Religion fought the pill and the pill won (religion didn’t fight hard enough)

Nor is Catholicism the only religion buffeted by the contraceptive revolution. Millions of Muslims have responded by accenting a more permissive side of their theology. In the process they have removed one barrier to reducing fertility in the Muslim crescent of South Asia and the Arab world, where birthrates are among the highest in the world.

Just what is and what is not allowed under Muslim law is a matter of debate. Throughout the 1,400-year history of Islam, the world's second largest faith, children have been considered one of the greatest blessings of God. The religion's long tradition, based on the Prophet Muhammad's injunction to "marry and have children"--the Islamic equivalent of the enjoinder in Genesis to "go forth and multiply"--is one reason why large families have been the rule in Muslim nations.

But in the Muslim world old teachings are bumping up against the hard realities of population trends that have fundamentally altered daily life. In Egypt, Mohammed Sayeed Tantawi, a government-appointed mufti, or interpreter of religious law, speaks with authority as a keeper of doctrine for the world's 850 million Sunni Muslims. "Islam provides no opposition to controlling birth. There is no Koranic verse which forbids family planning," says the cleric. "I personally, if I were to have a meeting with the pope at the Vatican, would explain to him that the Shari'a of Islam does not forbid family planning as long as the couple sees that there is a necessity for it."

Thirty years later, the logic of family planning extends even to the bastion of Shiite orthodoxy, Iran. When they seized control from the shah in 1979, the country's new Islamic rulers sneered at birth control as a Western plot. Fifteen years later, faced with twice the population but the same fixed, oil-based annual income, the mullahs have caught the spirit. With the zeal of converts, they have created a family-planning program that includes everything from aggressive public education to free vasectomies to financial disincentives that discourage anything larger than a three-child family.

The History of it all

Fertility in Iran was very high in the 1950s and 1960s: the total fertility rate was estimated at 7.3 from the 1956 population census and 7.7 from the 1966 census; and the rate of population growth was increasing (Maroufi Bozorgi 1967; Amani 1968; Bulatao and Richardson 1994). Partly in response to the heightened growth rate of 3.1 per cent per annum between 1956 and 1966, the government of Iran adopted a population policy with explicit health and demographic targets. A national family planning program was officially inaugurated in 1967 and the Ministry of Health was given responsibility for controlling the birth rate.

This family planning program was not warmly welcomed by rural people, however, as little attention was given to the socio-cultural and religious contexts of the society. Therefore, it is hardly surprising that during 1966-76, the Iranian population experienced only a modest fertility transition,(1) despite a reasonable rise in the proportion of eligible couples practising contraception (to 37 per cent in 1977); and how much this was attributable to the family planning program and how much to other factors is open to question. The fact that 54 per cent of urban couples were contracepting in 1977 does suggest that the idea of family planning had gained considerable legitimacy in these areas….

Shortly after the Islamic Revolution in early 1979, the family planning program was suspended. In contrast to the previous regime, high fertility and rapid population growth were looked upon favourably. Religious leaders emphasized marriage and family formation as basic Islamic virtues, and the government was urged to adopt economic policies that would facilitate and encourage early and universal marriage. Simultaneously, grassroots charitable foundations that had emerged in the wake of the Revolution offered tangible economic rewards, in the form of relatively generous wedding gifts or dowries, for early marriage and family formation.

Despite this drastic change in emphasis, the Ministry of Health kept the family planning program alive by obtaining fatwas (rulings) regarding the permissibility of contraceptive use from Imam Khomeini and several other leading Ayatollahs (Mehryar forthcoming).

With the start of the eight-year war with Iraq in September 1980, high fertility and population growth acquired new significance. Population size immediately began to be considered as a matter of comparative advantage. The creation of a popular 'Twenty Million Man Army' was adopted as a national slogan early in the war. On a more personal level, the rising casualties of the war encouraged many middle-aged couples to produce more children to replace those whose loss they were anticipating. The universal rationing system that was introduced as a means of ensuring equal access to basic necessities provided further impetus for high fertility. The rationing system included not only basic food items but also locally produced or imported modern consumer goods like television sets, refrigerators, carpets and even cars. These were distributed on a per capita basis and larger families were entitled to a better share of both the basic commodities and highly prized modem consumer items. Thus, newborn babies were automati cally entitled to a separate book of ration coupons which, in the case of ordinary families, was far above the costs involved in raising a child.

The demographic consequences of this pronatalist policy in the political context of the time soon became evident. The first general census of population and housing conducted in 1986 by the government of the Islamic Republic of Iran (IRI) indicated that the population had grown at an average annual rate of 3.9 per cent between 1976 and 1986. Even taking into account the effect of the immigration of Afghan and Iraqi refugees during this period, the natural growth rate was no less than 3.2 per cent. The Census indicated a TFR of 7.1:5.9 in urban and 9.0 in rural areas (SCI 1992). Other national TFR estimates derived from the same census vary from as low as 6.4 (PBO 1989: 2-6) to 7.7 (Agha 1989; Bulatao and Richardson 1994). The unexpectediy large population size (49.3 million) revealed by the 1986 Census was at first hailed as a 'God-sent' gift by the Prime Minister and other leaders of the IRI.

