Public Health Family Planning Services and Birth Control
by
Jessica Morse, Philip D. Darney
  • LAST REVIEWED: 22 April 2013
  • LAST MODIFIED: 22 April 2013
  • DOI: 10.1093/obo/9780199756797-0055

Introduction

Family planning services and birth control are integral to how families determine the number and timing of their children. The importance of these services is often described from four different perspectives: (1) as a human right; (2) as a means to social and economic development; (3) as a personal and public health issue; and (4) as a population/environment concern. Family planning as a human rights issue is often couched in terms of fundamental human rights to determine one’s own reproductive capacity. It has frequently been linked to a feminist perspective, with control over one’s body as being integral to basic autonomy and equality. Although abortion is an essential part of this, we will not be covering this topic in any detail. (For a more complete understanding, please see the separate article on Abortion.) Especially in the developing world, family planning is closely related to social and economic development, with decreases in family size typically correlating with improved economic and social well-being at both the family and societal level. From a medical standpoint, family planning and birth control are central to women’s basic health care, both as preventive and therapeutic measures. The global burden of maternal mortality would be significantly decreased with provision of comprehensive family planning services, including safe abortion. Given the limited resources of the planet, family planning services and birth control have been championed as effective ways to limit population growth and thereby limit the detrimental impact of overpopulation on the physical environment. The importance of each of these perspectives has waxed and waned through different cultural and political eras, with each offering different justifications for comprehensive family planning services and birth control. Independent of the theoretical background, how family planning services are structured varies broadly. Services typically include counseling and education around reproductive health and family planning, provision of birth control and abortion, and testing and treatment for sexually transmitted infections. Service delivery can be organized vertically with family planning programs separately administered and provided in specialized clinics or horizontally through integration into other health care. The effectiveness of service provision is often highly dependent on funding, as well as political, cultural, and religious trends. Due to the high personal and public health costs of unintended pregnancies, many efforts have been made to increase access to contraception. Actual method selection should be a patient-driven process, informed by counseling on effectiveness and the patient’s own medical history and risk factors. Public health trends, such as HIV and obesity, influence service provision and method selection at the individual and population level.

General Overviews

Numerous general overviews exist that could provide the layperson or clinician with valuable information. Zieman, et al. 2010 is a user-friendly and thorough resource that is updated regularly and incorporates the most evidence-based data from the Centers for Disease Control and Prevention (CDC). The World Health Organization (WHO) has a similar publication (World Health Organization and Johns Hopkins 2011) created for use in the developing world.

  • World Health Organization Department of Reproductive Health and Research, and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. 2011. Family planning: A global handbook for providers (2011 update). Baltimore and Geneva, Switzerland: CCP and WHO.

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    This handbook, available in nine languages, is targeted to clinic-based health-care professionals in the developing world. Published by Knowledge for Health (out of Johns Hopkins University) and updated regularly, it provides up-to-date information on family planning services for a global audience.

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  • Zieman, M., R. Hatcher, C. Cwiak, P. Darney, M. Creinin, and H. Stosur, eds. 2010. 2010–2012 Managing contraception: For your pocket. 10th ed. Atlanta: Bridging the Gap.

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    Now in its tenth edition, Managing contraception is a key resource for clinicians. Made as a small, pocket-sized book, it incorporates the new CDC medical eligibility criteria (MEC) for contraceptive use, as well as sexually transmitted infection screening and treatment guidelines.

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Reference Works

Many fields have a classic reference book that is referred to by everyone in the field. In reproductive health, it is Speroff and Darney 2011. Updated regularly, this easy-to-read book is an absolute must in every clinician’s office.

  • Speroff, L., and P. D. Darney. 2011. A clinical guide for contraception. 5th ed. Philadelphia: Lippincott Williams & Wilkins.

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    This comprehensive clinical guide, written in an easy-to-read manner, synthesizes the current literature on all contraceptive methods and makes clinical recommendations. Recently updated and now in its fifth edition, the book is an excellent resource for both historical and clinical aspects of contraception and is exhaustively referenced.

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Textbooks

A broad overview of family planning is likely best found in a textbook, of which there are many. However, the sources listed below are well-referenced, accurate options. Darney 2008 focuses on the basic endocrinology of hormonal contraception and is an excellent resource. Hatcher, et al. 2008 is a broader overview, covering all family planning methods as well as basic gynecologic problems. Guillebaud 2007 is also broad in its reach, but is targeted at a primary care audience.

  • Darney, P. D. 2008. Hormonal contraception. In Williams textbook of endocrinology. 11th ed. Edited by Henry Kronenberg, Shlomo Melmed, K. Polonsky, and P. Reed Larsen 615–644. Philadelphia: Saunders Elsevier.

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    This comprehensive chapter in one of the classic gynecology textbooks provides a well-referenced basic understanding of the basic endocrinology of hormonal contraception.

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  • Guillebaud, J. 2007. Contraception today: A pocketbook for primary care practitioners. 6th ed. London: Informa Healthcare.

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    Although geared toward clinicians, this comprehensive guide on the clinical aspects of contraception is written in an easy-to-read manner with case-based illustrations to facilitate use. Printed as a pocket-sized book, it is an excellent tool for health-care providers as well as others seeking accurate information on family planning methods.

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  • Hatcher, R. A., J. Trussell, A. L. Nelson, W. Cates, F. H. Stewart, and D. Kowal. 2008. Contraceptive technology. 19th rev. ed. New York: Ardent Media.

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    This comprehensive clinical resource provides a complete summary of the current evidence. Although focused on contraception and the US Medical Eligibility Criteria, it also contains information on basic gynecology topics such as irregular bleeding and cervical cancer screening, making it an excellent clinical resource.

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Anthologies

Often used as review materials or quick updates, both Shoupe 2011 and Gupta and Darney 2009 provide a comprehensive yet succinct review of contraceptive basics needed for the primary practitioner.

  • Gupta, P., and P. Darney. 2009. Family planning. In Precis: An update in obstetrics and gynecology: Primary and preventative care. 4th ed. By American College of Obstetricians and Gynecologists, Washington, DC: American College of Obstetricians and Gynecologists.

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    Used as a reference tool by many gynecologists, this succinct guide provides the basics needed for a generalist or primary care physician.

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  • Shoupe, D., ed. 2011. Contraception. Gynecology in Practice. Oxford: Wiley-Blackwell.

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    Part of the Gynecology in Practice series, this anthology is a useful compendium for accessing the most recent information about patient appropriateness for a specific method, as well as information on cost, risk factors, and noncontraceptive benefits. This is an excellent tool for gynecologists as well as other generalists providing contraceptive care to patients.

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Journals

Most clinicians and reproductive health researchers rely on several journals to keep them abreast of recent updates in the field. The most general of these, Contraception, is the top monthly journal on clinical issues related to family planning. Perspectives on Sexual and Reproductive Health has a somewhat broader target audience, geared more toward social scientists and program planners. The European Journal of Contraception and Reproductive Health Care is also clinically focused, although with most of the research coming out of Europe. Studies in Family Planning, like Perspectives, has a broader audience with both clinical and social issues addressed, both here and abroad.

Family Planning as a Human Right

Family planning is often described as a basic human right—the right of couples to determine their own reproductive capacity. Although considered a basic right in many countries much earlier, this was not an internationally accepted idea until after World War II when the United Nations General Assembly adopted the Universal Declaration of Human Rights in 1948. This first, international effort at making these rights explicit was groundbreaking solely by nature of it being the first time these ideas were internationally recognized. Through a series of United Nations conferences over the next fifty years, these rights were expanded and more fully described. In Bucharest, at the World Population Conference in 1974 (World Population Plan of Action 1974), this right was expanded to include not only the right to plan family size, but also access to the information necessary to carry out that right. Twenty years later, at the United Nations Population and Development Conference in Cairo (United Nations 1994), these rights were reaffirmed. Moreover, the importance of a full spectrum of sexual and reproductive health-care services being provided—devoid of coercion—was articulated as being central to exercising these rights. More recently, and mainly in the United States, the issue of family planning as a human right has been espoused by the religious community, although certainly not without sectarian disagreement. Some organizations, such as the Religious Coalition for Reproductive Choice (see Religious Pro-Choice Americans Speak Out; Family Planning: A Moral Good, A Human Right), describe family planning and reproductive rights as a moral good and a human right while the Catholic hierarchy opposes them.

Social and Economic Development

Although family planning is frequently considered at the individual or family level, at the societal level, it is often instrumental in achieving social and economic development. In many developing countries, as women gain more education and have increased access to family planning, social and economic development also ensues. This idea has been supported by the international community, which in 2000 made a major public commitment to ending poverty by 2015 by creating the Millennium Development Goals. Two of the eight goals—achieving gender equity (mainly in education) and improving maternal mortality—address the importance of women’s education and access to family planning as methods for improving social and economic development. Progress toward these goals is assessed intermittently at development conferences. Although the link between social and economic development and access to family planning has occasionally been debated, Bloom, et al. 2003 clarifies more striking population changes—changes in the age structure—that also affect social and economic development. Zosa-Feranil, et al. 2009, funded by the United States Agency for International Development (USAID), goes further in articulating the links between development, poverty, and fertility, closely linking the three and reiterating the importance of linking programs that attempt to address any of these issues.

  • Bloom, D. E., D. Canning, and J. Sevilla. 2003. The demographic dividend: A new perspective on the economic consequences of population change. Santa Monica, CA: RAND.

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    Recent reviews suggest that changes in the age structure of populations can have significant impacts on social and economic development, implying that family planning is fundamental to this process. Published by the Rand Corporation, this article articulates this new perspective in a timely manner, as many countries are currently undergoing significant changes in the age structure of their populations.

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  • Millennium Development Goals.

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    At the 2000 United Nations Millennium Summit, the international community signed on to the Millennium Development Goals (MDG), aimed at ending extreme poverty by 2015. Of the eight goals, two—achieving gender equity and improving maternal mortality—directly relate to family planning as a means to social and economic development.

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  • Zosa-Feranil, I., C. P. Green, and L. Cucuzza. 2009. Engaging the poor on family planning as a poverty reduction strategy. Washington, DC: Futures Group.

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    Published in 2009 with funding from USAID, this policy paper describes the multi-dimensional nature of poverty, its disproportionate impact on women, and how this affects fertility. Clearly laying out the detrimental consequences of increased fertility in poorer women, this paper makes a clear statement and recommendations on how policies aimed at reducing poverty must be linked with family planning programs.

