Birth control is the control of fertility, or the prevention of pregnancy, through one of several methods. Another common name for birth control is contraception, because that is precisely what the various birth control methods do; they prevent the viable sperm and egg from uniting to form a fertilized embryo. Though discussing birth control is no longer likely to lead to an arrest, as it did in the days of birth control pioneer Margaret Sanger, public debates remain. Some debates address which methods of birth control are the most effective at attaining one’s reproductive goals, while others address whether insurance benefits should include the cost of birth control, the likely long- and short-term effects of their use, how to increase the use of birth control among sexually active young people, and questions over why there are still so many more methods that focus on women’s fertility compared with those that focus on men’s fertility.
II. Brief History of Birth Control
III. Overview of Traditional Contraceptive Methods
A. Traditional Contraceptive Methods
B. Non-Barrier Contraceptive Methods
IV. New Contraceptive Technologies
V. Permanent Contraception
VI. Emergency Contraception
Controlling fertility affects the well-being of women, men, children, families, and society by providing methods and strategies to prevent unplanned pregnancies. Planned fertility positively impacts the health of children, maternal longevity, and the empowerment of women. Access to birth control provides women and men with choices regarding family size, timing between pregnancies, and spacing of children. Additionally, controlling fertility reduces the prevalence of chronic illness and maternal death from pregnancy-related conditions.
Globally, approximately 210 million women become pregnant each year. Of these pregnancies, nearly 40 percent are unplanned. In the United States, 49 percent of pregnancies are estimated to be unplanned. Research shows that unintended pregnancies can have devastating impacts on not only women but also children and families. An unintended pregnancy places a woman at risk for depression, physical abuse, and the normal risks associated with pregnancy, including maternal death. Pregnancies that are spaced closely together present risks to children, including low birth weight, increased likelihood of death in the first year, and decreased access to resources necessary for healthy development. Unintended pregnancies can have devastating impacts on the well-being of the family unit. An unplanned pregnancy often pushes families with limited economic resources into a cycle of poverty that further limits their opportunities for success.
Although control of fertility spans approximately 30 years of men’s and women’s reproductive life, preferences for birth control methods and strategies vary among individuals and across the life course and are influenced by multiple social factors. These factors may include socioeconomic status, religious or moral beliefs, purpose for using birth control (permanent pregnancy prevention, delay of pregnancy, or spacing between births), availability of birth control products, access to medical care, willingness to use birth control consistently, concern over side effects, and variability in the failure rates of different types of birth control products. Although the primary purpose of birth control is to control fertility, increases in the prevalence of sexually transmitted infections (STIs) and the human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), have created pressures to develop new pregnancy prevention options that combine contraception and STI prevention. The availability of contraceptive options allows women and men the opportunity to maximize the benefits of birth control while minimizing the risks of contraceptive use according to their needs.
The availability of birth control has raised important questions about reproductive control and the relationships between men and women. Traditionalists argue that pregnancy and child rearing are the natural or biologically determined roles of women, given their capacity to become pregnant and give birth. Opponents of this view argue that reproduction and motherhood are one of many choices available to women. Providing options to women and men that allow them to control their fertility has shifted pregnancy and motherhood from a position of duty to one of choice. This shift is a consequence of changes to the work force, increased opportunities for women, and changes in the economic structure of contemporary families. These changes, along with ongoing developments in fertility control research, provide women and men today with many innovative choices concerning birth control. These choices allow women and men to tailor birth control to their individual needs and life circumstances.
Today, birth control debates focus on the advantages and disadvantages of different birth control methods. The most common debates focus on the merits of temporary versus permanent methods of pregnancy prevention. Other debates examine the benefits of natural versus barrier methods of controlling reproduction. Still other debates examine the advantages and disadvantages of male and female contraception. With the growing pandemic of AIDS in sub-Saharan Africa and Asia and the increasing prevalence of sexually transmitted diseases that threatens world health, contemporary debates about birth control focus on the feasibility and practicality of combining STI prevention and contraception.
Brief History of Birth Control
Although women have sought to control their fertility since ancient times, safe and effective contraception was not developed until the 20th century. The large influx of immigrants in the 1900s and the emergence of feminist groups working for women’s rights helped bring to the forefront large-scale birth control movements in the United States and abroad. Ancient forms of birth control included potions, charms, chants, and herbal recipes. Ancient recipes often featured leaves, hawthorn bark, ivy, willow, and poplar, believed to contain sterilizing agents. During the Middle Ages, potions containing lead, arsenic, or strychnine caused death to many women seeking to control their fertility. Additionally, crude barrier methods were used in which the genitals were covered with cedar gum or alum was applied to the uterus. Later, pessary mixtures of elephant dung, lime (mineral), and pomegranate seeds were inserted into a woman’s vagina to prevent pregnancy. Other barrier methods believed to prevent pregnancy included sicklewort leaves, wool tampons soaked in wine, and crudely fashioned vaginal sponges.
