Identi cation of Reproductive Health Monitoring Indicators in Iran

Efat Mohamadi Tehran University of Medical Sciences Mahshid Taheri Ministry of Health and Medical Education Mahdieh Yazdanpanah Ministry of Health and Medical Education Sayyed Hamed Barakati Ministry of Health and Medical Education Foroozan Salehi Ministry of Health and Medical Education Nahid Akbari Iran University of Medical Sciences Ardeshir Khosravi Iranian Ministry of Health and Medical Education Hassan Eini-Zinab National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences Faezeh Ghafoori Ministry of Health and Medical Education Farzaneh kashe Ministry of Health and Medical Education Azamdokht Rahimi Ministry of Health and Medical Education Hakimeh Mostafavi Tehran University of Medical Sciences Alireza Olyaeemanesh Tehran University of Medical Sciences Amirhossein Takian (  takian@tums.ac.ir ) Tehran University of Medical Sciences


Introduction
Reliable health information is pivotal for effective health policy making and public health affairs. Indicators can measure and monitor health status, service delivery, acceptability of healthcare service performance or policy goals (1). Sustainable Development Goals (SDGs) have emphasized the need for reducing maternal and infant mortality and improving maternal health, achieving which requires reproductive health (RH) services (2). The World Health Organization (WHO) de nes RH as "a state of complete physical, mental and social well-being and not merely the absence of disease or in rmity, in all matters relating to the reproductive system and to its functions and processes" (3). RH is an integral segment of public health and a key ingredient of human development. It is essential to the meaning of being a human and is of paramount importance in the health system (4).
WHO, together with other international organizations, has developed a comprehensive list of RH indicators for monitoring RH services and status. These indicators measure RH services and their integration into the health systems, aiming to draw attention to the main measurable components of RH. Most of these indicators facilitate the evaluation of RH policies and are recommended for data collection, aggregation and dissemination at the national level. Both at the national and global levels, the RH indices should measure progress towards improving RH status, either as a direct measure or proxy of impact, or as a measure of progress towards policy goals (5,6). Therefore, regular monitoring and evaluation (M&E) of RH services and status needs the use of speci c indicators; which is essential to determine whether the goals have been met (3).
In the context of Iran, the main challenges in satisfying RH include unmet needs of family planning (FP), inequalities in access to basic obstetric services, and some challenges in data registration in relation to maternal morbidity and mortality (4,7). Monitoring RH indicators is an important task in Iran. Despite the global guideline for reporting RH indicators, there are some technical obstacle in Iran's health information systems for statistical modelling (8) to formulate globally comparable estimates.
In addition, the Total Fertility Rate (TFR) is declining in Iran (1980:2.9-2005:1.8-2019: 2.1) which indicates increasing aging as well as a decreasing population for the coming years (9,10). As a result, the recent mega policies for population decreed by the supreme leader (2014) have mandated a major shift in general population policies towards increasing TFR. The programs of the Ministry of Health and Medical Education (MoHME) of Iran regarding RH have accordingly changed to re ect the required policy change (11).
Given the changes in policy direction, short, mid and long-term planning is fundamental to achieve population growth. Taking into account the inconsistency between some international indicators and the current country's population policies, it is imperative to adopt appropriate approach for monitoring macro domestic programs and policies, both for monitoring purposes, as well as providing coherent reports to the international organizations and partners. This study aims to identify and de ne appropriate and tailored RH indicators, in line with Iran's recent population macro policies, as well as available evidence about international indicators. The study also identi ed areas of data quality concerns and put forward improvement strategies.

