Author's note: Numerous people in Oman's Ministry of Health facilitated my research. I particularly thank Dr. Ali Jaffer Mohammed, Dr. Yasmin Ahmed Jaffer, Mr. Ahmed al-Qasmi, Ms. Sabah al-Bahlani, Ms. Yusra al-Farsi, Mr. Ali Mehboob, Dr. Fatimah al-Ajami, and Dr. Manorama Vaswani, all of whom gave so freely of their time. My thanks also go to four anonymous reviewers, whose suggestions greatly strengthened the paper. Any opinions expressed in this paper, however, are the author's alone.

¹ The total population of the region quadrupled in the second half of the 20th century—a fifty-year increment of some 300 million, roughly equivalent to the current population of the United States and the fastest percentage growth of any major world region with the exception of Sub-Saharan Africa. The countries of the Middle East and North Africa currently have over 400 million people, but this number is projected to increase to almost 550 million people by 2025, and their combined populations could approach 700 million by 2050. By that time the predominant demographic problem could be entirely different: the massive youthful cohorts of today will have aged, and this huge, elderly population's needs will create heavy demands on health-care systems. See Population Trends and Challenges in the Middle East and North Africa (Washington, D.C.: Population Reference Bureau, 2001), 1; 2007 World Population Data Sheet (Washington, D.C.:, Population Reference Bureau, 2007). See also Roudi-Fahimi, Farzaneh and Kent, Mary Mederios, “Challenges and Opportunities—The Population of the Middle East and North Africa,” Population Bulletin 62 (2007): 1–24Google Scholar, and Winckler, Onn, Arab Political Demography, Volume 1, Growth and Natalist Policies (Eastbourne, U.K.: Sussex Academic Press, 2005)Google Scholar.

² Egypt, for example, has to annually produce an additional 650,000 jobs for school leavers joining the labor force. In Jordan, for every one person approaching retirement age, there are five people under fifteen poised to enter the labor force. See Hassan Fattah, “The Middle East Baby Boom,” American Demographics (2002): 55–60 and Central Intelligence Agency, Long-Term Global Demographic Trends: Reshaping the Geopolitical Landscape (Washington, D.C., 2001).

³ Roudi-Fahimi and Kent, “Challenges and Opportunities,” 3–5.

⁴ Oman, Ministry of Development, General Census of Population, Housing, and Establishments, 1993 (Muscat, Oman, 1994). It is striking that of the women who reported ten or more live births, only 55 percent of the children were still alive, indicating an exceptionally high infant and child mortality among women who were in their peak reproductive years in the 1950s and 1960s. Nevertheless, women reporting ten or more children who were still living accounted for 21 percent of mothers and formed the largest single category.

⁵ Parity measures the number of children to which a woman has ever given birth. The parity progression ratio is defined as the fraction of women at a given parity who proceed to have another child or progress to the next parity.

⁶ Chatty, Dawn, “Women Working in Oman: Individual Choice and Cultural Constraints,” International Journal of Middle East Studies 32 (2000): 247Google Scholar.

⁷ Eickelman, Christine, “Fertility and Social Change in Oman: Women's Perspectives,” Middle East Journal 47 (1993): 658Google Scholar.

⁸ This distinction is made by Cynthia Lloyd and Serguey Ivanov, “The Effects of Improved Child Survival on Family Planning Practice and Fertility,” Studies in Family Planning 19 (1988): 141–61.

⁹ Rosalind Miles, “Our Man in Oman; The Surprising Sultan—Feminist, Democrat and Steadfast US Ally,” Washington Post, 19 November 1995, C04.

¹⁰ “Qaboos For Birth Control and Nationalisation,” Arab Press Service Diplomatic Recorder, 15 January 1994.

¹¹ “Opinion: Sensing the Urgent Need for Checking Population Growth,” Times of Oman, 15 February 1994.

¹² Y. Sidhom, Z. Khairullah, A. Shrestha, and R. Timmons, Final Project Review Report of PRIME Project Support to the Oman Birth Spacing Program from June 1995 to June 1997 (n.p., 1997).

¹³ It is curious that no mention whatsoever is made of the Birth Spacing Program in Onn Winckler, “Demographic Developments in the Arabian Peninsula: The Case of Oman Under Sultan Qabus,” Journal of South Asian and Middle Eastern Studies 24 (2001): 34–60. Indeed Winckler observes that by mid-2000, “no specific steps have yet been taken by the Omani government in order to promote a national family planning program,” 51.

¹⁴ The ministry's Child Health Program Manual (1989) explicitly lists birth spacing through breastfeeding as one of its goals.

¹⁵ Al-Rawahi, Samira and Sharts-Hopko, Nancy C., “Birth Spacing Initiative in Oman,” Journal of Cultural Diversity 9 (2002): 23–26Google ScholarPubMed.

¹⁶ Sulaiman, Ali, Al-Riyami, Asya, and Farid, Samir, Oman Family Health Survey 1995: Principal Report (Muscat, Oman: Ministry of Health, 2000), 199Google Scholar.

¹⁷ Ibid., 117.

¹⁸ “Birth Spacing Campaign Achieves Good Results,” Times of Oman, 5 June 1997.

