Contraceptives

The practice of birth control prevents
conception, thus limiting reproduction. The term
birth control, coined by Margaret SANGER in
1914, usually refers specifically to methods of
contraception, including STERILIZATION. The
terms family planning and planned parenthood
have a broader application. METHODS OF
BIRTH CONTROL Attempts to control fertility
have been going on for thousands of years.

References to preventing conception are found in
the writings of priests, philosophers, and
physicians of ancient Egypt and Greece. Some
methods, though crude, were based on sound
ideas. For example, women were advised to put
honey, olive oil, or oil of cedar in their vaginas to
act as barriers. The stickiness of these substances
was thought to slow the movement of sperm into
the uterus. Wads of soft wool soaked in lemon
juice or vinegar were used as tampons, in the
belief that they would make the vagina sufficiently
acidic to kill the sperm. The Talmud mentions
using a piece of sponge to block the cervix, the
entrance to the uterus. Sperm Blockage Several
modern methods of birth control are practiced by
creating a barrier between the sperm and the egg
cell. This consists of the use of a chemical foam, a
cream, or a suppository. Each contains a
chemical, or spermicide that stops sperm. They
are not harmful to vaginal tissue. Each must be
inserted shortly before COITUS. Foams are
squirted from aerosol containers with nozzles or
from applicators that dispense the correct amount
of foam and spread it over the cervix; creams and
jellies are squeezed from tubes and held in place
suppositories–small waxy pellets melted by body
heat–are inserted by hand. More effective at
keeping sperm and egg apart are mechanical
barriers such as the diaphragm and cervical cap
(both used with a spermicide), the sponge, and the
condom. A diaphragm is a shallow rubber cup that
is coated with a spermicide and positioned over
the cervix before intercourse. Size is important;
women need to have a pelvic examination and get
a prescription for the proper diaphragm. The
cervical cap, less than half the size but used in the
same way, has been available worldwide for
decades. It was not popular in the United States,
however, and in 1977 it failed to gain approval by
the Food and Drug Administration (FDA); in
1988, the FDA again permitted its sale. The
contraceptive sponge, which keeps its spermidical
potency for 48 hours after being inserted in the
vagina, was approved in 1983. Like the
diaphragm and cervical cap, the sponge has an
estimated effectiveness rate of about 85%. The
devices only rarely produce side effects such as
irritation and allergic reactions and, very rarely,
infections. The condom, a rubber sheath, is rolled
onto the erect penis so that sperm, when
ejaculated, is trapped but care must be taken so
that the condom does not break or slip off. A
fresh condom should be used for each sexual act.

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Condoms also help protect against the spread of
VENEREAL DISEASES, and, unlike other
barrier devices, condoms made of latex do
foolproof–protection against AIDS (see AIDS).

Another method of preventing the sperm from
reaching the egg is withdrawal by the man before
ejaculation. This is the oldest technique of
contraception and, because of the uncertainty of
controlling the ejaculation, is considered one of the
least effective. Altering Body Functions Even in
ancient times, attempts were made to find a
medicine that would prevent a woman’s body from
producing a baby. Only within the last century,
however, have methods been developed that
successfully interrupt the complex reproductive
system of a woman’s body. The first attempt,
made in the 19th century, was based on a legend
that camel drivers about to go on long journeys in
the desert put pebbles in the wombs of female
camels to keep them from becoming pregnant.

Researchers tried to find something that would
work similarly in a woman’s cervix. The earliest
such objects were made of metal and were held in
by prongs. Later, wire rings were placed beyond
the cervix, in the uterus itself, thus giving rise to the
term intrauterine device, or IUD. IUDs appear to
work by altering the necessary environment in the
uterus for the fertilized egg. It was only with the
introduction of modern plastics such as
polyethylene, however, that IUDs were widely
accepted. Their pliability led to simpler insertion
techniques, and they could be left in place until
pregnancy was desired unless a problem arose
with their use. Copper-containing IUDs, and those
that slowly released the hormone progesterone,
had to be replaced periodically. Some users of
IUDs, however, complained increasingly of the
side effects of the devices. The most common
problem was bleeding, and the devices could also
cause uterine infections. More dangerous was the
possible inducement of pelvic inflammatory
disease (see UROGENITAL DISEASES), an
infection that may lead to blockage of the
Fallopian tubes and eventual sterility or an ectopic
pregnancy. Studies in the 1980s confirmed this
link with the increased risk of infertility even in the
absence of apparent infections, especially with
plastic IUDs. The A. H. Robins Company, in
particular, was ordered in 1987 to set aside nearly
$2.5 billion to pay the many thousands of claims
filed against it by women injured through use of its
Dalkon Shield. By that time only a single,
progesterone-releasing IUD remained on the U. S.

market, but a copper IUD later became available
and other steroid releasing devices were being
planned for issue. The birth control pill, taken once
a day, has become the most popular birth control
contraceptives are similar in composition to the
hormones produced naturally in a woman’s body.