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Personal and Public Health Issues

Family planning—considered one of the great public health achievements of the 20th century—is a basic health issue for women, both at the individual level and at a population level. Access to a full range of reproductive health services—including effective family planning and safe abortion—can result in improved health outcomes for infants, children, women, and families. By helping to make each pregnancy a planned pregnancy, family planning can result in decreased unintended pregnancies, abortions, and maternal mortality. This is significant in the United States, where half of pregnancies are thought to be unintended. Centers for Disease Control and Prevention (CDC) 1999, a historical piece, documents the trends in family planning and their effect on public health over the last century. In 1979, in an effort to focus US efforts on the most important public health issues domestically, the surgeon general released the first “Healthy People” report. Since then, a new report has been released every decade, laying out the public health priorities for the United States over the next ten years. In 2001, the Healthy People initiative set a goal of reducing contraceptive failure during the first year of use from 13 percent in 1995 to 7 percent by 2010. The public health benefits of family planning services are even more marked in the developing world, where maternal mortality is a major problem. Both Singh, et al. 2010 and Tsui, et al. 2010 document some of the impact of unintended pregnancies worldwide, reiterating the importance at a personal and public health level of effective family planning. Globally, maternal morbidity and mortality is driven not only by access to family planning and emergency obstetrics services, but also by access to safe and legal abortion. Shah and Ahman 2010 provide the most up-to-date information regarding the epidemiology of abortion around the world, as well as the significant morbidity and mortality form unsafe abortion and restrictive laws.

  • Centers for Disease Control and Prevention (CDC). 1999. Achievements in public health, 1900–1999: Family planning. MMWR Weekly. 48.47: 1073–1080.

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    In this comprehensive historical overview, the Centers for Disease Control and Prevention outlines the successes of family planning in the United States during the 20th century in contributing to demographic shifts resulting in smaller families and improved health and social outcomes for women, children, and their families.

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  • Healthy People.

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    In 2001, the “Healthy People 2010” initiative laid out public health goals for the country over the next decade. One of these goals was to reduce contraceptive failure during the first year of use from 13 percent in 1995 to 7 percent by 2010. Methods to meet this goal included an increased focus on long-acting reversible contraceptive methods such as intrauterine devices and implants. After 2010, the website was changed to “Healthy People.”

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  • Shah, I., and E. Ahman. 2010. Unsafe abortion in 2008: Global and regional levels and trends. Reproductive Health Matters 18:90–101.

    DOI: 10.1016/S0968-8080(10)36537-2Save Citation »Export Citation » Share Citation »

    The availability of safe and legal abortion is directly linked to women’s health status. This review provides the most recent global and regional estimates of the incidence and trends in induced abortion and the mortality due to unsafe abortion, demonstrating the increased morbidity and mortality in areas where abortion laws are restrictive.

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  • Singh, S., G. Sedgh, and R. Hussain. 2010. Unintended pregnancy: Worldwide levels, trends and outcomes. Studies in Family Planning 41:241–250.

    DOI: 10.1111/j.1728-4465.2010.00250.xSave Citation »Export Citation » Share Citation »

    Using modeling combined with the most recent data available, these authors estimate the incidence of pregnancy (by intention status and outcome), miscarriage, and abortion, demonstrating the massive public health consequences of unintended pregnancy. In 2008, 41 percent of worldwide pregnancies were estimated to be unintended, with highest rates in eastern and middle Africa.

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  • Tsui, A. O., R. McDonald-Mosley, and A. E. Burke. 2010. Family planning and the burden of unintended pregnancies. Epidemiological Review 32:152–174.

    DOI: 10.1093/epirev/mxq012Save Citation »Export Citation » Share Citation »

    This in-depth article uses an epidemiologic framework to discuss reproductive behavior, pregnancy intentions, and the significant burden posed by unintended pregnancies. Using this framework, the authors review population level data on pregnancy outcomes and the impressive benefits of family planning to prevent many of the poor maternal and neonatal outcomes, at huge cost savings to society.

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Population and Environment Issues

Family planning has been viewed by many as a fundamental link in dealing with overpopulation and its detrimental environmental impact. Malthus, in his “Essay on the Principle of Population” (Malthus 1798), describes this phenomenon at the end of the 18th century. This thinking continued, as population growth continued to surge throughout the 19th and 20th centuries. Lester Brown, a more recent thinker on these issues, articulates his influential ideas regarding these links in Plan B (Brown 2009). Most concern in the area of population and the environment relates to increases in population growth and its direct impact on natural resources depletion. Speidel, et al. 2009 clearly lays out the links between access to family planning and decreases in unintended pregnancy and overpopulation. Differing changes in age structures of populations in the developed versus developing world—not just growth in overall size—are also predicted to have a detrimental impact on our overall well-being. These trends are clearly described by the Population Reference Bureau (see Population Reference Bureau 2010), as well as by the United Nations Population Division (see United Nations 2008). Wheeler and Hammer 2010 takes a more focused approach, examining the novel concept of using family planning and girls’ education programs as a way toward decreased population growth and decreased carbon emissions. Millennium Ecosystem Assessment 2005 is a broader look at how changes in our natural ecosystem—brought about by population changes—will alter human well-being.

  • Brown, L. R. 2009. Plan B 4.0: Mobilizing to save civilization. New York: W. W. Norton.

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    The author of this influential book, Lester Brown, holds twenty-six honorary degrees, founded the Worldwatch Institute and Earth Policy Institute, is a former MacArthur fellow, and is considered a pioneer environmentalist. Although his writings cover broad topics in environmentalism, he continues to focus on the negative impacts of excessive population growth and its detrimental impact on the environment.

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  • Malthus, Thomas Robert, Gilbert, Geoffrey 1798. An essay on the principle of population. London: J. Johnson.

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    Malthus was less optimistic about societal improvement than many philosophers at the time, suggesting that population growth would always result in some segment of the population suffering from poverty. He suggested that overpopulation could be balanced by positive and negative checks that will either increase the death rate or decrease the fertility rate, such as birth control and abortion.

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  • Millennium Ecosystem Assessment. 2005. Ecosystems and human well-being: Synthesis. Washington, DC: Island Press.

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    The Millennium Ecosystem Assessment is a project of the United Nations to assess the consequences of ecosystem changes on human well-being. This work by international experts resulted in scientific appraisals documenting how demographic changes alter humans’ impact on ecosystems and thereby our well-being.

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  • Population Reference Bureau. 2010 World population data sheet. Washington, DC: Population Reference Bureau.

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    In this striking set of tables, the Population Reference Bureau documents the two major trends in world population—shrinking birthrates in developed countries with associated expansions of the older population and increasing population growth in developing countries, with increasing proportions of the population under age fifteen.

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  • Speidel, J. J., D. C. Weiss, S. A. Ethelston, and S. M. Gilbert. 2009. Population policies, programmes and the environment. Philosophical Transactions of the Royal Society of London Series B: Biological Sciences 364:3049–3065.

    DOI: 10.1098/rstb.2009.0162Save Citation »Export Citation » Share Citation »

    Using data from around the world, this policy paper clarifies the significant impact of recent consumption and population changes on our planet’s natural resources and reiterates the importance of family planning services in stemming this growth. The authors document the success of family planning programs in reducing unintended pregnancies, and the funding needed to continue such efforts with their resultant environmental benefits.

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  • United Nations. 2008. World population prospects: The 2008 revision. New York: Population Division of the UN Department of Economic and Social Affairs.

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    Similar to Population Reference Bureau 2010, this report—put out by the United Nations—documents the 2008 population data and demographic trends on an international scale.

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  • Wheeler, D., and D. Hammer. 2010. The economics of population policy for carbon emissions reduction in developing countries. Working Paper 229. Washington, DC: Center for Global Development.

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    Published by the Center for Global Development, this fascinating working paper examines the novel concept of improving access to family planning and girls’ education as a method of decreasing carbon emissions. Using cost and effectiveness data, the authors examine family planning and education programs and find them to be viable alternatives to other emissions control programs.

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Service Delivery Considerations

Delivery of family planning services is dependent not only on how services are structured, but also on how they are funded. See Organization of Services Delivery and Funding of Service Delivery.

Organization of Services Delivery

Delivery of family planning services—like all health care services—is highly variable, depending on the demographic, health, and governmental characteristics of a nation. Organizational strategies may incorporate an integrated approach, with family planning services as part of general medical care. In certain circumstances, family planning services are integrated into HIV care services or postpartum care. In developing countries, services are often stand-alone—meaning women and couples receive services for family planning—and possibly testing for sexually transmitted infections—separate from the rest of their care. The integrated approach is often considered more effective and is typically more convenient for patients. However, the stand-alone approach carries the benefit of likely having dedicated funding and staff, as opposed to generalists who are simply incorporating family planning services into their other care provision. Organization of services can be vertical, horizontal, or community-based. Vertical services—or “top-down” approaches—pull family planning services into referral centers where experts are available, but at the cost of accessibility. Horizontal programs aim to broaden accessibility to services, through community clinics and other local solutions. California’s Family PACT (Planning, Access, Care, and Treatment) Program is a unique example of both because it is a public-private partnership including dedicated family planning clinics such as those of Planned Parenthood and local health departments and the generalist offices of private practitioners. This combined approach increases the number of access points, a key element of a successful program. California’s Family PACT Program has done a remarkable job at reaching a large number of women who would otherwise not have access to reproductive care, and has been instrumental in providing family planning services to prevent many unintended pregnancies around the state, as documented by Foster, et al. 2011. Community-based provision of services is more common in the developing world and relies on distribution of contraceptives by trained, nonmedical personnel who are motivated by modest profit as well as community service. These initiatives are usually a part of a vertical family planning organization with urban clinics and rural community-based distribution (CBD). The Indonesian BKKBN provides a successful example of this model, as described by Suyono 1996. The ability to provide horizontal or community-based care is in part dependent on the demographics of the population, as well as medical licensing and prescription laws. Although most contraceptives require prescriptions in the United States, this is not the case in much of the developing world, allowing for more community-based provision of methods.

  • Family PACT (Planning, Access, Care and Treatment) Program Evaluation.

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    Administered by the California Department of Public Health’s Office of Family Planning, Family PACT is a Medicaid waiver program that provides comprehensive reproductive health care to under-served residents in California. In large part due to prevention of unintended pregnancy, this program has proven to be cost-saving for the state of California.

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  • Foster, D. G., M. A. Biggs, D. Rostovtseva, H. Thiel de Bocanegra, P. D. Darney, and C. D. Brindis. 2011. Estimating the fertility effect of expansions of publicly funded family planning services in California. Women’s Health Issues 21:418–424.

    DOI: 10.1016/j.whi.2011.05.008Save Citation »Export Citation » Share Citation »

    Markov modeling was used to estimate that over a quarter of a million unintended pregnancies were prevented through provision of family planning services to low-income women in California through the Family PACT Program.