Publication of the 1986 Census results focused attention on the long-term economic and social implications of the high rates of fertility and population growth, and behind-the-scene discussions on the need for a population control policy were initiated. Two government departments are known to have played a major role in this debate: the Ministry of Health and Medical Education (MOHME) and the Plan and Budget Organization (P80). The first had been responsible for the family planning program before the Revolution; indeed, the first Minister of Health of the IRI discussed the need for family planning with Imam Khomeini a few months after the Revolution and reportedly had secured his oral endorsement of contraceptive use by couples who did not want to have more children. As a result, MOHME had been allowed to continue with the provision of family planning services (including the free distribution of the three modem methods of contraception) to couples visiting its maternal and child health clinics throughout the period when there was no official program. The Plan and Budget Organization, as the national agency responsible for the monitoring and allocation of the government's financial resources, was in a unique position to know the critical state of the war-shattered economy and its fast-dwindling ability to support a large and rapidly increasing population.

To raise public support for the idea of population control and family planning, a three-day 'Population and Development' seminar jointly organized by the MOHME and PBO was held in the city of Mashad in September 1988. This seminar explicitly recommended the adoption of a national population policy aimed at birth control. At the end of the Mashad seminar, the Minister of Health and Medical Education, in a press conference, reiterated Imam Khomeini's fatwa regarding the legitimacy of contraceptive use by consenting couples, and announced that a family planning program would soon be established. Almost simultaneously, the prime minister declared that 'birth control' was a 'destiny factor' for Iran and invited Iranian women to prevent unwanted pregnancies by seeking help from publicly run clinics and rural health houses. To overcome any misconception regarding the legality of birth control, the head of the judicial system publicly declared that the use of contraceptive methods for preventing unwanted pregnancies was not against Islamic criminal law.

A KAP survey carried out by MOHME in 1989, just after the family planning program had commenced, revealed that almost half of married women aged 15-49 years were already using some form of contraception. Most of these (56 per cent) used such modem methods as the pill. condom, and IUD. Clearly, contraceptive use was already higher than most had realized, and this evidence of strong demand provided a favourable basis for development of the revived family planning program, despite the pessimistic view taken by the authors of the FFYDP and most other experts. A larger survey carried out in 1992 showed that contraceptive prevalence rates had risen to almost two-thirds of all married women, 69 per cent of whom used a modem method. These figures indicate a surprisingly high demand for and acceptance of family planning services when compared with the contraceptive prevalence rate (about 37 per cent) that had been achieved by the preRevolutionary family planning program by 1977, ten years after its formal introduction (Aghajanian 1994; Aghajanian and Mehryar 1999).

With regard to actual fertility behaviour, some evidence of a gradual decline in fertility rates had already been revealed by a 12-round household survey conducted by the Statistical Centre of Iran (SCI) between 1987 and 1989 (Mehryar and Gholipour 1995). This trend was supported by the findings of the combined census-survey carried out in 1991 which showed that the population had risen to only 55.8 million. This figure implied an annual growth rate of 2.5 per cent for the period 1986-91, a 64 per cent decline in comparison with the growth rate of 3.9 per cent revealed by the 1986 Census. Analysis of the 1991 data indicated that the TFR had declined from 7.1 to 4.9 during the preceding five years (SCI 1998: Table 10.1), although other estimates from these data range from 4.8 to 6.3 (Bulatao and Richardson 1994: Table 3). Judging by this evidence, the revived family planning program reached all of the demographic targets set in the FFYDP before the Plan had in fact been implemented.

Because of the unexpectedly sharp decline in the growth rate indicated by the 1991 census--survey and presumed anomalies in the age structure of the population enumerated, most demographers both within and outside Iran received these results with some scepticism. (2) Even PBO (1993), the parent organization of SCI, refused to accept the results as a basis for the projection of population trends during the period of the second plan (1993-98). However, large-scale annual population surveys conducted by SCI in 1992 and 1993 indicated a continuation of the downward trend revealed by the 1991 census--survey. These were supported by smaller-scale, but nationally representative, surveys undertaken by MOHME as well as a new set of panel surveys on the socio-economic conditions of Iranian households conducted by SCI between 1991 and 1995. All these were received with more than the usual measure of caution, if not disbelief, by demographers outside MOHME and SCI. At the same time, evidence of an accelerating fall in th e number of births registered by the Central Registration Office was not taken seriously even by the demographers working for that organization, presumably because of known under-coverage. Using the number of officially registered births, Ladier-Fouladi (1996) noted a marked drop (from 43.4 to 30.4 per thousand) in the crude birth rate of Iran between 1986 and 1991. The corresponding decline in TFR estimates was from 6.2 to 4.2.

