Childlessness in Iran, and to Assess the Level of Voluntary and Involuntary Childlessness

Are we facing a dramatic increase in infertility and involuntary childlessness that lead to lower fertility?

Hajiieh Bibi Razeghi-Nasrabad1, Mohamad Jalal Abbasi-Shavazi2, Maryam Moeinifar3

ABSTRACT

In response to low fertility and its long-term consequences, Iran’s policymakers pursue pronatlist policies aimed at increasing fertility. To this end, infertility has become the focus of media, the public, and policy makers’ attention, and there are claims that infertility is around 20 percent. As a result, there is a concern as to whether the sharp increase in infertility will lead to lower fertility or not? Using data from the 2011 IDHS and the 1996 and 2011censuses, this paper aims to estimate the level of childlessness in Iran, and to assess the level of voluntary and involuntary childlessness. Our results show that childlessness in five-year age-groups for those aged 15-39 increased during 1991-2011. In contrast, the proportion of lifetime childlessness has remained around 4 percent. In 2011 IDHS, voluntary and involuntary childlessness were 10.1 and 3.6 percent, respectively. with regard to low lifetime childlessness rate, advances in health system and better access to ART, recent estimates of the infertility does not portray a real picture of infertility. However, while providing support for infertile couples is important, any exaggerated claim about infertility and growing number of childless leads to adaption of inappropriate and ineffective policies toward increasing fertility.

 Assistant Professor of demography, National Institute of Population Research (NIPR), Iran. Email: [email protected] 2 Professor of demography, University of Tehran, Director, NIPR, Iran. Email:[email protected] 3 Ma in Demography, University of Tehran, Email: 1

INTROUDUCTION

Iran experienced a dramatic fertility decline during recent decades. The total fertility rate decreased from 7.7 in 1966 to around 6.0 by the mid-1970s, raised slightly during the late 1970s and early 1980s, and fell sharply during the 1990s. The own- children estimates of fertility for Iran based on the 2006 Census show that the TFR had reached replacement-level (2.1) in 2000 and further declined to 1.9 by 2006 (Abbasi-Shavazi, 2009). Total fertility rate declined to 1.8 in 2011. Provincial levels of fertility indicate that in 2011 the total fertility rate in 22 out of the 31 provinces of Iran is below replacement level (Abbasi-Shavazi & Hosseini 2013). In response to projected changes in the age structure as well as the possibility of population decline, from 2010, Iranian policymakers pursued policies aimed at increasing population growth. In recent years, in order to prevent further decline of fertility and increase it to replacement level, the focus of many programs and policies has been toward the reduction of infertility. A cited justification of the more attention is based on estimation of infertility in a cross sectional survey on infertility among married women aged 20-40 years old (Akhondi and et all 2011). This research revealed the prevalence of primary infertility to be around 20.2 per cent in Iran.

Increasing childlessness is one of the important aspects and a potential factor of low fertility (Merlo and Rowland, 2000). However, it should be considered that childlessness is both due to social and economic constraints and a consequence of endemic health problems. In the past, childlessness was mainly involuntary occurring within a large family but it is expected that contemporary childlessness is mostly voluntary (Morgan, 1991). Voluntary childlessness is mostly related to postponement of childbearing and it is occurring in the context of low fertility. Thus, it is important to distinguish between involuntary and voluntary infertility enabling policies makers to have a clear picture of those who are in need of support for assisted reproductive technology. Iran has a well-established health network system throughout the country that covers approximately all of the urban population and 95 per cent of the rural population (Hosseini-Chavoshi et al 2007). Advances in modern infertility treatment in the past two decades in Iran have been called the “Iranian ART revolution” (Abbasi Shavazi et al 2008). Currently, more than 75 centers in

Iran, one of the highest numbers of clinics in the Middle East, offer every type of infertility treatment including third-party donation and surrogacy (Tremayne, 2012). Despite advance in health system and more access to medical assistance, question arisen as why so much attention is paid to infertility? Is this claim of dramatic increase in infertility or childlessness real? We believe that recent estimates of the prevalence of infertility and involuntary childlessness need to be carefully examined. This paper aims to study level and patterns of childlessness at the national and province level in Iran. Using ‘tree model’ the paper also distinguishes between voluntary and involuntary childlessness.

