  in international conference on population and development ( icpd ) held in cairo , egypt in 
 1994 , reproductive health affected by the comprehensive definition of health by world health 
 organization ( who ) in 1946 and its subsequent revisions in alma ata declaration in 1978 and 
 ottawa charter in 1986 , was introduced a state of complete physical , mental 
 and social well - being dealing with reproductive system .   when millennium development goals ( mdgs ) were created in 2000 , reproductive health was 
 specifically omitted . in 2007 ,
based on a recommendation by the who , the united nations 
 general assembly formally approved the addition of target 5b  achieve universal access to 
 reproductive health  to be nested under goal 5 of mdgsand new indicators such as adolescent birth rate ( abr ) , antenatal care 
 coverage , unmet needs for family planning and contraceptive prevalence rate were included 
 under this target .   according to credible global reports
, improvement of reproductive health - related outcomes 
 such as reducing maternal and child mortality in countries such as iran , largely owes to the 
 application of integrated primary health care .   in response to other challenges of primary health care ( phc ) such as providing ineffective 
 and low responsive services and alongside 
 of comprehensive insurance coverage of iranian rural population from 2005 ,
almost 100 
 percent of rural population became under coverage of family physician program and referral 
 system .
implementation of this program and its effects on health indices has been evaluated 
 in short term and this evaluation and several ongoing monitoring programs have shown this 
 program has been led to implicit and explicit improvements in health indices .  
although many short course evaluations of rural family physician program in iran have 
 underlined its benefits in improvement of many reproductive health indicators such as 
 maternal and child deaths , deliveries carried out by skilled attendance and 
 family planning coverage but none of them has pointed the status of early marriage or 
 pregnancies outside the typical child - bearing ages ( i.e. pregnancies under 20 years or over 
 35 years olds ) especially after running of this program .  
also none of studies mentioned above has evaluated a wide gamut of reproductive health 
 indicators in symmetric intervals before and after implementation of the program .  
therefore , in this study , we intended to examine a wide range of the most important 
 reproductive health indicators such as pregnancy outside the typical childbearing ages and 
 compare them in equal intervals before and after implementation of rural family physician 
 program in east azerbaijan province , iran .
  this ecological , time - trend study examined changes in the reproductive health indicators . 

raw data related to both age specific fertility rates and reproductive health indicators 
 were gathered from zij of the east azerbaijan rural population recorded between the years 
 2001 to 2010 in the department of health informatics in regional health center of east 
 azerbaijan province and required indicators were calculated using spreadsheet software 
 designed for this purpose .  
 it is noteworthy that vital horoscope ( zij ) is an oldest population - based vital registry 
 and is considered one of the most reliable sources of information on primary health care in 
 iran and its face validity has been confirmed previously .  
 also in this trend study we used all data related to 191075 births of rural women of 
 east azerbaijan during decade mentioned above and no inclusion or exclusion criteria have 
 been used .   for statistical analysis , we first examined data distribution using non - parametric 
 kolmogorov  smirnov test .
the normal distribution of the data using this test was documented 
 when p0.05 . after having verified the normal distribution of data , while data was divided 
 in two five - year periods before and after implementation of the rural family physician 
 program , paired t - tests
the correlations 
 between age - specific fertility indicators , family planning coverage and obstetric services 
 and the outcomes of each were analyzed as well and pearson coefficient and statistically 
 significant relationships between variables were calculated .
after testing , the indicators 
 were classified into four groups based on statistically significant level . accordingly ,
if 
 the mean of indicators change in two five - year periods , before and after the implementation 
 of the rural family physician program were evident at the statistically significance level 
 of p<0.01 , they would have considered as the strong evidence and in the levels between 
 0.01 and 0.05 as the weak evidence .
the levels between 0.05 and 0.1 and above 0.1 were 
 interpreted and analyzed as minor evidence and no evidence respectively . in correlation analysis , depending on the 
 correlation direction , we considered values between -1 and + 1 for the pearson correlation 
 coefficient and p0.05 was considered as statistically significant level .
  in this study , twenty important reproductive health indicators of the 191,075 births 
 recorded in the zij of east azerbaijan province between 2001 and 2010 were reviewed and 
 analyzed .
as the rural family physician program in the country was carried out extensively 
 in september 2005 and established by the end of 2005, indicators of the years 2001 - 2005 
 related to the data of 94 , 379 births as the indicators before running the program and the 
 indicators of the next five years derived from the data of 96,696 births as indicators after 
 running the program were compared using paired t - test ( table 
 1 ) .   *
asfr : age specific fertility rate , u5mr : under five mortality 
 rate , lbw : low birth weight , nmr : neonatal mortality rate , 
 imr : infant mortality rate , cpr : contraceptive prevalence 
 rate , mmr : maternal mortality rate   in the correlation analysis between specific fertility indicators and adverse outcomes of 
 reproductive health such as increased low birth weight ( lbw ) and increased neonatal death 
 due to prematurity and congenital malformations , the ten years trend was examined firstly 
 table 2 which showed a correlation between increase 
 in lbw and increase in fertility rates among women 10 - 14 years old with r=0.69 and p= 0.025 
 but after restriction of our trend study to after program implementation period this 
 correlation was documented only for abr and lbw . 

