Wild Iris Medical Education
COURSE PRICE: $35.00
CONTACT HOURS: 5
This course is available until June 1, 2014.
ACCREDITATION / APPROVAL
Wild Iris Medical Education (CBRN Provider #12300) is approved as a provider of continuing education for RNs, LVNs, and respiratory therapists by the California Board of Registered Nursing.
Wild Iris Medical Education, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide an overview of the historical, legal, social and cultural issues surrounding the practice of contraception/family planning; the factors involved in choosing and using contraception; and the advantages and disadvantages of various methods of contraception.
Upon completion of this course, you will be able to:
Family planning is one of the ten great public health achievements of the twentieth century. The availability of family planning services allows individuals to achieve desired birth spacing and family size and contributes to improved health outcomes for infants, children, and women.
—Centers for Disease Control and Prevention (1999)
The U.S. Department of Health & Human Services’ publication Healthy People 2020 defines family planning services as including:
This course will focus on contraceptive health services and the prevention of sexually transmitted infections (STIs).
Contraception is the intentional prevention of pregnancy through the use of one or more methods. The methods may include the use of devices, drugs, surgical procedures, or sexual practices, such as abstinence. The use of contraception enables women and couples to decide if and when they will have children. The term contraception has become synonymous with family planning because, without the use of contraception, it is impossible to plan a family that you can afford and can care for.
Contraceptive use prevents unintended pregnancies, reduces the number of abortions, and reduces the incidence of illness and deaths related to complications of pregnancy and childbirth. It also reduces the transmission of HIV and helps reduce pressure on scarce natural resources. Contraceptive use also improves educational and employment opportunities for women and children, which in turn contribute to reducing poverty and spurring economic growth (Guttmacher Institute, 2010b).
Because of their unique reproductive capacities, women most often bear the burdens stemming from inadequate access to contraception. Whether a woman has access to contraception directly affects her ability to plan whether and when to have a family. This has an impact on every aspect of her life, including her socioeconomic, educational, and professional status, and the health and well being of her family.
—Association of Reproductive Health Professionals (2008)
In a perfect world, a woman and her partner(s) would make decisions about contraception. However, because pregnancy occurs only in women, contraception has long been considered a women’s issue and responsibility.
Contraception and family planning are central to the lifetime health of women and families around the world. The improvement of maternal health is one of the eight Millennium Development Goals adopted by the international community in 2000. According to the World Health Organization, “About 1,000 women die from pregnancy- or childbirth-related complications around the world every day. In 2008, 358,000 women died during and following pregnancy and childbirth.” Most of these deaths occur in developing countries, in rural areas, and among poorer and less-educated communities.
Adolescents face a higher risk of complications and death as a result of pregnancy than older women. Although maternal deaths globally have dropped by one third since 1990, the statistics are still grim. For example, the probability that a 15-year-old woman will eventually die from a maternal cause is 1 in 4,300 in developed countries, versus 1 in 120 in developing countries (WHO, 2010c).
UNINTENDED PREGNANCY AND INCREASED HEALTH RISK
Conditions associated with increased risk for adverse health events as a result of unintended pregnancy include:
Source: CDC, 2010a.
No woman can call herself free who does not own and control her body. No woman can call herself free until she can choose consciously whether she will or will not be a mother.
—Margaret Sanger (1884–1966)
When Sanger wrote the above words in the early twentieth century, birth control was a taboo subject in America. Although women in France and Scotland had access to public clinics, in the United States it was a federal crime to send information about birth control through the mails. Sanger was an obstetrical nurse who practiced in the tenements on New York’s Lower East Side, where poverty and uncontrolled fertility led to high rates of infant and maternal mortality. Many poor women died of infection or hemorrhage from do-it-yourself or back-alley abortions. Sanger herself was the sixth of eleven children.
When she opened the country’s first birth control clinic in Brooklyn in 1916, she was vilified by the religious community. She was arrested repeatedly and served 30 days in jail for distributing birth control information. Undaunted by her critics, she continued her efforts on behalf of a woman’s right to reproductive choice and eventually took her campaign to the international level. In 1953, Sanger became the founding president of the International Planned Parenthood Federation. Her legacy has given millions of women the freedom to choose if and when they will have children.
In twenty-first-century, birth control remains a hot-button issue socially and politically in the United States and elsewhere. Women have legal access to a range of contraceptive choices. However, actual access is limited by public policy; education; income; racial, ethnic, and cultural beliefs; and geography.
While abortion, the medical or surgical termination of pregnancy, was legalized in 1973 by the U.S. Supreme Court (Roe vs. Wade), this procedure remains under heated debate. “Pro-life” groups continue to oppose the practice, while “pro-choice” groups work to protect the right to abortion. Some pro-life groups regularly protest near family planning clinics, harass abortion patients and providers, and lobby state and federal governments to restrict access to birth control. Referred to by some as “anti-choice,” their intimidation tactics at times include violence, and a few extremists have murdered physicians who perform abortions, most recently Dr. George Tiller in Wichita, Kansas in 2009, calling these murders “justifiable homicide.”
One of the major goals of Healthy People 2020 is to “improve pregnancy planning and spacing and prevent unintended pregnancy.” Meeting that goal seems unlikely, given the ongoing legislative and public debate surrounding contraception and abortion rights. Some in Congress have proposed laws to block federal funding to organizations that perform abortions, which would prevent Planned Parenthood, the largest family planning provider in the United States, from receiving governmental support.
On August 1, 2011, the U.S. Department of Health and Human Services issued historic new guidelines ensuring that contraception and other women’s health services will be considered preventive healthcare under the new Affordable Care Act. New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012 (U.S. DHHS, 2011).
This issue was widely debated by women’s health advocates and organizations opposing contraception, including the U.S. Council of Catholic Bishops. The Council argued that birth control isn’t prevention because pregnancy isn’t a disease (Lerner, 2011). However, this argument did not stand with the Institute of Medicine, which recommended that women of reproductive capacity have access to “the full range of FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling” (IOM, 2011). Globally, the Catholic Church continues to oppose any form of contraception, even though many practicing Catholics ignore this prohibition.
The swift rise in nonmarital childbearing in the United States over the past 50 years has given rise to a new family form: fragile families, defined as couples who are unmarried when their children are born. Compared with more traditional families, these families face greater risks in terms both of family stability and of economic security—risks that can imperil child well being.
—The Future of Children (2010)
Not so very long ago, an unmarried girl or woman who had a child was considered shameful and often rejected by her family or forced into a “shotgun” marriage with the baby’s father. Many of those who did not marry relinquished their baby to adoptive parents immediately after birth. Today there is greater acceptance of unwed mothers, due in part to a culture in which childbirth before marriage is commonplace and widely reported in the media.
Likewise, most young people today are sexually active long before marriage and may have several partners before age 18. The falling age of puberty in girls has accelerated this trend. About half of all U.S. white girls show signs of breast development (thelarche) by their tenth birthday. In Black girls, thelarche occurs even earlier—by age 9. Early puberty is associated with many high-risk behaviors in later adolescence, including smoking, use of alcohol and other drugs, crime, and unprotected sex—behaviors that can have lifetime consequences, including unintended pregnancy (Steingraber, 2007).
Decades of research reveal striking racial and ethnic disparities in the health of Americans across the lifespan. These disparities are rooted in socioeconomic inequality, beginning before birth. Income, education, nutrition, housing, employment, and access to healthcare combine to influence health status. Sexual and reproductive health issues bring these disparities into even sharper focus, with poverty, unequal educational opportunity, and lack of access to healthcare all contributing to high rates of unintended pregnancy. “Unintended pregnancy disproportionately affects younger, minority, and low-income women” (Spain et al, 2010).
Disparities in family planning can exacerbate the cycle of disadvantage experienced by specific populations when women are unable to control their fertility (Dehlendorf, Rodriguez, et al., 2010). Hispanic and black women have higher birth rates and higher percentages of births to unmarried mothers than non-Hispanic white women (Mosher & Jones, 2010). Communities of color also have higher prevalence of STIs, including HIV, which increases the risk of transmission with each sexual encounter. Teens and young adults have higher rates of STIs compared with older adults.
Sexually transmitted infections (STIs) have long been a risk of unprotected sex. Unless a person is in a mutually monogamous relationship with an uninfected partner, each sexual encounter may expose him or her to one or more STIs. Although by the 1950s, syphilis, gonorrhea, and other STIs could be successfully treated or cured, HIV/AIDS remains an incurable disease. Unprotected sex can cause not only unintended pregnancy but also death.
The CDC (2011e) estimates that 1.1 million people in the United States are currently infected with HIV. At least one fourth of them do not know they are infected, putting them at high risk for transmitting the virus to others. The development of antiretroviral drugs has reduced deaths from AIDS; yet the number of new infections has not changed since the late 1990s. Each year another 56,000 people are infected with HIV—approximately 1 new infection every 9.5 minutes. Many people who are HIV-positive in the United States are not being treated, either because they lack access to care or because they have not been tested.
According to CDC estimates (2010b), each year there are approximately 19 million new cases of STIs. These include gonorrhea, chlamydia, and syphilis as well as human papilloma virus (HPV), trichomoniasis, chancroid, and genital herpes. The prevalence of other sexually transmitted viruses such as herpes and human papilloma virus may also have lifelong implications. For example, oncogenic (cancer-causing) types of HPV are responsible for nearly all cases of cervical cancer as well as 90% of anal cancer (Kim, 2011).
In choosing a contraceptive method or methods, sexually active adolescents and adults need to consider not only effectiveness in preventing pregnancy but also the need to protect against sexually transmitted infections (STIs). In a study by CDC scientists, only 8% of women reported using dual protection (condom plus another method of contraception) (Mosher & Jones, 2010).
According to CDC (2010), “Although hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against STIs. Consistent and correct use of the male latex condom reduces the risk for STIs. When a male condom cannot be used properly for infection prevention, a female condom should be considered. Women who use contraceptive methods other than condoms should be counseled about the use of condoms and the risk for STIs.”
The typical American woman spends three quarters of her reproductive life trying to avoid pregnancy.
