The Role of Iran's Health System on Sexual and Reproductive Health Rights: A Narrative Review

Introduction

Women's health is an important priority in public health (1); so that the fifth goal of the Millennium Development Goals (MDGs) (2-3) and the third goal of the Sustainable Development Goals (SDGs) are assigned to women's health (4). Moreover, four out of eight MDGs are related to sexual and reproductive health and rights (SRHRs) (5). Also, fourteen out of seventeen SDGs contain gender-specific indicators (4). It has been discussed that women would not be able to achieve other rights in the absence of sexual and reproductive health (SRH) (6).

The Charter of International Planned Parenthood Federation (IPPF) on SRHRs outlines a wide range of issues concerning sexual and reproductive health which fall under the scope of the basic human rights. The source of these rights is four international treaties including the International Covenant on Civil and Political Rights (ICCPR), as a Political treaty; the International Covenant on Economic, Social and Cultural Rights (ICESCR), an Economic treaty; the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), a treaty for Women; and the Convention on the Rights of the Child (CRC), an acceptable treaty for the Children’s rights. Worldwide, a broad range of countries has ratified these treaties. By ratifying human rights treaties, governments are bound by the international laws to fulfill the human rights obligations, including respecting, protecting and fulfilling various rights. Governments are also obliged to align their state policies, principles and customs with the global or regional treaties in which they are membered. Consequently, international human right laws can serve as a valuable instrument for advancing sexual and reproductive rights (7).

However, at present, women's SRHRs especially the right to health cannot be fully achieved, in many regions of the world. So that, based on the published records on the burden of disease, , 22% of the lost years of life in women of childbearing age (6) are due to the neglect of reproductive rights and related health problems such as unplanned pregnancies, unsafe abortions, maternal death and complications, sexually transmitted diseases and AIDS (6, 8). In comparison, these isssues account for only 3% of the burden in the male population (6).

Biological factors alone do not explain this disparity in the burden of disease between the sexes; social, economic and political shortcomings also have harmful effects on women's reproductive and sexual health. To the extent that ailments related to the reproductive and sexual health are responsible for about one-third and one-fifth of the global burden of disease in women of reproductive age and the entire population, respectively (6).

In every country, several policies, laws, and practices exist that affect SRHRs. They may provide information and education in relation to SRH, access to family planning services, and the other essential services for SRH. Regrettably, these policies, principles, and actions mostly limit, obstruct or prevent the fulfillment of women's SRHRs. Further, governments' inability to address specific issues can undermine or adversely affect the achievement of SRHRs. In either case, restrictions on SRHRs are considered a violation of human rights under international law, if governments have ratified treaties that recognize SRHRs (7).

There are several instances of violations of SRHRs, such as healthcare providers' bias in delivering anti-discriminatory care, which is fundamental to the ethical foundation of care provision (9). Health systems also reinforce clients’ customary gender roles and overlook gender inequalities in health. Health system patterns are rarley gender-responsive. In the healthcare workforce, women generally hold less authority than men. This can lead to their devaluation and abuse (10).

Iran is one of the countries that have ratified most of the mentioned treaties (7). A key question is whether there is any legislation concerning SRHRs and how the Ministry of Health in Iran support these rights. To the best of our knowledge, no study has comprehensively addressed all these isssues. Therefore, we aimed to review the role of Iran's health system in supporting SRHRs.

Materials and Methods

This narrative review article was conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA). This scale includes six criteria 1) expressing the review's value, 2) stating the aim of the article, 3) explaining the search strategy 4) providing references 5) scientific justification, and 6) offering relative endpoint data (11).

We combined keywords related to health system and SRHRs. A comprehensive search was conducted across global databases including Medline, Scopus, ScienceDirect, and Web of Science; using MeSH terms, such as Health Care System, Health Services, Women's Health Services, Maternal Health Services, Reproductive Right, Human rights, Reproductive Health Services, Reproductive Health, and Iran. Furthermore, Iranian databases including SID, IranMedex, and Magiran, were searched using equivalent Persian keywords. The references of the retrieved articles were also manually searched. We also searched for guidelines relating maternal health through website of the Maternal Health Office of the Ministry of Health and Medical Education, as well as any laws, legal acts or bills that mandated health systems to address specefic SRHR items, using the websites of the Ministry of Health and Medical Education, and the Parliament of Islamic Republic of Iran. The authors assessed the published studies from conception to April 2024.

