Contraception: Science and Practice Edited by Marcus Filshie, DM, FRCOG Reader and Consultant, Department of Obstetrics and Gynaecology University Hospital, Queen's Medical Centre, Nottingham and John Guillebaud, MA, FRCSE, FRCOG Medical Director, Margaret Pyke Centre, Soho Square, London Butterworths London Boston Singapore Sydney Toronto Wellington fë PART OF REED INTERNATIONAL RL.C. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means (including photocopying and recording) without the written permission of the copyright holder except in accordance with the provisions of the Copyright Act 1956 (as amended) or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 33-34 Alfred Place, London, England WC1E 7DP. The written permission of the copyright holder must also be obtained before any part of this publication is stored in a retrieval system of any nature. Applications for the copyright holder's written permission to reproduce, transmit or store in a retrieval system any part of this publication should be addressed to the Publishers. Warning: The doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. This book is sold subject to the Standard Conditions of Sale of Net Books and may not be re-sold in the UK below the net price given by the Publishers in their current price list. First published 1989 © Butterworth & Co. (Publishers) Ltd, 1989 British Library Cataloguing in Publication Data Contraception. 1. Contraception. For medicine 1. Filshie, Marcus II. Guillebiiud, John 613.9'4 | ISBN 0-407-01720-8 Library of Congress Cataloging in Publication Data Contraception: science and practice. Includes bibliographies and index. 1. Contraception. I. Filshie, Marcus. II. Guillebaud, John. [DNLM: 1. Contraception methods. WP 630 C7616] RG136.C5715 1989 613.9'4 88-26213 I ISBN 0-407-01720-8 Typeset by Latimer Trend & Company Ltd, Plymouth, UK Printed and bound by Hartnolls Ltd, Bodmin, Cornwall Preface Much has been written on the subject of contraception, yet there remain two incontrovertible facts. The first is that the world's population is increasing by rather more than one million every five days. The continuing lack of priority given to tackling this growth in human numbers (by reducing it rather than merely attempting to accommodate to it) shows that neither politicians nor voters have yet appreciated its devasting implications for meeting human needs. The second fact is the great extent of individual need even today. This was shown in developing countries by the World Fertility Survey. Numerous consumer surveys in developed countries have also demonstrated how deficient our current birth-control methods remain, despite much research, in terms both of perceived safety and of simplicity for users. Yet the methods are not nearly so bad as they are often made to appear by the media. Moreover, these methods could be so much better delivered by the caring professions to the ordinary couples of the world. This book has been conceived as a guidebook both in facing the emergency threatened by the first fact, and in using the available methods better to meet the human needs implicit in the second. The contributors are each world experts and innovators in their particular subject. They have been given free rein and have written with infectious enthusiasm as well as knowledge. The scene is set with a fascinating overview by Dr Malcolm Potts and Dr Bhiwandiwala. As a matter of policy the chapters have been only minimally edited, to preserve the stamp of each author's individuality. Therefore we believe the book reads more like an anthology or a proceedings than a treatise. Although there is much 'science', the aim throughout has been to aid 'practice'. Much space has been given to the expanding subject of hormonal contraception. Despite the improvements in formulation and hence increased safety, 'the pill' and its cousins continue to be attacked by the popular press. The relevant chapters should help to put the subject into perspective. The book is particularly intended for physicians engaged in teaching or research in birth-control techniques, although it will be a valuable reference book and resource for many others. It has been a privilege to work with such an articulate and talented team of invited experts, from whom we have had great cooperation. We gratefully thank each one for his or her invaluable contribution. We also acknowledge the help of Mr John Harrison of Butterworths and of the many secretaries and production assistants whose labours (so often unsung) have turned our ideas into the finished product. MARCUS FILSHIE JOHN GUILLEBAUD V Contributors P. Bhiwandiwala MB, BS, MSPH University of North Carolina, Chapel Hill, North Carolina, USA John Bonnar MA, MB, ChB, FRCOG Professor of Obstetrics and Gynaecology, and Dean of the Faculty of Medicine, University of Dublin, Trinity College, Dublin, Eire Walli Bounds SCM Associate Research Fellow, University College London; Research Co-ordinator, Margaret Pyke Centre for Study and Training in Family Planning, Soho Square, London, UK Peter Bowen-Simpkins MA, MB, BChir, FRCOG Consultant Obstetrician and