—Rachel Walden (2011)
About 4 million births occur in the United States each year, and about 40% of those births are to unmarried women. In addition to the 4 million births, about 1 million miscarriages (spontaneous abortions) and stillbirths occur each year (Martin et al., 2010; Ventura, 2009); and in 2007 about 800,000 elective abortions were performed (CDC, 2011a).
There are 62 million women of childbearing age (ages 15–44) in the United States. More than two thirds of them are sexually active and do not want to become pregnant but could unless they and/or their partners use contraception. One third of these women do not need contraception because they are infertile, currently pregnant, trying to become pregnant, or not sexually active (Guttmacher Institute, 2010a). Furthermore, most U.S. women want only two children, so contraception is needed for approximately thirty years of a woman’s life.
Nearly half of all pregnancies in the United States are unintended, despite the fact that nearly 90% of sexually active women of childbearing age use some form of contraception. Unintended pregnancy usually is attributed to incorrect or inconsistent use of contraception. Among teens (ages 15–19), the rate of unintended pregnancy is even higher: 82% of teen pregnancies are unintended. Although the rate of teenage pregnancy is declining, the U.S. rate is one of the highest in the developed world, more than twice as high as the rates in Canada and Sweden (Guttmacher Institute, 2011c).
Approximately one third of women ages 15–44 are not at risk of unintended pregnancy for a variety of reasons and are therefore not using any contraception. Most of the other two thirds of women in this cohort are using some form of contraception. However, CDC researchers recently found that 16% of Black women and about 9% of Hispanic, white, and Asian women were not using contraception. “This fact may be related to the higher rates of unintended pregnancy among Black women compared with non-Hispanic white women” (Mosher & Jones, 2010).
CDC also scientists report that use of contraception varies by age. Little more than one fourth of teens use contraception, but by ages 20–24, the proportion using contraception rises to 55%. The rate of contraception use among women ages 25–44 is estimated to be between two thirds and three fourths (Mosher & Jones, 2010).
Women in this study who did not use contraception before an unintended pregnancy gave different reasons for not using contraception, summarized in the table below.
| Reason | Percent |
|---|---|
| Source: Mosher & Jones, 2010. | |
| Did not expect to have sex | 43.9% |
| Didn’t really mind if you got pregnant | 22.8% |
| Worried about side effects of birth control | 16.2% |
| Male partner didn’t want you to use birth control | 7.3% |
| Male partner didn’t want to use birth control | 9.6% |
The most popular method of contraception among women under age 30 is the birth control pill. Women age 30 and older are more likely to choose sterilization. “Half of all women aged 40–44 who practice contraception have been sterilized, and another 20% have a partner who has had a vasectomy” (Mosher & Jones, 2010).
Choice of contraceptive method use also varies by racial and ethnic group. White women are twice as likely to use the pill as either Black or Hispanic women, who are more likely to choose female sterilization. Male sterilization is more common among white men (8%) than either Hispanic (2%) or Black men (1%).
Unintended pregnancy disproportionately affects younger, minority, and low-income women.
—Spain et al. (2010)
Adolescents, poor and minority women, homeless women, women in the military, and women experiencing intimate partner violence are all at high risk of unintended pregnancy. They also have the greatest need for information and other resources to help them prevent pregnancy and cope with it when it does occur.
Teens are waiting longer to have sex than they did in the very recent past, and contraceptive use is increasing among sexually active adolescents in the United States. As a result, teen birth rates are declining. Between 2007 and 2009, the teen birth rate declined 8%, reaching a historic low at 30.1 births per 1,000 teens aged 15–19 years. Rates dropped significantly for teens in all age groups and for all racial and ethnic groups. Rates among teens ages 15–17 also dropped in 31 states and remained stable in all the remaining states except West Virginia, which had a 17% increase in teenage births (CDC, 2011b).
The recent trend marks a resumption of the long-term decline in teenage childbearing that started in 1991. Previous studies have suggested that these declines reflected the impact of strong teenage pregnancy prevention messages that accompanied a variety of public and private efforts to focus teenagers’ attention on the importance of avoiding pregnancy.
Change in birth rate for women aged 15–17, by state: United States, 2007 and 2009. (Source: CDC, 2011b.)
Despite the encouraging decline in teen births, teenage pregnancy remains a problem. As of 2008, 1 of 5 female teens at risk of unintended pregnancy was not using any contraceptive method. Each year, almost 750,000 U.S. women aged 15–19 become pregnant. Nearly two thirds of these pregnancies end in birth, and more than one fourth end in abortion. Black and Hispanic women have the highest teen pregnancy rates, and non-Hispanic whites have the lowest (Guttmacher, 2010a).
In 2009, more than 400,000 infants were born to 15–19 year olds. Nearly two thirds of births to women younger than age 18 are unintended, and more than half of those among 18–19 year olds are unintended (Hamilton et al., 2010; Chandra et al., 2005).
COSTS OF TEEN PREGNANCY
Teen pregnancy and childbearing bring substantial social and economic costs through immediate and long-term impacts on teen parents and their children.
These effects persist for the teen mother and her child even after adjusting for those factors that increased the teenager’s risk for pregnancy, such as growing up in poverty, having parents with low levels of education, growing up in a single-parent family, and have low attachment to and performance in school (Singh & Darroch, 2000).
Source: CDC, 2011c.
Women now make up 17% of the U.S. military, a system built by men for men, so it is not surprising that women’s reproductive health needs are often overlooked in public policy debates. “Compared with their civilian counterparts, women in the military experience greater challenges in preventing unwanted pregnancy and have less access to contraceptive services” (Ponder & Nothnagle, 2010).
Young single female recruits are particularly vulnerable during deployment, when they may be working long hours across different time zones and are outnumbered by men 7 to 1. Binge drinking is common in the military, as are sexual harassment and assault. Between 10% and 33% of women report experiencing attempted or completed rape while serving in the military. The proportion of unintended pregnancies in the military is estimated to be higher than the national average of 49%.
In February 2010, the U.S. Department of Defense announced its decision to make emergency contraception (EC) available to women in the U.S. military. This groundbreaking shift in policy will reduce the need for abortion. Until EC was added to the formulary, a military woman with an unintended pregnancy who sought an abortion had to pay out-of-pocket for the service, and if she was stationed in a country where safe abortion was illegal, she had to travel back to the United States at her own expense or find a provider in another country where abortion was legal (Boonstra, 2010).
An estimated 600,000 women are homeless in America (National Coalition for the Homeless, 2009). This includes those who are actually living on the street or in shelters as well as the “hidden homeless” who live with friends, neighbors, family, or in their car. However, the nature of homelessness makes all statistics concerning this population imprecise.
Homeless women lead precarious lives, with little or no access to healthcare, including contraception. The economic realities of homelessness force many of these women to engage in activities such as panhandling or trading sex for food or other resources, which increases the risk of various types of victimization, including sexual assault. The prevalence of sexual assault among homeless women is estimated to be between 13% and 50% (Goodman et al., 2006). Sexual assault can lead to unintended pregnancy as well as STIs.
Even those homeless women not engaged in panhandling or the sex trade are at risk of unintended pregnancy. One study of homeless women in Los Angeles found that one third of homeless women were at risk for unintended pregnancy. Women who had a partner, were monogamous, and did not engage in the sex trade were 2.3 times as likely as other women to not use or rarely use contraception. Having a regular source of healthcare and being encouraged to use contraception led to increased use of contraception. Researchers suggested that homeless women “need to be targeted with integrated services that include education, a regular source of medical care, and encouragement to use contraception” (Gelberg et al., 2008).
Intimate partner violence can include reproductive coercion such as deliberately exposing a partner to sexually transmitted infections (STIs); attempting to impregnate a partner against her will (by damaging condoms or throwing away her birth control pills, also called birth control sabotage); threats or acts of violence if the partner does not comply with the perpetrator’s wishes concerning the decision to terminate or continue a pregnancy; as well as threats or acts of violence if the partner refuses to have sex (Family Violence Prevention Fund, 2008).
In a recent study of women ages 16–29 years seeking care in family planning clinics, researchers found that more than half of these women reported IPV and 1 in 5 of them reported pregnancy coercion and birth control sabotage. Both IPV and reproductive coercion are associated with unintended pregnancy (Miller et al., 2010).
Numerous factors affect whether a sexually active woman uses contraception. If she does use one or more contraceptive methods, those same factors also affect her choice of method(s) and how correct and consistent the use is. These interacting factors include:
The populations of women at highest risk for unintended pregnancy (discussed above) are affected by a combination of those factors. For example, sexually active teens from poor families may also lack health insurance and comprehensive sex education that includes information about contraception. Teens living in states such as Utah where abstinence-only sex education prevents distribution of contraceptive information are at higher risk of unintended pregnancy. Even teens who have health insurance and economic means to obtain contraceptives may need permission from parents who believe in abstinence only.
Education has a major impact on the use of contraception. In one study, CDC researchers found that use of contraception is directly correlated with the educational level of women’s mothers. Slightly more than half of women whose mothers were not high school graduates used contraceptives; more than two thirds of those whose mothers were high school graduates used contraception; three fourths of women whose mothers had some college used contraception; and more than 80% of daughters of college graduates used contraception (Mosher & Jones, 2010).
Language and cultural differences can be major barriers to the acquisition and use of contraceptives. For example, researchers found that rural Latinos were embarrassed to discuss birth control, STIs, or sexuality with clinicians; and Latinas were embarrassed to have a pelvic exam. This population was also concerned about the effects of long-term and short-term birth control methods, wondering whether birth control pills could cause cancer or sterility. Researchers also found a high cultural acceptance of withdrawal as a birth control method and that providers find this misinformation difficult to correct (Branch et al., 2010).
Relationship status is a key factor in the choice of contraceptive method. For example, any woman whose sexual partner(s) opposes her use of oral contraceptives or is unwilling to use condoms or to have a vasectomy must choose discrete contraception that she alone controls, such as an intrauterine device (IUD), an implant, or a vaginal ring. Married women who have decided they have as many children as they can care for and support may choose sterilization. Women in college or just starting a career may want to delay childbirth for a few years by choosing some type of long-acting reversible contraception (LARC).
