Diane M.

Tober University of California, San Francisco University of California, Berkeley Mohammad-Hossein Taghdisi School of Health Isfahan University of Medical Sciences Isfahan, Iran Mohammad Jalali School of Health Isfahan University of Medical Sciences Isfahan, Iran

Fewer Children, Better Life or As Many as God Wants?

Family Planning among Low-Income Iranian and Afghan Refugee Families in Isfahan, Iran
In the West it is often assumed that religion (esp. Islam) and contraception are mutually exclusive. Yet, the Islamic Republic of Iran has one of the most successful family-planning programs in the developing world, and is often looked to as a potential model for other Muslim countries. Although Irans family-planning program has been extremely successful among Iranians, it has been far less successful among Afghan refugees and other ethnic groups. Afghans and Iranians both seek services in Irans public health sector for family health care, treatment of infectious disease, and childhood vaccinations. On these occasions, all adult married patients are strongly encouraged to use family planning to reduce the number of offspring. In this article, we explore how Irans family-planning program is differentially perceived and utilized among low-income Iranian and Afghan refugee families in rural and urban locations. Particular attention is given to how different interpretations of Islam may or may not inuence reproductive health-related behaviors and how cultural factors inuence reproductive strategies. Keywords: [medical anthropology, family planning, maternal and child health, refugees, Shia Islam, Iran]

Medical Anthropology Quarterly, Vol. 20, Number 1, pp. 5071, ISSN 0745-5194, online ISSN 1548-1387. C 2006 by the American Anthropological Association. All rights reserved. Permission to photocopy or reproduce article content via University of California Press Rights and Permissions, www.ucpress.edu/journals/rights.htm.

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Introduction
Reproductive policies, practices, and principles are subject to historical, cultural, religious, and practical constraints. In the United States, there have been dramatic shifts in family-planning promotion in domestic and international policy and aid programs, corresponding to shifting religious views on reproduction and the family. In the United States, on the one hand, religious conservatism is assumed to hinder family-planning programs and use of contraception. The Islamic Republic of Iran, on the other hand, is a case in which family-planning programs are currently implemented in cooperation with the Shia Muslim religious system. Although Iran has developed a successful family-planning program that is widely accepted among the Iranian Shia majority, many ethnic and religious minority groups are not as accepting of family planning. Drawing on ethnographic eld research conducted by Tober in 2001, 2002, and 2004, in urban and rural Isfahan among Iranian and Afghan refugee families, we explore in this article divergent perceptions and use of family planning among these groups. This research was arranged and designed collaboratively among the authors, while Tober conducted interviews and data analysis. The dynamics between local communities, the health care system, and population policies in the Islamic Republic are also considered. Throughout this article, we pay particular attention to how ethnicity, different interpretations of Islam, and social conditions inuence family-planning acceptance and use among Afghan and Iranian informants. Iran has negotiated a successful family planning program within an Islamic system. Yet the tensions between local communities, refugees, and the state come to the fore in population policies. In the ten-year period from 197686, Irans population expanded by 16 million people (Aghajanian 1998). Additionally, 20 years of warfare and political upheaval in neighboring Afghanistan, as well as persecution of Iraqi Kurds in Iraq, made Iran host to millions of refugees. As of 2002, Iran had a total population of over 68 million, including up to 2.5 million documented Afghan refugees, approximately 500 thousand undocumented Afghan migrant workers, and over 200 thousand Iraqi Kurds (Abbasi-Shavazi and McDonald 2005; Bureau of Alien and Immigrant Affairs 2001). Iran has been challenged by the ramications of its own population explosion, such as ination and high unemployment rates, as well as meeting the needs of increasing numbers of refugees. Since 1989, the Iranian government has developed and implemented a comprehensive family-planning program to curb population growth in all communities living in Iran. From 2002 to the present, repatriation efforts have also been implemented to reduce the refugee population. Although Iranians accept and ask for contraceptive services, health ofcials and workers claim Afghans do not want to use contraceptive services and thus have much larger families than Iranians. Iranians view the large Afghan populationwhether caused by migration or reproduction to be particularly problematic. In public opinion, Afghans place a burden on Irans health, social, and economic systems.

Family Planning in IranA Response to Rising Population

Iran has had an ambivalent and uctuating relationship with the notion of family planning. Family-planning policy in Iran reects signicant ideological shifts,

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corresponding to three political periods: under the rule of Shah Mohammad Reza Pahlavi (r. 194179); following the revolution that brought Ayatollah Khomeini to power (1979) through the IranIraq War (198088); and the period (1989present) following the war (Abbasi-Shavazi et al. 2002). Iran rst initiated a family-planning program in 1967, during the shahs reign. This was only marginally successful in rural areas because, as some authors note, religious and cultural factors were not taken into consideration in family-planning education and promotion (Abbasi-Shavazi et al. 2002). After the revolution, family planning experienced a major setback in favor of more pronatalist policies. Programs were not abolished per se, but no government funding was provided to sustain them (Aghajanian and Mehryar 1999). Although religious leaders did not make the claim that contraception was forbidden (haram), health workers were discouraged from promoting contraception. Ayatollah Khomeini called on women to reproduce and to nd satisfaction in motherhood. Decisions surrounding medical treatment and medical ethics in Iran must, necessarily, conform to the Islamic principles as determined by leading Shia clerics. These clerics make religious declarations, or fatwas, surrounding what is and is not permissible according to Shia Islamic law. These fatwas dene the parameters of medical treatment, including womens health care, surgery, dental practices, pharmaceutical practices, determinations of life and death, abortion, organ transplantation, infertility treatment, stem cell research, and other policies surrounding the body. Following the war, Islamic leaders became concerned with the dramatic increase in population and feared that the country would exceed its ability to be self-sustaining if population growth was not curbed. Health ofcials cautioned that unless something was done quickly to reduce the birth rate, it would soon be necessary to employ a one child policy similar to that in China. After some debate regarding whether or not contraception was or was not acceptable in Islam, high-ranking clergy decided that a goal of Islam is to promote healthy families over plentiful families, and issued new fatwas declaring that family planning was halal, or permissible. In 1988, Irans new family-planning program was approved by Ayatollah Khamenei. The aim was to build a comprehensive program that also incorporated efforts to increase literacy and education among women, involve men in family-planning decision making, and encourage child spacing and discourage child bearing before the age of 18 and after 35. Posters with the slogan not too late, not too soon, not too many (nah kheili dir, nah kheili zoud, nah kheili ziad) are found in most health clinics. Arguments in favor of family planning drew on verses in the Quran that emphasize the importance of maintaining family harmony (Roudi-Fahimi 2005), and that extend the argument that if a family has too many children, tranquility in domestic life will be compromised. The teachings of the Prophet Mohammad and his direct successors (hadith) were also incorporated to demonstrate that contraception in the form of withdrawal (azl) was also practiced at the time of the Prophet. Because large family size is positively correlated with poverty and high infant and maternal death rates, religious leaders determined family-planning programs were consistent with the Islamic principles of promoting a health family (Hoodfar 1995; Obermeyer 1994). The Islamic Republics family-planning program was the result of health ofcials working together with leading clergy to design a program that would be culturally and religiously acceptable. It was ofcially instituted in 1989. The total fertility rate has since dropped by more than 50 percent, from 5.5 births per woman

