Birth Control Safe and effective options.

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Definition

Contraception (birth control) prevents pregnancy by interfering with the normal process of ovulation, fertilization,

and implantation. There are different kinds of birth control that act at different points in the process.

Description

All the different forms of birth control have one thing in common. They are only effective if used faithfully. Birth control pills will work only if taken every day; the

diaphragm is effective only if used during every episode of sexual intercourse. The same is true for condoms and the cervical cap. Some methods are automatically working every day, no matter what. These methods include Depo Provera, Norplant, the IUD, and tubal sterilization.

There are many different ways to use birth control. They can be divided into several groups:

• By mouth (oral)—Birth control pills must be taken by mouth every day.
• Injected—Depo Provera is a hormonal medication that is given by injection every three months.
• Implanted—Norplant is a long-acting hormonal form of birth control that is implanted under the skin of the upper arm.
• Vaginal—Spermicides and barrier methods work in the vagina.
• Intra-uterine—The IUD is inserted into the uterus.
• Surgical—Tubal sterilization is a form of surgery. A doctor must perform the procedure in a hospital or surgical clinic. Many women need general anesthesia.

The methods of birth control differ from each other in the timing of when they are used. Some methods of birth control must be used specifically at the time of sexual intercourse (condoms, diaphragm, cervical cap, spermicides). All other methods of birth control must be working all the time to provide protection (hormonal methods, IUDs, tubal sterilization).

— Amy B. Tuteur, MD

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n.

Intentional prevention of conception or impregnation through the use of various devices, agents, drugs, sexual practices, or surgical procedures.

[CONTRA– + (CON)CEPTION.]

Many social practices reduce the birth rate — delaying marriage, imposing taboos on the frequency of marital intercourse, and prolonged breastfeeding, for example. Contraception, however, is usually taken to mean deliberate resort to practices to prevent sexual intercourse resulting in the birth of a child, or, more strictly speaking, to preclude conception. Methods can be divided into ‘natural’ — those not requiring any apparatus — and ‘artificial’ means. The latter can be subdivided, though not entirely, into barrier and chemical methods locally applied to the genitals; intrauterine; surgical; and the more recent hormonal contraceptives. Magical prescriptions, of dubious efficacy, for the prevention of pregnancy have also proliferated.

Refraining from sexual intercourse may have been an underestimated element in attempts to restrict family size. A modification is indulgence only when the woman is believed to be infertile: however, the relationship between menstruation and ovulation was not reliably established until 1929, and many previous calculations of a ‘safe period’ were seriously in error — though, due to variation in the cycles of individual women, even an inaccurate idea may have been occasionally effective in delaying if not preventing conception. The independent discoveries of the Japanese K. Ogino and Austrian Hermann Knaus enabled more effective calculations, but nonetheless the ‘rhythm method’ is widely known as ‘Vatican roulette’ (as the only method, apart from abstention, approved by the Catholic Church) because of its unreliability. Recently developed devices, however, now enable extremely precise pinpointing of the actual period of fertility through hormonal analysis of the female urine.

Another possibility occurring to the ingenious very early in human history was the practice of coitus interruptus, whereby the man withdraws and ejaculates outside the vagina (cf. Onan — Genesis 38: 9). To think of this method means that a connection must be made between emission of semen and conception. Another method requiring no appliances is anal intercourse.

Barrier methods

Barrier methods have a long history. Egyptian papyri describe pessaries and vaginal douches, which could have been effective. The pessaries both formed a barrier, and consisted of substances either spermicidal, or likely to slow sperm motility, while the douches could have altered the chemical balance of the vagina, rendering conception less likely. Many other societies are recorded as having had similar devices capable of lowering the probability of conception.

The condom, or male sheath, was quite a late development. It became more widely used following the discovery of the vulcanization of rubber in the 1840s, which also led to the development of various forms of occlusive cap for female use. These required, to be most effective, careful fitting — indeed, the first were custom-made for each individual. The most commonly used type is the ‘Dutch cap’ or diaphragm, invented by the German physician Wilhelm Mensinga of Flensburg in the 1870s, a domed rubber cap with a metallic spring in the rim, which comes in a range of sizes and is easier to fit than similar devices. Used conscientiously, with spermicide, and left in for several hours following intercourse, it has a success rate of around 95% in preventing pregnancy. The smaller cap, covering only the cervix, has had its advocates. Rubber itself tends to destroy sperm. Using sponges for birth control dates back probably to the eighteenth century, a method particularly efficacious if the sponge is soaked in some spermicidal or sperm-weakening substance, such as vinegar, olive oil, or even soapy water; modern sponges, for a single use only, are permeated with spermicide. The recently-promoted female condom, covering the entire interior surface of the vagina, has a longer history than often realized, and is primarily a protective against sexually transmitted disease.

