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CONTRACEPLIVE USE AND ~ WONTROLLED (ERLILITY Health Issues for Women and Children Backgrouncl Papers Allay M. Parnell, editor Working Group on the Heady Consequences of Contraceptive Use and Controlled Fertility Committee on Population Comrrussion 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, NW 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. lbe members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Ibis report has been reviewed by a group other than the authors according to procedures approved by a Report Review Ccm~nittee consisting of members of the National Academy of Sciences, the National Academy of Engineering, 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. She 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 govemment. Ihe National Academy of Engineenng also sponsors engineering programs aimed 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 Engineenng. Ihe 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. She 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 0. wilier 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 government. Functioning in accordance with general policies detennined 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 adauni- stered jointly by both Academies and the Institute of Medicine. Dr. Frank Press and Dr. Robert M. White are chaimman and vice chairman, respectively, of the National Research Council. Library of Congress Catalog Card No. 89~3018 Intemational Standard Book Number ~309-04096-5 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 S030 Printed in the United States of America First Printing, December 1989 Second Printing, September 1990

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1 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 Adrninisuation, Rockville, Md. PETER J. DONALDSON, Study Director ALLAN M. PARNELL, Research Associate SUSAN M. ROGERS, Research Associate DIANE L. GOLDMAN, Administrative Assistant .. . . . 111

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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, JR., Hickory Corners, Mich. CHARLES B. KEELY, Deparunent 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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Contents Pref ace . e e e e e e ~ The Relationship Between Fertility and Maternal Mortality Susan Zir~ucla Definitions and Measurement Issues, 2 World Patterns, 7 Aspects of Fertility as Risk Factors for Maternal Mortality, 7 Other Important Risk Factors, 17 Causal Patterns of Mortality, 22 Aspects of Fertility and Be Mapr Causes of Death, 28 Conclusion' 38 Appendix~ontents of Causal Categones, 40 References, 41 Hemp Effects of Contraception ........................... Nancy C. Lee, Herbert B. Peterson, and Susan Y. Chu Introduction, 48 Oral Contraceptives, 50 Intrauterine Devices, 62 Barrier Methods, 64 Long-Acting Methods, 68 Tubal Sterilization, 72 Vasectomy, SO References, 85 . . V11 48

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~ . ~ Vlll CONTENTS Mechanisms for the Association of Maternal Age, Parity, and Birth Spacing With Infant Health . . e ~ e e e ~ e e e ~e e e ~96 John G. Haaga Introduction, 96 Young Maternal Age and Primiparity, 101 Older Maternal Age and Grand Multiparity, 112 Effects of Short Intervals Between Pregnancies, 121 Acknowledgment, 133 References, 133 Psychosocial Consequences to Women of Contraceptive Use and Controlled Fertility 140 Ruth Dixon-Mueller Concepts of Health and Well-Being: Indicators of Psychosocial Stress, 141 Psychosocial Stress and Role Perfonnance, 142 Contraceptive and Reproductive Patterns as Potential Stressors, 144 Conclusions, 156 References, 157 Appendix: Background Papers .... 161

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Preface The four papers in this volume are the result of work earned out by a Commit- tee on Population-sponsored Working Group on the Health Consequences of Contraceptive Use and Controlled Fertility. The Committee on Population was asked to undertake an assessment of the likely health consequences to women and their children of changes that were under way or anticipated in many developing counties in the number of children, the timing between them, and the age at which women were giving birth. A working group, chaired by William Foege and Julie DaVanzo, investigated this topic. The result of their assessment, Contracep- tion and Reproduction: Health Consequences for Women and Children in the Developing World, has been published by the National Academy Press in a separate volume. In the course of completing their assessment, the working group commissioned a series of background papers dealing with different aspects of the relationships among changing reproductive patterns, contraceptive use, and the health of women and children. A complete list of these papers is given in the appendix to this report. In addiDon, the working group also benefited from a series of special analyses undertaken on its behalf by scholars with a special interest in the topic of fertility and health. Unfortunately, it was not possible to publish all of the papers and analyses commissioned by the working Coup. Some of the work resulted in only a set of tabulations Mat members of the working group themselves incorporated into the report and that would not be appropriate for separate publication. Other papers were highly specialized and judged to be more appropriate for publication in scientific journals. There were, however, a series of papers that provided impor ix

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X PREFACE tent background information for the report and that brought together data and analyses that are otherwise difficult to obtain in a single source. Two of the selected papers combined biomedical and demographic perspectives in a particu- larly useful way, while a third provides an unusually comprehensive overview of technical issues of great concern to those interested in fertility and health. The fourth suggests a framework for thinking about the psychosocial consequences to women of contraceptive use and controlled fertility. The Committee on Popula- tion decided to publish these four papers. The first paper, by Susan Zimicki of the University of Pennsylvania, deals with the relationship between changing reproductive patterns and women's health. The second paper, by Nancy Lee, Herbert B. Peterson, and Susan Y. Chu of the Centers for Disease Control, provides an overview of the risks and benefits of different modern contraceptives. The third paper, by John G. Haaga of the Rand Corporation, reviews the evidence on the relationship between changing repro- ductive patterns and child health. In addition, a more specialized paper is included, which in the judgment of the working group, brings together reports of particularly important aspects of the relationship between health and fertility and merits wider consideration than it might otherwise receive. This paper, by Ruth Dixon-Mueller of the University of California, Berkeley, deals with psychologi- cal aspects of changing reproductive pattems. The working group's report, like almost all the other literature in this field, deals almost entirely with physical health; nevertheless, the working group recognizes that there are important psy- chological and mental health aspects to human reproduction that to date have not been carefully evaluated. It is our hope that this paper will encourage more careful thinking about this topic. The Committee on Population and the Working Group on the Health Conse- quences of Contraceptive Use and Controlled Fertility are very grateful for the work completed on its behalf by the authors of these papers as well as by those who prepared the other papers and analyses listed in the appendix. In addition, the committee and the working group wish to thank the Agency for International Development and the Rockefeller Foundation for providing financial support for the completion and publication of its report and these papers. The Committee on Population and the working group are also grateful to the staff members who worked on this project, including Peter J. Donaldson, study director; Susan Rogers, research associate; Diane Goldman, administrative secre- tary; and Eugenia Grohman, associate director for reports of the Commission on Behavioral and Social Sciences and Education. Special thanks are due Allan Parnell, who served as the principal staff officer for the Working Group on the Health Consequences of Contraceptive Use and Controlled Fertility and as editor of this volume of papers. ALBERT I. HERMALIN Chair, Committee on Population