In view of the persistent doubts regarding the coverage and quality of the 1991 census-survey and later surveys conducted by the SCI and MOHME, the 1996 Census had been anxiously awaited. The results of this census indicated an even more precipitous decline in fertility than the 1991 census--survey. The population growth rate fell to only 1.47 per cent in 1991-96. The inference that fertility decline was the main reason was clearly supported by the marked decline in the number of children aged 0-4 between censuses (6.16 million in 1996 compared with 8.14 million in 1991 and 9.04 million in 1986), and by the fertility indices officially calculated on the basis of the 1996 Census (TFR of 2.96, and CBR of 20.5). The TFR of 2.96 was only 42 per cent of that for 1986 (7.1) and 60 per cent of that for 1991 (4.9).

Nuptiality change

Fertility transition in developing countries is often associated with an increase in age at marriage for women. Since 1979, the government of the IRI has consistently encouraged early marriage. The legal minimum age at marriage for girls was reduced from sixteen to nine years after the 1979 Islamic revolution. During the following decade, young couples received many incentives for early marriage. However, despite this wholehearted campaign for early marriage, female age at first marriage hardly changed during this period, as Table 1 shows. After 1986, there was a profound change in the marriage pattern. The singulate mean age at marriage (SMAM) increased from 19.7 to 22.1 years between 1986 and 1996. This shift to later marriage took place in both rural and urban areas. There is very little difference between rural and urban areas in females' SMAM (Abbasi-Shavazi 2000b).

While the mean age at marriage has increased, universality remains one of the major characteristics of the Iranian marriage pattern. Marriage is strongly supported by both religion and tradition in Iranian society. To get married is not only a matter of personal interest, but also a duty of the young to their families and to society. As a result, the vast majority of women marry before age 30, and almost all women marry by their early 40s.

The change in marriage patterns is consistent with other socio-economic changes in the IRI over the last two decades. Economic pressure appears to have been a major factor in the postponement of marriage. Smith (1983:496) has asserted that age at marriage is late where the direct costs of marriage (both ceremonial and transfer costs) are high. Iran has been experiencing economic hardship since the revolution, particularly in the decade after the war. The cost of living has risen dramatically in recent years. In order to be able to afford the high living costs, young people tend to delay their marriage until they get a job.

Abbasi-Shavazi (2000b) decomposed the change in the TFR from 1976 to 1996 into the components due to nuptiality and marital fertility. He found that the increase from 6.09 in 1976 to 6.24 in 1986 was entirely due to the increase in marital fertility, which was offset to some extent by nuptiality change. The TFR then fell substantially by 3.71 births per woman from 1986 to 1996. Nuptiality contributed 14 per cent to this fertility decline, but most of the decline (86 per cent) was due to marital fertility. For rural and urban areas, the decomposition of the change in TFR is identical to that of the total population.

The contraceptive prevalence rates by rural and urban area over the 1976-97 period are summarized in Table 2. At the time of the 1976 survey, Iran was ten years into its pre-Revolutionary family planning program. Yet interestingly, contraceptive prevalence had reached only 37 per cent at that time, and rose to almost 50 per cent by 1989, despite the official pronatalism during most of the 1980s. By 1992, almost two-thirds of married women aged 15-49 were practising some form of contraception, and five years later, almost 75 per cent. The urban-rural gap was shrinking over time, and was down to 12 percentage points in 1997.

More history of it all

The Islamic Republic of Iran arguably has one of the most successful family planning programs in the developing world. This success is all the more interesting for advocates of population programs because the political leaders of the Islamic regime were once strongly opposed to family planning. Indeed, after gaining power following the 1979 revolution, they were responsible for dismantling Iran's relatively new family planning program and introducing pronatalist policies. This article provides an account of the different phases of the population policy in Iran and examines the diverse elements that led politicoreligious leaders to revise their views about fertility control and to participate in creating a workable family planning program. The complex formal and informal strategies that the political experts, the media, the religious authorities, and the government of the Islamic Republic adopted in order to achieve this about-face are described. The analysis is based on data collected by the first author duri ng anthropological field research in 1993-96, by means of informal interviews with officials, with medical personnel, with family planning clients, and with religious leaders (STUDIES IN FAMILY PLANNING 2000; 31 [1]: 19-34)

Iran, in contrast to its regional counterparts such as Turkey and Egypt, came late to a concern for population issues: The first official family planning policy was introduced in 1967. This inattention stemmed from a lack of appreciation of the importance of population issues rather than from any official desire for continued population growth. In fact, Iran had experienced a rapid rate of population growth since the turn of the century (see Table 1).

The 1967 family planning program targeted the urban population primarily and focused on women as the major recipients of services, even though most traditional contraceptive methods (notably withdrawal) are male-oriented. For this reason, and because technical and financial resources were lacking, oral contraceptives eclipsed other possible options, including the intrauterine device (IUD), condoms, and vasectomy. The pill evolved as the de facto official contraceptive method, distributed chiefly through the network of Ministry of Health clinics and hospitals (Lieberman 1979; Aghajanian 1991a; Aghajanian and Mehyar 1999; MossavarRahmani 1983).