The women at highest risk of unintended pregnancy are the least likely to have access to healthcare and the fewest resources to obtain costly contraception. Since 1970, contraception and other family planning services have been available to low-income and uninsured women through clinics funded by Title X of the Public Health Service Act. This legislation not only subsidizes direct patient services but is also critical to putting family planning centers in communities and to supporting their ongoing infrastructure needs (Guttmacher Institute, 2011b).
Title X funding is an essential component of healthcare for low-income women and families. In 2009, Title X–funded providers served more than 5 million low-income men and women—an increase of more than 130,000 patients over 2008. This is the largest number of patients in the last 10 years (Fowler et al., 2010). “Health centers receiving Title X funds must provide an array of confidential preventive health services, including contraceptive services; pelvic exams; pregnancy testing; screening for cervical and breast cancer; screening for high blood pressure, anemia, and diabetes; screening for STDs [STIs], including HIV; basic infertility services; health education; and referrals for other health and social services” (National Family Planning & Reproductive Health Association, 2011).
By preventing unintended pregnancies and abortions, contraceptive care funded by Title X saves money for U.S. taxpayers. Every $1 invested in contraceptive care saves $3.74 in Medicaid expenditures. Despite these facts, the level of Title X funding is uncertain and dependent on the politics of the day. Without sufficient Title X funding, millions of low-income and uninsured women and their families will have no access to family planning services.
Low-income and uninsured women and families face other health system barriers to family planning and reproductive services. These may include inconvenient clinic hours, lack of transportation to clinics, and unmet childcare needs during appointments.
| Contraceptive Method† | Directly Available On-site (%) |
Available by Prescription (%) |
Available
by Referral to Other Providers (%) |
Not Available (%) | |
|---|---|---|---|---|---|
| Sources: CDC, 2011d. | |||||
| Levonorgestrel-releasing intrauterine device (LNG-IUD; Mirena) |
Office-based physicians | 56.4 | 16.2 | 24.6 | 1.9 |
| Title X clinics | 46.6 | 9.6 | 37.9 | 3.8 | |
| Copper intrauterine device (ParaGard) |
Office-based physicians | 53.5 | 15.8 | 25.2 | 2.8 |
| Title X clinics | 59.7 | 7.4 | 29.6 | 2.0 | |
| Implant (Implanon) |
Office-based physicians | 32.0 | 13.2 | 40.0 | 8.0 |
| Title X clinics | 35.7 | 6.7 | 44.5 | 9.2 | |
| Depot medroxyprogesterone acetate (DMPA; Depo-Provera) |
Office-based physicians | 60.9 | 36.4 | 1.6 | 0.2 |
| Title X clinics | 96.6 | 2.6 | 0.2 | 0.2 | |
| Combined oral contraceptives | Office-based physicians | 48.8 | 50.4 | 0.0 | 0.2 |
| Title X clinics | 92.1 | 6.9 | 0.2 | 0.2 | |
| Progestin-only oral contraceptives | Office-based physicians | 24.9 | 70.9 | 1.4 | 1.1 |
| Title X clinics | 78.3 | 17.4 | 1.1 | 1.4 | |
| Patch (Ortho Evra) |
Office-based physicians | 29.1 | 60.5 | 1.7 | 4.9 |
| Title X clinics | 56.9 | 29.0 | 7.5 | 4.8 | |
| Vaginal ring (NuvaRing) |
Office-based physicians | 43.0 | 52.3 | 3.3 | 0.5 |
| Title X clinics | 58.1 | 28.9 | 8.0 | 3.5 | |
| Male condom | Office-based physicians | 26.3 | 60.8 | 2.4 | 5.5 |
| Title X clinics | 95.6 | 2.9 | 0.3 | 0.4 | |
| Female condom | Office-based physicians | 7.1 | 47.9 | 6.5 | 17.8 |
| Title X clinics | 49.4 | 24.9 | 6.7 | 9.9 | |
| * Total = 2,003; office-based physicians = 635; Title X clinic providers = 1,368. ** Percentages might not sum to 100% because of missing or “not applicable” responses. † Classifications of contraceptive method availability were mutually exclusive. Male and female condoms were available by recommendation. |
|||||
Providers have an important effect on what contraceptive method(s) their patients choose. Unfortunately, many young women know little about the variety of contraceptive methods available other than the “Pill.” They also have many erroneous ideas about how the methods work and little information about the advantages. Women who might be appropriate candidates for LARC may not choose one of those methods without educational counseling by a clinician.
In one study of women ages 14–27, more than half the women had not heard of the IUD. Participants who heard about the IUD from a provider were almost 3 times as likely to be interested in that method (Fleming et al., 2010). Another study of more than 1,300 young, low-income showed that provider counseling was an influential factor in choosing the vaginal ring and the transdermal patch, rather than the Pill or DMPA (Whitaker et al., 2010).
Provider education and training also influence what methods he or she recommends to patients. A study of more than 800 providers in California showed that almost 95% considered IUDs to be safe, but fewer than 65% generally discuss the option with patients seeking contraception. About one fourth were misinformed about side effects of the copper T device, a nonhormonal device, which they described as having hormonal side effects (Harper et al., 2008). In another study, family physicians who had inserted IUDs during their residency were more comfortable discussing and recommending IUDs in their practice (Rubin et al., 2011).
Providers’ racial/ethnic and socioeconomic biases may also affect their recommendations for contraceptive methods. In one study, videos of standardized patients of white, black, and Latina ethnicity and high and low socioeconomic status (SES) were shown to 524 providers, asking whether they would recommend the Merina IUS. Researchers reported that the IUS was less likely to be recommended to low SES whites than to high SES whites, whereas SES had no significant effect among Latinas and Blacks. Low SES Latinas and Blacks were more likely to have the LNG IUD recommended than were low socioeconomic whites. Low SES patients were judged to be much more likely to have an STI and an unintended pregnancy and to be less knowledgeable (Dehlendorf, Ruskin et al., 2010). Provider gender and religious beliefs may also influence whether the provider offers emergency conception (discussed later in this course) (Lawrence, 2010).
There are many forms of family planning and contraception available in the United States. They fall into a number of broad categories, including: fertility awareness, situational, spermicidal, barrier, long-acting reversible, shorter-term hormonal, permanent (sterilization), and clinical interruption of pregnancy (medical/surgical abortion). These methods demonstrate differing levels of effectiveness, side effects, cost, ease of use, and other advantages and disadvantages.
| Method | Number of Users |
|---|---|
| Source: Mosher & Jones, 2010. | |
| Oral contraceptives | 10.1 million |
| Female sterilization | 10.3 million |
| Emergency contraception | 5.2 million |
| Intrauterine device (IUD) | 2.1 million |
| Male condom | 5.3 million |
| Male sterilization (vasectomy) | 3.7 million |
Fertility awareness methods are also called natural family planning. These methods are most effective for women who have regular menstrual cycles (between 26 and 32 days in length) and a cooperative, committed partner. These methods also assume monogamy, because they do not protect against STIs. Effectiveness also depends on extensive counseling and education by a clinician.
All fertility awareness methods are designed to determine the fertile days in a woman’s menstrual cycle, either by counting the days and/or observing changes in cervical mucus and basal body temperature. On fertile days, the couple either abstains from penile-vaginal intercourse, uses another method of contraception (such as a condom), or engages in non-penile-vaginal forms of sexual expression.
Correct and consistent use of fertility awareness methods is somewhat effective; the failure rate varies from 3 to 5%. With typical use, however, the failure rate may be as high as 25% (Arevalo et al., 2002).
Fertility awareness methods involve no hormones or devices (other than a basal body temperature thermometer), so they are comparatively low cost and without side effects. Some couples find that using these methods enhances their relationship. If they want children in the future, fertility awareness also can be used to time conception.
Using the Standard Days Method, the woman tracks the days of her menstrual cycle on a calendar. Day 1 is the first day of menstruation and days 8 through 19 are the fertile days, when unprotected intercourse is avoided.
The Calendar Days Method is the least reliable fertility awareness method, and it requires more advance planning. The woman keeps track of her menstrual cycle for 6 to 12 months and then subtracts 18 from the number of days in the shortest cycle and 11 from the number of days in the longest cycle. The two resulting numbers mark the beginning and end of the fertile period. This method has been largely replaced by methods that rely on observable changes such as temperature and cervical mucus changes.
This method also requires 3 to 4 months advance planning. Each morning, as soon as she wakes, the woman takes her BBT and records the temperature on a graph. The BBT method is based on the premise that BBT sometimes drops just before ovulation and almost always rises about 0.4 to 0.8° F and remains elevated for several days afterward. After three or four months of recording temperatures, a woman who has regular menstrual cycles should be able to predict when ovulation will occur. Because sperm are thought to be viable for 5 days, the couple avoids unprotected sex for several days before ovulation begins and for several days after.
This method involves tracking daily changes in the cervical mucus during a month of abstinence from vaginal intercourse. Normally, there is little cervical mucus present between the end of menstruation and just before ovulation. At the time of ovulation, the mucus becomes clear and slippery like raw egg whites and is more permeable to sperm. Following ovulation and just before the onset of menstruation, the mucus becomes thick and sticky, blocking the sperm from entering the uterus.
This is the most complex fertility awareness method and includes BBT and cervical mucus tracking, as well as assessing and recording cycle length, increased libido, abdominal bloating, and mittelschmerz (midcycle abdominal pain). This method improves the effectiveness of birth control but necessitates intense commitment by the couple and extensive education and counseling by an expert in this method.
Breastfeeding has many benefits for both mother and infant. The U.S. Department of Health and Human Services recommends that infants be exclusively breastfed during the first 4 to 6 months of life. Ideally, breastfeeding should continue through the first year of life (Office on Women’s Health, 2000).
One of the maternal benefits of breastfeeding is a natural contraceptive effect, an essential factor in family planning in developing countries. However, lactation is an effective contraceptive for the first 6 months postpartum only if women breastfeed exclusively and at regular intervals, including nighttime. “The effectiveness of this method is dependent on the intensity and frequency of infant suckling and the extent to which supplemental food is added to the infant’s diet.” “Regular intervals” means no intervals of more than 4 hours between feedings during the day or 6 hours at night. “Exclusive breastfeeding” means that supplemental food not should exceed 5% to 10% of total feedings (King, 2007).
