Contraception is defined as the use of medications, devices, surgery, or sexual timing or practices to voluntarily avoid unintended pregnancy and to space childbirth. Birth control, family planning, fertility control, pregnancy prevention, and planned parenthood are other terms used for contraception. A general medical or gynecological health exam for girls and women of reproductive age is not complete unless the health caregiver has addressed the need for contraception. Appropriate counseling for the selection and use of a contraceptive method should include information regarding the benefits, risks, alternatives, and instructions for use presented in a noncoercive and nonjudgmental manner, as well as the opportunity for questions. The choice to use a contraceptive method is a decision made by the woman and her partner based on personal, social, religious, and financial considerations. In addition, other health factors including the possibility of exposure to sexually transmitted infections and personal health history should be considered. Noncoercive, collaborative, and thorough counseling increases the likelihood that the user will be comfortable and competent to use the selected method.
People have attempted to control their fertility since antiquity. As long as 4,000 years ago, the Cahun Papyrus, the oldest written document on fertility control, describes the use of pessaries made from crocodile dung and fermented dough. Condoms made from linen and the skins of sheep, goats, and even snakes were widely used. In the ruins of Pompeii, curettes and dilators similar to instruments used in modern-day abortion were discovered (New Internationalist, 1998).
Until the mid-19th century, few effective methods of fertility control existed. In the early 20th century, Margaret Sanger (1883-1966), a nurse and feminist, introduced the diaphragm into the United States. She founded the organization that would later become Planned Parenthood Federation of America. In 1965, the U.S. Supreme Court declared birth control to be a basic right in the Estelle T. Griswold and C. Lee Buxton v. State of Connecticut decision. Abortion, a subject that continues to divide the country today, was legalized in 1973 in the Roe v. Wade decision. This action by the Supreme Court limited the circumstances under which states could restrict the “right to privacy” under local law (Youngkin & Davis, 1998). In 1987, in the Webster v. Reproductive Health Services decision, the Supreme Court weakened the right to abortion on demand. This 5-4 decision allowed the states to restrict abortion in public facilities, to forbid the use of public employees in the performance of abortion, and to require viability testing for fetuses thought to be greater than 20 weeks gestation. This divisive national controversy continues to be far from resolved.
Socioeconomic and medical implications of unintended pregnancy are far-reaching and expensive in both economic and human terms. A 1995 report by the Institute of Medicine on the implications of unintended pregnancy on the well-being of women and families reports:
- A woman with an unintended pregnancy is less likely to seek early prenatal care and more likely to expose the fetus to harmful substances such as alcohol and tobacco.
- Births from unintended pregnancies are more likely to occur to mothers who are adolescent, unmarried, or over age 40—characteristics that carry special medical risks and socio-economic burdens.
- Children born from an unwanted conception are at greater risk of being born at low birth-weight, of dying in the first year of life, of being abused, and of having developmental disabilities.
- Mothers who experience unintended pregnancy are at greater risk for depression and both parents may suffer economic hardship or failure to reach educational or career goals.
Teen pregnancy creates especially challenging social problems. According to the Alan Guttmacher Institute (1999), 78% of teen pregnancies are unplanned, accounting for one fourth of all accidental pregnancies annually. Seven in ten teen mothers finish high school but are less likely to go on to college. Partly because most teen mothers come from disadvantaged backgrounds, 28% are poor between the ages of 20 and 30 while only 7% who give birth after adolescence are poor at those ages.
There is ample evidence demonstrating the costeffectiveness of contraceptive use. In a 1995 study, Trussel et al. measured the cost of contraceptive methods compared to the cost of unintended pregnancies when no contraception was used. They found the total savings to the health care system to fall between $9,000 and $14,000 per woman over 5 years of contraceptive use. These figures do not include the costs to women and families for the needs of children and the loss in earnings potential due to educational and employment discrepancies between those with planned and unplanned childbearing. It is estimated that for every $1.00 spent on publicly funded reproductive health care, $3.00 of Medicaid funding for prenatal and pediatric medical care is saved (Planned Parenthood Federation of America, 2001).
