iran fertility

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Diane M. Tober University of California, San FranciscoUniversity of California, Berkeley

Mohammad-Hossein TaghdisiSchool of HealthIsfahan University of Medical SciencesIsfahan, Iran

Mohammad JalaliSchool of HealthIsfahan University of Medical SciencesIsfahan, Iran

Fewer Children, Better Life or As Many asGod Wants?Family Planning among Low-Income Iranian and Afghan Refugee Families inIsfahan, Iran

In the West it is often assumed that religion (esp. Islam) and contraception are mu-tually exclusive. Yet, the Islamic Republic of Iran has one of the most successful family-planning programs in the developing world, and is often looked to as a po-tential model for other Muslim countries. Although Irans family-planning programhas been extremely successful among Iranians, it has been far less successful among Afghan refugees and other ethnic groups. Afghans and Iranians both seek services inIrans public health sector for family health care, treatment of infectious disease, and childhood vaccinations. On these occasions, all adult married patients are stronglyencouraged to use family planning to reduce the number of offspring. In this arti-cle, we explore how Irans family-planning program is differentially perceived and

utilized among low-income Iranian and Afghan refugee families in rural and urbanlocations. Particular attention is given to how different interpretations of Islam mayor may not inuence reproductive health-related behaviors and how cultural factorsinuence reproductive strategies.Keywords: [medical anthropology, family planning, maternal and child health,refugees, Shia Islam, Iran]

Medical Anthropology Quarterly , Vol. 20, Number 1, pp. 5071, ISSN 0745-5194, online ISSN1548-1387. C 2006 by the American Anthropological Association. All rights reserved. Permis-sion to photocopy or reproduce article content via University of California Press Rights andPermissions, www.ucpress.edu/journals/rights.htm.

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Family Planning among Low-Income Iranian and Afghan Refugee Families 51

Introduction

Reproductive policies, practices, and principles are subject to historical, cultural,religious, and practical constraints. In the United States, there have been dramaticshifts in family-planning promotion in domestic and international policy and aidprograms, corresponding to shifting religious views on reproduction and the family.In the United States, on the one hand, religious conservatism is assumed to hinderfamily-planning programs and use of contraception. The Islamic Republic of Iran,on the other hand, is a case in which family-planning programs are currently imple-mented in cooperation with the Shia Muslim religious system. Although Iran hasdeveloped a successful family-planning program that is widely accepted among theIranian Shia majority, many ethnic and religious minority groups are not as accept-ing of family planning. Drawing on ethnographic eld research conducted by Toberin 2001, 2002, and 2004, in urban and rural Isfahan among Iranian and Afghan

refugee families, we explore in this article divergent perceptions and use of familyplanning among these groups. This research was arranged and designed collabora-tively among the authors, while Tober conducted interviews and data analysis.

The dynamics between local communities, the health care system, and populationpolicies in the Islamic Republic are also considered. Throughout this article, we payparticular attention to how ethnicity, different interpretations of Islam, and socialconditions inuence family-planning acceptance and use among Afghan and Iranianinformants. Iran has negotiated a successful family planning program within anIslamic system. Yet the tensions between local communities, refugees, and the statecome to the fore in population policies.

In the ten-year period from 197686, Irans population expanded by 16 millionpeople (Aghajanian 1998). Additionally, 20 years of warfare and political upheavalin neighboring Afghanistan, as well as persecution of Iraqi Kurds in Iraq, madeIran host to millions of refugees. As of 2002, Iran had a total population of over68 million, including up to 2.5 million documented Afghan refugees, approximately500 thousand undocumented Afghan migrant workers, and over 200 thousand IraqiKurds (Abbasi-Shavazi and McDonald 2005; Bureau of Alien and Immigrant Affairs2001). Iran has been challenged by the ramications of its own population explosion,such as ination and high unemployment rates, as well as meeting the needs of

increasing numbers of refugees.Since 1989, the Iranian government has developed and implemented a compre-hensive family-planning program to curb population growth in all communitiesliving in Iran. From 2002 to the present, repatriation efforts have also been im-plemented to reduce the refugee population. Although Iranians accept and ask forcontraceptive services, health ofcials and workers claim Afghans do not want touse contraceptive services and thus have much larger families than Iranians. Iraniansview the large Afghan populationwhether caused by migration or reproductionto be particularly problematic. In public opinion, Afghans place a burden on Iranshealth, social, and economic systems.

Family Planning in IranA Response to Rising Population

Iran has had an ambivalent and uctuating relationship with the notion of familyplanning. Family-planning policy in Iran reects signicant ideological shifts,


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52 Medical Anthropology Quarterly

corresponding to three political periods: under the rule of Shah Mohammad RezaPahlavi (r. 194179); following the revolution that brought Ayatollah Khomeini topower (1979) through the IranIraq War (198088); and the period (1989present)following the war (Abbasi-Shavazi et al. 2002). Iran rst initiated a family-planning

program in 1967, during the shahs reign. This was only marginally successful in ru-ral areas because, as some authors note, religious and cultural factors were not takeninto consideration in family-planning education and promotion (Abbasi-Shavaziet al. 2002). After the revolution, family planning experienced a major setbackin favor of more pronatalist policies. Programs were not abolished per se, but nogovernment funding was provided to sustain them (Aghajanian and Mehryar 1999).Although religious leaders did not make the claim that contraception was forbidden(haram), health workers were discouraged from promoting contraception. AyatollahKhomeini called on women to reproduce and to nd satisfaction in motherhood.

Decisions surrounding medical treatment and medical ethics in Iran must, nec-essarily, conform to the Islamic principles as determined by leading Shia clerics.These clerics make religious declarations, or fatwas, surrounding what is and is notpermissible according to Shia Islamic law. These fatwas dene the parameters of medical treatment, including womens health care, surgery, dental practices, pharma-ceutical practices, determinations of life and death, abortion, organ transplantation,infertility treatment, stem cell research, and other policies surrounding the body.

Following the war, Islamic leaders became concerned with the dramatic in-crease in population and feared that the country would exceed its ability to beself-sustaining if population growth was not curbed. Health ofcials cautioned that

unless something was done quickly to reduce the birth rate, it would soon be nec-essary to employ a one child policy similar to that in China. After some de-bate regarding whether or not contraception was or was not acceptable in Islam,high-ranking clergy decided that a goal of Islam is to promote healthy familiesover plentiful families, and issued new fatwas declaring that family planning washalal, or permissible. In 1988, Irans new family-planning program was approved byAyatollah Khamenei. The aim was to build a comprehensive program that also in-corporated efforts to increase literacy and education among women, involve men infamily-planning decision making, and encourage child spacing and discourage childbearing before the age of 18 and after 35. Posters with the slogan not too late, nottoo soon, not too many (nah kheili dir, nah kheili zoud, nah kheili ziad) are foundin most health clinics.