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in 1988, to below 2.8 in 1996, and 2.0 in 2000 (Abbasi-Shavazi 2002), exceeding the World Health Organization 2005 target (UN Development Programme 2000). In the face of a rapidly growing population, Iran reframed its prior pronatalist policies to a more liberal stance on contraceptive use. Irans current family-planning program, which now includes vasectomy and tubal ligation as well as other contraceptive methods, emphasizes how in Islam God prioritizes having a healthy family over a plentiful family.1 Furthermore, Iran has made great efforts to include men in family-planning promotion. Although women remain the primary users of contraception, survey data in 2000 indicate male method contraception makes up 34 percent of contraceptive use, with some ruralurban and regional variations (Mehryar et al. 2002). Of families who use male methods, condoms (9.3 percent urban and 5.3 percent rural) and withdrawal (27.8 percent urban and 13.9 percent rural) are the most popular methods (Aghajanian and Mehryar 1999; Ministry of Health and Medical Education 1998). Of couples who chose surgical sterilization, nationwide 31 percent underwent tubal ligation and 5 percent chose vasectomy (Roudi-Fahimi 2002, 2005). Iranian men are much more involved in family-planning decisions than men in other Middle Eastern countries with strong family-planning programs such as Turkey and Egypt (see Roudi-Fahimi 2005). The inclusion of surgical sterilization in Irans family-planning program is also unusual in comparison to family-planning programs in most other Muslim countries. In many interpretations of Islamic law, surgical sterilization is viewed as haram both because of its permanence and because it involves cutting on the body, which is forbidden unless being done to save ones life.2 Family-planning education has received wide acceptance in the Iranian community. According to health ofcials and health workers, though, Afghan refugees in Iran do not use these services to the same degree or they reject them outright. The most common explanation for this among Iranian informants in the health sector is that Shiism allows for a more exible interpretation of the Quran, incorporated with an emphasis on using individual reasoning when applying Islamic law to ones life. Sunnism, they argued, requires a more literal reading of the Quran and hadith (for Sunnis, the hadith is only from the teachings of the Prophet, not his successors as in Shiism). According to this argument, most Sunnis would disagree with many of the fatwas issued by Shia clergy if they are found to be too far from a literal reading of Islamic texts. Similarly, Marcia Inhorn (2004) addresses how sectarian differences and acceptance of fatwas on reproductive technologies inuence infertility treatment choice among Sunnis and Shias in Lebanon. Along these lines, Iranian health ofcials and health workers perceived religious differences to be impediments to family-planning promotion: Many Afghans dont use contraception because they are Sunni, and it is against their religion, they argued. Although cultural differences were also acknowledged, religious differences were considered to be the primary inuence over decisions not to use contraception. At the policy level, a process of reasoning (ijtihad) in Shiism allows for the exibility to respond to social and technological changes. Yet, employing these policy shifts at the individual level often requires strategies to make them comprehensible and acceptable. Because Irans population is 95 percent Shia, it is easier to rework and explain policy shifts within a Shia framework. It is a greater challenge to get these changes in policy accepted by Irans minority groups that are already somewhat

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marginalized. Hence, where family planning has been heavily marketed to Irans Iranian Shia communities, through health clinics, mosques, and other mechanisms, Irans Sunni Afghan communities are much less likely to accept these programs because many do not accept Shia fatwas; they fall on the perimeters of where these programs are promoted, they have different cultural and situational circumstances that do not t with the notion that it is better to have fewer numbers of children; and because they are already marginalized, they are more likely to interpret family planning as politically motivated rather than for the betterment of their families or communities. It is tempting to analyze acceptance versus rejection of family planning solely along the lines of religious differences between Sunnis and Shias. Indeed, among Iranian health professionals and health workers interviewed, this is the common explanation for why Afghans dont want family planning. Sectarian differences, however, do not completely account for rejection or acceptance of family planning. Iran has used several innovative programs to extend care to its population. One of these, the Primary Health Care System, has received international attention. Under this system, rural and urban health houses staffed by auxiliary health workers (behvarz) extend health care to areas having limited access to medical treatment. Behvarz are typically chosen from the village, trained for two years, and return to their own village to work as the primary contact between patients and the clinic. Behvarz also visit people in their homes and bring them to the clinics when necessary. Another program, the Womens Health Volunteer Program, involves villagers themselves in the health care system through the creation and maintenance of household les of entire villages. Women health volunteers (rabetin) are responsible for visiting households, providing basic care, bringing patients to the clinic, and making sure all childrens vaccinations are current. They also promote use of contraception to families with one to two children. Mosques have also been central in promoting family-planning acceptance. Here, female religious leaders hold informational sessions promoting contraception and discuss the positive aspects of having smaller families in their sermons (Hoodfar 2001). In Isfahan, where this investigation was conducted, there are also vasectomy support groups in most factories, where men who have had vasectomies counsel other men who are considering this as an option to other method. Interestingly, Isfahan boasts the highest rate of vasectomies in Iran, where vasectomies make up one-third of all cases of permanent sterilization, including tubal ligation and vasectomy. Today, phrases like fewer children, better life (farzand kamtar, zendegi behtar) or two children are enough (do-ta bacheh kaeh) are found in every health clinic and pervade family-planning discourse. Overall, the public health system has been very effective in promoting family planning and in providing other basic health needs. The vaccination rate for children is 99 percent, with all children having access to free vaccinations, regardless of whether or not they are citizens. Family-planning services and treatment for infectious disease are also provided free of charge. For Iranian women, prenatal care is provided without cost, but this service is not free for Afghan women. In urban areas, most Iranian women Tober interviewed had had hospital births, with only a couple having had home births. In rural communities, though, unless complications were expected, home birth was standard with assistance from a local, biomedically trained

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midwife. Afghan women, however, all gave birth at home with the assistance of a lay midwifeusually an older woman in the community who has had many children herself and has helped other women deliver but who has no formal medical training.