Spermicides

The nineteenth century also saw the commercial development of chemical contraceptives, usually in the form of pessaries for insertion into the vagina. In theory these contained a spermicidal substance (though some worked because the greasy agents hindered the sperm), but in the unregulated industry of contraceptive manufacture, the unreliability of these products led to the belief (as with condoms) that the law required one ‘dud’ in every box. In Britain the issue of an ‘Approved List’ of effective products by the National Birth Control Association (later the Family Planning Association) led to improvement in standards, though spermicidal activity as measured in laboratory circumstances and in practice can still differ widely. Chemical contraceptives currently come as creams and jellies (specifically for use with a barrier method), pessaries, and foam and are recommended to be employed in conjunction with a barrier method.

IUD

As far as can be ascertained, the intrauterine device in its modern form dates back to the experiments of Gr̈afenburg and other German gynaecologists before World War I, although the British obstetrician C. H. F. Routh claimed in the 1870s that women were using uterine pessaries intended for gynaecological conditions for contraceptive purposes. Early IUDs were made of gold or silver; modern ones are made of plastic or copper. They work, it is believed, by irritating the uterus so that implantation of the fertilized ovum does not take place. The method has fallen into some disfavour following the highly damaging effects of the Dalkon Shield, which became apparent during the 1970s.

Sterilization

sterilization may be regarded as a contraceptive method, but unlike other methods it cannot be reversed, or not with any substantial probability of success. In women ligating the Fallopian tubes was originally a relatively major abdominal operation, carried out under general anaesthesia. More recently, sterilizations have been performed using a laparoscope, inserted through a small incision, to locate the tubes so that they can be cauterized; this can be done as an outpatient operation. Vasectomy is a much less serious operation.

The Pill

The greatest advance in contraceptive technology in the twentieth century was the female contraceptive pill. Ever since the discovery of the sex hormones and steroids there were hopes of a contraceptive which could be taken orally or injected. The earliest combination birth control pill, developed in the late 1950s, contained both oestrogen and progestin, and was taken for 21 days followed by a 5-day break during which menstruation occurred. It caused the suppression of ovulation and the thickening of the cervical mucus, hindering sperm from entering the uterus. The sequential pill (1965) consisted of oestrogen-only pills taken for the first 16 days of the cycle and combination oestrogen-progestin pills for the final five days, inhibiting ovulation but having no effect on the cervical mucus. The minipill, conversely, contains only progestin, is taken without breaks, and works by the constant production of thick cervical mucus which blocks the entry of the sperm. There are a number of other variations, and hormonal contraceptives are also given as implants or injections (e.g. Depo-Provera) with long-term efficacy. Related developments are the ‘morning after’ pill, a post-coital contraceptive, and the so-far unfulfilled hope of a ‘male pill’.

The Pill came into general use in the 1960s. It is an extremely reliable contraceptive method (97-99%) and has the important qualities of being totally detached from the genital organs, not requiring any dexterity to fit, and being unintrusive on the sexual act. This rendered it popular with both doctors and the general public. Side-effects, ranging from mild to extremely serious, and the implications for the dissemination of sexually transmitted disease of a reliable non-barrier method of contraception, have dimmed the initial glowing enthusiasm it generated, but it is still one of the most widely used methods of birth control.

Family limitation and society

Methods of birth control have been known from distant antiquity, but it is less easy to establish to what extent they may have been used. As Angus McLaren pointed out in A History of Contraception (1992), the desire of human couples to exercise control over their reproductive capacities may in some epochs veer towards the promotion of conception rather than its prevention. Many factors bear upon the possibility of even imagining that births might be restricted, and upon the putting of such a possibility into efficacious practice. Economic, social, and cultural factors led to increasing debate on the subject during the nineteenth century, particularly associated with the name of the political economist T. R. Malthus and his calculation that the population would always tend to outrun the means of subsistence — though he did not recommend artificial interference with this state of affairs. French peasants were apparently already limiting their families through coitus interruptus during the eighteenth century, because of their reluctance to let family holdings be divided between several heirs. The cause-and-effect relationship between the decline in infant mortality and the rise of family limitation is not clear: it is often claimed that the increased chances of child survival encouraged parents to reduce family size, but it can also be argued that infants born at wider intervals into smaller families have a better chance of survival through access to more maternal attention, and division of family resources between fewer family members.

In spite of the number of birth control methods available, they are still far from universally employed, due to simple lack of access; economic factors, either local factors encouraging large families, or the inability to afford the means; and in large areas of the world, because of religious objections.

— Lesley A. Hall

The contraceptive pill contains chemicals that prevent fertilization of the ovum by a sperm. Other options for preventing unwanted pregnancies include abstinence (not popular with many!); the rhythm method, which restricts sexual intercourse to periods when the chances of conception are low; barrier methods, such as condoms, a diaphragm or sponge; and intrauterine devices. Each has its own advantages and disadvantages so it is important to obtain comprehensive advice from a doctor when deciding which form of contraception to use.