Gynaecologist, Singleton Hospital, Swansea, West Glamorgan, UK Elizabeth B. Connell MD Professor of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta, Georgia, USA James Drife BSc, MD, ChB, FRCS (Ed), MRCOG Consultant and Senior Lecturer, University of Leicester, Department of Obstetrics and Gynaecology, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK Marcus Filshie DM, FRCOG Reader/Consultant in Obstetrics and Gynaecology, University Hospital, Queen's Medical Centre, Notting ham, UK Anna M. Flynn MB, BCh, BAO NUI, FRCOG Senior Clinical Research Fellow, Department of Obstetrics and Gynaecology, Birmingham Maternity Hospital, Queen Elizabeth Medical Centre, Birmingham, UK K. Fotherby PhD Reader in Chemical Pathology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK Ian S. Fraser MD, BSc(Hons), MB, ChB, FRCOG, FRACOG Department of Obstetrics and Gynaecology, University of Sydney, New South Wales, Australia Michael Gillmer MA, MD, FRCOG Consultant Obstetrician and Gynaecologist, John Radcliffe Hospital, Oxford, UK John Guillebaud MA, FRCSE, FRCOG Medical Director, Margaret Pyke Centre for Study and Training in Family Planning, Soho Square, London, UK W. F. Hendry ChM, FRCS Consultant Genitourinary Surgeon, St Bartholomew's and Royal Marsden Hospitals, London, UK vii viii Contributors S. L. Jeffcoate MB, BChir, PhD, FRCPath National Institute for Biological Standards and Control, Hertfordshire, UK A. Kubba MB, ChB, MRCOG Deputy Medical Director, Margaret Pyke Centre for Study and Training in Family Planning, Soho Square, London, UK M. PottS MB, BChir, PhD President, Family Health International, Research Triangle Park, North Carolina, USA Jacques-E. Rioux MD, MPH Professor, Department of Obstetrics and Gynaecology and Director, Department of Gynaecology- Reproduction, Le Centre Hospitalier de l'Université Laval, Sainte-Foy, Quebec, Canada G. Robinson BSc, PhD, CBiol, MlBiol Senior Lecturer, Department of Pathology, University of Nottingham, Nottingham, UK Howard J. Tatum MD, PhD Professor, Department of Gynecology-Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA Martin Vessey MD, FRCP, FFCM, FRCGP Professor, Department of Community Medicine and General Practice, Gibson Laboratories Building, RadclifTe Infirmary, Oxford, UK C. C. Welch MB, ChB, MRCOG Consultant, Department of Obstetrics and Gynaecology, Basildon Hospital, Essex, UK A. Yuzpe MD, MSc, FRCS(C), FACOG, F AC S Professor, Department of Obstetrics and Gynaecology, The University of Western Ontario, London, Ontario, Canada Chapter 1 Birth control: a world view M. Potts and P. Bhiwandiwala Need All non-seasonally breeding mammals have evolved mechanisms for the optimum spacing of pregnancies. The higher primates such as man and the chimpanzees are slow breeders, and on the average reproduce every 3-5 years. Throughout most of human evolution the total fertility rate (average number of children born during a fertile lifetime) was probably 5-6. The !Kung, who live in the Kalahari desert, have a population doubling time of approximately 300 years even though they use no 'modern' methods of birth control. In hunting/food-gathering societies, as among the large primates, the pregnancy interval is determined by the suppression of ovulation during lactation. In the West we think of breast-feeding as an unimportant and unreliable method of family planning. However, a woman in, say, Bangladesh who is breast-feeding at one year is much more likely to be anovulatory than an American woman who also happens to breast-feed for one year. It appears that the suppression of ovulation is more complete and consistent when the child is exclusively dependent upon the mother's breastmilk, when (a) suckling is frequent (on average the IKung suckle every 14 minutes), (b) when the child sleeps with the mother at night, and (c) when the mother has an adequate but not overgenerous diet and is physically active. Under these conditions ovulation can be suppressed for 30-40 months. For the !Kung, the average child-spacing interval is 44 months. Epidemiological studies confirm that the human reproductive system has been finely tuned by evolution to produce an optimum interval between two pregnancies. Both infant and maternal mortality and morbidity rise when pregnancy intervals are reduced by abandoning traditional methods of breast-feeding. Currently the human race is experiencing a second population explosion. The first occurred when hunter/gatherer societies moved into agricultural communities, begin ning ten thousand or so years ago when there were probably 50 million people in the world. Fertility almost certainly rose due to minor changes in lactation and access to more food with less effort, but infant mortality remained high - or possibly even rose a little as population densities grew. Until the Industrial Revolution, most human populations grew slowly at about half a percent per year and a poor harvest or an outbreak of disease often caused a sudden rise in the death rate. Historical demographers, reconstituting families from church records, have shown that such jumps in the death rate were often