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Birth control is a regimen of one or more actions, devices, or medications followed in order to deliberately prevent or reduce the likelihood of a woman becoming pregnant or giving birth. Methods and intentions typically termed birth control may be considered a pivotal ingredient to family planning. Mechanisms which are intended to reduce the likelihood of the fertilisation of an ovum by a spermatozoon may more specifically be referred to as contraception. Contraception differs from abortion in that the former prevents fertilization, while the latter terminates an already established pregnancy. Methods of birth control which may prevent the implantation of an embryo if fertilization occurs are medically considered to be contraception but characterized by some opponents as abortifacients.

Birth control is a controversial political and ethical issue in many cultures and religions, and although it is generally less controversial than abortion specifically, it is still opposed by many. There are various degrees of opposition, including those who oppose all forms of birth control short of sexual abstinence; those who oppose forms of birth control they deem "unnatural", while allowing natural birth control; and those who support most forms of birth control that prevent fertilisation, but oppose any method of birth control which prevents a fertilized embryo from attaching to the uterus and initiating a pregnancy.

History

Probably the oldest methods of contraception (aside from sexual abstinence) are coitus interruptus, certain barrier methods, and herbal methods (emmenagogues and abortifacients).

Coitus interruptus (withdrawal of the penis from the vagina prior to ejaculation) probably predates any other form of birth control. Once the relationship between the emission of semen into the vagina and pregnancy was known or suspected, some men began to use this technique. This is not a particularly reliable method of contraception, as few men have the self-control to correctly practice the method at every single act of intercourse. Although it is commonly believed that pre-ejaculate fluid can cause pregnancy, modern research has shown that pre-ejaculate fluid does not contain viable sperm.

There are historic records of Egyptian women using a pessary (a vaginal suppository) made of various acidic substances (crocodile dung is alleged) and lubricated with honey or oil, which may have been somewhat effective at killing sperm. However, it is important to note that the sperm cell was not discovered until Anton van Leeuwenhoek invented the microscope in the late seventeenth century, so barrier methods employed prior to that time could not know of the details of conception. Asian women may have used oiled paper as a cervical cap, and Europeans may have used beeswax for this purpose. The condom appeared sometime in the seventeenth century, initially made of a length of animal intestine. It was not particularly popular, nor as effective as modern latex condoms, but was employed both as a means of contraception and in the hopes of avoiding syphilis, which was greatly feared and devastating prior to the discovery of antibiotic drugs.

Various abortifacients have been used throughout human history, although many do not associate induced abortion with the term 'birth control'. Some of them were effective, some were not; those that were most effective also had major side effects. One abortifacient reported to have low levels of side effects—silphium—was harvested to extinction around the 1st century. The ingestion of certain poisons by the female can disrupt the reproductive system; women have drunk solutions containing mercury, arsenic, or other toxic substances for this purpose. The Greek gynaecologist Soranus in the 2nd century suggested that women drink water that blacksmiths had used to cool metal. The herbs tansy and pennyroyal are well-known in folklore as abortive agents, but these also "work" by poisoning the woman. Levels of the active chemicals in these herbs that will induce a miscarriage are high enough to damage the liver, kidneys, and other organs, making them very dangerous. However, in those times where risk of maternal death from postpartum complications was high, the risks and side effects of toxic medicines may have seemed less onerous. Some herbalists claim that black cohosh tea will also be effective in certain cases as an abortifacient.

The fact that various effective methods of birth control were known in the ancient world sharply contrasts with a seeming ignorance of these methods in wide segments of the population of early modern Christian Europe. This ignorance continued far into the 20th century, and was paralleled by eminently high birth rates in European countries during the 18th and 19th centuries.. Some historians have attributed this to a series of coercive measures enacted by the emerging modern state, in an effort to repopulate Europe after the population catastrophe of the Black Death, starting in 1348. According to this view, the witch hunts were the first measure the modern state took in an attempt to eliminate knowledge about birth control within the population, and monopolize it in the hands of state-employed male medical specialists (gynecologists). Prior to the witch hunts, male specialists were unheard-of, because birth control was naturally a female domain.

Presenters at a family planning conference told a tale of Arab traders inserting small stones into the uteruses of their camels in order to prevent pregnancy, a concept very similar to the modern IUD. Although the story has been repeated as truth, it has no basis in history and was meant only for entertainment purposes. The first interuterine devices (which occupied both the vagina and the uterus) were first marketed around 1900. The first modern intrauterine device (contained entirely in the uterus) was described in a German publication in 1909, although the author appears to have never marketed his product.