Little is known about the effects of most contraceptives on athletic performance although some women endurance athletes found that their weight increased when they took steroid contraceptive pills. New low-dose oral contraceptives have much lower hormone concentrations than the older pills. Their side-effects (e.g. weight gain) have been greatly reduced. However, many athletes are still wary of using these pills because there have been reports that they reduce maximal oxygen consumption and aerobic power. Also, some athletes still believe that use of such pills may lead to weight increase and fluid retention.

Contraceptive pills containing steroids are sometimes taken by athletes to control the menstrual cycle so that blood flow does not coincide with important competitions. The onset of a period can be delayed for up to 10 days. The potential health risks of this practice are not known but women are advised not to engage in it repeatedly.

n

A process or technique for the prevention of pregnancy by means of a medication, device, or method that blocks or alters one or more of the processes of reproduction in such a way that sexual union can occur without impregnation.

Definition

Contraception (birth control) prevents pregnancy by interfering with the normal process of ovulation, fertilization, and implantation. There are different kinds of birth control that act at different points in the process.

Purpose

Every month a woman's body begins the process that can potentially lead to pregnancy. An egg (ovum) matures, the mucus that is secreted by the cervix (a cylindrical-shaped organ at the lower end of the uterus) changes to be more inviting to sperm, and the lining of the uterus grows in preparation for receiving a fertilized egg. Any woman who wants to prevent pregnancy must use a reliable form of birth control. Birth control (contraception) is designed to interfere with the normal process and prevent the pregnancy that could result. There are different kinds of birth control that act at different points in the process, from ovulation through fertilization to implantation. Each method has its own side effects and risks. Some methods are more reliable than others.

Although there are many different types of birth control, they can be divided into a few groups based on how they work. These groups include:

• Hormonal methods: These use medications (hormones) to prevent ovulation. Hormonal methods include birth control pills (oral contraceptives), Depo Provera injections, and Norplant.
• Barrier methods: These methods work by preventing the sperm from getting to and fertilizing the egg. Barrier methods include male condom and female condom, diaphragm, and cervical cap. The condom is the only form of birth control that also protects against sexually transmitted diseases, including human immunodeficiency virus (HIV) that causes acquired immune deficiency syndrome (AIDS).
• Spermicides: These medications kill sperm on contact. Most spermicides contain nonoxynyl-9. Spermicides come in many different forms such as jelly, foam, tablets, and even a transparent film. All are placed in the vagina. Spermicides work best when they are used at the same time as a barrier method.
• Intrauterine devices (IUDs): These devices are inserted into the uterus, where they stay from one to ten years. An IUD prevents the fertilized egg from implanting in the lining of the uterus and may have other effects as well.
• Tubal ligation: This medical procedure is a permanent form of contraception for women. Each fallopian tube is either tied or burned closed. The sperm cannot reach the egg, and the egg cannot travel to the uterus.
• Vasectomy: This medical procedure is a the male form of sterilization and should be considered permanent. In vasectomy, the vas defrens, the tiny tubes that carry the sperm into the semen, are cut and tied off.

Unfortunately, there is no perfect form of birth control. Only abstinence (not having sexual intercourse) protects against unwanted pregnancy with 100 percent reliability. The failure rates, or the rates at which pregnancy occurs, for most forms of birth control are quite low. However, some forms of birth control are more difficult or inconvenient to use than others. In actual practice, the birth control methods that are more difficult or inconvenient have much higher failure rates, because they are not used faithfully.

Description

All forms of birth control have one feature in common. They are only effective if used faithfully. Birth control pills work only if taken every day; the diaphragm is effective only if used during every episode of sexual intercourse. The same is true for condoms and the cervical cap. Some methods are automatically working every day, no matter what. These methods include Depo Provera, Norplant, the IUD, and tubal sterilization.

There are many different ways to use birth control. They can be divided into several groups:

• By mouth (oral): Birth control pills must be taken by mouth every day.
• Injected: Depo Provera is a hormonal medication that is given by injection every three months.
• Implanted: Norplant is a long-acting hormonal form of birth control that is implanted under the skin of the upper arm.
• Vaginal: Spermicides and barrier methods work in the vagina.
• Intra-uterine: The IUD is inserted into the uterus.
• Surgical: Tubal sterilization is a form of surgery. A doctor must perform the procedure in a hospital or surgical clinic. Many women need general anesthesia.

The methods of birth control differ from each other regarding when they are used. Some methods of birth control must be used specifically at the time of sexual intercourse (condoms, diaphragm, cervical cap, spermicides). All other methods of birth control must be working all the time to provide protection (hormonal methods, IUDs, tubal sterilization).

