Midwifery Principal officer, Ministry of Health and Medical Education, Tehran, I.R. Iran

In the name of God

Introduction

Iranian Moslem women act as the main axis of the family and on the other hand play a constructive role as half of community's work- force.

After the glorious victory of the Islamic Revolution (1979) in particular in the last decade all indices show that great steps have been taken in women's status and elimination of inequity specially health status.

General information about I.R.Iran

The Islamic Republic of Iran is the seventeenth largest country in the world and located in South-West Asia in the middle east region and spanning an area of over 1,648,000 square kilometers.

Iran divided into 28 provinces, which are further broken down into smaller administrative area (Districts) and it's capital is Tehran.

According to the latest census, which was conducted in 1996, Iran's population is 60,055,488 of which 61% are settled in urban areas and 39% live in rural communities.

99.6% of population are Moslem, 0.2% are Christian, 0.07% Zoroastrians and 0.05% Jews.

The official language and script is Persian. Literacy rate has shown much improvement and in the recent year are about 80%.

The current health system and medical care in i.r.iran

Until the establishment of the primary health care network in Iran mortality rates for mothers and children were very high.

However, after the creation of the medical care network in 1985, the situation of mothers and children has improved.

Three distinct sectors are currently involved in health provision in Iran: Governmental services, Health insurance and Private sector. The country public health system in turn, can be reviewed at District, Regional and National levels.

At District level, the executive units are Health Houses, Health posts , Rural and Urban Health Centers , Behvarz Training Center , District Health centers , District Hospital and District Health Directorate.

At the provincial level the Universities of Medical Sciences and Health Services have to supervise the activities of the district level; to support health delivery facilities and to manage overall provincial affairs of public health, curative services, pharmaceuticals and medical education. The chancellors of these universities are the representatives of the MOH&ME at the provincial level.

At the national level, the MOH&ME is in charge of policy- making; overall planning and leadership and supervision of activities of lower levels.

Currently there are over 15000 health houses and more than 4000 health centers in rural and urban areas. At present 40% of health personnel are women.

Women and health improvement

Despite of the fact that women's population has increased by 80%; since 1976 their social, cultural and health indices reveal enormous progress.

Implementation of reproductive health /family planning /safe motherhood strategies

The government strategy is providing RH/FP/SM services is based on the following principles:

• Strengthening delivery of RH/FP/SM care through PHC network and private sector.
• Improving the quality and quantity of wide range of RH/FP/SM services.
• Enhancing active community participation.
• Promoting inter- sectional cooperation for the implementation of above mentioned strategy, the following activities have been undertaken by MOH&ME.
• Improving the technical capability of the health care personnel at various levels for delivering RH/FP/SM services through organizing training program and refresher courses.
• Upgrading the public awareness on RH/FP/SM issues through appropriate information, education, and communication program.
• Establishing close relationships with community key persons and religious leaders to enlist their support towards RH/FP/SM programs.
• Procurement and provision of various types of contraceptives and free delivery of preventive services to the public through the Government Health outlets.
• Establishment of Information, Education, and Communication (IEC) center for population and reproductive health care activities by the MOH&ME in 1995.
• Conducting researches on knowledge, attitude and practice of RH/FP/SM clients on an annual basis and evaluating the program.
• The Rural Midwives (RMWs) are acting as FP advocates and provides RH/FP/SM information to the villagers. Also we have more than 7000 midwives only in governmental health system.

Reproductive health including family planning and sexual health

The RH/FP services are now being provided to the public health network system. The services provided include pre/post natal care, safe delivery and family planning, mother and child care, diagnosis and treatment of infertility, prevention and control of carcinoma of breast and cervix and sexually transmitted diseases. Various modern contraceptives are available in rural and urban health centers and health houses. This includes surgical contraception, which is available through mobile teams free of charge.

Efforts have been made to improve the quality of care through training of service providers at different levels of the PHC network system. In view of importance of FP counseling in making free and informed choice, nearly 487 pre marriage counseling centers have been established throughout the country.

Also Network Health providers pre and post natal care, nutrition during pregnancy, and lactation, breast feeding, prevention and early diagnosis of breast and cervical cancer.

Efforts have also been made strengthen the elderly program and technical capability of the existing RH/FP research and training centers.

Family planning and other components of reproductive health care were added to the national research agenda.

The health care services in Iran's health network system address the real needs of community, in particular women at reproductive age and adolescents.

The services are provided through community participation and are based on decentralization of reproductive health care management, cooperation of private sector and NGOs.

Women And Health Indices

* Female Population / Gender Ratio

Iran's population is 60,055,488 of which 29,540,329 are women and 30,515,159 are men.

The population ratio between men and women in Iran has changed very little in the past twenty years. In 1998 this ratio was 105 to 100.

* Marriage / Fertility Rates

Statistic's results showed the mean age of first marriage to be 24.4 years for men and 19.7 years for Women. General Fertility rate is 79.6/1000 and total fertility rate is 2.8.

* Life Expectancy

Women's life expectancy in Iran increases from 56 years in 1976 to 69 years in recent years. This trend is expected to continue because of expanding health and medical attention given to mothers and infants as a mean of long-term planning and investment.

* Specific Health Services for Women and Children

Since the creation of the medical care network in 1985, the situation of mothers and children under five, as major vulnerable groups, has improved significantly. Continuation of the mother and child health care services and programs, including Expanded Program on Immunization (EPI), Control of Diarrhea Diseases (CDD), Acute Respiratory Infection (ARI), Promotion of Breast- Feeding, Iodine Deficiency Disorders (IDD), Safe motherhood, Cervix and Breast cancers screening, etc.

