63075 Fertility Decline in the Islamic Republic of Iran 1980–2006 A Case Study The World Bank May 2010 Fertility Decline in the Islamic Republic of Iran 1980–2006 A Case Study May 2010 iii Contents Acknowledgements vi List of Acronyms vii Executive Summary viii Introduction: Iran’s Fertility Transition 1 Reasons for High Fertility and the First Fertility Decline in Iran 3 Proximate Determinants of High Fertility 3 Marriage 3 Age at marriage 3 Age at first birth 4 Contraceptive prevalence 4 Duration of breastfeeding 5 Induced abortion 5 Infertility 5 Socioeconomic Factors Affecting High Fertility 6 Religion 6 Iran-Iraq War 6 Child mortality and the value of children 7 Education 7 Female participation in the labor force 7 Second Fertility Decline in Iran: Delayed Marriage, Increased Education, and Widespread Family Planning 9 Decline in Adolescent Fertility 9 Family Planning Programs — The Right Mix 10 Family planning classes for young couples 10 Education in sexual and reproductive health 11 Contraceptive use 11 Role of the private sector 11 Regional variations 11 iv Investment in Primary Health Care: Expanded Access to Maternal and Child Services 12 Health care for women 14 HIV/AIDS 15 Investment in Education — A Key Factor in Declining Fertility 15 The literacy movement 15 Levels of education 16 Economic and Political Conditions — A Paradigm Shift 17 Age structure of the population 17 Employment 18 Conclusion 21 References 22 Annex 1: Iran at a Glance 26 Annex 2: Contraceptive Use in Iran 28 Annex 3: Age Structure in Iran, 1966–2006 30 Annex 4: Age-Specific Fertility Rates for Iran 33 Annex 5: Iran’s Family Planning Law of 1993 35 End Notes 36 Tables Table 1. Education Indicators for Iran, 2000–06 16 Table 2. Labor Force Participation by Gender, Ages 10 and Over (1976–2006) 19 Table A2.1. Proportion of Women Ages 15–49 Years Using a Modern Method of Contraception, by Age Group, Urban-Rural Status, and Province 28 Table A2.2. Contraceptive Use by Age Group, Urban-Rural Status, and Method Used, in Percentages 29 Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study v Figures Figure 1. Map of Iran viii Figure 2. Fertility Trends in Iran, 1965–2006 1 Figure 3. Rise in Age at Marriage in Iran by Gender, 1966–2006 4 Figure 4. Adolescent Fertility in Iran, the Region, and Lower Middle-Income Countries, 1997–2006 9 Figure 5. Decline in Adolescent Marriage (Ages 15–19), by Gender, 1956–2006 10 Figure 6. Urban-Rural Convergence in Contraceptive Use in Iran, 1977–2000 12 Figure 7. Dependency Ratios, Iran 1960–2007 18 Figure 8. Age Distribution of Iran’s Population, 1986 and 2006 19 Figure 9. Employment Trends in Iran, Ages 15 and Over, 1991–2007 20 Figure A3.1. Age Structure of Iran’s Population, 1966 30 Figure A3.2. Age Structure of Iran’s Population, 1976 30 Figure A3.3. Age Structure of Iran’s Population, 1986 31 Figure A3.4. Age Structure of Iran’s Population, 1996 31 Figure A3.5. Age Structure of Iran’s Population, 2006 32 Figure A4.1. Number of Births Registered Annually by the Civil Registration Organization (Left Scale) and Percent Urban (Right Scale) 33 Figure A4.2. Total Fertility Rates in Iran, 1956–2006 33 Figure A4.3. Age-Specific Fertility Rates of All Women Ages 10 Years and Over in Iran, 2006 34 Figure A4.4. Age-Specific Fertility Rates of Ever-Married Women Ages 10 Years and Over in Iran, 2006 34 Boxes Box 1. Gains and Losses for Women’s Rights in Iran, 1910–1982 8 Box 2. Contraceptive Use in Iran: A Mix of Methods 13 Box 3. Registration of Vital Statistics 14 vi Acknowledgements T his report was prepared by Seemeen Saadat le développement), Jose Guzman (United of the Health, Nutrition, and Population Nations Population Fund), Karen Hardee unit of the Human Development Network (Population Action International), Daniel (HDNHE), Sadia Chowdhury (HDNHE) and Kraushaar (Bill and Melinda Gates Founda- Amir Mehryar (Professor of Behavioural Sci- tion), Gilda Sedgh (Guttmacher Institute), ences & Head, Department of Population and Amy Tsui (Johns Hopkins University, Bloom- Social Studies, Institute for Research on Plan- berg School of Public Health), and Wasim ning and Development, Tehran, Iran). Zaman (International Council on Manage- The case study benefitted from comments ment of Population Programmes). The World received from Ajay Tandon (EASHH) and Bank advisory group comprised: Martha Ain- Djavad Salehi-Isfahani (Professor, Virginia sworth (IEGWB), Peter Berman (HDNHE), Polytechnic Institute and State University, Vir- Eduard Bos (HDNHE), Rodolfo Bulatao ginia). The authors would also like to thank (HDNHE), Hugo Diaz Etchevere (HDNVP), Akiko Maeda (MNSHD), Anton Dobronogov Rama Lakshminarayanan (HDNHE), John (AFTP2) and Naoko Ohno (SASHN) for their May (AFTHE), Elizabeth Lule (AFTQK), and guidance and advice. The authors are grateful Thomas Merrick (WBIHS). to the World Bank Library Research Services Bruce Ross-Larson, Communications De- for assisting with the literature search. Mukesh velopment Incorporated, edited the draft report Chawla, Sector Manager (HDNHE), and Ju- and Samuel Mills (HDNHE) reviewed the final lian Schweitzer, Sector Director, (HDNHE) draft. The authors would like to thank the gov- provided overall guidance and support. Thanks ernment of the Netherlands, which provided to Victoriano Arias (HDNHE) for providing financial support through the World Bank- administrative support. Netherlands Partnership Program (BNPP). This case study was part of a larger World Bank Economic AND Sector Work enti- Correspondence Details: tled Addressing the Neglected MDG: World Bank Review of Population and High Fertility Æ Sadia Chowdhury (HDNHE), World with an external advisory group comprising: Bank, Mail Stop G7-701, 1818 H Street Stan Bernstein (United Nations Population N.W., Washington, DC 20433, USA, Fund), John Bongaarts (Population Council), Tel: 202 458 1984, email: schowdhury3@ John Casterline (Ohio State University), Bar- worldbank.org bara Crane (IPAS), Adrienne Germain (In- Æ This report is available on the following ternational Women’s Health Coalition), Jean website:http://www.worldbank.org/ Pierre Guengant (L’Institut de recherché pour hnppublications. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study vii List of Acronyms AFTHE Health, Nutrition, and Population HDNVP Office of the Senior Vice President unit of the Africa region and Head of Human Develop- AFTQK Africa Operational Quality and ment Network Knowledge Services IEGWB Independent Evaluation Group, DPT Diphtheria, Pertussis, Tetanus World Bank EASHH East Asia HNP Sector Unit WBIHS World Bank Institute Health HDNHE Human Development Network, Systems Health, Nutrition and Population unit viii Executive Summary D espite its volatile history, the Islamic a package of services for maternal and child Republic of Iran has performed well health. This enabled a rapid increase in family on social indicators, especially in pro- planning services to both rural and urban viding basic services such as health care and populations. Contraceptive prevalence rates education. This country of 70 million people increased rapidly between 1989 and 1992— has undergone a substantial fertility decline from 49 percent to 64 percent—highlighting in recent decades. In 1980 Iran’s total fertility a significant unmet need. By 2000 contracep- rate was 6.58, but by 2006 it had declined to tive use had reached 74 percent. 1.9, with the most rapid decline during the The fertility decline coincided with im- 1990s. provements in primary and secondary edu- Iran’s fertility decline may have pro- cation, possibly affecting the rapid decline in ceeded in two stages, the first beginning in adolescent fertility during 1997–2006, espe- the late 1960s. The Iranian government in- cially when compared to other Middle East troduced a family planning program during and North Africa region countries. Adult lit- the 1960s with explicit health and demo- eracy programs introduced under the gov- graphic objectives. Between 1967 and 1977, ernment’s development policies also brought fertility declined—mainly in urban areas— education to rural women who had not had to an average of 4 children per woman. access to formal education. Female employ- Although the family planning program con- ment has increased since the 1980s, con- tinued after the 1979 Islamic revolution, it tributing to delayed childbirth and fertility was suspended after war broke out with Iraq decline, but remains low at 13.7 percent when in 1980. During the war, the government compared to other lower-middle income pursued a pronatalist population policy, in- countries. cluding incentives for childbearing. Today regional disparities in fertility exist Following the Iran-Iraq war, high unem- with higher fertility in less developed dis- ployment and concerns about population sus- tricts. Yet Iran’s example shows how good tainability prompted the government to pass public policy interventions in health (in- the 1993 Family Planning Law. Family plan- cluding family planning) and education can ning services were incorporated into the ex- reduce fertility and contribute to human de- isting primary health care system as part of velopment. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study ix Figure 1 | Map of Iran Source: World Bank Map Design Unit. 1 Introduction: Iran’s Fertility Transition H ome to over 70 million people in Cen- 1960s, stalled—and possibly reversed—during tral Asia (figure 1), the Islamic Republic the late 1970s and early 1980s, then con- of Iran has a rich and sometimes volatile tinuing from the late-1980s to the present day. history. Despite recent turbulence—including Reasons for this interrupted fertility transition a decade-long war with Iraq and international may include the drastic rise in oil revenues in sanctions—the country has performed well 1973, the Islamic revolution of 1979, and the on social indicators for health and education 1980–88 war with Iraq. (annex 1). Iran has recently accomplished a Iran is also on track to meet its child- successful fertility transition—from a high related Millennium Development Goals by total fertility rate of 6.58 in 1980 to a low of 2015. The country has made substantial prog- 1.9 in 2006—greater than other Middle East ress in reducing infant and child mortality, and North African countries and on a par though low birth weight has increased. The with lower middle-income countries world- government’s proactive approach to primary wide (figure 2). health care—with local health workers visiting Iran’s case is unusual because evidence in- homes as necessary—has led to a continual dicates that its fertility decline may have oc- decline in the infant mortality rate. In 1974 curred in two stages: starting in the early the infant mortality rate was 120 per 1,000 Figure 2 | Fertility Trends in Iran, 1965–2006 8 (births per woman ages 15–49) 7 Total Fertility Rate 6 5 4 3 2 1 0 1965 1970 1975 1980 1982 1985 1987 1990 1992 1995 1997 2000 2002 2005 2006 Years Iran, Islamic Rep. Middle East & North Africa Lower middle income countries Source: World Development Indicators Online. National Census of Housing and Population, 2006. 