Overview of modern contraception

The large-scale initiatives to address the global unmet needs for family planning (FP) have gathered and compelled scientists, providers, program managers, and other stakeholders (including users) to re-examine the various methods of modern contraception, focusing on those that are proven to be more effective (long-acting reversible contraceptives and permanent methods), historically more widely used (oral contraceptives, condoms), and in development (male hormonal contraception). Implementing FP programs requires an understanding of the human rights principles underpinning the delivery of contraceptive services, the various indicators related to demand, need, and use (demand satisfied, unmet need, and contraceptive prevalence), and its effectiveness (perfect or correct use and typical use), which will be presented in this article. Tools and guidance documents developed using the best available evidence have also been listed in this review article. This issue will also look at new initiatives about providing care (self-care), and key population groups (post-pregnancy and adolescence). The clinical use of the methods should go hand in hand with the programmatic initiatives to ensure that women, men, or couple take up the appropriate method of choice and continue using these based on their reproductive health goals.     

Reviving permanent contraception: New medical procedures or new service delivery modalities?

Despite the prevalent increase of permanent contraception, there are still 222 million women with unmet needs for contraception; a large proportion of these women could opt for permanent contraception. New approaches to permanent contraception are in development; in the meantime, services need to be accessible, affordable, safe, and convenient to allow women, men, and couples to realize their reproductive intentions. Among the available approaches, we recommend minilaparotomy and no-scalpel vasectomy. These are proven as safe, effective, and feasible surgical techniques that can be offered through a wide range of service modalities such as static clinics, mobile outreach, and using task sharing. Both of these approaches have low complication rates, these being mostly minor complications, and low failure rates. Programs must ensure that they address the provision of these services under a human rights-based approach that will allow services to thrive and individual needs will be fulfilled.     

Beyond the pill: new data and options in hormonal and intrauterine contraception

With the goal of helping clinicians facilitate contraceptive success for their patients, this Clinical Opinion provides an update regarding older hormonal and intrauterine contraceptives and details newer methods that include the progestin-releasing intrauterine system, the contraceptive patch and ring, and extended and emergency oral contraception. Last, I will look over the horizon and briefly describe potential future methods that include the single rod progestin-releasing implant, folic acid-supplemented oral contraceptives, and hormonal contraception for men.     

Contraception prior to counselling for termination of pregnancy.

OBJECTIVE: This study investigates the methods of contraception used by women attending for pregnancy counselling at the time of an unintended pregnancy. METHOD: Women attending three pregnancy counselling clinics in Birmingham were asked to fill in a questionnaire which was designed to obtain demographic data and history of women's methods of contraception, prior to attending for termination of pregnancy. RESULTS: The contraceptive methods used most widely by women presenting for termination of pregnancy were the condom (n = 188; 43%) and the oral contraceptive pill (n = 96; 22%). A proportion of women did not use any contraception (n = 117; 27%). Women who had undergone a previous termination of pregnancy (32%) [corrected] had similar contraceptive patterns to those with no history of termination of pregnancy. Women aged 19 and under were less likely to be using contraception (non-users 30/90; 33%) compared with women aged 20 and over (non-users 82/324; 25%), but this difference was not statistically significant. Forty per cent (n = 31) of Afro-Caribbeans did not use any contraception; this was statistically significant when compared with the percentage of Caucasians not using contraception. Only 30% of those eligible had actually presented for post-coital emergency contraception. However, the uptake of emergency contraception was similar in the different age groups. CONCLUSION: Effective contraception is important in the prevention of unwanted pregnancies and, although it will not prevent all conceptions, it will contribute significantly to a reduction in unintended pregnancies. This study indicates that there is a need to consider and be sensitive to the different cultural needs of ethnic groups in the development and presentation of future contraceptives.     

Contraception in nulliparas

After a discussion of the physiologic, psychologic, and social needs of married, single and adolescent nulliparas, the applicability for these women of IUDs, pills, injectables, once monthly pills, condoms, and diaphragms is considered. Physiologically, the uterus is small and tonic, and the hypophyseal system is immature. Psychologically, the chief dichotomy is between mature and young women. Nulliparas may be uninformed sexually and susceptible to contraceptive failure because the nullipara is "incomplete." Socially, nulliparas often are involved with irresponsible partners who will not accept coitus-associated methods of contraception and do not contribute to the woman's mature sexual development. The IUDs and pills are contraindicated in young nulliparas, but should be considered because of their particular need for effective contraception. Condoms could be suggested for those in need of protection from venereal disease or diaphragms for the well-informed, but estrogen morning-after pills should be available.     

