Chapter 4 Contraception: Counseling Principles
THE CHALLENGE
Assisting couples in identifying and using the most appropriate method of controlling fertility is an important challenge. Changing patterns of sexual expression, new technologies, increased consumerism, and heightened cost pressures all affect the choices made in the search for fertility control. The very nature of the topic gives contraception personal, religious, and political overtones that often lead to conflict, emotionality, and confusion.
SCOPE OF THE PROBLEM
In the United States, more than half (56%) of all pregnancies are unplanned, despite the fact that 90% of women at risk (fertile, sexually active, and neither pregnant nor seeking pregnancy) are using some form of contraception. The 10% or so of women not using contraception account for more than half of these unintended pregnancies. The remaining unplanned pregnancies occur as a result of either failure of the contraceptive method used or the improper or inconsistent use of the method.
OBJECTIVES OF COUNSELING
No “ideal” contraceptive method exists. Although efficacy and an acceptable risk of side effects are important in the choice of contraceptive methods, these are often not the factors on which the final choice is made. Motivation to use, or continue to use, a contraceptive method is based on education; cultural background; cost; and individual needs, preferences, and prejudices. Factors such as availability, cost, coital dependence, personal acceptability, and the patient’s perception of the risk all have a role in the final choice of methods.
TACTICS
Relevant Pathophysiology
Currently available contraceptive methods seek to prevent pregnancy by preventing the sperm and egg from uniting or by preventing implantation and growth. These goals are accomplished by preventing the development and release of the egg (oral and nonoral hormonal contraceptives, long-acting hormonal methods), preventing union of sperm and egg by imposing a mechanical, chemical, or temporal barrier between sperm and egg (condom, diaphragm, foam, intrauterine devices, rhythm, withdrawal, postcoital oral contraception), or altering the likelihood of implantation or growth (RU-486). Relative efficacy (first-year failure, both real and theoretical) is shown in the accompanying table.
Strategies
For a couple to use a method, it must be accessible, immediately available (especially in coitally dependent or “use-oriented” methods), and of reasonable cost. The impact of a method on spontaneity, or the modes of sexual expression preferred by the patient and her partner, may also be important considerations. A decision tree based on these concepts is presented in the accompanying figure.
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