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( ONTRACEPllON AND hEPRODUCIION Health Consequences for Women and Children in the Developing World Working Group on the Health Consequences of Contraceptive Use and Controlled Fertility Committee on Population Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1989

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NTV Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Goveming Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineenng, and the Institute of Medicine. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distin- guished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Frank Press is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs anned at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Robert M. White is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Samuel O. Tier is president of the Institute of Medicine The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal govemment. Functianng in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the govemment, the public, and the scientific and engineering communities. The Council is admini- stered jointly by both Academies and the Institute of Medicine. Dr. Frank Press and Dr. Robert M. White are chairman and vice chamnan, respectively, of the National Research Council. Library of Congress Catalog Card No. 89-63004 International Standard Book Number 0-30904094-9 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 Printed in the United States of America S028 First Printing, August 1989 Second Printing, May 1990

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Working Group on the Health Consequences of Contraceptive Use and Controlled Fertility WILLIAM FOEGE (Chair), Carter Presidential Center, Atlanta, Ga. JULIE DaVANZO (Cochair), Economics and Statistics Department, The RAND Corporation, Santa Monica, Calif. JOHN BONGAARTS, The Population Council, New York RONALD GRAY, Deparunent of Population Dynamics, Johns Hopkins University JOHN E. KNODEL, Population Studies Center, University of Michigan JORGE MARTINEZ-MANAUTOU, Family Planning Services, Mexican Institute of Social Security ANNE R. PEBLEY, Office of Population Research, Princeton University ALLAN G. ROSENFIELD, School of Public Health, Columbia University BRUCE V. STADEL, Epidemiology Branch, Food and Drug Administration, Rockville, Md. PETER ]. DONALDSON, Study Director ALLAN M. PARNELL, Research Associate SUSAN M. ROGERS, Research Associate DIANE L. GOLDMAN, Administrative Assistant . .

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Committee on Population ALBERT I. HERMALIN (Chair), Population Studies Center, University of Michigan FRANCISCO ALBA, E1 Colegio de Mexico, Mexico City DAVID E. BELL, Center for Population Research, Harvard University JULIE DaVANZO, Economics and Statistics Department, The RAND Corporation, Santa Monica, Calif. MAHMOUD F. FATHALLA, World Health Organization, Geneva RONALD FREEDMAN (NAS), Population Studies Center, University of Michigan KENNETH H. HILL, Department of Population Dynamics, Johns Hopkins University WILLIAM N. HUBBARD, '}R., Hickory Comers, Mich. CHARLES B. KEELY, Department of Demography, Georgetown University JAMES E. PHILLIPS, The Population Council, New York T. PAUL SCHULTZ, Department of Economics, Yale University SUSAN SCRIMSHAW, School of Public Health, University of California, Los Angeles JAMES TRUSSELL, Office of Population Research, Princeton University

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Preface This report is one of a series of studies that have been carried out under the auspices of the Committee on Population to examine the consequences of changes in demographic behavior, particularly as they influence the lives of people in the developing world. In 1986 a working group of the committee released a landmark study of the consequences of population growth for the economic development of the Third World. This report concentrates on what many analysts regard as an equally important aspect of the demographic behavior of couples in developing countries, namely, the health consequences of different patterns of childbearing and contraceptive use. This report focuses on the health effects for mothers and their children of changes in the timing of pregnancies, the interval between them, and the number of children women have. In addition, it provides an overview of what is known about the health risks and benefits of different contraceptive methods used in the developing world. Throughout, the report focuses on the consequences that changes in the number and spacing of pregnancies and the ages of childbearing would have on the health of individual women and children, their families, and the larger population. This report and the research on which it is based deal almost entirely with the situation in the developing world, in counties that are characterized by low per capita income and limited health services. On the basis of a comprehensive review of the available evidence, the working group concludes that reproductive patterns exercise an important influence on the health of women and children. Moreover, the working group believes that a series of public policy measures related to reproduction could be undertaken that would improve the health of mothers and children in developing countries. In the view V11