2 live births in rural areas and 62 in urban cen- Organization estimate of 140 per 100,000 live ters.1 By 1990 the overall rate had dropped to births in 2005 to an estimate using Ministry 54 per 1,000 and by 2006 was estimated at of Health and Medical Education data of 32 30 per 1,000.2 Neonatal mortality was 19 per per 100,000 in 2001–05.8 Ministry of Health 1,000 live births in 2004.3 On the other hand, data show a significant decline in maternal incidence of low birth weight increased from mortality from a level of 237 per 100,000 live 2.9 percent in 1993 to 4.6 percent in 2005,4 births in 1974 to 47 per 100,000 live births possibly indicating poor quality prenatal care.5 in the late 1990s to the current levels.9 But Mortality of children under 5 years old studies also confirm that, despite improve- also declined, partly because early investments ments in the overall maternal mortality ratio, in health systems improved child immuniza- there are inequalities across provinces, with tion. Under-5 mortality in 2006 was 35 per those lagging behind in other development in- 1,000 live births, down from 72 in 1990.6 dicators (such as education and infrastructure), Immunizations rose from 32 percent for DPT also lagging behind in maternal mortality ra- and 39 percent for measles in 1980 to near- tios. The worst outcomes are in the Sistan va universal coverage by 2005—with 95 percent Baluchestan and Kohkilooye va Boyerahmad of children ages 12–23 months immunized for provinces.10 At the district level maternal mor- DPT and 94 percent for measles.7 tality ratio can vary between zero deaths per Data on maternal mortality show signifi- 100,000 live births (such as in Tehran) to 174 cant variation, ranging from a World Health deaths per 100,000 live births. 11 Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 3 Reasons for High Fertility and the First Fertility Decline in Iran T radition and social practices created high Baluchistan were consanguineous but only 23 levels of fertility in Iran, but changes af- percent in Gilan.15 Two traditional practices, fecting proximate determinants of fertility temporary marriage (mut’a)16 and polygyny, are had begun to influence fertility rates by the sanctioned but uncommon, limiting their in- end of the 1970s. The war with Iraq delayed or fluence—if any—on overall fertility.17 reversed many of these changes in the 1980s. Age at marriage Proximate Determinants of High Because Islam prohibits extramarital sex, any Fertility discussion of fertility in Iran focuses on mar- Iran’s traditionally high fertility was supported ried women. Menarche is viewed as time of by early marriage and childbearing. The gov- transition to adulthood. Once girls reach this ernment’s introduction of family planning biological threshold, they become eligible for services in the 1960s and the rising age of marriage, regardless of age. In 1935 the Gov- marriage during the 1970s began to lower fer- ernment of Iran established the legal age for tility rates, especially in urban areas. marriage at 15 years for girls and 18 years for boys,18 but evidence—especially from rural Marriage Iran—shows that girls as young as 10 years Shaped by early religious practices of Zorastri- old were being married into the early 1960s.19 anism and later the social philosophy of Islam, Reasons for girls’ low age at marriage included Iranian culture has always encouraged early poverty (compelling parents to marry off their marriage and parenthood.12 Historically, mar- daughters early), parents’ desire for the bride riages were arranged by parents or family elders price (‘Mehr’iah’, typically higher for younger to create and maintain social and political al- girls), social and political ties, women’s low so- liances, especially within tribal groups. Chil- cial status, and religious beliefs.20 dren were betrothed at an early age as a sign of Female age at marriage had begun to rise goodwill and married when they reached pu- by the 1970s. In 1976 the average age at mar- berty.13 In modern Iran, bride and groom have riage for girls was 19.5 years, lower in rural direct say in their marriage decision.14 Mar- areas (19.1 years) than in urban (20.2 years).21 riages to biological relatives remain common, By the early 1980s the government had ad- but with regional variations. According to the opted a pronatalist population policy encour- 2002 Iran Fertility Transition Survey, 78 per- aging early marriages.22 Scholars maintain cent of marriages in the provinces of Sistan and that socioeconomic factors and culture have 4 remained the main forces determining age at Contraceptive prevalence marriage in Iran.23 However, data from the Iran was one of the first developing countries Iran Demographic and Health Survey (2000) to initiate government-sponsored family plan- show that the upward trend in female mean ning programs,29 the first in 1967.30 Initial age at marriage stalled during 1979–84, before efforts—focused on social marketing and pro- climbing sharply between 1986 and 1996.24 viding free services—met with modest suc- Mean age at marriage for women rose from cess. The 1977 Iran Fertility Survey indicated 19.8 years in 1986 to 23.2 years by 2006, while that 37 percent of eligible couples were using the mean age at marriage for men rose from modern contraceptives (50 percent urban and a low of 23.6 years in 1986 to 25.6 years by 20 percent rural), mostly provided by the na- 1996 and has not changed since (figure 3).25 tional family planning services.31 Fertility reflected an urban-rural difference in contra- Age at first birth ceptive use. Between 1966 and 1976 urban Because sexual union is strictly within the fertility declined from an average of 5.7 chil- realm of marriage in Iran, women’s age at first dren per woman to 4.4, while rural fertility birth is highly correlated to age at first mar- fell only slightly, from 7.2 to 6.6.32 And fer- riage. Traditionally, great cultural pressure to tility in both rural and urban areas began to have children early into the marriage made increase again before the Islamic revolution, contraception use rare prior to first birth,26 perhaps indicating a decline in the quality of suggesting that age at first birth would also the family planning delivery system.33 have been low. Analysis of evidence from the After the 1979 Islamic revolution, family 1988 Fars Population Growth Rate Survey 27 planning programs continued to operate, but shows that age at first marriage had a mod- the general public and health service providers erately significant impact on the risk of first were confused about the legality of these pro- birth for all age cohorts in that province.28 grams under an Islamic regime.34 For the first Figure 3 | Rise in Age at Marriage in Iran by Gender, 1966–2006 30 25 Age at marriage 20 15 10 5 0 1966 1976 1986 1996 2006 Years Men Women Source: Adapted from Mehryar 2008. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 5 two years following the revolution, the new tended to breastfeed their children for at least government allowed the family planning pro- a year, only 10 percent did so exclusively.42 Be- gram to continue, but with restrictions on cause the breastfeeding was not exclusive de- abortion and sterilization.35 IUDs, male con- spite its extended length, the study concluded doms, and oral contraceptives were considered that the period of amenorrhea had most likely acceptable forms of contraception and pro- been short. vided free of charge. Government and religious leaders allowed contraceptives as long as they Induced abortion did not physically harm the woman and both The process for obtaining a legal abortion in members of the couple agreed on their use.36 Iran is complicated, and evidence suggests that Sterilization was permitted but no longer free most induced abortions are carried out secretly of charge.37 Yet during this time a dual decline and are unsafe.43 An estimated 73,000 abor- in supply and demand for family planning ser- tions are performed in Iran annually, about vices began, driven by uncertainty about the 7.5 abortions per 1,000 women in the 15–49 new regime’s policy on contraception. age group, with significant regional varia- After the war with Iraq began in 1980, tions.44 Although insufficient evidence makes government policies shifted from popula- it is difficult to estimate abortion’s impact on tion control to population expansion, and the fertility, some evidence suggests that abortion family planning program was eventually sus- would increase the birth interval between first pended.38 During the war years, the popu- and second birth.45 A study based on a sample lation of Iran grew rapidly, at a rate of 3.9 survey of 1,287 ever-married women in the percent annually.39 Kohgiluyeh and Bovairahmad province in- dicates that abortion would impact the birth Duration of breastfeeding interval between first and second births but Since the early 1980s the government of Iran would not significantly affect the interval be- has actively promoted breastfeeding as an Is- tween the second and third births.46 lamic value and as a means of safeguarding the health of children. The practice may have Infertility helped counter the impact of serious short- A 2004–2005 nationally representative ages in powdered milk during the war years.40 sample survey estimates current primary in- Although the active promotion and use of fertility at 3.4 percent.47, 48 This is much lower breastfeeding probably did affect fertility than the estimated infertility of 8 to 12 per- levels, the extent of its impact is unclear. A cent worldwide.49 Historical trends on in- [1993] study of nearly