Condoms and Spermicides

Condoms are about 85 percent effective in preventing pregnancies. That means that out of 100 females whose partners use condoms, 15 will still become pregnant during the first year of use, according to the nonprofit advocacy group Planned Parenthood. Unwanted pregnancies usually occur because the condom is not attached or used properly or breaks during intercourse. More protection against pregnancy is possible if a spermicide is used along with a condom. Spermicide is a pharmaceutical substance used to kill sperm, especially in conjunction with a birth-control device such as a condom or diaphragm. Spermicides come in foam, cream, gel, suppository, or as a thin film. The most common spermicide is called nonoxynol-9, and many condoms come with it already applied as a lubricant. However, spermicides do not kill HIV or other sexually transmitted viruses and do not prevent the spread of HIV and other STDs. Also, nonoxynol-9 can irritate vaginal tissue and thus increase the risk of getting an STD. In anal sex, especially between two males, spermicides also can irritate the rectum, increasing the risk of getting HIV. Spermicides are specifically discouraged for use by gay or bisexual males for anal sex.

Latex condoms are also recommended over condoms made from other materials, especially lambskin, because they are thicker and stronger and have less risk of breakage during sex. Non-latex condoms do not prevent the spread of STDs, including HIV, and should not be used by gay or bisexual men or men who have HIV or other sexually transmitted diseases. Condoms are available over-the-counter, meaning they do not require a prescription, and there are no age restrictions on purchasing condoms. They are available at a variety of locations, including drug stores, convenience stores, supermarkets, and family planning clinics. They are also available for purchase on the Internet.

FEMALE CONDOM. The female condom is a seven-inch polyurethane pouch that fits into the vagina. It collects semen before, during, and after ejaculation, keeping semen from entering the uterus through the cervix and thus protecting against pregnancy. In one year of use, it is 79 percent effective in preventing pregnancies. It also reduces the risk of many STDs, including HIV. There is a flexible ring at the closed end of the thin, soft pouch of the female condom. A slightly larger ring is at the open end. The ring at the closed end holds the condom in place in the vagina. The ring at the open end rests outside the vagina. When the condom is in place during sexual intercourse, there is no contact of the vagina and cervix with the skin of the penis or with secretions from the penis. It can be inserted up to eight hours before sex.

Precautions

There are risks associated with some forms of birth control. Some of the risks of each method are:

• Birth control pills: The hormone (estrogen) in birth control pills can increase the risk of heart attack in women over forty who smoke.
• IUD: This device can increase the risk of serious pelvic infection. The IUD can also injure the uterus by poking into or through the uterine wall. Surgery might be needed to fix this injury.
• Tubal sterilization: "Tying the tubes" is a surgical procedure and has all the risks of any other surgery, including the risks of anesthesia, infection, and bleeding.
• Condom: The most common problems associated with condoms are breakage during use and improper technique in using condoms. These can lead to pregnancy and sexually transmitted diseases, especially HIV.

Preparation

No specific preparation is needed before using contraception. However, a woman must be sure that she is not already pregnant before using a hormonal method or having an IUD placed.

Risks

Many methods of birth control have side effects. Knowing the side effects can help a woman to determine which method of birth control is right for her. There is no perfect form of birth control. Every method has a small failure rate and side effects. Some methods carry additional risks. However, every method of birth control has fewer risks than pregnancy. The risks include:

• Hormonal methods: The hormones in birth control pills, Depo Provera, and Norplant can cause changes in menstrual periods, changes in mood, weight gain, acne, and headaches. In addition, once a woman stops using Depo Provera or Norplant, she may go many months before she begins ovulating again.
• Barrier methods: A woman must insert the diaphragm in just the right way to be sure that it works properly. Some women get more urinary tract infections if they use a diaphragm because the diaphragm can press against the urethra, the tube that connects the bladder to the outside.