Later birth control developments were based on more accurate information concerning conception. Condoms were developed in the early 1700s by the physician to King Charles II. By the early 1800s, a contraceptive sponge and a contraceptive syringe were available. By the mid-1800s, a number of more modern barrier methods to control conception were available to women. However, it was illegal to advertise these options, and most were available only through physicians and only in cases that were clinically indicated. Thus, early modern conception was limited to health reasons.
Modern contraceptive devices such as the condom, diaphragm, cervical cap, and intrauterine device (IUD) were developed in the 20th century and represented a marked advance in medical technology. Effectiveness was largely dependent on user compliance. Although these methods represented a significant improvement over more archaic methods, contraceptive safety remained an issue. Other modern methods included the insertion of various substances (some toxic) into the vagina, resulting in inflammation or irritation of the vaginal walls, while other devices often caused discomfort.
The birth control pill, developed in the 1950s by biologist Charles Pincus, represented a major advance in fertility control. Pincus is credited with the discovery of the effects of combining estrogen and progesterone in an oral contraceptive that would prevent pregnancy. The development and mass marketing of the birth control pill provided women with a way to control not only their fertility but also their lives.
Overview of Traditional Contraceptive Methods
Traditional contraception includes both temporary and permanent methods of controlling fertility. Temporary contraception provides temporary or time-limited protection from becoming pregnant. Permanent contraception refers to surgical procedures that result in a lasting or permanent inability to become pregnant. The choice of contraception takes into consideration several biological and social factors, including age, lifestyle (frequency of sexual activity, monogamy or multiple partners), religious or moral beliefs, legal issues, family planning objectives, as well as medical history and concerns. These factors vary among individuals and across the life span.
Traditional Contraceptive Methods
Traditional contraceptive methods provide varying degrees of protection from becoming pregnant and protection from STIs. While some of these methods provide noncontraceptive benefits, they require consistent and appropriate use and are associated with varying degrees of risks. Traditional contraception includes both hormonal and non-hormonal methods of preventing pregnancy and sexually transmitted diseases. These methods provide protection as long as they are used correctly but their effects are temporary and reversible once discontinued. Traditional contraceptive methods include sexual abstinence, coitus interruptus, rhythm method, barrier methods, spermicides, male or female condoms, IUDs, and oral contraceptive pills.
Sexual abstinence refers to the voluntary practice of refraining from all forms of sexual activity that could result in pregnancy or the transmission of sexually transmitted diseases. Abstinence is commonly referred to as the only form of birth control that is 100 percent effective in preventing pregnancy and STIs; however, failed abstinence results in unprotected sex which increases the risks of unintended pregnancy and transmission of STIs.
Coitus interruptus is the oldest method of contraception and requires the man to withdraw his penis from the vagina just prior to ejaculation. Often referred to as a so-called natural method of birth control, coitus interruptus is highly unreliable because a small amount of seminal fluid, containing sperm, is secreted from the penis prior to ejaculation and can result in conception. This method offers no protection from sexually transmitted diseases.
The rhythm method of birth control developed in response to research on the timing of ovulation. Research findings indicate that women ovulate approximately 14 days before the onset of their menstrual cycle. The rhythm method assumes that a woman is the most fertile during ovulation. To determine an individual cycle of ovulation, this method requires a woman to count backward 14 days from the first day of her menstrual period. During this time period, a woman should abstain from sexual activity or use another form of birth control (such as condoms) to avoid pregnancy. The rhythm method is another natural form of birth control that is highly risky. Few women ovulate at the exact same time from month to month, making accurate calculations of ovulation difficult. Additionally, sperm can live inside a woman for up to seven days, further complicating the calculations of safe periods for sex. Finally, the rhythm method does not provide protection from sexually transmitted diseases.
Barrier methods of contraception prevent sperm from reaching the fallopian tubes and fertilizing an egg. Barrier methods include both male and female condoms, diaphragms, cervical caps, and vaginal sponges. With the exception of the male condom, these methods are exclusively used by women. Barrier contraception is most often used with a spermicide to increase effectiveness. Spermicides contain nonoxynol-9, a chemical that immobilizes sperm to prevent them from joining and fertilizing an egg. Barrier methods of contraception and spermicides provide moderate protection from pregnancy and sexually transmitted diseases although failure rates (incidence of pregnancy resulting from use) vary from 20 to 30 percent.