A total of 559 records were obtained from several databases. After removing duplicates, 347 records remained. They were screened by the researcher. 13 records were deemed potentially relevant and their full texts were evaluated for eligibility. Further, 55 records were obtained from websites. Among them, 33 records were sought for retrieval. 28 records were retrieved and assessed for eligibility. Of which 13 records were eligible for review. Finally, 26 records containing 12 studies and one report were included in the review via databases, as well as 13 booklets, acts, and legal artcles included from the other websites. Additionally, we found four booklets containing guidelines, six legal articles and three acts related to SRHRs on the websites (Figure 1).

All literature, including quantitative and qualitative studies, guidelines, reports, and legal acts that assessed the role of health systems in supporting SRHRs in English or Persian, were included in the present study.

Articles without full-text access, as well as case reports, editorials, commentaries, short communications, conference abstracts, and documents in languages other than English or Persian were excluded.

The reviewer (BLH) obtained the included studies, reports, guidelines, and acts relevent to the scope of the study. In cases of ambiguity, the document was assessed by two senior reviewers (RLR, KhM).

Following the priniciples of the American Psychological Association (APA), ethical commitments were considered in the reporting of this new data collection. The researchers were required to avoide fibricating data or refining discovered mistakes, refrain from redundant publication of data or plagiarism, assign authorship credit appropriately, and share their findings with others to verify the objectives (12).

Results

In each country, multiple policies, laws, and practices exist that affect SRHRs(7). In this study, we assess the Acts and policies of the Parliament of Islamic Republic of Iran and the procedures supported by Iran's Ministry of Health that affect SRHR.

The right to life and survival

All human beings have the inherent right to life, (7, 13) which should be preserved by the law (7). To achieve this right, one of the policies implemented by Iran is to improve maternal health through a state program that includes 1) Merged care for safe motherhood, i.e out-hospital services (including preconception, prenatal, and postpartum care) (14) 2) Mother-friendly hospitals i.e hospital services (which includs ten actions of mother-friendly hospitals) 3) The National Maternal Mortality Surveillance System (to determine the prevalence and risk factors of Maternal Mortality Rate (MMR) (15) 4) Programs to prevent HIV transmission from mother to child 5) The implementation of a housing plan for near to childbirth mothers with special care needs, in difficult-to-access areas 6) The establishment of maternity facilities 7) Empowering mothers to choose the appropriate method of safe delivery 8) Follow-up care for mothers who need special care 9) The Severe Pregnancy Complications Surveillance System (registering information of severe pregnancy cases and their complications, monitoring and evaluating the quality of services in severe pregnancy complications, standardizing the processes and formulation of in-hospital protocols in severe complications of pregnancy and childbirth to assess maternal care process and complications) (16)  10) Designing and implementation of appropriate interventions to improve maternal health indicators in the country 11) Training skilled birth attendants for deprived and remote areas 12) Community health education 13) Professional development programs for gynecologists and obstetricians including workshops on obstetric emergencies along with the website of the Maternal Health Office to prevent maternal death (15).

The right to security

The right to security of the person is considered one of the most fundamental defenses of individual entirety in the context of reproductive and sexual health care. Some instances in this regard include unsafe abortion and female genital mutilation/cutting (FGM/C) (7).

It is obvious that health system does not advocate for unsafe abortion. However, the only permissible article for abortion under the legal resolution of Parliamant of Islamic Republic of Iran (2005) is as follows: "Therapeutic abortion is allowed by a definite diagnosis from three specialist physicians, and also confirmation from Iranian Legal Medicine Organization, before the fetal soul is blown (gestational age of four months) with the consent of the woman. The indications for abortion include fetal disorders such as intellectual developmental disorders or malformation that result in maternal distress after birth, or any maternal disease that threatens her life" (17-19).