two thousand married fertility in Iran are not available. The scant women aged 15 and above in Fars province evidence that exists on impact of exposure found that the average duration of breast- to chemicals during Iran’s war years does not feeding was 22.7 months for rural women and show a significant impact on fertility.50 Re- 18.7 months for urban women.41 Yet a 1994 search on the impact of consanguineous mar- study using available survey information in- riage on fertility is limited to small samples dicated that, while 60–70 percent of women making it harder to extrapolate its effects 6 at the country level. Traditional norms that growth at a low level. Certain forms of con- greatly value large families also attach a stigma traception, such as sterilization and abortion to infertility. This may cause some underre- (also not explicitly promoted by the pre-rev- porting, but given that the infertile popula- olution family planning program), were dis- tion is a small proportion of the total, it is couraged. unlikely that infertility contributed signifi- cantly to the fertility trend. Iran-Iraq War When war with Iraq began in 1980, the gov- Socioeconomic Factors Affecting ernment began to consider population size High Fertility a comparative advantage. A general belief Socioeconomic factors such as religion and that, with its vast area and natural resources, gender roles affect the fertility rate. In Iran, the country needed and could afford a much changes in women’s education and work- larger population was shared by many Iranian force participation after the Islamic revolu- intellectuals and planners.52 Religious beliefs tion may have affected long-term fertility promoting marriage and childbearing were trends. Though the government continued augmented with public programs that encour- to support family planning services immedi- aged larger families. ately after the 1979 Islamic revolution, its re- Lasting for almost a decade, the Iran- sponse to the Iran-Iraq war was a pronatalist Iraq war was mainly fought on the battle- public policy that ended the family planning field—not until 1985 did cities and towns program and gave families incentives to have on both sides of the border begin coming more children. under attack. The greatest causalities were among the soldiers and volunteers mobilized Religion by the Basij organization affiliated with the Religious thought has played a key role in Guardians of Revolution.53 Most volunteers shaping the Iranian government’s family plan- came from religious families where the idea ning policies, especially since the Islamic revo- of early marriage was taken very seriously, lution of 1979. and most were married before volunteering Since Islam does not prohibit use of con- for war. In other cases, boys may have been traceptives,51 the government’s family plan- married early to avoid being drafted into the ning program was allowed to continue during army.54 the initial months of the post-revolution pe- During the war, the government offered riod. Given their traditionally favorable at- incentives for early marriage and larger fami- titude towards contraception, the Iranian lies.55 A new rationing system provided tan- clergy initially had no objection to a family gible incentives for fertility in separate rations planning program that addressed the needs for each newborn: infants were entitled to of individual couples who wanted to delay an adult’s share of subsidized food and other or postpone pregnancy. But they hesitated to household items.56 These rations appear to support a program explicitly designed to re- have been a significant incentive for the popu- duce fertility and keep the rate of population lation expansion of the early 1980s. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 7 Child mortality and the value of fairly quickly but universities remaining closed children for two years.58 Female higher education Insufficient evidence exists on mortality trends also suffered a setback. For example, within during the war; deaths registered by the Civil months of the revolution, the Ayatollah Kho- Registration Organization of Iran are much meini issued a decree dismissing all female lower than estimates by the United Nations judges and barring women from attending Population Division. Given the economic from law schools (see box 1 for a chronology value of having an identity card during war- of women’s rights before and after the revolu- time shortages, households may have refused tion).59 In the absence of educational opportu- to report deaths of their members. Although nities, especially for women in urban regions, the rationing system encouraged timely reg- the incentive to get married was higher. On istration of births and therefore an improve- the other hand, these measures probably had ment in the birth registration system, it may little impact on female enrollment and mar- have had the reverse effect on the timely regis- riage in rural areas, where families had already tration of deaths.57 been under pressure from the clergy to keep The economic literature on fertility sug- girls from attending the country’s coeduca- gests that when the cost of bearing children is tional public schools.60 low, fertility is high, and vice versa. Iran’s war- However, after the reorganization, time rationing system provided a distorted schools became segregated by gender and incentive to have larger families by reducing free, addressing the socio-economic obsta- the cost of bearing children. Though empir- cles faced by rural populations when sending ical evidence is unavailable, it seems likely daughters to school. that, in the absence of the ration card incen- tive, Iranian fertility would have continued Female participation in the labor force its decline. But by rationing food and other Women’s employment is positively associ- services on the basis of family size with sepa- ated with lower fertility and higher age at rate rations for infants, the incentive for larger marriage. Economic inequalities before the families may have distorted the fertility trend revolution created availability of cheap fe- upwards. male labor, which was in higher demand than male labor.61 Yet, as with most patriar- Education chal social systems, women had little con- The link between education and fertility is trol over their resources. It was among this well-established. Girls who stay in school cadre of women that the revolution found longer have a higher age at marriage and support.62 Women’s labor force participation childbirth. Immediately following the Islamic declined considerably after the Islamic revo- revolution, the government of Iran had re- lution, from 12.9 percent in 1976 to 8.2 per- organized the education system, including a cent in 1986.63 This reduction was primarily revision of all curricula. During this reorgani- caused by a drastic decline in rural female zation, all education institutions were tempo- labor force participation during 1976–86, rarily closed, with primary schools reopening from nearly 17 percent to 8 percent. Urban 8 Box 1 | Gains and Losses for Women’s Rights in Iran, 1910–1982 Iran’s Islamic revolution reversed most of Iran’s previous gains in women’s rights. Within months of the revolution, women’s mobility came under severe scrutiny by the Islamic regime. Women were required to cover themselves from head to toe when in public and were discouraged from working outside the home. Women were barred from practicing law, and secular courts were replaced by religious courts. By late 1982, women’s rights and status had been systematically changed. Their main role in society was to be wives and mothers, in keeping with the pronatalist strategies of the government. Islam was used to justify this more traditional role for women—and to validate various laws under the new regime that subordinated women to men, also eroding their decision making power about fertility and family size. Policy Timeline: Rights and Reversal 1910 Access to education 1936 Abolition of the veil 1962 Right to vote 1965 Legislation requiring nurseries/childcare at all work places 1967 Family protection law (women gain the right to initiate divorce) 1973 Right to contest for the custody of children 1974 Free abortion on demand 1976 Ban on polygamy and the right to maintenance after divorce 1979 Female students barred from law school (later reversed) 1979 Female judges removed from their posts and secular courts replaced with religious courts (1967 Family protection law repealed) 1982 Diyat laws enacted (women’s evidence unless corroborated by a man is inadmissible; blood money for a woman is half that for a man) 1982 Qissas law enacted (a man who murders a woman can only be punished if his descendants receive blood money from the murdered woman’s relatives) Source: Afshar 1985; Mahdavi 1983. female labor participation declined more their workforce participation steady at lower slowly during the same time period, 9 per- levels. While the government enacted laws to cent to 8.1 percent.64 provide support to women in the workplace, Although the revolutionary government including provisions for child care centers and did not ban women from working, post-rev- maternity leave, the cost of these measures fell olution labor markets were segmented along on employers—creating disincentives for pri- gender lines and the labor market for women vate sector employment of women.66 In the shrunk: female employment shifted from the presence of a shrinking labor market and gov- private sector to the public sector, mainly in ernment incentives for marriage and child education and health,65 affecting rural wom- bearing, leaving the active labor force may en’s employment more than urban women’s. have been a matter of choice and coincided And few new opportunities for women kept with increasing fertility.67 Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 9 Second Fertility Decline in Iran: Delayed Marriage, Increased Education, and Widespread Family Planning I ran’s current fertility decline began in the late 2.1 for rural.69 (See annex 4 for 2006 fertility 1980s and continued throughout the 1990s data.) The main causes of Iran’s declining fer- and 2000s. During this period, the govern- tility since 1990 have been: lower adolescent ment reversed its policies on family planning. fertility, emphasis on family planning, better This was in response to limited resources and primary health care services, access to educa- the prospect of high unemployment when the tion, and increased employment. large cohort born during the 1980s entered the workforce. As the country recovered from Decline in Adolescent Fertility war—and access to primary health care services With free access to basic education in the and basic education improved—fertility began postwar era, age at marriage began to in- to decline sharply. By 2000, 14 out of 28 prov- crease, leading to a more rapid decline in ad- inces in Iran had below replacement fertility olescent fertility from 1997 to 2006 in Iran levels.68 At the most recent census (2006), the than in the Middle East and North Africa re- total fertility rate was below replacement levels gion or in other lower middle-income coun- nationally (1.9), only 1.8 for urban centers and tries (figure 4).70 Figure 4 | Adolescent1997–2006 Iran, the Region, and Lower Middle-Income Countries, Fertility in 60 Births per 1,000 women 50 (ages 15–19) 40 30 20 10 0 1997 2000 2002 2005 2006 Years Iran, Islamic Rep. Middle East & North Africa Lower middle income countries Source: World Development Indicators Online. 