Women who supplement breastfeeding or do not breastfeed at all need to use another method of contraception beginning at 3 weeks postpartum. Although research shows that most nonlactating women will not ovulate until 6 weeks postpartum, a small number may ovulate as early as 3 weeks postpartum (Jackson & Glasier, 2011).
Ideally, clinicians would discuss lactation and contraceptive options with patients during the third trimester of pregnancy. Nonhormonal methods are preferred for women who plan to breastfeed because contraceptives containing estrogen can interfere with lactation and may have negative effects on the infant. However, the progestin-only pill can be used by breastfeeding mothers. The copper IUD can be inserted as early as 10 minutes after the placenta is delivered or anytime up to 3–4 weeks postpartum. Barrier methods such as the condom, the diaphragm, or the cervical cap can also be used. If the woman wants no additional children, tubal ligation can be accomplished at the time of delivery.
Abstinence means not having vaginal, anal, or oral sex at any time. Abstinence is the only guaranteed method of preventing pregnancy and transmission of STIs. It is safe, effective, free, and has no negative side effects. According to the CDC (2011b), an increasing number of teens and young adults are choosing abstinence to avoid pregnancy and STIs, some for religious reasons. Internet support groups for those who choose abstinence are growing. It should be noted, however, that the proliferation of Title V abstinence-only sex education programs after 2000 was followed by an increase in the teen birth rate in 2006 and 2007, reversing a steady decline that began in 1991.
This method is ineffective. Because the preejaculation fluid often contains sperm, even when the male withdraws before ejaculating, sperm may be left in the vagina. Unfortunately, some population groups, particularly Latinos, rely on this method. Questioned about birth control use, many Latinas say: “My husband takes care of me.” What she means is that he’s withdrawing and ejaculating outside her vagina (Branch et al., 2010).
Douching after intercourse is ineffective and not recommended. It may increase the risk of pregnancy by forcing sperm upward into the cervix.
Spermicides are available as creams, foams, gels, suppositories, and films that contain a chemical called nonoxynol-9 (N9) that kills sperm. Used alone, they are somewhat effective in preventing pregnancy but are more effective when used with a barrier method such as a condom, diaphragm, or other barrier. Spermicides do not protect against HIV or other STIs.
Creams, foams, and gels are placed high up in the vagina near the cervix with a plastic plunger-type applicator. Suppositories and films are inserted into the vagina and take 10–15 minutes to become effervescent and effective. These products can be applied up to 1 hour before intercourse and should be reapplied with each act of intercourse. The woman should not rinse the vagina or douche for at least 6 hours after the final act of intercourse.
Using spermicides twice daily or more increases the risk of vaginal irritation, yeast infection, bacterial vaginosis, urinary tract infection, and HIV transmission.
In 2007, the FDA issued a warning for nonoxynol-9 over-the-counter contraceptive products, requiring manufacturers of these products to include labeling with the following information:
Barrier methods of contraception prevent sperm from entering the uterus. These methods include the male condom, female condom, diaphragm, cervical cap, and vaginal sponge. Effectiveness of any of these methods in preventing pregnancy depends on correct and consistent use. The male latex condom affords the greatest protection against transmission of STIs. Only abstinence from any sexual activity offers more effective contraception and prevention of STI transmission.
Condoms are inexpensive, convenient to use, widely available, and can be combined with a spermicide for additional protection against pregnancy and STI transmission. However, some men may resist using condoms because they reduce sensation and spontaneity. In addition, some individuals are allergic to latex. Spermicides containing nonoxynol-9 also can irritate genital tissues, which can heighten the risk of STI transmission. Women whose partners refuse to use condoms need to choose a method that does not rely on male partner participation, such as hormonal contraceptives (oral, transdermal, injection, or implant); a diaphragm or cervical cap with contraceptive jelly or foam; or an intrauterine device (IUD).
To achieve maximum protection from unintended pregnancy and/or STI/HIV transmission by using condoms, they must be used consistently and correctly (see box). The failure of condoms to protect against STI/HIV transmission usually results from inconsistent or incorrect use, rather than product failure.
HOW TO USE A CONDOM
Source: CDC, 2010c.
The female condom (FC2) is a plastic sheath worn inside the woman’s vagina during intercourse. It helps prevent pregnancy and reduces the risk of STIs. Made of thin plastic (nitrile), the female condom is inserted in the vagina much like a tampon. The condom has flexible rings at each end and is lubricated. The ring at the closed end of the condom holds the pouch in place, and the ring at the open end stays about an inch outside the vaginal opening during intercourse. The female condom collects preejaculate fluid and semen, thereby preventing sperm from entering the vagina. Before anal intercourse, the ring at the closed end of the condom is inserted into the anus.
Female condom. (Source: aids.gov.)
Using a spermicide with the female condom increases its effectiveness in preventing pregnancy. Spermicide or lubricant should be used on the outside of the closed end of the condom before insertion into the vagina.
Do not use a male condom with a female condom. If the two condoms rub together, the friction between them can cause the male condom to be pulled off or the female condom to be pushed in.
The female condom is removed by squeezing and twisting the outer ring to retain the semen inside the pouch and carefully pulling it out before discarding. Used condoms should be put in the trash, not flushed down the toilet. Female condoms should not be reused.
One randomized trial comparing the effectiveness of male and female condoms found that they were equally effective as barriers to semen. Effectiveness as barriers was measured by the concentration of prostate specific antigen (PSA) in vaginal fluid. However, study participants reported 4 times as many mechanical problems with female condoms as with male condoms (Macaluso et al., 2007).
The diaphragm is a shallow latex or silicone cup that fits over the cervix and is generally used with spermicidal gel or foam. Diaphragms come in different sizes, ranging from 50 to 95 mm in diameter, and must be fitted by a physician or nurse practitioner. Patients need to be refitted after pregnancy or weight gain or loss of 10 or more pounds.
Clinicians need to teach the patient how to:
Diaphragms can be inserted up to 6 hours before intercourse and should remain in place for at least 6 hours but no more than 24 hours after the last act of intercourse. For additional acts of intercourse during the 6-hour period, fresh spermicide should be inserted into the vagina without removing the diaphragm. The patient should not rinse the vagina or douche while wearing the diaphragm or for at least 6 hours after the last act of intercourse.
The latest CDC study on contraceptive use found that use of the diaphragm has declined steadily since 1982 from 8% to near 0% (Mosher & Jones, 2010).
The cervical cap (FemCap) is a thimble-shaped silicone cup that fits over the cervix and has a strap for removal. Like the diaphragm, the cap requires fitting by a physician or nurse practitioner and is designed to be used with a spermicide. The cervical cap is available in three sizes: 22, 26, and 30 mm as measured by the inner diameter of the rim. The 22 mm cap is intended for women who have never been pregnant. The 26 mm cap is designed for women who have been pregnant even for 2 weeks and did not have a vaginal delivery. The 30 mm cap is intended for women who have had a vaginal delivery of a full-term infant.
Clinicians need to teach patients how to:
The cap can be inserted ahead of time and should be left in place for at least 6 hours after the last act of intercourse, but should not be worn for more than 48 hours. Additional acts of intercourse during the 6-hour period do not require additional spermicide. The patient should not rinse the vagina or douche while wearing the cervical cap and for at least 6 hours after the last act of intercourse.
The cap should not be used during menstruation.
The vaginal sponge (Today sponge) is a soft, disk-shaped polyurethane device with a depression on the side that fits over the cervix and a loop on the other side for removing the device. It contains the spermicide nonoxynol-9 and is intended for one-time use only. Before insertion, the woman wets the sponge with tap water, squeezes it once to spread the spermicide, and inserts it into the vagina with the depression next to the cervix. There is no need to add spermicide for additional acts of intercourse.
The sponge may be inserted ahead of time and remains effective for 24 hours after insertion. It should be left in place for at least 6 hours after having sex to prevent pregnancy. The sponge must be removed within 30 hours after insertion because the risk of toxic shock syndrome increases after that time. Women should not rinse the vagina or douche while wearing the sponge.
(Toxic shock syndrome is a rare and sometimes fatal syndrome among women of reproductive age, primarily associated with use of tampons and IUDs. Clinical features include sudden onset of fever, chills, vomiting, diarrhea, muscle aches, and rash. It can rapidly progress to severe and intractable hypotension and multisystem dysfunction. Desquamation, particularly on the palms and soles, can occur 1–2 weeks after onset of the illness (CDC, 2005).)
The vaginal sponge is more effective in preventing pregnancy in nulliparous women. It does not prevent transmission of STIs.
LARC refers to birth control methods that provide effective contraception over a period of 3 to 10 years without requiring any action on the part of the user. “Long-acting reversible methods of contraception (LARC), which includes IUDs and the subdermal implant Implanon, have been proven to be the most effective method of reversible contraception, with failure rates of <1% in the first year of use” (Spain et al., 2010). Despite this fact, use of LARC is much lower in the United States compared with other countries.
One reason is the lingering distrust of intrauterine devices (IUDs) among women and clinicians, based on early problematic devices such as the Dalkon Shield. Another reason is the higher initial cost to both patient and provider, even though LARC methods are very cost-effective over the long term. Providers may also lack adequate training in IUD and implant insertion. A study in California found that only 60% felt “very comfortable” inserting the copper T device (ParaGard), and just 40% felt “very comfortable” inserting Mirena (Harper et al., 2009).
The profit motive may also play a role in the comparatively low usage of LARC methods in the United States. The devices generate far less revenue and profit for their manufacturers than do refillable methods. For example, in an earlier study, the one-time sale of a copper IUD yielded only about $200, whereas the 10-year refillable prescription for OCPs might have generated a profit of more than $1,000 (Trussel et al., 1995).
For women with conditions that may make unintended pregnancy an unacceptable health risk, long-acting, highly effective contraceptive (LARC) methods may be the best choice. Women with these conditions should be advised that sole use of barrier methods for contraception and behavior-based methods of contraception may not be the most appropriate choice because of their relatively higher typical-use rates of failure.
Intrauterine contraceptive devices were introduced in the 1970s, an era of little or no regulation of medical devices. Many of the early IUDs caused serious health problems. The most notorious IUD was the Dalkon Shield, which caused serious infections, infertility, other injuries, and death. Women were outraged that devices so widely marketed were not regulated by the U.S. Food & Drug Administration (FDA). This outrage led to federal legislation in 1976 authorizing the FDA to require testing and approval of all medical devices, including IUDs. The FDA also required clinicians to provide unbiased information about IUDs so that women could make an informed choice.