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  • Suyono, H. 1996. Ready to sell our program. Integration 47:10–11.

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    This article describes the history and successes of the much-touted Indonesian family planning program, coordinated by BKKBN (the National Family Planning Coordinating Board). The program is family-centered and community-based, although supported at the highest levels of government. Community education and community control have been key elements of this successful program.

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Funding of Service Delivery

The impact of changes in funding is obvious and well documented, both domestically and internationally. Perhaps the most widely known of these policies is the Mexico City Policy. Since 1961, the United States’ Foreign Assistance Act has prohibited nongovernmental organizations that receive federal funds from using those funds to pay for abortions. This restriction was expanded by President Reagan in 1984 into what became known as the Mexico City Policy, which called for the withdrawal of United States Agency for International Development funds from any organization that uses other funds for a wide range of activities associated with abortion. This was further expanded by President George W. Bush in 2001 to include “voluntary family planning.” In one of the first acts of his presidency, Barack Obama rescinded the policy, commenting on its excessive breadth and detrimental impact on promoting safe and effective family planning programs (Obama 2009). Singh, et al. 2009, a report published by the Guttmacher Institute, enumerates the potential benefits associated with comprehensive, global family planning service provision and what it would cost to attain them. Speidel, et al. 2009 continues along these lines, documenting the importance of family planning in decreasing unintended pregnancies. It goes a step further in suggesting the importance of continued and increased funding for family planning services to help stem the environmental impacts from anticipated population changes. Sonfield, et al. 2008 takes a domestic approach, cataloging the public expenditures on family planning in the United States.

  • Obama, Barack. 2009. Mexico City policy: Voluntary population planning.

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    This White House report gives a brief history on the “Mexico City Policy” and Obama’s reasons for rescinding it shortly after entering office due to concerns about its negative impact on promoting safe and effective family planning programs.

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  • Singh, S., J. E. Darroch, L. S. Ashford, and M. Vlassoff. 2009. Adding it up: The costs and benefits of investing in family planning and maternal and newborn health. New York: Alan Guttmacher Institute.

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    Published by the Guttmacher Institute, this comprehensive report quantifies the current status of maternal and neonatal health globally and the potential benefits associated with family planning, maternal, and neonatal services. The report argues for significantly increased investments in these services to meet Millennium Development Goals.

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  • Sonfield, A., C. Alrich, and R. B. Gold. 2008. Public funding for family planning, sterilization and abortion services, FY 1980–2006. Occasional Report 38. New York: Guttmacher Institute.

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    This comprehensive report put out by the Guttmacher Institute catalogues public expenditures on family planning in the United States, explaining the different federal and state programs that provide these services. These sources, most predominantly Medicaid, provide a safety net for these services for low-income Americans.

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  • Speidel, J. J., D. C. Weiss, S. A. Ethelston, and S. M. Gilbert. 2009. Population policies, programmes and the environment. Philosophical Transactions of the Royal Society of London Series B: Biological Sciences. 364:3049–3065.

    DOI: 10.1098/rstb.2009.0162Save Citation »Export Citation » Share Citation »

    Based on international data, Speidel and colleagues chart the impressive impact of family planning programs in reducing unintended pregnancies and make estimations of the funding needed to continue these programs.

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Birth Control Methods

Provision of family planning services requires providing a broad method mix to ensure that a full range of needs can be met. Selecting an appropriate method of family planning requires an understanding of the patient’s preferences as well as her medical history. For many patients, family planning is used for noncontraceptive reasons, so a thorough understanding of these benefits, as well as any inherent risks, is of utmost importance. The timing of family planning initiation is also key, with many opportunities for making the services convenient for the patient and efficient for the health-care system. See General Considerations, Method-Specific Considerations, Timing of Contraceptive Initiation, and Noncontraceptive Benefits for further explanation of these concepts.

General Considerations

Provision of family planning services requires not only an understanding of the methods available and their effectiveness, but also of their risks and benefits. Weighing these options is based on individualized patient counseling regarding the patient’s specific medical history as well as personal preferences. In the past contraceptive counseling has mainly revolved around method type. However, with the increasing availability of long-acting reversible methods, a shift in counseling has been encouraged toward grouping methods by effectiveness, as evidenced by the World Health Organization’s new tiers of effectiveness tool (see Comparing Effectiveness of Family Planning Methods). Kost, et al. 2008, using the National Survey of Family Growth, documents the current effectiveness of birth control methods in the United States. Other resources for clinicians in determining appropriate methods for patients include World Health Organization 2009, Medical Eligibility Criteria for Contraceptive Use, criteria used around the world, and the United States–focused version of it—Division of Reproductive Health 2010. Both of these documents synthesize the available data and make recommendations based on these data and expert opinion.

  • Comparing Effectiveness of Family Planning Methods.

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    This chart—developed by the World Health Organization and the United States Agency for International Development—demonstrates the new strategy for counseling along levels of effectiveness, as opposed to method type or class.

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  • Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. 2010. United States medical eligibility criteria for contraceptive use. Atlanta: Centers for Disease Control and Prevention.

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    The Centers for Disease Control and Prevention Medical Eligibility Criteria is a comprehensive document to help determine the appropriateness of specific methods for specific patients. Based on a modification of the World Health Organization (WHO) criteria, the Centers for Disease Control (CDC) lays out nationally accepted recommendations for contraceptive use. Appropriate to the US patient population and health-care setting.

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

    DOI: 10.1016/j.contraception.2007.09.013Save Citation »Export Citation » Share Citation »

    Using nationwide data, this report documents the effectiveness of contraceptive methods in the United States, showing actual use rates (as opposed to perfect use rates often reported in clinical trials).

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  • World Health Organization. 2009. Medical eligibility criteria for contraceptive use. 4th ed. Geneva, Switzerland: World Health Organization Reproductive Health and Research.

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    The World Health Organization Medical Eligibility Criteria (MEC) is an evidence-based review of contraceptive data to assist the clinician in determining a patient’s appropriateness for a specific birth control method based on her medical conditions and characteristics. It is used widely throughout the world and is considered the definitive source for such decision making in the international setting. a comprehensive document designed for clinicians to help determine the appropriateness of specific methods for specific patients. Using a rating system by method and medical condition, it lays out internationally accepted recommendations for contraceptive use.

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Method-Specific Considerations

Although any clinical decision is best discussed with a physician or other health-care provider, the resources below provide information regarding contraceptive methods by type. Other resources for clinicians in determining appropriate methods for patients are World Health Organization 2009, which is used around the world, and the United States–focused version of it—Division of Reproductive Health 2010 (both cited under General Considerations). Both of these documents synthesize the available data and make recommendations based on these data and expert opinion. Additional clinical guidance can be found in Speroff and Darney 2011, a comprehensive review of all methods.

  • Centers for Disease Control and Prevention. United States Medical Eligibility Criteria (USMEC) for Contraceptive Use.

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    Having updated the WHO MEC (World Health Organization 2009), this CDC document is the definitive source for practitioners in the United States who are trying to determine the appropriateness of a method for their patient. This evidence-based document is tailored to practitioners in the developed world, with additional information not found in the WHO MEC that is more applicable to a resource-rich health care setting.

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  • Speroff, L., and P. Darney. 2011. A clinical guide for contraception. 5th ed. Philadelphia: Lippincott Williams & Wilkins.

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    This comprehensive clinical guide, written in an easy to read manner, synthesizes the current literature on all contraceptive methods and makes clinical recommendations. This is an excellent resource for both historical and clinical aspects of contraception and is exhaustively referenced.

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  • World Health Organization. 2009. Medical eligibility criteria for contraceptive use. 4th ed. Geneva, Switzerland: World Health Organization Reproductive Health and Research.

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    The World Health Organization Medical Eligibility Criteria is a comprehensive document designed for clinicians to help determine the appropriateness of specific methods for specific patients. Using a rating system by method and medical condition, it lays out internationally accepted recommendations for contraceptive use.

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Combined Oral Contraceptive Pills

Often the first thing that comes to mind when mentioning contraception, combined oral contraceptive pills are the most commonly used reversible method in the United States. Combined oral contraceptive pills, as their name suggests, combine estrogen and a progestin to achieve their contraceptive effect. Thought mainly to work by inhibiting ovulation, pills are very effective when used consistently. The story of their development, as described by Djerassi 1992, outlines their scientific, political, and social history. This development is traced through articles in medical journals as well, such as Rock, et al. 1956, which describes ovulation inhibition for the first time and laying the groundwork for the development of contraceptive pills. Once pills were developed and widely used, significant effort was put into documenting their safety and efficacy, especially given their popularity. A recently published study, Hannaford, et al. 2010, is one of the largest to lay to rest the fears raised earlier about possibly harmful effects of pill use. One of these fears—about increased risk of blood clots (or venous thromboembolism)—is well-documented in World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception 1995, along with a growing body of evidence to corroborate these results. Chang, et al. 1999 has also documented the increased risk of ischemic stroke in women with migraines. Although clot risk does appear to worsen with the use of estrogen, the Cancer and Steroid Hormone Study of the CDC and the National Institute of Child Health and Human Development (NICHD, see Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development 1987a; Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development 1987b; Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development 1986) shows protective effects against ovarian and uterine cancer in women who had used birth control pills. This same group also looked at breast cancer risk and overall found no significant increase. All of these findings combined inform how women are counseled about pill use, and who is deemed to be an appropriate candidate.

  • Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. 1986. Oral-contraceptive use and the risk of breast cancer. New England Journal of Medicine 315:405–411.

    DOI: 10.1056/NEJM198608143150701Save Citation »Export Citation » Share Citation »

    Published in the influential New England Journal of Medicine, this CDC-sponsored study used national cancer registries to determine whether oral contraceptives increase the risk of breast cancer. Although not all studies agree, this one found no increased risk of breast cancer in women using oral contraceptive pills, independent of pill type or length of use.

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  • Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. 1987a. Combination oral contraceptive use and the risk of endometrial cancer. Journal of the American Medical Association 257:796–800.

    DOI: 10.1001/jama.1987.03390060086029Save Citation »Export Citation » Share Citation »

    This pivotal study published in JAMA was the initial, declarative work describing the protective effect of oral contraceptives against endometrial cancer. Using a multi-center, population-based case-control study, the study showed an approximately 60 percent decreased risk of endometrial cancer in women who had used birth control pills for at least twelve months.

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  • Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. 1987b. The reduction in risk of ovarian cancer associated with oral-contraceptive use. New England Journal of Medicine 316:650–655.

