Are we facing a dramatic increase in infertility and involuntary - PDF document

Are we facing a dramatic increase in infertility and involuntary childlessness that lead to lower fertility? Hajiieh Bibi Razeghi-Nasrabad 1 , Mohamad Jalal Abbasi-Shavazi 2 , Maryam Moeinifar 3 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: hajiieh.razeghi@gmail.com 2 Professor of demography, University of Tehran, Director, NIPR, Iran. Email:mabbasi@ut.ac.ir 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 2

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. 3

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 57.3 65.7 72.6 75.6 15-19 26.1 29.7 42.4 45.3 20-24 6.7 10.2 19.8 24.8 25-29 2.9 4.2 8.7 10.8 30-34 2.5 2.5 5.4 5.5 35-39 3.6 2.0 4.3 4.1 40-44 3.8 2.0 3.8 3.7 45-49 10.1 13.2 18.8 18.8 total 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. 4

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). 5