Today’s IUDs are vastly different and much safer from those available in the 1970s, and their use is increasing. The latest CDC study on contraceptive use reported that by 2006–2008, 5.5% (2.1 million women) were using IUDs, up from 1% in 1995 (Mosher & Jones, 2010). Current IUDs are also far more expensive than their predecessors because of the need for premarketing testing and approval, which makes them inaccessible to many women. For example, for an uninsured woman, the out-of-pocket costs for an IUD run between $500 and $1,000, including examinations, tests, the IUD, insertion, and removal (Planned Parenthood, 2010a). If the woman continues to use the IUD for several years, the cost can be amortized over that period, making it less expensive. However, such a large up-front cost is a barrier for many women.
In states where Medicaid or other insurance reimbursements fail to cover the cost of IUDs, some providers either do not offer them or buy IUDs from outside the United States. The latter practice is illegal because the unapproved devices may be unsafe or ineffective. However, if the devices were purchased in Canada, they are likely to be as safe as those produced in the United States since Canada has rigorous approval standards for medical devices.
The cost issue may be resolved by 2010 Patient Protection and Affordable Care Act, which requires insurance companies to cover preventive health services without imposing costs on patients. This would guarantee family planning coverage without co-payments and deductibles. However, as mentioned earlier, the debate continues over whether family planning qualifies as preventive care since pregnancy is not an illness.
There are two types of highly effective intrauterine contraceptive devices available in the United States. Both are long acting and reversible, which means there is a quick return to fertility after removal of the device. Each IUD has a string, which the clinician cuts to an appropriate length. Patients need to check the string each month to be sure the IUD is still in place.
Both IUDs are T-shaped devices, but one contains copper (ParaGard, CopperT380A) and the other releases a small amount of the progestin levonorgestrel (LNG) (Mirena). Both require insertion by a physician or other specially trained clinician. The copper IUD was approved for use in 1988; it remains effective for 10 years. The Mirena device was approved for use in 2001 and remains effective for 5 years.
ParaGard (left) and Mirena (right) intrauterine devices.
The ParaGard IUD is made of polyethylene with copper along the vertical stem and horizontal arms. Once inserted, it releases a small of copper into the uterus, which blocks the sperm from reaching and fertilizing the egg (ovum). If fertilization does occur, the IUD prevents the fertilized egg from implanting in the endometrium. There is a risk of ectopic pregnancy if an egg is fertilized outside the uterus. Paragard can also be used as emergency contraception. If inserted within 5 days after unprotected intercourse, it reduces the risk of pregnancy by more than 99%.
The Mirena hormonal IUD is sometimes called an intrauterine system (IUS).It releases progestin (LNG) into the uterus, which prevents ovulation and causes the cervical mucus to thicken so sperm can’t reach the egg. It also prevents implantation. Initially, the Mirena releases 20 mg of LNG per day; over time the dose decreases to 10 mcg per day after 5 years. The high levels of LNG cause the endometrium to atrophy, diminishing the menstrual flow and, in some women, ending periods altogether. Women with uterine fibroids or adenomyosis may find that the LNG reduces menstrual symptoms. Some women may experience side effects of LNG such as mood changes, acne, headache, breast tenderness, and follicular ovarian cysts in the first few months after insertion.
In women for whom estrogen is contraindicated (smokers older than age 35, postpartum breastfeeding women, those with breast cancer), LNG offers an effective alternative to prevent pregnancy.
For the first 7 days after insertion of Mirena, women should use a non-hormonal backup method of contraception. Neither ParaGard nor Mirena protects against transmission of STIs.
These devices can be inserted any time during the menstrual cycle when pregnancy can be excluded, usually within a week after the woman’s period has started. They can also be inserted immediately after delivery of the placenta or after complete postpartum uterine involution or post-abortion.
Patients should be screened for gonorrhea and chlamydia (cultures) when an IUD is inserted. If the results are positive, antibiotic treatment should begin but removal of the IUD is usually unnecessary.
Neither ParaGard nor Mirena protects against transmission of STIs.
Complications of IUD insertion include uterine perforation at the time of insertion (rare), expulsion of the device, and slight increased risk of infection during the first month of use if bacteria enter the uterus during insertion. Expulsion occurs in no more than 5% of users and is more common in nulliparous women.
Some women who use the copper IUD may experience bleeding and cramping, but menstrual cycles are generally unaffected. Those who use Mirena may have frequent light bleeding for the first three months after insertion, but by 6 months, most women experience reduced bleeding. About 20% of women experience amenorrhea after 12 months of use of Mirena.
Contraindications to use of either IUD include:
The subdermal contraceptive Implanon is the only subdermal contraceptive implant available in the United States since Norplant was taken off the market in 2006. Implanon is a single matchstick-sized rod made of ethylene vinyl acetate that contains the progestin etonogestrel. This implant provides 3 years of very effective contraceptive protection by inhibiting ovulation.
Insertion and removal of the implant must be performed by a physician, nurse practitioner, or other trained clinician. The implant is inserted under the skin on the inside of the upper non-dominant arm. Insertion is done thru a needle, so no incision is required. The procedure takes less than 1 minute and is normally relatively painless. The implant must be removed at the end of 3 years, and this procedure generally takes about 3 minutes.
Nonhormonal backup contraception (abstinence or a condom) is needed for the first 7 days after insertion of Implanon.
Implanon may be less effective in overweight women (more than 130% of their ideal body weight), particularly any woman taking drugs that induce liver enzymes to treat active liver disease.
Implanon is not visible but it is palpable if inserted correctly. The clinician should palpate the arm immediately after insertion of the device to ensure that it is properly placed. The FDA warns that “deep insertions may lead to difficult or impossible removals. Failure to remove Implanon may result in infertility, ectopic pregnancy, or inability to stop a drug-related adverse event. Undetected failure to insert Implanon may lead to an unintended pregnancy.”
Risks and side effects of Implanon are similar to other progestin-only contraceptive methods, the most common of which is irregular bleeding patterns, including:
Implanon is contraindicated in women who have:
Clinicians should be alert to the possibility of ectopic pregnancy among patients using Implanon who become pregnant or complain of lower abdominal pain. Although pregnancy is uncommon among users of this implant, a pregnancy that does occur is more likely to be ectopic than pregnancy occurring in a patient using no contraception.
Implanon does not prevent transmission of STIs.
Hormonal methods of contraception prevent pregnancy by interfering with ovulation, fertilization, and/or implantation of the fertilized egg (Office on Women’s Health, 2010). (The long-acting reversible contraception mentioned above also prevents pregnancy through these same means, although for much longer periods of time.)
Hormonal contraception in the United States began with FDA approval of the “Pill” in 1960. Since then, the range of hormonal contraceptives has expanded beyond pills to include intrauterine and intravaginal devices, a transdermal patch, an implantable rod, and an injectable contraceptive. Some of these methods deliver both estrogen and progestin, referred to as combined hormonal contraception; others deliver only progestin. Each method and each medication have unique risks and benefits.
None of the hormonal methods prevent STIs.
Combined hormonal contraception is now available as oral contraceptive pills as well as the vaginal ring (NuvaRing) and the transdermal patch (Ortho Evra). Combined oral contraceptives (COCs) are the most widely used type of oral contraceptive pill (OCP).
When the first birth control pill was approved by the FDA half a century ago, it changed women’s lives around the world. For the first time, women could control their fertility on their own with a daily pill. Preventing pregnancy did not require a condom or a diaphragm or the cooperation of a partner—only the “Pill.” This new freedom helped fuel the women’s movement and the surge of women into the American workforce. However, not all women were free to use the Pill in 1960: “Contraceptives were not available to married women in all states until Griswold v. Connecticut in 1965 and were not available to unmarried women in all states until Eisenstadt v. Baird in 1972” (QuickOverview.com, 2010).
As one physician wrote, “Today there are over 60 formulations of the Pill, containing varying amounts of estrogen and progesterone, and taken on varying cycles. In the last 50 years OCPs have become the number-one contraceptive for women in the United States” (Hathaway, 2010). The early pills contained 3 times as much estrogen as today’s formulation, as well as lower doses of different, more potent progestins.
OCPs prevent pregnancy by preventing ovulation. They also cause changes in the endometrium and thicken the cervical mucus to prevent the sperm from reaching the egg. Taken correctly, OCPs are very effective at preventing pregnancy. However, correct use means remembering to take the Pill at the same time every day. It also means having access to a clinician for a prescription and having insurance or sufficient income to pay for the drug over time. These factors create barriers for many women.
As mentioned earlier, there are more than 60 formulations of the Pill, which vary in dosage, the forms of estrogen and progestin they contain, and usage. There are four basic types of COCs as described in the following table.
| 21-day | Taken for 21 days each month, followed by a 7-day period without pills during which menstruation occurs. |
| 28-day | Taken for 28 days. Depending on the type, the last 7 pills in the packet may be hormone-free pills or estrogen pills, either of which allows menstruation to occur. |
| Extended use (Seasonale, Seasonique) | Packaged for 3-month use (84 days). Depending on the brand, the final 7 pills are either hormone-free or contain estrogen, which allows menstruation to occur. |
| Continuous use (Lybrel) | Taken daily for 1 year, during which menstruation will be infrequent and may even stop. |
In December 2010, the FDA approved the first low-dose oral contraceptive to combine 0.8 mg norethindrone and 0.025 ethinyl estradiol in chewable form, with four 75 mg ferrous fumarate (iron) placebo tablets. The 24-day active hormone regimen is intended to provide users with a low level of breakthrough bleeding and short, light, predictable periods (PR newswire, 2010).
OCPs should be taken at the same time each day. COCs can be started on the first day of the menstrual cycle or on the Sunday after menstruation begins. This method requires a backup method of contraception for the next 7 days of the first cycle. Whatever day a woman starts taking the pill, she should always start the next pack on the same day of the week she started the first pack. Clinicians recommend that patients keep an extra pack of pills and a backup method such as condoms available in case she misses some pills or loses her initial pack.