    DOI: 10.1056/NEJM198703123161102Save Citation »Export Citation » Share Citation »

    Although the protective effect of oral contraceptive pill use against ovarian cancer was already well documented, this case-control study clarified the risk based on pill formulation and cancer type. The protective effects were noted independent of the type of pill taken or the histology of the epithelial ovarian cancer, and were noted after only three to six months of use.

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  • Chang, C. L., M. Donaghy, and N. Poulter. 1999. Migraine and stroke in young women: Case-control study. British Medical Journal 318:13–18.

    DOI: 10.1136/bmj.318.7175.13Save Citation »Export Citation » Share Citation »

    This hospital-based, case-control study was part of the growing body of literature documenting the increased risk of ischemic stroke in young women with migraine. Other risk factors are known to exacerbate the stroke risk, including oral contraceptive pill use, smoking, and high blood pressure.

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  • Djerassi, C. 1992. The pill, pygmy chimps, and Degas’ horse. New York: Basic Books.

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    An entertaining autobiography by the “father of the birth control pill,” this book traces Djerassi’s fascinating career path as a biochemist turned writer who first synthesized norethindrone, the steroid derivative used for the first oral contraceptive pills. Considered a Renaissance man, his story traces his personal, professional, and political path through biochemistry, contraception, and the fine arts.

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  • Hannaford, P. C., L. Iversen, T. V. Macfarlane, A. M. Elliott, V. Angus, and A. J. Lee. 2010. Mortality among contraceptive pill users: Cohort evidence from Royal College of General Practitioners’ Oral Contraception Study. British Medical Journal 340: c927.

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    Falling in the footsteps of the Nurses’ Health Study, this very large British trial laid to rest many of the earlier fears regarding the risks to cardiovascular health and overall mortality from birth control pills. This study, like many before it, deemed pills safe, finding if anything decreased mortality in women who had used birth control pills.

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  • Rock, J., G. Pincus, and C. R. Garcia. 1956. Effects of certain 19-nor steroids on the normal human menstrual cycle. Science 124:891–893.

    DOI: 10.1126/science.124.3227.891Save Citation »Export Citation » Share Citation »

    This groundbreaking work was the first to describe ovulation inhibition via synthetically derived progestins in humans, laying the groundwork for the first oral contraceptive pill.

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  • World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. 1995. Venous thromboembolic disease and combined oral contraceptives: Results of international multicentre case-control study. Lancet 346:1575–1582.

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    This oft-cited study is one of the controversial trials in the body of evidence on venous thromboembolic risk from oral contraceptive pills. This was a hospital-based case-control study that spanned four continents and seventeen countries and found significantly different risks of VTE dependent on the exact progestin involved.

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Combined Hormonal Contraceptive Patch

Initially approved by the Food and Drug Administration in 2001, the combined hormonal contraceptive patch works similarly to birth control pills. Using a weekly patch instead of daily pills, this method relies on estrogen and a progestin to suppress ovulation, resulting in effective birth control. In studies performed by the manufacturer (Ortho Evra; see Audet, et al. 2001) as well as independent researchers (Creinin, et al. 2008), efficacy is similar to the pill although compliance and side effects may be slightly improved. In 2005 the US Food and Drug Administration (FDA) issued a warning about the increased estrogen exposure in women using the patch, prompting the manufacturer to fund several studies assessing thromboembolism risk. These studies did not definitively answer the question, finding discordant results. One of these trials, Cole, et al. 2007, used an insurance claims database and found that patch users had a greater than twofold increased odds of venous thrombosis relative to pill users. The FDA has since altered the labeling again, documenting this increased clot risk in patch users on the package itself.

  • Audet, M.-C., M. Moreau, et al. 2001. Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: A randomized controlled trial. Journal of the American Medical Association 285:2347–2354.

    DOI: 10.1001/jama.285.18.2347Save Citation »Export Citation » Share Citation »

    Because oral contraceptive pills are taken as the standard for combined hormonal contraceptive methods, any new combined method is compared to pills in terms of efficacy and acceptability. In this randomized trial of efficacy, the patch was slightly more effective although the difference was not statistically significant and was attributed to better compliance with the patch.

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  • Cole, J. A., H. Norman, M. Doherty, and A. M. Walker. 2007. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstetrics and Gynecology 109:339–346.

    DOI: 10.1097/01.AOG.0000250968.82370.04Save Citation »Export Citation » Share Citation »

    In 2005 the US Food and Drug Administration (FDA) issued a warning about increased estrogen exposure in women using the patch, prompting the manufacturer to fund three studies assessing thromboembolism risk. They found discordant results. This trial used an insurance claims database and found twofold increased odds of venous thrombosis in patch users relative to pill users.

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  • Creinin, M. D., L. A. Meyn, L. Borgatta, et al. 2008. Multicenter comparison of the contraceptive ring and patch: A randomized controlled trial. Obstetrics and Gynecology 111:267–277.

    DOI: 10.1097/01.AOG.0000298338.58511.d1Save Citation »Export Citation » Share Citation »

    In a randomized trial comparing the contraceptive ring and patch, women were happier with the ring because of fewer side effects and were therefore more likely to continue using it.

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Combined Hormonal Contraceptive Ring

Initially approved by the Food and Drug Administration in 2001, the combined hormonal contraceptive ring works similarly to birth control pills. Using a flexible plastic ring that is inserted into the vagina every three weeks instead of daily pills, this method relies on estrogen and a progestin to suppress ovulation, resulting in effective birth control. In studies performed at the request of the manufacturer (Dieben, et al. 2002) as well as by independent researchers (Ahrendt, et al. 2006), the ring is similar to birth control pills in terms of efficacy and acceptability.

  • Ahrendt, H. J., I. Nisand, C. Bastianelli, et al. 2006. Efficacy, acceptability and tolerability of the combined contraceptive ring, NuvaRing, compared with an oral contraceptive containing 30 μg of ethinyl estradiol and 3 mg of drospirenone. Contraception 74:451–457.

    DOI: 10.1016/j.contraception.2006.07.004Save Citation »Export Citation » Share Citation »

    In an effort to assess patient experiences with the vaginal ring as compared to oral contraceptive pills, Ahrendt, et al. conducted this randomized clinical trial and found that efficacy, tolerability, and acceptability were similar between the two methods.

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  • Dieben, T. O., F. J. Roumen, and D. Apter. 2002. Efficacy, cycle control, and user acceptability of a novel combined contraceptive vaginal ring. Obstetrics and Gynecology 100:585–593.

    DOI: 10.1016/S0029-7844(02)02124-5Save Citation »Export Citation » Share Citation »

    This seminal study, done by the makers of the vaginal contraceptive ring, documented the efficacy, acceptability, and tolerability of the ring, suggesting it was a good option for women interested in combined methods but not wanting to take the pill.

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Progestin-Only Pills

Although the most commonly used birth control pills contain a combination of estrogen and a progestin, progestin-only pills also exist. Often referred to as “the minipill,” they contain a low dose of a progestin and are taken daily and in a continuous fashion. Because of the low hormone dose, progestin pills must be taken at the same time every day to maintain efficacy. Due in part to this issue, as well as their mechanism of action (effects on the endometrium and cervical mucus as opposed to ovulation suppression) they are generally not as effective as combined pills, as described in this review by Chi 1993. Vessey, et al. 1985 documents decreased efficacy in adolescents, likely stemming from decreased compliance in taking them at the same time daily. However, in certain women—those who are postpartum and breastfeeding (Halderman and Nelson 2002), or for women who cannot take estrogen and prefer not to use any of the other delivery methods, progestin-only pills offer a safe alternative. Because of their decreased efficacy, they are mainly used in the United States in the postpartum period in women who are breastfeeding. This combination is known to provide effective contraception without compromising lactation. Although their side effects—mainly bleeding irregularities (Brooms and Fotherby 1990)—likely contribute to the low use in the United States, they are much more commonly used in the developing world.

  • Brooms, M., and K. Fotherby. 1990. Clinical experience with the progestogen-only pill. Contraception 42:489–495.

    DOI: 10.1016/0010-7824(90)90077-9Save Citation »Export Citation » Share Citation »

    This prospective trial documented not only efficacy, but side effects and reasons for discontinuation. For almost half of the women discontinuing use, bleeding irregularities were the cause.

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  • Chi, I. 1993. The safety and efficacy issues of progestin-only contraceptives: An epidemiologic perspective. Contraception 47:1–21.

    DOI: 10.1016/0010-7824(93)90105-GSave Citation »Export Citation » Share Citation »

    This review summarizes the literature on the safety and efficacy of progestin-only pills from an epidemiologic perspective. Although only small studies are available to evaluate safety, efficacy is likely compromised due to poor compliance resulting from irregular bleeding patterns.

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  • Halderman, L. D., and A. L. Nelson. 2002. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. American Journal of Obstetrics and Gynecology 186:1250–1258.

    DOI: 10.1067/mob.2002.123738Save Citation »Export Citation » Share Citation »

    In this prospective, observational trial, the authors show no effects on breastfeeding continuation or supplementation in women started on progestin-only pills prior to discharge from the hospital.

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  • Vessey, M. P., M. Lawless, D. Yeates, and K. McPherson. 1985. Progestogen-only contraception: Findings in a large prospective study with special reference to effectiveness. British Journal of Family Planning 10:117–121.

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    These findings from a large, prospective study document the wide range of effectiveness seen with progestin-only pills.

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Injectables

Injectable contraceptive methods, available in the United States since 1992, have benefits over combined methods that make them quite popular with some women. Because injectables contain progestin only, they are not thought to carry the cardiovascular risks associated with estrogen and combined methods, as documented in World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception 1998. For women who are unable or unwilling to share their contraceptive decisions with their partners, this is an easily concealed method. The first injectable (depot medroxyprogesterone acetate or DMPA or “Depo”) available in the United States requires a shot every three months. Although the method is easily hidden, some women do not like the inconvenience of needing a clinic visit every three months. A monthly version, which has a lower dose but can be more easily administered by the user herself (under the skin instead of into the muscle), appears to be similarly effective and with the same side effects (Kaunitz, et al. 2009). Although some early evidence suggested a possible increased risk of breast cancer in Depo users, Shapiro, et al. 2000, in concordance with more of the recent data, refutes this association. Despite a favorable side-effect profile, injectable contraception does have several drawbacks—mainly effects on bone mineral density and weight gain. A vast body of literature (including Cromer, et al. 1996 and Berenson, et al. 2004) has now documented the temporary loss of bone mineral density that occurs with Depo use. The actual clinical implication of the loss of bone mineral density is not totally clear. Many studies suggest that bone mineral density returns to baseline levels after discontinuation. Currently, no conclusive evidence exists as to how this decrease in bone mineral density relates to fracture risk. However, one study (Meier, et al. 2010) suggests that fracture risk may increase as length of Depo use increases. Unlike most birth control methods, Depo has been shown to be associated with weight gain (Berenson and Rahman 2009 and Bahamondes, et al. 2001).