The program, devised under Shah Reza Pahlavi's aegis, was followed by a number of limited improvements in women's legal status, notably the introduction of the Family Protection Laws in the late 1960s and 1970s, which curbed men's unilateral right to divorce at will and limited the practice of polygyny by requiring either the court's authorization or the first wife's permission (Sanasarian 1982; Aghajanian 1991b and 1996). More important, the custody of children following a divorce was to be decided according to their best interest rather than by traditional precedent, which denied custody (except that of infants) to divorced mothers (Mir-Hosseini 1993). This law marginally improved women's chances of gaining custody of their children. Moreover, both socially and legally, women were encouraged to take public employment. On the whole, these reforms presented the most significant improvement in the legal position of women in twentieth-century Iran and aroused strong opposition from many conservatives and some religious leaders (Paidar 1995; Sanasarian 1982).

Both the family planning program and the reform of marriage and divorce laws were sharply criticized by the religious opposition, notably Ayatollah Khomeini (Algar 1981). Many religious leaders used their Friday sermons to condemn family planning as an imperialist plot to reduce the number of Muslims in the world and to subjugate Muslim countries. Although historically contraception had been permitted in Islam, following the introduction of the Shah's program many religious leaders denounced it as haram (religiously prohibited). [1] Not surprisingly, with the dawn of the revolution and the establishment of the Islamic Republic in 1979, the family planning program fell into disarray (Hoodfar 1995).

Whatever its shortcomings, the short-lived program was successful. By 1976, it covered 11 percent of women of childbearing age (Aghajanian 1991a). Such success stemmed in part from previously unmet demand among urban, middle-class, and established working-class families who were dissatisfied with traditional methods of contraception and eager to limit their family size (Hoodfar forthcoming).

With the success of the Iranian revolution and the establishment of the Islamic Republic, the country's new leaders continued to view the program as an imperialist tool for maintaining the dominance of the West over the "Third World," and in particular, its Muslim populations. For a short period, confusion persisted about whether drugstores could continue to sell oral contraceptives, because some religious leaders had pronounced them un-Islamic. As a result, a black market in contraceptives developed in major cities where demand remained relatively high. After some public debate, however, religious authorities conceded that no religious impediment to the use of contraceptives existed. Nonetheless, supplies continued to be erratic and prices inflated. [2] The family planning board was dismantled, and employees of family planning clinics were transferred to other sectors, notably to school health clinics.

Expanding Choice

In advocating particular contraceptive methods as part of the public program, the program directors had to bear in mind the views of religious authorities who believed that safe, temporary methods met the Islamic standard, whereas tubal ligation and vasectomy were problematic. Methods that permanently injure or harm a person were deemed unacceptable to Islam. Some religious leaders argued that because both tubal ligation and vasectomy would render individuals aghim (sterile), they were not acceptable. Others argued that if the couples concerned already had children, such methods could not be considered aghim, whereas if they did not yet have children, they should not choose such a method. Some experts and religious groups pointed out that these methods (particularly vasectomy) are potentially reversible, and therefore are not sources of permanent injury.

Such debates were carried out in public as well as behind closed doors and culminated in the informal consensus to offer these methods only to couples who have three children or who are older than 30. Moreover, the program directors made a commitment to increase research and training for surgical reversal of vasectomy and tubal ligation. They agreed to allocate more funds for training doctors in this field. Priority was given to training female doctors in these specialties, since ideally, in an Islamic society, women should visit female doctors, particularly for gynecological care. Despite much early debate, vasectomy has remained less popular than other methods, although with new initiatives to provide physicians on site, tubal ligation and, to a lesser extent, vasectomy are becoming more popular among the rural population.

The Program's Achievements and Shortcomings

In some quarters, a common assumption exists that religion, Islam in particular, is a major barrier to family planning and fertility control (Obermeyer 1995). In clear contradiction to this view, the Islamic Republic of Iran has demonstrated an adaptability and resilience to changing social and economic realities by a pragmatic revision of ideological positions. The directors of the family planning program generally admit that the most significant achievement of the program has been the creation of an understanding and appreciation of population issues among the general public, particularly in poor rural and urban areas. Much of the credit for this fundamental social achievement must go to the politicoreligious leaders who educated themselves and changed their position on population issues and then proceeded to mobilize thousands of low-ranking clerics to gain support for fertility control within their communities. This aspect of the program makes it fundamentally different from the family planning policy int roduced by the Shah's regime and different from most other family planning programs in counterpart countries. Clearly, the success of the family planning program has depended upon the existence of a superior basic health network, in both cities and rural areas.

According to conventional criteria for family planning programs, Iran's can be evaluated as one of the most successful. The program has helped Iran's citizens to achieve a high level of contraceptive diversity (as shown in Table 5), a considerable decline in population growth (see Table 6), and a decline in overall fertility (as shown in Figure 1). Although the data from the Ministry of Health may be exaggerated to some extent, nevertheless, as one of the directors of Iran's Statistics Institute skeptical about the Ministry of Health's statistics said, "Although I am critical of their optimistic figures and their statistical treatment of their survey material, I have to admit that what has happened in the area of family planning and population growth is little short of miraculous..." [18]

Given that those younger than 18 make up 45 percent of Iran's total population, however, the government must continue to monitor population growth for several decades before the population pyramid becomes more balanced. This process will be much slower than reducing the rate of population growth, because of population momentum. Unfortunately, directors of the family planning boards and many experts feel that after the program's initial success, both the government and the Ministry of Health, although remaining committed to it, are giving it less emphasis, and they worry that this trend may modify the continued rate of success of the program. This trend may stem from the earlier decision to frame the program within "crisis" modality. The current challenges for Iran will be to institutionalize a population policy based on the country's resources and economic, political, and ideological goals, thereby providing a long-term vision and a sustainable framework for future action.