Condoms, a popular and non-prescription form of barrier contraception available to both men and women, provides moderate protection from pregnancy and STIs. The male condom is a latex, polyurethane, or natural skin sheath that covers the erect penis and traps semen before it enters the vagina. The female condom is a soft, loosely fitting polyurethane tube-like sheath that lines the vagina during sex. Female condoms have a closed end with rings at each end. The ring at the closed end is inserted deep into the vagina over the cervix to secure the tube in place. Female condoms protect against pregnancy by trapping sperm in the sheath and preventing entry into the vagina. Used correctly, condoms are between 80 and 85 percent effective in preventing pregnancy and the transmission of STIs. Risks that decrease the effectiveness of condoms include incorrect usage, slippage during sexual activity, and breakage. Natural skin condoms used by some males do not protect against the transmission of HIV and other STIs.
The female diaphragm is a shallow, dome-shaped, flexible rubber disk that fits inside the vagina to cover the cervix. The diaphragm prevents sperm from entering the uterus. Diaphragms are used with spermicide to immobilize or kill sperm and to prevent fertilization of the female egg. Diaphragms may be left inside the vagina for up to 24 hours but a spermicide should be used with each intercourse encounter. To be fully effective, the diaphragm should be left in place for six hours after intercourse before removal. Approximately 80 to 95 percent effective in preventing pregnancy and the transmission of gonorrhea and Chlamydia, the diaphragm does not protect against the transmission of herpes or HIV.
Cervical caps are small, soft rubber, thimble-shaped caps that are fitted inside the woman’s cervix. Cervical caps prevent pregnancy by blocking the entrance of the uterus. Approximately 80 to 95 percent effective when used alone, effectiveness is increased when used with spermicides. Unlike the diaphragm, the cervical cap may be left in place for up to 48 hours. Similar to the diaphragm, the cervical cap provides protection against gonorrhea and chlamydia but does not provide protection against herpes or HIV.
Vaginal sponges, removed from the market in 1995 due to concerns about possible contaminants, are round, donut-shaped polyurethane devices containing spermicides and a loop that hangs down in the vagina allowing for easy removal. Sponges prevent pregnancy by blocking the uterus and preventing fertilization of the egg. Vaginal sponges are approximately 70 to 80 percent effective in preventing pregnancy but provide no protection against STIs. Risks include toxic shock syndrome if left inside the vagina for more than 24 hours.
Barrier methods of birth control provide moderate protection from pregnancy and STIs but are not fail-safe. Effectiveness is dependent on consistency and proper use. Advantages include lower cost, availability without a prescription, and ease of use (with the exception of the diaphragm). Disadvantages include lowered effectiveness as compared to other forms of birth control and little or no protection against certain STIs.
Non-Barrier Contraceptive Methods
Two other traditional contraceptive methods are the IUD and oral contraceptive pills. Both of these methods are characterized by increased effectiveness if used properly. The IUD is a T-shaped device inserted into a woman’s vagina by a health professional. Inserted into the wall of the uterus, the IUD prevents pregnancy by changing the motility (movement) of the sperm and egg and by altering the lining of the uterus to prevent egg implantation. The effectiveness of IUDs in preventing pregnancy is approximately 98 percent, however, IUDs do not provide protection from STIs. Oral contraceptive pills are taken daily for 21 days each month. Oral contraceptives prevent pregnancy by preventing ovulation, the monthly release of an egg. This form of contraception does not interfere with the monthly menstrual cycle. Many birth control pills combine progesterone and estrogen, however, newer oral contraceptives contain progesterone only. Taken regularly, oral contraceptives are approximately 98 percent effective in preventing pregnancy but do not provide STI protection.
New Contraceptive Technologies
In spite of the availability of a broad range of contraceptive methods, the effectiveness of traditional contraceptive methods is largely dependent on user consistency and proper use. Even with consistent and proper use, each method is associated with varying degrees of risk. Risks include the likelihood of pregnancy, side effects, and possible STI transmission. New developments in contraceptive technology focus on improvement of side effects and the development of contraceptives that do not require users to adhere to a daily regiment. These new technologies are designed to make use simpler and more suitable to users’ lives. Additionally, many of the new technologies seek to combine fertility control with protection from STIs.
