Birth control

For other uses, see Birth control (disambiguation).

A rolled up male condom

A half-finished package of birth control pills

Birth control, also known as contraception and fertility control, refers to methods or devices used to prevent pregnancy. Planning and provision of birth control is called family planning. Safe sex, such as the use of male or female condoms, can also help prevent transmission of sexually transmitted infections. Contraceptive use in developing countries has cut the number of maternal deaths by 44% (about 270,000 deaths averted in 2008) but could prevent 73% if the full demand for birth control were met. Because teenage pregnancies are at greater risk of poor outcomes such as preterm birth, low birth weight and infant death, some authors suggest adolescents need comprehensive sex education and access to reproductive health services, including contraception. By lengthening the time between pregnancies, birth control can also improve adult women's delivery outcomes and the survival of their children.

Effective birth control methods include barriers such as condoms, diaphragms, and the contraceptive sponge; hormonal contraception including oral pills, patches, vaginal rings, and injectable contraceptives; and intrauterine devices (IUDs). Emergency contraception can prevent pregnancy after unprotected sex. Long-acting reversible contraception such as implants, IUDs, or vaginal rings are recommended to reduce teenage pregnancy. Sterilization by means such as vasectomy and tubal ligation is permanent contraception. Some people regard sexual abstinence as birth control, but abstinence-only sex education often increases teen pregnancies when offered without contraceptive education. Non-penetrative sex and oral sex are also sometimes considered contraception.

Birth control methods have been used since ancient times but effective and safe methods only became available in the 20th century. For some people, contraception involves moral issues, and many cultures limit access to birth control due to the moral and political issues. About 222 million women who want to avoid pregnancy in developing countries are not using a modern contraception method. Birth control increases economic growth because of fewer dependent children, more women participating in the workforce, and less consumption of scarce resources. Women's earnings, assets, body mass index, and their children's schooling and body mass index all substantially improve with greater access to contraception.

Methods

Birth control includes barrier methods, hormonal contraception, intrauterine devices (IUDs), sterilization, and behavioral methods. Hormones may be delivered by injection, by mouth (orally), placed in the vagina, or implanted under the skin. The most common types of oral contraception include the combined oral contraceptive pill and the progestogen-only pill. Most methods are typically used before sex while emergency contraception is effective for up to a few days after intercourse.

Determining whether a woman with one or more illnesses, diseases, risk factors, or abnormalities can use a particular form of birth control is a complex medical question sometimes requiring a pelvic examination or medical tests. The World Health Organization publishes a detailed list of medical eligibility criteria for each type of contraception.

• Birth control methods
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  An unrolled male latex condom
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  A polyurethane female condom
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  A diaphragm vaginal-cervical barrier, in its case with a quarter U.S. coin to show scale
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  A contraceptive sponge set inside its open package
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  Three varieties of birth control pills in calendar oriented packaging
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  A transdermal contraceptive patch
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  A NuvaRing vaginal ring
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  A hormonal intrauterine device (IUD) against a background showing placement in the uterus
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  A split dose of two emergency contraceptive pills (most morning after pills now only require one)

Barrier

File:Condoms 08293403.jpg

Male condoms in the rolled-up position

Barrier contraceptives are devices that attempt to prevent pregnancy by physically preventing sperm from entering the uterus. They include: male condoms, female condoms, cervical caps, diaphragms, and contraceptive sponges with spermicide.

The condom is most commonly used during sexual intercourse to reduce the likelihood of pregnancy and of spreading sexually transmitted infections (STIs/STDs—such as gonorrhea, syphilis, and HIV). It is put on a man's erect penis and physically blocks ejaculated semen from entering the body of a sexual partner. Modern condoms are most often made from latex, but some are made from other materials such as polyurethane, polyisoprene, or lamb intestine. A female condom is also available, most often made of nitrile. Male condoms have the advantage of being inexpensive, easy to use, and having few side effects.

Contraceptive sponges combine a barrier with spermicide. Like diaphragms, they are inserted vaginally prior to intercourse and must be placed over the cervix to be effective. Typical effectiveness during the first year of use is about 84% overall, and 68% among women who have already given birth. The sponge can be inserted up to 24 hours before intercourse and must be left in place for at least six hours afterward. Some people are allergic to spermicide used in the sponge. Women who use contraceptive sponges have an increased risk of yeast infections and urinary tract infections. Leaving the sponge in for more than 30 hours can result in toxic shock syndrome.