  • Bahamondes, L., S. Del Castillo, G. Tabares, X. E. Arce, M. Perrotti, and C. Petta. 2001. Comparison of weight increase in users of depot medroxyprogesterone acetate and copper IUD up to 5 years. Contraception 64:223–225.

    DOI: 10.1016/S0010-7824(01)00255-4Save Citation »Export Citation » Share Citation »

    Depo-Provera is one of the few birth control methods with well-documented weight gain. Although studies find differing ranges of weight gain, it has been documented above normally expected gains in most studies, including this one.

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  • Berenson, A. B., C. R. Breitkopf, J. J. Grady, V. I. Rickert, and A. Thomas. 2004. Effects of hormonal contraception on bone mineral density after 24 months of use. Obstetrics and Gynecology 103:899–906.

    DOI: 10.1097/01.AOG.0000117082.49490.d5Save Citation »Export Citation » Share Citation »

    This was one of the early trials in a now wide body of literature documenting loss of bone mineral density in Depo-Provera users. Compared to combine oral contraceptive pill users, Depo users had 5.7 percent loss in bone mineral density.

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  • Berenson, A. B., and M. Rahman. 2009. Changes in weight, total fat, percent body fat, and central-to-peripheral fat ratio associated with injectable and oral contraceptive use. American Journal of Obstetrics and Gynecology 200:329.e1–329.e8.

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    This large cohort study contributes to the large body of evidence documenting the weight gain associated with Depo-Provera use. This trial not only showed weight gain (5.1 kg over three years) but also changes in body composition (increases in percent body fat) in Depo users while showing no weight gain in oral contraceptive pill users.

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  • Cromer, B. A., J. M. Blair, J. D. Mahan, L. Zibners, and Z. Naumovski. 1996. A prospective comparison of bone density in adolescent girls receiving depot medroxyprogesterone acetate (Depo-Provera), levonorgestrel (Norplant), or oral contraceptives. Journal of Pediatrics 129:671–676.

    DOI: 10.1016/S0022-3476(96)70148-8Save Citation »Export Citation » Share Citation »

    This small trial compared bone mineral density in adolescents using Depo-Provera, Norplant, and oral contraceptive pills and found that Depo-Provera may temporarily suppress bone mineralization, but that pills and implants had no effects on expected, age-appropriate increases in density.

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  • Kaunitz, A. M., P. D. Darney, D. Ross, K. D. Wolter, and L. Speroff. 2009. Subcutaneous DMPA vs. intramuscular DMPA: A 2-year randomized study of contraceptive efficacy and bone mineral density. Contraception 80:7–17.

    DOI: 10.1016/j.contraception.2009.02.005Save Citation »Export Citation » Share Citation »

    Due to effects on bone mineral density (BMD) and the need for a provider visit, efforts have been made to create a smaller dose (with the hope of decreased effects on BMD) that is subcutaneous (and self-administered). This randomized trial compared the intramuscular dosing with subcutaneous dosing and found similar efficacy rates as well as similar effects on bone mineral density.

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  • Meier, C., Y. B. Brauchli, S. S. Jick, M. E. Kraenzlin, and C. R. Meier. 2010. Use of depot medroxyprogesterone acetate and fracture risk. Journal of Clinical Endocriniology and Metabolism 95.11: 4909–4916.

    DOI: 10.1210/jc.2010-0032Save Citation »Export Citation » Share Citation »

    This case-control study used a national database to evaluate incident fractures to see if Depo use was associated with increased fracture risk. Length of Depo use did coincide with an increased risk of fracture.

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  • Shapiro, S., L. Rosenberg, M. Hoffman, et al. 2000. Risk of breast cancer in relation to the use of injectable progestogen contraceptives and combined estrogen/progestogen contraceptives. American Journal of Epidemiology 151:396–403.

    DOI: 10.1093/oxfordjournals.aje.a010219Save Citation »Export Citation » Share Citation »

    Due to early, population-based case-control studies suggesting a possible increased risk of breast cancer in Depo users, additional trials were conducted to clarify this important question. This case-control study in South Africa (confirmed by a larger trial in the United States) found no increased risk of breast cancer among Depo-Provera users.

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  • World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. 1998. Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives: Results of an international, multicenter, case-control study. Contraception 57:315–324.

    DOI: 10.1016/S0010-7824(98)00041-9Save Citation »Export Citation » Share Citation »

    This WHO-conducted international, multi-center case-control trial found no statistically significant increased risk of cardiovascular disease (stroke, venous thromboembolism, or acute myocardial infarction) in users of oral or injectable progestogen-only contraception or combined injectable contraceptives.

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Implants

Using hormone-impregnated rods that are placed just under the skin in the arm, implants provide highly effective contraception. This effectiveness is due in part to their mechanism of action—ovulation suppression and cervical mucus thickening—as well as the lack of further intervention required by the user once the device is inserted. Because only progestin is used, implants do not carry the risks associated with estrogen-containing methods. The implant currently available in the United States, Implanon, a single implant containing the progestin etonogestrel, is effective and safe (Darney, et al. 2009). A different implant, Norplant, was available in the United States until 2002, but is no longer sold in the United States; it does have widespread use throughout the rest of the world. Fraser, et al. 1998 is a consensus statement review of the literature on Norplant documenting its safety and efficacy. Norplant, a six-capsule system, has been replaced in many countries by the two-rod systems, Jadelle or Sinoplant, which, like Norplant, utilize low doses of levonorgestrel.

  • Darney, P., A. Patel, K. Rosen, L. S. Shapiro, and A. M. Kaunitz. 2009. Safety and efficacy of a single-rod etonogestrel implant (Implanon): Results from 11 international clinical trials. Fertility and Sterility 91:1646–1653.

    DOI: 10.1016/j.fertnstert.2008.02.140Save Citation »Export Citation » Share Citation »

    The etonogestrel implant is the only implant available in the United States. This trial reports the safety and efficacy data that were part of the appeal to the United States Food and Drug Administration (FDA) to get the device approved for the US market. It is highly effective (similar to sterilization), safe (no estrogen), and well tolerated, although does present changes in bleeding patterns more marked than other methods.

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  • Fraser, I. S., A. Tiitinen, B. Affandi, et al. 1998. Norplant® consensus statement and background review Contraception 57:1–9.

    DOI: 10.1016/S0010-7824(97)00200-XSave Citation »Export Citation » Share Citation »

    Although no longer available in the United States, Norplant was widely used throughout the world. This review, an international consensus statement affirming the benefits of its widespread use, documented its impressive efficacy, safety, and acceptability.

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Intrauterine Contraception

Intrauterine devices are small devices that are inserted into the uterus to provide contraception. Their safety and efficacy was reviewed by Tietze and Lewit 1970 when use in the United States was increasing rapidly. The copper IUD, which has been in use for several decades, works by creating an inflammatory response in the endometrium (Ortiz and Croxatto 2007). Because it has no hormones, there are very few contraindications to its use. The other intrauterine device available in the United States and worldwide is Mirena, a progesterone-containing device. The mechanism of action is thought to be mainly from the local effects of the hormone—cervical mucus thickening and thinning of the endometrial lining (Ortiz and Croxatto 2007). Both of these IUDs have been shown to be safe, even with long-term use (Sivin and Stern 1994). Despite this proven efficacy and safety, IUD use in the United States is still much lower than in the rest of the world (United Nations 2008). This is due in large part to the Dalkon Shield—an IUD used in the 1960s with design flaws that led to an association of increased risks of infection in women who used them. The fallout from the Dalkon Shield was huge, with many clinicians and the public associating IUDs with an increased risk of pelvic inflammatory disease (PID). Kessel’s important study (Kessel 1989), published in Fertility and Sterility in 1989, laid to rest some of these concerns, setting the record straight about current IUDs. Although the Dalkon Shield was associated with an increased risk of PID, the newer IUDs, with a better design, were noted in prospective cohort studies not to have this association. This was in part due to a better understanding of the other risk factors that contribute to increased risk of PID. Given this history, many clinicians were concerned that placing an IUD could lead to an infection. Farley, et al. 1992, a pivotal review, documents that infection rates are slightly higher immediately after IUD insertion but then return to the patient’s baseline risk. This baseline risk is now known to be related to sexual risk factors, not a woman’s contraceptive method of choice. Because pelvic infections are known to be associated with infertility, much concern existed around IUDs causing infertility. However, as the influential study Hubacher, et al. 2001 has shown, that is not the case. IUDs are now known to be safe and are even recommended as appropriate birth control for women with HIV. Heikinheimo, et al. 2006 found no increases in complications rates from insertion or disease progression, nor any effects on viral shedding in this high-risk group of women in need of effective contraception. The copper IUD can also be used for emergency contraception (see Emergency Contraception).

  • Farley, M. M., M. J. Rosenberg, P. J. Rowe, J.-H. Chen, and O. Meirik. 1992. Intrauterine devices and pelvic inflammatory disease: An international perspective. Lancet 339:785–788.

    DOI: 10.1016/0140-6736(92)91904-MSave Citation »Export Citation » Share Citation »

    In response to the disaster with the Dalkon Shield, this review evaluated whether insertion of an intrauterine device could increase infection risk. Evaluating years of IUD clinical trials, this review found that the risk of PID was six times higher in the twenty days immediately after IUD insertion, and then returned to baseline levels.

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  • Heikinheimo, O., P. Lehtovirta, J. Suni, and J. Paavonen. 2006. The levonorgestrel-releasing intrauterine system (LNG-IUS) in HIV-infected women: Effects on bleeding patterns, ovarian function and genital shedding of HIV. Human Reproduction 21:2857–2861.

    DOI: 10.1093/humrep/del264Save Citation »Export Citation » Share Citation »

    Early cross-sectional studies suggested that IUDs may increase the risk of transmission from HIV-infected men to uninfected women. This study followed women for a year, looking at bleeding patterns and disease markers, including viral shedding. They found no increases in complications rates from IUD insertion or disease progression, nor any effects on viral shedding.

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  • Hubacher, D., R. Lara-Ricalde, D. J. Taylor, F. Guerra-Infante, and R. Guzman-Rodriguez. 2001. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. New England Journal of Medicine 345:561–567.

    DOI: 10.1056/NEJMoa010438Save Citation »Export Citation » Share Citation »

    Given the mechanism of action of copper IUDs—establishing a disruptive inflammatory response—there was concern that this could impact fertility, especially in women who have never been pregnant. This case-control study, published in the highly influential New England Journal of Medicine, found no association between prior IUD use and infertility.