- MMR: Twenty years age, maternal mortality rates were very high, particularly in the rural community. The expanding of medical care services and implementation of family planning programs in the past twenty years has decreased MMR from 240 (per 100'000 Live births) before revolution to about 40 in a few years ago and then reached to 37.4 in recent years (Figure 1).

Percent of pregnant women having less than two antenatal visits during pregnancy in 1997 is about 23.5% and the percent of six or more antenatal visits for pregnant women is about 64%.

The percent of births taking place at hospital or health centers, etc; is about 81% and the percent of birth attended by trained health personnel is 86%.

-NMR/IMR/U5MR: In past ten years, NMR, IMR and U5MR have decreased significantly. In recent year NMR, IMR, U5MR are about 16/1000 live births, 26/1000 and 33/1000 (Figure 2). Nutrition / Breast feeding: One specific indicator of improved nutrition of pregnant women is that at present, about 92% of the infants born today weight over 2500 grams at birth. The other indicator of improved child nutrition is percentage of breast fed children at least one year, which has increased from 65% in 1987 to 86% in 1997. 66% of mothers exclusively breast feed their children for the first four months of age and the percentage of first 6 months is about 56%.

Increasing the production of iodine-supplemented salt, administration of medicated iodine injections and identification of hyper-endemic regions are some of the current measures being implemented to correct iodine deficiency in women. At present the percentage of families who used the Iodine supplemented salt is 96.5%.

- Immunization: Immunization against six disease those are controllable by vaccines has expanded considerable and currently immunization coverage children is about 89.7% and for pregnant mothers against tetanus is about 82%(Figure 3).

*Growth Rate / Family Planning

Within a period of 90 years from 1904 to 1996, the population of Iran increased from about 10 millions to over 60 millions. The highest growth rate was experienced between 1976 and 1986, when the annual growth rate reached 3.2 percent (Figure 4).

Three major factors were responsible for this unprecedented growth rate:

• Noticeable decrease in infant mortality rates, brought by improved health services.
• Laxity in family planning techniques and, at times, encouraging the birth of more children.
• Arrival of immigrants and refugees from neighboring countries, particularly Afghanistan.

The disproportionate growth of population has created a closed circle of under- Development leading to more increase of population.

To prevent this trend the Iran has adopted and implemented appropriate and effective population policies since 1985.This policies include promotion population awareness and providing a variety of modern contraceptives, conducted by health network system that we discussed before. In recent year contraceptive prevalence rate is about 72.9% (Figure 5).

Women and HIV

Fortunately, Iran is one of the safest countries in the world in regard to the rate of AIDS. Religious beliefs and deep-rooted traditions have been the strongest safeguards against the spread of Aids in Iran.

In 1989, the first HIV positive woman was identified in Iran. From that Date until the 1 January of 2001, we have 1962 HIV positive and 309 cases of AIDS (total 2271). Of the total HIV positive only 88 cases are women (Figure 6). Iranian's Ministry of Health and Medical Education has many programs for prevention of STDs including HIV and AIDS.

Conclusion

The country's basic policies in health include the following priorities and principles:

• Preventive measures are regarded as long-term investments.
• Rural areas and remote corners have priority in the allocation of medical resources.
• Out- patient treatment is preferred to hospitalization.
• General health care services have priority over specialized services (especially health care for women).

In spite of delayed implementation of the RH/FP program, considerable progress was achieved. This was due to:

• Full agreement and support of the religious leaders,
• Strong commitment of the government and considerable resource allocating,
• Existence of PHC Network infrastructure, which enable the system to provide the family planning services, and
• Considerable support provided by international bodies.

The ground for implementation of ICPD program of action was completely ready. As mentioned above, a nation -wide PHC Network, religious leader's approval, strong political commitment, and sufficient resource allocation enabled the government to follow-up the program of action.

Main events in the past 5 years are:

• Continuation of family planning program in the government PHC Network, and solving most of its problems.
• Continuation of the other mother and child health care services and programs, including Expanded Program on Immunization (EPI), Control of Diarrhea Diseases (CDD), Acute Respiratory Infections (ARI), promotion of breast feeding, Iodine Deficiency Disorders (IDD), safe motherhood, cervix and breast cancers screening, etc.
• Start of pilot intervention studies on adolescent health, in line with cultural values, by using the community health volunteers' services and/or through schools.
• Widening the range of legal abortion, in order to include more maternal and fetal justifications.
• New gender-related legislation, to promote the women's rights.
• Promotion of civil society concept and role and relevance of the Non-Governmental Organizations (NGOs) in the reproductive health field.

Women should not be regarded as mere recipients of health services. It is absolutely necessary that women's role enhanced and they be regarded as expediters in provision of health priorities to their household in particular and the society in general.

Hence more concerted efforts are required for the education of female children and adolescent girls as along-term investment.

References

1. Shad pour, k. The PHC experience in Iran. UNICEF, Tehran, 1994.

2. Health and Medical Education in The Islamic Republic of Iran. Ministry of Health and Medical Education, 1997.

3. Country Report on population, reproductive and family planning program in the Islamic Republic of Iran. Family Health Department of Ministry of Health and Medical Education, Iran. Feb 1998.

4. National report on women. Women's bureau of presidential office I.R.Iran. March 1997.

5. Statistical report on midwifery. Midwifery department of Ministry of Health and Medical Education , 1999.

6. Maternal health around the world. World Health Organization, 1997.

7. The progress of provinces. Ministry of Health and Medical Education, UNICEF, 1998.

8. Population censuses at a glance. Statistical Center of Iran. 1998.

9. Reproductive health and family planning in the Islamic Republic of Iran. Family planning association. Feb 1999.