10 Although a significantly higher propor- time rate of population growth (3.9 percent). tion of young (ages 15–19) girls were married Within a year, the government of Iran had re- compared to boys during 1956–2006, since introduced the family planning program, with 1986 this trend has been declining steadily three objectives: (figure 5). By 2006, only 17.7 percent of ad- olescent girls aged 15–19 were reported ever Æ Delay first pregnancy. married compared with 3 percent of boys.71 Æ Discourage pregnancy for women under Better birth spacing and timing of births 18 and over 35 years of age. also helped reduce fertility as age at marriage Æ Limit family size to three children.76 rose. For girls who marry at younger ages, fe- cundity plays a role in the timing of first birth, The Ministry of Health and Medical Ed- which may be more delayed than for women ucation was given the mandate and resources marrying at older ages.72 Differences in edu- to provide free family planning services.77 And cation, empowerment and employment also the 1993 Family Planning Law removed pre- affect the timing of their second and higher vious incentives for high fertility (see annex 5). order births.73, 74 These socioeconomic changes in women’s lives, along with greater access to Family planning classes for young family planning services, helped reduce the couples risk of higher order births in Iran.75 Under the 1993 Family Planning Law, com- pletion of family planning counseling classes Family Planning Programs — is a prerequisite for obtaining a marriage cer- the Right Mix tificate. The classes inform couple of their By 1988, it had become apparent that the choices, encourage birth spacing, and provide country would not be able to sustain its war- samples of accepted contraceptives.78 Figure 5 | Decline in Adolescent Marriage (Ages 15–19), by Gender, 1956–2006 50 45 Percentage ever-married 40 35 30 25 20 15 10 5 0 1956 1966 1976 1986 1991 1996 2006 Years Men Women Source: Adapted from Mehryar 2008. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 11 Education in sexual and reproductive to improving public–private partnerships for health health care, such as transferring management In addition to family planning classes, com- to private health care providers and engaging pulsory population education is included in their services for support functions (from lab- secondary school and university curricula.79 oratory services to facilities maintenance).85 Though no thorough impact evaluation of this But little concrete information is available on program exists, available evidence suggests that the extent of the private sector’s role in family only some topics are covered and that girls have planning and maternal health services. more knowledge about the subject than boys.80 Regional variations Contraceptive use Despite an overall convergence in contracep- Highlighting a significant unmet need, contra- tive prevalence rates (figure 6), there are still ceptive prevalence rates increased rapidly be- wide provincial differences (annex 2). For tween 1989 and 1992, from 49 percent to 65 example, data from the 2000 demographic percent for all married women ages 15–49 (74 health survey show that border provinces have percent for urban women and 52 percent for higher fertility than others.86 rural). By 2000 the overall contraceptive prev- A number of factors could account for alence rate was estimated at 74 percent, 77 regional variation in contraceptive preva- percent urban and 67 percent rural.81 lence rates. One possibility is that socio-cul- Contraceptive use is perhaps one of the tural differences may be responsible for the most important reasons behind the current fer- differences—but current data tend to con- tility decline (box 2)—responsible for 61 per- tradict this explanation. Sistan-Baluchistan cent of the decline according to data from the and Hormozgan both have sizeable Sunni 2000 Demographic Health Survey of Iran.82 Muslim populations that may have been less The kinds of contraceptive behavior most re- receptive to the Shiite leadership’s stance on sponsible for the decline are birth spacing and family planning. But Kurdistan, with a ma- delayed first birth among younger women and jority Sunni population, has the highest rate stopping childbearing among older women.83 of modern contraceptive use (69.7 percent) of These data suggest that the knowledge gained all 29 provinces covered by the demographic from family planning classes was important in health survey. It is also one of the 13 provinces changing childbearing behavior. where rural women use modern contracep- tives at a higher rate (71.4 percent) than their Role of the private sector urban counterparts (68.7 percent). Indeed, By 1995, 55 percent of women received their Kurdistan province had one of the lowest total contraceptive supplies from public health fertility rates in Iran by 2006. In Qom prov- centers, the remaining from private sector ince, predominantly Shiite and with Iran’s sources—highlighting the growing role of the highest urbanization and literacy rates, use of private sector in Iranian family planning.84 Ac- modern contraceptives has been considerably cording to the Third Five-Year Development lower (45.6 percent) and fertility higher than Plan for Iran, the government is committed in Kurdistan.87 12 Figure 6 | Urban-Rural Convergence in Contraceptive Use in Iran, 1977–2000 90 80 Couples using contraceptives 70 60 50 40 30 20 10 0 1977 1989 1992 1994 1997 2000 Years Rural Urban Total Source: National Census of Population and Housing, 2006. Another possible explanation is that dif- vision of basic foodstuffs, and access to basic ferences in the level of provincial development health care.90 Several early-1970s pilot projects are responsible for variations in the contra- to provide health care to rural areas later be- ceptive prevalence and total fertility rates. For came the basis of an extensive primary health example, in Sistan-Baluchestan (Iran’s least- care network centered on “health houses” developed province bordering Pakistan and (serving a central and several surrounding vil- Afghanistan) the contraceptive prevalence rate lages) in rural areas and “health centers” in is below 50 percent and in Hormozgan (an urban areas.91 underdeveloped southeastern province bor- By 1991 Iran had nearly 12,000 health dering Sistan-Baluchestan) it is below 60 per- houses and 4,000 health centers.92 For a ma- cent.88 A third possibility is that discrepancies jority of the rural population, the health house in the quality of family planning services may is the only available health care facility.93 Ac- account for at least part of regional variation. cess to primary health care services has im- Further analysis is required for complete un- proved dramatically since the 1980s, reaching derstanding of the causes of regional varia- 95 percent of the rural population by 2002.94 tions in fertility and contraceptive use. A majority of the country’s population has health insurance,95 which includes antenatal Investment in Primary Health Care: and postnatal care.96 When family planning Expanded Access to Maternal and was reintroduced in 1989, it was integrated Child Services into the existing primary health care network Iran’s good primary health care network has as part of the package of services for maternal facilitated the spread of family planning ser- and child health, enabling a rapid increase in vices.89 After the revolution, the government family planning services for both rural and focused on three policy areas: education, pro- urban populations. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 13 Box 2 | Contraceptive Use in Iran: A Mix of Methods Modern methods were introduced in Iran in the 1960s, when the government allowed imports of oral contraceptives. Early efforts focused mainly on providing oral contraceptives, which may have slowed the program’s growth by limiting options available. Traditional contraceptive methods had been used in Iran for centuries and may also have contributed to fertility decline in the 1970s, especially in urban areas. However, as early as 1989, data show a growing preference for modern contraceptive methods, which have steadily replaced traditional methods (see figures). Contraceptive Prevalence in Iran, 1989–2000 Urban contraceptive prevalence Rural contraceptive prevalence 60 80 50 60 Percentage Percentage 40 30 40 20 20 10 0 0 1989 1992 1996 2000 1989 1992 1996 2000 Modern methods Traditional methods Modern methods Traditional methods By 1992, traditional methods accounted for only Use of Modern Contraceptives in one-third of the contraceptive prevalence rate. Despite their initial popularity, these methods have Iran, 1992 and 2000 (%) been steadily replaced by modern methods of con- 1992 2000 traception (see table). Method Urban Rural Urban Rural While oral contraceptives remain the most popu- Oral 20.1 26.1 16.5 21.9 lar contraceptive method, female sterilization has contraceptives gained steady acceptance and popularity, especial- Condom 8.0 4.2 7.2 3.6 ly among women ages 33–34 from more religiously conservative provinces and with an average of five IUD 10.0 3.1 10.2 5.3 children. These