Hormonal

Hormonal contraceptives inhibit ovulation and fertilization. These include oral pills, subdermal implants, and injectable contraceptives as well as the patch, hormonal IUDs and the vaginal ring. The most commonly used hormonal contraceptive is the combined oral contraceptive pill—commonly known as "the pill"—which includes a combination of an estrogen and a progestin (progestogen). There is also a progestin-only pill. Currently, hormonal contraceptives are available only for females.

Combined hormonal contraceptives are associated with a slight increased cardiovascular risk, including an increased risk of venous and arterial thrombosis, blood clots that can cause permanent disability or even death. However, the benefits are greater than the risk of pregnancy, because pregnancy also increases those risks.

According to the U.S. National Cancer Institute, oral contraceptives reduce the risk of ovarian cancer and endometrial cancer but increase the risk of breast cancer and cervical cancer. Some reduce water retention, and several are used to treat mild to moderate acne, although they are not approved by the US Food and Drug Administration (FDA) for the sole use of acne treatment because the risk of blood clots outweighs those potential benefits. Some types of combination hormonal contraceptives may reduce the symptoms of premenstrual dysphoric disorder (PMDD) and can reduce heavy menstrual bleeding and dysmenorrhea (painful menstruation) by replacing menstruation with bleeding that imitates the menstrual cycle but does not regulate it. Lower doses of estrogen required by vaginal administration (i.e., from the vaginal ring or hormonal IUDs instead of the pill) may reduce the breast tenderness, nausea, and headache associated with oral contraceptives for some women.

Progestin-only pills and intrauterine devices are not associated with an increased risk of thromboses and may be used by women with previous venous thrombosis, or hepatitis. In those with a history of arterial thrombosis, non-hormonal birth control should be used. Progestin-only pills may improve menstrual symptoms such as dysmenorrhea, menorrhagia, premenstrual syndrome, and anemia, and are recommended for breast-feeding women because they do not affect lactation. Irregular bleeding can be a side effect of progestin-only methods, with about 20% of users reporting amenorrhea (often considered a benefit) and about 40% of women experiencing regular menstrual cycles, leaving the remaining 40% with irregular spotting or bleeding. Uncommon side effects of progestin-only pills, injections, and implants include headache, breast tenderness, mood effects, and dysmenorrhea, but those symptoms often resolve with time. Newer progestins, such as drospirenone and desogestrel, minimize the androgenic side effects of their predecessors but increase the risks of potentially fatal blood clots and dangerously high potassium.

Intrauterine devices

The contemporary intrauterine device (IUD) is a small 'T'-shaped birth control device, containing either copper or progesterone, which is inserted into the uterus. IUDs are a form of long-acting reversible contraception, the most effective type of reversible birth control. As of 2002, IUDs were the most widely used form of reversible contraception, with nearly 160 million users worldwide. Evidence supports both effectiveness and safety in adolescents.

Advantages of the copper IUD include its ability to provide emergency contraception up to five days after unprotected sex. It is the most effective form of emergency contraception available. It contains no hormones, so it can be used while breastfeeding, and fertility returns quickly after removal. Disadvantages include the possibility of heavier menstrual periods and more painful cramps.

Hormonal IUDs do not increase bleeding as copper-containing IUDs do. Rather, they reduce menstrual bleeding or stop menstruation altogether, and can be used as a treatment for heavy periods. Levonorgestrel-releasing IUDs may be used during breastfeeding whether or not they also include copper.

Sterilization

Surgical sterilization is available in the form of tubal ligation for women and vasectomy for men. There are no significant long term side effects and tubal ligation decreases the risk of ovarian cancer. Some women regret such a decision: about 5% over 30 years, and about 20% under 30. Short term complications are less likely from a vasectomy than a tubal ligation. Neither method offers protection from sexually transmitted infections.

Although sterilization is considered a permanent procedure, it is possible to attempt a tubal reversal to reconnect the fallopian tubes in females or a vasectomy reversal to reconnect the vasa deferentia in males. The rate of success depends on the original technique, tubal damage, and the person's age.

Behavioral

Behavioral methods involve regulating the timing or methods of intercourse to prevent introduction of sperm into the female reproductive tract, either altogether or when an egg may be present. If used properly the failure rate is about 3.4%, however if used poorly failure rates may approach 85% for a year.

