Reproductive health in Iran: pragmatic achievements, unmet needs, and ethical challenges in a theocratic system.

Since its revival in 1989, the reproductive health and family planning program of Iran has made great strides in raising the contraceptive prevalence rate and reducing fertility. The majority of couples are using modern methods promoted and provided by the national program, although a sizable proportion of couples continue to depend on the traditional method of withdrawal. The longstanding urban-rural gap in contraceptive prevalence rates has been reduced to about 10 percent, which is mainly the result of better-educated urban couples' continued practice of withdrawal. Despite its enormous success in meeting the needs of married couples, in narrowing the urban-rural gap in access to and use of modern contraceptives, and in reducing fertility, the Iranian family planning program is open to criticism for confining its target audience to married couples and failing to address the issue of abortion. The restrictive aspects of the program are often justified on the grounds of religious values and fear of encouraging sexual promiscuity. Because of the theocratic nature of the political system and the immense power enjoyed by Shiite ulama (religious leaders), no step can be taken to address these restrictions without their implicit support and approval. This study describes some of the ethical issues facing the reproductive health program of Iran and indicates how pragmatic approaches adopted by the ruling Shiite ulama to solve some of the social and medical challenges of a rapidly modernizing society may be extended to overcome ethical hurdles faced by the reproductive health program.