women appear to use steriliza- Tubectomy 7.7 7.4 16.1 18.9 tion as a last resort when they have achieved their Vasectomy 1.3 0.3 3.5 1.3 desired family size. They also may be responding to the family planning program, which encourages Injection — — 1.3 5.5 women to stop childbearing after the age of 35. Norplant — — 0.3 0.7 Still unclear is whether these women had used any other form of contraceptive before sterilization. Source: Aghajanian 1998; Mehryar 2001; World Bank 2007. In rural areas all health houses are staffed child care, and male behvarzan are trained in by two “behvarzan,” or health workers: local environmental health. These basic health ser- people, generally a man and a woman, who vices are provided free of charge, including have undergone two years of training. Female immunizations and family planning services. behvarzan are responsible for maternal and The behvarzan also conduct a yearly census 14 of the villages under their charge97—a system vide obstetrics and gynecological services. Nor that has improved collection and updating of can they perform pap smears or place IUDs. vital statistics in Iran, including data on ma- Women must be referred to rural health cen- ternal mortality (box 3). ters for these services.99 Moreover, the female behvarz is not trained as a midwife, and preg- Health care for women nant women are referred to health centers for Because of these efforts, primary health care checkups.100 has significantly improved in rural areas. Child In urban areas, however, health posts can immunization has remained high throughout perform these functions. The main problem the past two decades—currently 99 percent in urban areas seems to be that residents for measles, DPT, and Hepatitis B. And a ma- often choose higher cost private health care jority of births (89.6 percent) are attended by providers,101 because of perceived differences skilled birth personnel, with some rural–urban in the quality of public and private sector differences.98 care. While there have been no large-scale The presence of female behvarzan at the studies on the quality of care, one study of health houses ensures that women have ac- 25 urban health care clinics in western Iran cess to health care, including family planning found large variations in the performance of services. Yet gaps remain in the delivery of re- health care workers. The study found that productive health care. Health houses, the health workers with a bachelor’s degree or first point of contact, are not equipped to pro- higher performed worse on recording med- Box 3 | Registration of Vital Statistics Iran has one of the better vital registry systems in the developing world, first established in 1920. The rationing system during the Iran-Iraq war that awarded extra adult rations for each infant further helped to improve the timely registration of births because an identity card was needed to prove the birth of a child. Today, health houses collect annual census information for all villages under their charge, facilitating regis- tration of vital statistics for rural areas. The behvarzan at each health house are responsible for collecting data on demographic, health, and education indicators such as age, sex, literacy level, and health status of each individual within a household. Information on pregnancies and major illnesses is also recorded, along with the type of treatment provided. Though detailed logbooks are kept, this information is also summarized in an easy-to-read ”vital horoscope” for future reference. Over the past few decades the Ministry of Health and the Civil Registration Organization (CRO) have de- veloped dual registration systems to ensure accurate recording, resulting in detailed information on cause- specific mortality rates for most of the provinces. These data suggest that Iran has reached an advanced stage of health transition, with the majority of deaths being due to accidents, heart diseases, and cancers. Yet the World Bank’s 2007 Health Sector Review of Iran points to important gaps in information about urban centers, where better coordination with private health providers could improve the flow of information into the health management information system. Moreover, the system would benefit from more data on the quality of health services provided. Source: World Bank 2007b; Mehryar and others 2008; Mansoorian and Rajulton 1993. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 15 ical histories and counseling thoroughly on underscores the potential spread of sexually family planning services.102 But the authors transmitted infections—including HIV— concede that their study has limitations. A because of poor knowledge on the subject better understanding of this phenomenon among young men.109 requires more in-depth analysis of both de- mand and supply issues. Continuity of care Investment in Education — A Key is also a problem in urban health posts, as in- Factor in Declining Fertility dividual patients do not have named physi- The constitution of Iran guarantees every cit- cians, often leading to duplication of work izen the right to an education. After the rev- and investigation.103 There is no guarantee olution of 1979, the education system went that pregnant women will see the same through a period of change, resulting in seg- health care provider, obstetrician, or gynecol- regated schools for girls and boys, and an “Is- ogist for each antenatal visit, or that the same lamized” curricula. In practice these changes provider or doctor will be available at birth eased restrictions on girls’ basic education, es- or follow up. pecially in rural and conservative communi- Though data suggest that 97 percent of ties.110 Enrolment levels at the primary and births are attended by skilled birth atten- secondary schools are now high, but tertiary dants, wide variations exist across provinces enrolment is lagging. in the maternal mortality ratios (0 to 174 per 100,000 women), suggesting that quality of The literacy movement care may be a problem.104 The increasing in- As part of its efforts to educate the entire na- cidence of low birth weight may also indicate tion, the post-revolution government also re- poor-quality perinatal care.105 introduced adult literacy programs.111 The One thing is certain: Iran has moved be- main beneficiaries were rural women who yond first generation health care issues to had not been able to access formal educa- second generation problems that must be ad- tion.112 Although it is not clear how im- dressed to maintain the country’s advances in proved education affected daily life on a health care. The World Bank’s 2007 health large scale, some qualitative evidence sug- sector review for Iran calls for improvements gests that women felt more empowered. Ac- in the quality of services and monitoring.106 cording to one study, “increased literacy has In addition, ensuring that the continuum contributed to women’s confidence and has of care for maternal and reproductive health increased women’s perceptions that they is strengthened at each level and across the have options in many aspects of their lives, country would be important to ensure survival particularly women in rural areas who have of both mother and child.107 been much more constrained by traditional social norms.”113 These women stated in- HIV/AIDS terest in becoming teachers and nurses or in Current (2007) HIV prevalence is only 0.2 joining politics—options these women had percent,108 suggesting that it does not influ- not considered viable prior to their educa- ence fertility trends in Iran. But a recent study tion.114 16 Levels of education fewer children than women whose husbands Higher education is generally associated with had primary or lesser education.115 Data from lower levels of fertility because it affects the the 2000 demographic health survey also in- age at marriage and age at first birth. The dicates the importance of husband’s education longer girls stay in school, the higher their age on fertility: among rural women, those with at marriage and consequently age at first birth. more educated husbands are less likely to have Fertility is further affected by women’s access third and higher order births.116 to job markets—for which access to secondary Education for both men and women–at education is critical. In Iran the husband’s least up to the secondary level—may in part be education is perhaps equally important—if responsible for the sharp decline in adolescent not more so—as a determinant of women’s fertility rates from 1997 to 2005—and con- fertility. A 1993 study revealed that women sequently the decline in overall fertility. But whose husbands had secondary or higher in the absence of reliable data on dropout and levels of education were more likely to have completion rates at the secondary level, or on Table 1 | Education Indicators for Iran, 2000–06 Indicator/year 2000 2003 2005 2006 Expected years of schooling Female 11 11 13 — Male 12 12 13 — Primary education School enrollment (% gross) Female 92 91 123 132 Male 96 94 101 104 Persistence to grade 5 (% of cohort) Female 97 — — — Male 98 — — — Secondary education Progression to secondary school (%) Female 90 100 83 — Male 90 98 93 — School enrollment (% gross) Female 76 77 78 — Male 81 81 83 — Tertiary education School enrollment (% gross) Female 18 21 25 28 Male 20 20 23 25 Source: World Development Indicators Online. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 17 adolescent fertility before 1997, it is difficult to vincing government of the need for family assess the true impact of education on Iran’s de- planning. During the war years, Iran’s economy clining total fertility rate. By 2007 both male contracted at a rate of 1.3 percent per year121, and female enrollments—especially at the pri- while population growth rate was 3.9 percent mary and secondary levels—were high, with an per annum.122 By the end of the war in 1988, average of 13 years of schooling (table 1). the majority of the population was under 14 Enrollment falls sharply at the tertiary years of age. Figure 7 shows that prior to 1993, level for both women and men, with levels youth age dependency ratio remained at 90 of university enrolment marginally higher percent. Of concern was the potential of fur- for girls than boys. Given the limited oppor- ther increase in unemployment as this age tunities for white collar jobs in Iran and the group would move into the working age group high grade requirements for university admis- over the next decade. Without rapid economic sion, most secondary school male students are growth, levels of unemployment were likely to tracked into technical and vocational educa- rise leading to increased poverty. These con- tion.117 How this will affect future fertility re- siderations encouraged the government to ease mains to be seen. In recent years, gender-based restrictions on family planning and begin a quotas have been imposed in some regions to proactive population control campaign with encourage greater male participation in uni- the passage of the 1993 Family Planning Law. versity education.118 Age structure of the population Economic and Political One of the key population dynamics of in- Conditions — A Paradigm Shift terest to economists is the population de- According to some analysts, economic and so- pendency ratio.123 A lower dependency ratio cial development during the 1950s and 1960s allows for greater productivity and savings helped set the stage for the first fertility de- and is achieved when fertility declines from cline in Iran, which lasted till the late 1970s.119 higher levels to replacement or near replace- This decline in fertility coincided with rising ment level.124 However, when there are limited incomes and improvements in primary edu- resources, poor-quality institutions, or macro- cation, with women with more educated hus- economic instability, the benefits of increased bands experiencing a greater fertility decline. savings and productivity—the demographic At the macro level, the second fertility de- dividend—cannot be realized. Since Iran had cline in Iran, which began after the end of the a high dependency ratio at the end of the war Iran-Iraq war, was prompted by two main fac- in 1988, one option available to the govern- tors: unemployment and constrained economic ment to encourage economic growth was to growth. Immediately after the war, the gov- bring the fertility rate down, which would ernment of Iran embarked on a massive infra- lower the dependency ratio over the long structure improvement program that may have term. With lower dependency ratios, house- absorbed some of the labor force. But by 1992 holds would in theory be able to save more, unemployment was beginning to increase.120 leading to greater investment and productivity Economic conditions played a key role in con- and consequently spur economic growth. 18 Figure 7 | Dependency Ratios, Iran 1960–2007 100 Ratio of dependents to working age 90 80 70 60 50 40 30 20 10 0 1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 Years Ages 65 and above Ages 14 and below Total Source: World Development Indicators. Note: The total age dependency ratio is the ratio of the population ages birth to 14 years and ages 65 and over years to the working-age population (15–64 years). The old age dependency ratio is the ratio of the population ages 65 years and over to the working-age population. The child dependency ratio is the ratio of the population ages birth to 14 years to the working- age population. Age dependency ratios in Iran began de- will depend on its economic policies and the clining rapidly in 1992 (figure 7). By 2006 level of access to labor markets for women. the child dependency ratio was 36 percent, the old age dependency ratio 7.4 percent. As Employment old age dependency has remained under 10 Unemployment levels have been very high percent for the past four decades, the main in Iran—an indicator of a significant depen- driving force in the changing population de- dency burden. By 1996 only 32 percent of the pendency ratio was the youth dependency working-age population (ages 10 and above) ratio. was gainfully employed and only 35 percent Coming out of the Iran-Iraq war, Iran had of the total population was economically ac- a large population of youth under 15 years tive (table 2).125 old. By 2006 this group had joined—and ex- Between 1986 and 1996 female em- panded—the working-age population (figure ployment increased, reaching 13.7 percent 8; see annex 3 for age distributions 1966– by 2000. Though low by international stan- 2006). Though Iran is now undergoing a tran- dards, this represents a significant increase sition to lower fertility, its population size will in female labor force participation since the keep increasing over the next few decades be- 1980s. Some data indicate that female labor cause of population momentum. Whether the force participation dropped between 2000 country can realize demographic dividends and 2006 for reasons unclear. But World Bank Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 19 Figure 8 | Age Distribution of Iran’s Population, 1986 and 2006 90–94 90–94 80–84 80–84 70–74 70–74 60–64 60–64 Age groups Age groups 50–54 50–54 40–44 40–44 30–34 30–34 20–24 20–24 10–14 10–14 0–4 0–4 –21 –18 –15 –12 –9 –6 –3 0 3 6 9 12 15 18 21 –15 –12 –9 –6 –3 0 3 6 9 12 15 1986 2006 Male Female Source: National Census of Population and Housing, 1986 and 2006. data shows a rising trend in female employ- High unemployment—though stable— ment. In 2007 the employment-to-population continues to be a problem for the Iranian ratio was 47.8 percent, with a youth employ- economy.127 Unemployment is higher among ment ratio of 34.8—of which the female share white collar jobseekers, especially women: 50 was only 23.7 percent (figure 9). Overall fe- percent of female university graduates and male employment was 26.9 percent, compared 10 percent of male university graduates in with 68 percent for males.126 Most of the gains 2004 were unable to find jobs.128 By 2006 in female employment have been driven by the overall unemployment rate was 11.3 per- the increasing number of female youth (ages cent, with majority of the unemployed in the 15–24) gaining employment. 15–24 age group.129 Women form the bulk of Table 2 | Labor Force Participation by Gender, Ages 10 and Over (1976–2006) Economically active population (%) Employed population (%) Year Male Female Total Male Female Total 1976 70.8 12.9 42.6 64.3 10.8 38.3 1986 68.4 8.2 39.1 59.5 6.1 33.5 1996 60.8 9.1 35.3 55.6 7.9 32.1 2000 67.8 17.3 42.6 56.7 13.7 35.2 2006 65.6 12.39 47.24 58.94 9.60 34.71 Source: Adapted from Mehryar and Aghajanian 2002; Mehryar 2008. 20 Figure 9 | Employment Trends in Iran, Ages 15 and Over, 1991–2007 80 70 60 Employment ratio 50 40 30 20 10 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Years Male, youth(%) Male, working age (%) Female, youth (%) Female, working age (%) Source: World Development Indicators Online. Note: Youth represents ages 14–24; working age includes ages 15 to 64. the unemployed, with nearly half of the eco- How the high levels of unemployed nomically active women being unemployed.130 women will affect future fertility in Iran is un- According to one estimate (assuming that the clear. Will the fertility decline stall or reverse labor force growth rate remains stable at 3 per- again? Also unclear is the distribution of un- cent), the government would have to create employment across provinces. Does high fe- 800,000 additional jobs per year to absorb male unemployment coincide with higher the unemployed labor force—unlikely in slow fertility provinces? Likewise unclear is the ex- economic times.131 tent to which women participate in Iran’s Attitudes about women’s work continue significant informal economy, or how that af- to be key in determining the roles of men and fects fertility. And other socio-cultural aspects women in the workplace. For example, in one of Iran’s polity need to be taken into consid- survey of Iranian men and women,132 69 per- eration, such as the establishment of quotas cent of the respondents stated that in times of on female tertiary education enrollment in job scarcity, men have a greater right to jobs some regions134 or the work environment for than women. And over 70 percent of men women, which could act as deterrents to the and women respondents agreed with the state- fertility decline. ment that men make better executives than women.133 Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 21 Conclusion D id the basic roadmap to lower fertility Family planning services already exist before the 1979 Islamic Scholars and development practitioners agree revolution? Ideological factors after the that, while family planning programs by them- revolution may have caused a spike in fertility selves are not sufficient to bring down the total but also contributed to fertility-lowering fac- fertility rate, allowing access to such programs tors such as better health and education. The is essential to accelerate a fertility decline. war with Iraq initially encouraged more child- bearing but also destroyed resources needed to Education absorb significant population growth. Once Investment in education—especially higher fe- the government removed fertility incentives male education—is linked to lower fertility. and actively promoted family planning, fer- Women who are more educated have a higher tility declined drastically. Regional dispari- age at marriage and lower fertility even when ties in fertility do exist, but further analysis is they do not actively participate in the labor needed to understand and address these dispar- market. Iran’s experience illustrates that in- ities. Iran is an example of good public policy vesting in male education is also important in interventions in health (including family plan- bringing down fertility rates. ning) and education that have significantly brought down the country’s fertility rate. Invest in health care Iran’s experience offers lessons for other Iran’s initial investment in primary health care developing countries seeking to reduce fer- has led to a decline in infant and child mor- tility: tality. The extensive network of health houses and centers has successfully reached highly dis- Key stakeholder buy-in persed populations and provided necessary im- The Islamic clergy’s acceptance of family plan- munizations and health education on topics ning was essential in getting people to use such as hygiene and sanitation.135 These efforts family planning services. Approximately 90 have helped to reduce mortality rates—and re- percent of Iranians are Shiite Muslim, perhaps duce the desire for higher fertility. The primary making it easier for local clergy to adhere to health care system in Iran is also an example national edicts by the Ayatollah. For family of a good service delivery system, with both planning policies to succeed in countries with urban and rural outreach. It was the obvious major religious or ethnic divisions, obtaining choice as a delivery mechanism for family buy-in from most—if not all—groups will be planning programs that have been successful in critical. achieving overall fertility reduction targets. 