The vaginal contraceptive ring is inserted into a woman’s vagina for a period of three weeks and removed for one week. During the three week period, the ring releases small doses of progestin and estrogen, providing month-long contraception. The release of progestin and estrogen prevents the ovaries from releasing an egg and increases cervical mucus that helps to prevent sperm from entering the uterus. Fully effective after seven days, supplementary contraceptive methods should be used during the first week after insertion. Benefits include a high effectiveness rate, ease of use, shorter and lighter menstrual periods, and protection from ovarian cysts and from ovarian and uterine cancer. Disadvantages include spotting between menstrual periods for the first several months and no protection against STIs.
Hormonal implants provide highly effective, long-term, but reversible, protection from pregnancy. Particularly suitable for users who find it difficult to consistently take daily contraceptives, hormonal implants deliver progesterone by using a rod system inserted underneath the skin. Closely related to implants are hormonal injections that are administered monthly. Both hormonal implants and injections are highly effective in preventing pregnancy but may cause breakthrough bleeding. Neither provides protection from STIs at this stage of development.
Contraceptive patches deliver a combination of progestin and estrogen through an adhesive patch located on the upper arm, buttocks, lower abdomen or upper torso. Applied weekly for three weeks, followed by one week without, the contraceptive patch is highly effective in preventing pregnancy but does not protect against the transmission of STIs. The use of the patch is associated with withdrawal bleeding during the week that it is not worn. Compliance is reported to be higher than with oral contraceptive pills.
Levonorgestrel intrauterine systems provide long-term birth control without sterilization by delivering small amounts of the progestin levonorgestrel directly to the lining of the uterus to prevent pregnancy. Delivered through a small T-shaped intrauterine plastic device implanted by a health professional, the levonorgestrel system provides protection from pregnancy for up to five years. It does not currently offer protection from STIs.
New contraceptive technologies are designed to provide longer-term protection from pregnancy and to remove compliance obstacles that decrease effectiveness and increase the likelihood of unintended pregnancies. The availability of contraceptive options provides users with choices that assess not only fertility purposes but also variations in sexual activity. However, until new contraceptive technologies that combine pregnancy and STI prevention are readily available, proper use of male and female condoms provides the most effective strategy for prevention of sexually transmitted diseases and HIV.
Permanent contraception refers to sterilization techniques that permanently prevent pregnancy. Frequently referred to as sterilization, permanent contraception prevents males from impregnating females and prevents females from becoming pregnant.
Tubal ligation refers to surgery to tie a woman’s fallopian tubes, preventing the movement of eggs from the ovaries to the uterus. The procedure is considered permanent and involves the cauterization of the fallopian tubes. However, some women who later choose to become pregnant have successfully had the procedure reversed. The reversal of tubal ligation procedures are successful in 50 to 80 percent of cases.
Hysterectomy refers to the complete removal of a woman’s uterus or the uterus and cervix, depending on the type of procedure performed, and results in permanent sterility. Hysterectomies may be performed through an incision in the abdominal wall, vaginally, or by using laparoscopic incisions on the abdomen.
Vasectomy refers to a surgical procedure for males in which the vas deferens are tied off and cut apart to prevent sperm from moving out of the testes. The procedure results in permanent sterility although the procedure may be reversed under certain conditions. Permanent contraception is generally recommended only in cases in which there is no desire for children, family size is complete, or in cases where medical concerns necessitate permanent prevention of pregnancy.
Emergency contraception, commonly referred to as postcoital contraception or the so-called morning-after pill, encompasses a number of therapies designed to prevent pregnancy following unprotected sexual intercourse. Emergency contraception is also indicated when a condom slips or breaks, a diaphragm dislodges, two or more oral contraceptives are missed or the monthly regimen of birth control pills are begun two or more days late, a hormonal injection is two weeks overdue, or a woman has been raped. Emergency contraception prevents pregnancy by preventing the release of an egg from the ovary, by preventing fertilization, or by preventing attachment of an egg to the uterine wall. Most effective when used within 72 hours of unprotected sex, emergency contraception does not affect a fertilized egg already attached to the uterine wall. Emergency contraception does not induce an abortion or disrupt an existing pregnancy; it prevents a pregnancy from occurring following unprotected sexual intercourse.
Ideally, birth control should be a shared responsibility between a woman and her partner. In the U.S., approximately 1.6 million pregnancies each year are unplanned. Unplanned pregnancies position women, men, and families in a precarious situation that has social, economic, personal and health consequences. An unintended pregnancy leaves a woman and her partner facing pregnancy termination, adoption, or raising an unplanned child— often times under less-than-ideal conditions. Contraceptive technologies and research developments in the transmission of sexually transmitted diseases represent increased opportunities for not only controlling fertility but also improving safe sex practices.
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