Yemen is a desperately poor Muslim country that occupies the southernmost section of the Arabian peninsula. Its capital, Sana’a, contains about one million of the country’s 16 million to 17 million people, three-fourths of whom live in rural areas. Aden, at sea level, is the country’s other major city.

The present-day Republic of Yemen was born in 1990 from a fusion of the Yemen Arab Republic and the People’s Democratic Republic of Yemen. Although the fusion was expected to end the recurrent civil wars, it was interrupted by yet another period of strife, the brief and fiercely destructive "war of unity" in 1994.

I went to Yemen accompanying psychologist Dr. Henry David, a veteran international consultant who directs the Transnational Family Research Institute in Bethesda, Md. Our task, supported by an international foundation, was to consult with the Ministry of Public Health in Sana’a on reproductive behavior and family health and to lecture on these topics at the University of Aden under the auspices of the Eastern Mediterranean Region of the World Federation for Mental Health and the Yemen Psychological Association. More broadly, the task was to help further the process of culture change regarding reproductive behavior initiated by dedicated Yemeni professionals.

These were familiar tasks for me as a longtime student of reproductive behavior and personal fertility regulation, and our hosts understood my primary identity as a psychiatrist, as well as Dr. David’s, the mission organizer, as a psychologist. The problem is, after all, a psychosocial one, and culture change is essential to improving the nation’s health. Reproductive behavior is the country’s most fundamental health challenge.

Yemen has one of the highest fertility rates in the world, 6.5 children for each woman of reproductive age, recently down from 7.5. The country has high rates of infant mortality because of short intervals between birthsand obstetrical mortality from deliveries by village midwives. Having a baby is still a potentially lethal event in Yemen. Many infants die from umbilical-cord infections, virtually unheard of in the developed world. These are attributed both to lack of sanitary precautions and the use of ineffective or dangerous traditional methods to stop postpartum bleeding.

Several problems contribute to these pathologies. One is the very high rate of female illiteracy (estimated at perhaps 75 percent in the villages, less in the two major cities). While perhaps 80 percent of Yemeni boys are currently in school, that is true for less than 30 percent of the girls. Illiteracy is a major factor contributing to the lack of familiarity with and fear of contraceptive use.

Besides illiteracy, local variations of traditional beliefs (not supported by the Koran) contribute to the continued subjugation of women in this male-dominated society. With rare exceptions (the head of Aden’s department of psychiatry is a woman), motherhood is the only career and source of status available to most Yemeni women. A major contributor to the high birth rate is the lack of communication between marital partners about the possible reproductive consequences of their sexual behavior. This appears to be both a function of religious belief (that God determines the number of babies born to a couple) and a conviction that important decisions should be made by men. One approach to opening this situation for discussion is by initiating research on couples communication, and Dr. Maan Barry, the new head of the Aden medical school’s department of behavioral science, is working with Dr. David on this possibility.

These concerns are well known to health authorities, but they have few resources and little experience as agents of culture change. However, satellite television is making a difference for the more educated and affluent citizens. Some religious leaders appear increasingly accepting of change.

The minister of public health, Dr. Abdullah Abdul Wali Nasher, a former professor of surgery, has made a commitment to primary health care that recognizes the importance of literacy and fertility management. The ministry’s dynamic director for reproductive health, Dr. Nagiba A. Abulghani, notes that despite official verbal support, her only funds come from contraceptive marketing and clinical fees earned by her own department. Another dynamic woman leader is Jamila Al-Sharie, the national program officer of the Yemen Family Care Association, an affiliate of International Planned Parenthood. The association is heavily engaged in school education and communication programs. A final sign of hope for the cultural transition necessary for improved health is the newly reconstituted Woman’s Research and Training Center of the University of Aden directed by Dr. Ruckhsana M. Ismail. It will contribute substantially to the changes in women’s status and capacity to be self-determining.