¹⁹ Sulaiman, Al-Riyami, and Farid, Oman Family Health Survey 1995, 221.

²⁰ Roudi, Farzaneh, An Analysis of Birth Spacing in the Near East (Washington, D.C.: Futures Group, Options for Population Policy, 1995)Google Scholar.

²¹ Oman, Ministry of Health, Al-Sukkan wa-l-Tanmiyya fi Saltanat ʿUman (Population and Growth in the Sultanate of Oman) (Muscat, Oman, n.d.), 28.

²² “Contraceptive Choice: 1997 Report Card” (Washington, DC: Population Action International, 1997).

²³ Oman, Ministry of Health, Department of Family and Community Health, Changes in Birth Spacing Knowledge, Attitudes and Practices in the Sultanate of Oman (Muscat, Oman, 1998), 5.

²⁴ One very remote government health center I visited, Wadi Shafan, was two hours from the nearest small town (Khabura) by four-wheel-drive vehicle along a mostly unpaved road that followed the course of a wadi. Although the catchment area of the facility included only 1,300 people in nineteen settlements from as far away as forty kilometers, the clinic was staffed by two Indian nurses, who on average saw only ten patients daily. The clinic provided birth spacing services to only ten women; one of these, a forty-year-old woman with fifteen children, had been pressed by a nurse to have an injectable contraceptive “for her own good.”

²⁵ One director general of a government ministry who also owns a pharmacy indicated in an interview that government statistics understate contraceptive use because they do not include the private sector. Nonprescription sales of condoms and pills from his pharmacy were increasingly important, particularly among educated women in Muscat who did not wish to visit or wait in a government clinic. Interview, Muscat, Oman, 20 January 2001.

²⁶ Oman, Ministry of Health, “Contraceptive Units Dispensed and Couple Years of Protection,” http://www.moh.gov.om/stat/HTML_FILE/Contraceptive%20Units%20Dispensed.htm (accessed 19 April 2008).

²⁷ Oman, Ministry of Health, Department of Family and Community Health, Birth Spacing Standard Operating Procedures: BS Manual, 2nd ed. (Muscat, Oman, 1997).

²⁸ Oman, Ministry of Health, Department of Family and Community Health, Programme of Strengthening Mother and Child Health Care Training Package, 4 vols. (Muscat, 1999).

²⁹ Oman, Ministry of Health, Birth Spacing Project, National Plan for Information, Education, and Communication in Birth Spacing (1995–2000) (Muscat, Oman, n.d), 7.

³⁰ The logo shows a married couple with only three children. Beneath it is the Arabic caption: “The health of the family is in birth spacing.”

³¹ Q. 46:15 (Ahqaf).

³² Oman, Ministries of Education and Health and UNICEF, Haqaʾiq li-l-Hayat (Facts for Life) (Muscat, Oman, 2000).

³³ Oman, Ministry of Health, Exit Interview: Birth Spacing Counseling (Muscat, Oman, 1999), 6.

³⁴ Ahmed Al-Mandhary, Ibrahim Al-Zakwani, and Mustafa Afifi, “Primary Health Care Consumers’ Acceptance, Trust and Gender Preferences Towards Omani Doctors,” Oman Medical Journal 22 (2007), 51–56.

³⁵ Center for Communication Programs, The Johns Hopkins School of Public Health, “Reaching Men Worldwide: Lessons Learned from Family Planning and Communication Projects, 1986–1996,” Working Paper No. 3, January 1997.

³⁶ Oman, Ministries of Health and Education and UNICEF, Fawaʾid al-Mubaʿada bayn al-Wiladat wa Wasaʾiliha (The Benefits of Birth Spacing and its Methods) (Muscat, Oman, 2000).

³⁷ Oman, Ministry of Health, Directorate General of Planning, Directorate of Research and Studies, National Health Survey, vol. 2, Reproductive Health Study (Muscat, Oman, n.d.), 88–89.

³⁸ Christine Eickelman, “Fertility and Social Change in Oman,” 652–66.

³⁹ “Birth Spacing Programme Bearing Fruit,” Times of Oman, 22 February 1995.

⁴⁰ Oman, Exit Interview, 21.

⁴¹ Oman, Ministry of Health and UNICEF, The Baby Friendly Hospital Initiative in the Sultanate of Oman (Muscat, Oman, 1994).

⁴² Oman, Ministry of Health and UNICEF, The Circle Has Widened: A Study of Omani Women Working as Community Support Group Volunteers in the Sultanate of Oman. Final Report (Muscat, Oman, 1998), 23, 28.

⁴³ However, Dawn Chatty notes that in the past, when the age of marriage was younger, it was considered inappropriate among the Harasiis to have a child until three or four years after marriage. Chatty, Dawn, Mobile Pastoralists: Development Planning and Social Change in Oman (New York: Columbia University Press, 1996), 145Google Scholar.

⁴⁴ Riyami, A. Al, Afifi, M., and Mabry, R., “Women's Autonomy, Education, and Employment in Oman and their Influence on Contraceptive Use,” Reproductive Health Matters 12 (2004): 144–54CrossRefGoogle ScholarPubMed.

