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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-
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government on scientific and technical matters. Dr. Frank Press is president of the National
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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