In Islam, only type one of female circumcision (removal of all or part of the clitoris) is considered circumcision, and the other types of genital cutting are considered female genital destruction. In the laws of the Islamic Republic of Iran, there is no law addressing female circumcision (prohibition or permission), directly. However, in Article 230 of the Islamic Penal Code, it is stated: "If the circumciser causes a crime or damage by cutting more than the necessary amount, he is a guarantor, even if he is skilled." Since male circumcision is obligatory in Islam, this law can be applied to both gender. As mentioned above, female genital cutting is distinct from female circumcision and is subjected to punishment (20).

The Right to Privacy

Every person has the right to autonomously decide regarding their sexual and reproductive life, and their right to privacy must be respected (7). The Right to Privacy ensures the confidentiality of personal information and to recognize the individuals' right to decide independently (21) in relation to sexuality and reproduction like safe abortion (7). One of the global health system obligations regarding confidentiality is the "Oath of Hippocrates", which has been a well-known principle in medical ethics since the fourth century B.C.E.: "Whatever I see or hear relating to the men's lives, when I attend the sick or apart thereof, which ought not to be heard out, I will be silent thereon, and count them like saint mysteries (Bulger, 1987)"(22). Furthermore, there are training programs, such as "ethical codes" in different fields of medicine including the "Midwifery Codes" in the field of midwifery (23-24). Similarly,there is the Pregnant Patient's Bill of Rights, approved by the Council of Policy Making at the Ministry of Health in 2009 (25). Moreover, the Ministry of Health has established more than 1800 labor across the country to protect and keep the privacy of pregnant women and ensure a positive delivery experience (26).

The Right to Information and Education

This right includes access to information and education on SRHR (7). The Ministry of Health is obliged to consult with the government and Parliament to protect SRHRs. According to the legal resolution of the Parliament of Islamic Republic of Iran, universities must allocate maternity leave for pregnant and lactating women, ranging from one semester to four semesters. This ensures that pregnant and lactating women do not have to stop their education. Additionally, universities must provide facilities for ditance education for pregnant women and mothers with children under 3 years old (27). Furthermore, training classes are held for pregnant women to prepare them for childbirth by governmental prenatal care clinics (14). Since higher education and information are associated with better outcomes in children's breastfeeding (28), nutrition and growth (29-30), and timely diagnosis and treatment of diseases (31).

The Right to Choose Whether or Not to Marry and to Found and Plan a Family

All individuals have the right to choose voluntarily whether or not to marry and to found and plan a family. This right supports non-discriminatory access to sexual and reproductive health services, including infertility treatment, family planning, and the prevention and treatment of sexually transmitted infections (STIs) such as HIV/AIDS (7). One of the bills from the Supreme Council for Cultural Revolution in this regard is "the goals and principles of family formation and policies for its consolidation and excellence". According to this act, the ministry of health's obligations include informing women about the effect of proper nutrition, exercise, and hygiene; providing physical health and mental vitality; providing necessary training for girls and boys to choose a spouse. Additionally, it includes increasing and strengthening counseling centers for genetic and dangerous diseases and conducting medical tests before marriage to assess the physical and mental health status of couples. Also, it ensures and improves women's physical, mental, and social health at various stages of life and creats necessary facilities and provides appropriate services in these stages (pregnancy, nutrition, employment and child custody)(32). In addition, according to the Plan to Support the Family and Youth Population, (2021), the Ministry of Health is obligated to build dormitories for married students (27).

The prevalence of the child marriage is more common in border regions of Iran like Sistan and Baluchestan, Khorasan Razavi, and Kurdistan provinces. Health system strategies to decrease child marriage include raising family awareness about the negative effects of child marriage by engaging religious leaders, especially in these regions, and involving non-governmental organizations (NGOs) to raise public awareness and inform relevant authorities to react in instances of child marriage (26). 

The Right to Decide Whether or When to Have Children

Everybody has the right to make responsible decisions freely regarding the number of children and the interval between them. This includes the right to decide whether or when to have children and access to the means to exercise this right (7). Mostly, this right is affected by population policies, which governments and health systems implement based on the population censuses. Iran also works by enacting encouraging and punitive laws in this area (33). The family planning program in Iran started in the 1970s (33-34). After the census of 1986, population control became a general policy of the country. The program was supported by mass media, the establishment of the Department of Population and Family Planning in the Ministry of Health, increased coverage of basic health services, training skilled personnel, and providing free services. Volunteers and NGOs were also used to strengthen community activities. Other activities of the health system included family planning education in schools, universities, workplaces, the army, and pre-marriage classes, with men's participation promoted by offering male methods such as vasectomy or condoms (33).