Contraception
Type of contraceptive	Description	Use	Failure rate per 100 women in one year
SOURCE: Food and Drug Administration, December 2003; Planned Parenthood, March 2004; kidshealth.org, September 2001.
Abstinence	Refraining from intercourse, anal sex, and oral sex	Universally applicable. Also prevents spread of sexually transmitted diseases	0
Birth control pill	Prescription pill containing estrogen and progestin that suppresses ovulation	Must be taken daily, regardless of the frequency of intercourse	1-2
Cervical cap with spermicide	Soft rubber cup that fits around the cervix, obtained by prescription	Inserted before intercourse. May be difficult to insert	17-23, depending on type
Condom, female	Lubricated sheath that is inserted into the vagina. Similar in shape to the male condom, with a flexible ring	Applied immediately before intercourse, for single use	21
Condom, male	Latex or polyurethane sheath placed over erect penis, widely available in drugstores	Applied immediately before intercourse, for single use. Best protection against sexually transmitted diseases	11
Depo-Provera injection	Injection that inhibits ovulation, obtained by prescription	Injections performed at a doctor's office, once every three months	Less than 1
Diaphragm with spermicide	Dome-shaped rubber disk that covers the cervix, obtained by prescription	Inserted before intercourse and left in place at least six hours after	17
Douching	Use an over-the-counter feminine douche immediately after intercourse in an effort to wash out the sperm	Sperm travel quickly to the cervix, making this an ineffective method of birth control	40
IUD (intrauterine device)	T-shaped device inserted in the uterus during a visit to the doctor	Can remain in place for up to one or 10 years, depending on type	Less than 1
Morning-after pill (emergency contraceptive)	Pills similar to regular birth control pills, obtained by prescription	Must be taken within 72 hours of unprotected intercourse	80% reduction in pregnancy risk
Patch	Adhesive patch worn on the skin that releases hormones preventing ovulation. Obtained by prescription	New patch is applied once a week for three weeks, followed by one week without the patch	1-2
Periodic abstinence	Refraining from intercourse when conception is likely	Requires regular menstrual cycles and close monitoring of body functions pertaining to ovulation	20
Spermicide alone	A foam, cream, jelly, film, or suppository, or tablet containing nonoxynol-9	Depending on product, inserted between five and 90 minutes before intercourse; usually left in place at least six to eight hours after	20-50, depending on product
Withdrawal	Having intercourse, but removing the male penis before ejaculation	Not recommended for teens, and some seminal fluid leaks before ejaculation, making it an ineffective method of birth control	27

• Spermicides: Some women and men are allergic to spermicides or find them irritating to the skin.
• IUD: The device is a foreign object that stays inside the uterus, and the uterus tries to get it out. A woman may have heavier menstrual periods and more menstrual cramping with an IUD in place.
• Tubal ligation: Some women report increased menstrual discomfort after this surgery. It is not known if this side effect is related to the tubal ligation itself.

Parental Concerns

Nearly 60 percent of sexually active girls under age 18 would discontinue at least some reproductive health services if their parents were informed that they were seeking contraceptive services, according to a study published in the August 14, 2002 issue of the Journal of the American Medical Association (JAMA). If parental notification would cause the majority of minor girls to stop seeking reproductive health services or to use less effective methods of contraception, the rates of teen pregnancies and STD infections would substantially increase, Carol Ford of the Adolescent Medicine Program at the University of North Carolina–Chapel Hill and Abigail English of the Center for Adolescent Health & the Law state in an accompanying JAMA editorial. Although there is widespread consensus that communication between adolescents and their parents about sexual decision-making is important, there is no reason that confidential reproductive health care and efforts to improve communication between parents and their adolescent children cannot occur simultaneously, these authors suggest.

Parents of adolescents often are concerned that distribution of contraceptives leads to increased sexual activity. However, a study of 4,100 high school students published in the June 2003 issue of the American Journal of Public Health found that students who had access at school to condoms and instructions on their proper use were no more likely to have sexual intercourse than students at schools without condom distribution programs.

See also Condom.

Resources

Books

Birth Control Pills: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Health Publications, 2003.

Peacock, Judith. Birth Control and Protection: Choices for Teens. Santa Rosa, CA: LifeMatters, 2000.

Whitney, Leon Fradley. Birth Control Today: A Practical Approach to Intelligent Family Planning. Temecula, CA: Textbook Publishers, 2003.

Periodicals

"Give Teens More Info to Bridge Information Gap." Contraceptive Technology Update 25(September 2004): 106–07.

Sullivan, Michele G. "Teens View Hormonal Contraception as Unsafe." Internal Medicine News 37 (July 15, 2004): 24.

"Teens Face Obstacles When Obtaining EC (Emergency Contraceptives)." Contraceptive Technology Update 25 (April 2004): 41–2.

Tucker, Miriam E. "Newer Contraceptives Give Teens More Options." OB GYN News 38 (August 1, 2003): 9.

Organizations

Advocates for Youth. 2000 M St. NW, Suite 750, Washington, DC 20036. Web site www.advocatesforyouth.org.

Planned Parenthood Federation of America Inc. 434 W. 33rd St., New York, NY 10001. Web site: www.plannedparenthood.org.

Web Sites

"Teens and Condoms." Avert.org, August 13, 2004. Available online at www.avert.org/teencondoms.htm (accessed November 23, 2004).

[Article by: Amy B. Tuteur Ken R. Wells]

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Contraception is the use of any of various methods to prevent pregnancy. Family planning, in contrast, involves the use of contraception or other measures to limit the number of children and plan the timing and spacing of births. Contraception has been used throughout history. Early methods, however, were ineffective (drinking potions or douching) or dangerous and not available to all people. By the middle of the twentieth century, only 13 percent of couples worldwide used effective methods of contraception. By the year 2000, UNICEF estimated that this figure had risen to 50 percent.