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  • Kessel, E. 1989. Pelvic inflammatory disease with intrauterine device use: A reassessment. Fertility and Sterility 51:1–11.

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    After the unfortunate consequences result from the faulty design of the Dalkon Shield, this important study laid to rest some of the historical concerns about IUDs and clarified other PID risk factors. Although the Dalkon Shield was associated with an increased risk of PID, the better designed modern IUDs were not.

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  • Ortiz, M. E., and H. B. Croxatto. 2007. Copper-T intrauterine device and levonorgestrel intrauterine system: Biological bases of their mechanism of action. Contraception 75: S16–S30.

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    This study summarizes our understanding of the biological basis of IUDs, both copper and levonorgestrel. Both are thought to induce a local inflammatory reaction in the endometrium that is inhospitable to sperm or implantation. The progestin in the IUDs also results in glandular atrophy and cervical mucus thickening that contribute to its contraceptive effects.

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  • Sivin, I. and J. Stern. 1994. Health during prolonged use of levonorgestrel 20 mg/day and the copper TCu 380Ag intrauterine contraceptive devices: A multicenter study. Fertility and Sterility 61:70–77.

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    Although the most commonly used IUDs are dependent on copper for their contraceptive efficacy, there are now hormone-releasing IUDs that use levonorgestrel for their contraceptive efficacy. This multicenter, prospective randomized trial documented the safety and efficacy of long-term use of both types of IUD.

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  • Tietze, C., and S. Lewit. 1970. Evaluation of intrauterine devices: Ninth progress report of the cooperative statistical program. Studies in Family Planning 1:1–40.

    DOI: 10.2307/1965076Save Citation »Export Citation » Share Citation »

    Intrauterine devices, although used since the 1800s, became increasingly common in the United States in the 1960s. Given the numerous kinds, the Population Council established the Cooperative Statistical Program to evaluate IUDs. This seminal report documented the efficacy and differences between the different IUDs available at the time.

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  • United Nations. 2008. World contraceptive use 2007. New York: United Nations Department of Economic and Social and Economic Affairs.

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    The disaster with the Dalkon Shield had a major impact on IUD use in the United States. Although modern IUDs are known to be safe, use is still much lower than in the rest of the world. The IUD is the most widely used reversible method in the rest of the world, with 16.5 percent of reproductive aged women in the developing world and 9.5 percent in the developed world using the method.

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Barrier Methods

Barrier methods of contraception have been in use throughout recorded history. Prior to oral and intrauterine devices, condoms, diaphragms, and cervical caps were the only methods available and were mainstays of the family planning movements launched by Margaret Sanger in the United States and Marie Stopes in Britain. Although generally not as effective in preventing pregnancy as hormonal methods, they have none of the side effects or contraindications of hormonal methods. More important, they carry the distinct advantage of providing protection against sexually transmitted infections, or STIs. They are thought to decrease the risk of STIs by about 50 percent, as described by Cates and Stone 1992. As the AIDS epidemic has continued to spread, condom use has become increasingly recommended and widespread, especially in endemic areas such as sub-Saharan Africa. Condoms are the only method proven to decrease transmission of HIV (Van de Perre, et al. 1987; Davis and Weller 1999; Diaz, et al. 1995). Nonmechanical barriers such as gels, creams, and foams are far less effective contraceptives than either condoms or modern methods and do not protect against sexually transmitted infections. Gels containing anti-HIV drugs (tenofovir) have been shown to reduce AIDS risk but do not prevent pregnancy (Abdool Karim, et al. 2010). Condoms also reduce the risk of transmission of human papillomavirus (HPV), the virus responsible for cervical cancer, as documented by Winer, et al. 2006. Although the female condom is also protective against HIV, some women consider it awkward to use and too expensive. The vaginal diaphragm was the first effective contraceptive method under a woman’s control. Although use now is quite low, in the first half of the 20th century, one-third of contracepting American couples were using the diaphragm. The cervical cap has taken the place of the diaphragm for some couples, because it can be left in place for longer than the diaphragm its placement is less dependent on the time of intercourse. A vaginal contraceptive sponge with a sustained release system for the spermicide nonoxynol-9 used to be available in the United States, but it has not been produced since 1995.

  • Abdool Karim, Q., S. S. Abdool Karim, J. A. Frohlich, et al. 2010. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 329.5996 (3 September): 1168–1174.

    DOI: 10.1126/science.1193748Save Citation »Export Citation » Share Citation »

    In a novel approach, this double blind, randomized controlled trial documented the safety and effectiveness of vaginal tenofovir gel—an antiretroviral microbicide—at preventing the transmission of HIV. The gel reduced HIV acquisition by 39 percent overall, and up to 54 percent in women with high adherence.

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  • Cates, W., Jr., and K. M. Stone. 1992. Family planning, sexually transmitted diseases and contraceptive choice: A literature update—Part I. Family Planning Perspectives 24.2: 75–84.

    DOI: 10.2307/2135469Save Citation »Export Citation » Share Citation »

    This extensive literature review discusses the importance of effective family planning methods as well as effective methods for preventing STIs, and the lack of a single method that can easily provide both. The authors then review the efficacy of barrier methods in preventing STIs.

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  • Davis, K. R., and S. C. Weller. 1999. The effectiveness of condoms in reducing heterosexual transmission of HIV. Family Planning Perspectives 31:272–279.

    DOI: 10.2307/2991537Save Citation »Export Citation » Share Citation »

    This longitudinal study used data from prior studies of serodiscordant couples to evaluate the effectiveness of condom use in preventing heterosexual transmission of HIV. The authors found condoms’ effectiveness at preventing HIV transmission to be around 87 percent (ranging from 60 to 96 percent), similar to their effectiveness at preventing pregnancy.

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  • Diaz, T., B. Schable, and S. Y. Chu. 1995. Relationship between use of condoms and other forms of contraception among human immunodeficiency virus–infected women. Supplement to HIV and AIDS Surveillance Project Group. Obstetrics and Gynecology 86:277–282.

    DOI: 10.1016/0029-7844(95)00144-GSave Citation »Export Citation » Share Citation »

    In an effort to describe the relationship between condom use and use of other methods of contraception among HIV positive women, these researchers interviewed women who recently seroconverted regarding their contraceptive practices. They found that women who are partners of condom users are less likely to become HIV-infected.

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  • Van de Perre, P., D. Jacobs, and S. Sprecher-Goldberger. 1987. The latex condom, an efficient barrier against sexual transmission of AIDS-related viruses. AIDS 1.1: 49–52.

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    Using a mechanical model, this study documented the effectiveness of condoms as serving as a barrier to the transmission of the HIV virus.

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  • Winer, R. L., J. P. Hughes, Q. Feng, et al. 2006. Condom use and the risk of genital human papillomavirus infection in young women. New England Journal of Medicine 354.25: 2645–2654.

    DOI: 10.1056/NEJMoa053284Save Citation »Export Citation » Share Citation »

    Published in the highly influential New England Journal of Medicine, this prospective observational study was pivotal in documenting the decrease in HPV infection in condom users.

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Emergency Contraception

Emergency contraception or postcoital contraception is used after intercourse to prevent pregnancy. This refers to copper IUDs as well as oral hormonal options. The use of copper IUDs for postcoital contraception is well documented in Cheng, et al. 2008. Although often referred to as the “morning-after pill,” there are numerous oral regimens of emergency contraception. The idea of postcoital contraception is an important option for patients, especially when condoms break or a sexual assault has occurred. Using combined oral contraceptive pills for emergency contraception was first described by Yuzpe, et al. 1982. Newer trials showed that progestin-only methods not only were more effective, but also had fewer side effects (Task Force on Postovulatory Methods of Fertility Regulation 1998). Since then, several dedicated products have been marketed that are packaged expressly for the purpose of emergency contraception. When these products were introduced, there was initially great hope that access to them might have a profound impact on unintended pregnancy rates. However, as Raine, et al. 2005 found, even if the pills are available over the counter, unintended pregnancy rates do not change, mainly due to fairly low levels of use. There has been significant media and political debate surrounding such pills’ over-the-counter status, with many inaccuracies suggesting that emergency contraception is an abortifacient, despite the overwhelming scientific literature to suggest otherwise (Trussell, et al. 2003).

  • Cheng, L., A. M. Gülmezoglu, G. Piaggio, E. Ezcurra, and P. F. Van Look. 2008. Interventions for emergency contraception. Cochrane Database of Systematic Reviews 2: CD001324.

    DOI: 10.1002/14651858.CD001324.pub3Save Citation »Export Citation » Share Citation »

    This Cochrane Review compiles the best research in this area, documenting the 99 percent effectiveness of copper IUDs to prevent pregnancy within five days of unprotected intercourse.

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  • Raine, T. R., C. C. Harper, C. H. Rocca, et al. 2005. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: A randomized controlled trial. Journal of the American Medical Association 293.1 (5 January): 54–62.

    DOI: 10.1001/jama.293.1.54Save Citation »Export Citation » Share Citation »

    This randomized trial was designed to assess whether direct access to emergency contraception would decrease unintended pregnancies. Although women with direct access (mimicking over-the-counter status) did use it more, there were no differences in sexual behaviors, condom use, or unintended pregnancies.

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  • Task Force on Postovulatory Methods of Fertility Regulation. 1998. Randomised trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 352:428–433.

    DOI: 10.1016/S0140-6736(98)05145-9Save Citation »Export Citation » Share Citation »

    This double-blind, randomized trial was the first to document the improved superiority of levonorgestrel only for emergency contraception relative to the Yuzpe regimen. Not only was it more effective, but women experienced fewer side effects.

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  • Trussell, J., C. Ellertson, and L. Dorflinger. 2003. Effectiveness of the Yuzpe regimen on emergency contraception by cycle day of intercourse: Implications for mechanism of action. Contraception 67:167–171.

    DOI: 10.1016/S0010-7824(02)00486-9Save Citation »Export Citation » Share Citation »

    Pooling data from prior studies, Trussell and colleagues provide evidence for the mechanism of action of emergency contraception. Using specific information regarding cycle day and day of intercourse, they were able to document that prevention of implantation is not the primary mechanism of action of emergency contraception.

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  • Yuzpe, A. A., R. P. Smith, and A. W. Rademaker. 1982. A multicenter clinical investigation employing ethinyl estradiol combine with dl-norgestrel as postcoital contraceptive agent. Fertility and Sterility 37:508–513.