Afghan Refugees in Iran

Iran has one of the worlds largest refugee populations, comprised of primarily Afghans and Iraqi Kurds (UN High Commission for Refugees 1999, 2000). There have been several waves of Afghan migration to Iran, which correspond to signicant political events: The rst and largest recent wave of Afghan refugees occurred around the same time as the inux of Iraqi refugees, in 1979, when the Soviet Union invaded Afghanistan. A second wave corresponded with the 1989 Soviet withdrawal, because of internal ghting. From 2001 to the present, more ed Afghanistan with the ascension of the Taliban government and subsequent U.S. military activity. With the most recent exodus, though, many Afghans were not permitted into Iran and were set up in camps at the IranAfghan border. In Afghanistan, infant mortality is at 165 children per 1,000 born, 257 out of 1,000 are likely to die before their fth birthday, and maternal mortality is 1,600 per 100,000 women. In Iran, infant and under ve mortality rates are currently 28.6 and 35.6 per 1,000 births, respectively, and maternal mortality rate is 37 per 100,000 (Human Development Reports 2002). Overall, life expectancy for men and women in Iran is 67 and 72, respectively (World Health Organization 2005). In Afghanistan, mortality and morbidity gures caused by tuberculosis are alarmingly high, especially among women. According to some estimates, the incidence of active TB cases is 278 per 100,000 and mortality rates from tuberculosis are 15,000 cases per year (Khan and Laaser 2002a, 2000b). In Iran, by contrast, the 2003 notication rate of new TB cases is 16 per 100,000 (Millennium Development Goals, Iran 2004).3 Each year in Iran, between 120 and 130 multidrug-resistant cases of tuberculosis are discovered, 50 percent of which are among non-Iranians (Millennium Development Goals, Iran 2004). Unlike Afghanistan, Irans aggressive TB screening and DOTS, or Directly Observed Treatment-Shortcourse, have dramatically reduced TB deaths. Although there are no data on these rates for Afghans in Iran compared to their Iranian counterparts, it is likely that conditions in their host country are dramatically better than in Afghanistan, given their access to health services in Iran, including treatment for infectious disease and childhood immunizations.4 Aside from the minority of Afghans who live in the few refugee camps (around 5 percent) whose health status is recorded by Red Crescent and other relief workers, record keeping on Afghan health conditions is less than accurate in Iran. Documented Afghan families who settle in a given area and are served by the local health clinic do have medical les in the clinic. However, many Afghan families are highly mobile, traveling to nd work, and others are illegal. Although Afghans seek care at local health clinics, the clinics only keep les of patients who are relatively settled and have cards documenting that they are in Iran legally. Afghan patients who are in Iran illegally may be treated, but les are not kept for them. This makes it difcult to assess the overall health conditions of Afghans in Iran. Still, the major diseases aficting Afghans as they arrive in Iran, and throughout the Iran, Pakistan, and Afghanistan region, include tuberculosis, cholera, polio, and malaria (Poureslami et al. 2004).

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These diseases are actively screened for and treated by Iranian health workers who visit Afghan communities. Children living in rural Afghan communities also suffer from dysentery and eye infections caused by poor sanitary conditions. Over 95 percent of Afghans who live in Iran are integrated into Iranian communities or are in their own communities within Irans cities and villages. Unlike in Pakistan, less than 5 percent of Afghans are actually living in refugee camps. Many Afghans in this study told us how they left Pakistan for Iran because they heard Iran was better and provided more services for Afghans. Although there are weekly reports of refugees returning to Afghanistan, as of May 2004, there were still over one million documented Afghan refugees in Iran living in extended families, as well as another 500 thousand undocumented migrant workers (Abbasi-Shavazi et al. 2005). Iranian health ofcials are not only concerned with the rising number of Afghan refugees in Iran but are also concerned with the dramatically higher birth rates of refugee Afghans compared with Iranians. This is partially caused by the perception within the Iranian public health system that too many Afghanis [sic] overburden an already stressed system of care; that Iran is a country suffering from excessive population growth brought about during the IranIraq War; and that rising unemployment and poor economic conditions (exacerbated by economic sanctions) make it difcult for the country to support its own citizenry, let alone large refugee populations. In this context, Iranian health ofcials and health workers repeatedly ask, Why dont Afghans accept family planning like Iranians do? For them, the obvious answer is that it is because they are mostly Sunni, and thus less exible. Yet, clearly, some Sunni Afghans see no problem with using contraception; others who are against its use provide a variety of complex reasons, including religion but also larger issues of identity, high rates of child mortality, and feeling pressure to reduce the numbers of Afghans through both birth control and repatriation. At a time when Iranian health ofcials have been actively promoting the use of family planning as an answer to overpopulation and rising unemployment rates, the inux of refugeesfrom the Iranian perspectivehas challenged the health and social system. Afghans are viewed as a potential health threat to Iranians because of higher rates of infectious disease, such as cholera, tuberculosis, and malaria. According to Iranian health ofcials, Afghans arrive in Iran in poor health because they had no health care in their own country. Many have not been exposed to basic community health education and they lack the knowledge for maintaining health and sanitation in their own families and communities. At the University of Isfahan, Department of Health and Behavioral Sciences, public health scholars, in cooperation with health ofcials in the district, were actively involved in designing public health care programs to educate all families in health-promoting behavior. Physicians in the rural district held regular sessions to (1) identify a few Afghans who might be interested in learning more about health to work to help educate members of their own community; and (2) to educate other Afghans on basic sanitation, including the importance of boiling of water, the importance of separating animal and human living spaces, and other ways to prevent dysentery and eye diseases in children. During these sessions, they promoted family planning as a method to improving overall family health. Afghans in this community were receptive to learning more about how to improve their own health, especially

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the health of their children. But most did not perceive having fewer children to be an essential part of improved health or better quality of life. At the local level, poorer Iranians in rural and urban locations acknowledge that although Afghans have been very unlucky and it is important to provide assistance to other Muslims, they should go back to their own country. Resentment toward Afghans has been growing, particularly in urban areas, where there is more competition for limited jobs and resources. Wealthier Iranians, however, who own land or are in position to employ Afghans as day laborers, would like to see the Afghans remain in Iran as a pool for inexpensive and efcient labor. Although most refugees Tober spoke to reported having lived in Iran for many years without conict, most in the urban areas agree that tensions are now at a peak and they feel that they are no longer welcome, but are uncertain about the safety in their own country and are reluctant to return. This ethnographic research addresses the struggle over differences in familyplanning beliefs and practices within a larger context of interethnic relations and population policies. First, we explore different perceptions toward family planning in Iranian and Afghan communities, based on ethnic and religious differences as well as ruralurban locality. Then we explore Afghan perceptions of Irans familyplanning programs within the larger context of Iranian and Afghan views toward their own repatriation. For its part, the Iranian public health sector has worked hard to develop efcient programs for improving the health of refugees in Iran, including family-planning services. Yet, in the context of feeling under pressure to leave Iran, many Afghans remain suspicious of the motives of these programs.

