The Iranian miracle: The most effective family planning program in history?

By Patrícia Dérer

In the second part of our Population Policy Case study series, following Indonesia, The Overpopulation Project Team examines the history of population policies in the Islamic Republic of Iran. Iran stands out for lowering its fertility in a very short time without coercion. The total fertility rate dropped from almost 6 in 1988 at the start of its more recent strong framily planning (FP) program, to around replacement level by 2000 and has remained below that level since. In rural areas it dropped from 8.1 to 2.1 in only one generation, which in comparison, took European countries 300 years.

The history of population policies and consequential fertility transition of Iran should be discussed by identifying three distinct periods:

  • The first period started in 1967 with the launching of the FP program as part of the government’s development plan, and ended with the Islamic Revolution in 1979.
  • The second period is characterized by pro-natalist leaders and decreased support for the FP program, and lasted until the end of the Iran-Iraq War (1988).
  • The third period, from 1988 onward, family planning policies and programs were resumed and dramatically expanded. This is the most effective period that lasted until the early 2010s.
Family planning for prosperity
Stamps from the times of the first period of the Iranian FP program, 1972

The first indication that Iran might face a demographic problem came from the 1956 census, which showed a rapid population increase. Alarmed, the government formed a population committee. However, what shocked the government into real action was the next census in 1967, which showed a dramatic population growth of 3% per year. The prospects of doubling the population to 100 million in only 23 years, and its foreseeable economic and social consequences prompted fertility reduction polices and the initiation of a national FP program1.

Whereas the International Planned Parenthood Federation introduced contraceptives through the commercial sector already in the early 1950s, during the early 1960s the first stage of the program was still mainly focused on making them available and enabling family planning choice and decision-making. The government set an ultimate goal for the next 20 years: to reduce the annual increase in population to 1 percent2. In this period, family planning became involved in the promotion of legislation aimed at improving the status of women, such as raising the age of marriage (from 9 years to 15 for women and to 18 for men), implemented by The Family Protection Law of 1967. To increase success, the program involved a huge mass media campaign to promote family planning 3. Despite the generous allocation (above $800 million)2, the contraceptive prevalence rate among married couples was only 37% in 1977, and the gap between rural (20%) and urban (54%) areas remained large3. By the end of the first stage, the total fertility rate, although steadily declining, remained high at more than six births per woman.

TFR decline Iran
The dramatic fertility decline in Iran was a result of non-coercive governmental population policies. Blue: first period of the program; Orange: second, pro-natalist period; Green: the most effective period

During the second stage starting after the Islamic revolution, the FP program stopped being a priority: the new pro-natalist government dismantled it as being “too Western”. During the eight-year war with Iraq, having a large population was considered an advantage, and population growth became a major propaganda issue calling on women to help the country build a “Twenty Million Man Army”. The family protection law of 1975 was abrogated, right after the 1979 revolution, and the previously operating family planning council dissolved. The marriage age reverted to 9 for girls. Fortunately, the low priority of the FP program did not mean the total discontinuation of family planning services and supplies. Both government-sponsored and private sector health facilities continued to provide family planning services as part of their primary health care through the family and school health program of the Ministry of Health, but most of the rural areas were not covered by this office.

The third, most effective stage that can be called a true success story, started after the ceasefire with Iraq in 1988. In this year at the population and development seminar in Mashhad, demographers and other experts (several of whom had been trained in Western universities in the ‘population control’ context of the 1970s) explicitly called for national population policy aimed at birth control4. Consequently, population policies were declared to be a leading priority, and a year later the new National FP Program was launched with three main goals:

  • Encourage birth spacing intervals of 3-4 years
  • Discourage pregnancy among women younger than 18 and older than 35
  • Limit family size to three children, but encourage family size of two or less

To achieve these objectives 4 main activities were carried out:

  • Educational programs through schools, colleges and mass media regarding population issues and family planning
  • Increased access to free contraceptives
  • A variety of quality family planning methods and advice on family size provided to couples
  • Research conducted on various aspects of family planning delivery and population policy

In order to foster a supportive environment, seminars were held to convince religious and other opinion leaders to endorse the newly launched program. The High Judicial Council declared there were no Islamic barriers (principles and laws) to family planning methods and sterilization, helping to remove doubts about religious acceptability of methods.

An important achievement was the ratification of The Family Planning Bill in 1993, which removed most of the economic incentives for large families. For example, selected social benefits for children were provided for only a couple’s first three children. The law also gave special attention to goals such as reducing infant mortality, promoting women’s education and employment, and expanding social security and retirement benefits to all parents so that they would not be motivated to have many children as a source of old age security. Population education became part of the curriculum at all educational levels; even university students had to take a course on population and family planning.

