The recent RH and population programs aim at increasing birth rate to address the pattern of demographic changes in Iran. This is a radical policy change of family planning policy that was in practice for about two decades. As a result, the Family Health Office of the MoHME (as the stewardship of health system) needs to identify appropriate indicators to quantitatively measure the implementation of these programs and their consequences in Iran. This study was conducted to identify and develop monitoring and evaluation indicators for RH and population programs in Iran.
The main goals of the most cutting-edge programs for population increase in Iran were increasing fertility, reducing infant mortality, raising public awareness about RH, preventing and treating infertility, reducing abortion, family strengthening, and improving the quality of couples' sexual relationships. The outputs of national programs implemented in Turkey and Kuwait, whose approach to increasing childbearing is similar to that of Iran, had both similarities and differences with those of programs implemented in Iran. Similarities included outcomes such as Turkey's study of marriage, divorce and infant mortality (18) and Kuwait’s programs on infertility, access to RH, marriage, and maternal death (19). Output differences between programs in these countries and Iran included the gender gap and violence against women, cesarean section, and sex education in schools (18, 19). These differences could be attributed to differences in the infrastructure and the priorities of different interventions and policies in Iran, as opposed to these two countries.
One study that reviewed international indicators in RH and population among OECD member states (20-22) concluded that based on the focus of policies on different dimensions involved in childbearing, the indicators of RH and education have undergone significant changes. The type of model used in population policies and the extent to which social welfare improved in interventions, had a positive effect on the output of indicators promoting childbearing. The most successful programs to promote childbearing have been reported to focus on balancing work and childcare, and the indicators of these programs have led to the highest positive growth (22).
Results of studies in countries in line with current population policies in Iran, e.g. Russia, as one of the most successful countries in encouraging childbearing, revealed the use of different indicators to monitor its population programs. In Russia, the main problem of low fertility rate is related to Russian couples' interest in single-child families. As a result, their focus is on indicators of RH such as safe sex, prenatal care, delivery method, and postpartum care. Indicators associated with reducing fertility age and increasing infertility treatment have also shown their ultimate impact on the fertility rates growth in Russia (23).
Two of the most important indicators of population policies are total fertility rate and age specific fertility rate, which are used as the main indicators of policy outcome in the current programs of European countries and Singapore (24). These were also among the selected indicators of Iran in the present study. Age specific fertility rate allows policymakers to determine whether executive interventions have the same effect on any age group of women in the country. It can also indirectly demonstrate delays in family formation and childbearing. Analyzing the relationship between this and other indicators, especially process indicators, might provide insights about the impact of population policies and apply the necessary reforms accordingly (25).
Indicators such as age dependency ratio, population under 15 years, and population aged 65 years and older look like to be more relevant in countries that have been experiencing population aging in recent years or are likely to do so in the coming years. Turkey, which is very similar to Iran in terms of the population pyramid and the aging population in years to come, uses these indicators in its population policies (26). Iran is on a very sensitive edge of transition to population aging and increasing dependency ratio, particularly in the regions with high population density. These outcome indicators will change along with the long-term impact of population policies, which will be possibly helpful in the planning and allocation of health services (27).
We also developed infertility indicators, including both population indicators and specific indicators of infertility prevention and diagnosis programs. In Portugal, population growth programs focus specifically on insurance coverage of infertility and its diagnosis and treatment. One specific indicator that directly measures the outcome of this program is “Proportion of deliveries associated with assisted reproductive technologies (ART)” (28). Turkey is another country that funds the treatment of infertile couples as one of its programs to promote childbearing. Diagnosis and referral of infertility has been implemented in the Turkish health system for about ten years. Similar to Portugal, the indicators of this program have examined the births following assisted reproductive treatments (29). Our study, however, determined the indicator “Prevalence of infertility in women by age/reason” for Iran, which is more at the input level of the evaluation system. In case that policies on infertility treatment coverage will change in Iran, an indicator similar to the one used in Portugal can be utilized.
Our study also selected indicators related to marriage, divorce, and marriage counseling programs for Iran, which are similar to Turkey, South Korea, Kuwait, Russia and global health organizations (18, 30, 31). RH indicators, i.e., access to RH care services and contraceptives, are also used in the population policies of many other countries, especially at the level of international reports (5). In Iran, with the transformation of macro population policies, contraceptive health programs underwent some reforms. Therefore, lack of access to contraceptives and the related indicators are the unique features of the current Iranian program (32). Indeed, identified indicators in this study can be modified considering the initial feedback received after measuring them. Sexual health indicators selected in this study are also a subset of international RH indicators. All RH indicators that were proposed in this study have been selected in line with the religious and cultural context and within the framework of family bonds and normal relations in Iran.
This study sought to monitor and evaluate childbearing promotion programs in Iran by compiling the set of indicators that are consistent with current RH programs and macro-population policies. The indicators that were extracted, screened and finalized in different stages of this research are specific to the current policies and health programs of Iran. Utilization of these indicators can, in a given period of time, show the pattern of changes in input, process and amount of service coverage, output of each program, and ultimately the consequences of policies. The unification of these indicators and their method of extraction throughout the country, even at the level of comprehensive health centers, can facilitate, we envisage, the evaluation of system performance, and will enable, we hope, contextual-based and timely feedback for appropriate revision of the related programs.
One strength of this study is obtaining smart indicators for monitoring and evaluation of RH programs from the list of available international indicators and adapting them with the national policies of Iran. This was galvanized by two rounds of experts’ consensus, which enhanced the validity and reliability of the indicators, which can be used by other countries. Nevertheless, actual measurement and evaluation of the indicators are necessary to ensure their contextual suitability in Iran and other similar settings.