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    This oft-referred to study demonstrates the effectiveness of a combined hormonal regimen (ethinyl estradiol and dl-norgesterl) to be used as postcoital contraception. This trial documented what came to be known as the “Yuzpe regimen,” which spawned numerous other investigations of varying doses and hormones, as well as increasingly widespread use of emergency contraception.

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Sterilization

Sterilization—whether male or female—is a permanent method of family planning employed by over a third of American couples and widely used in Asia. Although some methods of surgical sterilization are reversible, the return to fertility is not universal and the methods should be thought of as irreversible. The seminal study evaluating sterilization procedures is the CREST trial, which examined the efficacy of varying methods of surgical sterilization (Peterson, et al. 1996). Follow-up studies have been done to evaluate newer techniques for sterilization, as well as risk factors for regret (Peterson, et al. 1996). Interviewing thousands of women before and after their sterilization procedures, Wilcox, et al. 1991 found that young age was the biggest risk factor for regret. Although sterilization via mini-laparotomy or laparoscopic methods is quite safe, new, hysteroscopic procedures have been developed that are even lower risk. Cooper, et al. 2003 demonstrates the safety and efficacy of this procedure, which is done as an outpatient procedure. Based on data from the Nurses’ Health Study, we know that tubal ligation has some protective effect against ovarian cancer (Hankinson, et al. 1993). Although female sterilization is quite safe, vasectomy is safe, easier, cheaper, and more effective (Smith, et al. 1985).

  • Cooper, J. M., C. S. Carignan, D. Cher, J. F. Kerin, and Group STOPI. 2003. Microinsert nonincisional hysteroscopic sterilization. Obstetrics and Gynecology 102:59–67.

    DOI: 10.1016/S0029-7844(03)00373-9Save Citation »Export Citation » Share Citation »

    This article reports the findings from a phase III, international, multicenter trial to determine the safety, efficacy, and reliability of hysteroscopic sterilization using microinserts. The method was found to be quite successful, with no pregnancies reported in women successfully getting the inserts placed.

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  • Hankinson, S. E., D. J. Hunter, G. A. Colditz, et al. 1993. Tubal sterilization, hysterectomy, and risk of ovarian cancer: A prospective study. Journal of the American Medical Association 270:2813–2818.

    DOI: 10.1001/jama.1993.03510230051034Save Citation »Export Citation » Share Citation »

    Using data from the Nurses’ Health Study, this large prospective study found a protective effect of tubal sterilization against ovarian cancer.

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  • Peterson, H. B., Z. Xia, J. M. Hughes, L. S. Wilcox, L. R. Tylor, and J. Trussell. 1996. The risk of pregnancy after tubal sterilization: Findings from the U.S. collaborative review of sterilization. American Journal of Obstetrics and Gynecology 174.4: 1161–1168.

    DOI: 10.1016/S0002-9378(96)70658-0Save Citation »Export Citation » Share Citation »

    This seminal study reviewed the efficacy rates of varying sterilization techniques, finding them all to be very safe and effective, although with differences in efficacy by technique.

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  • Smith, G. L., G. P. Taylor, and K. F. Smith. 1985. Comparative risks and costs of male and female sterilization. American Journal of Public Health 75:370–374.

    DOI: 10.2105/AJPH.75.4.370Save Citation »Export Citation » Share Citation »

    Using previously published data, these investigators estimated the safety, effectiveness, and costs of male versus female sterilization. No deaths have been attributed to male sterilization, and the cost is estimated to be at least three times less.

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  • Wilcox, L. S., S. Y. Chu, E. D. Eaker, S. L. Zeger, and H. B. Peterson. 1991. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertility and Sterility 55.5: 927–933.

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    Interviewing thousands of women both before and after their sterilization procedures, investigators found that young age was the biggest predictor of regret.

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Behavioral Methods

Many couples would like to plan their pregnancies but prefer methods of doing so that seem more natural. These options include periodic abstinence, the rhythm or calendar method, and lactational amenorrhea. Periodic abstinence as a method of contraception is keyed to the observation of naturally occurring signs and symptoms of the fertile phase of the menstrual cycle. This method must take into account the viability of sperm in the female reproductive tract (two to seven days) and the lifespan of the ovum (one to three days). The variability in the timing of ovulation is the reason why the period of abstinence must be relatively lengthy unless barrier methods are used during the fertile days. This method of periodic abstinence was based on the assumption that menstrual cycles were relatively constant, and, therefore, the fertile period of the subsequent month could be predicted by the timing of the past cycle. Because of the normal variation in menstrual cycles, the average couple would practice periodic abstinence sixteen days each month. This method is useful only for women who have relatively regular and consistent menstrual cycles. Because this method has a pregnancy rate of about forty pregnancies per one hundred women per year, it is not advocated without combining it with other techniques. Lactational amenorrhea (the absence of menstruation), lasting up to two years, has been nature’s most effective form of contraception. Indeed, lactation is the mechanism that maintains a reasonable interval between pregnancies in all nonseasonally breeding animals. In Africa and Asia, breastfeeding reduces the fertility rate by an average of about 30 percent. The contraceptive effectiveness of lactation depends on the level of nutrition of the mother. If the nutrition level is low, the contraceptive interval is longer. Other important determinants are the intensity of suckling, and the extent to which supplemental food is added to the infant diet. If suckling intensity and/or frequency is diminished, contraceptive effect is reduced. Only amenorrheic women who exclusively breastfeed (full breastfeeding) at regular intervals, including nighttime, during the first six months have the contraceptive protection equivalent to that provided by oral contraception (98 percent efficacy as described by Labbok, et al. 1997).

  • Labbok, M. H., V. Hight-Laukaran, A. E. Peterson, V. Fletcher, H. von Hertzen, and P. F. A. Van Look. 1997. Multicenter study of the Lactational Amenorrhea Method (LAM): Efficacy, duration, and implications for clinical application. Contraception 55:327–336.

    DOI: 10.1016/S0010-7824(97)00040-1Save Citation »Export Citation » Share Citation »

    This prospective, multicenter trial was conducted to assess the acceptability and efficacy of the Lactational Amenorrhea Method (LAM). LAM (defined as exclusive breastfeeding including nighttime) was found to be 98 percent effective at six months and 92 percent effective at twelve months.

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Timing of Contraceptive Initiation

Aside from considering effectiveness, timing of contraception initiation is important to be aware of, not only to address with patients, but also to ensure appropriate clinical protocols that maximize access. Timing that is convenient for the patient improves access to contraception and continuation rates. Although pelvic and breast exams were thought to be a necessary precursor to hormonal contraceptive initiation, Stewart, et al. 2001 documents the lack of evidence supporting this practice and recommends removing this barrier to increase access to contraception. Westhoff, et al. 2007 has also documented the lack of data supporting the traditional “Sunday after your period” start to birth control pills. This clinical trial shows that women allowed to start pills the day they present to clinic have better continuation rates of the method. Timing of contraception after delivery is dependent in large part on the method selected and the patient’s breastfeeding intentions. Especially in areas where access to care is minimal, starting a long-acting reversible method (such as an IUD or implant), is safe postpartum for most women and may allow a woman to more safely space her next pregnancy (Grimes, et al. 2010). Although other risks may need to be weighed (mainly clot risk), most contraceptives do not have any negative effects on breast milk once supply is well established, or on a growing newborn (Pardthaisong, et al. 1992; Tankeyoon, et al. 1984). Another important time for initiating contraception is after abortion, when a woman is known to no longer be pregnant, and is likely still at risk for an unintended pregnancy. In this setting, long-acting reversible contraception is often the best choice. Recent data (Bednarek, et al. 2011) provides evidence as to the increased continuation rates of IUDs in women who get them placed immediately after the procedure, as opposed to waiting for a follow-up visit. Shifts in practice patterns around these issues could have a significant impact on unintended pregnancy rates.

  • Bednarek, P. H., M. D. Creinin, M. F. Reeves, et al. 2011. Immediate versus delayed IUD insertion after uterine aspiration. New England Journal of Medicine 364.23: 2208–2217.

    DOI: 10.1056/NEJMoa1011600Save Citation »Export Citation » Share Citation »

    This randomized noninferiority trial was conducted to evaluate the safety and efficacy of IUD insertion immediately after a first trimester abortion. Conducted as a noninferiority trial, these findings found that postprocedure insertion of an IUD may result in slightly higher expulsion rates but still leads to higher continuation rates at six months of follow-up, suggesting important changes to many clinicians’ current practices of not providing this service.

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  • Grimes, D. A., L. M. Lopez, K. F. Schulz, H. A. Van Vliet, and N. L. Stanwood. 2010. Immediate post-partum insertion of intrauterine devices. Cochrane Database of Systematic Reviews 12.5: CD003036.

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    This systematic review of immediate, postpartum IUD insertion found the practice to be safe and effective although with higher expulsion rates than insertions later in the postpartum period.

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  • Pardthaisong, T., C. Yenchit, and R. Gray. 1992. The long-term growth and development of children exposed to Depo-Provera during pregnancy or lactation. Contraception 45:313–324.

    DOI: 10.1016/0010-7824(92)90053-VSave Citation »Export Citation » Share Citation »

    Exposure to Depo-Provera both in pregnancy and during lactation has been widely studied with no evidence of adverse outcomes. This trial followed children into their teens and noted no changes in growth or pubertal development despite Depo exposures during either pregnancy or breastfeeding.

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  • Stewart, F. H., C. C. Harper, C. E. Ellertson, D. A. Grimes, G. F. Sawaya, and J. Trussell. 2001. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs. evidence. Journal of the American Medical Association 285:2232–2239.

    DOI: 10.1001/jama.285.17.2232Save Citation »Export Citation » Share Citation »

    This groundbreaking study, published in the influential Journal of the American Medical Association, re-examined the standard practice of requiring a breast and pelvic exam prior to starting hormonal contraception and found no evidence to support this practice. Since its publication, many evidence-based practitioners have changed their protocols, resulting in easier access to contraception.

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  • Tankeyoon, M., N. Dusitsin, S. Chalapati, et al. 1984. Effects of hormonal contraceptives on milk volume and infant growth. WHO, Special Programme of Research, Development, and Research Training in Human Reproduction, Task Force on Oral Contraceptives. Contraception 30:505–522.

    DOI: 10.1016/0010-7824(84)90001-5Save Citation »Export Citation » Share Citation »

    The World Health Organization (WHO) undertook a multicenter study comparing women taking combined oral contraceptive methods versus progesterone-only methods and evaluated neonatal and infant growth, as well as milk volume. Earlier findings of decreased milk volume were confirmed, but no changes in infant growth were noted, suggesting compensation through more frequent feeding or supplementation.