Contraceptive use is not equally distributed throughout the world. Most of western Europe, the United States, parts of Latin America, and Oceania demonstrate high levels of use. India, Pakistan, Nigeria, Sudan, Oman, Yemen, Haiti, Guatemala, Bolivia, and nations in sub-Sahara Africa demonstrate low contraceptive use and high fertility. In the past, family planning programs in some countries were, in effect, population control programs. They were often coercive and did not allow families choice. This is changing, as more people want to limit their family size. In some places, such as China, a strict population control policy is still in place.

In l994, the global attendees at the International Conference on Population and Development (ICPD) in Cairo, Egypt, placed family planning within a holistic context of reproductive health, and family planning is now considered to be a human right. Family planning helps save women's lives. Over 585,000 women die every year from unsafe abortion, childbirth, and pregnancy, with 90 percent of the deaths occurring in developing countries. These deaths are largely preventable; and contraception could play a role in preventing them.

Despite advances in contraceptive technologies, there is no single method that suits everyone. In some places, choice is limited and access is difficult, resulting in an unmet need for contraception (the condition of wanting to avoid or delay childbearing, but not using a contraceptive method).

One way to categorize contraceptive technologies is by the duration of protection. There are permanent, long-term, and short-term methods. In addition to these technologies, there are also behavioral methods of contraception. What follows is a list of all contraceptive technologies and behaviors, how they prevent pregnancy, their effectiveness, potential problems or side effects, and whether they also prevent reproductive tract infections (RTIs), hepatitis C, or sexual transmission of HIV (human immunodeficiency virus).

Permanent Methods

The two permanent surgical methods of contraception are 99 to 99.5 percent effective. They do not prevent RTIs, or HIV transmission, and they both involve a risk of infection or bleeding. In male sterilization, or vasectomy, the vas deferens (the tubes that carry the sperm from the testicles to the penis) are blocked or cut. Female sterilization, or tubal ligation, is a surgical procedure in which a woman's fallopian tubes are cut, burnt, or blocked to prevent sperm from reaching and fertilizing the egg.

Long-Acting Methods

None of the long-acting methods protect against RTIs or HIV transmission. IUDs, implants, and injections are 99 percent effective. Oral contraceptive pills are theoretically 99 percent effective, but pregnancies do occur if pills are missed or not taken on time.

IUD. An intrauterine device (IUD) is most often a nonhormonal method of contraception. The IUD is a small plastic or plastic and copper device placed inside a woman's uterus by a trained health care provider, and it protects against pregnancy for up to twelve years. The IUD may increase the risk of RTIs for women who have more than one partner. Side effects include increased cramping and bleeding during monthly periods. Some IUDs contain a hormone (progesterone) to increase their pregnancy protection while decreasing the risk of heavy bleeding. All of the other long-acting contraceptive methods are hormonal method.

Oral Contraceptive Pill. "The Pill" was introduced in the United States in the 1960s. It contains one or two hormones (either estrogen and progesterone together, or progesterone alone) that prevent ovulation and create a hostile environment for sperm. Although there was originally controversy over the health risks of the pill, it is now considered to be relatively safe for nonsmokers. In fact, it may protect against cancer of the ovaries and uterus. Side effects include nausea, breast tenderness, spotting, weight gain, mood changes, and headaches. Women who smoke should not take the pill as it may cause fatal blood clots. The pill's effectiveness is 99.5 percent if used perfectly, but 95 percent in real use.

Contraceptive Implants. Manufactured under the brand name Norplant®, contraceptive implants are silicone rods containing the hormone progesterone. Six of these matchstick-sized rods are placed under the skin of a woman's upper arm. The progesterone is released over time, and the implants remain effective for five years. While the effectiveness of implants is 99 percent, side effects include irregular monthly periods, spotting, acne, headaches, weight gain, and hair loss. Newer implants use one or two rods and may contain more than one hormone.

Hormonal Injections. Progesterone injections are given every two to three months, while those containing estrogen and progesterone are administered monthly. Injections work by stopping ovulation and making the cervical mucus hostile to sperm. Side effects include irregular periods, spotting, weight gain, headaches, depression, loss of libido, and hair loss.

Short-Acting Methods

Somewhat less effective than long-lasting methods, these contraceptives have fewer side effects. They are primarily physical or chemical barriers that also prevent or decrease the chances of transmitting RTIs and HIV.

Male Condom. This type of condom consists of a latex or animal intestine sheath that is placed over the erect penis before intercourse. Effectiveness is about 86 percent, as condoms can tear or slip off. Some people are allergic to latex and cannot use this type of condom. Latex condoms protect against RTIs and HIV infection, while those made from animal intestine do not.

Female Condom. The thin, female condom is plastic, tunnel-shaped device that is closed on one end. The closed end is placed over the cervix. It protects against both RTIs and pregnancy. One advantage of the female condom is that is it controlled by the woman. This feature is particularly important in a relationship where the woman cannot negotiate for safe sex. There are no medical limitations or side effects. At 80 percent effectiveness, the female condom is slightly less effective than the male condom.

