Family Planning

Chapter 26 Family Planning

REVERSIBLE CONTRACEPTION, STERILIZATION, AND ABORTION

Family planning plays a critical role in promoting the personal health of women, and it uniquely optimizes both maternal health and fetal well-being by allowing couples to plan and prepare for the pregnancies they desire. As such, family planning also has major public health implications.

Condoms and oral contraceptives (OCs) were recognized by the U.S. Centers for Disease Control and Prevention (CDC) as among the 10 most important public health inventions of the 20th century. Considering that this was the century in which vaccinations and treatments for smallpox, polio, yellow fever, and many other diseases that had plagued humans for eons were developed, such recognition highlights the magnitude of the contributions these birth control methods have made. Every year, 600,000 women die worldwide from pregnancy and pregnancy-related causes, and another 3 million women suffer significant permanent disabilities.

Many contraceptive methods also help reduce the spread of some sexually transmitted infections (STIs). For example, even though only 13% of married African women use effective barrier methods of contraception, it has been estimated that, in 2002, those birth control methods prevented 173,000 cases of human immunodeficiency virus (HIV) infection in sub-Saharan Africa.

As effective as modern contraceptives have been, they have not yet achieved their full potential. Nearly half of pregnancies in the United States are classified as “unintended,” meaning that the woman electively aborts the pregnancy, or continues with a pregnancy that she did not plan. Many unintended pregnancies occur in women who are using contraception but are not using their chosen method correctly. Nearly 1 million pregnancies occur every year in women taking OCs. More than half of OC users miss three or more pills each cycle, and many do not refill their prescriptions on a timely basis. Pregnancies that are categorized as “intended” include planned and prepared pregnancies as well as pregnancies to which women are indifferent.

When birth control methods in sexually active women are grouped into tiers based on their efficacy with typical use (Table 26-1), it becomes obvious that the most efficient methods are those that are long-term, convenient, and do not require any ongoing action from the woman (Tier 1). For example, the intrauterine devices (IUDs) and progestin implants provide the highest level of pregnancy protection, with first-year failure rates in typical use of less than 1% (Table 26-2). Other hormonal methods, such as the once-every-3-months injection, monthly vaginal rings, weekly patches, and daily pills are in tier 2. Each of these hormonal methods has the potential for very low pregnancy rates (1%), but in typical use, they have first-year failure rates of 7% to 8%. Tier 3 contraceptive methods are the barrier and behavioral methods. Here the differential between the potential that the method offers and what is really seen is widest. For example, male condoms have a less than 2% failure rate if used correctly and consistently with every episode of intercourse. However, in real life, the pregnancy rate is 17.4%. Female barrier methods (diaphragms, cervical caps, shields, and female condoms) have higher pregnancy rates. Interestingly, behavioral methods such as coitus interruptus and fertility awareness methods have rates that are almost equivalent to many barrier methods in typical use.

TABLE 26-1 TIERS OF EFFICACY

Tier	Method of Contraception
1: Longer term	Progestin implants and intrauterine devices
2: Combined hormonal	Depot medroxyprogesterone acetate injections Vaginal rings, transdermal patches Oral contraceptive pills
3: Barrier and behavioral	Male condoms, diaphragms Caps, female condoms, shield Spermicides Withdrawal, fertility awareness method, natural family planning

TABLE 26-2 CONTRACEPTIVE FAILURE RATES COMPARING TYPICAL USE AND PERFECT USE

Contraceptive Method	Percent Failure within First Year of Use
Contraceptive Method	Perfect Use	Typical Use
No method	85	85
Male sterilization	0.10	0.15
Female sterilization	0.5	0.5
Copper ParaGard T 380A IUD	0.6	0.8
Levonorgestrel-releasing IUD	0.1	0.1
DMPA	0.3	6.7
OC—combined	0.3	8.7
OC—progestin only	0.5	8.7
Diaphragm with spermicide	6	16
Condom—male, latex	2	17.4
Cervical cap—parous	26	32
Cervical cap—nulliparous	9	16
Spermicides	15	29
Fertility awareness	19	25.3
Withdrawal	—	18.4

DMPA, depot medroxyprogesterone acetate; OC, oral contraceptive.

1. Kost K, Singh S, Vaughan B, Trussell J, Bankole A. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception. 2008;77(1):10–21

2. Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart FH, Kowal D. Contraceptive Technology, 19^th ed. NewYork, Ardent Media, Inc. 2007.

The mechanisms of action vary among method of family planning. Contrary to prevailing opinion, the primary action of virtually all methods of birth control is contraception (the prevention of fertilization). Abortion is the disruption of an established pregnancy. Interception is defined as an action that blocks implantation (i.e., one that works after fertilization but before pregnancy is established 7 days later).

The safety of all methods of family planning is well established. In selecting options for an individual woman, the requirement is that any method offered must be safer to the woman’s health than pregnancy. It is from that perspective that the World Health Organization (WHO) has developed its Medical Eligibility Criteria (MEC; Table 26-3), which rates the appropriateness of each major contraceptive method in a variety of medical circumstances. Recommendations are made on a 1 to 4 scale, in which a rating of 1 indicates approval and 4 represents an absolute contraindication. This rating often differs from the labeling for individual products, which generally reflects theoretical concerns and desires by the manufacturers to protect themselves from product liability. Prescribers should act on evidence-based recommendations such as the WHO MEC.

TABLE 26-3 WORLD HEALTH ORGANIZATION MEDICAL ELIGIBILITY FOR INITIATING CONTRACEPTION: ABSOLUTE AND RELATIVE CONTRAINDICATIONS