Arguments in favor of family planning drew on verses in the Quran that empha-size the importance of maintaining family harmony (Roudi-Fahimi 2005), and thatextend the argument that if a family has too many children, tranquility in domesticlife will be compromised. The teachings of the Prophet Mohammad and his directsuccessors (hadith) were also incorporated to demonstrate that contraception in theform of withdrawal (azl) was also practiced at the time of the Prophet. Becauselarge family size is positively correlated with poverty and high infant and maternaldeath rates, religious leaders determined family-planning programs were consistentwith the Islamic principles of promoting a health family (Hoodfar 1995; Obermeyer1994). The Islamic Republics family-planning program was the result of healthofcials working together with leading clergy to design a program that would beculturally and religiously acceptable. It was ofcially instituted in 1989. The totalfertility rate has since dropped by more than 50 percent, from 5.5 births per woman


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in 1988, to below 2.8 in 1996, and 2.0 in 2000 (Abbasi-Shavazi 2002), exceedingthe World Health Organization 2005 target (UN Development Programme 2000).

In the face of a rapidly growing population, Iran reframed its prior pronatalistpolicies to a more liberal stance on contraceptive use. Irans current family-planning

program, which now includes vasectomy and tubal ligation as well as other contra-ceptive methods, emphasizes how in Islam God prioritizes having a healthy familyover a plentiful family. 1 Furthermore, Iran has made great efforts to include men infamily-planning promotion. Although women remain the primary users of contra-ception, survey data in 2000 indicate male method contraception makes up 34 per-cent of contraceptive use, with some ruralurban and regional variations (Mehryaret al. 2002). Of families who use male methods, condoms (9.3 percent urban and5.3 percent rural) and withdrawal (27.8 percent urban and 13.9 percent rural) arethe most popular methods (Aghajanian and Mehryar 1999; Ministry of Health andMedical Education 1998). Of couples who chose surgical sterilization, nationwide31 percent underwent tubal ligation and 5 percent chose vasectomy (Roudi-Fahimi2002, 2005). Iranian men are much more involved in family-planning decisions thanmen in other Middle Eastern countries with strong family-planning programs suchas Turkey and Egypt (see Roudi-Fahimi 2005). The inclusion of surgical sterilizationin Irans family-planning program is also unusual in comparison to family-planningprograms in most other Muslim countries. In many interpretations of Islamic law,surgical sterilization is viewed as haram both because of its permanence and becauseit involves cutting on the body, which is forbidden unless being done to save oneslife.2

Family-planning education has received wide acceptance in the Iranian commu-nity. According to health ofcials and health workers, though, Afghan refugees inIran do not use these services to the same degree or they reject them outright. Themost common explanation for this among Iranian informants in the health sector isthat Shiism allows for a more exible interpretation of the Quran, incorporatedwith an emphasis on using individual reasoning when applying Islamic law to oneslife. Sunnism, they argued, requires a more literal reading of the Quran and hadith(for Sunnis, the hadith is only from the teachings of the Prophet, not his successorsas in Shiism). According to this argument, most Sunnis would disagree with manyof the fatwas issued by Shia clergy if they are found to be too far from a literalreading of Islamic texts.

Similarly, Marcia Inhorn (2004) addresses how sectarian differences and accep-tance of fatwas on reproductive technologies inuence infertility treatment choiceamong Sunnis and Shias in Lebanon. Along these lines, Iranian health ofcials andhealth workers perceived religious differences to be impediments to family-planningpromotion: Many Afghans dont use contraception because they are Sunni, and itis against their religion, they argued. Although cultural differences were also ac-knowledged, religious differences were considered to be the primary inuence overdecisions not to use contraception.

At the policy level, a process of reasoning (ijtihad) in Shiism allows for theexibility to respond to social and technological changes. Yet, employing these policyshifts at the individual level often requires strategies to make them comprehensibleand acceptable. Because Irans population is 95 percent Shia, it is easier to reworkand explain policy shifts within a Shia framework. It is a greater challenge to getthese changes in policy accepted by Irans minority groups that are already somewhat


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marginalized. Hence, where family planning has been heavily marketed to IransIranian Shia communities, through health clinics, mosques, and other mechanisms,Irans Sunni Afghan communities are much less likely to accept these programsbecause many do not accept Shia fatwas; they fall on the perimeters of where these

programs are promoted, they have different cultural and situational circumstancesthat do not t with the notion that it is better to have fewer numbers of children;and because they are already marginalized, they are more likely to interpret familyplanning as politically motivated rather than for the betterment of their families orcommunities.

It is tempting to analyze acceptance versus rejection of family planning solelyalong the lines of religious differences between Sunnis and Shias. Indeed, amongIranian health professionals and health workers interviewed, this is the commonexplanation for why Afghans dont want family planning. Sectarian differences,however, do not completely account for rejection or acceptance of family planning.

Iran has used several innovative programs to extend care to its population. Oneof these, the Primary Health Care System, has received international attention. Un-der this system, rural and urban health houses staffed by auxiliary health workers(behvarz) extend health care to areas having limited access to medical treatment.Behvarz are typically chosen from the village, trained for two years, and return totheir own village to work as the primary contact between patients and the clinic.Behvarz also visit people in their homes and bring them to the clinics when necessary.Another program, the Womens Health Volunteer Program, involves villagers them-selves in the health care system through the creation and maintenance of household

les of entire villages. Women health volunteers (rabetin) are responsible for visitinghouseholds, providing basic care, bringing patients to the clinic, and making sureall childrens vaccinations are current. They also promote use of contraception tofamilies with one to two children.

Mosques have also been central in promoting family-planning acceptance. Here,female religious leaders hold informational sessions promoting contraception anddiscuss the positive aspects of having smaller families in their sermons (Hoodfar2001). In Isfahan, where this investigation was conducted, there are also vasectomysupport groups in most factories, where men who have had vasectomies counselother men who are considering this as an option to other method. Interestingly,Isfahan boasts the highest rate of vasectomies in Iran, where vasectomies makeup one-third of all cases of permanent sterilization, including tubal ligation andvasectomy. Today, phrases like fewer children, better life (farzand kamtar, zendegibehtar) or two children are enough (do-ta bacheh kaeh) are found in every healthclinic and pervade family-planning discourse.

Overall, the public health system has been very effective in promoting familyplanning and in providing other basic health needs. The vaccination rate for chil-dren is 99 percent, with all children having access to free vaccinations, regardless of whether or not they are citizens. Family-planning services and treatment for infec-tious disease are also provided free of charge. For Iranian women, prenatal care isprovided without cost, but this service is not free for Afghan women. In urban areas,most Iranian women Tober interviewed had had hospital births, with only a couplehaving had home births. In rural communities, though, unless complications wereexpected, home birth was standardwith assistance from a local, biomedically trained


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midwife. Afghan women, however, all gave birth at home with the assistance of a laymidwifeusually an older woman in the community who has had many childrenherself and has helped other women deliver but who has no formal medical training.