limited to small geographical areas. In industrialized nations during the nineteenth century the population grew at l 2 Birth control: A world view about 1% per annum. Improved transport, ameliorated localized food shortages, better sanitation, clean water, and a gradual growth in economic wealth all helped cut down infant mortality and led to some improvement in adult health. In England and Wales in 1771 there were less than 6.5 million people, whereas in 1871 there were more than 21.5 million. The birth rate during that interval probably fluctuated between about 36 and 40 per thousand, and the death rate fell marginally from 22 to perhaps 18 per thousand of the population. The growth in numbers in the Western industrialized nations was associated with emigration to North and South America, Africa, Australia, New Zealand and other colonies of the European powers. When animals become crowded, the age of sexual maturity, infant mortality, and the interval between births all tend to rise. During the nineteenth- and twentieth- century population explosions, the age of the menarche has declined. The interval between pregnancies grew less with reduced intervals of breast-feeding, early wean ing, and finally an increase in artificial feeding. While these changes were instrumental in the rise in fertility, the infant mortality rate also fell. Since the Second World War, the population explosion has spread to the developing world. The changes that took place in the West have occurred much more rapidly in the Third World. Mortality has fallen due to improvements in political stability, the ability to meet local food shortages, improvements in sanitation, the vaccination of infants, the advent of antibiotics, and the partial control of malaria and other endemic diseases. Fertility has risen as bottle feeding has spread and as the age of the menarche has decreased slightly. When a nuclear weapon explodes, 99.9% of the energy release occurs in the last seven generations of the 58 generations of nuclear fission before the core of the bomb is vaporized. The human population explosion takes decades rather than micro seconds to occur, but as with a nuclear explosion, nearly all the consequences are concentrated in the last one or two doublings of the population. Whatever actions are taken, barring a global war on an unprecedented scale, human population will certainly double, may treble, and could even quadruple in the twenty-first century. Global population passed the two thousand million mark in the 1920s, reached four thousand million by 1975, five thousand million in 1987 and will certainly exceed six thousand million by the year 2000. The so-called low' projection of the United Nations is for 8.4 thousand million people by the year 2050, and the 'high' projection is 12.4 thousand million for that date. Which of these two numbers is achieved depends largely upon the vigour with which birth control initiatives are pursued in the 1990s. More than half the population of the developing world is below the age of marriage, and even if those now born were to settle for only two children - which is certainly not going to happen - the distortion of the age pyramid that has occurred since the Second World War would ensure that populations continue to grow rapidly. Most of this growth will occur in the countries of Asia, where the population base is largest, although the highest absolute rates of population growth are being recorded in Africa. In the world as a whole the percentage rate of growth in population has declined marginally in the last ten years, but so much demographic momentum has already been set up that the absolute annual increment in population continues to grow. To take a specific example, the population of Japan continues to increase by almost one million people a year, even though the total fertility rate is near to biological replacement - that is, each woman is currently expected to bear slightly more than two children in her fertile lifetime. For zero population growth to occur, which is the Need 3 number of deaths equalling the number of births in the society, the population structure of the society must also be stable, as in Western Europe in the 1980s. Some countries have had less than replacement birth rates, and such an event always triggers political extremists to make wild statements about a 'birth dearth', although in reality population changes tend to be slow and to correct themselves. It is always easier to rise slowly to some sort of ceiling than to try to control an explosion. The annual increment in the world's population is, by pure coincidence, approxi mately in step with the Western calendar year - 88 million more births than deaths in 1988 and 89 million more a year later. The population and the calendar year are marching in step towards a difficult and threatening future. The world has accommodated significant population increases before: thus, some forecasting the future find comfort in the fact that the prices of raw materials tend to fall with increasing demand, and they also feel that these extra hands and brains will be available