 

 

The Iranian example is particularly instructive for understanding the interaction between religious teachings and the role played by religious institutions. As Hoodfar and Assadpour (2000: 20) explain, in the immediate postrevolutionary period religious leaders spearheaded opposition to family planning, which was portrayed as part of a Western plot to reduce the size and influence of the Muslim population. Their teachings, which contrasted with the generally positive view of family planning that had been advanced by religious leaders under the Shah, led to considerable confusion among the population. But those religious leaders who now also held positions of political leadership were soon faced with the need to solve many problems that were aggravated by the rapid growth of Iran's population. Moreover, there was considerable pressure from intellectuals, civil servants, and elements of the general population to support a policy that would make access to contraception easier and slow the rate of population growth. This pressure led to a widespread debate in which religious leaders played an important part and in turn forged a consensus that the practice of family planning was, under most circumstances, consistent with the teachings of Islam. Perhaps most importantly, once consensus had been achieved, it became possible for state authorities to use the institutions of the faith to promote contraceptive use. The vast network of mosques, which extended to even the most remote villages, was employed to spread the details of the officially sponsored population program. Local religious leaders were especially effective in presenting the message in a way that would be acceptable to poorer, less-educated Iranians who might have resisted the advice had it been offered by government officials. Thus, in spite of an environment that still involves substantial restrictions on the social roles open to women, restrictions that are at least partially religiously based, religious leaders have made a substantial contribution to Iran's rapid decline in fertility, which saw the total fertility rate fall from 5.6 in 1986 to 3.3 in 1995 (Hoodfar and Assadpour 2000: 32). Iran's experience underlines the need for demographers to attend both to the content of religious beliefs and to the willingness and ability of religious leaders and institutions to promote compliance with those teachings among their followers.

 

In Saudi Arabia, Islamic influence has been associated with the persistence of high fertility. By contrast, in Iran, where Islamic influence in society has been far-reaching since the revolution of 1979, religious leaders and institutions have contributed to the legitimization of family planning programs that have led to a rapid decline in fertility (Hoodfar and Assadpour 2000).

 

 

In late nineties

% Married      Total

               women using   Fertility

              contraception    Rate

                 (total)

Iran               73           2.6

 

(highest rate of contraception amoung married women and 4^th lowest fertility rate in middle east)

 

 

“In Iran”, Castle (2003, quoted in Nichter and Nichter 1996) found that “the pill was believed to cause the body to dry up and to hasten menopause”

 

 

Traditional Islamic views on Contraception

Just as the Vatican presents itself as the authoritative Catholic voice in the context of UN forums, Islamic countries such as Iraq, Lebanon, Saudi Arabia, and Sudan have presented themselves as the "voice of Islam" in many international contexts. In his chapter "Family planning, contraception and abortion in Islam: Undertaking khilafah," Sa'diyya Shaikh not only challenges this monolithic voice by pointing to the Islamic intellectual legacy according to which "eight of nine classical legal schools permitted the practice of contraception" (page 105) but also emphasizes the critical role of the individual believer--the moral agent (khalifah, in Arabic). The individual has a right to make his or her own decisions informed by "primary sources, Islamic principles of justice, human well-being, mercy, and compassion."

Colliding with the often progressive convictions of individual agents and learned scholars of Islam, however, is a political context of postcolonial power dynamics. In the increasingly bifurcated world of Islam versus the West, concepts such as family planning, contraception, and abortion are often perceived as intrusions by infidels in either "a conspiracy to limit the growth and power of the Muslim world or as a reflection of the permissive sexual mores of Western society" (page 106). Shaikh portrays conservative Islam as a defensive reaction rather than as an ideologically or theologically driven stance. In light of the "siege mentality" of Islam, any assessment of the tenets of Islam is, at best, problematic. Shaikh makes a strong case for the possibility of a holistic response to family planning based on Islamic principles, addressing structural injustices relating to economic and gender hierarchies.

Diers, J., (2003 December) Daniel C. Maguire, editor Sacred Rights: the Case for Contraception and Abortion in World Religions. (Book Review). Studies in Family Planning 34(4) 295-298

The section on contraception implies that Islam is against it in general and that the religion supports unlimited procreation. This view represents a misbelief that many Muslims around the world held for a long time, which was based on an incorrect interpretation of the Holy Qur'an and Hadith. The consensus of opinion in the Islamic world today is that family planning and contraception are to be encouraged as a health necessity to maintain a high standard of health for both the wife and the children. Islam is a religion of planning of all aspects of life, including reproduction.