Methods
Fieldwork for this project was carried out over the course of three visits to Iran, from 2001 to 2004. In 2001 and 2004, the visits were brief (several weeks). In 2002, however, Tober lived in Iran for six months by invitation from the Isfahan University of Medical Sciences. This ethnographic research focuses on perceptions and use of family planning in Iran, comparing beliefs and practices of low-income Iranians and Afghan refugees in rural and urban locations in Isfahan Province. The research beneted from the support of both university faculty and health ofcials. Close to 20 interviews with health workers, physicians, and health ofcials were conducted in health centers and health houses, in the university, and in the district health center headquarters in Isfahan. These interviews provided data about Irans public health system as well as about Iranian perceptions of the health needs and challenges in Afghan communities. Access to these resources informed the research regarding larger health and family-planning policy issues and the difculties the health care system has in meeting the needs of refugee and migrant communities. The interviews also revealed the dynamics between ofcial views toward refugees, Iranian health workers who try to meet their needs and struggle with language and cultural differences, and Afghans themselves who may or may not want some, but not all, of the services provided. This qualitative study took place in two areas where both Iranians and Afghan refugees reside: one of the older, poorer sections of urban Isfahan and a cluster of villages approximately 40 kilometers outside of Isfahan, but still in Isfahan Province.

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These eld sites were selected because they had large populations of Afghan refugees and because they had nearby health centers that served both Iranian and Afghan communities. Data were collected through open-ended, semistructured interviews, observation in rural and urban health clinics, and visits to informants homes. The different ethnic groups of Afghan refugees living in and around Isfahan include primarily Hazara, Pashtun, Tajik, and Parsi. Exact numbers of each group and of Afghan refugees in generalare difcult to determine because they tend to be highly mobile and although many refugees return to their homeland, still others continue to enter Iran because of ongoing difculties in Afghanistan. In the rural district where this research was conducted, there is a population of approximately 10,242 Iranians, including 716 children under the age of ve, and 2,121 Afghans, with 590 children under the age of ve. The age distribution among Afghans is thus signicantly younger than among Iranians in this district, with far more births per woman. All informants were Muslimall Iranians were Shia Muslim; Hazara Afghans were also Shia Muslim; and all other Afghan groups (Pashtun, Tajik, Parsi, and Herati) were Sunni Muslim. To participate in the research, informants had to be married, be of reproductive age (ranging from 14 to menopause), have preferably at least one child, and be willing to be interviewed. Although the study was designed initially so that only women would be interviewed, experiences in the eld led us to also include men. This was particularly important in the Afghan communities, where men often spoke for their wives. Two Afghan women who had been trying to conceive for several years without success were also included. Initially, informants who had come to local health centers for health and reproductive services were recruited. Among rural Afghans, there was signicant reluctance to being interviewed in the clinic. Tober recruited rural Afghan informants by rst following Iranian health workers on their rounds to Afghan communities when delivering polio vaccinations. Subsequently, Tober began to go directly to their homes and communities. This was particularly important with the Pashtun Afghans. In total, 101 people agreed to be interviewed, including 15 urban-dwelling Iranians, 17 rural-dwelling Iranians, 17 urban-dwelling Hazara Afghans, four other urbandwelling Afghans (three Tajiks, one Herati), six rural Tajiks, seven rural Parsis, and over 30 rural Pashtuns. In urban locations, all interviews were with women in health clinics or in a nearby mosque, without their husbands. In rural locations, interviews were conducted with both women and men, sometimes individually and sometimes as a couple, and they took place in clinics and in peoples homes. Conditions in rural locations required a much more exible approach to eldwork. Health ofcials, physicians, and health care workers were also interviewed regarding details on the public health system and their perception of health in Iranian and Afghan communities. Most interviews lasted between 45 minutes to two hours. Approximately half the interviews were conducted in semiprivate rooms in the health centers and about half were done in peoples homes. Initially, Tober conducted interviews in Persian with the assistance of an Iranian health worker. Within the rst month, Tober was able to conduct interviews with Iranian informants without the assistance of an interpreter. Where local dialects were particularly difcult to understand (esp. among Pashtun Afghans), a community or volunteer health worker (behvarz or rabet, respectively)

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assisted in translating informants comments from the local dialect to standard Farsi. Informants were assured that participation was voluntary and anonymous. Interviews with Pashtun informants were more informal than with other groups, primarily because it worked better with this group to have a more exible, conversational style. The research was approved by the Institutional Review Board at the University of California, San Francisco, as well as by the Isfahan University of Medical Sciences. Interviews were audiotape-recorded only when verbal permission was granted by the informants, despite the fact that one Pashtun informant advised the interviewer to hide her recorder in her pocket and not tell anyone it was there. Data also consisted of extensive notes taken immediately following the interview and basic demographic information taken from health clinic les. In-depth interviews were also performed with health ofcials at both Isfahan University of Medical Sciences and at the District Health Center in charge of the section of Isfahan Province where the research was conducted. Several focus groups and training sessions were also attended: one teaching adolescent girls about sexual health, one to recruit and train Afghan refugees to be volunteer health workers for their communities, and one session training rural behvarz to identify complications during pregnancy. All the women in this study were housewives, except for four Iranian women living in urban Isfahan. Both Iranian and Afghan men were predominantly employed as temporary day laborers and agricultural workers, or were unemployed. Many of the Pashtun Afghan men had their own herds of sheep and/or goats. Only three Iranian informants had medical insurance (bimeh). None of the Afghan informants had insurance. In the village, none of the women were employed outside the home, aside from assisting their husbands in agricultural work; all rural Iranian women supplemented the family income by weaving ne carpets, which they planned to sell to bazaar merchants or individuals. None of the Afghan women interviewed were involved in this industry. Urban families lived mainly in one-room apartments in nuclear family units, with few belongings. Rural Iranians lived in much larger homes, with several rooms and often owned agricultural land, such as sunower elds or elds of fresh greens (sabzi), including parsley, cilantro, spinach, or small leeks, and livestock. Some rural Afghans (particularly Tajiks and Parsis and a few Pashtuns) lived in one-room-perfamily dwellings with a shared courtyard and basic amenities such as electricity and a water fountain in the courtyard. Most of the rural Pashtun Afghan homes were built of mud and straw, in collectives or long rows housing between ve and 100 families, alongside agricultural elds, and had no electricity or running water. Urban and rural Iranian women tended to have formal educationat least up to the fth grade. Urban and rural Afghan women were all illiterate, except one. The main difference between Iranian informants and non-Pashtun Afghan informants was not the acceptability of family planning in Islam, but when to begin to use birth control. Iranians typically used some form of contraception following the second child. For non-Pashtun Afghans, whether Shia or Sunni, contraception was initiated after the fourth or fth child. Thus, for these groups, differences in rst use of contraception could be a function of desired family size. Unlike other Afghan Sunnis, most Pashtun informants, who all lived in rural Isfahan, emphasized that it was up to God to determine how many children they had and that Afghans like to