Afghan Refugees in Iran

Iran has one of the worlds largest refugee populations, comprised of primarilyAfghans and Iraqi Kurds (UN High Commission for Refugees 1999, 2000). Therehave been several waves of Afghan migration to Iran, which correspond to signi-cant political events: The rst and largest recent wave of Afghan refugees occurredaround the same time as the inux of Iraqi refugees, in 1979, when the Soviet Unioninvaded Afghanistan. A secondwave correspondedwith the 1989 Sovietwithdrawal,because of internal ghting. From 2001 to the present, more ed Afghanistan withthe ascension of the Taliban government and subsequent U.S. military activity. Withthe most recent exodus, though, many Afghans were not permitted into Iran andwere set up in camps at the IranAfghan border.

In Afghanistan, infant mortality is at 165 children per 1,000 born, 257 out of 1,000 are likely to die before their fth birthday, and maternal mortality is 1,600per 100,000 women. In Iran, infant and under ve mortality rates are currently28.6 and 35.6 per 1,000 births, respectively, and maternal mortality rate is 37 per100,000 (Human Development Reports 2002). Overall, life expectancy for menand women in Iran is 67 and 72, respectively (World Health Organization 2005). InAfghanistan, mortality and morbidity gures caused by tuberculosis are alarmingly

high, especially among women. According to some estimates, the incidence of activeTB cases is 278 per 100,000 and mortality rates from tuberculosis are 15,000 casesper year (Khan and Laaser 2002a, 2000b). In Iran, by contrast, the 2003 noticationrate of new TB cases is 16per 100,000 (Millennium Development Goals, Iran 2004). 3Each year in Iran, between 120 and 130 multidrug-resistant cases of tuberculosis arediscovered, 50 percent of which are among non-Iranians (Millennium DevelopmentGoals, Iran 2004). Unlike Afghanistan, Irans aggressive TB screening and DOTS, orDirectly Observed Treatment-Shortcourse, have dramatically reduced TB deaths.

Although there are no data on these rates for Afghans in Iran compared to theirIranian counterparts, it is likely that conditions in their host country are dramaticallybetter than in Afghanistan, given their access to health services in Iran, includingtreatment for infectious disease and childhood immunizations. 4 Aside from the mi-nority of Afghans who live in the few refugee camps (around 5 percent) whosehealth status is recorded by Red Crescent and other relief workers, record keep-ing on Afghan health conditions is less than accurate in Iran. Documented Afghanfamilies who settle in a given area and are served by the local health clinic do havemedical les in the clinic. However, many Afghan families are highly mobile, travel-ing to nd work, and others are illegal. Although Afghans seek care at local healthclinics, the clinics only keep les of patients who are relatively settled and have cardsdocumenting that they are in Iran legally. Afghan patients who are in Iran illegallymay be treated, but les are not kept for them. This makes it difcult to assessthe overall health conditions of Afghans in Iran. Still, the major diseases afictingAfghans as they arrive in Iran, and throughout the Iran, Pakistan, and Afghanistanregion, include tuberculosis, cholera, polio, and malaria (Poureslami et al. 2004).


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These diseases are actively screened for and treated by Iranian health workers whovisit Afghan communities. Children living in rural Afghan communities also sufferfrom dysentery and eye infections caused by poor sanitary conditions.

Over 95 percent of Afghans who live in Iran are integrated into Iranian com-

munities or are in their own communities within Irans cities and villages. Unlike inPakistan, less than 5 percent of Afghans are actually living in refugee camps. ManyAfghans in this study told us how they left Pakistan for Iran because they heard Iranwas better and provided more services for Afghans. Although there are weeklyreports of refugees returning to Afghanistan, as of May 2004, there were still overone million documented Afghan refugees in Iran living in extended families, as wellas another 500 thousand undocumented migrant workers (Abbasi-Shavazi et al.2005).

Iranian health ofcials are not only concerned with the rising number of Afghanrefugees in Iran but are also concerned with the dramatically higher birth rates of refugee Afghans compared with Iranians. This is partially caused by the perceptionwithin the Iranian public health system that too many Afghanis [ sic] overburdenan already stressed system of care; that Iran is a country suffering from excessivepopulation growth brought about during the IranIraq War; and that rising un-employment and poor economic conditions (exacerbated by economic sanctions)make it difcult for the country to support its own citizenry, let alone large refugeepopulations. In this context, Iranian health ofcials and health workers repeatedlyask, Why dont Afghans accept family planning like Iranians do? For them, theobvious answer is that it is because they are mostly Sunni, and thus less exible.

Yet, clearly, some Sunni Afghans see no problem with using contraception; otherswho are against its use provide a variety of complex reasons, including religion butalso larger issues of identity, high rates of child mortality, and feeling pressure toreduce the numbers of Afghans through both birth control and repatriation.

At a time when Iranian health ofcials have been actively promoting the use of family planning as an answer to overpopulation and rising unemployment rates,the inux of refugeesfrom the Iranian perspectivehas challenged the health andsocial system. Afghans are viewed as a potential health threat to Iranians becauseof higher rates of infectious disease, such as cholera, tuberculosis, and malaria.According to Iranian health ofcials, Afghans arrive in Iran in poor health becausethey had no health care in their own country. Many have not been exposed to basiccommunity health education and they lack the knowledge for maintaining healthand sanitation in their own families and communities.

At the University of Isfahan, Department of Health and Behavioral Sciences,public health scholars, in cooperation with health ofcials in the district, were ac-tively involved in designing public health care programs to educate all families inhealth-promoting behavior. Physicians in the rural district held regular sessionsto (1) identify a few Afghans who might be interested in learning more about healthto work to help educate members of their own community; and (2) to educate otherAfghans on basic sanitation, including the importance of boiling of water, the im-portance of separating animal and human living spaces, and other ways to preventdysentery and eye diseases in children. During these sessions, they promoted familyplanning as a method to improving overall family health. Afghans in this communitywere receptive to learning more about how to improve their own health, especially


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the health of their children. But most did not perceive having fewer children to bean essential part of improved health or better quality of life.

At the local level, poorer Iranians in rural and urban locations acknowledge thatalthough Afghans have been very unlucky and it is important to provide assistance

to other Muslims, they should go back to their own country. Resentment towardAfghans has been growing, particularly in urban areas, where there is more com-petition for limited jobs and resources. Wealthier Iranians, however, who own landor are in position to employ Afghans as day laborers, would like to see the Afghansremain in Iran as a pool for inexpensive and efcient labor. Although most refugeesTober spoke to reported having lived in Iran for many years without conict, mostin the urban areas agree that tensions are now at a peak and they feel that they areno longer welcome, but are uncertain about the safety in their own country and arereluctant to return.