Lactation

The lactational amenorrhea method, or LAM, involves the use of a woman's natural postpartum infertility which occurs after delivery and may be extended by breastfeeding. This usually requires the presence of no periods, exclusively breastfeeding the infant, and a child younger than six months. If breastfeeding is the infant's only source of nutrition the World Health Organization states that it is 98% effective in the six months following delivery. Trials have found effectiveness rates between 92.5% and 100%. Effectiveness decreases to 93-96% at one year and 87% at two years. Feeding formula, pumping instead of nursing, the use of a pacifier, and feeding solids all reduce its effectiveness. In those who are exclusively breastfeeding about 10% begin having periods before three months and 20% before six months. In those who are not breastfeeding fertility may return four weeks after delivery.

Fertility awareness

A CycleBeads birth control chain, used for a rough estimate of fertility based on days since menstruation

Fertility awareness methods are used by about 3.6% of couples. Calendar-based contraceptive methods such as the discredited rhythm method and the Standard Days Method estimate the likelihood of fertility based on the length of past menstrual cycles. To avoid pregnancy with fertility awareness, unprotected sex is restricted to a woman's least fertile period. During her most fertile period, barrier methods may be used, or she may abstain from intercourse. The term "natural family planning" (NFP) is sometimes used to refer to any use of fertility awareness methods. However, this term specifically refers to the practices that are permitted by the Roman Catholic Church.

The effectiveness of fertility awareness-based methods of contraception is unknown because of the lack of completed standardized and controlled scientific trials. More effective than calendar-based methods, systems of fertility awareness that track basal body temperature, cervical mucus, or both, are known as symptoms-based methods. Teachers of symptoms-based methods take care to distance their systems from the poor reputation of the rhythm method. Many consider the rhythm method to have been obsolete for at least 20 years, and some even exclude calendar-based methods from their definition of fertility awareness.

The Standard Days Method has a simpler rule set and is more effective than the rhythm method. The Standard Days Method has a typical failure rate of 12% per year. A product called CycleBeads was developed alongside the method to help the user keep track of estimated high and low fertility points during her menstrual cycle. The Standard Days Method may only be used by women whose cycles are always between 26 and 32 days in length. In this system:

• Days 1-7 of a woman's menstrual cycle are considered infertile
• Days 8-19 are considered fertile; considered unsafe for unprotected intercourse
• From Day 20 onwards, infertility is considered to resume

Symptoms-based methods of fertility awareness involve a woman's observation and charting of her body's fertility signs, to determine the fertile and infertile phases of her cycle. Charting may be done by hand or with the assistance of fertility monitors. Most methods track one or more of the three primary fertility signs: changes in basal body temperature, in cervical mucus, and in cervical position. If a woman tracks both basal body temperature and another primary sign, the method is referred to as "symptothermal." Other bodily cues such as mittelschmerz are considered secondary indicators. Unplanned pregnancy rates have been reported from 1% to 20% for typical users of the symptothermal method.

Withdrawal

Coitus interruptus (literally "interrupted sexual intercourse"), also known as the withdrawal or pull-out method, is the practice of ending sexual intercourse ("pulling out") before ejaculation. The main risk of coitus interruptus is that the man may not perform the maneuver correctly or in a timely manner. Effectiveness varies from 4% with perfect usage to 27% with typical usage.

There is little evidence regarding the sperm content of pre-ejaculatory fluid. While some tentative research does did not find sperm one trial found it present in 10 out of 27 volunteers. It is used as a method of birth control by about 3% of couples.

Abstinence

Though some groups advocate total sexual abstinence, by which they mean the avoidance of all sexual activity, in the context of birth control the term usually means abstinence from vaginally penetrative sexual activity. Abstinence is 100% effective in preventing pregnancy; however, not everyone who intends to be abstinent refrains from all sexual activity, and in many populations there is a significant risk of pregnancy from nonconsensual sex.

Abstinence-only sex education does not reduce teen pregnancy. Teen pregnancy rates are higher in students given abstinence-only education, compared to comprehensive sex education. Some authorities recommend that those using abstinence as a primary method have backup method(s) available (such as condoms or emergency contraceptive pills). Non-penetrative and oral sex will generally avoid pregnancy, but pregnancy can still occur with intercrural sex and other forms of penis-near-vagina sex (genital rubbing, and the penis exiting from anal intercourse) where semen can be deposited near the entrance to the vagina and can itself travel along the vagina's lubricating fluids.