to solve problems. However, the unprecedented growth in population is making itself felt in relation to employment even before it impinges on food and natural resources. In order for agriculture to become more productive it must be more mechanized, and is thus likely to employ fewer rather than more people. The biggest migration in human history is taking place as hundreds of millions of people leave a traditional village way of life, which in many ways has changed little over the past 4000 years, to enter the exploding cities of the contemporary world with their multiplying problems. In the past 15 years nearly 600 million people, approximately the population of India, have become city dwellers for the first time. By the end of this century there will be another 1.5 thousand million, approximately equal to the total world population in 1900. In 1950 Brazil was 64% rural; in 1970, it was 56% urban. It costs many thousands of dollars to create a new non-agricultural job in any part of the world. Between 1970 and 1985 the number of Asians of working age increased by 500 million. Unemployment, and with it political frustration and social instability, is bound to increase. Millions of people will live in squatter areas in the meanest of shacks on the poorest land, while governments pretend they do not exist or bulldoze down their fragile homes. Mexico City is probably destined to contain more than 30 million people by the year 2000. Such a concentration of human beings is unprece dented and its consequences difficult to predict. The AIDS epidemic is reminding the world that Homo sapiens is not the omniscient species we believed ourselves to be. Most virologists believe the human immuno deficiency virus (HIV) has jumped from a primate host into the human population. It is a reasonable speculation that such a transition has probably occurred on a number of occasions in the past. The reason that the epidemic appeared in the 1970s and 1980s was that urbanization had provided the tinder where the spark of HIV infection could catch hold. In Africa the massive migration to cities and the breakdown of family life set up a situation where many men were having sufficient sexual partners to spread HIV infection rapidly. In the West, socially disadvantaged and largely unemployed urban groups joined the subculture of drug abusers and spread the disease through contaminated needles, while the specialized lifestyles of urban gay men in North America proved to be the flash point for homosexual transmission of the virus. If uncontrolled, HIV infection may involve 100 million people by the turn of the century. If such a catastrophe occurs, it could lead to three times as many deaths from AIDS in the decade 2000-2010 than occurred during the Black Death in the fourteenth century, yet it would still only represent one year's global population growth for the end of the twentieth century: AIDS has the potential to kill vast numbers of people but not to reverse the population explosion. 4 Birth control: A world view In undeveloped countries fertility is high, most women are delivered by traditional birth attendants, and maternal mortality reaches appalling levels. Studies by Family Health International (FHI) show that some rural areas of Egypt and Indonesia have up to 77 times the maternal mortality rate of the US. It is likely that more women will die in childbirth between now and the end of the century than at any similar interval in human history. Whereas 85% of all births and 95% of all the infant mortality are in the developing world, an astonishing 99% of all maternal deaths occur in Third World countries, predominantly in rural areas outside the reach of medical services. More women die in one month in India from pregnancy, childbirth and illegal abortions than die in the whole of North America, Eastern or Western Europe and Scandinavia, Japan, Australia and New Zealand in one year. At a global level, maternal mortality is equivalent to crashing a jumbo jet full of parturient or aborting women every 5 hours, day after day. Response It took Great Britain more than a hundred years to bring its births and deaths into balance after the Industrial Revolution. Over most of this interval, contraceptives were of poor quality, the medical profession made little or no contribution to research or services, abortion was illegal, and voluntary sterilization was rarely used. Popula tion was dependent upon do-it-yourself methods of family planning, such as coitus interruptus or corner-store and mail-order sales of relatively poor-quality condoms and spermicides. Illegal abortions were rampant, showing that desired family size was for a great many people smaller than what was being achieved. All the countries in Asia except Burma and North Korea, and nearly all the countries of the developing world, now have a national commitment to family planning and the reduction of population growth. Governments are attempting to make services available to people. In the last 10-15 years a revolution in legislation has abrogated restrictive laws on contraception in most countries, with a few