Hormonal contraception for males--an option for adolescents?

Although effective contraceptive methods are available, the incidence of teenage pregnancies and consecutive pregnancy interruptions remains high in industrial nations, including Germany. There are several reasons for this high incidence. Apart from earlier sexual maturation, the absence of contraceptive use or the use of inefficient methods contributes mainly towards this increase. Existing contraceptive methods for men either show unsatisfying efficacy (coitus interruptus, use of condoms) or problems of reversibility (vasectomy), which limits their broader use. Of the different experimental approaches towards male contraception, the hormonal approach is closest to practical implementation. Androgens are an essential part of all experimental approaches to hormonal contraception in males; they cause suppression of spermatogenesis through gonadotropin suppression. Previous clinical trials have validated the concept of hormonal contraception in men. However, the application modalities and the ineffectiveness of all self-administered androgen preparations have been unacceptable for practical use. Therefore recent developments focus either on androgen implants or on injectable, long-acting testosterone esters in combination with progestins, which also suppress gonadotropin secretion. Over the last decades various combinations of androgen preparations with different progestins or GnRH antagonists have been tested in clinical trials. Of these, testosterone with either depot medroxyprogesterone acetate, norethisterone, desogestrel or etonogestrel have shown promising efficacy in phase II clinical trials. However, whether hormonal contraception might be given to adolescent males remains to be elucidated. This will have to be assessed once a hormonal contraceptive for men has reached the market. Special attention will need to be given to bone maturation as androgens at the prescribed doses might induce premature closure of the epiphyseal joints.     

Current status and future perspectives in male contraception

Contraception is a crucial human right for its role on health, development and quality of life. Since the introduction of hormonal female contraception the burden of family planning has fallen mostly on women. The few methods of family planning available for men--namely condoms, vasectomy, periodic abstinence and withdrawal--are hundred year old in concept, are based on preindustrial practices and have low efficacy or are difficult to reverse. In spite of the shortcomings of currently available male contraceptives, 1/3 of the couples that use contraception worldwide rely on male methods suggesting that development of a safe, effective, reversible and affordable contraceptive method for men would meet a critical need. Recent surveys have shown that men want to know more about reproductive health and want to support their partner more actively. In recent decades, there have been exceptional advances in the development of safer and more effective contraceptives. Currently, several methods of contraception for men are under development. This paper summarises the efforts performed over the past decades to develop an effective, safe and reversible male contraceptive.     

Hormonal contraceptive methodology: an historical review

The introduction of the first hormonal contraceptive was one of the most important events of the twentieth century for women. The availability of oral contraceptives (OCs) provided women with greater control over their reproductive lives. As OC usage steadily increased, so did concern over health risks associated with their use. Concluding that adverse events were dose-related, scientists sought to develop lower-dose formulations. In the four decades since the first OC, women seeking contraception have benefited from the development of non-oral hormonal delivery systems, including injectables, intrauterine devices, implants, a vaginal ring, and a contraceptive patch. It is hoped that this expanding menu of choices affords women opportunities to find methods better suited to their individual needs. Clinicians should continually evaluate their patients' hormonal contraceptive needs, and provide adequate counseling so that every woman is afforded the opportunity to achieve contraceptive success.     

Contraception prior to counselling for termination of pregnancy

Objective This study investigates the methods of contraception used by women attending for pregnancy counselling at the time of an unintended pregnancy.

Method Women attending three pregnancy counselling clinics in Birmingham were asked to fill in a questionnaire which was designed to obtain demographic data and history of women's methods of contraception, prior to attending for termination of pregnancy.

Results The contraceptive methods used most widely by women presenting for termination of pregnancy were the condom (n= 188; 43%) and the oral contraceptive pill (n = 96; 22%). A proportion of women did not use any contraception (n = 117; 27%). Women who had undergone a previous termination of pregnancy (29%) had similar contraceptive patterns to those with no history of termination of pregnancy. Women aged 19 and under were less likely to be using contraception (non-users 30/90; 33%) compared with women aged 20 and over (non-users 82/324; 25%), but this difference was not statistically significant. Forty per cent (n = 31) of Afro-Caribbeans did not use any contraception; this was statistically significant when compared with the percentage of Caucasians not using contraception. Only 30% of those eligible had actually presented for post-coital emergency contraception. However, the uptake of emergency contraception was similar in the different age groups.