The Rhythm Method (with a rather high method failure rate of 10% per year) was developed in the early twentieth century, as researchers discovered that a woman only ovulates once per menstrual cycle. Not until the mid-20th century, when scientists better understood the functioning of the menstrual cycle and the hormones that controlled it, were oral contraceptives and modern methods of fertility awareness (also called natural family planning) developed.

Methods

Physical methods

Barrier methods

Barrier methods place a physical impediment to the movement of sperm into the female reproductive tract.

The most popular barrier method is the male condom, a latex or polyurethane sheath placed over the penis. The condom is also available in a female version, which is made of polyurethane. The female condom has a flexible ring at each end—one secures behind the pubic bone to hold the condom in place, while the other ring stays outside the vagina.

Cervical barriers are devices that are contained completely within the vagina. The cervical cap is the smallest cervical barrier. It stays in place by suction to the cervix or to the vaginal walls. The Lea's shield is a larger cervical barrier, also held in place by suction. The diaphragm fits into place behind the woman's pubic bone and has a firm but flexible ring, which helps it press against the vaginal walls. The contraceptive sponge has a depression to hold it in place over the cervix.

Hormonal methods

There are variety of delivery methods for hormonal contraception.

Combinations of synthetic estrogens and progestins (synthetic progestogens) are commonly used. These include the combined oral contraceptive pill ("The Pill"), the Patch, and the contraceptive vaginal ring ("NuvaRing"). Not currently available for sale in the United States is Lunelle, a monthly injection.

Other methods contain only a progestin (a synthetic progestogen). These include the progestin only pill (the POP or 'minipill'), the injectables Depo Provera (a depot formulation of medroxyprogesterone acetate given as an intramuscular injection every three months) and Noristerat (norethisterone acetate given as an intramuscular injection every 8 weeks), and contraceptive implants. The progestin-only pill must be taken at more precisely remembered times each day than combined pills. The first contraceptive implant, the original 6-capsule Norplant, was removed from the market in the United States in 1999, though a newer single-rod implant called Implanon was approved for sale in the United States on July 17, 2006. The various progestin-only methods may cause irregular bleeding while being used.

Ormeloxifene (Centchroman)

Ormeloxifene (Centchroman) is a selective estrogen receptor modulator, or SERM. It causes ovulation to occur asynchronously with the formation of the uterine lining, preventing implantation of a zygote. It has been widely available as a birth control method in India since the early 90s, marketed under the trade name Saheli®. Centchroman is legally available only in India.

Intrauterine methods

These are devices that are placed in the uterus. They are usually shaped like a "T"—the arms of the T hold the device in place inside the uterus. In the United States, all devices which are placed in the uterus to prevent pregnancy are referred to as IUDs. In the UK, a distinction is made between the IUDs and IUS. This is probably because there are seven different kinds of IUDs available in the UK, compared to two in the US.

Intrauterine Devices ("IUDs") contain copper (which has a spermicidal effect).

IntraUterine Systems ("IUS") release a progestogen (either progesterone or a progestin).

Emergency contraception

Some combined pills and POPs may be taken in high doses to prevent pregnancy after a birth control failure (such as a condom breaking) or after unprotected intercourse. Hormonal emergency contraception is also known as the "morning after pill," although it is licensed for use up to three days after intercourse.

Copper intrauterine devices may also be used as emergency contraception. For this use, they must be inserted within five days of the birth control failure or unprotected intercourse.

Induced abortion

Abortion can be done with surgical methods, usually suction-aspiration abortion (in the first trimester) or dilation and evacuation (in the second trimester). Medical abortion uses drugs to end a pregnancy and is approved for pregnancies of less than 8 weeks gestation.

Some herbs are believed to cause abortion (abortifacients). Peer-reviewed research has proven the efficacy of some of these substances, but the use of herbs to induce abortion is not recommended, due to the risk of serious side effects.

Abortion is subject to ethical debate.

Sterilization

Surgical sterilization is available in the form of tubal ligation for women and vasectomy for men.

A non-surgical sterilization procedure, Essure, is also available for women.

Behavioral methods

Fertility awareness methods

Fertility awareness (FA) methods involve a woman's observation and charting of one or more of her body's primary fertility signs, to determine the fertile and infertile phases of her cycle. Unprotected sex is restricted to the least fertile period. During the most fertile period, barrier methods may be availed, or she may abstain from intercourse. Different methods track one or more of the two primary fertility signs: changes in basal body temperature and changes in cervical mucus. If a woman tracks both basal body temperature and cervical mucus, the method is referred to as symptothermal. Other bodily cues including cervical position and mittelschmerz are considered secondary indicators. A woman may chart these events on paper or with software. FA is versatile and may also be practiced to achieve pregnancy, by identifying the fertile period and having intercourse prior to and during that time.