Most pills prevent ovaries from producing eggs.

Use of the pill, however, does not prevent
periods to be more regular, with less cramps and
blood loss. Recent studies seem to indicate that
the pill may also protect its users against several
relatively common ailments, including iron
deficiency anemia (the result of heavy menstrual
bleeding), pelvic inflammatory disease, and some
benign breast disorders. In addition (and contrary
to fears that were expressed when the pills were
first marketed and contained much higher levels of
hormones), long-term statistical studies point to a
lower incidence of ovarian and uterine cancer
among women who use contraceptive pills. Other
studies, however, have linked its use with the
increased occurrence of breast cancer. Ongoing
studies by such organizations as the American
Cancer Society continue to study a possible breast
cancer link. For some users, the pill may have
undesirable and sometimes serious side effects
such as weight gain, nausea, hypertension, or the
formation of blood clots or noncancerous liver
tumors. The risk of such effects increases above
the age of 35 among women who smoke. Pills are
obtainable only by prescription and after a
woman’s medical history and check of her physical
condition. In 1991 the FDA approved the use of
Norplant, a long-lasting contraceptive that is
implanted under the skin on the inside of a
woman’s upper arm. The implant consists of six
matchstick-size flexible tubes that contain a
synthetic hormone called progestin. Released
slowly and steadily over a five-year period, this
drug inhibits ovulation and thickens cervical
mucus, preventing sperm from reaching eggs.

Avoiding Intercourse The time to avoid sex, when
conception is not desired, is about midway in a
woman’s menstrual cycle; this was not discovered
until the 1930s, when studies established that an
egg is released (ovulation) from an ovary about
once a month, usually about 14 days before the
next menstrual flow. Conception may occur if the
egg is fertilized during the next 24 hours or so or if
intercourse happens a day or two before or after
the egg is released, because live sperm can still be
present. Therefore, the days just before, during,
and immediately following the ovulation are
considered unsafe for unprotected intercourse;
other days in the cycle are considered safe. The
avoidance of intercourse around ovulation, the
rhythm method, is the only birth control method
approved by the Roman Catholic church.

Maintenance of calendar records of menstrual
cycles proved unreliable, because cycles may vary
due to fatigue, colds, or physical or emotional
stress. A woman’s body temperature, however,
rises slightly during ovulation and remains high until
just before the next flow begins. Immediately
preceding the release of the egg, the mucus in the
vagina becomes clear and the flow is heavier. As
the quantity of mucus is reduced, it becomes
cloudy and viscous and may disappear. These
signals can help a woman determine the time when
she must avoid intercourse to prevent pregnancy.

Permanent Contraception Couples who wish to
have no more children or none at all may choose
sterilization of the man or of the woman instead of
prolonged use of temporary methods. To be
considered irreversible, sterilization blocks or
separates the tubes that carry the sperm or the
eggs to the reproductive system. The man is still
capable of ejaculating, but his semen no longer
contains sperm. The woman continues to
menstruate and an egg is released each month, but
it does not reach her uterus. Neither operation
affects hormone production, male or female
characteristics, sex drive, or orgasm. Tubes may
be separated by surgically cutting them, they may
be blocked with clips or bands, or they may be
sealed using an electric current. The man’s
operation, or VASECTOMY, is simpler and is
usually performed in a doctor’s office or a clinic.

The operation for women is usually performed in a
hospital or an out-patient surgical center. Some of
the most recent techniques require a stay of only a
few hours. Some soreness and discomfort may be
expected after surgery, occasionally with swelling,
bleeding, or infection; the risk of serious
complication is slight. In the 1980s sterilization
became the preferred method among U.S. couples
desiring no further children. The most optimistic
prospects for reversing sterilization for women and
men exists when there is the least damage to their
tubes at the time of sterilization. It is estimated that
as many as 60 percent of reversals are successful
(success is measured by a pregnancy). Many
individuals, however, may not even be candidates
for an attempt at reversal, especially women who
have undergone electrocauterization or surgical
cutting of their tubes. New or Experimental
Contraceptives Several new drugs and
contraceptive devices are at present undergoing
examination in the United States. Thus an injection
of the synthetic progesterone Depo-Provera
(currently used in more than 90 countries)
prevents ovulation for three months. Animal tests,
however, suggest that the drug may induce some
cancers, and have other undesirable side-effects.