OCPs, like all drugs, also have side effects and, for some women, serious risks. CDC scientists found that nearly one third of women who had ever used the pill discontinued use of the pill because they were dissatisfied with it, either because of side effects, changes in their menstrual cycle, or the difficulties in remembering to take the pill (Mosher & Jones, 2010).
Side effects of OCPs include:
Many of the side effects disappear after the first few cycles of use.
More serious risks include:
CONTRAINDICATIONS FOR COMBINED ORAL CONTRACEPTIVES (COCs)
Source: ARHP, 2009; ACOG, 2010.
There is less risk of serious side effects and complications with progestin-only contraceptives, which are discussed later in this course.
According to the American College of Obstetricians and Gynecologists (2010), OCPs offer women many benefits beyond effective contraception, which include:
NuvaRing.
The vaginal contraceptive ring, called NuvaRing (Organon), is a latex-free, flexible transparent vaginal ring made of ethylene vinyl acetate copolymers and magnesium stearate. It contains low doses of both estrogen and progesterone. Once placed in the vagina, it releases an average daily dose of 15 mcg ethinyl estradiol (EE) and 120 mcg of etonogestrel into the systemic circulation over a 3-week time period. The ring is removed and discarded at the end of 3 weeks, and 7 days later a new ring is inserted. Backup non-hormonal contraception should be used for the first 7 days after insertion of the ring.
The NuvaRing was approved by the FDA in 2001. Used correctly, it is comparable to the effectiveness of COCs and the patch. It comes in one size that fits most women and does not have to be fitted by a health professional. However, it does require a prescription.
As with other combined oral contraceptives (COCs), the ring prevents pregnancy by inhibiting gonadotropins and preventing ovulation. In addition to contraceptive benefits, the ring helps regulate irregular menstruation cycles, decreases menorrhagia and dysmenorrhea, and reduces the frequency of bacterial vaginosis.
User acceptability of this device is high among both younger and older reproductive-age women regardless of parity. A large international study showed that, compared with COCs, the vaginal ring was preferred by 8 out of 10 women (Novak et al., 2003). Another study comparing the NuvaRing and the transdermal patch found that 7 out of 10 women preferred the ring (Creinin et al., 2008).
Side effects and contraindications are similar to COCs and the patch. Expulsion of the device, interference with intercourse, or leukorrhea are uncommon (less than 3% of users discontinue use because of these events).
Close clinical surveillance is also needed for users with significant pelvic relaxation (uterovaginal prolapse), those with a history of vaginal irritation or toxic shock syndrome, those who experience severe constipation or vaginal obstruction, or those who are uncomfortable touching their genitalia (Wieder & Pattimakiel, 2010).
The NuvaRing does not protect against STIs.
The transdermal contraceptive patch (Ortho Evra) is a thin, flexible beige adhesive patch that is applied to the upper arm, buttock, stomach, or chest (but not the breast) once a week for 3 weeks. The patch releases progesterone (150 mcg of norelgestromin) and estrogen (20 mcg of ethinyl estradiol) daily to prevent ovulation. Each patch contains 9 days of medication so if the patient forgets to change the patch at the end of 7 days, it retains its contraceptive effectiveness for 2 more days. Three consecutive 7-day patches are applied, followed by 1 week without a patch per cycle.
A prescription is required for the patch. Clinicians also need to provide an extra prescription for patients in the event of detachment. Any patch that becomes detached must be replaced by a new patch because the medication is in the adhesive. The patch is water-resistant and can be worn during exercise, showers, bathing, and swimming. Heat, humidity, and exercise do not affect adhesion.
The patch is comparable in effectiveness to COCs but may be slightly less effective in women who weigh more than 198 pounds. However, the patch can still be effective for these women (Zieman et al., 2002).
The side effects of the patch are similar to those of COCs. However, side effects generally lessen during the first 2 or 3 months of use. Skin irritation may occur at the site of application. According to CDC scientists (Mosher & Jones, 2010), one half of the women who had ever used the patch had discontinued it either because of side effects or because they didn’t like the changes in their menstrual cycles.
Since 2005, the FDA has required a “black box warning” on the Ortho Evra label, cautioning clinicians about the increased risk of venous thromboembolism in some women using the patch compared with the risk of COCs. This increased risk is apparently due to the higher sustained concentration of ethinyl estradiol (EE) delivered by the patch compared with the EE in COCs, which quickly drops to lower concentrations following administration.
The black box warning also highlights the risk of smoking while using the patch as follows:
Cigarette smoking increases the risk of serious cardiovascular side effects from hormonal contraceptive use. This risk increases with age and with heavy smoking (15 or more cigarettes per day) and is quite marked in women over 35 years of age. Women who use oral contraceptives, including Ortho Evra®, should be strongly advised not to smoke.
CONTRAINDICATIONS FOR ORTHO EVRA CONTRACEPTIVE PATCH
Ortho Evra should not be used in women who currently have the following conditions:
Source: Food & Drug Administration, 2010.
Progestin-only contraceptives include the oral contraceptive “Mini-pill,” the subdermal implant Implanon (discussed above under long-acting reversible contraception), and the injectable Depo-Provera. An earlier implant called Norplant was removed from the U.S. market in 2000 because of side effects.
The progestin-only pill contains no estrogen and is an option for those women for whom estrogen is contraindicated, such as those who are breastfeeding, over 35, or at risk for thromboembolism. However, women with liver tumors or lupus erythematosus should not take progestin-only pills. Taken daily, the mini-pill thickens cervical mucus, which prevents fertilization. Less often, it stops ovulation.
The mini-pill must be taken at the same time each day. If a woman is more than 3 hours late in taking the pill, she needs to use a backup method of birth control for at least the next 48 hours. Clinicians recommend that women taking the mini-pill have emergency contraception (EC) on hand. Patients under the age of 17 must have a prescription for EC (see discussion later in this course). Antibiotics may interfere with efficacy of the mini-pill.
Side effects of the mini-pill include:
Irregular bleeding normally decreases after several months.
The mini-pill is contraindicated in women with a history of or current breast cancer.
The mini-pill does not prevent transmission of STIs.
Injectable Depo-Provera (DMPA) provides 3 months of highly effective contraception to inhibit ovulation. The shot (either intramuscular or subcutaneous) delivers 150 mg of medroxyprogesterone acetate and must be administered by a trained clinician. Nonhormonal backup contraception is needed for the first 7 days after the initial injection of DMPA.
The efficacy and convenience of DMPA have made it very popular with sexually active adolescents, although one large study showed that the copper-T IUD was more effective in preventing pregnancy (Hofmeyr et al., 2010). DMPA side effects are similar to other progestin-only contraceptives and include initial irregular bleeding, weight gain, and delayed return to fertility after stopping the shots.
A Dutch study of more than 400 premenopausal women ages 18–50 years found that DMPA more than tripled the risk of deep vein thrombosis (DVT) in users. They did not find a similar effect in users of the Merina intrauterine system containing levonorgestrel (LNG) (van Hylckama Vlieg et al., 2010).
Women who are overweight when beginning to use DMPA may find that the shots increase their appetite, raising their risk of further weight gain. However, the shots may decrease the risk of dysfunctional bleeding in overweight women. Being overweight seems to mitigate the loss of bone density common in women who use DMPA (discussed in more detail below). Some women also experience anxiety or depression, headache, and breast tenderness. It takes 6 to 10 months after the final shot for DMPA to leave the body, and side effects persist until clearance occurs.
CDC scientists (Mosher & Jones, 2010) found that more than 40% of women who had ever used DMPA discontinued it because of side effects or because they didn’t like the changes to their menstrual cycle.
DEPO-PROVERA AND BONE LOSS
Research indicates that women using DMPA experience significant loss of bone mineral density (BMD). A recent large study in Switzerland found that DMPA users ages 20–44 years had a “slightly increased risk of fractures” compared with nonusers. Fracture rates were highest among women using DMPA more than 2–3 years (Meier et al., 2010).
This risk raises concerns about the long-term effects of DMPA use during adolescence because this is normally a period of peak BMD development. Studies show that some BMD loss is recovered after DMPA use is stopped. However, recovery rates vary, and women ages 18–21 experience greater loss and reduced acquisition of BMD than older women (Walsh et al., 2008; Practice Committee of the ASRM, 2008).
Research also indicates that DMPA has different effects on BMD in different bones; the femoral head (the top of the thigh bone) is most vulnerable to BMD loss among women using DMPA. This finding is worrisome since the femoral head is the most common fracture site among post-menopausal women.
Concern about the loss of BMD among users of DMPA prompted the Food & Drug Administration to require a black box warning on DMPA in 2004 recommending that DMPA use be limited to two years or less. The warning cautions that “bone loss is greater with increasing duration of use and may not be completely reversible. Depo-Provera Contraceptive should be used as a long-term birth control method (e.g., longer than 2 years) only if other birth control methods are inadequate” (FDA, 2004).
Some professional organizations have questioned the need for this warning, citing studies that BMD is recovered after DMPA is stopped. However, women’s health advocacy organizations remain concerned. As Susan K. Flinn wrote, “The length of time it takes a woman’s bone mineral density to recover after using the shot makes it important to weigh the method’s use carefully, particularly for young women (whose BMD is still developing) and women approaching menopause (who are at greater risk for osteoporosis and fractures)” (Flinn, 2010).
DMPA is contraindicated in women with:
Clinicians should encourage women who use DMPA to:
DMPA does not prevent transmission of STIs.
Emergency contraception can prevent most pregnancies when taken after intercourse. It provides an important back-up in cases of unprotected intercourse or contraceptive accident (such as forgotten pills or torn condoms) and is especially valuable after rape or coerced sex.
—World Health Organization (2010b)
Emergency contraception is used after unprotected sex in order to prevent pregnancy. EC is most effective the sooner it is taken after unprotected sex. All women at risk for unintended pregnancy should be encouraged to have EC on hand in the event of contraceptive failure, forgotten pills, rape, or coerced sexual intercourse.