Data and Method Using data from the 1996, 2006 and 2011 censuses, the level and trend of childlessness across time in Iran is estimated. The childlessness rates are computed based on 'Zero Parity' among ever-married women as given in the censuses. In addition using 2000 and 2011 IDHS , the survival function calculated that is derived from life tables to calculate the percentage of women who remain childless. One of the main limitations of census data is that voluntary childlessness and involuntary childlessness cannot be distinguished. Lake of information on contraceptive use and women's’ fertility intention makes it difficult to interpret childlessness. The Iran Demographic and Health Survey provide valuable information that is relevant to the analysis of childlessness. Therefore, using the 2000 and 2011 Iran Demographic and Health Survey (IDHS) six principal measures for childlessness is used in the analysis: general childlessness, self-reported infertility, voluntary and involuntary childlessness, lifetime childlessness, and expected childlessness. General Childlessness includes all 'Zero Parity' ever- married women aged 15-49. Voluntary childlessness includes both childless women who are using contraception and women whose do not have intention to bear children at research time. Involuntary childlessness consists of childless women who have not used contraception and main reasons for not using contraception are infertility, hysterectomy. Lifetime childlessness is considered as all 'Zero Parity ever-married women aged 40-44 or 45-49. Expected childlessness is sum of involuntary childlessness and intended childlessness.

RESULT

Table 1 indicates age-specific childlessness rate that is percentage of women with zero parity by age group during 1991 and 2011. As can be observed, in 1991 around 57 percent of women aged 15-19 did not have any child. This figures increased to 75.6 percent in 2011. Percentage of women with zero parity in age group 25-29 increased from around 6.7 to 24.8 during the same period. However, percentage of childlessness in age group 40-44 has remained around 4 percent. Figure 2 shows the percentage of lifetime childlessness for 40-44 age group derived from the 2011 census. Based on the result prevalence of lifetime childlessness in Iran are 4.1. Table 1. Age-specific childlessness rate among ever-married women aged 15-49, Iran 1996- 2011 Age group 1996 2000 2006 2011 15-19 57.3 65.7 72.6 75.6 20-24 26.1 29.7 42.4 45.3 25-29 6.7 10.2 19.8 24.8 30-34 2.9 4.2 8.7 10.8 35-39 2.5 2.5 5.4 5.5 40-44 3.6 2.0 4.3 4.1 45-49 3.8 2.0 3.8 3.7 total 10.1 13.2 18.8 18.8

Source: Statistical Centre of Iran (1991-2003), the Survey of Socio-Economic Characteristics of Household.

In provincial level, the prevalence of lifetime childlessness ranged from 2.2 percent in Yazd to 6.2 in Sistan and Balochestan. Our finding is in line with the work of Poston and Trent (1982) who argued that voluntary and involuntary childlessness varied according to the level of development. The provincial estimates show that most provinces that are considered to have a low level of socio- economic development, displayed the highest of lifetime childlessness as compared to all other province.

Figure 1. Provincial level of childlessness at age 40-44 (lifetime childlessness), 2011

Source: Statistical Centre of Iran 2011.

Survival of the Childlessness

Using life table techniques we calculated percentage of women who failed to give birth after marriage. The survival curve from the 2000 IDHS, reveal that more than 90 percent of women have first birth within 5 years of their marriage. The median survival time is 2.7 year and only 0.04% of the females failed to give birth within 10 years of their marriage. These women probably are infertile and do not progress to their first child during their reproductive life. The synthetic parity progression ratios for a lifetime of ten years indicate that in 2011 about 16.7 percent of women in reproductive age remained childless; of which more than half (10.2 percent) had never married and only 6.5 percent had remained childless within 10 years since marriage (McDonald et al. 2015).