⁴⁵ Oman, Ministry of Health, Directorate General of Planning, Annual Health Report, 2007 (Muscat, Oman, 2008), 8.19–20.

⁴⁶ As comparison, in Jordan 46 percent of married women who have ever used a contraceptive have relied on oral contraceptives and 37 percent have used an IUD. Injectables are almost completely insignificant, having been used by only 4 percent of women. See Jordan, Department of Statistics, Jordan: Population and Family Health Survey, 2007 (Amman, Jordan, 2007), 46–47.

⁴⁷ Eltigani E. Eltigani, Levels and Trends of Fertility in Oman and Yemen (New York: Population Division, Department of Economic and Social Affairs, United Nations Secretariat, Workshop on Prospects for Fertility Decline in High Fertility Countries, July 2001).

⁴⁸ The number of births fell from 47,000 in 1993 to 39,000 in 2001, as the overall population grew. Since then the number has risen to 44,000 in 2006, but this is an echo and simply reflects the large cohort of Omanis now reaching reproductive age.

⁴⁹ Over the years, the reliability of official data has steadily improved. A royal decree was passed in October 1999 making birth and death registration mandatory. Nevertheless, Oman did not enforce vital registration until May 2004. See Medhat K. El Sayed, “Civil Registration in the Sultanate of Oman: Its Development and Potential Implications on Vital Statistics,” Global Forum on Gender Statistics, Rome, December 2007.

⁵⁰ World Health Organisation, Regional Office for the Eastern Mediterranean, Country Cooperation Strategy for WHO and Oman, 2005–2009 (Cairo, 2006), 26.

⁵¹ The baseline survey was conducted among women attending gynecological clinics as outpatients in all parts of the country. The follow-up survey questioned a random sample of women and men between the ages of fifteen and forty-nine from pediatric and outpatient clinics and health centers in every region of Oman. Although these samples are not strictly comparable, the surveys do provide some indication of longitudinal changes in reproductive attitudes and behavior. See Oman, Ministry of Health, Department of Family and Community Health, Changes in Birth Spacing Knowledge.

⁵² United Nations Development Program, Human Development Report 2007 (New York, 2007), 248. In Jordan, Egypt, and Iran the percentages of married women between the ages of fifteen and forty-nine using contraceptives were 57 percent, 59 percent, and 79 percent, respectively. Population Reference Bureau, http://prb.org/Datafinder/Topic/Bar.aspx?sort=v&order=d&variable=44 (accessed 10 September 2009).

⁵³ Peterson, J. E., “Oman: Three and a Half Decades of Change and Development,” Middle East Policy 11 (2004): 125–37CrossRefGoogle Scholar.

⁵⁴ Dawn Chatty, “Women Working in Oman,” 242–43.

⁵⁵ Hill, Allan G. and Chen, Lincoln, A Summary of Rapid Health Transition in the Sultanate of Oman (Muscat, Oman: UNICEF and WHO, 1996), 1Google Scholar.

⁵⁶ Oman, Ministry of National Economy, Thirty Years of the Development Process (1971–2000) (Muscat, Oman, 2000), 23.

⁵⁷ Farzaneh Roudi, “Spotlight: Oman,” Population Today (1997), 7; Human Development Report 2007, 248.

⁵⁸ World Health Organisation and UNICEF, Joint Monitoring Programme for Water Supply and Sanitation, Coverage Estimates, Improved Drinking Water (Muscat, Oman, 2006).

⁵⁹ “Oman Tops WHO Health Efficiency List,” Oman Observer, 11 August 2001.

⁶⁰ “UNICEF Hails Oman's Achievement,” Times of Oman, 22 June 1994.

⁶¹ A. Al Riyami and M. Afifi, “Determinants of Women's Fertility in Oman,” Saudi Medical Journal 27 (2003): 748–53.

⁶² In the United Arab Emirates, the average cost of a wedding now exceeds $80,000. The trend to delayed marriage is found throughout the Arab world. See Rashad, Hoda, Osman, Magued, and Roudi-Fahimi, Farzaneh, Marriage in the Arab World (Washington, D.C.: Population Reference Bureau, 2005)Google Scholar and Bonnie L. Shepard and Joceyn L. DeJong, Breaking the Silence and Saving Lives: Young People's Sexual and Reproductive Health in the Arab States and Iran (Cambridge, Mass.: International Health and Human Rights Program, Harvard School of Public Health, 2005).

⁶³ Oman, Reproductive Health Study, 21–25.

⁶⁴ Eltigani, Levels and Trends of Fertility in Oman and Yemen, 8–13.

⁶⁵ Oman, Reproductive Health Study, 45.

⁶⁶ Oman, Ministry of Health, Oman Family Health Survey (Muscat, Oman, 2000), 146.

⁶⁷ Jaffer, Y. A., Afifi, M., Ajmi, F. Al, and Alouhaishi, K., “Knowledge, Attitudes and Practices of Secondary-School Pupils in Oman: II. Reproductive Health,” La Revue de Santé de la Méditerranée Orientale 12 (2006): 54Google ScholarPubMed.