Also in use in several countries is a capsule,
implanted beneath the skin of the upper arm, that
slowly releases the synthetic hormone
levonorgestrel over a period of five years. The
capsule, which was approved by the World
Health Organization in 1985 for distribution by
United Nations agencies, has minimal known side
effects but should not be used by women who
have liver disease or breast cancer. Another
contraceptive approach, successful in animals and
currently undergoing human trials, is vaccination.

One vaccine delivers antibodies against a hormone
that plays a crucial role in pregnancy. A second
works against a hormone in the matrix surrounding
the egg, blocking sperm from penetrating. Male
and unisex oral contraceptives are currently in
research. SOCIAL ISSUES Birth control, or
limiting reproduction, has become an issue of
major importance in the contemporary world
POPULATION growth. Until relatively recently,
however, most cultures have stressed increasing,
rather than reducing, procreation. The English
economist Thomas MALTHUS (1766-1834) was
the first to warn that the population of the world
was increasing at a faster rate than its means of
support. However, 19th-century reformers who
advocated birth control as a means of controlling
population growth met bitter opposition both from
the churches and from physicians. The American
Charles Knowlton, author of an explicit treatise on
contraception entitled The Fruits of Philosophy
(1832), was prosecuted for obscenity, and similar
charges were brought against the free-thinkers
Annie BESANT and Charles Bradlaugh, who
distributed the book in Britain. Nonetheless, the
movement persisted, gathering strength at the end
of the century from the WOMEN’S RIGHTS
MOVEMENT. In Britain and continental Europe,
Malthusian leagues were formed, and the Dutch
league opened the first birth control clinic in 1881.

An English clinic was started by Dr. Marie Stopes
(1882-1958) in 1921. In the United States,
Margaret Sanger’s first clinic (1916) was closed
by the police, but Sanger opened another in 1923.

Her National Birth Control League, founded in
1915, became the Planned Parenthood Federation
of America in 1942 and then, in 1963, the Planned
Parenthood-World Population organization. In
GRISWOLD V. CONNECTICUT (1965) the U.

S. Supreme Court struck down the last state
statute banning contraceptive use for married
couples, and in 1972 the Court struck down
remaining legal restrictions on birth control for
single people. The federal government began
systematically to fund family planning programs in
1965. Contraceptive assistance was provided to
minors without parental consent until Congress
ruled in 1981 that public health-service clinics
receiving federal funds must notify parents of
minors for whom contraceptives have been
prescribed. Suits challenging the regulation have
been upheld; the government has announced plans
to appeal. Despite the wide availability of
contraceptives and birth control information, the
rate of childbirth among unmarried teenage girls
rose throughout the 1970s and 1980s. A major
focus of current concern, therefore, is the
adolescents. Other countries where the birth
control movement has been notably successful
include Sweden, the Netherlands, and Britain,
where family planning associations early received
government support; Japan, which has markedly
reduced its birthrate since enacting facilitating
legislation in 1952; and the Communist countries,
which after some fluctuations in policy, now
provide extensive contraceptive and abortion
services to their inhabitants. Many of the less
developed countries are now promoting birth
control programs, supported by technical,
educational, and financial assistance from various
United Nations agencies and the International
Planned Parenthood Federation. A series of
World Population Conferences has sought to
strengthen the focus on population control as a
major international issue. At present the strongest
opposition to birth control in the Western world
comes from the Roman Catholic church, which
continues to ban the use of all methods except
periodic abstinence. In Third World countries
resistance to birth control programs has arisen
from both religious and political motives. In India,
for example, a country whose population is
increasing at a net rate of 10-13 million a year, the
traditional Hindu emphasis on fertility has impeded
the success of the birth control movement. Some
Third World countries continue to encourage
population growth for internal economic reasons,
and a few radical spokespersons have alleged that
the international birth control movement is
attempting to curtail the population growth of
Third World countries for racist reasons. A similar
argument has been heard within the United States
with regard to ethnic minorities; the latter,
however, voluntarily seek family planning in an
equal proportion to nonminorities. Despite such
arguments, most educated individuals and
governments acknowledge that the health benefits
of regulating fertility and slowing the natural
expansion of the world’s population are matters of
Bibliography:
Louise B. Tyrer, M.D.

Bibliography: Belcastro, P. A., The Birth Control
Book (1986); Bullough, Bonnie, Contraception: A
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Filshie, Marchs, and Guillebaud, John,
Contraception: Science and Practice (1989);
Gordon, Linda, Woman’s Body, Woman’s Right:
A Social History of Birth Control in America
(1976); Harper, Michael J. K., Birth Control
Technologies: Prospects by the Year 2000
(1983); Kennedy, David M., Birth Control in
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