asfr : age specific fertility rate , lbw : low birth 
 weight , pearson r , the rural family physician program    also our analysis showed a significant correlation between increased neonatal mortality 
 due to prematurity and congenital malformations and increased abr ( r=0.765 , p= 0.010 ) and 
 increased specific fertility rate among women over 35 year olds ( r=0.68 and p= 0.028 ) , this 
 correlation was strongly evident only for age - specific fertility over the 35 years after 
 running the program ( r=0.91 , p= 0.031 ) .
it is worth noting that with restriction of trend 
 period from 10 years to 5 years although the magnitude of correlation has been improved it s 
 statistically significance has been diminished due to reduction in the number of 
 observations .  
correlation analysis of indicators related to family planning and obstetric facilities and 
 their desirable effects in reducing child mortality rates ( ranging from perinatal mortality 
 to under five mortality rates ) shown in tables 3 
 suggested that although the increase in all methods contraceptive prevalence rate ( cpr ) 
 after running the program in comparison to before it was not statistically significant and 
 its correlation with the reduction of child mortality was negligible , ten - year trend 
 analysis indicated its correlation with the reduction of many mortality indicators .
however , 
 the correlation analysis of the mentioned indicators in the 5-year period after the 
 implementation of the program confirmed the minor role of the increased cpr , and there was a 
 relatively strong reverse correlation between the increased hospital delivery and reducing 
 stillbirth rates either in the ten - year period(r=-0.91 , p=0.00 ) or in the period after the 
 implementation of the program ( r= - 0.91 , p=0.03 ) . 

u5mr : under five mortality rate , lbw : low birth weight , 
  imr : infant mortality rate , nmr : neonatal mortality 
 rate , pearson r 
 figure 1 to figure 
 3 shows the adolescent birth rate , adolescent marriage trends from 2001  2010 . adolescent birth rate and under five mortality rate of east azerbaijan rural 
 population ; ( 2001 to 2010 ) trends adolescent number , marriage and birth rate of east azerbaijan rural women ; ( 2001 to 
 2010 ) trends adolescent marriage and birth rate of east azerbaijan rural women ; ( 2001 to 2010 ) 
 trend
  as the results of this study shows primary health care in this province has achieved 
 unique successes in the field of reproductive health , especially after implementation of 
 family physician program in rural areas in the mid-2000s , some of them were 
 the reduction of child mortality rates namely stillbirth rate , neonatal mortality rate 
 ( nmr ) , infant mortality rate ( imr ) and under five 
 mortality rate ( u5mr ) , increase of the safe delivery and decrease of unsafe delivery and 
 increase of using contraceptive methods ( all methods not only safe ones ) .  
our literature review about the impacts of family physician implementation on reproductive 
 health of iranian rural population yielded only a few similar studies . in a study on qazvin 
 rural population ,
data was extracted from rural zij during seven years 
 ( 2004 - 2010 ) .
this study concluded that 
 family physician program improved some health indicators such as maternal mortality rate 
 ( mmr ) , nmr , imr , safe delivery and contraception methods use but was accompanied with rising 
 lbw and stillbirth rate . with the exception of the last measure , changes of others have 
 similarities to our study findings though time intervals before and after program running 
 were not equal in this study .   in another study that has the most similarities to our analysis , reproductive health 
 indicators adapted from rural zij of isfahan province during 2000s i.e. four years before 
 and six years after running of family physician program were analyzed and like to our study , 
 decreased mortality rates of children and increased rate of safe delivery have been 
 introduced as beneficial achievements of program implementation .  
another study that was done upon rural population auspices of mashhad university of 
 medical sciences used only eight health indicators of mother and children extracted from 
 sources other than zij and compared these measures from four years before until three years 
 after family physician program implementation.findings of this study could not show any significant difference between 
 the mean values of indices before and after implementation of the program though the authors 
 believed that the seven years trend of indicators confirmed positive impact of the 
 program .  
finally , in addition to above investigations in which were done in sub - national level , one 
 national study using data from iranian rural zij , analyzed changes of eleven main health 
 indicators from 2003 to 2007 and concluded that there was an acceptable improvement in many 
 of them such as mmr , nmr , u5mr , safe delivery and also in stillbirth rate to some extent 
 since starting family physician program . 