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Table 1 Attitudes and Use of Contraception in Islam: Comparisons by Religion, Urban/Rural Locality, and Ethnicity
Not OK but use FP 2 1 5 19 5 2 4 2

Informants Iranian Urb (Shia) n = 15 Iranian Rur (Shia) n = 17 Hazara urban (Shia) n = 21 Pashtun Rural (Sunni) n = 31 Tajik, Parsi Rur/urb (Sunni) n = 17

FP OK 11 14 14 7 9

Not ok 2 1 4 22 3

Unknown 2 2 3 2 5

Use FP 13 15 16 8 10

Dont FP 2

have lots of children. Although the numbers are small, Table 1 demonstrates the attitudes toward and use of contraception among the informants in this research, based on ethnicity, ruralurban location, and religion. Other rural and urban Afghans included Sunni Tajiks and Parsis. Their perceptions and use of contraception were not signicantly different from those of urban Hazara Shias. As can be seen from Table 1, several Sunni Afghan informants were using contraception and did not think it was against their religion; several stated that it was against their religion but used it anyway; and several Shia believed that family planning was against Islam. In fact, ethnic differences could play a larger role than religion. For example, ethnic Tajiks and Parsis, who were also Sunni, expressed no moral conict about using family planning, and did not perceive it to be against their religion. Many Sunni Pashtun informants declared that Irans promotion of contraception was against Islam, because it is up to God to determine when to give life and when to take it away. Except for a few, all Shia Iranian informants believed the use of contraceptionincluding sterilizationwas acceptable in Islam because God wants us to have healthy families.

Fewer Children, Better Life (Farzand Kamtar, Zendegi Behtar)

Throughout health clinics in Iran, there are numerous posters that advocate family planning. One of the most often-repeated phrases uttered by health workers and Iranian women alike was farzand kamtar, zendegi behtara prerevolutionary slogan that is being recirculated in current family-planning outreach efforts. All women patients who come to the clinic for a variety of complaints, or who bring in their children for vaccinations or check-ups, are rst diverted to the familyplanning nurse. If the patient has a chart, the nurse looks up the patients birth control method, asks her if she is still using it, and if it is working well for her. If there is no patient le, as in cases with undocumented refugees and people new to

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the clinic, the patient is questioned about her method of birth control. (The patients were almost all women bringing in their children. If a couple came in they were both questioned together, but this only happened on three occasions in the rural clinic, and not at all in the urban one.) The nurse then tells all Iranian and Afghan patients who have at least two children that they must use family planning. Although the nurses insistence sounds like an order, many women who do not want contraception nd ways not to comply by simply nodding, taking what is offered, and walking away. Iranian women are encouraged to use any method they choose, such as condoms, contraceptive pills, IUDs, and so on. Afghan women, however, are strongly encouraged to choose either Depo-Provera injections (ampul), Norplant, or IUDs. Nurses explain that Afghans will not use the pill properly, cannot get their husbands to use condoms, and that longer-lasting methods that they do not have to worry about will work better for them. Many Afghan women who did want birth control, in both urban and rural locations, also preferred ampul over other methods because it could not be detected by their husbands. Although contraception is equally encouraged, there is a discrepancy between promoting certain kinds of contraception for Iranian women that rely on patient self-control and other types of contraception for Afghan women that require clinical control. Clinic staffs assume that either Afghan women will not comply with family-planning recommendations or will not know how to properly use methods that require their involvement. In almost every interview in which women were asked why they had decided to limit their families to one or two childrenin both rural and urban settings Iranian women repeated the phrase farzand kamtar, zendegi behtar. Such slogans were not typically reiterated by Afghan informants. Other reasons Iranian women gave for limiting their family size included poor economic conditions, unemployed husbands, lack of space in their homes, and feelings that they and their existing children had few opportunities for a better future (emkenaat nadarim). Iranian women who had four or more children often complained of lack of space and resources to meet the needs of their families, and claimed a lack of knowledge about contraceptive services. The majority of Iranian women felt that in Islam it was acceptable to use contraception because, as several women stated, God wants us to have healthy families and does not want us to suffer. Only ve Iranian women felt that it was a sin (gonah) to use contraception in Islam, but they used it anyway because of economic necessity. Of these ve, all but one lived in a rural village. In one village outside Isfahan a group of ten women, of three generations, were discussing birth control and family over the fast-breaking dinner (eftar) during the month of Ramadan. All agreed that in the early years after the revolution it was desirable for Iranian women to have at least ve or six children. Currently, because of Irans economic situation, unemployment rate, and drought that has had a severe impact on farming villages, it is becoming preferable to only have one or two children. One of the women, the wife of the village behvarz has only one son. She stated: I would love to have more children, but we cant afford it. Also, my husband is the behvarz here. He says if we have more children, it will be more difcult for him to encourage family planning among others in the village. I hope in a year or two he will say we can have another.