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~ Vlll PREFACE of the working group, improving the performance of family planning programs may have significant effects on the health of women and children. We have written this report for a scientific audience. It will probably be most congenial and most useful to researchers actively involved in studies of the relationship between reproduction and health in developing countries. In addi- tion, we hope that the report will be useful to others: to policy makers who may be concerned about the possible utility of family planning programs as a health intervention, as well as to students, both in the United States and throughout the developing world, who are interested in the relationship between health and reproduction, whether they are in research-oriented programs or in training in public health or clinical service. Although the report is undeniably technical in orientation and approach, we have attempted, through the executive summary, the glossary, and the style of presentation throughout, to make it accessible to a wide audience. In carrying out its study, the working group commissioned experts in the field to prepare background papers. These papers, which are listed in the appendix, deal with specific topics related to health and fertility, and they contributed significantly to this report. A volume containing the papers of greatest interest will be published separately later this year. The committee and the working group very much appreciate the efforts of those who prepared these background papers. The paper by Susan Zimicki provided a basis for Chapter 3. The paper by Nancy Lee, Herbert Peterson, and Susan Cho provided a basis for Chapter 4. The paper by John Haaga provided the basis for parts of Chapter 5. Chapter 6 is an expanded version of a draft initially prepared by James McCarthy. The other background papers were also influential in the working group's deliberations and in the drafting of this report. The Working Group on Health Consequences of Contraceptive Use and Con- trolled Fertility met six times to discuss the background papers, to review the relevant scientific literature and other studies of similar topics that were under way or recently completed, and to discuss and review the various drafts of this report. In addition, working group member Anne Pebley spent much of the summer of 1988 working full-time on this report at the Committee on Popula- tion's offices. Each member of the working group also participated in several smaller, less formal meetings during which specific aspects of the report were reviewed. The Committee on Population undertook this study at the request of the Agency for International Development (AID), which asked for an authoritative assessment of the health consequences of the changing patterns of fertility and the increasing use of modern contraceptives that have been taking place in develop- ing countries as an aid in designing its program of assistance to developing countries. The Rockefeller Foundation also provided significant support for this project through a grant to the Committee on Population; the Rockefeller Founda- tion support allowed considerable flexibility in preparing the report and facilitated

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PREFACE iX wide dissemination by making possible translations of the report into Spanish and French. The William and Flora Hewlett Foundation also provided support for the working group through a grant to the Committee on Population. The committee and the working group appreciate the work provided by Peter J. Donaldson, study director, and Susan M. Rogers, research associate. Special thanks are also due Allan McMillan Parnell, research associate, who had principal responsibility for coordinating the preparation of this report. Laurence Grummer- Strawn, who served as a research assistant to the working group during the summer of 1988, also made important contributions to the report. Jeremiah Sullivan and Ann Way, of the Demographic and Health Surveys, provided some of the data used in Chapter 6. Michael Koenig provided data on infant and maternal mortality from Bangladesh. Carol Bradford skillfully prepared all figures in the report. Sivaporn Pokpong, a student at the University of Michigan, Audrey Vanden Heuvel, a student at the University of Norm Carolina, Irma Elo, a student at Princeton University, and Lisa Brecker all assisted in compilation of materials and preparation of tables. The committee and the working group especially appreciate the help received from Christine L. McShane, editor of the Commission on Behavioral and Social Sciences and Education. The working group responsible for this report was composed of a carefully selected, balanced group of experts with backgrounds in both medical and social sciences. The Committee on Population is very grateful to the members of this group for their hard work, and particularly to William Foege and Julie DaVanzo, who served as chair and cochair, respectively, and to Anne Pebley, whose concen- trated effort contributed greatly to the report. ALBERT I. BRMALIN, Chair Committee on Population

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Contents Executive Summary 1 In~oduction.................... The Demographic Context, 6 Family Planning in Developing Countries, 9 Organization of the Report, 11 , . . Hypotheses about Reproductive Patterns and Women's and Children's Hearth ................... Direct Effects of Reproductive Patterns on Health, 13 Indirect Effects of Reproductive Patterns on Health, 20 Other Possible,Explanations, 21 Available Evidence, 22 Reproductive Patterns and Women's Health Sources of Evidence, 26 Effects of Young Maternal Age and Primiparity, 29 Effects of Older Maternal Age, High Parity, or Both, 30 Effects of Short Intervals Between Births, 31 Effects of Pregnancy in Increasing Mortality From Other Conditions, 31 Effects of Unsafe Induced Abortion, 32 Conclusion, 32 X1 5 12 .... 25

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Xii CONTENTS 4 Contraceptive Benefits and Risks Oral Contraceptives, 37 Intrauterine Devices, 43 Barrier Methods, 45 Long-Acting Contraceptives, 46 Sterilization, 48 Traditional Methods, 50 Dimensions of New Research, 51 5 Reproductive Patterns and Children's Health . . Sources of Evidence, 55 Effects of Being Firstborn and Young Maternal Age, 58 Effects of High Birth Order and Older Maternal Age, 61 Effects of Short Birth Intervals, 61 Effects of Unwanted Pregnancy, 65 Effects of Maternal Health Conditions, 66 Minimizing the Risks of Child Death, 67 Changes in Reproductive Patterns .......... Fertility Declines and Birth Order Distribution, 78 Maternal Ages at Childbearing, 79 Spacing of Births, 82 Contraceptive Use and Induced Abortion, 86 Effects of Changes in Reproductive Patterns on Mortality Rates, 87 Conclusion, 88 7 Conclusions........... Reproductive Patterns and Women's Health: Risks for Individual Women, 91 Reproductive Risks and Children's Health: Risks for Individual Children, 93 Aggregate-level Effects, 94 Indirect Effects of Reproductive Change on the Health of Women and Children, 96 Family Planning and the Health of Women and Children, 97 References . Appendix: Background Papers Glossary 36 53 76 90 99 ... 113 .... 115