Method
This is an applied mixed-methods study. We collected data from 21/06/2020 until 18/02/2021 and conducted simultaneous data analysis during each stage of the study. The study was designed and implemented in four phases (Table 1). were classi ed and synthesized. The obtained documents were carefully studied, the related phrases were extracted, and notes were taken accordingly. At this stage, a document information worksheet was used to delve into the relevant documents, programs, and regulations. During the review of the programs, we attempted to identify the goals related to the input, processes and output of programs.
Qualitative content analysis was used to analyze the textual data of the documents and policies, whose aim was to analyze the content of documents manually and without any software program. The output of the document analysis at this stage was identifying the goals and executive activities of RH and population programs in a systematic and transparent manner. C-Examining the indicators of countries that similar to Iran put population growth policies on their agenda.
They included Kuwait, Turkey, Russia, Germany, Japan and Singapore. The keywords used included: -Indicators */ Measure */ Evaluation */Implementation */ Monitoring */Population policy **/Family policy **/ Pronatalist policy **/ Family size **/Fertility preference **/Fertility desire **/Childbearing preference**/Determinants of fertility **/Low fertility ***/Fertility decline ***/Rise in fertility ***/ Marriage age ****/ Delay rst pregnancy ****/ Parenthood postponement ****/Reproductive health***** We included studies that were relevant to the objectives of this research and were published in Persian or English between 2000 and 2020 and analyzed them by narrative synthesis. Second stage screening: We asked selected experts from the MoHME to examine the indicators in terms of their relevance to the research topic, importance, and the possibility of their integration into national monitoring agenda. We held two consultation sessions that took six hours in total and was facilitated by the principal investigator (AT).
Third stage screening: We used a standard tool as a checklist to evaluate the content and construct validity of the indicators that were screened in the previous stages. The checklist had four criteria: utility of the indicator; technical competence of the indicator; collectability and analyzability of the indicator; and consistency of the indicator ( Table 2). Is there a need for this indicator at a national level?
Could the information obtained from this indicator be necessary for management and policy making in the relevant elds at the national level?
Is it likely to collect the relevant data systematically?
Is it likely to collect the relevant date during designated time frame?
Technical competence of the indicator Is this indicator signi cant and important in this technical and specialized eld (RH and population programs)?
Is this indicator sensitive to changes in performance?
Is this indicator reliable and sensitive?
Is this indicator valid and speci c?
Is this indicator repeatable?
Has been this indicator designed and developed based on scienti c evidence?

Collectability and analyzability of the indicator
Are there any particular systems and mechanisms required to collect the data required for this indicator in the country?
Can this indicator be calculated using available data?
Dose this indicator currently exist in the national monitoring and evaluation system?
Are the nancial and human resources available to measure this indicator?
Is measuring this indicator worth its cost?
Consistency, of the indicator Dose the data obtained from this indicator allow an acceptable assessment of the national response to reproductive health and population measures?
Dose the data obtained from the indicator allow the country's performance to be compared with that of other countries?
Is the indicator consistent with the national context?
We screened the indicators against the checklist and then sent them to 40 experts in two groups: RH experts at the MoHME and a liated medical universities (staff and executive levels/scienti c and executive experts) across Iran (N=27); plus, selected university faculty members and researchers in the eld of demography and RH (N=13). The two groups of experts examined the developed indicators using the index evaluation tool and scored these indicators in terms of their content and construct validities. The overall response rate was 28 (70%).
We used MS Excel 2017 software (https://www.microsoft.com/en-us/microsoft-365/excel) for data analysis in the third phase. A cut-off point of 75% was applied to the studied indicators. That is, indicators the importance of which was veri ed (according to each of the four criteria) as high or very high by at least three quarters of the experts, were considered. A score between 1 and 10 was assigned to each indicator based on each criterion. Then, based on the frequencies of the respondents, the weight and priority of each indicator were calculated.

Phase 4: Finalization of indicators
To determine the nal list of indicators, the research team established two expert panel and policy dialogue sessions with relevant o cials (N=13) at the MoHME. The sessions lasted six hours in total, during which all indicators were re-examined and the nal amendments were made to nalize the indicators.