There are many types of contraception. They are categorized as abstinence, coitus interruptus, lactational amenorrhea method, barrier methods, hormonal methods, fertility awareness methods, intrauterine device, and surgical sterilization. Each of these methods has risks, benefits, and individual effectiveness rates. When deciding to use a method of contraception, safety, efficacy, and personal factors should be taken into consideration (Hatcher et al., 1998).
Virtually all methods of contraception are safer than pregnancy-related complications. Safety issues that should be taken into account are personal health risks, future fertility, side effects, and specific precautions that can make using the method safer. For instance, when using an IUD, minimizing the number of sexual partners decreases the risk of pelvic infection and subsequent decreased future fertility.
Efficacy of a method is determined by both the chosen method and user characteristics. Some sources document efficacy statistics as perfect use versus typical use. Typical use is affected by the frequency of use (taking a pill everyday vs. an injection every 3 months), whether the method interferes with spontaneity by requiring the partner(s) to use it at the time of intercourse, whether it requires cooperation of both partners, and whether it can be used consistently due to issues of availability and cost of supplies. Methods that require a prescription must be ordered by a medical provider thus incurring the additional cost of a medical visit. Over-the-counter methods are more easily available and less expensive but often less effective.
Personal factors that should be taken into consideration when selecting a contraceptive method include:
- personal preference and comfort with a method;
- frequency of intercourse;
- personal health factors that might be complicated or improved by a method (i.e., irregular periods improve with oral contraceptives);
- religious prohibitions to a given method;
- previous positive or negative experience using a method.
Barrier methods such as condoms, vaginal pouch, contraceptive sponge, and spermicidal foams, jellies, and inserts are widely available over the counter in most pharmacies. They do not require a prescription, are inexpensive, simple to obtain, and uncomplicated to use. The only barrier methods requiring a prescription and medical exam for fitting are diaphragms and cervical caps.
Hormonal contraception is the most common reversible method used in the United States. These methods include oral contraceptives (the pill), emergency contraception (morning-after pill), injectable medications (Depo-Provera), transdermal hormones (the patch), and vaginal hormones (the ring). All these methods require medical visits for prescriptions and/or injection or surgical placement. Some insurance carriers pay for the medical visits, medication, devices, and procedures for placement. Many cover only the cost of the medical visit. Checking insurance coverage and cost of the medical services and method prior to making a decision about use avoids unexpected expense. Many methods are available at reduced cost at Planned Parenthood, local family planning clinics, health departments, or free clinics for those who qualify for services.
The use of fertility awareness and lactational amenorrhea methods requires education by a knowledgeable professional. Fertility awareness is a complex method requiring motivated couples and a willingness to abstain from intercourse cyclically during fertile times. This method necessitates several hours of instruction and follow-up to assure accurate measurements and observations of signs of fertility. It is the only method currently authorized by the Catholic Church.
Intrauterine devices (IUDs) and sterilization (tubal ligation and vasectomy) require medical intervention and costs for medical evaluation and visits. Sterilization, particularly tubal ligation, may incur hospital costs as well. Insurance coverage for these procedures varies greatly. Some family planning clinics insert IUDs at reduced cost but do not perform surgical sterilization. Again, the key is to ascertain information about cost and insurance coverage prior to making decisions to use either of these methods.
The decision to use contraception is complex and multifactorial. It is essential to consider personal health and financial factors, safety, efficacy, and the impact that an unintended pregnancy may have. Unplanned pregnancy will have lifelong consequences whether it ends in termination, adoption, or personally raising a child. Trusting one’s reproductive fate to chance may cause unforeseen and unwelcome consequences. With the widespread availability and increased numbers of options, the need for contraception can be met for everyone who desires to prevent unintended pregnancy.