22 References Abbasi-Shavazi, M.J., P. McDonald, and M. Aghajanian, A. 1998. “Family Planning Pro- Hosseini-Chavoshi. 2008. “Moderniza- grams and Fertility Trends in Iran.” Mea- tion or cultural maintenance: The prac- sure Evaluation Working Paper. Carolina tice of consanguineous marriage in Iran”. 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Above 70 Percent and Cut TFR by Two- Musallam, B.F. 1986. Sex and Society in Islam: Thirds in Less than a Decade?” Paper pre- Birth Control Before the Nineteenth Cen- sented at the International Union for tury. Cambridge Studies in Islamic Civ- the Scientific Study of Population World ilization. Cambridge University Press: Congress, August 18–24, Brazil. Cambridge. Moghadam, V. M. 1995. “Women’s Employ- O’Donnell, E. 2008. “Infertile in Iran.” Le ment Issues in Contemporary Iran: Prob- Monde Diplomatique, April 15, 2008. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 25 Omran, A. R. 1992. Family Planning in the Shahidzadeh-Mahani, A., S. Omidvari, H. R. Legacy of Islam. New York: Routledge/ Baradaran, and S. A. Azin. 2008. “Factors United Nations Population Fund. Affecting Quality of Care in Family Plan- Raftery A.E., S.M. Lewis, and A. Aghaja- ning Clinics: A Study from Iran. Interna- nian.1995. “Demand or Ideation? 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Washington, DC: Salehi-Isfahani, D., Tandon, A. 1999. “Fer- World Bank. tility Transition or Intertemporal Substi- World Bank. 2007c. Economic Growth in tution in Post-revolution Iran? Evidence Iran: Opportunities and Constraints. Wash- from household data”. Virginia Poly- ington, DC: World Bank. technic Instititute, Department of Eco- nomics. mimeo 26 Annex 1: Iran at a Glance Earliest available Latest available between 1980 and between 1980 and 2006 2006 Series Name Value Year Value Year Demographics Population, total (millions) 39.1 1980 70.1 2006 Population growth (annual %) 3.5 1980 1.5 2006 Population ages 0–14 (% of total) 44.7 1980 27.8 2006 Urban population (% of total) 49.7 1980 67.4 2006 Fertility rate, total (births per woman) 6.58 1980 1.90 2006 Adolescent fertility rate (births per 1,000 women ages 46.07 1987 21.20 2006 15–19) Life expectancy at birth, female (years) 59.7 1980 72.3 2006 Mortality rate, infant (per 1,000 live births) 92 1980 30 2006 Mortality rate, under-5 (per 1,000) 130 1980 34.4 2006 Maternal mortality ratio (modeled estimate, per 100,000 140 2005 140 2005 live births) Maternal mortality ratio (national estimate, per 100,000 37 1996 37 1996 live births) Economy GNI per capita, Atlas method (current US$) 2,190 1980 2,960 2006 GNI per capita, PPP (current international $) 3,410 1980 9,870 2006 Health Health expenditure, total (% of GDP) 6.1 2001 7.8 2005 Health expenditure, public (% of GDP) 2.5 2001 4.4 2005 Health expenditure per capita (current US$) 78.0 2001 212.0 2005 Prevalence of HIV, total (% of population ages 15–49) 0.1 2001 0.2 2007 Contraceptive prevalence (% of women ages 15–49) 49.0 1989 73.8 2000 Births attended by skilled health staff (% of total) 86.1 1997 97 2005 Nurses and midwives (per 1,000 people) 1.60 2005 1.60 2005 Physicians (per 1,000 people) 0.34 1981 0.89 2005 (continued on next page) Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 27 (continued) Earliest available Latest available between 1980 and between 1980 and 2006 2006 Series Name Value Year Value Year Education Literacy rate, adult female (% of females ages 15 and 41.0 1986 76.8 2005 above) Literacy rate, youth female (% of females ages 15–24) 65.6 1986 96.7 2005 School enrollment, secondary, female (% gross) 49.0 1991 78.4 2005 School enrollment, secondary, female (% net) 76.1 2004 75.0 2005 School enrollment, primary, female (% gross) 103.6 1991 132.2 2006 School enrollment, primary, female (% net) 88.7 1991 99.9 2005 Primary completion rate, female (% of relevant age 76.6 1989 107.8 2006 group) Source: World Development Indicators Online database; National Census of Population and Housing 2006. 28 Annex 2: Contraceptive Use in Iran Table A2.1 | Proportion of Women Ages 15–49 Years Using a Modern Method of Contraception, by Age Group, Urban-Rural Status, and Province Age groups (years) Urban Rural Region 10–29 30–39 40–49 10–29 30–39 40–49 Iran 45.5 63.7 58.1 46.1 68.7 63.0 Markazi 41.4 63.6 65.4 51.7 73.5 63.4 Gilan 37.9 53.2 42.5 49.5 64.0 50.3 Mazand 33.5 56.5 60.8 41.0 64.6 69.6 Azar, East 42.1 64.9 54.4 50.1 79.1 71.7 Azar,West 56.3 68.6 57.8 54.0 75.6 65.2 Kersha 57.8 76.1 71.2 53.0 75.3 74.6 Khuzist 53.1 70.0 63.0 42.8 60.2 62.4 Fars 47.5 68.1 64.9 44.7 76.1 68.5 Kerman 42.6 56.7 58.0 38.7 63.7 55.6 Khoras 36.3 59.8 56.4 38.7 62.3 59.4 Esfahan 44.0 62.1 59.3 49.0 75.9 64.9 Sistan 39.4 55.2 53.5 22.7 34.1 30.3 Kurdist 61.9 74.1 72.7 60.1 82.4 76.6 Hamadan 50.9 68.8 66.3 557.3 79.8 68.7 Charmah 53.6 75.1 72.9 50.6 76.0 79.3 Loristan 53.9 72.0 66.9 51.3 78.5 73.5 Ilam 57.0 78.6 74.7 49.8 73.8 66.7 Kohgilu 51.7 69.6 73.3 40.5 71.3 62.5 Bushehr 41.1 61.0 54.6 43.2 61.5 46.1 Zanjan 56.3 72.3 64.6 54.9 75.0 66.8 Semnan 41.0 54.4 58.3 45.1 72.6 69.2 Yazd 45.8 62.7 51.6 48.4 72.5 60.5 Hormoz 44.8 60.7 58.3 34.7 46.7 35.8 Tehran Province 47.8 64.3 61.4 49.6 66.6 64.8 Ardabil 56.7 76.0 68.3 55.5 78.8 71.5 Qom 36.5 56.1 45.9 36.4 68.0 62.9 Ghazvin 45.9 65.1 59.4 48.2 73.2 68.9 Golestan 44.4 60.0 59.2 48.7 73.1 63.8 Tehran City 44.4 61.8 51.5 Source: Demographic and Health Survey for Iran, 2000. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 29 Table A2.2 | Contraceptive Use by Age Group, Urban-Rural Status, and Method Used, in Percentages Modern Methods Age Oral group Any Tubec- Vasec- contra- (years) Residence method tomy tomy IUD Norplant Injection ceptives Condom Total 15–19 All 39.3 0.1 0.0 4.8 0.2 0.9 14.3 5.4 25.6 Urban 42.8 0.1 0.0 6.0 0.1 0.6 13.1 6.6 26.5 Rural 32.9 0.1 0.0 2.6 0.3 1.2 16.4 3.4 23.9 20–24 All 61.5 0.3 0.4 11.0 0.6 2.9 22.0 6.0 43.2 Urban 64.9 0.3 0.5 12.7 0.5 1.7 19.6 6.9 42.2 Rural 55.5 0.4 0.2 7.8 0.8 5.1 26.3 4.3 44.9 25–29 All 74.7 3.7 1.1 13.2 0.7 3.7 25.5 7.1 55.0 Urban 78.2 2.9 1.4 15.7 0.6 2.0 23.2 8.1 53.9 Rural 68.3 5.1 0.6 8.7 0.9 6.9 29.7 5.2 56.9 30–34 All 81.5 16.4 3.0 11.1 0.6 3.6 21.3 6.9 62.9 Urban 84.3 14.4 3.7 13.4 0.3 1.6 18.9 8.6 61.0 Rural 76.4 20.0 1.7 6.9 1.0 7.2 25.6 3.8 66.1 35–39 All 85.9 30.7 5.3 6.7 0.6 3.1 16.4 5.7 68.5 Urban 88.5 27.6 6.9 8.4 0.3 1.2 15.0 7.2 66.6 Rural 81.2 36.2 2.5 3.6 1.0 6.6 19.0 2.9 71.8 40–44 All 82.9 36.4 4.6 4.4 0.2 2.4 13.3 4.7 66.1 Urban 85.1 33.6 5.7 5.5 0.1 0.9 11.8 6.1 63.7 Rural 79.0 41.5 2.4 2.5 0.4 5.1 16.0 2.4 70.3 45–49 All 68.0 31.3 3.3 2.3 0.3 1.4 8.7 4.4 51.7 Urban 71.2 30.0 4.2 2.9 0.1 0.3 7.3 5.7 50.5 Rural 62.2 33.8 1.7 1.0 0.6 3.5 11.3 1.9 53.9 15–49 All 73.8 17.1 2.7 8.5 0.5 2.8 18.4 5.9 55.9 Urban 77.4 16.1 3.5 10.2 0.3 1.3 16.5 7.2 55.2 Rural 67.2 18.9 1.3 5.3 0.7 5.5 21.9 3.6 57.3 Source: Demographic and Health Survey for Iran, 2000. 30 Annex 3: Age Structure in Iran, 1966–2006 Figure A3.1 | Age Sstructure of Iran’s Population, 1966 80–84 70–74 60–64 Age groups 50–54 40–44 30–34 20–24 10–14 0–4 –21 –18 –15 –12 –9 –6 –3 0 3 6 9 12 15 18 21 Male Female Source: National Census of Population and Housing, 1966. Figure A3.2 | Age Structure of Iran’s Population, 1976 80–84 70–74 60–64 Age groups 50–54 40–44 30–34 20–24 10–14 0–4 –18 –15 –12 –9 –6 –3 0 3 6 9 12 15 18 Male Female Source: National Census of Population and Housing, 1976. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 31 Figure A3.3 | Age Structure of Iran’s Population, 1986 90–94 80–84 70–74 60–64 Age groups 50–54 40–44 30–34 20–24 10–14 0–4 –21 –18 –15 –12 –9 –6 –3 0 3 6 9 12 15 18 21 Male Female Source: National Census of Population and Housing, 1986. Figure A3.4 | Age Structure of Iran’s Population, 1996 80–84 70–74 60–64 Age groups 50–54 40–44 30–34 20–24 10–14 0–4 –18 –15 –12 –9 –6 –3 0 3 6 9 12 15 18 Male Female Source: National Census of Population and Housing, 1996. 32 Figure A3.5 | Age Structure of Iran’s Population, 2006 90–94 80–84 70–74 60–64 Age groups 50–54 40–44 30–34 20–24 10–14 0–4 –15 –12 –9 –6 –3 0 3 6 9 12 15 Male Female Source: National Census of Population and Housing, 2006. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 33 Annex 4: Age-Specific Fertility Rates for Iran Figure A4.1 | Number of Births Registered Annually by the (RightRegistration Organization (Left Scale) and Percent Urban Civil Scale) 3,000,000 80 70 2,500,000 Total registered births 60 2,000,000 50 Percentage 1,500,000 40 30 1,000000 20 500,000 10 0 0 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 Years Total Births Percentage Urban Source: National Census of Population and Housing, 1956–2006. Figure A4.2 | Total Fertility Rates in Iran, 1956–2006 8 7 6 Total fertility rate 5 4 3 2 1 0 1956 1966 1976 1986 1991 1996 2006 Years Rural Urban Total Source: National Census of Population and Housing, 1956–2006. Note: Total fertility rates are derived from child-woman ratios of the total, urban, and rural population. 34 Figure A4.3 | Age-Specific Fertility Rates of All Women Ages 10 Years and Over in Iran, 2006 140 120 Age specific fertility rate 100 80 60 40 20 0 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 Years Rural Urban Tribal Total Source: National Census of Population and Housing, 2006. Figure A4.4 | Age-SpecificIran, 2006Rates of Ever-Married Women Ages 10 Years and Over in Fertility 250 Age specific fertility rate 200 150 100 50 0 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 Years Rural Urban Tribal Total Source: National Census of Population and Housing, 2006. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 35 Annex 5: Iran’s Family Planning Law of 1993* Article 1. All privileges envisaged in the law lation and mother and child health care in according to the number of children are no the curriculum texts. more valid regarding the fourth child and B. The Ministry of Culture and Higher more, born one year after enactment of this Education and the Ministry of Health and law. The children born prior to this date Medical Education are entrusted with the would be enjoying the privileges as envisaged task [of including] the subject of popu- by the law. lation and family planning in all educa- Note 1. The procedure of using the privi- tional curriculums. leges envisaged in the labor law and ap- C. The Ministry of Islamic Culture and proved on November 19th, 1990 by the Guidance is called to prepare grounds for Council to Identify the Expediencies of active and effective participation of jour- the System as well as the social security nalists, film makers and other artists re- law approved in 1965 is as follows: lated in a way to the Ministry in order to A. Maternity leave for female workers (ar- increase the general awareness of people ticle 75 of labor law, and approved by the regarding the population and family plan- Council to Identify the Expediencies of ning programs. the System on Nov. 19th, 1990) for the Article 3. The Islamic Republic of Iran Broad- fourth child and more born one year after casting (IRIB) is entrusted with the task of the approval of this law, will be decided producing and broadcasting of direct and in- separately and will be paid by the insured direct programs to increase the general aware- according to the tariffs set by social securi- ness about mother and child health care and ties organization. population. Article 2. The Ministries of Education; Cul- Article 4. The cost for realization of articles 2 ture and Higher Education; Health and and 3 will be compensated for by reduction in Medical Education and Islamic Culture and government expenditure through implementa- Guidance are entrusted with the task to imple- tion of article one of this law. ment following programs: A. The Ministry of Education is assigned * Government of the Islamic Republic of Iran with the task of effectively incorporating 1994, p. 20–21. Available from http://cyber.law. the educational materials regarding popu- harvard.edu/population/policies/IRAN.htm 36 End Notes 1 LeBaron and Schultz 2005. 18 Article 1041 of the Iranian Civil Code. 2 For more on the primary health care system 19 Momeni 1972. see World Bank 2007b; Couper 2004; Ab- 20 Momeni 1972. basi-Shavazi and others 2004; LeBaron and 21 National Census of Population and Schultz 2005. Housing 1976. 3 World Health Organization Statistical Infor- 22 Abbasi-Shavazi, Hosseini-Chavoshi, and mation System. McDonald 2007. 4 Movahedi and others 2009. 23 Abbasi-Shavazi, Hosseini-Chavoshi, and 5 Movahedi and others 2009. McDonald 2007; Tremayne 2006; Aghaja- 6 World Health Organization Statistical Infor- nian and Mehryar 1998; Momeni 1972. mation System. 24 Abbasi-Shavazi and others 2007. 7 World Development Indicators database. 25 Mehryar and others 2008. 8 World Health Organization Statistical Infor- 26 Aghajanian 1991; Mansoorian and Ra- mation System; Movahedi and others 2009. julton 1993; Mansoorian 1993. 9 Marandi 1996. 27 The survey was conducted during 1988. 10 Movadehi and others 2009. Sample size was 2,511 married women ages 11 Mehryar and others 2008. 15 and above. 12 Mansoorian and Rajulton 1993; Aghajanian 28 Mansoorian and Rajulton 1993. 1991. 29 Moore 2007. 13 Momeni 1972; Aghajanian and Mehryar 30 Mehryar and others 2001. 1998; Abbasi-Shivazi, McDonald, and Hos- 31 Mehryar and others 2001. seini-Chavoshi 2008. 32 National Census of Population and 14 Azadarmaki 2005. Housing 1976. 15 Abbasi-Shivazi, McDonald, and Hosseini- 33 Abbasi-Shavazi and others 2004. Chavoshi 2008. 34 Mehryar and others 2001. 16 Mut’a refers to a fixed term marriage con- 35 Moore 2007. tract. A pre-determined sum of money is 36 Mansoorian 1993; Mehryar and others given to the wife at the end of the contract. 2001. Children born to the couple are considered 37 Mehryar and others 2001. legitimate offspring and given same status as 38 Mehryar and others 2001. children born from traditional marriages. 39 Abbasi-Shavazi] and others 2002. 17 Azadarmaki 2005; Afshar 1996; Tremayne 40 Mehryar, Amir. 2009. Email correspon- 2006. dence on fertility decline in Iran. Professor Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 37 of Behavioural Sciences & Head, Depart- of Behavioural Sciences & Head, Depart- ment of Population and Social Studies ment of Population and Social Studies (retd.), Institute for Research on Planning (retd.), Institute for Research on Planning and Development, Tehran, Iran, June 6. and Development, Tehran, Iran, June 6. 41 Mansoorian 1993. 58 Mehryar, Amir. 2009. Email correspon- 42 Bulatao and Richardson 1994. dence on fertility decline in Iran. Professor 43 Erfani 2008. of Behavioural Sciences & Head, Depart- 44 Erfani and McQuillan 2008b. ment of Population and Social Studies 45 Mansoorian 2008. (retd.), Institute for Research on Planning 46 Mansoorian 2008. and Development, Tehran, Iran, June 6. 47 Vahidi and others 2009. 59 Afshar 1985. 48 Primary infertility refers to instances where 60 Hoodfar 1996. couples have never been able to become 61 Afshar 1985. pregnant after at least 1 year of unprotected 62 Afshar 1985. intercourse. 63 Mehryar and others 2002. 49 Inhorn 2003). 64 Salehi-Isfahani 2005. 50 Ghanei and others 2004. 65 Salehi-Isfahani 2005; Afshar 1985. 51 See, for example, Musallam 1986 DONE 66 Ebadi 2002. for contraceptive use in medieval Islamic 67 Another explanation for at least part of the societies and Omran 1992DONE for Is- decline in rural labor force participation lamic teachings on the practice of “azl,” or provided by Tabatabai and Salehi-Isfahani withdrawal, as a means of family planning. (2001) is the change in definition of “ac- 52 Mehryar, Amir. 2009. Email correspon- tive” labor force participation between the dence on fertility decline in Iran. Professor 1976 and 1986 censuses. It is also likely of Behavioural Sciences & Head, Depart- that younger girls were absorbed into the ment of Population and Social Studies school system. Before the Islamic revolu- (retd.), Institute for Research on Planning tion, rural girls aged 10–19 years partici- and Development, Tehran, Iran, June 6. pated in the labor force much more than 53 The Guardians of the Revolution, also urban women. This may have accounted known as the Iranian Revolutionary for decline in at least the female labor force Guards, are a branch of the Iranian military participation for girls under the age of 14 parallel to the regular forces of the army (primary and lower secondary level of edu- and responsible for national security. cation). 54 According to Tremayne (2006), mar- 68 Mehryar and Aghajanian 2006. riage did not prevent the boys from being 69 Mehryar and Aghajanian 2006. drafted. 70 Earlier data on adolescent fertility is not 55 Abbasi-Shavazi and others 2002. available. 56 Abbasi-Shavazi and others 2002. 71 Marriages have been reported in youth ages 57 Mehryar, Amir. 2009. Email correspon- 10–14 as well, but this constitutes a small dence on fertility decline in Iran. Professor proportion of the population. Further study 38 would be required to understand the nature 96 Ebadi 2002. of these early marriages. According to the 97 Ebadi 2002. 2006 census, 3.4 percent of boys and 5.2 98 World Health Organization Statistical In- percent of girls ages 10–14 years were cur- formation System. rently married. 99 LeBaron and Schultz 2005. 72 Salehi-Isfahani and Tandon 1999; Erfani 100 Couper 2004. and McQuillan 2009. 101 World Bank 2007b. 73 Erfani and McQuillan 2009. 102 Shahidzadeh-Mahani and others 2008. 74 Roudi-Fahimi 2002; Abbasi-Shavazi and 103 World Bank 2007b. others 2002. 104 Mehryar and others 2008. 75 Hashemi 2009; Erfani and McQuillan 105 Movahedi and others 2009. 2009. 106 World Bank 2007b. 76 Roudi-Fahimi 2002. 107 World Bank 2007b. 77 Abbasi-Shavazi and others 2002. 108 World Development Indicators, 2007 data. 78 Abbasi-Shavazi, Hosseini-Chavoshi, and 109 Mohammadi and others 2006. McDonald 2007. 110 Hoodfar 1996; Hoodfar and Assadpour 79 Roudi-Fahimi 2002. 2000. 80 Mohammadi and others 2006; Dejong 111 Adult literacy classes were first introduced 2005; Moslehuddin and others 2002. in Iran during the 1960s. 81 Mehryar and others 2001. 112 Mehryar and others 2002. 82 Erfani and McQuillan (2008a) use Bon- 113 Hoodfar 1996, p. 35. gaarts’ age-specific fertility model. 114 Hoodfar 1996. 83 Erfani and McQuillan 2008a. 115 Raferty, Lewis, and Aghajanian 1995. 84 Aghajanian 1998. 116 Hashemi 2009. 85 World Bank 2007b. 117 World Bank 2007a; Salehi-Isfahani and 86 Abbasi-Shavazi, Hosseini-Chavoshi, and Egel 2007. McDonald 2007. 118 Shavarini 2009. 87 Mehryar, Ahmed-Nia, and Kazemipour 119 Raferty, Lewis, and Aghajanian 1995. 2007; Mehryar and others 2008. 120 World Bank 2007a. 88 Mehryar and others 2008. 121 World Bank 2007c. 89 The World Bank (2007b) provides a de- 122 Abbasi-Shavazi and others 2002. tailed examination of the health sector, in- 123 The total age dependency ratio is the ratio cluding primary health care. of the population ages birth to 14 years 90 Hoodfar and Assadpour 2000. and ages 65 and over to the working- 91 World Bank 2007b; Roudi-Fahimi 2002. age population (15–64 years). The old 92 Government of the Islamic Republic of Iran age dependency ratio is the ratio of the 1994. population ages 65 years and over to the 93 Abbasi-Shavazi and others 2004. working-age population. The child or 94 Roudi-Fahimi 2002. youth dependency ratio is the ratio of the 95 World Bank 2007b. Fertility Decline in the Islamic Republic of Iran, 1980–2006 | A Case Study 39 population ages birth to 14 years to the 127 World Bank 2007b. working-age population. 128 World Bank 2007b. 124 For more on the relationship between 129 World Bank 2007b. economic development and popula- 130 World Bank 2007b. tion growth see Coale and Hoover 1958; 131 Salehi-Isfahani 2007. Bloom and Canning 2006. 132 World Values Survey. www.worldvalues- 125 The Statistical Center of Iran defines “ec- survey.com (accessed April 28, 2009). onomically active population” as all indi- Iran’s survey was conducted in 2005 viduals ages 10 years and over who report (n=2,652). having been “employed” or “unemployed 133 World Values Survey. www.worldvalues- but looking for a job” during the week pre- survey.com (accessed April 28, 2009). ceding the date of the census or survey. 134 Shavarini 2009. 126 World Development Indicators, 2007 data. 135 World Bank 2007b. THE WORLD BANK 1818 H Street, N.W. Washington, DC 20433