However, according to the current policies aimed at increasing the population size, health care strategy of Iran, "the provision of family‐planning services was somehow changed" (34-35). Currently, these services are only offered freely to people with high‐risk behavior and/or high‐risk pregnancies (35). The amendment to the population and family planning act approved by the Parliament of Islamic Republic of Iran (2013), states: "maternity leave increased to 9 months, and a two-week paternity leave was considered for fathers" (36). Moreover, for each child, six months was deducted from the obligations of the "law relating to the service of physicians and paramedics" for mothers subject to this law. Married women with children can fulfill their obligations at the family residence. Pregnant women and mothers with children under two years can postpone the start of their obligations during pregnancy and until the child is two years old (27).

Ayatollah Khamenei, the Supreme Leader of the Islamic Republic of Iran, promulgates Iran's general family policies. Some of these policies, which have been served to the heads of three branches of government besides the chairman of the Expediency Council, and especially the Ministry of Health is as follows:

• Systemizing counseling and instruction before, during and after family formation, and facilitating access to them according to Islamic-Iranian principles to foster family foundations.
• Developing necessary mechanisms to improve the overall health of families especially reproductive health and birthrate growth to build a young, dynamic, healthy, and growing community (37-38).

The Right to Health Protection and Health Care

Everybody has the right to the highest attainable standard of mental and physical health, including access to all methods of fertility regulation, safe abortion, infertility, and STIs such as AIDS/HIV(39), infertility and pregnancy counselling(7). Iran's efforts to promote health protection against HIV include the establishment of a strategic plan to end AIDS with participation from 20 ministries and organizations by 2020; the operation of 37 centers providing HIV services under the Ministry of Health, with a focus on medical education for affected women, estabilishing 160 Behavioral Disease Counseling centers, 24 Positive Gym Centers, 8502 centers of testing and counseling HIV, initiating prevention of mother-to-child transmission (PMTCT) program from 2014 with 40 pilot hospitals and 170 centers and expanding to all regions and universities of Iran by 2018. These implementations have resulted in 98.2% of babies born to HIV-positive mothers being healthy (26).

To reduce the risk of HIV sexual transmission, the Ministry of Health has conducted four strategic plans to date. Some programs under the fourth strategic plan including education and information for different population groups, provision of blood health, harm reduction for People Who Inject Drug (PWID), condom distribution, care and treatment of STI and also care and treatment for People Living with HIV/AIDS (PLWH), recommendations for HIV diagnostic testing and counseling, PMTCT, support and empowerment, strengthening the epidemiological care system, data management and infrastructure improvment (40-41).

The Right to the Advantages of Scientific Advancement

All persons have the right to access the advantages of all available technologies in reproductive health such as new contraceptive methods, infertility treatments and abortion. These technologies must be safe, acceptable and gender-sensitive. They should mitigate harmful effects of technologies applied in reproductive health care (7).

Healthcare systems are obliged to critically appraise the most suitable, feasible, local, and ethical approaches to offer infertility services including infertility prevention and treatment within available social systems and health-care systems, and also to prohibit any unintended consequences, especially for marginalized groups (42).

The Ministry of Health was responsible for "The Embryo Donation to Infertile Couples Act". By this act, all competent, specialized fertility centers are allowed to transfer the embryo produced by in vitro fertilization (IVF) from legal couples, after written consent by the couples owning the embryo to the uterus of women whose infertility has been proven after marriage and medical procedures (each one or both) (43-44). In this regard, Article 43 of the Law to Support Family and Youth Population, which focuses on the causes of infertility and full insurance coverage, guarantees access to the advantages of scientific advancement (27).

The Right to Be Free from Ill Treatment

All people have the right not to be exposed to cruelty or persecution, degrading or inhuman treatment and not to receive scientific or medical treatment without informed and free consent. This right protects children from sexual abuse, exploitation, prostitution and all persons from sexual assault, rape, sexual abuse and violence, including domestic violence (7).