Spermicides and Vaginal Barriers. Spermicides are chemicals that kill sperm or immobilize them. They come in many forms, including foaming tablets or suppositories, melting suppositories, foam, melting film, creams, and jellies. All are placed in the vagina prior to intercourse. Some women have allergic reactions to spermicides. Effectiveness is 80 percent. Spermicides can be used alone or in combination with condoms or vaginal barriers. These devices may also protect against RTIs and HIV, but their effectiveness in this regard is as of yet unknown.

Vaginal barriers (diaphragm, cervical cap, and sponge) are inserted in the vagina before inter-course and must be used with spermicides to be effective. A diaphragm is a soft rubber cup that covers the cervix, a cervical cap is a smaller rubber cup that fits right over the cervix, and a contraceptive sponge is a sponge impregnated with spermicide.

Emergency Contraceptive Pills. Also known as morning-after pills or post-coital pills, these are either estrogen and progesterone or progesterone-only pills that are taken within seventy-two hours of unprotected intercourse or in cases of contraception failure (e.g., forgotten pills, condom breakage, or slippage). Taken as directed they reduce the risk of pregnancy by 75 percent. They provide no RTI or HIV protection.

Behavioral Methods

There are a number of ways to prevent pregnancy that rely on human behavior rather than contraceptive technology.

Abstinence. Abstaining from sexual inter-course, whether completely or periodically, is 100 percent effective, but may be difficult to maintain.

Fertility Awareness. There are a variety of methods a woman can use to tell the fertile time of her menstrual cycle. These include calendar calculation, cervical secretions, basal body temperature (BBT), chemical ovulation prediction kits, and cervical changes. All of these methods are used in combination with either barrier methods (during the fertile time) or periodic abstinence (not having intercourse during the fertile time). Effectiveness is approximately 75 to 80 percent. Fertility awareness can also be used to time intercourse in order to facilitate pregnancy.

Lactational Amenorrhea Method (LAM). This is a behavioral method used by women who have recently given birth. It involves simply the use of breastfeeding during the first six months postpartum, and requires that 85 percent of the baby's food be breast milk. During this period and under these conditions, LAM is 100 percent effective. It is also inexpensive, has no hormonal side effects, and benefits the baby.

Future Methods

Methods of contraception being developed include both variations of existing methods and new concepts. Among the modifications of current methods are biodegradable hormonal implants, subdermal hormonal pellets, injectable hormonal "microspheres" (hybrids of injectables and implants), and intravaginal hormonal rings. New methods include male hormonal contraceptive pills, hormonal patches for men and women, and vaccines against sperm, ovum, or hormones. Microbicides—chemicals that kill bacteria and viruses—are also being tested for use alone, or in combination with spermicides for dual protection.

(SEE ALSO: Abstinence; Condoms; Contraception; Family Health; Family Planning Behavior; Maternal and Child Health; Menstrual Cycle; Planned Parenthood; Pregnancy; Reproduction; Sexually Transmitted Diseases; Women's Health)

Bibliography

Casterline, J. B., and Sinding, S. W. (2000). Unmet Need for Family Planning in Developing Countries and Implications for Population Policy. Working Paper #135. New York: Population Council.

Hatcher, R. A.; Rinehart, W.; Blackburn, R.; Geller, J. S. and Shelton, J. D. (1997). The Essentials of Contraceptive Technology. Baltimore, MD: Population Information Communication Programs, Johns Hopkins School of Public Health.

Hatcher, R. A.; Trussell, J.; Stewart, F.; Cates, W.; Stewart, G. K.; Guest, F.; and Kowal, D. (1998). Contraceptive Technology, 17th edition. New York: Ardent Media.

Klein, S.; Miller, S.; Bishop, J.; and Hansen, M. A Book for Midwives: A Manual for Traditional Birth Attendants and Community Midwives. Palo Alto, CA: Hesperian Foundation.

Speroff, L., and Darney, P. (1992). A Clinical Guide for Contraception. Baltimore, MD: Williams and Watkins.

— SUELLEN MILLER

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The Supreme Court's involvement in defining the constitutional right to obtain and use contraceptives has been limited until the relatively recent past. In 1927, however, the Court upheld the constitutionality of one contraceptive practice. Buck v. Bell (1927) involved the forced eugenic sterilization of a woman in a state mental institution who was considered to be genetically “unfit.” Justice Oliver Wendell Holmes, writing for the Court, found that none of her rights were violated and that sterilization was “better for all the world” (p. 207) than childbearing by persons with poor genes. In Skinner v. Oklahoma (1942), the Court limited the permissible scope of forced sterilizations, overturning an Oklahoma law providing for compulsory sterilization as a punishment for repeat offenders of certain crimes. The Court held that the right to procreate was a fundamental liberty protected by the Constitution. Skinner was decided on equal protection grounds and did not reverse Buck v. Bell. Although at odds with present privacy jurisprudence, Buck has never been overruled.