Results
A review of the upstream and supporting documents and laws related to RH and population policies led to the identi cation of six policies and programs (Table 3). After analyzing the content, goals, and outputs of each program, a total of 106 indicators were determined.
A total of 2026 studies were found in the initial English search, i.e. Cochrane (35)  In total, after document analysis, scoping review, review of global organizations, and comparative study of countries, 689 indicators were identi ed (Appendix 2). The largest number of indicators (371 indicators) was extracted from the scoping review (Table 4) (Table 4). Validity and reliability of indicators: The validity and reliability of indicators were assessed during the third stage screening. 28 out of 40 experts from various elds of RH, obstetrics and demography from the of the MoHME and medical universities from across Iran responded to our survey (Table 5). The average score of the majority of indicators was above 7 (the score of each indicator was between 1 and 10). The highest score was related to the total fertility rate index (mean = 9, standard deviation = 1.8) and the lowest score was related to the recuperation index (degree of recuperation relative to fertility decline at younger ages) (mean 5.07, standard deviation 3.5). The highest scores of the utility of and need for the indicator (0-1), technical competence of the indicator (0-1), and consistency, balance and convergence of the indicator (0-1), were assigned to total fertility rate (0.03, 0.028, and 0.030, respectively). The highest score of collectability and analyzability of the indicator (0-1) was assigned to the raw birth rate (0.034) ( Table 5).
The ve indicators that received the highest averages were: • Total fertility rate

Discussion
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 O ce 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)(21)(22) concluded that based on the focus of policies on different dimensions involved in childbearing, the indicators of RH and education have undergone signi cant 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 speci c 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 speci c 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 speci c indicators of infertility prevention and diagnosis programs. In Portugal, population growth programs focus speci cally on insurance coverage of infertility and its diagnosis and treatment. One speci c 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, identi ed indicators in this study can be modi ed 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 nalized in different stages of this research are speci c 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 uni cation 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.

Conclusion
Successful implementation of population policies, speci cally in the case of fundamental variations with the international programs and policies such as population growth policies in Iran, requires identi cation and development of speci c indicators for monitoring and evaluation of relevant policies and interventions.
In response to the recent shifts in Iran's population macro policies, this study reported the rst comprehensive national attempt in identi cation and classi cation of appropriate indicators for effective, timely and e cient monitoring and evaluation of the current RH programs in Iran.
The nature and number of indicators for monitoring and evaluation of RH and population programs might vary at different organizational levels (micro service delivery level, macro policy level, etc,.). It would be desirable therefore to develop distinct indicators for each level separately. We advocate the MoHME to use our identi ed indicators as a baseline to de ne hierarchical sets of indicators for various local, provincial, national and international levels, when measuring progress towards the intended outcomes of reproductive and population policies in Iran.
In addition, timely and appropriate data collection, which is a multisectoral task, is essential for many selected indicators d in this study. We advocate fostering a meaningful intersectoral collaboration between the MoHME and other entities, i.e. the National Register O ce, and the Iran's Center of Statistics, to bridge the gap in data collection and analysis. In particular, the Integrated Portal of Iranian's Health (SIB system) at the MoHME needs reconstruction to accommodate necessary pieces of citizens' information to gather data in response to selected indicators.
While Iran is determined to increase its population birth rate in response to recent demographic changes and according to ongoing reproductive policies, our selected indicators, subject to necessary modi cations to be used in various monitoring and evaluation levels, can bring a solid foundation to ensure successful implementation of such policies, in line with other national plans towards sustainable health development.

Declarations
Ethics approval and consent to participate

Consent for publication
Not applicable

Availability of data and materials
The data is all presented in the text.

Competing interests
The authors declare that have no competing interest that may be relevant to the submitted work.

Funding
This project is funded and supported by Tehran University of Medical Sciences (TUMS); grant No:49372.
Authors' contributions EM and MT designed the study protocol and undertook the data analysis; they conducted the rst and 2 nd phases of the study, respectively. MY, FS, and NA contributed to the 3 rd phase. AK, HE, FG, FK, and AR contributed to the 4 th phase. MY, SHB, and AO contributed to the ndings interpretation. AT supervised all these processes. All authors contributed to the manuscript drafting. HM critically revised the manuscript. AT is the guarantor. All authors read and approved the nal manuscript.