Iran has prioritized some forms of violence against women and girls for action including domestic violence, child marriage and sexual violence in public spaces in the last years. The actions of Iran have prioritized to address cruelty against girls and women including:

To strengthen laws: The bill entitled "Securing Women against Violence" has been scheduled by the Vice Presidency of Women and Family Affairs in 2016 regarding preventive, supportive, and judiciary actions for supporting women against all types of violence containing domestic violence (26). However it was not yet approved, but there have been some attempts to do so as soon as possible (45).

To develop services for survivors of violence: Obligations of the health system include the interventions focused on women such as education, support, and psychological and therapeutic counseling for women who are at risk. The second category is the interventions focused on the healthcare providers in order to train and empower them for diagnosis and management of domestic violence against women (46). Comprehensive Program of Preventing and Controlling Domestic Violence implemented by Iran's Ministry of Health include a primary screening by healthcare professionals of married women above 15  for women who have experienced violence, referring them to the psychologist for additional screening, and then to a general practitioner for a definite diagnosis, enrollment, and documentation of risk assessments, treatment, as well as training principles and life skills, offering them a psychosocial support and psychological counseling, referring particular cases to the supportive resources or specialized centers outside health system, and follow-up sessions (26).

One of the advancement in the health system for domestic violence is the development of smartphones and apps. This application named "Be my voice", offers Iranian victims the chance to freely access information, plans, and supports consistent with local culture and laws to fight the stigma surrounding domestic violence (47).

Discussion

This review showed that the Ministry of Health and the Parliament of Islamic Republic of Iran have addressed nearly all SRHRs. There are some reports that have addressed the fulfilment of these rights by healthcare systems especially the right to life and survival. Some declining trends like MMR and Infant Mortality Rate (IMR) are good performance indicators to achieve the right to health by Iran's health system (48-49). Moreover, the mentioned strategies of Iran's healthcare services to improve maternal health in order to achieve the right to life and survival and also the right to health care and protection are consistent with WHO strategies to reduce MMR. Health strategies to protect health right against AIDS are also consistent with WHO strategies including abstinence, being faithful to sexual partner and using condom.   

To reduce unsafe abortion, some obligations proposed by the healthcare systems including strengthening their commitment to women’s health, addressing unsafe abortion as a major public health concern, and providing counseling services for women (50).  Some centers have been launched in Iran like "NAFAS" to consult and help the mothers who plan to abort healthy fetuses (51) .

In contrast, there are some studies showing that some SRHRs have not been addressed completely. Some reasons include lack of legislation or guidelines from healthcare services, lack of follow-up by healthcare providers, or lack of users' preparedness.

For instance, although FGC is commonly performed in some southern and western regions of Iran (52), participating midwives still have average knowledge and mixed attitudes toward FGM/C, indicating a need to develop effective strategies to improve midwives' knowledge and attitude toward FGM/C (53). However, there are some recommendations and obligations worldwide for healthcare systems including alerting healthcare community to the immediate and long-term consequences of the procedure by, for example, helping to develop and use curricula on the prevention and management of FGC for healthcare providers, including nurses and midwives, and also encouraging medical licensing authorities, whose mandate is to protect the public against unqualified and unethical practice, to urge more systematic and transparent approaches to the enforcement of criminal law and other prohibitions, including the suspension of licenses to practice medicine for those qualified practitioners who perform FGC (50). Thus it is required to enforce the laws, empowerment training programs, and recruitment campaigns to change factors such as knowledge and attitude from within communities (54-55).

Another example is some limitations in the legal, jurisprudential and ethical aspects of embryo donation in Iran. According to Ghorbani et al. (2022), the process of embryo donation, and its legal dimensions, such as lineage, inheritance, marriage, alimony, custody, and citizenship should be considered in infertility counseling for both recipient and donor couples. Also, the ethical dimensions of embryo donation, i.e., informed consent, as well as screening donors and recipients, and its jurisprudential aspects are salient issues to be taken into account (56). Afshar et al. (2012) also found that the embryo donation act lacks clarity, and it is subject to misunderstanding and confusion (57). Furthermore, Behjati-Ardakani et al. (2015) stated that many legal aspects of this incident are not determined in this act and it has caused several uncertainties regarding recipients' and the child's duties and rights, which creat main problems (58).