This ethnographic research addresses the struggle over differences in family-planning beliefs and practices within a larger context of interethnic relations andpopulation policies. First, we explore different perceptions toward family planningin Iranian and Afghan communities, based on ethnic and religious differences aswell as ruralurban locality. Then we explore Afghan perceptions of Irans family-planning programs within the larger context of Iranian and Afghan views towardtheir own repatriation. For its part, the Iranian public health sector has worked hardto develop efcient programs for improving the health of refugees in Iran, includingfamily-planning services. Yet, in the context of feeling under pressure to leave Iran,many Afghans remain suspicious of the motives of these programs.

Methods

Fieldwork for this project was carried out over the course of three visits to Iran,from 2001 to 2004. In 2001 and 2004, the visits were brief (several weeks). In2002, however, Tober lived in Iran for six months by invitation from the IsfahanUniversity of Medical Sciences. This ethnographic research focuses on perceptionsand use of family planning in Iran, comparing beliefs and practices of low-incomeIranians and Afghan refugees in rural and urban locations in Isfahan Province. Theresearch beneted from the support of both university faculty and health ofcials.Close to 20 interviews with health workers, physicians, and health ofcials wereconducted in health centers and health houses, in the university, and in the districthealth center headquarters in Isfahan. These interviews provided data about Iranspublic health system as well as about Iranian perceptions of the health needs andchallenges in Afghan communities. Access to these resources informed the researchregarding larger health and family-planning policy issues and the difculties thehealth care system has in meeting the needs of refugee and migrant communities.The interviews also revealed the dynamics between ofcial views toward refugees,Iranian health workers who try to meet their needs and struggle with language andcultural differences, and Afghans themselves who may or may not want some, butnot all, of the services provided.

This qualitative study took place in two areas where both Iranians and Afghanrefugees reside: one of the older, poorer sections of urban Isfahan and a cluster of villages approximately 40 kilometers outside of Isfahan, but still in Isfahan Province.


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These eld sites were selected because they had large populations of Afghan refugeesand because they had nearby health centers that served both Iranian and Afghancommunities. Data were collected through open-ended, semistructured interviews,observation in rural and urban health clinics, and visits to informants homes.

The different ethnic groups of Afghan refugees living in and around Isfahaninclude primarily Hazara, Pashtun, Tajik, and Parsi. Exact numbers of each groupand of Afghan refugees in generalare difcult to determine because they tend tobe highly mobile and although many refugees return to their homeland, still otherscontinue to enter Iran because of ongoing difculties in Afghanistan. In the ruraldistrict where this research was conducted, there is a population of approximately10,242 Iranians, including 716 children under the age of ve, and 2,121 Afghans,with 590 children under the age of ve. The age distribution among Afghans is thussignicantly younger than among Iranians in this district, with far more births perwoman.

All informants were Muslimall Iranians were Shia Muslim; Hazara Afghanswere also Shia Muslim; and all other Afghan groups (Pashtun, Tajik, Parsi, andHerati) were Sunni Muslim. To participate in the research, informants had to bemarried, be of reproductive age (ranging from 14 to menopause), have preferably atleast one child, and be willing to be interviewed. Although the study was designedinitially so that only women would be interviewed, experiences in the eld led usto also include men. This was particularly important in the Afghan communities,where men often spoke for their wives. Two Afghan women who had been tryingto conceive for several years without success were also included.

Initially, informants who had come to local health centers for health and repro-ductive services were recruited. Among rural Afghans, there was signicant reluc-tance to being interviewed in the clinic. Tober recruited rural Afghan informantsby rst following Iranian health workers on their rounds to Afghan communitieswhen delivering polio vaccinations. Subsequently, Tober began to go directly to theirhomes and communities. This was particularly important with the Pashtun Afghans.In total, 101 people agreed to be interviewed, including 15 urban-dwelling Iranians,17 rural-dwelling Iranians, 17 urban-dwelling Hazara Afghans, four other urban-dwelling Afghans (three Tajiks, one Herati), six rural Tajiks, seven rural Parsis, andover 30 rural Pashtuns. In urban locations, all interviews were with women in healthclinics or in a nearby mosque, without their husbands. In rural locations, interviewswere conducted with both women and men, sometimes individually and sometimesas a couple, and they took place in clinics and in peoples homes. Conditions inrural locations required a much more exible approach to eldwork. Health of-cials, physicians, and health care workers were also interviewed regarding detailson the public health system and their perception of health in Iranian and Afghancommunities.

Most interviews lasted between 45 minutes to two hours. Approximately half theinterviews were conducted in semiprivate rooms in the health centers and about half were done in peoples homes. Initially, Tober conducted interviews in Persian withthe assistance of an Iranian health worker. Within the rst month, Tober was able toconduct interviews with Iranian informants without the assistance of an interpreter.Where local dialects were particularly difcult to understand (esp. among PashtunAfghans), a community or volunteer health worker (behvarz or rabet, respectively)


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assisted in translating informants comments from the local dialect to standard Farsi.Informants were assured that participation was voluntary and anonymous. Inter-views with Pashtun informants were more informal than with other groups, primar-ily because it worked better with this group to have a more exible, conversational

style.The research was approved by the Institutional Review Board at the University of

California, San Francisco, as well as by the Isfahan University of Medical Sciences.Interviews were audiotape-recorded only when verbal permission was granted by theinformants, despite the fact that one Pashtun informant advised the interviewer tohide her recorder in her pocket and not tell anyone it was there. Data also consistedof extensive notes taken immediately following the interview and basic demographicinformation taken from health clinic les. In-depth interviews were also performedwith health ofcials at both Isfahan University of Medical Sciences and at the DistrictHealth Center in charge of the section of Isfahan Province where the research wasconducted. Several focus groups and training sessions were also attended: one teach-ing adolescent girls about sexual health, one to recruit and train Afghan refugees tobe volunteer health workers for their communities, and one session training ruralbehvarz to identify complications during pregnancy.

All the women in this study were housewives, except for four Iranian womenliving in urban Isfahan. Both Iranian and Afghan men were predominantly employedas temporary day laborers and agricultural workers, or were unemployed. Many of the Pashtun Afghan men had their own herds of sheep and/or goats. Only threeIranian informants had medical insurance (bimeh). None of the Afghan informants

had insurance. In the village, none of the women were employed outside the home,aside from assisting their husbands in agricultural work; all rural Iranian womensupplemented the family income by weaving ne carpets, which they planned to sellto bazaar merchants or individuals. None of the Afghan women interviewed wereinvolved in this industry.