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  • Westhoff, C., S. Heartwell, S. Edwards, et al. 2007. Initiation of oral contraceptives using a quick start compared with a conventional start: A randomized controlled trial. Obstetrics and Gynecology 109:1270–1276.

    DOI: 10.1097/01.AOG.0000264550.41242.f2Save Citation »Export Citation » Share Citation »

    Westhoff, et al. explored other ways of increasing access to oral contraceptives, evaluating the quick start method—allowing patients to initiate the pill on the day of the clinic visit. Their randomized clinical trial showed better continuation rates with the quick start method, suggesting that this is another option for improving access to birth control.

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Noncontraceptive Benefits

Aside from providing safe birth control, many methods have noncontraceptive effects that are beneficial to women’s health. Some of these effects are quite well documented, and even used by the manufacturers as selling points. One such benefit is the improvement in acne seen with many combined hormonal contraceptive pills, as documented by Rosen, et al. 2003. Symptoms from fibroids, a very common reason for gynecology office visits and procedures, are improved by combined hormonal contraceptive pills as well as hormone-releasing IUDs (Friedman and Thomas 1995; Zapata, et al. 2010). Other common problems such as ovarian cysts (Grimes and Hughes 1989), endometriosis (Vessey, et al. 1993; Petta, et al. 2005), and chronic pelvic pain (Petta, et al. 2005) also improve with combined hormonal contraceptives and hormone-releasing IUDs. Interestingly, tubal sterilization has been found to decrease the risk of ovarian cancer, a condition for which there are no good screening tests (Hankinson, et al. 1993). Thus, when counseling patients on contraceptive options, it is also important to discuss some of the noncontraceptive benefits their preferred method offers.

  • Friedman, A. J., and P. P. Thomas. 1995. Does low-dose combination oral contraceptive use affect uterine size or menstrual flow in premenopausal women with leiomyomas?. Obstetrics and Gynecology 85:631–635.

    DOI: 10.1016/0029-7844(95)00007-ESave Citation »Export Citation » Share Citation »

    Friedman and Thomas found that although low-dose oral contraceptive pills do not affect uterine size or hematocrit levels, they do decrease the duration of menstrual blood flow, an important quality of life factor for symptomatic patients.

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  • Grimes, D. A., and J. M. Hughes. 1989. Use of multiphasic oral contraceptives and hospitalizations of women with functional ovarian cysts in the United States. Obstetrics and Gynecology 73:1037–1039.

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    Using a population-based epidemiologic approach, this study was undertaken to discredit the anecdotal evidence that ovarian cysts are more common or are more difficult to suppress in women taking oral contraceptive pills, especially the multiphasic variety. Because the authors used indirect evidence, they could not definitively refute the suggested association, but they were able to demonstrate that if it exists, the public health impact is insignificant.

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  • Hankinson, S. E., D. J. Hunter, G. A. Colditz, et al. 1993. Tubal sterilization, hysterectomy, and risk of ovarian cancer: A prospective study. Journal of the American Medical Association 270:2813–2818.

    DOI: 10.1001/jama.1993.03510230051034Save Citation »Export Citation » Share Citation »

    Using data from the Nurses’ Health Study, this large prospective study found a protective effect of tubal sterilization against ovarian cancer.

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  • Petta, C. A., R. A. Ferriani, M. S. Abrao, et al. 2005. Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Human Reproduction 20:1993–1998.

    DOI: 10.1093/humrep/deh869Save Citation »Export Citation » Share Citation »

    Aside from excellent contraceptive efficacy, the levonorgestrel IUD has also been documented to have other health benefits. This randomized clinical trial demonstrated its efficacy in decreasing chronic pelvic pain in women suffering from endometriosis.

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  • Rosen, M. P., D. M. Breitkopf, and M. Nagamani. 2003. A randomized controlled trial of second- versus third-generation oral contraceptives in the treatment of acne vulgaris. American Journal of Obstetrics and Gynecology 188:1158–1160.

    DOI: 10.1067/mob.2003.294Save Citation »Export Citation » Share Citation »

    This randomized trial evaluated a question of great concern to many patients—the effects of oral contraceptives on acne. This trial found improvements in acne across pill type, independent of the exact progesterone used.

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  • Vessey, M. P., L. Villard-Mackintosh, and R. Painter. 1993. Epidemiology of endometriosis in women attending family-planning clinics. British Medical Journal 306:182–184.

    DOI: 10.1136/bmj.306.6871.182Save Citation »Export Citation » Share Citation »

    Using hospital admission data, Vessey, et al. were able to document temporary suppression of endometriosis in women currently or recently using oral contraceptive pills.

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  • Zapata, L. B., M. K. Whiteman, N. K. Tepper, D. J. Jamieson, P. A. Marchbanks, and K. M. Curtis. 2010. Intrauterine device use among women with uterine fibroids: A systematic review. Contraception 82.1: 41–55.

    DOI: 10.1016/j.contraception.2010.02.011Save Citation »Export Citation » Share Citation »

    This exhaustive review documented the beneficial effects of IUDs (hormone releasing) in women with fibroids. These women experience less bleeding both objectively and subjectively.

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Effects of Public Health Trends

Public health trends can have a significant impact on how family planning services are delivered, or what methods are dispensed. One such trend is the growing obesity epidemic in the United States. Although there are clear data documenting the impressive rise in overweight and obesity in this country, even in otherwise young, healthy women, the effects this trend will have on family planning and unintended pregnancy is unclear. With more obesity and its resultant diabetes, pregnancies could become increasingly higher risk, making unintended pregnancy an even greater public health concern. However, as documented in the thorough review Edelman, et al. 2010, very little is known about how obesity may affect contraceptive pharmacokinetics and effectiveness. Earlier there was concern regarding possibly decreased effectiveness of oral contraceptive pills in obese women. However, the contrasting findings of Holt, et al. 2005 and Dinger, et al. 2009 suggest that this is likely not a significant effect. Other public health trends closely linked to family planning include teen pregnancy. The United States has a much higher rate of teen pregnancy than anywhere else in the developed world, even with recent decreases in teen birthrates in the early 21st century (see Centers for Disease Control and Prevention). HIV and AIDS have been the other main public health trend affecting family planning and reproductive health. Because condoms are the only birth control method that can prevent transmission of HIV, condom use has become increasingly recommended and widespread (Van de Perre, et al. 1987; Davis and Weller 1999; Diaz, et al. 1995). Gels containing anti-HIV drugs (tenofovir) have been shown to reduce AIDS risk but do not have the contraceptive effect of preventing pregnancy (Abdool Karim, et al. 2010). Other “dual purpose” methods are under development that could prevent pregnancy and decrease HIV transmission. These include vaginal rings that release both anti-HIV drugs and progestins as well as a modern version of the cervical cap that not only releases both types of drug but also physically protects the cervix from HIV and sperm entry.

  • Abdool Karim, Q., S. S. Abdool Karim, J. A. Frohlich, et al. 2010. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 329.5996: 1168–1174.

    DOI: 10.1126/science.1193748Save Citation »Export Citation » Share Citation »

    This groundbreaking trial demonstrated the efficacy of tenofovir gel in decreasing HIV transmission by almost 40%, offering a new tool in the armamentarium of prevention methods available to women and their partners.

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  • Centers for Disease Control and Prevention. Preventing teen pregnancy in the US. CDC Vital Signs.

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    The CDC reports “Vital Signs” on important public health issues, including teen pregnancy. Despite a sizable drop in the teen birthrate over the past decade, the United States still has a rate nine times higher than any other developed country, with approximately 10 percent of births occurring in teens.

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  • Davis, K. R., and S. C. Weller. 1999. The effectiveness of condoms in reducing heterosexual transmission of HIV. Family Planning Perspectives 31:272–279.

    DOI: 10.2307/2991537Save Citation »Export Citation » Share Citation »

    This study, which is the basis for current clinical recommendations, followed serodiscordant couples to evaluate the effectiveness of condom use in preventing heterosexual transmission of HIV. Their findings – an 87% prevention rate – continue to influence counseling on safe sexual practices between serodiscordant couples.

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  • Diaz, T., B. Schable, and S. Y. Chu. 1995. Relationship between use of condoms and other forms of contraception among human immunodeficiency virus-infected women. Supplement to HIV and AIDS Surveillance Project Group. Obstetrics and Gynecology 86:277–282.

    DOI: 10.1016/0029-7844(95)00144-GSave Citation »Export Citation » Share Citation »

    Diaz and colleagues attempted to untangle the relationship between contraceptive use and prevention of infections, specifically HIV. They found that HIV-infected women who used more effective methods of contraception were less likely to use condoms, suggesting a need for more effective counseling regarding the different roles of contraception and infection prevention.

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  • Dinger, J. C., M. Cronin, S. Möhner, I. Schellschmidt, T. D. Minh, and C. Westhoff. 2009. Oral contraceptive effectiveness according to body mass index, weight, age, and other factors. American Journal of Obstetrics and Gynecology 201.3: 263.

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    Contrary to earlier data, this large European cohort found little association between weight, body mass index (BMI), and oral contraceptive pill failure rates. These data, combined with the earlier studies, suggest that there is likely no significant impact and that the most effective and safest method should be chosen for obese women.

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  • Edelman, A. B., G. Cherala, and F. Z. Stanczyk. 2010. Metabolism and pharmacokinetics of contraceptive steroids in obese women: A review. Contraception 82:314–323.

    DOI: 10.1016/j.contraception.2010.04.016Save Citation »Export Citation » Share Citation »

    This thorough review examines the basics of metabolism, absorption, and drug pharmacokinetics in the setting of obesity, and applies this to contraceptive steroids. Unfortunately, few data exist clearly documenting the effects of obesity on steroid pharmacokinetics.

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  • Holt, V. L., D. Scholes, K. G. Wicklund, K. L. Cushing-Haugen, and J. R. Daling. 2005. Body mass index, weight, and oral contraceptive failure risk. Obstetrics and Gynecology 105:46–52.

    DOI: 10.1097/01.AOG.0000149155.11912.52Save Citation »Export Citation » Share Citation »

    Given the growing obesity epidemic, this case-control study provides important information about the slightly increased risk of pregnancy in obese women (BMI over 27 in this study) on oral contraceptive pills. Although the increase was small (two additional pregnancies per one hundred women), it is worthy of considering continuous dosing or non–weight dependent methods (such as IUDs and implants) for this group of women.

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  • Van de Perre, P., D. Jacobs, and S. Sprecher-Goldberger. 1987. The latex condom, an efficient barrier against sexual transmission of AIDS-related viruses. AIDS 1.1 (May): 49–52.

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    Van de Perre and colleagues demonstrated the effectiveness of condoms as a barrier to HIV transmission by using a mechanical model.

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