Five methods of emergency contraception are available in the United States, as described in the table below.
| Name | Description | Availability |
|---|---|---|
| Plan B One-Step | A single 1.5 mg levonorgestrel pill, also known incorrectly as the “morning-after” pill. In fact, Plan B should be taken within 72 hours of unprotected sex. | Only by prescription for women younger than 17 years; over the counter for women 17 years and older. |
| Next Choice (Generic) | Comprises two 0.75 mg levonorgestrel pills. The first pill should be taken orally as soon as possible within 72 hours after unprotected intercourse, and the second should be taken 12 hours after the first pill. However, both pills can be taken at the same time without increasing side effects or decreasing efficacy. | Only by prescription for women younger than 17 years; over the counter for women 17 years and older. |
| Yuzpe Method | Consists of taking COCs containing levonorgestrel in higher doses. | Only by prescription for women younger than 17 years; over the counter for women 17 years and older. |
| Copper T IUD (ParaGard) | Can be inserted within 72 hours after unprotected sex and is more than 99% effective in reducing pregnancy risk. (The Mirena IUD cannot be used for EC.) | Must be inserted by a health professional. |
| Ella | The newest emergency contraceptive tablet approved for the U.S. market. It contains ulipristal acetate and acts to inhibit or delay ovulation. Ella should be taken within 120 hours (5 days) after unprotected sex. | Only by prescription for all ages. |
A team of experts from around the globe has reviewed the scientific evidence on levonorgestrel EC pills and concluded that they are very safe (WHO, 2010a). “They do not cause abortion or harm future fertility. Side-effects are uncommon and generally mild.” The most common side effect from taking levonorgestrel EC pills is irregular menses. In addition, some women may experience short-term side effects similar to PMS symptoms, such as nausea, cramps, diarrhea, and fatigue.
Emergency contraception (EC) appears to be one of medicine’s best-kept secrets. Myths and misinformation EC abound not only among teens and young women but among physicians and pharmacists. Ignorance, prejudice, and religious beliefs are barriers to prescribing and obtaining EC.
A survey of 1,800 U.S. obstetricians and gynecologists found that gender, religion, and divergent beliefs about the effects of EC shaped physicians’ beliefs and practices. Only half of the physicians surveyed offer EC to all women of childbearing age, while 6% never offer it, and another 6% offer it only after sexual assault. Male physicians and those who were religious were more likely to never offer EC or only after sexual assault (Lawrence et al., 2010). State health policies can also interfere with a woman’s access to EC (see Table 00).
Although EC pills are available in many countries, many adolescents and adult women are uninformed or misinformed about this method. The World Health Organization (2010b) attributes this to “the very poor basic understanding of fertility, contraception, and pregnancy risk that seems widespread in both developing and developed countries.” A 2007 study of adolescents in New York City schools found that less than half of them had heard of EC pills (New York City Department of Health, 2007). Other studies in California have found that knowledge about EC is highest among college-educated white women and lowest among poor women and women of color.
Widespread, sensationalist, and often inaccurate media coverage of EC have created fear of these and other hormonal birth control methods. However, according to WHO (2010a), “In the case of levonorgestrel-alone emergency contraceptives, safety has been clearly demonstrated through countless studies and many decades of use: no new research needs to be conducted. The urgent question is how we can explain and disseminate the science in simple terms.”
To counter the inaccurate messages about EC, the National Institute for Reproductive Health initiated a national public awareness campaign called Back Up Your Birth Control, committed to raising awareness of and expanding access to EC. (Information on obtaining free informational materials is listed below under “Resources.”) Begun over 10 years ago, this campaign targets high school and college women and encourages participation through social media networks.
EMERGENCY CONTRACEPTION AND MEDICAL ABORTION
Some pro-life/anti-choice organizations have misrepresented emergency contraception as “medical abortion.” This creates confusion not only among patients but also among healthcare providers. Emergency contraception prevents pregnancy, whereas medical abortion terminates pregnancy. “According to general medical definitions of pregnancy that have been endorsed by AHRP, the American College of Obstetricians and Gynecologists, and the U.S. Department of Health and Human Services, pregnancy begins when a pre-embryo completes implantation into the lining of the uterus” (ARHP, 2008).
Medical abortion involves the use of different medications that can induce abortion. Three such drug regimens are available in the United States: mifepristone (RU-486) and misoprostol, methotrexate with misoprostol, and misoprostol alone. These drugs require a prescription and careful clinical monitoring of patients.
Women and couples who choose to remain childless or who decide they have as many children as they want or can support may choose some form of permanent contraception for one or both partners. Female sterilization can be performed either through surgery (tubal ligation) or nonsurgical insertion of microinserts (Essure, Adiana) to block the fallopian tubes. The cost of female sterilization ranges from $1,500 to $6,000. Male sterilization (vasectomy) is surgically performed and is much less expensive. Costs range from $350 to $1,000 (Planned Parenthood, 2010b,c).
Patients considering sterilization need to know that these are essentially irreversible procedures. They need to consider how their lives might change in the future, for example, the death of a child or partner, or divorce and remarriage. Attempts to restore fertility are often unsuccessful as well as expensive.
Researchers in the United Kingdom found that women chose sterilization for three principal reasons: (1) to avoid the possible side effects of hormones; (2) to avoid the continuing need to make decisions about child-bearing; and/or (3) lack of information about long-acting reversible methods of contraception. Some of the women who had chosen sterilization had regrets later about their choice even though they had received counseling before deciding (Kane et al., 2009).
Permanent contraception may be most appropriate for women who:
Female surgical sterilization to occlude (block), cut, band, cauterize, or tie the fallopian tubes is a low-risk procedure that achieves immediate contraceptive effectiveness. The surgery may be a laparoscopic procedure, a mini-laparotomy, or a laparotomy. All of these procedures can be performed on an outpatient basis, although the mini-laparotomy and laparotomy are generally used for postpartum sterilization or during abdominal surgery for another reason (cesarean section or removal of adhesions from pelvic inflammatory disease [PID] or endometriosis). Laparoscopy usually involves general anesthesia. A mini-laparotomy or laparotomy may involve general anesthesia or regional anesthesia (an epidural).
The only risks of surgical sterilization include only those related to general anesthesia and any surgery. Patients should be counseled concerning the following possible short-term effects:
Sexual intercourse can be resumed as soon as it does not cause pain, usually 1 week after surgery. The menstrual cycle is not affected by surgical sterilization. Although no backup method of birth control is necessary after surgery, patients who are not in a monogamous relationship with an HIV-negative partner should be counseled to use condoms to protect against STIs.
There are two types of microinserts available for nonsurgical occlusion of the fallopian tubes: Essure and Adiana. These inserts are placed in the fallopian tubes near where they join the uterus using a hysteroscopic procedure. Patients are screened for vaginal infection and STIs before implants are inserted. Usually performed under local anesthesia or sedation, the procedure takes about 15 minutes. Backup birth control is needed for 3 months until scar tissue forms around the inserts, thereby blocking the tubes. At the end of three months, a hysterosalpingogram is performed to confirm that the tubes are occluded.
The Essure device consists of two small concentric metal (containing nickel) coils around a mesh of polyethylene terephthalate (PET) fibers. After insertion, the outer coils expand to hold the device in place, and the PET fibers cause a moderate inflammatory reaction, leading to the formation of scar tissue from the surrounding tubal walls. Over the next 3 to 6 months, the lining of the tubes grows into the microinserts to occlude the tubes.
(Recent research suggests that PET may leach endocrine-disrupting chemicals from packaging made with this plastic [Sax, 2010]. However, there is currently insufficient research to conclude that such leaching will occur with all PET products when exposed to human tissue.)
The Adiana device uses radiofrequency (RF) radiation as part of the microinsert procedure. After exposing the wall of each tube to a low level of RF, creating a superficial lesion, a soft silicone polymer microinsert is placed at the lesion sites. Over the next 3 months, the lining of the tubes grows into the microinserts, occluding the tubes.
These microinserts are new, so the long-term effects are unknown. Risks of the procedure include perforation of the uterus and/or tube during insertion and improper placement of the inserts.
Short-term effects include cramping, pain, and bleeding or spotting on the day of the procedure.
Contraindications for either Essure or Adiana include:
Vasectomy is a decades-old method of male sterilization. Safe, swift, and highly effective, vasectomy is an outpatient procedure performed on approximately 13% of American men each year. The no-scalpel vasectomy (NSV) is the standard of care and involves 10 minutes for prep and administration of local anesthesia and 10 minutes for the procedure itself. The surgeon makes a small opening (a few millimeters) in the skin of the scrotal sac to expose the vas deferens. The vas are then ligated or cauterized; no sutures are necessary. Sexual activity can be resumed as soon as local discomfort (short-term tenderness and possible bruising) has ended.
Backup contraception (a condom) is needed for the first 15 to 20 ejaculations (or about 12 weeks) after the procedure because sperm may remain in the vas beyond the point of occlusion. It is important for the patient to return for a sperm check before stopping the backup contraception. Men who are not in a monogamous relationship with an HIV-negative partner should continue condom use to protect against STIs.
Approximately one fifth of all pregnancies in the United States end in abortion (Ventura et al., 2009). According to the CDC (2011a), there were more than 800,000 legal abortions performed in the United States in 2007, the latest year for which complete data analysis was available. Most abortions (more than 90%) were performed in the first trimester, two thirds of those before the 13th week of pregnancy. Less than 2% were performed later than 21 weeks’ gestation. Abortion rates were highest among women ages 20–29 (29.4 per 1,000 women).
Most abortions are performed because of an unintended pregnancy. However, an estimated 4% of abortions result from intended pregnancy. Presumably, those abortions are performed because of maternal medical indications and/or fetal abnormalities (Finer & Henshaw, 2006).
The average cost of a nonhospital abortion performed at 10 weeks gestation ranges from $350 to $900. Performed at 20 weeks, the average cost more than doubles. In-hospital late-term abortions may cost as much as $7,500.
DECIDING TO HAVE AN ABORTION
For most women of any age, the decision to terminate a pregnancy is seldom made lightly. Each woman has her own reasons, based on her age, relationship status, economic status, and cultural and spiritual beliefs. The most important reasons given include:
Most women who choose to have an abortion understand what it means to be a parent; a majority already have children. According to the Guttmacher Institute (2011d), each year 10,000–15,000 abortions are performed because the pregnancies resulted from rape or incest.