Urban families lived mainly in one-room apartments in nuclear family units,with few belongings. Rural Iranians lived in much larger homes, with several roomsand often owned agricultural land, such as sunower elds or elds of fresh greens(sabzi), including parsley, cilantro, spinach, or small leeks, and livestock. Some ruralAfghans (particularly Tajiks and Parsis and a few Pashtuns) lived in one-room-per-family dwellings with a shared courtyard and basic amenities such as electricity anda water fountain in the courtyard. Most of the rural Pashtun Afghan homes werebuilt of mud and straw, in collectives or long rows housing between ve and 100families, alongside agricultural elds, and had no electricity or running water. Urbanand rural Iranian women tended to have formal educationat least up to the fthgrade. Urban and rural Afghan women were all illiterate, except one.

The main difference between Iranian informants and non-Pashtun Afghan infor-mants was not the acceptability of family planning in Islam, but when to begin touse birth control. Iranians typically used some form of contraception following thesecond child. For non-Pashtun Afghans, whether Shia or Sunni, contraception wasinitiated after the fourth or fth child. Thus, for these groups, differences in rstuse of contraception could be a function of desired family size. Unlike other AfghanSunnis, most Pashtun informants, who all lived in rural Isfahan, emphasized that itwas up to God to determine how many children they had and that Afghans like to


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Table 1 Attitudes and Use of Contraception in Islam: Comparisons by Religion,Urban/Rural Locality, and Ethnicity

Not OK

Informants FP OK Not ok Unknown Use FP Dont FP but use FPIranian Urb 11 2 2 13 2 2

(Shia) n = 15Iranian Rur 14 1 2 15 1

(Shia) n = 17Hazara urban 14 4 3 16 5 2

(Shia) n = 21Pashtun Rural 7 22 2 8 19 4

(Sunni)n = 31

Tajik, Parsi 9 3 5 10 5 2Rur/urb (Sunni)n = 17

have lots of children. Although the numbers are small, Table 1 demonstrates the at-titudes toward and use of contraception among the informants in this research, basedon ethnicity, ruralurban location, and religion. Other rural and urban Afghansincluded Sunni Tajiks and Parsis. Their perceptions and use of contraception were

not signicantly different from those of urban Hazara Shias.As can be seen from Table 1, several Sunni Afghan informants were using con-traception and did not think it was against their religion; several stated that it wasagainst their religion but used it anyway; and several Shia believed that familyplanning was against Islam. In fact, ethnic differences could play a larger role thanreligion. For example, ethnic Tajiks and Parsis, who were also Sunni, expressed nomoral conict about using family planning, and did not perceive it to be againsttheir religion. Many Sunni Pashtun informants declared that Irans promotion of contraception was against Islam, because it is up to God to determine when togive life and when to take it away. Except for a few, all Shia Iranian informants

believed the use of contraceptionincluding sterilizationwas acceptable in Islambecause God wants us to have healthy families.

Fewer Children, Better Life (Farzand Kamtar, Zendegi Behtar)

Throughout health clinics in Iran, there are numerous posters that advocate fam-ily planning. One of the most often-repeated phrases uttered by health workersand Iranian women alike was farzand kamtar, zendegi behtara prerevolution-ary slogan that is being recirculated in current family-planning outreach efforts.All women patients who come to the clinic for a variety of complaints, or whobring in their children for vaccinations or check-ups, are rst diverted to the family-planning nurse. If the patient has a chart, the nurse looks up the patients birthcontrol method, asks her if she is still using it, and if it is working well for her. If there is no patient le, as in cases with undocumented refugees and people new to


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the clinic, the patient is questioned about her method of birth control. (The patientswere almost all women bringing in their children. If a couple came in they were bothquestioned together, but this only happened on three occasions in the rural clinic,and not at all in the urban one.) The nurse then tells all Iranian and Afghan patients

who have at least two children that they must use family planning. Although thenurses insistence sounds like an order, many women who do not want contraceptionnd ways not to comply by simply nodding, taking what is offered, and walkingaway.

Iranian women are encouraged to use any method they choose, such as condoms,contraceptive pills, IUDs, and so on. Afghan women, however, are strongly encour-aged to choose either Depo-Provera injections (ampul), Norplant, or IUDs. Nursesexplain that Afghans will not use the pill properly, cannot get their husbands to usecondoms, and that longer-lasting methods that they do not have to worry about willwork better for them. Many Afghan women who did want birth control, in bothurban and rural locations, also preferred ampul over other methods because it couldnot be detected by their husbands. Although contraception is equally encouraged,there is a discrepancy between promoting certain kinds of contraception for Iranianwomen that rely on patient self-control and other types of contraception for Afghanwomen that require clinical control. Clinic staffs assume that either Afghan womenwill not comply with family-planning recommendations or will not know how toproperly use methods that require their involvement.

In almost every interview in which women were asked why they had decidedto limit their families to one or two childrenin both rural and urban settings

Iranian women repeated the phrase farzand kamtar, zendegi behtar. Such slo-gans were not typically reiterated by Afghan informants. Other reasons Iranianwomen gave for limiting their family size included poor economic conditions, un-employed husbands, lack of space in their homes, and feelings that they and theirexisting children had few opportunities for a better future (emkenaat nadarim).Iranian women who had four or more children often complained of lack of spaceand resources to meet the needs of their families, and claimed a lack of knowl-edge about contraceptive services. The majority of Iranian women felt that in Islamit was acceptable to use contraception because, as several women stated, Godwants us to have healthy families and does not want us to suffer. Only ve Iranianwomen felt that it was a sin (gonah) to use contraception in Islam, but they usedit anyway because of economic necessity. Of these ve, all but one lived in a ruralvillage.

In one village outside Isfahan a group of ten women, of three generations, werediscussing birth control and family over the fast-breaking dinner (eftar) during themonth of Ramadan. All agreed that in the early years after the revolution it wasdesirable for Iranian women to have at least ve or six children. Currently, becauseof Irans economic situation, unemployment rate, and drought that has had a severeimpact on farming villages, it is becoming preferable to only have one or two chil-dren. One of the women, the wife of the village behvarz has only one son. She stated:I would love to have more children, but we cant afford it. Also, my husband is thebehvarz here. He says if we have more children, it will be more difcult for him toencourage family planning among others in the village. I hope in a year or two hewill say we can have another.


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Her mother replied:

When I was young we were told it is good to have lots of children. Everyone Iknow had at least four or more kids. Myself, I had given birth to ten children,and half of them died from a blood problem [she was Rh negative]. Before theyused to tell us its best to marry your cousin because the families are alreadyclose and it is easier, now they tell us dont marry your cousin because it istoo close, and there are problems with disease that run in the family. Thatis probably why I lost so many children. Now I think it is probably best notto marry your cousinbut to have only one or two children? Our lives werebetter when our houses were lled with children.