Conclusion Effective contraception is important in the prevention of unwanted pregnancies and, although it will not prevent all conceptions, it will contribute significantly to a reduction in unintended pregnancies. This study indicates that there is a need to consider and be sensitive to the different cultural needs of ethnic groups in the development and presentation of future contraceptives.     

Reversing the downward trend in men''s share of contraceptive use

Five years after the International Conference on Population and Development which had reached the consensus that men do not adequately share responsibility for family planning with women, the proportion of contraceptive prevalence attributed to men has fallen to 26 per cent down from 31 per cent in 1994 and 37 per cent in 1987. This gender imbalance in contraceptive responsibility is occurring in a context of rapid growth in the population of reproductive age who need family planning, and of 16,000 new HIV infections daily. Meeting the enormous demand for reproductive health services requires that service delivery systems maximise the potential for use of male methods. This paper explores why use of male methods has fallen, and provides some programmatic examples of how to promote male methods successfully. In the period of time before new reversible methods for men become available, service delivery systems should be strengthened so that they are effective in reaching men both as users of male methods and as supportive partners. Gender equity will be enhanced when both men and women are provided with unbiased information about the full range of options for contraception and STDIHIV prevention and their appropriate use.     

Emergency contraception: the state of the art

Emergency contraception, otherwise known as post-coital contraception, is part of the continuum of contraceptive methods that women and couples can use for pregnancy prevention. Although emergency contraception should not be used as a regular, plan-ahead contraceptive method, it gives a woman one last-ditch effort to prevent unwanted pregnancy. This paper reviews the history of emergency contraception, the need for further studies, and results of studies conducted at the World Health Organization. Various methods used for emergency contraception are discussed, as well as their efficacies and side effects.     

Contraception at 40

During forty, fertility decreases but the risk of spontaneous pregnancy is not negligible, so contraception for forty years old women remains necessary. Several contraceptive methods are available: local contraception, intra-uterine devices, hormonal contraception. Progestogen-only pills, microdosed and continuously administered are to be avoided at this time of life because they can result in hyperestrogenic adverse events. Progestin implants are interesting if the woman presents contraindication with estrogens or if she is non compliant with oral contraceptives. Oral contraceptive use is associated with numerous benefits during forty: it controls properly cycles and menstruations, it decreases bone loss and it decreases gynaecological disorders and risk of endometrial and ovarian cancer... But cardiovascular risk (venous and arterial thrombo-embolism) remains increased, whatever oral contraceptive is used, second or third generation, and in spite of lower dose of ethinylestradiol, even if a trend towards the decrease of this risk is observed. Contraindication for one kind of oral contraceptive means contraindication for all oral contraceptives and necessarily bare respect of this. These contraindications led to contraceptive use of progestin with antigonadotropic activity; however if pregnane derivatives are devoid of any deleterious metabolic effects, they have no indication for contraception in their marketing authorization.     

Whither methods for men? Emerging gender issues in contraception

Few would deny that the knowledge and use of the means to control fertility have contributed to women's empowerment. Yet in addition to being a right for women, contraception can also be a burden, and dissatisfaction with female-dependent methods is common. Men wanting to share responsibility for birth spacing have few reversible options at present but new reversible methods for men are under development. Acceptability was studied during a recent contraceptive trial of a prototype injectable hormonal method for men. Of the British men who participated in the trial and their women partners, many were dissatisfied with the pill and other female-dependent methods they had tried. This paper examines why the development of an effective, reversible, non-barrier contraceptive method for men is an important gender issue, and why prospects for its success could hinge on how it is perceived by women as well as by men.     

Use of injectable hormonal contraceptives: diverging perspectives of women and men,service providers and policymakers in Uganda

The unmet need for family planning in Uganda is among the world's highest. Injectable contraceptives, the most available method, were used by only 14.1% of married women in 2011. Recent data suggest that the main reason for unmet need is not lack of access, but fear of and unacceptability of side effects. In this qualitative study, 46 women and men were interviewed about their experience of injectable contraceptive side effects and the consequences for their lives. Thirty-two family planning service providers and policymakers were also interviewed on their perceptions. While using injectables, many of the women experienced menstrual irregularities and loss of libido. Both women and men experienced strained sexual relationships and expressed fear of infertility, often resulting in contraceptive discontinuation. Family planning service providers and policymakers often minimized side effects as compared to the risks of unintended pregnancy. Policymakers noted a lack of contraceptive alternatives and promoted family planning education to correct what they thought were misconceptions about side effects among both service providers and contraceptive users. Information alone, however, cannot diminish disturbances to social and sexual relationships. A common understanding of recognised side effects, not only with injectables but all contraceptives, is necessary if unmet need in Uganda is to be reduced.     

