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Family Planning: Reversible Contraception, Sterilization, and Abortion
Clinical Keys for This Chapter
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There are three types of interventions available in family planning to prevent unwanted pregnancies. The first is contraception, which prevents fertilization by blocking the union of the gametes. The second is interception, which works after fertilization but before implantation. The third is abortion, which is defined as the interruption of an established pregnancy. The patient's perspective and preferences for family planning must always be the primary focus.
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Ongoing contraceptive options are grouped into three tiers that are based on their efficacy in typical use. Tier 1 methods (implants, intrauterine devices [IUDs], and permanent contraception) have the lowest failure rates. Tier 2 methods include injections, pills, patches, and rings. Tier 3 methods include barrier and behavioral methods.
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Emergency contraception provides pregnancy protection after intercourse has taken place. It involves hormonal (oral contraceptives) or mechanical methods, which may be interceptive (e.g., placement of an IUD).
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Permanent contraception (previously referred to as sterilization ) may be performed just after childbirth, between pregnancies, or as an interval procedure at any time. Tubal interruption is the most common technique. There has been a recent recommendation that fimbriectomy or complete salpingectomy should be used because it may reduce the risk of subsequent serous ovarian or peritoneal cancer.
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Elective termination of a pregnancy (abortion) is controversial and is unavailable in some areas of the United States. Medical and surgical abortion are as safe as other common procedures, such as tonsillectomy. Better access to effective contraception has been shown to reduce abortion rates.
Family planning plays a significant role in improving the health of women and provides a unique opportunity to optimize pregnancy outcomes by helping couples to control childbearing until conditions are favorable for them. As such, family planning contributes substantially to individual health care, to public health, and even to population control and environmental well-being.
Despite these recognized benefits, there is no other area of women's health that is as controversial and polarizing as family planning. Much of the controversy is based on a misunderstanding about reproductive facts, the safety of modern contraception, and the health risks posed by pregnancy and childbirth. Box 27-1 lists some important family planning facts and misconceptions held by many women and men.
Box 27-1
Family Planning Facts
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All methods of birth control that would typically be prescribed to a woman today are far less hazardous to a woman's health than a pregnancy would be.
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In the United States, nearly half of all pregnancies are unintended. This has been the case for more than two decades.
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The maternal mortality rate in the United States is at its highest point in 15 years. There is currently 1 maternal mortality for every 30,000 live births.
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The mortality rate for healthy, young, nonsmoking women using oral contraceptives for 1 year is approximately 1 death in 1 million user-years.
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In spite of this, a large majority of women of reproductive age rate oral contraceptives to be more hazardous to a woman's health than pregnancy.
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A first-trimester elective pregnancy termination is safer than a tonsillectomy.
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Providing safe, affordable, and effective methods of contraception reduces the rates of abortion.
Overview
Before going into detail about the various methods of family planning, it is important to note several facts about reproductive health. About 85% of sexually active couples having unprotected intercourse for 1 year will experience pregnancy. Pregnancy is not established within the uterus until about 7 days after conception, which itself may not occur for up to 5 to 7 days following intercourse. Half of all conceptions are lost before implantation, and at least 10-15% of established pregnancies spontaneously abort.
Although the goal of family planning is to provide couples with the ability to plan and prepare for pregnancy, efforts to date have fallen far short of that goal. More than half of pregnancies that occur in the United States are unintended, meaning that the woman did not want to become pregnant at the time she did. More than half of these unplanned pregnancies are eventually accepted.
Most women underestimate the health risks of pregnancy and overestimate the risks of contraception. There is no method of contraception that a clinician would prescribe to a woman that is as hazardous to her health as pregnancy itself. The contraceptive needs of a couple are often given lower priority and may not be mentioned, even when clinicians prescribe drugs that may be teratogenic to women of reproductive age. The controversy that surrounds family planning makes it essential for those caring for women of reproductive age to be informed about all the available methods of birth control and to be dedicated to educating couples about their importance and safety.
Contraception
Ongoing contraceptive methods themselves may be categorized into reversible methods used before intercourse and those methods that are permanent. The efficacy of a method is estimated by first-year failure rates measured under two different conditions: (1) correct and consistent use (reflecting a method's full potential) and (2) typical use (estimates are derived from surveys of everyday, “real-world” users). Table 27-1 lists all the methods and their failure rates for both perfect and typical use. The differences in failure rates between the reversible Tier 1 methods and those in Tier 2 or 3 are so remarkable that most authorities recommend that first-line contraceptive options for women of all ages be implants and intrauterine devices (IUDs) (Tier 1). Any method is more effective than unprotected intercourse, and even one of the lower-tier methods can be made quite effective if the gap between typical use and correct and consistent use is reduced. Different forms of emergency contraception are available after coitus to provide a second chance of pregnancy prevention when nonuse or method misuse occurs.