The older women present nodded in agreement, contradicting the ofcial viewthat fewer children necessarily meant a better life. Cases such as this demonstrate aremarkable shift in thinking about family that has occurred in just one generation,which coincides with the timing of Irans family-planning promotion efforts.

As Many as God Wants(Har Che Khoda Mikhoad)

When Tober asked Afghan informants How many children are enough? responsesvaried more according to ethnic differences than religious differences. Sunni Tajikand Parsi women living in rural Isfahan typically said four or ve children was theideal and use contraceptives (usually IUDs) to ensure that no more children wouldbe conceived. Their husbands also agreed with the use of contraception, stating that

the four or ve children they had was enough.Shia Hazara Afghan women, who lived in urban Isfahan, were divided on theissue of using contraceptives. Approximately half of the Hazara women who alreadyhad four or ve children and stated they did not want more used ampul. Their mainreason for using ampul over other birth control methods was that it is not easilydetected by their husbands. Although ofcially a woman is supposed to have herhusbands permission before using contraception, this is not usually what happens inpractice. Women who came to the clinic asking for contraception usually received itwithout further questioning. Several Hazara women also came to the clinic to havetheir IUDs removed and to schedule tubal ligations before their anticipated return toAfghanistan, citing fear that the lack of reproductive health services in Afghanistanwould put them at risk of infection. These women also expressed fear that unlessthey were sterilized they would likely have more children than they were able to carefor or would likely die in childbirth. In Afghanistan, maternal mortality is the leadingcause of death for women (UNICEF 2004). Unlike other contraceptive measures,women were unable to get surgical sterilization without their husbands permission.Women who did have their husbands permission opted for oral contraceptives,IUDs, or tubal ligation over ampul.

Hazara women who decided not to use contraception, regardless of the numberof children they had, stated that they were afraid their husband would take a secondwife if they did not continue to have more babies (a practice not typically found inthe Iranian communities today). All of these women reported feeling overwhelmedand exhausted by too many children; poor economic conditions caused by theirhusbands lack of employment; fear of having to return to Afghanistan where their


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children were more likely to die from disease, hunger, and lack of medical services;and fear that their children would have no opportunities for a better life.

Pashtun informants in this study lived in rural Isfahan, were Sunni, and werethe least likely to use family-planning services. They also came from agricultural

communities in Afghanistan and for the most part had little or no primary schooleducation. When asked how many children are enough? Pashtun men almostunanimously declared as many as God wants (Har che Khoda mikhoad). Out of the earshot of men, Pashtun women would often say that the number of children theyhad was enough, (basteh), whether they had two or ten children. When queriedfurther regarding what they were doing to make sure that they did not conceivemore children, the typical response was nothing, (hichi). Out of over 30 Pashtunfamilies that were visited and interviewed, only four families were found in which thehusband permitted his wife to use contraception after four or ve children. SeveralPashtun women were using some contraception without their husbands knowledge.

Only one Pashtun couple expressed a desire to limit their family to two children.This man and woman had come to Iran with their families when they were two yearsold and were rst cousins. In Iran they had received an education to the fth grade,and were the only couple in this community that could read and write. They werethus recruited by the physician at the village health center to be trained as volunteerhealth workers and were assigned to educate other members of their communityabout family planning, food preparation, and other health-promoting activitiesaplan that appears to be improving living conditions in this rural community.

Several important aspects inuencing Pashtun lack of contraceptive use include:

extremely low literacy (less than 5 percent in this community), a declared Pashtuncultural identity that Afghans like lots of children, and the notion that birthcontrol is against Islam. One Pashtun man declared that the Islam in Afghanistanunder the Taliban was better, or more correct, than the Islam in Iran, because of their respective positions on family planning. He states: In Islam, God wants us tohave many children. He decides when to give children, and he decides when to takethem away. Iran is a good country, it is an Islamic country, but they dont want usto have so many children, and that is not correct.

Here, tension can be seen between PashtunSunni and IranianShia interpre-tations of what constitutes proper Islamic conduct in regard to procreation. Inter-estingly, though, Afghans from other ethnic groups (e.g., Hazara, Tajik, and Parsi)voiced a higher degree of acceptance to using contraception, regardless of whetherthey identied as Shia or Sunni or lived in urban or rural locations. Thus, culturaland situational differences between various Afghan groups inuence reproductivebehavior. Among the Pashtuns, these cultural differences are expressed through thelanguage of religion and cultural identity.

Another major point made by the informant above is that life and death arecompletely in Gods hands, and a notion of submitting to divine will. This particu-lar man had eight sons, including four who had died in Afghanistan. When askedhow they had died his response was: I dont know why they died; the doctorsdont know why they died; only God knows. When he is ready to take them, hetakes them. This notion of God taking ones children was expressed repeatedly byall Afghan informants who had lost children in Afghanistan because of war andsickness.


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Girls Are Not Good(Dokhtarha Khub Nistand)

Research in Pakistan (Winkvist and Akhtar 2000) and Egypt (Yount 2005; Yountet al. 2000) demonstrates the inuence of son preference on larger family size and re-duced contraceptive use. As part of Irans efforts to promote family planning withinits own population, son preference has been reframed to emphasize that girls andboys are equally good, and that in Islam both girls and boys are valued. Repeatedlyin clinics, when a woman expresses a desire for a son, the health care worker admon-ished: Why? You should be happy to have a healthy child. There is no differencebetween girls and boys. Gradually, this notion that girls and boys have equal valuehas become more accepted in the Iranian community, where opportunities for girlsare much greater. Some Iranian women even voiced a preference for girls, statingdaughters will always stay closer to their mothers and help them in old age, whereas,sons will go off and take care of their own families, forgetting about their parents.

The effect of promoting the notion of equality between boys and girls theoreticallyreduces the possibility that couples will continue to have children until they get thedesired number of boys. As Yount (2005) points out, increased education amongwomen also reduces son preference.

Desire for sons among Afghans in Iran does affect family-planning practices.Informants repeatedly stated how they would continue to have children until theyproduce a son, regardless of the numbers of daughters they already have. Others,who have either more sons, or an equal number of daughters and sons, seem morelikely to stop at four or ve children. One Pashtun man with six sons (plus two whohad died in Afghanistan) emphasized he never had a desire for daughters, consideredhimself lucky to only have sons, and thanked God for his good fortune. One HazaraAfghan woman, 26, with three daughters (ages one, two, and nine), living in urbanIsfahan, described her quest to have a son:

In Afghanistan, I had two sons die. It was 3 years agoright before we cameto Iran. They were 3 and 5. . . . I dont know why they died. They were sick.Perhaps God was ready to take them. Ever since, my husband has been verydepressed (naraahat) because he no longer has sons. When we came to Iran,we had two more children. I prayed they would be sons, for the sake of myhusband, but we got two more daughters. I am so tired all the time. I hardlyeat, so I can feed my family. We have no space for more children, but I wantto try again to have a son for my husband, so he wont be so depressed.