this study notified that factors other than family physician program should be included in 
 interpretation of these improvements .  
it is noteworthy that none of studies mentioned above has analyzed a wide range of health 
 indicators in equal intervals before and after family physician program running similar to 
 our study .
also our study has a unique characteristic in which discriminate it from other 
 evaluation studies described before and it is its focus on trend changes of pregnancies 
 outside the child - bearing age and their adverse consequences as will be described below .  
the results of the present study evidenced this fact that achieving some successes , such 
 as reducing child mortality and the emerging of some problems such as higher occurrence of 
 adolescent birth rate ( abr ) , as shown in figure 1 , 
 occurred symmetrically and simultaneously .  
examining the trend of rural abr in east azerbaijan in a ten - year period(2001 to 2010 ) 
 represented a dramatic increase of the indicator from the figure of 35 to 52 births per 1000 
 adolescents which was higher than the global average of 49 births per 1000 and the national 
 average of 31 births per 1000 .  
one of the reasons for the slow decrease in abr in the world is the increase of the 
 adolescent population.the subject is not 
 true for the population in this study because of the population decline in rural adolescents 
 of east azerbaijan province in this study period in which doubtlessly is due to 
 reestablishment of family planning and birth control in iran after 1989,the pregnancy trend in this age group has had 
 relative stability which exacerbated abr .
this means that the proportion of birth to total 
 number of adolescent women ( i.e. abr ) has been increased obviously because of decreasing 
 magnitude of the denominator ( figure 2 ) .   according to figure 3 which shows the trends of 
 ten - year marriage and pregnancy of rural adolescents we achieved this fact that adolescent 
 birth rates have been increasing more rapidly than the marriage of adolescents after 
 implementation of the rural family physician program , especially since 2007 .  
statistics show that 30 percent of girls in low - to middle - income countries are married 
 before 18 mostly are from poor and rural families with low education.in the present study , the percentage of the 
 married under 20 year olds was close to the aforementioned figure .
it is expected between 
 the years 2021 to 2030 , maintaining the current trend of child marriages , more than 150 
 million children worldwide will suffer early marriage each year .
thus , putting an end to the 
 marriage in childhood and adolescence should be considered as a priority for the development 
 of human society after 2015 in which the assessment of mdgs will be finalized .  
investigations of the achievement rates of the mdgs have shown that the role of child 
 marriage should be considered as an obstacle to achieve an acceptable level for many goals 
 such as eradication of poverty and hunger , promotion of primary education and gender 
 equality and reducing child and maternal mortality .  
although prevention of girls marriage before age 18 has been expressed in the first part 
 of guideline of reducing adolescent pregnancy and its complications- prepared by the 
 who , it seems that the implementation 
 of this item of the guideline is not possible without changing cultural and traditional 
 attitudes of the communities . by the way , it requires the serious participation of family , 
 school , health care institutions for privation of adolescent pregnancy under 20 years 
 olds .   in the present study ,
what was considered as the main reason for the increase in 
 adolescent pregnancy after intensification of maternal care system , in addition to running 
 rural family physicians program since 2005 was merely implementation of the item 2 in the 
 aforementioned guideline in which the increase of prenatal care and safe delivery have been 
 focused , and of course the first 
 item of the guidelines is not easily applicable because of legal and cultural barriers in 
 iranian community .  
one of the main causes of lbw is adolescent pregnancy which its correlation has been fully 
 confirmed in the present study .
in addition to the short - term effects of lbw such as 
 increased neonatal mortality rate and the child 's developmental growth disorders , it causes 
 long - term complications such as cardiovascular diseases and diabetes mellitus in the older 
 ages .
some justify the correlation 
 between adolescent pregnancy and lbw with lower weight gaining of adolescent mothers during 
 pregnancy which was not confirmed by 
 some other studies and they considered this correlation very important and significant even 
 after adjusting the confounding factors such as maternal weight gain rate during pregnancy , 
 socio - economic factors and the level of prenatal care .   unlike many studies that suggested an association between advanced maternal age and 
 increased lbw , the correlation between these two indicators has not been proved in 
 this study .
however , examining of the association between maternal age and increased 
 congenitally malformed and premature births in this study was impossible , because numbers of 
 the congenitally malformed and premature births were not recorded in the zij ; so , we 
 inevitably focused on and analyzed the mortality of premature and congenitally malformed 
 neonates . in this respect , it seems that there is a strong and direct correlation between 
 the increasing of pregnancy rates over 35 year olds and increased mortality in premature and 
 congenitally malformed infants .
perhaps , the age of mother determines the severity of the 
 malformation and prematurity of infants born .
of course with calculation of other indicator 
 that refers to specific mortality rate for children ( up to age 5 year ) caused by 
 malformation and prematurity and noticing its decreasing trend , we may conclude that if 
 malformations and prematurity put children 's lives at risk , it is limited to more severe 
 kinds in neonatal period .   providing maternal health affects many demographic rates and reproductive health outcomes 
 such as birth rates , fertility rates ( general and total ) and rates of miscarriages and 
 stillbirths , particularly lbw in which 
 the last one is one of the reproductive health problems in our studied rural population .  
one of the reproductive health achievements of our studied rural population is decreasing 
 stillbirth that has a strong reverse correlation with increasing safe delivery at the 
 hospital .
stillbirth rates reduction less than one percent ( or 9 per thousand births ) in the 
 rural population compared to world statistics with an average of 1.9 percent ( 19 cases per 
 thousand births ) is regarded as one of 
 the public health successes .   finally , the main strength of our study is that we used population - based data .
but the 
 obvious limitation of our study is that time trend analysis for the evaluation of the 
 relation between two health indicators is a relatively crude method .
so any association 
 discovered between age - specific fertility rates and adverse outcomes in our study does nt 
 imply any causality relationship . to confirm any causality relationship we recommend the 
 implementation of studies with high level of evidence such as historical cohort or 
 case - control study .
also our findings have many limitations to become generalized to iranian 
 population mainly because our data was gathered from only rural population of east 
 azerbaijan .  
another limitation is related to our data source in which does nt contain many 
 reproductive health indicators regardless of its strong reliability . also to have a better 
 judgment about any difference between health measures as an event rate before and after a 
 widespread intervention such as family physician program we decide to use an appropriate 
 model such as poisson regression .
  all in all , after implementation of family physician program and using skilled midwifery 
 workforce in rural areas , the rates of the perinatal care and the occurrence of safe 
 delivery were increased even for pregnancies outside the typical child - bearing ages and by 
 more accurate implementation of integrated maternal and childcare and appropriate and timely 
 referral system , the rates of child mortality and stillbirth have been obviously reduced . 
 however , examining the causality relationship between pregnancies outside the typical 
 child - bearing ages and incidence of lbw and mortality of premature and congenital malformed 
 neonates requires further appropriate studies . also decreasing lbw deliveries should be 
 regarded as a healthcare priority due to its long - term adverse outcomes .
  the researchers would like to render their thanks to staff of the department of health 
 informatics of east azerbaijan health center , who made the rural vital statistics available 
 for the researchers .
 