As mentioned above, another reason for SRHRs violation is healthcare providers' incompetency. Ebrahimi et al. (2012) revealed the perspective of Iranian patients regarding their dignity. According to them, nearly all patients, regardless of their state of health or hospital location, perceived their dignity had been violated while receiving care in the hospital (59). As shown in other studies, dignity is still not being maintained in most cases (60-61). Some studies argue that culture plays an important role in how dignity is interpreted and maintained (62). It is surprising that, despite having a quite different culture, participants in this research shared similar views with the above studies (59). The healthcare providers' incompetency and lack of access to SRHRs are observed worldwide. As Solo et al. (2019) conducted a review study in this regard in five countries. They revealed that healthcare providers have demonstrated bias based on age, marital status, parity, and some other criteria, with a bias against providing different contraceptive methods to youth being the most common. Provider inclination is often originated from more general social norms, especially judgments concerning sexual activity among youth and some concerns regarding the effect of hormonal methods on coming fertility(9). Mahendra et al. (2018) also found that coercion potentially occurs in the contraceptive decision-making process in Indonesia(63). Similarly, Yirgu et al. (2020) indicated provider bias against women’s preferred methods of family planning (64).

On the other hand, despite the widespread utilization and development of reproductive healthcare systems in Iran, single women face some limitations in accessing these services such as low health literacy, the poor family’s attitudes and functions, and sociocultural issues. In this respect, it is required to develop a culture that accepts reproductive health services as an integral part of general healthcare. Also, families need to be educated about the importance of single women's reproductive healthcare. Lastly, single women should be empowered to do self-care regarding reproductive health (65-66).

Finally, there are some examples of SRHR violations created by other countries including economic sanctions, which is an important issue that has affected Iranians’ SRHR, especially right to health and also healthcare system services. One crucial example is supply of advanced drugs, which treat the most serious diseases, such as cancers like breast cancer (67-69). Although advanced medications are manufactured primarily by Western companies with a 20-year patents, and some people think that it is not possible to replace medications from another resource (67), there are some studies that report contradictory data. Indeed, there are some expensive drugs, like biological drugs for treatment of multiple sclerosis (MS), which are not importable especially by under-sanctions countries. Therefore, producing these drugs has been prioritized by policymakers in our country, resulting in the biosimilar productions (70). Since MS mostly occurrs in women of reproductive age, it raises major concerns with treatment approaches before and during pregnancy (71).

The above-mentioned advances indicate the excitement of the states, policy makers and health systems for active engagement and investment to promote autonomy and authority, especially for preserving SRHRs.  

Conclusion

According to the findings, Iran's Ministry of Health and Medical Education has played a substantial role in supporting sexual and reproductive health rights. However, despite the legislations and practices codified and implemented by the Parliamant of Islamic Republic of Iran and the Ministry of Health, some SRHRs are not provided completely. The reasons may include lack of legislation or guidelines from healthcare services in this regard, inefficacy of healthcare providers, unsuitable preparedness of people to accept some of these services, and finally SRHRs violations due to sanctions imposed by other countries. However, the sanctions have had a two-way effect, i.e., both positive (self-actualization) and negative effects. So, it is recommended to pay more attention to certain SRHRs by policy-makers and politicians. In addition, it is essential to consider more executive guarantee for some legislations related to SRHRs. Similarly, Iran should adopt approaches to protect people from the unfavorable effects of sanctions.

Declerations

Acknowledgments

Not applicable.

Conflicts of interest

The authors declared no conflicts of interest.

Ethical considerations

Not applicable.

Code of Ethics

Not applicable.

Use of Artificial Intelligence (AI)

None.

Funding

The authors declare that there is no funnding source in relation to the present study.

Authors’ contribution

RLR, KhM and BLH contributed substantially in the conception and design of the study. RLR and BLH carried out the data collection. RLR, KhM and BLH analysed and interpreted the data. BLH drafted the manuscript. RLR and KhM reviewed the manuscript critically for important intellectual content. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.