The consequences of extended war, forced migration, and lack of health servicesin Afghanistan, resulting in the deaths of ones children, has a dramatic affect onreproductive decisions, even when other factors (fatigue, lack of space, economicconstraints, etc.) would weigh heavily in favor of the use of contraceptive measures.In this particular case, the womans desire to alleviate her husbands depressionprompts her to continue to try to have more children, despite her own fatigue.

All Afghan groupsalthough particularly Pashtunsprioritize having boys.However, this emphasis on having sons is also overstated by Iranian health careworkers. Health workers repeatedly express frustration that Afghan families donot count the number of daughters. They state, when asked how many chil-dren do you have? (chandta bacheh darid?), most Afghans will only count the


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number of boys, or they will reply, I have three children (bacheh) and two girls(dokhtar).

What the health workers do not understood is that in most Afghan languagesbacheh means boy (whereas in Farsi it means child), and the generic term for chil-

dren in many Afghan dialects is olaad. 5 Thus, a lack of understanding of Afghanlanguages and dialects leads some Iranian health workers to overestimate son pref-erence. Still, Afghan informants repeatedly statein the presence of little girlsthatgirls are not good (dokhtarha khub nistand). Even preteen girls reiterate that girlsare no good and express a desire for brothers and, after marriage, sons.

In many Afghan communities, bride price is the custom for marriage. Iranianhealth workers perceived this practice as further evidence that Afghans dont valuetheir daughters. Although girls can be sold at any age, especially among poorAfghanseither for adoption, for household labor, or marriagethis does not nec-essarily demonstrate that Afghans do not love or value their daughters, or that theysee them solely as property. This practice is more likely to occur if the family ispoorer than average and if the people receiving the girl live close by and are consid-ered to be a good family. One Hazara woman had sold her third daughter at birth toa childless couple in her community: They are a good Muslim family. They do theirprayers; the woman has good hejab [dresses modestly and wears the chador]. Theywere not blessed with children of their own, so I sold them my daughter. In thiscase, selling her daughter is similar to adoption, which is technically not allowed inIslam, rather than for the purpose of becoming a bride.

When possible, girls will be exchanged as brides between households, especially

between two related households (e.g., two girl cousins who marry each others broth-ers). When an Afghan girl gets married (usually between the ages of 11 and 16),families must go to great expense to provide their daughters with a sufcient dowryof household items to take with them to their new homes. This exchange avoidsthe cost of bride price, which in Iran is equivalent to between $2,000 and $3,000.Several Afghan fathers reported how they missed their married daughters after theyleft (delam tang shod lit., my heart became tight). When we asked one father whojust sold his daughter for marriage how he felt, he responded: If I cut off my armwould I miss it? Of course I would. Selling [ foroukhtan ] my daughter is like cuttingoff my own arm. Mothers commonly discussed their fears that their daughterswould have an unhappy life, and would be unlucky (badbakht) like themselves.The preference for sons in this community is thus for practical and nancial reasons,as well as for emotional reasons.

Afghanistan, the Broken Country (Afghanistan Kharaab Shod)

Although family planning and repatriation policies appear to not be related, in-terviews with Afghan informants prove otherwise. As a marginalized group, manyAfghans view Irans family-planning efforts with some suspicion, especially in lightof government efforts to repatriate them. Afghan refugees are caught in an un-tenable situation: low-income Iranians blame them for their own rising costs andunemployment. The Iranian government, which has borne the burden of their carewith little outside assistance, declares that their health care costs cause an economicstrain on the Iranian economy. Many Afghans themselves feel it is time to return


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to Afghanistan but fear that there are no opportunities in Afghanistan and that thecountry is still unsafe for themselves and their children. Others, however, want tostay in Iran: they have more services available to them than they had in Afghanistan,they have rebuilt their lives, and feel Iran is their home now.

Since 2002, Iran, under the guidance of the UN High Commission for Refugees,has aggressively stepped up repatriation efforts. Irans own internal economic dif-culties, including ination, increased taxes to support refugee costs, high unemploy-ment rates, and a large population of highly educated (but unemployed) youth, hasled to increased tensions between Iranians and Afghans in urban locations. Whilebeing interviewed about perceptions on using contraception, urban Afghans (mostlyHazaras) repeatedly mentioned fears surrounding repatriation, forced or voluntary.They believed that reducing their family size was probably a good thing, becauseof the high costs of raising children and lack of resources. Yet they also felt family-planning programs were another attempt by the government to reduce the overallnumber of Afghans, despite the fact that Iranians were being equally targeted forfamily-planning services. As tensions between Afghans, Iranian neighbors, and thestate were on the rise, their suspicions of the system increased.

The tensions between urban Iranians and Afghans became glaringly evident dur-ing one clinic interview in urban Isfahan. A group of Iranian women were sittingon a bench outside the ofce waiting for vaccinations for their children. A group of Afghan women were on another bench outside the same ofce. The health workerdeclared vaccinations had just run out for the day. One of the Iranian women stated:We would have plenty of vaccinations for our children if it werent for the Afghanis

[sic]. They come here and our taxes go up. They increase the cost of our housing.Their husbands take our husbands jobs, so we have no money. Their children go toour schools, and they have too many of them. Life in Iran would be better if theywould all go back to their own country.

The Afghan women on the other bench pulled me aside, crying:

What can we do? My own country is broken like my body, and it will neverget better. I am so tired all the time from worry. My family has lived in Iranfor 20 years. It used to be good. It is an Islamic country, for us Shia. InAfghanistan they dont like Hazara. Now, we cant live here and we cant live

there. In Iran, they want to keep us from having too many children, and thenthey want to send us back [to Afghanistan]. What can we do? Nowhere ishome for us.

After everyone left, the health worker complained: I had 50 children in herefor vaccinations today. Forty-three of them were Afghan, and only seven Iranians.If the Afghans didnt have so many children, there would be more vaccinationsfor everyone. We dont have enough supplies to go around. Iran bears all of theresponsibility for these refugees and we dont get enough assistance from othercountries to take care of them.

In both rural and urban clinics, staff expressed frustration at the shortage of medical supplies and believed that Afghans use too many of some resources, butnot enough of others, like contraception. Repeatedly, health workers remarked thatcaring for the refugees should be a global responsibility, but that Iran is forced tocarry most of the burden.