The term "natural family planning" (NFP) is sometimes used to refer to any use of FA methods. However, this term specifically refers to the practices which are permitted by the Roman Catholic Church — breastfeeding infertility, and periodic abstinence during fertile times. FA methods may be used by NFP users to identify these fertile times. Two observational methods of NFP are the Billings ovulation method and the Creighton Model. Both are based on cervical mucus observation.

Statistical methods

Statistical methods such as the Rhythm Method and Standard Days Method are dissimilar from observational fertility awareness methods, in that they do not involve the observation or recording of bodily cues of fertility. Instead, statistical methods estimate the likelihood of fertility based on the length of past menstrual cycles. Statistical methods are much less accurate than fertility awareness methods, and are considered by many fertility awareness teachers to have been obsolete for at least twenty years.

Coitus interruptus

Coitus interruptus (literally "interrupted sex"), also known as the withdrawal method, is the practice of ending sexual intercourse ("pulling out") before ejaculation. The main risk of coitus interruptus is that the man may not make the maneuver in time. Although concern has been raised about the risk of pregnancy from sperm in pre-ejaculate, several small studies have failed to find any viable sperm in the fluid.

Avoiding vaginal intercourse

The risk of pregnancy from non-vaginal sex, such as outercourse (sex without penetration), anal sex, or oral sex is low. (A very small risk comes from the possibility of semen leaking onto the vulva (with anal sex) or coming into contact with an object, such as a hand, that later contacts the vulva). However, with this method, discipline is required to prevent the progression to intercourse.

Abstinence

Sexual abstinence is the practice of refraining from all sexual activity. As with avoiding intercourse, the intention to remain abstinent may not prevent pregnancy, due to the level of discipline required.

Lactational

Most breastfeeding women have a period of infertility after the birth of their child. The Lactational Amenorrhea Method, or LAM, gives guidelines for determining the length of a woman's period of breastfeeding infertility.

Methods in development

Experimental contraceptives for males

Research is being done into a variety of substances that have potential as male oral contraceptives, or implants or injections that may be used as male hormonal contraceptives.

RISUG (Reversible Inhibition of Sperm Under Guidance), is an injection into the vas deferens that coats the walls of the vas with a spermicidal substance. This method can be reversed by washing out the vas deferens with a second injection.

Vas-occlusive contraception would be analogous to intrauterine contraception in women.

Heat-based contraception involves heating the testicles to a high temperature for a short period of time.

Misconceptions

Modern misconceptions and urban legends have given rise to a great deal of false claims:

• The suggestion that douching immediately following intercourse works as a contraceptive is untrue. While it may seem like a sensible idea to try to wash the ejaculate out of the vagina, it does not work. Due to the nature of the fluids and the structure of the female reproductive tract–if anything, douching spreads semen further towards the uterus. Some slight spermicidal effect may occur if the douche solution is particularly acidic, but overall it is not scientifically observed to be a reliably effective method.
• The suggestion to shake a bottle of Coca-Cola and insert it into the vagina after ejaculation is not a form of birth control, it does not prevent pregnancy, and doing this can also promote candidiasis (yeast infections).
• It is a myth that a female cannot get pregnant the first time she engages in sexual intercourse.
• While women are usually less fertile for the first few days of menstruation, it is a myth that a woman cannot get pregnant if she has sex during her period.
• Having sex in a hot tub does not prevent pregnancy, but may contribute to vaginal infections.
• Although some sex positions may encourage pregnancy, no sexual positions prevent pregnancy. Having sex while standing up or with a woman on top will not keep the sperm from entering the uterus. The force of ejaculation, the contractions of the uterus caused by prostaglandins in the semen, as well as ability of sperm to swim overrides gravity.
• Sneezing or urinating after sex are also completely ineffective, they do not prevent pregnancy and are not forms of birth control.
• Toothpaste cannot be used as an effective contraceptive

Effectiveness

See also the table at: Comparison of birth control methods

Effectiveness is measured by how many women become pregnant using a particular birth control method in a year. Thus, if 100 women use a method that has a 12% failure rate, sometime during that year, 12 of the women will become pregnant.

The most effective methods in typical use are those that do not depend upon regular user action. Surgical sterilization, Depo-Provera, implants, and intrauterine devices (IUDs) all have failure rates of less than 1% per year for perfect use. Depo-Provera, or the shot, has a typical failure rate of 3%, while sterilization, implants, and IUDs still have a typical failure use under 1%.