FIGURE 2. Survival Function OF FIRST BIRTH INTERVAL (IN YEAR) IN IRAN, IDHS 2000.

Voluntary and involuntary childlessness

Figure 3 and 4 demonstrate the distribution of different categories of childlessness among ever- married women aged 15-49 in 2000 and 2011. Following Tanturri and Mencarini's findings in Italy (2008) the figure shows various pathways to distinguish between voluntary - and involuntary childlessness.

The results from this method are similar to previous model that are presented in Figure 2. In 2000 IDHS from 90,141 ever-married women, 86.8 per cent (78,817 women) experienced first birth and 13.2 per cent (11,324 women) were childless. With respect to reasons of not using contraception, 2.2 per cent of women stated that their main reason for not using contraceptive methods was pregnancy.

Involuntary childlessness includes 4.5 percent of women; 2 percent has reported infertility, hysterectomy and illness and 2.5 percent have intention to childbearing and are trying to get pregnant.

Around 5.8 percent of women were voluntary childlessness; around 2.2 percent of women are using contraceptive and 3.8 percent were nonuse. The main reasons of nonuse were no intercourse with husband, separation of husband, fear of side effects, the opposition of husband and other relatives or opposition of women themselves to family planning programs.

In addition, expected childlessness can be estimated using DHS data. It is sum of involuntary childlessness and intended childlessness, what Tanturris and Mencarini label ‘permanent postponement’ (2004). In 2000, most of women intend to have children in future but just 0.1 percent does not want any children, thus expected childlessness is very low.

As figure illustrates, in 2011, 83 percent of ever-married women aged 15-49 experienced first birth and 17% were childless. Voluntary and involuntary childlessness also has changed to 10.1 and 3.6 percent, respectively. However Result shows that Iranian women are progressively likely to plan children and 0.3 percent of them don’t have Intention to childbearing at the future.

Figure 2, Distribution of different categories of Childlessness among ever-married women aged 15-49, the 2000 IDHS

Ever married women aged 15-49 100%

Women who Widowed and Childless women have children divorce (0.5%) (total childlessness) 86.8% 13.2 %

Non use of contraceptive 10.5% Use of contraceptive 2.2%

Self- Trying to No intercourse with Pregnancy reported husband, Irregular 2.2% get pregnant Infertility, 2.5% intercourse 3.8% 2 %

Involuntary childlessness Voluntary childless 5.8% 4.5%

Don’t want any children at Intention to childbearing the future 0.1% at the future 5.7%

Figure 1, Distribution of different categories of Childlessness among ever-married women aged 15-49, the 2011 DHS

Ever married women aged 15-49 100%

Women who Widowed and Childless women have children divorce (1%) (total 83% childlessness) 17% Non use of contraceptive 10 % Use of contraceptive 6%

Pregnancy 2.3% Trying to get No intercourse with Self- husband, Irregular reported pregnant intercourse 4.1% Infertility 2.2% 1.4%

Involuntary childlessness Voluntary childless 3.6% 10.1%

Don’t want any children Intention to childbearing at the future (childfree) at the future (temporary 0.3% childlessness) 9.8%