Legal restriction on the sale and use of birth control dates back to Congress's passage in 1873 of the Comstock Act, which made sending contraceptives or information about them through the mails or in interstate commerce a crime. Many states passed their own statutes restricting the sale or use of birth control. During the first half of the twentieth century, the lower federal courts and some state courts narrowly construed bans on birth control so that by the 1940s, in most jurisdictions, prescription of contraceptives by medical professionals was legal. In the states of Connecticut and Massachusetts, however, birth control bans continued. These statutes kept birth control clinics closed for years, interfering with access to effective birth control methods by low‐income women.

The Supreme Court had opportunities to review the constitutionality of birth control bans on a number of occasions but dismissed cases on standing grounds, Tileston v. Ullman (1943), or for want of a substantial federal question, Gardner v. Massachusetts (1938). In Poe v. Ullman (1961), the Court denied review of a declaratory judgment action challenging the Connecticut law because it believed that the statute was not being enforced.

After Planned Parenthood of Connecticut opened a birth control clinic, the clinic's executive director and medical director were arrested for violating the state law. Their conviction was appealed to the U.S. Supreme Court in Griswold v. Connecticut (1965). The Court struck down the law, finding that married persons have a constitutionally protected privacy right to use contraceptives. This right of marital privacy was “older than the Bill of Rights” (p. 486). Although not explicitly mentioned in the Constitution, it was implicitly protected, for it lay “within the zone of privacy created by several fundamental constitutional guarantees” (p. 485).

Griswold's holding centered on privacy in marital relations. The right to privacy in the use of birth control was extended to unmarried persons in Eisenstadt v. Baird (1972). Justice William J. Brennan wrote that “[i]f the right of privacy means anything, it is the right of the individual, married or single, to be free from unwarranted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child” (p. 453). This right was extended to minors when, in 1977, a plurality struck down a ban on distribution of contraceptives to persons under the age of sixteen because minors, as well as adults, had privacy rights (Carey v. Population Services International, 1977).

Also in Carey, the Court overturned a New York law permitting only pharmacists to distribute nonprescription contraceptives because the statute burdened the fundamental right to decide whether to bear a child, without serving any compelling state interests. It struck down the statute's total ban on advertising contraceptives on the ground that it suppressed commercial speech in violation of the First Amendment. The Court expanded First Amendment protection of the advertising of contraceptives when it struck down a federal ban on mailing unsolicited advertisements for contraceptives: Bolger v. Youngs Drug Product Corp. (1983).

The right to privacy developed in the birth control cases served as the basis for the Court's ruling that women have a privacy right to obtain an abortion in Roe v. Wade (1973). Although the Court has recently retreated somewhat in its protection of abortion rights (e.g., Webster v. Reproductive Health Services, 1989), the right to obtain and use contraceptives remains firmly, and broadly, protected.

See also Due Process, Substantive; Family and Children; Gender; Privacy.

Bibliography

• C. Thomas Dienes, Law, Politics, and Birth Control (1972)

— Mary L. Dudziak

For more information on contraception, visit Britannica.com.

Any practice that serves to prevent conception during sexual activity.

Prevention of conception or impregnation. Little practiced in the animal world (except in dogs and cats), population control being effected by other means. Is used in some less-developed communities where cattle are used as draft animals.

• immunological c. — involves immune-mediated control of hormone or degeneration of reproductive tissues. Some methods investigated in dogs include immunization with bovine or ovine luteinizing hormone (LH) or gonadotropin so that cross-reacting antibodies neutralize the animal's own hormone. Antibodies to porcine zona pellucida antigens inhibit fertilization and implantation.

Dansk (Danish)
n. - svangerskabsforebyggelse

Nederlands (Dutch)
anticonceptie

Français (French)
n. - contraception

Deutsch (German)
n. - Empfängnisverhütung

Ελληνική (Greek)
n. - (ιατρ.) αντισύλληψη, αντισυλληπτικές προφυλάξεις

Italiano (Italian)
contraccezione

Português (Portuguese)
n. - contracepção (f)

Русский (Russian)
предупреждение беременности

Español (Spanish)
n. - contracepción

Svenska (Swedish)
n. - användning av preventivmedel/födelsekontroll

中文（简体） (Chinese (Simplified))
避孕, 避孕法

中文（繁體） (Chinese (Traditional))
n. - 避孕, 避孕法

한국어 (Korean)
n. - 피임, 피임법

日本語 (Japanese)
n. - 避妊

العربيه (Arabic)
‏(الاسم) منع الحمل‏

עברית (Hebrew)
n. - ‮מניעת הריון‬

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