Other methods may be highly effective if used consistently and correctly, but can have typical use failure rates that are considerably higher due to incorrect or ineffective usage by the user. Hormonal contraceptives, fertility awareness methods, and ecological breastfeeding, if used strictly, have failure rates of less than 1% per year. Typical use failure rates of hormonal contraceptives are as high as 8% per year. Fertility awareness methods as a whole have typical-use failure rates as high as 25% per year; however, as stated above, perfect use of these methods reduces the failure rate to less than 1%.

Condoms and cervical barriers such as the diaphragm have similar typical use failure rates (15.0% and 16%, respectively), but perfect usage of the condom is more effective (2% failure vs 6%) and condoms have the additional feature of helping to prevent the spread of sexually transmitted diseases such as HIV. The withdrawal method, if used consistently and correctly, has a failure rate of 4%. Due to the difficulty of consistently using withdrawal correctly, it has a typical use failure rate of 27% and is not recommended by some medical professionals, although others believe it deserves more support.

Protection against sexually transmitted infections

Not all methods of birth control offer protection against sexually transmitted infections. Abstinence from all forms of sexual behavior will protect against the sexual transmission of these infections. The male latex condom offers some protection against some of these diseases with correct and consistent use, as does the female condom, although the latter has only been approved for vaginal sex. The female condom may offer greater protection against sexually transmitted infections that pass through skin to skin contact, as the outer ring covers more exposed skin than the male condom, and can be used during anal sex to guard against sexually transmitted infections. However, the female condom can be difficult to use. Frequently a woman can improperly insert it, even if she believes she is using it correctly.

The remaining methods of birth control do not offer significant protection against the sexual transmission of these diseases.

However, so-called sexually transmitted infections may also be transmitted non-sexually, and therefore, abstinence from sexual behavior does not guarantee 100% protection against sexually transmitted infections. For example, HIV may be transmitted through contaminated needles which may be used in tattooing, body piercing, or injections. Health-care workers have acquired HIV through occupational exposure to accidental injuries with needles.

Religious and cultural attitudes

Religious views on birth control

Religions vary widely in their views of the ethics of birth control. In Christianity, the Roman Catholic Church accepts only Natural Family Planning, while Protestants maintain a wide range of views from allowing none to very lenient. Views in Judaism range from the stricter Orthodox sect to the more relaxed Reformed sect. In Islam, contraceptives are allowed if they do not threaten health or lead to sterilty, although their use is sometimes discouraged. Hindus may use both natural and artificial contraceptives.

Birth control education

Many teenagers, most commonly in developed countries, receive some form of sex education in school. What information should be provided in such programs is hotly contested, especially in the United States and Great Britain. Possible topics include reproductive anatomy, human sexual behavior, information on sexually transmitted diseases (STDs), social aspects of sexual interaction, negotiating skills intended to help teens follow through with a decision to remain abstinent or to use birth control during sex, and information on birth control methods.

One type of sex education program, called abstinence-only education, promotes abstinence until marriage and does not provide information on birth control, or heavily emphasizes negative information such as failure rates. Because abstinence offers better protection against pregnancy and disease than sexual activity with even the best birth control methods, advocates of abstinence-only education believe they will result in decreased rates of teenage pregnancy and STD infection. However, some studies have found that abstinence-only sex education programs actually increase the rates of pregnancy and STDs in the teenage population.