Family planning was practised by the companions of the Prophet Muhammad(PBUH), who used coitus interruptus, and he did not forbid them from doing so. At that time, the Holy Qur'an was being revealed to the Prophet Muhammad(PBUH) by Prophet Gabriel, and had it been against the instructions of Islam it would have been mentioned immediately in The Qur'an, as happened with other practices. Going by analogy, which is one of the secondary sources of Sharia, temporary methods of contraception available today would be similar to coitus interruptus, which was used by the companions of the Prophet. Furthermore, Islam encouraged lactation for infants until 2 years of age. We all now know that this by itself is a fairly effective method of contraception. Islam forbids only permanent contraception, namely sterilisation. But even sterilisation is allowed for health indications such as uncontrolled diabetes, heart disease, or congenital abnormalities incompatible with life. Going by the principle of "necessity permits the forbidden", these patients can be sterilised after they have given their free, informed consent.

More history of it all

Iran's population growth rate dropped from an all-time high of 3.2 percent in 1986 to just 1.2 percent in 2001, one of the fastest drops ever recorded. In reducing its population growth to 1.2 percent, a rate only slightly higher than that of the United States, Iran has emerged as a model for other countries that want to accelerate the shift to smaller families.

Historically, family planning in Iran has had its ups and downs. The nation's first family planning policy, introduced in 1967 under Shah Reza Pahlavi, aimed to accelerate economic growth and improve the status of women by reforming divorce laws, encouraging female employment, and acknowledging family planning as a human right.

Unfortunately, this promising initiative was reversed in 1979 at the beginning of the decade-long Islamic Revolution led by Shiite Muslim spiritual leader Ayatollah Khomeini. During this period, family planning programs were seen as undue Western influences and were dismantled. Health officials were ordered not to advocate contraception. During Iran's war with Iraq between 1980 and 1988, a large population was viewed as a comparative advantage, and Khomeini pushed procreation to bolster the ranks of "soldiers for Islam," aiming for "an army of. 20 million," according to Doug Schwartz's article entitled "Iran: Islam Embraces Contraception" published on the Foreign Wire website.

This strong pronatalist stance led to an annual population growth rate of well over 3 percent. United Nations data show Iran's population doubling from 27 million in 1968 to 55 million in 1988, according to the World Population Prospects.' The 2000 Revision.

During postwar reconstruction in the late 1980s, the economy faltered. Severe job shortages plagued overcrowded and polluted cities. Iran's rapid population growth was finally seen as an obstacle to development. Receptive to the nation's problems, Khomeini reopened dialogue on the subject of birth control. By December 1989, Iran had revived its national family planning program. Its principal goals were to encourage women to wait three to four years between pregnancies, to discourage childbearing for women younger than eighteen or older than thirty-five, and to limit family size to three children.

Affect

In May of 1993, the Iranian government passed a national family planning law that encouraged couples to have fewer children by restricting maternity leave benefits after three children. It also called for the Ministries of Education, of Culture and Higher Education, and of Health and Medical Education to incorporate information on population, family planning, and mother and child health care in curriculum materials. The Ministry of Islamic Culture and Guidance was told to allow the media to raise awareness of population issues and family planning programs, and the Islamic Republic of Iran Broadcasting was entrusted with airing such information. Money saved on reduced maternity leave funds these educational programs.

From 1986 to 2001, Iran's total fertility--the average number of children born to a woman in her lifetime--plummeted from seven to less than three. The United Nations projects that by 2010 total fertility will drop to two, which is replacement-level fertility.

Strong government support has facilitated Iran's demographic transition. Under the current president, Mohammad Khatami, the government covers 80 percent of family planning costs. A comprehensive health network made up of mobile clinics and fifteen thousand "health houses" provides family planning and health services to four-fifths of Iran's rural population. Almost all of these health care centers were established after 1990. Because family planning is integrated with primary health care, there is little stigma attached to modern contraceptives.

Religious leaders have become involved with the campaign for smaller families, citing them as a social responsibility in their weekly sermons. They also have issued fatwas, religious edicts with the strength of court orders, that permit and encourage the use of all types of contraception, including permanent male and female sterilization--a first among Muslim countries. Birth control, including the provision of condoms, pills, and sterilization, is free.

One of the strengths of Iran's promotion of family planning is the involvement of men. Iran is the only country in the world that requires both men and women to take a class on modern contraception before receiving a marriage license. And it is the only country in the region with a government-sanctioned condom factory. In the past four years, some 220,000 Iranian men have had a vasectomy. While vasectomies still account for only 3 percent of contraception, compared with female sterilization at 28 percent, men nonetheless are assuming more responsibility for family planning.

 

IRAN

In Iran, we can see that family planning initiatives, including widespread contraceptive use, can coexist with traditional Islamic law. Over the last fifteen years, with the official inauguration of Iran's family planning program in 1989, fertility rates have dropped dramatically, and maternal and child health has vastly improved. In 2000, fertility rates in Iran dropped to 2.0 from a high of 5.6 in 1985. In 2000, 74 percent of married women practiced family planning, up from 37 percent in 1976. Back in 1966, Iran (under the Shah) was one of the first countries to establish a family planning program.