 introduction : implementation of rural family physician 
 program in iran in 2005 has been evaluated and shown that this program has been led to 
 some improvements in health indicators . in this study , some reproductive health ( rh ) 
 indicators were compared before and after implementation of this program in rural areas of 
 east azerbaijan , iran . 
 
 methods : in this ecologic- time trend study , the data of 
 191075 births of rural women of east azerbaijan from 2001 to 2010 was extracted from vital 
 horoscope ( zij ) and used for calculation of 20 important rh indicators . the paired t - test 
 and correlation analysis wear used for data analysis . 
 
 results : some indicators such as adolescent marriage rate , 
 adolescent birth and over 35 year olds birth rate were increased after rural family 
 physician program implementation in 2005 . also stillbirth rate and unsafe delivery 
 were 
 decreased during this period . 
 there was a significant correlation between increasing 
 adolescent birth rate and increasing low birth weight deliveries ( r= 0.911 , p= 0.031 ) and 
 also between increasing over 35 year olds birth rate and increasing neonatal mortality 
 rate in term of prematurity and congenital malformations ( r= 0.912 , p= 0.031 ) after 
 program implementation . 
 
 conclusion : perinatal care and safe delivery even for 
 pregnancies outside the typical child - bearing ages are promoting after implementation of 
 rural family physician program in east azerbaijan . also decreasing unsafe delivery and 
 stillbirth rate can be considered as achievements of running this program in this 
 province . 
Introduction
Materials and methods
Results
Discussion
Conclusion
Acknowledgments
Ethical issues
Conflict of interest