See also

• Population control
• One-child policy
• Reproductive Health

References

1. ^ "Researchers find no sperm in pre-ejaculate fluid". Contraceptive Technology Update. 14 (10): 154–156. October 1993. PMID 12286905.{{cite journal}}: CS1 maint: year (link)
2. ^ Zukerman, Z. (April 2003). "Short Communication: Does Preejaculatory Penile Secretion Originating from Cowper's Gland Contain Sperm?". Journal of Assisted Reproduction and Genetics. 20 (4): 157–159. PMID 12762415. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: year (link)
3. Tatman, John. Silphium: Ancient Wonder Drug? Accessed December 21, 2005
4. ^ Riddle, John M. (1999). Eve's Herbs: A History of Contraception and Abortion in the West. Harvard MA: Harvard University Press. ISBN 0-674-27026-6.
5. see John M. Riddle: "Eve's Herbs: A History of Contraception and Abortion in the West", Princeton: Harvard University Press 1999, ISBN-10: 0674270266,esp. Chapter 6: "The Broken Chain of Knowledge"
6. see Gunnar Heinsohn/Otto Steiger: "Witchcraft, Population Catastrophe and Economic Crisis in Renaissance Europe: An Alternative Macroeconomic Explanation.", University of Bremen 2004(download); John M. Riddle: "The Great Witch-Hunt and the Suppression of Birth Control: Heinsohn and Steiger's Theory from the Perspective of an Historian", Appendix to: Gunnar Heinsohn/Otto Steiger: "Witchcraft, Population Catastrophe and Economic Crisis in Renaissance Europe: An Alternative Macroeconomic Explanation.", University of Bremen 2004; also see John M. Riddle: "Eve's Herbs: A History of Contraception and Abortion in the West", Princeton: Harvard University Press 1999, ISBN-10: 0674270266, Chapters 5-7
7. "A History of Birth Control Methods". Planned Parenthood. June 2002. Retrieved 2006-09-02.{{cite web}}: CS1 maint: year (link), which cites:
   Thomas, Patricia. (1988). Contraceptives, Medical World News, 29(5) (14 March), 48
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10. Weschler, Toni (2002). Taking Charge of Your Fertility (Revised Edition ed.). New York: HarperCollins. pp. p.52. ISBN 0-06-093764-5. {{cite book}}: |edition= has extra text (help); |pages= has extra text (help)
11. Kippley, John (1996). The Art of Natural Family Planning (4th addition ed.). Cincinnati, OH: The Couple to Couple League. pp. 108–111, 148. ISBN 0-926412-13-2. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help), which cites:

    Wade ME, McCarthy P, Braunstein GD; et al. (October 1981). "A randomized prospective study of the use-effectiveness of two methods of natural family planning". American journal of obstetrics and gynecology. 141 (4): 368–376. PMID 7025639. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) CS1 maint: year (link)

    Barbato M, Bertolotti G (1988). "Natural methods for fertility control: A prospective study—first part". International Journal of Fertility. 33 Suppl: 48–51. PMID 2902027.

    Roetzer, J (1979). "Sympto-thermal method—Ten years of change". Linacre Quarterly. 45: 358–374. PMID 12309198.

12. "Sex & the Holy City" (htm). Foreign Correspondent. Retrieved 2006-11-21.
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14. Hilgers T.W. and Stanford J.B. (1998) "Creighton Model NaProEducation Technology for avoiding pregnancy. Use effectiveness", Journal of Reproductive Medicine 43(6):495-502
15. Evaluation of the Effectiveness of a Natural Fertility Regulation Programme in China: Shao-Zhen Qian, et al. Reproduction and Contraception (English edition), in press 2000.
16. Howard, M.P. and Stanford, J.B. (1999) "Pregnancy probabilities during use of the Creighton Model Fertility Care System", Archives of Family Medicine 8(5):391-402
17. ^ James Trussell et, al.Contraceptive effectiveness rates. Contraceptive Technology — 18th Edition, New York: Ardent Media. On-press, 2000.
18. Skouby, SO. The European Journal of Contraception and Reproductive Health Care (2004) "Contraceptive use and behavior in the 21st century: a comprehensive study across five European countries." 9(2):57-68
19. Do AN, Ciesielski CA, Metler RP, Hammett TA, Li J, Fleming PL (2003). "Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States". Infect Control Hosp Epidemiol. 24 (2): 86–96. PMID 12602690.{{cite journal}}: CS1 maint: multiple names: authors list (link)
20. "Humanae Vitae: Encyclical of Pope Paul VI on the Regulation of Birth, July 25, 1968" (html). The Vatican. Retrieved 2006-10-01.
21. Dennis Rainey (2002). ""The Value of Children" (11 July 2002 FamilyLife Today Radio Broadcast)" (Transcript of radio broadcast). FamilyLife Today. Retrieved 2006-09-30.
22. Feldman, David M. (1998). Birth Control in Jewish Law. Lanham, MD: Jason Aronson. ISBN 0-7657-6058-4.
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24. ""Hindu Beliefs and Practices Affecting Health Care"" (html). University of Virginia Health System. Retrieved 2006-10-06.
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External links

• Planned Parenthood of America - Birth Control Methods
• Contraception Resource Center from the Association of Reproductive Health Professionals.
• Johns Hopkins University's Reproline
• ContraceptINFO Birth Control Guide for Couples and Teens
• American FDA Baby Guide: approved contraceptive method profiles (published 1997, several newer methods not listed).
• A Guide to Condoms and birth control methods. by Consumer Reports.
• History of Contraception
• "The Contraception Museum" (The History of Contraception Museum, Cleveland, Ohio, US.)
• Ingenious: an archive of historical images related to obstetrics, gynaecology, and contraception.

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