The 1967 Tehran Declaration recognized family planning as a human right and emphasized its social and economic benefits.. The program was dismantled soon alter the 1979 Revolution ... In 1980, Iran was attacked by Iraq. Throughout the eight-year conflict, a large population was seen as an asset, and population growth became a major propaganda issue ...

When the war with Iraq ended, Iran returned to its policy of supporting family planning initiatives. The program was heavily promoted by the Plan and Budget Organization, which stressed the impossibility of rebuilding Iran if its population continued to balloon

 

Background views of contraception

The first source of Islamic law, the Koran, does not mention contraception. On the contrary, most of the 'sayings' (hadith) of the Prophet Mohammed (the second source of Islamic law) on the subject, tolerate coitus interruptus (azl). The position commonly and historically shared by Islamic jurists coincides with Al-Ghazali's interpretation according to which, under many circumstances, coitus interruptus is a blameworthy but tolerated (makruh) act. However, there has always been a minority of jurists opposed to contraception. Analogical reasoning (qiyas, the fourth source of Islamic law) makes it possible to legitimize most modern contraceptive techniques. Nowadays, because of the risks of overpopulation, the majority of Islamic governments have passed family planning laws; however among the masses the wrong belief that Islamic law prohibits contraception is spreading.

Problems with pills

Covert pill users--that is, women using the pill without their partners' knowledge--fear that breakthrough bleeding will reveal their contraceptive use to their partners and families. Changes in menstrual patterns, irregular bleeding, and amenorrhea are a primary concern and often the main reason for discontinuation among covert pill users (22). Islamic women, for example, cannot pray while menstruating. Not attending prayers for weeks at a time could alert husbands and members of the extended family to covert contraceptive use (22).

In cultures where women's activities are restricted during menstruation, breakthrough bleeding amounts to far more than dealing with an unpleasant or frightening side effect. Women's participation in food preparation, religious rituals, community events, school attendance--in general, their mobility--is severely constrained while they are menstruating (13, 134). For example, some women in India cannot touch their children during menstruation, while others are forced to sleep away from their families (77). Prolonged or frequent bleeding episodes that limit women's everyday activities can contribute considerably to discontinuation of OC use.

Contraceptions

IUD:

American Family Physician, Dec 1998 v58 i9 p2087(1)

The Intrauterine Device (IUD).

Full Text: COPYRIGHT 1998 American Academy of Family Physicians

What is an intrauterine device?

An intrauterine device, called an IUD for short, is a small, plastic, T-shaped stick with a string attached to the end. The IUD is placed inside the uterus to prevent pregnancy. Your doctor can place one in your uterus in an office visit. Once in place, the IUD stays in your uterus until a doctor removes it.

How does it work?

The IUD prevents sperm from joining with an egg. It does this by making the sperm unable to go into the egg and by changing the lining of the uterus.

What are the advantages of an IUD?

The IUD has many advantages:

   * It's very effective in preventing pregnancy, because you're always

     protected from pregnancy and there's nothing to remember to do (for

     example, no pills to take).

   * It's the cheapest form of birth control in the long run.

   * An IUD can be removed by your doctor at any time.

   * It starts working right away.

   * There's a low risk of side effects.

   * Mothers who use an IUD can breast-feed safely.

   * Neither you nor your partner can feel it.

What are the disadvantages?

You may have cramps and backache for the first few hours after an IUD is put in your uterus. Some women have bleeding for a couple of weeks after the IUD is inserted, and heavy periods after that. Rarely, the uterus can be injured when the IUD is put inside.

An older kind of IUD, which is no longer available, had serious side effects, including pelvic infections and infertility (problems getting pregnant after removal). These problems are very rare with the new IUDs.

The IUD doesn't protect you from sexually transmitted diseases, such as AIDS and herpes. In fact, these infections can be more serious in women who have an IUD. In addition, the more people you have sex with, the greater your chance of getting an infection if you have an IUD. The IUD is best for women who have only one long-term sex partner. In addition, you shouldn't use the IUD if you're pregnant, if you're allergic to copper, or if you have abnormal bleeding or cancer of the cervix or uterus.

How long does the IUD stay inside?

It depends on the kind you have. The one used most often is covered in copper and can stay in your body for up to 10 years. The other kind contains a hormone called progesterone. This one must be replaced every year. Either kind can be removed by a doctor at any time if you decide to get pregnant or don't want to use it anymore.

How do I care for my IUD?

After your IUD is put in place, you may swim, exercise, use tampons and have sex as soon as you want to. At the time of each menstrual period, you should check for the string inside the vagina by inserting a clean finger in your vagina. Call your doctor if you can't feel the string or if you feel the IUD itself. Either of these could mean that the IUD is not in the right place. Call your doctor if you miss your period or if you notice any unusual fluid or odor coming from your vagina. Keep having regular check-ups every year.

This information provides a general overview of the IUD and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.

 

Oral Contraception

Student Health Center
University of Oregon

ORAL CONTRACEPTIVES

What are Birth Control Pills?

