the selection of enumeration areas and residential clusters was taken from the 2011 Census of Iran. In the third stage, 15 households were selected in each cluster by a systematic random sampling method. From each selected household one eligible woman was then asked to participate in the survey. The study sample is limited to the 2461 women who reported using a contraceptive method during their interview. Analyses were adjusted for the survey sampling design using svy syntax in Stata software. The survey was granted ethical approval by Nipissing University's Research Ethics Board in June 2012.

To address the study's research question, we examined women's contraceptive use by method according to their socioeconomic and demographic characteristics. The dependent variable, therefore, was contraceptive method use in three categories: (1) long-acting modern methods, including vasectomy, tubectomy, IUDs and injections; (2) contraceptive pills and (3) withdrawal and condoms. The rationale for this classification is two-fold. First, the methods in the first group are publicly funded and they are delivered to women by public healthcare practitioners, while pills and condoms, as two other funded methods, can be obtained from drugstores at affordable prices by the majority of the population. Second, methods with similar user profiles, as shown in Table 1, were grouped into the same category. Women's socioeconomic status was measured by education and residential districts, where residents in the northern districts of Tehran are generally wealthier and more educated, and hold more modern attitudes regarding family formation and childbearing, while women living in the southern districts generally are of lower socioeconomic status.

Bivariate analyses were employed to describe women's contraceptive method use by their characteristics. Also, multinomial logistic regression models were used to identify women who were at elevated risk of relying on long-acting contraceptive methods rather than male contraception, namely condoms and withdrawal.