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Her mother replied: When I was young we were told it is good to have lots of children. Everyone I know had at least four or more kids. Myself, I had given birth to ten children, and half of them died from a blood problem [she was Rh negative]. Before they used to tell us its best to marry your cousin because the families are already close and it is easier, now they tell us dont marry your cousin because it is too close, and there are problems with disease that run in the family. That is probably why I lost so many children. Now I think it is probably best not to marry your cousinbut to have only one or two children? Our lives were better when our houses were lled with children. The older women present nodded in agreement, contradicting the ofcial view that fewer children necessarily meant a better life. Cases such as this demonstrate a remarkable shift in thinking about family that has occurred in just one generation, which coincides with the timing of Irans family-planning promotion efforts.

As Many as God Wants (Har Che Khoda Mikhoad)

When Tober asked Afghan informants How many children are enough? responses varied more according to ethnic differences than religious differences. Sunni Tajik and Parsi women living in rural Isfahan typically said four or ve children was the ideal and use contraceptives (usually IUDs) to ensure that no more children would be conceived. Their husbands also agreed with the use of contraception, stating that the four or ve children they had was enough. Shia Hazara Afghan women, who lived in urban Isfahan, were divided on the issue of using contraceptives. Approximately half of the Hazara women who already had four or ve children and stated they did not want more used ampul. Their main reason for using ampul over other birth control methods was that it is not easily detected by their husbands. Although ofcially a woman is supposed to have her husbands permission before using contraception, this is not usually what happens in practice. Women who came to the clinic asking for contraception usually received it without further questioning. Several Hazara women also came to the clinic to have their IUDs removed and to schedule tubal ligations before their anticipated return to Afghanistan, citing fear that the lack of reproductive health services in Afghanistan would put them at risk of infection. These women also expressed fear that unless they were sterilized they would likely have more children than they were able to care for or would likely die in childbirth. In Afghanistan, maternal mortality is the leading cause of death for women (UNICEF 2004). Unlike other contraceptive measures, women were unable to get surgical sterilization without their husbands permission. Women who did have their husbands permission opted for oral contraceptives, IUDs, or tubal ligation over ampul. Hazara women who decided not to use contraception, regardless of the number of children they had, stated that they were afraid their husband would take a second wife if they did not continue to have more babies (a practice not typically found in the Iranian communities today). All of these women reported feeling overwhelmed and exhausted by too many children; poor economic conditions caused by their husbands lack of employment; fear of having to return to Afghanistan where their

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children were more likely to die from disease, hunger, and lack of medical services; and fear that their children would have no opportunities for a better life. Pashtun informants in this study lived in rural Isfahan, were Sunni, and were the least likely to use family-planning services. They also came from agricultural communities in Afghanistan and for the most part had little or no primary school education. When asked how many children are enough? Pashtun men almost unanimously declared as many as God wants (Har che Khoda mikhoad). Out of the earshot of men, Pashtun women would often say that the number of children they had was enough, (basteh), whether they had two or ten children. When queried further regarding what they were doing to make sure that they did not conceive more children, the typical response was nothing, (hichi). Out of over 30 Pashtun families that were visited and interviewed, only four families were found in which the husband permitted his wife to use contraception after four or ve children. Several Pashtun women were using some contraception without their husbands knowledge. Only one Pashtun couple expressed a desire to limit their family to two children. This man and woman had come to Iran with their families when they were two years old and were rst cousins. In Iran they had received an education to the fth grade, and were the only couple in this community that could read and write. They were thus recruited by the physician at the village health center to be trained as volunteer health workers and were assigned to educate other members of their community about family planning, food preparation, and other health-promoting activitiesa plan that appears to be improving living conditions in this rural community. Several important aspects inuencing Pashtun lack of contraceptive use include: extremely low literacy (less than 5 percent in this community), a declared Pashtun cultural identity that Afghans like lots of children, and the notion that birth control is against Islam. One Pashtun man declared that the Islam in Afghanistan under the Taliban was better, or more correct, than the Islam in Iran, because of their respective positions on family planning. He states: In Islam, God wants us to have many children. He decides when to give children, and he decides when to take them away. Iran is a good country, it is an Islamic country, but they dont want us to have so many children, and that is not correct. Here, tension can be seen between PashtunSunni and IranianShia interpretations of what constitutes proper Islamic conduct in regard to procreation. Interestingly, though, Afghans from other ethnic groups (e.g., Hazara, Tajik, and Parsi) voiced a higher degree of acceptance to using contraception, regardless of whether they identied as Shia or Sunni or lived in urban or rural locations. Thus, cultural and situational differences between various Afghan groups inuence reproductive behavior. Among the Pashtuns, these cultural differences are expressed through the language of religion and cultural identity. Another major point made by the informant above is that life and death are completely in Gods hands, and a notion of submitting to divine will. This particular man had eight sons, including four who had died in Afghanistan. When asked how they had died his response was: I dont know why they died; the doctors dont know why they died; only God knows. When he is ready to take them, he takes them. This notion of God taking ones children was expressed repeatedly by all Afghan informants who had lost children in Afghanistan because of war and sickness.

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Girls Are Not Good (Dokhtarha Khub Nistand)

Research in Pakistan (Winkvist and Akhtar 2000) and Egypt (Yount 2005; Yount et al. 2000) demonstrates the inuence of son preference on larger family size and reduced contraceptive use. As part of Irans efforts to promote family planning within its own population, son preference has been reframed to emphasize that girls and boys are equally good, and that in Islam both girls and boys are valued. Repeatedly in clinics, when a woman expresses a desire for a son, the health care worker admonished: Why? You should be happy to have a healthy child. There is no difference between girls and boys. Gradually, this notion that girls and boys have equal value has become more accepted in the Iranian community, where opportunities for girls are much greater. Some Iranian women even voiced a preference for girls, stating daughters will always stay closer to their mothers and help them in old age, whereas, sons will go off and take care of their own families, forgetting about their parents. The effect of promoting the notion of equality between boys and girls theoretically reduces the possibility that couples will continue to have children until they get the desired number of boys. As Yount (2005) points out, increased education among women also reduces son preference. Desire for sons among Afghans in Iran does affect family-planning practices. Informants repeatedly stated how they would continue to have children until they produce a son, regardless of the numbers of daughters they already have. Others, who have either more sons, or an equal number of daughters and sons, seem more likely to stop at four or ve children. One Pashtun man with six sons (plus two who had died in Afghanistan) emphasized he never had a desire for daughters, considered himself lucky to only have sons, and thanked God for his good fortune. One Hazara Afghan woman, 26, with three daughters (ages one, two, and nine), living in urban Isfahan, described her quest to have a son: In Afghanistan, I had two sons die. It was 3 years agoright before we came to Iran. They were 3 and 5. . . . I dont know why they died. They were sick. Perhaps God was ready to take them. Ever since, my husband has been very depressed (naraahat) because he no longer has sons. When we came to Iran, we had two more children. I prayed they would be sons, for the sake of my husband, but we got two more daughters. I am so tired all the time. I hardly eat, so I can feed my family. We have no space for more children, but I want to try again to have a son for my husband, so he wont be so depressed. The consequences of extended war, forced migration, and lack of health services in Afghanistan, resulting in the deaths of ones children, has a dramatic affect on reproductive decisions, even when other factors (fatigue, lack of space, economic constraints, etc.) would weigh heavily in favor of the use of contraceptive measures. In this particular case, the womans desire to alleviate her husbands depression prompts her to continue to try to have more children, despite her own fatigue. All Afghan groupsalthough particularly Pashtunsprioritize having boys. However, this emphasis on having sons is also overstated by Iranian health care workers. Health workers repeatedly express frustration that Afghan families do not count the number of daughters. They state, when asked how many children do you have? (chandta bacheh darid?), most Afghans will only count the