Oral contraceptives, known as "The Pill", contain two synthetic female hormones (estrogen and progesterone) which prevent pregnancy by inhibiting the monthly release of the "egg" from the ovaries. These are the same female hormones you normally produce. The quantities in the pill are less than what your body would produce if you were pregnant. Oral contraceptives are almost 100% effective when taken correctly. To be absolutely safe, you should use a second form of contraception the first seven days of the first cycle.

Birth controll pills do not protect a woman from getting sexually transmitted diseases.

How to Take Them:

There are a number of ways to start oral contraceptives. We most commonly have you start the pills on the Sunday after your normal menstrual period begins. If your period begins on Sunday, then start the pills on that Sunday. Take one pill at about the same time each day so you will not forget them. Keeping the pills with your toothbrush is one way to remember. They are least likely to cause nausea if taken with dinner or along with a snack before going to bed. If you forget one pill, take it as soon as you remember. If you do not remember untill the next day, then take two pills that day. If you miss two pills, take two pills a day for two days. If you miss three or more pills, call the clinic for instructions.

IMPORTANT: If you miss more than one pill in a row, you need to use a backup method for one week to prevent pregnancy that cycle.

All birth contril pill cycles are three weeks of active hormone pills followed by one week of no hormones. The fourth week of pills are just "reminder" pills and do not contain hormones. You may either take them or just use them for counting. When you get to the fourth week of pills, you should have a menstrual period. Always start a new packet every fourth week, the next day after completing the last pack regardless of your menstrual flow.

At times, and for some women, there may be no menstrual bleeding while using birth control pills. If you miss one menstrual period and have taken the tablets exactly as directed, continue as usual with your next cycle. If you have not taken them correctly and miss a period you should be evaluated for pregnancy. If two consecutive menstrual periods are missed you should be evaluated for pregnancy. It is not a health hazard to miss your menstrual period when you are on birth control pills.

If you are not happy with the pills you are using, discuss this with your practitioner rather than giving up and stopping them. There are many kinds of pills and one may be more closely related to your normal hormonal pattern than another.

Always make an appointment well before you run out of pills so there is no scheduling difficulty and you have the pills when you need them.

Side Effects:

When taking the pill, some women occasionally experience side effects which are annoying, but will not damage their health. These changes are usually temporary and may disappear in the first three to four cycles. We encourage you to remain on the pill for at least three cycles so that we can evaluate how you are adjusting. If symptoms persist longer than three months, consult your medical practitioner who may be able to solve the problem by changing your pill.

Some women experience slight nausea which may be relieved by taking the pill along with a snack just before going to sleep or with a meal.

Breakthrough bleeding (spotting between periods) may occur while taking the three weeks of active hormone pills and is not serious. Continue your pills as instructed and you will continue to be protected. This is not unusual and most commonly occurs during the first two or three cycles. If this bleeding is heavier than light flow or lasts more than a few days, you should contact your practitioner.

Emotional changes can be due to life stressors, birth control pills, or a combination of both. In some cases depression or loss of interest in sex may occur. Excercise and a healthy diet and lifestyle can be helpful, but sometimes a change of pills may be needed. A few women may develop freckling of the skin or acne, although in most cases pre-existing acne is improved by oral contraceptives. Your breasts may enlarge or become somewhat tender.

Complications:

If you have special health problems, such as fibrous growths of the uterus, heart or kidney disease, depression, diabetes, thyroid disease, migraine headaches, or epilepsy, you should inform your practitioner of these or any other problems. If you have a history of blood clots anywhere in your body, cancer of the breast or uterus, or liver disease, you may not be able to use the pill.

There is a small risk of benign liver tumors which can be serious among pill users. The pill slightly increases the incidence of gallbladder disease. If you are prescribed antibiotics for a serious infection, there is a possible risk of reduced effectiveness of birth control pills. The data is limited and unclear. If taking antibiotics, to be absolutely safe, you could use an additional backup method of birth control with the remainder of that cycle of pills. Rifampin, an antibiotic for treatment of tuberculosis and meningitis prophylaxis, reduces effectiveness and another method would be advised. Certain medications to treat seizure disorders and sedatives may also reduce effectiveness slightly. Your practitioner will guide you if you have any questions.

Important:

Most women taking oral contraceptives have few or no problems. But do call your practitioner if you notice any of the following symptoms:

·         vision disturbance, blurred vision, flashing lights

·         headaches (severe)

·         unusual leg pain (calf or thigh)

·         chest pain (severe), shortness of breath, or coughing up blood

·         abdominal pain (severe)

Benefits:

There are numerous benefits from the use of oral contraceptive pills and, in fact, for most women they significantly outweigh any risks. These include a reduced incidence of benign ovarian cysts, ectopic pregnancy, pelvic inflammatory disease, anemia, rheumatoid arthritis, and most importantly, endometrial cancer and ovarian cancer. Periods are usually lighter, shorter, and occur every 28 days. Decreased menstrual cramping is another benefit of the pill. Birth control pills do not decrease a woman's chance of getting pregnant once she has stopped them. Oral contraceptives continue to be one of the most effective reversible methods of birth control.

Please contact the Health Center if you have questions about or problems with your birth control pills.

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