Conclusion

Our results clearly show that the proportion childless among ever married women has increased during the last decades in Iran, This is especially true in first five-year age-groups, for those aged 15-39, childlessness increased during 1991-2011. In contrast, the proportion of childlessness at ages 40-49 (lifetime childlessness) has remained around 4 percent. Our estimates from DHS data also suggested that voluntary childlessness increased from 5.6% in 2000 to 10.1% in 2011, but involuntary childlessness declined from 4.6 in 2000 to around 3.6 in 2010. We argued that declining involuntary childlessness may have been due to the increased access to Assister Reproductive Technologies. In other hand recent increase in voluntary childlessness can be attributed to postponement of first birth within marriage. Continuing higher education and women's aspiration for paid work, unfavorable economic conditions (economic insecurity) … seems to be important factors of postponement childbearing and voluntary childlessness. (Abbasi Shavazi and et al 2011, Hoseini Chavoshi and et al 2015). Our previous on delay childbearing and first birth timing show many young couple tend to short delay first birth until they have established themselves professionally or become socially and economically ready for independent living, and then go on to have the desired number of children in quick succession (Razeghi Nasrabad and et al 2014, 2015). In addition to the life table calculated from the 2000 IDHS and the 2010 DHS show only 4 and 6.5 percent of women had remained childless within 10 years since marriage. According to Hosseini Chvoshi and et al (2016)” the age-specific rate of first birth has shifted to somewhat older ages in recent years, but has not dropped in its level. With the constant trend of parity progression from marriage to the first birth, it is likely that childlessness will not rise in the future “(p39). These results suggest that lifetime childlessness and infertility is close to the prevailing base level of primary infertility in any population. According to Bongaarts and Potter (1983) in historical populations with no evidence of controlled fertility 2 to 3% remained childless probably because of congenital and genetic disorders. Based on this analysis, in Iran reported high rate of primary infertility and involuntary childlessness seem to be not real. An important demographic reality is that “despite the differing estimates of global infertility prevalence 10

infertility rate, it is not seem to have increased significantly over the past two decades’ (Inhorn and Patrizio 2015). Even in Africa, rates of both primary and secondary infertility are decreasing due to reductions in unsafe abortions and sexually transmitted infections (STIs) (Inhorn and Patrizio 2015: 414). Finally paper suggests that life time childlessness and infertility is not as high as some epidemiological surveys of infertility (Akhondi and et al 2011, Vahidi and et al 2006) have presented. In fact there are exaggerated claims about infertility rate and growing number of childless. Although there are critical differences between estimation of infertility based on large-scale population surveys versus epidemiological surveys of infertility, with regard to low life time childlessness rate, advance in health system, Advances in modern infertility treatment and better access to several type of infertility treatment (Abbasi Shavazi et al 2008), It can be concluded that recent estimates of the prevalence of infertility by epidemiological surveys of infertility does not portray a real picture of infertility in Iran. And their claims, recent sharp increase in infertility and involuntary childlessness in Iran will lead to lower fertility in next years, is not real. Many European countries characterised by both low overall fertility and high childlessness rate. High lifetime childlessness (around 20%) in Europe has become increasingly linked to the postponement of fist birth, is suggested the negative relationships between completed cohort fertility and the prevalence of childlessness for many European countries (Miettinen and et al 2015). However in Iran Lifetime childlessness has remained constant. Therefore Iran’s fertility decline has been associated with decrease in the number of large families and long birth interval and not rise in childlessness. Our results from recent patterns of childlessness in Iran don’t confirmed this theoretical explanation and negative relationship between the prevalence childlessness and the current level of fertility. Now, the question is, why some epidemiologists centered on infertility and show it as large social concern? It seems medicalisation perspective can provide suitable response to this question. Involuntary childlessness is a distressing condition for many men and women in Iran and exaggerate in infertility rate just create more concern and challenge in young couple. In this situation even those young couples who decide to short postpone may face social pressure and

stigma of infertility and may need to reconsider their decision It is clear that good data are needed on the levels of primary infertility in order to address this significant public health problem. Finally, In order to prevent further decline of fertility and increase it to replacement level, seeking practical policy and based on fact, seems an appropriate option for Iran’s fertility policy. While we believe that infertility is an issue and it is important to provide support for the infertile couples (Abbasi Shavazi and et al, 2005, 2008), any exaggerated claims about infertility and growing number of childless leads to adaption of inappropriate and ineffective policies toward increasing fertility. We believe that increase in childlessness in Iran is contemporary and partly due to tempo effects related to short postponement of childbearing. Nevertheless, due as infecundity is risen by age, it is suggested that health policy makers and planners provide advice on appropriate age of fertility, the impact of age on fertility, and reproductive outcomes in later life.

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