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number of boys, or they will reply, I have three children (bacheh) and two girls (dokhtar). What the health workers do not understood is that in most Afghan languages bacheh means boy (whereas in Farsi it means child), and the generic term for children in many Afghan dialects is olaad.5 Thus, a lack of understanding of Afghan languages and dialects leads some Iranian health workers to overestimate son preference. Still, Afghan informants repeatedly statein the presence of little girlsthat girls are not good (dokhtarha khub nistand). Even preteen girls reiterate that girls are no good and express a desire for brothers and, after marriage, sons. In many Afghan communities, bride price is the custom for marriage. Iranian health workers perceived this practice as further evidence that Afghans dont value their daughters. Although girls can be sold at any age, especially among poor Afghanseither for adoption, for household labor, or marriagethis does not necessarily demonstrate that Afghans do not love or value their daughters, or that they see them solely as property. This practice is more likely to occur if the family is poorer than average and if the people receiving the girl live close by and are considered to be a good family. One Hazara woman had sold her third daughter at birth to a childless couple in her community: They are a good Muslim family. They do their prayers; the woman has good hejab [dresses modestly and wears the chador]. They were not blessed with children of their own, so I sold them my daughter. In this case, selling her daughter is similar to adoption, which is technically not allowed in Islam, rather than for the purpose of becoming a bride. When possible, girls will be exchanged as brides between households, especially between two related households (e.g., two girl cousins who marry each others brothers). When an Afghan girl gets married (usually between the ages of 11 and 16), families must go to great expense to provide their daughters with a sufcient dowry of household items to take with them to their new homes. This exchange avoids the cost of bride price, which in Iran is equivalent to between $2,000 and $3,000. Several Afghan fathers reported how they missed their married daughters after they left (delam tang shodlit., my heart became tight). When we asked one father who just sold his daughter for marriage how he felt, he responded: If I cut off my arm would I miss it? Of course I would. Selling [foroukhtan] my daughter is like cutting off my own arm. Mothers commonly discussed their fears that their daughters would have an unhappy life, and would be unlucky (badbakht) like themselves. The preference for sons in this community is thus for practical and nancial reasons, as well as for emotional reasons.

Afghanistan, the Broken Country (Afghanistan Kharaab Shod)

Although family planning and repatriation policies appear to not be related, interviews with Afghan informants prove otherwise. As a marginalized group, many Afghans view Irans family-planning efforts with some suspicion, especially in light of government efforts to repatriate them. Afghan refugees are caught in an untenable situation: low-income Iranians blame them for their own rising costs and unemployment. The Iranian government, which has borne the burden of their care with little outside assistance, declares that their health care costs cause an economic strain on the Iranian economy. Many Afghans themselves feel it is time to return

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to Afghanistan but fear that there are no opportunities in Afghanistan and that the country is still unsafe for themselves and their children. Others, however, want to stay in Iran: they have more services available to them than they had in Afghanistan, they have rebuilt their lives, and feel Iran is their home now. Since 2002, Iran, under the guidance of the UN High Commission for Refugees, has aggressively stepped up repatriation efforts. Irans own internal economic difculties, including ination, increased taxes to support refugee costs, high unemployment rates, and a large population of highly educated (but unemployed) youth, has led to increased tensions between Iranians and Afghans in urban locations. While being interviewed about perceptions on using contraception, urban Afghans (mostly Hazaras) repeatedly mentioned fears surrounding repatriation, forced or voluntary. They believed that reducing their family size was probably a good thing, because of the high costs of raising children and lack of resources. Yet they also felt familyplanning programs were another attempt by the government to reduce the overall number of Afghans, despite the fact that Iranians were being equally targeted for family-planning services. As tensions between Afghans, Iranian neighbors, and the state were on the rise, their suspicions of the system increased. The tensions between urban Iranians and Afghans became glaringly evident during one clinic interview in urban Isfahan. A group of Iranian women were sitting on a bench outside the ofce waiting for vaccinations for their children. A group of Afghan women were on another bench outside the same ofce. The health worker declared vaccinations had just run out for the day. One of the Iranian women stated: We would have plenty of vaccinations for our children if it werent for the Afghanis [sic]. They come here and our taxes go up. They increase the cost of our housing. Their husbands take our husbands jobs, so we have no money. Their children go to our schools, and they have too many of them. Life in Iran would be better if they would all go back to their own country. The Afghan women on the other bench pulled me aside, crying: What can we do? My own country is broken like my body, and it will never get better. I am so tired all the time from worry. My family has lived in Iran for 20 years. It used to be good. It is an Islamic country, for us Shia. In Afghanistan they dont like Hazara. Now, we cant live here and we cant live there. In Iran, they want to keep us from having too many children, and then they want to send us back [to Afghanistan]. What can we do? Nowhere is home for us. After everyone left, the health worker complained: I had 50 children in here for vaccinations today. Forty-three of them were Afghan, and only seven Iranians. If the Afghans didnt have so many children, there would be more vaccinations for everyone. We dont have enough supplies to go around. Iran bears all of the responsibility for these refugees and we dont get enough assistance from other countries to take care of them. In both rural and urban clinics, staff expressed frustration at the shortage of medical supplies and believed that Afghans use too many of some resources, but not enough of others, like contraception. Repeatedly, health workers remarked that caring for the refugees should be a global responsibility, but that Iran is forced to carry most of the burden.