exceptions such as Madagascar. The majority of the population now lives in countries where abortion is legal, from Muslim Tunisia and Turkey to capitalist USA and Western Europe to Communist China and Cuba. The World Fertility Survey conducted in the 1970s was the largest exercise in social science ever undertaken. It found a surprisingly strong desire for fertility control in nearly all societies. Almost without exception, desired family size is less than achieved family size. At present about half of all the women in the world who currently have three or more children do not wish to have any more. However, a gap remains between the stated desire to control fertility and actual practice. And even desired family size remains high when considered in the light of the world's demographic problems. Nevertheless the vigorous and realistic provision of services in the remaining years of this century may still permit mankind to control its numbers on a voluntary basis. The problem that faces those professionally involved in any aspect of fertility regulation, whether in rich or in poor countries, is to ensure that the services that we make available actually meet the perceived needs of the societies we have the privilege to serve. In the developing world an instructive contrast can be drawn between the experiences of India and China in fertility regulation. In the last 15 years the birth rate Response 5 in the Peoples' Republic of China has plummeted from 34 per thousand to 18 per thousand - a 47% reduction. Fundamental social changes have taken place, and unique concepts such as the one-child family have evolved. However, the two main lessons to come out of China are the dangers of delaying action in the face of population growth and the need to make the full range of fertility regulation services available. The problem that faces China, which the leadership of the country now fully understands, is that for too long in the 1960s and 1970s population growth was either ignored or too little was done too late. It is a measure of the momentum of demographic change and the predominantly young population of developing coun tries that, if 70% or more of all Chinese couples now adopt the one-child family policy, the population of the nation will still grow by 200 million in the next 20 years. This means that a country the physical size of the United States will add almost as many people as now live in the United States to a base population of 1 thousand million. The imposition of the one-child family is unpopular, and has been accepted by the political leaders, the medical profession and the citizens of the country only because there is no viable alternative. Tragically, many women in China today find themselves having to abort a wanted pregnancy, often under considerable social pressure from their neighbours, because their parents a generation ago were not able to prevent unwanted pregnancies. It will be interesting to see if Nigeria, Brazil, Mexico, and other countries with rapidly growing populations learn from the errors of China. The second lesson to be gained from China is that the successes that have been achieved have resulted from policies encouraging the widespread availability of the maximum number of methods - including voluntary sterilization through a variety of channels. India started family planning earlier than China but has still not really come to grips with what needs to be, or can be, done. The Indian census estimate for 1981 (638 million) was considerably higher than had been hoped. The birth rate was 36 per thousand and the death rate 14.8 per thousand. India adds 13 million extra people to its population each year, and may well have the dubious honour of being the most populous nation in the world by the year 2000. Unlike China, India has concentrated on single-method solutions to her problems: first, the use of IUDs, and later, sterilization. Unlike the 'barefoot doctors' in China who play an important family planning role, the traditional practitioners who are their counterparts in India and who are found in every one of India's half-million villages, have been steadfastly excluded from the programme. There is no reason why they should not have been taught to handle pills and even injectables and simple surgical techniques. The Indian Government has never offered oral contraceptives on a significant scale: injectables, which would probably prove popular, have been rejected by the medical establish ment. The medical infrastructure in many developing countries is woefully weak. What doctors there are, are concentrated in the cities. Government workers often have considerable security, but are paid less than their colleagues in business so that motivation to provide quality services is often weak. Sick people, driven by pain or fear, will usually seek out some form of health care. However, in the case of family planning, especially when it is a novelty within society, people are easily deterred from seeking advice. Geographical or social distance can appear as insurmountable barriers even to individuals who wish to limit their family size.