TABLE 27-1
First-Year Failure Rates
| Percentage of Women Experiencing an Unintended Pregnancy within the First Year of Use | ||
|---|---|---|
| Method | Typical Use | Perfect Use |
| No method | 85 | 85 |
| Spermicides | 28 | 18 |
| Fertility awareness–based methods | 24 | |
| Standard days method | 5 | |
| 2-Day method | 4 | |
| Ovulation method | 3 | |
| Symptothermal method | 0.4 | |
| Withdrawal | 22 | 4 |
| Sponge | ||
| Parous women | 24 | 20 |
| Nulliparous women | 12 | 9 |
| Condom | ||
| Female (FC2) | 21 | 5 |
| Male | 18 | 2 |
| Diaphragm | 12 | 6 |
| Combined pill and progestin-only pills | 9 | 0.3 |
| ORTHO EVRA patch | 9 | 0.3 |
| NuvaRing | 9 | 0.3 |
| Depo-Provera | 6 | 0.2 |
| Intrauterine contraceptives | ||
| ParaGard T 380A intrauterine copper contraceptive | 0.8 | 0.6 |
| Mirena LNG-IUS (20 µg/24 hr) | 0.2 | 0.2 |
| IMPLANON/NEXPLANON | 0.05 | 0.05 |
| Female sterilization | 0.5 | 0.5 |
| Male sterilization | 0.15 | 0.10 |
LNG-IUS, Levonorgestrel intrauterine system.
Contraceptive practice in the United States has been greatly simplified by the publication of two important documents by the Centers for Disease Control and Prevention (CDC): the United States Medical Eligibility Criteria (US MEC) for Contraceptive Use and the U.S. Selected Practice Recommendations (US SPR) for Contraceptive Use. Each of these sets of guidelines is periodically updated based on the latest available evidence, and both sets in their entirety can be accessed online: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm and http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm . The US MEC rates the eligibility of women with a variety of medical conditions for each of the reversible Tier 1 and Tier 2 methods of birth control on a scale of 1 to 4, where 1 represents no concern and 4 represents an absolute contraindication. Added to this evaluation is a consideration of the risks that a woman would face with pregnancy and the likelihood she would experience a pregnancy if she were to use the method. For example, a woman with advanced diabetes may not experience any direct medical harm by using male condoms, but the 18% chance of pregnancy with typical use of condoms poses significant risks to her health. Table 27-2 contains a sample of the entire US MEC to illustrate its usefulness. The complete chart can also be accessed electronically at StudentConsult.com .
TABLE 27-2
Sample Chart of U.S. Medical Eligibility Criteria for Contraceptive Use
From Centers for Disease Control and Prevention.
Updated June 2012. This summary sheet only contains a subset of the recommendations from the US MEC. For complete guidance, see: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm .
Most contraceptive methods do not protect against sexually transmitted infections (STIs). Consistent and correct use of the male latex condom reduces the risk of STIs and HIV.
C, Continuation of contraceptive method; I, initiation of contraceptive method; NA, not applicable.
*Please see the complete guidance for a clarification to this classification: www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm .
‡Condition that exposes a woman to increased risk as a result of unintended pregnancy.
The US SPR separates the elements of well-woman care from those needed for contraception, provides clear direction about the evaluations needed (beyond taking a complete medical history) before offering the method, and describes what follow-up is needed after method initiation. It also offers advice on managing potential side effects associated with each of the methods. Table 27-3 highlights the recommended testing for each method and emphasizes the importance and feasibility of initiating every method of contraception at the time a patient is seen (any time in a woman's cycle as long as she is not pregnant). Immediate initiation of birth control and provision of adequate contraceptive supplies have both been shown to reduce unintended pregnancy rates and abortions.
TABLE 27-3
Routine Examinations and Tests Needed before Initiation of Contraceptive Methods by Healthy Women
Adapted from Centers for Disease Control and Prevention: U.S. selected practice recommendations for contraceptive use, 2013. MMWR Morb Mortal Wkly Rep 62(5):1–46, 2013.
| Examination Needed | IUD | Implant | Injectable | Combined Hormonal Contraceptive | Progestin-Only Pills |
|---|---|---|---|---|---|
| BP | C | C | C | A | C |
| BMI | C | C | C | C | C |
| Breast examination | C | C | C | C | C |
| Pelvic examination * | A | C | C | C | C |
A, Essential and mandated; BMI, body mass index; BP, blood pressure; C, Does not contribute substantially to safe and effective method use; IUD, intrauterine device.
Laboratory tests: All methods were rated Category C for the following tests: glucose, lipids, liver enzymes, hemoglobin, presence of thrombogenic mutations, cervical cytology, and human immunodeficiency virus.
Note: Use of IUDs is the only contraceptive method for which sexually transmitted infection screening has any potential benefit; a woman may need risk- or age-related testing done at the time of placement if she has not previously had routine testing as recommended by the Centers for Disease Control and Prevention guidelines.
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