Since the establishment of the separate Department of Population and Family Planning in the Ministry of Health, the family planning services penetrated to the remotest villages, as they were provided via rural health houses. The health houses and mobile clinics, in total 15,000 units, formed the backbone of Iran’s well-regarded primary health care system, covering 95% of the population4. These easily accessible, low-cost or free community-based health houses with workers and thousands of trained volunteers having continuous personal contact with their clients have played a major role in the provision of family planning and other health services.

How successful was the new FP program?

The level and speed of the fertility decline was beyond any expectations – so much so, it has been designated the “other revolution”. The first official target of the revitalized FP program was to decrease the 1980 fertility rate of >6 births per woman to 4 births by 2011. By 2000, the fertility rate was already down to half of the stated goal: two births per woman. Increased contraception use had the largest effect on fertility, accounting for 61% of this steep drop5. Above 70% of married women used contraception with a very small urban-rural difference, marking Iranian families among the highest contraceptive consumers in developing countries 6. Mirroring the impressive increases in contraceptive prevalence rates, the Iranian annual population growth rate decreased from 4% in 1985 to 1.1% in 2005, around where it remains today.

Remarkably beside the main objectives (such as increasing contraceptive use), the program used a broad approach in forming good population policies, including improvements in overall social and economic indices. They focused on increasing income and the standard of living in low-income groups, increasing women’s workforce and education participation, and improving the health-care system in general. Another important, novel strategy was increasing male participation in family planning. They received the same family planning education in schools and universities and on mandatory pre-marital counseling sessions, highlighting the responsibility of using contraception of both men and women, and the “male-methods” (as condoms and vasectomy) were highly promoted7.

Sadly, the two decades of effective FP programs ended in the 2010’s, when the Iranian government reversed its population policy. Alarmed by the country’s rapidly aging population, and below replacement fertility rates, Iran’s Supreme Leader Ayatollah Ali Khamenei called on women to procreate and have more children. As the Iranian Minister of Health and Medical Education has said: “The budget for the population control program has been fully eliminated and such a project no longer exists in the health ministry. The policy of population control does not exist as it did previously.” 8. In 2014, a bill to Increase Fertility Rates and Prevent Population Decline outlawed voluntary sterilization and blocked women’s access to information about contraception, denying them the ability to make informed decisions about pregnancy.

Today the free access to family planning services are restricted to a great extent and the old public campaign took a sharp turn: the old “Two is enough” message is substituted, with billboards around the country that read “One flower does not make spring” and “More children, a happier life.”

more children happier life
Billboards advocating for larger families – procreation campaign in the 2010s’

The demographic effect of today’s strong pro-natalist policies remains to be seen in the future, but by abolishing FP programs and blocking access to vital sexual and reproductive health services, the authorities are exposing women to health risks and violating their human rights. However, it seems that, with a long tradition of family planning, already educated women and couples are not easy to persuade: the family size might not increase, at least not easily or in the immediate future9.

References:

  1. Friesen JK, Moore R V. Country Profiles: Iran. New York; 1972. https://files.eric.ed.gov/fulltext/ED070612.pdf.
  2. Robinson WC, Ross JA. The Global Family Planning Revolution : Three Decades of Population Policies and Programs. World Bank; 2007.
  3. Simbar M. Achievements of the Iranian family planning programmes 1956-2006. East Mediterr Heal J. 2012;18(3). http://pubmed.gov/.
  4. Abbasi-Shavazi MJ, McDonald P, Hosseini-Chavoshi M. The Fertility Transition in Iran: Revolution and Reproduction. Dordrecht: Springer Netherlands; 2009.
  5. Erfani A, Mcquillan K. Rapid fertility decline in Iran: Analysis of intermediate variables. J Biosoc Sci. 2008;
  6. Mehryar AH, Delavar B, Farjadi G., Hosseini-Chavoshi M, Tabibian M. Iranian Miracle : How to Raise Contraceptive Prevalence Rate to above 70 % and Cut TFR by Two-thirds in less than a Decade ? In: Presented at the 24th IUSSP Conference. ; 2001:1-45. http://archive.iussp.org/Brazil2001/s20/S20_02_Mehryar.pdf.
  7. Roudi-Fahimi F. Men and Family Planning in Iran. https://iussp2005.princeton.edu/papers/50083.
  8. Roudi F. Iran Is Reversing Its Population Policy.; 2012. https://www.wilsoncenter.org/sites/default/files/iran_is_reversing_its_population_policy.pdf.
  9. Aloosh M, Saghai Y. Birth control policies in Iran: A public health and ethics perspective. J Epidemiol Community Health. 2016;

5 thoughts on “The Iranian miracle: The most effective family planning program in history?

  1. Thanks Patrícia for this well written report. The use of modern contraceptives seems to be the main cause of lower fertility rates. The main challenge is to sort out which factors determine this use most effectively.

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