Access to Reproductive Health Care in Juvenile Justice Facilities

Study ObjectiveThe juvenile justice system houses adolescents with unique and unmet reproductive needs, including family planning. The purpose of this study was to identify access to contraceptive counseling and methods for young women in the juvenile justice system.DesignWe administered a cross-sectional survey that was used to examine services related to reproductive health care, including contraceptive counseling, and ability to initiate or continue contraceptive methods in custody.SettingJuvenile justice systems in the United States.ParticipantsState-level health care administrators in juvenile justice systems.Interventions and Main Outcome MeasuresWe analyzed responses to determine the ability of young women in custody to continue or initiate specific contraceptive methods, in addition to other measures of reproductive health access.ResultsTwenty-one respondents representing systems in 20 US states were included in analysis. All participating sites provided contraceptive counseling and all allowed at least 1 form of preincarceration contraception to be continued. Eighty-one percent (17/21) of systems enabled young women to initiate contraception while in custody, with the most common method available on-site being birth control pills. Twenty percent (4/20) of sites provided long-acting reversible contraceptive methods.ConclusionThis study shows that it is feasible to provide contraception in this setting. However, there exists considerable variability in availability of methods across the United States. Continued work is needed in increasing access to contraception and standardization of care in the juvenile justice system.     

Extended cycle combined hormonal contraception

Extended cycle contraception is a safe and acceptable form of contraception and may be more efficacious than cyclic regimens, especially for users of oral contraceptive pills. Most extended cycle regimens result in fewer scheduled bleeding episodes, an outcome desired by many women. They may also result in more unscheduled bleeding and/or spotting episodes that decrease with time. Women who use extended cycle contraception experience fewer menstrual symptoms, particularly headache. Some women have medical conditions or menstrual symptoms that make extended cycle contraception a preferred method. Although we do not have enough data to recommend one particular extended cycle regimen over another, the use of these new regimens will provide women with more options, and almost certainly will improve the acceptability and efficacy of hormonal contraception. In this article, the authors focus on extended cycle combined hormonal contraceptive regimens and summarize their acceptability, efficacy, and safety. They also argue that extended cycle combined hormonal contraceptive may have increased efficacy compared with traditional cyclic combined hormonal contraceptive.     

The Copper-T 380A IUD: A ten-year alternative to female sterilisation in India

High unmet need for limiting contraception persists in most states of India despite wide access to sterilisation. Qualitative evidence from a rural community in which child mortality is high and women's autonomy is low suggests that women may seek reversibility in a contraceptive even if they have finished childbearing. This paper describes the introduction of the Copper-T 380A--a contraceptive with an effective life span of ten years--as an alternative to female sterilisation in a rural area of the state of Rajasthan, in a clinic linked to an outreach programme. The intervention addressed women's apprehensions, ensured service standards and guaranteed women's right to have the Copper-T removed at will. Data on 216 insertions over 34 months revealed a preference for the Copper-T 380A among older women and women who had achieved desired family size, especially among tribal women. More than a quarter of the 30 removals in that period were for non-medical reasons, such as family opposition, child death or remarriage. As a long-term but reversible option, the Copper-T 380A allows women room to change their minds in relation to future childbearing until they have reached menopause. Including this option in family planning services can help to meet a portion of the unmet need for contraception among women not willing to choose sterilisation, while reducing dependence on doctors and expensive equipment.     

Factors affecting unmet need for contraception among currently married fecund young women in Bangladesh

Objectives: The aim of our study was to explore the factors associated with unmet need for contraception among currently married fecund women under age 25, in Bangladesh.

Methods: This study utilised a cross-sectional data (n?=?4982) extracted from the Bangladesh Demographic and Health Survey (BDHS) 2011. Multinomial logistic regression was used to identify the determinants of unmet need for contraception among currently married fecund young women.

Results: The unmet need for contraception was 17% and contraceptive prevalence was 54% in this young group. Total demand for contraception was 71% and the proportion of demand satisfied was 77%. The results suggest that region, place of residence, religion, husband’s desire for children, visits of FP workers, decision-making power on child health care, reading about FP in newspaper/magazine and number of births in three years preceding the survey were significant predictors of unmet need for contraception.

Conclusions: The BDHS of 2011 found that unmet need for contraception among currently married, fecund women under 25 years old is higher than the national level, and hence different or more intensive programme initiatives are required for them than for older women. The present study identifies important predictors of unmet need for contraception among fecund married Bangladeshi women under age 25.