Abortion procedures can be either medical or surgical, depending on the gestational stage and the preferences of the patient and the physician. Medical abortion, sometimes called therapeutic abortion, has been available in the United States since 2000, when the FDA approved mifepristone (RU-486). Medical abortion is an option during the first 9 weeks after a woman’s last menstrual period (LMP) and does not require hospitalization.
Surgical abortion may be used in either the first or second trimester and includes three different types of procedures. During the first 16 weeks, the most commonly used procedure is vacuum curettage (vacuum aspiration), which can be performed in a clinic or hospital. Some surgeons prefer to use dilation and curettage (D&C) during the first trimester. The procedure for second-trimester abortion is called dilation and evacuation (D&E) and is usually done in a hospital, sometimes under general anesthesia.
Legalized abortion is one of the safest types of medical/surgical procedures. The risk of serious complications from a first-trimester surgical abortion is less than the risk of complications from pregnancy and childbirth. For example, the risk of death from surgical abortion is 1 in 160,000 cases. The risk of death from medical abortion is even less than death related to surgical abortion (Grimes, 2005). The risk of death from complications of pregnancy and childbirth in the United States is 11 in 100,000 (Hogan et al., 2010).
Medical abortion can be performed as soon as pregnancy and gestational stage can be confirmed. Medical abortion involves taking two medications, either mifepristone (“the Abortion pill”) or methotrexate, followed by misoprostol. Methotrexate is seldom used in the United States because mifepristone is somewhat more effective and works more quickly than methotrexate. Methotrexate is given as an injection. The earlier the procedure is done, the more effective the medications will be.
Mifepristone and methotrexate work by blocking progesterone, which is necessary to sustain pregnancy. In the absence of progesterone, the uterine lining breaks down, the cervix softens, and bleeding begins. A few days after taking the first drug, the second drug is taken by swallowing or placing it either in buccal area (between the cheek and the gum) or in the vagina. (The Planned Parenthood protocol uses the buccal area rather than the vagina.) This second drug terminates the pregnancy.
Medical abortion takes longer than surgical abortion: from a day up to 3–4 weeks from the time a woman takes the first medication until all the products of conception are expelled. Mifepristone works more quickly than methotrexate. More than 90% of women who take mifepristone will abort within one week after taking misoprostol , more than half of them during the first 4 hours.
Patients who choose medical abortion should be counseled and provided with written information about the following:
Complications of medical abortion are rare (occurring in 2% to 5% of cases) but may include:
Vacuum aspiration (vacuum curettage) abortion is the most common kind of in-clinic abortion, used up to 16 weeks after a woman’s LMP. Prior to the procedure, the clinician will order tests, which may include an ultrasound, and examine the patient. The actual aspiration procedure takes 5 to 10 minutes, but additional time is required to counsel the patient, dilate the cervix, and administer pain medication and antibiotics. Some clinics also offer sedation.
Some clinicians place osmotic dilators in the cervix the day before or several hours before the aspiration. Osmotic dilators include laminaria (a small tube made of dried seaweed) or a synthetic dilator (a manufactured sterile sponge). As the dilator absorbs body fluids, it enlarges and thereby stretches the cervix. Medication may also be used to help soften and dilate the cervix. After inserting a tube through the cervix into the uterus, the clinician uses either a handheld suction device or a suction machine to gently aspirate the pregnancy tissue.
If additional tissue remains in the uterus after aspiration, a curette is used to determine that the uterus is empty. When a curette is used, the procedure is called dilation and curettage (D&C). The D&C procedure is also used for conditions other than abortion. For example, D&C is used in diagnosing uterine cancer, causes of dysfunctional bleeding, or infertility as well as to stop heavy bleeding or remove uterine polyps.
COUNSELING PATIENTS
Patients undergoing vacuum aspiration abortion should be counseled and provided written information on the following:
Dilation and evacuation (D&E) abortion is usually performed during the second trimester of pregnancy and generally includes a combination of vacuum aspiration, D&C, and the use of surgical instruments such as forceps. It usually takes 10 to 20 minutes. D&E is usually done in a hospital but does not require an overnight stay. It can also be performed in a clinic by practitioners specially trained to perform abortion.
D&E is always preceded by an ultrasound examination to determine the size of the uterus and the number of weeks of the pregnancy. Most clinicians place an osmotic dilator in the cervix 24 hours before the D&E, and some also administer misoprostol to help soften the cervix. These measures reduce the risk of injury to the cervix during the procedure. Second trimester abortion requires more cervical dilation than required for a vacuum aspiration in early pregnancy.
Preoperative preparation also includes the administration of antibiotics to reduce the risk of infection.
The clinician administers local anesthesia in the cervical area (paracervical block) as well as a sedative. If the procedure is done in a hospital operating room, some clinicians will use spinal anesthesia or general anesthesia. However, general anesthesia carries its own risks and increases hospitalization and recovery time.
Suction aspiration is used first, followed by insertion of forceps to grasp larger pieces of tissue. Finally, a curette is used to gently scrape the endometrium and remove any remaining tissue. Additional suction is used to ensure that the uterine contents are completely removed. The clinician may also use ultrasound during the D&E procedure to confirm that all tissue has been removed and the abortion is complete.
Additional antibiotics are prescribed to prevent infection.
Possible complications of D&E include infection and, rarely, uterine perforation, uterine rupture, moderate to severe hemorrhage due to retained pregnancy tissue, or blood clots in the uterus.
COUNSELING PATIENTS
Patients undergoing dilation and evacuation abortion should be counseled and provided written information on the following:
Even though abortion is safe and legal, it may not be easily accessible, especially to teens, low-income women, and those without health insurance.
The Hyde Amendment of 1977 eliminated federal funding for abortion services except to save a woman’s life. Today, federal Medicaid funding is provided only in cases of rape, incest, or life endangerment. Seventeen states provide public funding to pay for abortions for some low-income women, but only four do so voluntarily; the rest do so under a court order (Guttmacher, 2011b).
There is a severe lack of abortion providers in the United States. As of 2005, 87% of U.S. counties reported having no abortion providers. The relatively small number of women seeking second-trimester procedures may have to travel long distances, an additional burden for low-income women.
The shortage of providers is likely to continue not only because of harassment and violence but because of inadequate training programs. Only half of ob/gyn residency programs offer routine training in abortion care. New York and California are the only states with laws requiring this training for medical residents.
The same inadequate training situation is true for advanced practice clinicians such as nurse practitioners, physician assistants (PAs), and certified nurse midwives (CNMs). The practices of these clinicians is regulated by state statutes. For example, 11 states and the District of Columbia do not have physician-only laws for therapeutic/medication abortions. PAs are legally allowed to perform therapeutic abortion procedures in two states (ARHP, 2008).
Legislation restricting women’s access to abortion is proliferating in many states and now includes the federal “partial-birth abortion” ban, passed in 2003. Thirty-five states require some type of parental involvement for teens to have an abortion. Waiting periods of 24 hours between counseling and obtaining an abortion are mandated in 24 states. These restrictive laws increase the risk of unintended births among teens, and for some, the preventable risk associated with abortion later in pregnancy (Coles et al., 2010; Davis & Beasley, 2009).
Pro-life/anti-choice activists have tried to link abortion with a host of physical and mental health effects (for example, breast cancer and mental illness) despite the absence of scientific research to validate their claims. The American Psychological Association stated in 2008 that there is no scientific evidence supporting the so-called post-abortion syndrome of psychological trauma or deep depression (APA, 2008). Researchers from Oregon State University reported that teens who have abortions are no more likely to have mental health problems such as depression, than teens who carry their babies to term (Warren et al., 2010). The Guttmacher Institute suggests that pre-abortion counseling about mental health effects from abortion might “jeopardize women’s health by adding unnecessary anxiety and undermining women’s right to informed consent.” A study in the Netherlands found that there was no evidence of increased risk of mental disorders after a first-trimester induced abortion (Munk-Olsen, 2011).
Effectiveness of contraceptive methods. (Source: USAID et al., 2007.)
The comparative effectiveness of various contraceptive methods is summarized in the figure above, and a summary of other characteristics is provided below. (Failure rate indicates the number of pregnancies expected per 100 women.)
SPERMICIDE ALONE
VAGINAL CONTRACEPTIVE FILM, FOAM, INSERTS
MALE CONDOM
FEMALE CONDOM
CERVICAL CAP (FemCap) WITH SPERMICIDE
DIAPHRAGM WITH CONTRACEPTIVE JELLY OR FOAM
SPONGE WITH SPERMICIDE (Today Sponge)
COMBINATION PILL (The “Pill”)
CONTINUOUS / EXTENDED USE (“No-Period”) PILL
PROGESTIN-ONLY PILL (“Mini-Pill”)
SKIN PATCH (Ortho Evra)
VAGINAL RING (NuvaRing)
PLAN-B (“Morning-After Pill”)
IMPLANTABLE ROD (Implanon)
INTRAUTERINE DEVICE (Paragard, Mirena)
INJECTION (Depo-Provera)
STERILIZATION IMPLANT (Essure)
STERILIZATION SURGERY FOR WOMEN
STERILIZATION SURGERY FOR MEN (Vasectomy)
Contraception and family planning services are essential components of public health throughout the world. Making these services available to all women and families will reduce untold suffering and deaths, particularly among girls and women. Comprehensive sex education will better prepare young women to avoid unintended pregnancy at a critical juncture in their lives and to prevent the transmission of HIV and other STIs. Until and unless girls and women have unbiased information; the right to make informed choices about their reproductive lives; and access to safe, effective contraception, there will be more fragile families trapped in a continued cycle of suffering.
Association of Reproductive Health Professionals
http://www.arhp.org
Feminist Women’s Health Center
http://www.fwhc.org/
Emergency Contraception Website
http://ec.princeton.edu/questions/morningafter.html
Guttmacher Institute
http://www.guttmacher.org
Guttmacher Institute, Emergency Contraception State Policies http://www.guttmacher.org/statecenter/spibs/spib_EC.pdf
National Family Planning & Reproductive Health Association
http://www.nfprha.org/main/index.cfm
National Institute for Reproductive Health, Back Up Your Birth Control
http://backupyourbirthcontrol.tumblr.com
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http://nwhn.org/
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