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Although many rural Iranians did say that they felt the Afghans had too many children and it was time for them to return, they also acknowledged that it was Irans duty to help other Muslims and that Afghans were unlucky. Rural Afghans whether Pashtun, Tajik, or Parsidid not have the same kind of conict with their Iranian neighbors and expressed little or no desire to return to Afghanistan. Still, Pashtun men repeatedly voiced resentment that Irans family-planning program was aimed at controlling the Afghan population, and that having children was a private matter, or up to God.

Conclusion
The Iranian public health system provides basic health services for all low-income patients. Many of these services, like childhood vaccinations, treatment of infectious disease, and family planning, are free. For Iran, which is actively trying to reduce the size of its own population, large Afghan families are seen as creating further economic challenges because of the costs of their care. At the state and healthsector levels, Iranian ofcials express frustration that family-planning services are not positively received across the board. Although many Afghans (esp. Pashtuns) do not want family planning at all, those who do, want it on their own terms and resent feeling pressured to use contraception before they reach their desired family size. Carolyn Sargent (this issue and Sargent and Cordell 2003) has discussed the moral conicts that Muslim Malian migrants in France face when confronted with Frances attempts to promote family planning in their communities. One would assume that when Muslim migrant populations move to a country with the same basic religionalthough, of course, there are signicant differences between Sunni and Shia Islamthere would be substantial ideological agreement between the two cultures in regard to family and reproduction. Yet this is not the case in Iran. Similar population policies that, when used in Western countries might be interpreted to be targeted at reducing the number of Muslims, in Iran are interpreted as aiming to reduce the number of Afghans. Thus, whether there is a difference in ethnicity or a difference in religion (or both), it is the difference that can be perceived to drive family-planning programs. Although in Iran, Iranians and Afghans are equally targeted for family planning, many Afghans perceive that there is a difference. Among marginalized communities, family-planning programs become particularly suspect when accompanied by tensions between immigrant and local communities and an intense drive to repatriate refugees and immigrants. In Iran, these tensions were particularly felt in urban locations, where there is higher competition for resources between Afghan and Iranian communities. There are complex cultural, religious, and situational differences between poor Iranian and Afghan communities in Iran that affect perceptions and use of family planning. However, among Afghan groupswhich have had similar experiences of illness, death, trauma, loss, and dislocationthere are still signicant differences in the perceived acceptability and usage of family-planning services. Rural Sunni Pashtun families appear to have, on the average, more children than other Afghan groups (Hazara, Tajik, and Parsi), and to view family planning as being against Islam. Urban Shia Hazara families tend to be more inclined to utilize available services and do not express a conict with their religion to the same degree. There were

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comparatively fewer Tajiks and Parsis than the other two groups; however, those interviewed had all started using contraception after the fourth or fth child. Religious interpretations and cultural differences may have an impact on reproductive decision making, but religion itself does not seem to preclude the use of family planning in these cases. Urban or rural locality may also have an inuence on family-planning use. Urban or rural differences do not exist to the same degree for low-income Iranian families. Decisions to use or not use family planning are informed by a variety of factors, including cultural and religious differences, differential access to resources, and experiences of child death and infant mortality. In Iran, literacy, education, and acceptability and promotion of family planning by the clergy have positively inuenced the acceptance of family planning among the Iranian community. Among Afghans, those who had at least some access to formal education were more inclined to believe that having fewer children would positively inuence family health and overall quality of life. The inuence of exposure to education on views toward family planning deserves further investigation. Irans family-planning programs have been much more successful among Iranians than Afghans because, for one, Iranian clerical support for family-planning programs led to a reframing of Shia Islamic beliefs that God does not want people to suffer and that a healthy family is more important than a plentiful family. Afghan refugees, falling outside this reframing of Islamic discourse in regard to familyeither because of religious differences (e.g., Sunni), cultural differences (e.g., among Afghan Shias), or situational differencesaccept Irans family-planning initiatives to a lesser degree. Afghans who do use contraception do so later, after the fourth or fth child, rather than after the second, like most Iranians. Afghans who live in urban areas, where resources and space are limited, are most likely to want family-planning services. Among low-income Iranians, use of family planning is the same for those living in urban and rural locations, regardless of education, age of marriage, and other considerations. The experience of losing children to sickness and war in Afghanistan has undoubtedly had a dramatic impact on Afghan decisions to have larger families, as they know that some children will not survive. Among the Pashtuns, the belief that it is up to God to determine when life is given and taken away precludes the use of contraception in most cases. Health, economic, and social conditions for all Afghans have been much better in Iran than in Afghanistan. Yet Iranians are beginning to resent their presence and the perceived costs of meeting their health and other needs. With increasing tensions in Iran and continued instability in Afghanistan, Afghans remain trapped in a borderland, in an untenable situation, and this is reected in their reproductive decisions.

Notes
Acknowledgments. This material is based on work supported by the National Science Foundation under Grant 0220594; the University of California, San Francisco Academic Senate; and the American Association of Iranian Studies, all of which were awarded to Tober for the purposes of carrying out this research. We are extremely grateful for their generous support. Special thanks to the Isfahan University of Medical Sciences for its assistance in inviting and coordinating this work and to Dr. Zargarzadeh and Mr. Moradmand for

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the ofcial invitation and visa assistance. Deep gratitude is also extended to all the people who agreed to help coordinate and/or participate in this research. Any opinions, ndings, or recommendations expressed in this material are those of the authors and do not necessarily reect the views of the National Science Foundation or other organizations or institutions that facilitated this work. 1. Although the family-planning program was instituted in 1989, surgical sterilization methods such as vasectomy and tubal ligation were not approved until around 1992. 2. In Iran, the notion of harm has been redened with a more strict interpretation by Islamic leaders. Sterilization is not considered harmful because for men it can be reversed, and for women it is considered less harmful than bearing many children. This tendency to redene basic Islamic concepts to meet changing social circumstances and technological advances has led to more exibility in procedures and practices surrounding health and the body, including contraceptive treatments and infertility procedures. 3. Prevalence rates not available. 4. The principle investigator asked health ofcials and health workers at numerous urban and rural health clinics for health data and infant and maternal mortality rates among Afghans in Iran. During interviews, Tober was told that it was impossible to collect this information; many Afghans have no les because they move around too much looking for work and most Afghan women give birth at home so infant deaths will not necessarily be recorded. 5. Thanks to Patricia Omidian (personal communication, January 2003) for her observations on this distinction in Pakistan and Afghanistan.

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