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Although many rural Iranians did say that they felt the Afghans had too manychildren and it was time for them to return, they also acknowledged that it wasIrans duty to help other Muslims and that Afghans were unlucky. Rural Afghanswhether Pashtun, Tajik, or Parsidid not have the same kind of conict with their

Iranian neighbors and expressed little or no desire to return to Afghanistan. Still,Pashtun men repeatedly voiced resentment that Irans family-planning program wasaimed at controlling the Afghan population, and that having children was a privatematter, or up to God.

Conclusion

The Iranian public health system provides basic health services for all low-incomepatients. Many of these services, like childhood vaccinations, treatment of infectiousdisease, and family planning, are free. For Iran, which is actively trying to reducethe size of its own population, large Afghan families are seen as creating furthereconomic challenges because of the costs of their care. At the state and health-sector levels, Iranian ofcials express frustration that family-planning services arenot positively received across the board. Although many Afghans (esp. Pashtuns) donot want family planning at all, those who do, want it on their own terms and resentfeeling pressured to use contraception before they reach their desired family size.

Carolyn Sargent (this issue and Sargent and Cordell 2003) has discussed themoral conicts that Muslim Malian migrants in France face when confronted withFrances attempts to promote family planning in their communities. One would as-

sume that when Muslim migrant populations move to a country with the same basicreligionalthough, of course, there are signicant differences between Sunni andShia Islamthere would be substantial ideological agreement between the two cul-tures in regard to family and reproduction. Yet this is not the case in Iran. Similarpopulation policies that, when used in Western countries might be interpreted to betargeted at reducing the number of Muslims, in Iran are interpreted as aiming toreduce the number of Afghans. Thus, whether there is a difference in ethnicity ora difference in religion (or both), it is the difference that can be perceived to drivefamily-planning programs. Although in Iran, Iranians and Afghans are equally tar-geted for family planning, many Afghans perceive that there is a difference. Amongmarginalized communities, family-planning programs become particularly suspectwhen accompanied by tensions between immigrant and local communities and anintense drive to repatriate refugees and immigrants. In Iran, these tensions wereparticularly felt in urban locations, where there is higher competition for resourcesbetween Afghan and Iranian communities.

There are complex cultural, religious, and situational differences between poorIranian and Afghan communities in Iran that affect perceptions and use of familyplanning. However, among Afghan groupswhich have had similar experiences of illness, death, trauma, loss, and dislocationthere are still signicant differencesin the perceived acceptability and usage of family-planning services. Rural SunniPashtun families appear to have, on the average, more children than other Afghangroups (Hazara, Tajik, and Parsi), and to view family planning as being against Is-lam. Urban Shia Hazara families tend to be more inclined to utilize available servicesand do not express a conict with their religion to the same degree. There were


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comparatively fewer Tajiks and Parsis than the other two groups; however, those in-terviewed had all started using contraception after the fourth or fth child. Religiousinterpretations and cultural differences may have an impact on reproductive deci-sion making, but religion itself does not seem to preclude the use of family planning

in these cases. Urban or rural locality may also have an inuence on family-planninguse. Urban or rural differences do not exist to the same degree for low-incomeIranian families.

Decisions to use or not use family planning are informed by a variety of fac-tors, including cultural and religious differences, differential access to resources,and experiences of child death and infant mortality. In Iran, literacy, education, andacceptability and promotion of family planning by the clergy have positively in-uenced the acceptance of family planning among the Iranian community. AmongAfghans, those who had at least some access to formal education were more inclinedto believe that having fewer children would positively inuence family health andoverall quality of life. The inuence of exposure to education on views toward familyplanning deserves further investigation.

Irans family-planning programs have been much more successful amongIranians than Afghans because, for one, Iranian clerical support for family-planningprograms led to a reframing of Shia Islamic beliefs that God does not want peopleto suffer and that a healthy family is more important than a plentiful family.Afghan refugees, falling outside this reframing of Islamic discourse in regard tofamilyeither because of religious differences (e.g., Sunni), cultural differences (e.g.,among Afghan Shias), or situational differencesaccept Irans family-planning

initiatives to a lesser degree. Afghans who do use contraception do so later, afterthe fourth or fth child, rather than after the second, like most Iranians. Afghanswho live in urban areas, where resources and space are limited, are most likely towant family-planning services. Among low-income Iranians, use of family planningis the same for those living in urban and rural locations, regardless of education,age of marriage, and other considerations.

The experience of losing children to sickness and war in Afghanistan has un-doubtedly had a dramatic impact on Afghan decisions to have larger families, asthey know that some children will not survive. Among the Pashtuns, the belief thatit is up to God to determine when life is given and taken away precludes the use of contraception in most cases. Health, economic, and social conditions for all Afghanshave been much better in Iran than in Afghanistan. Yet Iranians are beginning toresent their presence and the perceived costs of meeting their health and other needs.With increasing tensions in Iran and continued instability in Afghanistan, Afghansremain trapped in a borderland, in an untenable situation, and this is reected intheir reproductive decisions.

Notes

Acknowledgments. This material is based on work supported by the National ScienceFoundation under Grant 0220594; the University of California, San Francisco AcademicSenate; and theAmerican Association of Iranian Studies, all of which were awarded to Toberfor the purposes of carrying out this research. We are extremely grateful for their generoussupport. Special thanks to the Isfahan University of Medical Sciences for its assistancein inviting and coordinating this work and to Dr. Zargarzadeh and Mr. Moradmand for


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the ofcial invitation and visa assistance. Deep gratitude is also extended to all the peoplewho agreed to help coordinate and/or participate in this research. Any opinions, ndings, orrecommendations expressed in this material are those of the authors and do not necessarilyreect the views of the National Science Foundation or other organizations or institutions

that facilitated this work.1. Although the family-planning program was instituted in 1989, surgical sterilization

methods such as vasectomy and tubal ligation were not approved until around 1992.2. In Iran, the notion of harm has been redened with a more strict interpretation by

Islamic leaders. Sterilization is not considered harmful because for men it can be reversed,and for women it is considered less harmful than bearing many children. This tendencyto redene basic Islamic concepts to meet changing social circumstances and technologicaladvances has led to more exibility in procedures and practices surrounding health and thebody, including contraceptive treatments and infertility procedures.

3. Prevalence rates not available.4. The principle investigator asked health ofcials and health workers at numerous

urban and rural health clinics for health data and infant and maternal mortality ratesamong Afghans in Iran. During interviews, Tober was told that it was impossible to collectthis information; many Afghans have no les because they move around too much lookingfor work and most Afghan women give birth at home so infant deaths will not necessarilybe recorded.

5. Thanks to Patricia Omidian (personal communication, January 2003) for her obser-vations on this distinction in Pakistan and Afghanistan.

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