Emergency (after sex)

Emergency contraceptives, or "morning-after pills," are drugs taken after sexual intercourse intended to prevent pregnancy. Levonorgestrel (progestin) pills, marketed as "Plan B" and "Next Choice," are available without prescription (to women and men aged 17 and older in the U.S.) to prevent pregnancy when used within 72 hours (3 days) after unprotected sex or condom failure. Ulipristal ("Ella") is the newest emergency contraceptive, available by prescription only for use up to 120 hours (5 days) after unprotected sex, resulting in a pregnancy risk 42% lower than levonorgestrel up to 72 hours and 65% lower in the first 24 hours following sex. Providing morning after pills to women in advance does not affect sexually transmitted infection rates, condom use, pregnancy rates, or sexual risk-taking behavior. Pharmacists are a major source of access to emergency contraception. Morning after pills have almost no health risk, no matter how often they are used.

Copper T-shaped IUDs can also be used as emergency contraceptives. Copper IUDs can be inserted up to the time of implantation (6–12 days after ovulation) but are generally not inserted more than five days after unprotected sex.

For every eight expected pregnancies, the use of levonorgestrel morning after pills will prevent seven. Ulipristal is about twice as effective as levonorgestrel. Copper IUDs are more than 99% effective in reducing the risk of pregnancy.

Effectiveness

See also: Comparison of birth control methods

Chance of pregnancy during first year of use:

Method	Typical use	Perfect use
No birth control	85%	85%
Combination pill	8%	0.3%
Progestin-only pill	13%	1.1%
Sterilization (female)	0.5%	0.5%
Sterilization (male)	0.15%	0.10%
Condom (female)	21%	5%
Condom (male)	15%	2%
Copper IUD	0.8%	0.6%
Hormone IUD	0.2%	0.2%
Lactational amenorrhea method	0-7.5%	<2%
Patch	8%	0.3%
Vaginal ring	8%	0.3%
Depo Provera	3%	0.3%
Implant	0.05%	0.05%
Diaphragm and spermicide	16%	6%
Withdrawal	27%	4%
Standard days method	~12-25%	~1-9%

Estimates of the effectiveness of a birth control method are generally expressed as the percentage of women who become pregnant using the method in the first year of use. Thus, if 100 women use a method that has a 0 percent first-year failure rate, then 0 of the women should become pregnant during the first year of use. This equals 0 pregnancies per 100 woman-years, an alternative unit. Sometimes the effectiveness is expressed in lifetime failure rate, more commonly among methods with high effectiveness, such as vasectomy after the appropriate negative semen analysis.

The most effective methods in typical use are those that do not depend upon regular user action. Surgical sterilization, Depo-Provera, implants, and intrauterine devices (IUDs) all have first-year failure rates of less than one percent for perfect use. In reality, however, perfect use may not be the case, but still, sterilization, implants, and IUDs also have typical failure rates under one percent. The typical failure rate of Depo-Provera is disagreed upon, with figures ranging from less than one percent up to three percent.

Other methods may be highly effective if used consistently and correctly, but can have typical use first-year failure rates that are considerably higher due to incorrect or ineffective usage by the user. Hormonal contraceptive pills, patches or rings, and the lactational amenorrhea method (LAM), if used strictly, can have first-year (or for LAM, first-6-month) failure rates of less than 1%. In one survey, typical use first-year failure rates of hormonal contraceptive pills (and by extrapolation, patches or rings) were as high as five percent per year.

Intrauterine devices (IUDs) were once associated with health risks, but most recent models of the IUD, including the ParaGard and Mirena, are both extremely safe and effective, and require very little maintenance.

Condoms and cervical barriers such as the diaphragm have similar typical use first-year failure rates (14 and 20 percent, respectively), but perfect usage of the condom is more effective (three percent first-year failure vs six percent) and condoms have the additional feature of helping to prevent the spread of sexually transmitted diseases such as HIV/AIDS.

The withdrawal method, if used consistently and correctly, has a first-year failure rate of four percent. Due to the difficulty of consistently using withdrawal correctly, it has a typical use first-year failure rate of 19 percent, and is not recommended by some medical professionals. Fertility awareness methods as a whole have typical use first-year failure rates as between 12 and 25 percent; perfect use effectiveness depends on which system is used and are typically 1 to 9 percent. The evidence on which these estimates are based however is poor.

Family planning counselors should assess their client's needs and behaviors: "If exposure is likely, particularly to the more serious infections such as HIV, the one-method approach [consistent condom use] should be given greater weight. Conversely, in settings where unintended pregnancy is the greater concern, such as in many family planning clinics in developed countries, emphasizing the two-method approach as a first option may be appropriate." Although experts' opinions vary on this topic and some of them consider correct and consistent use of condoms as the most effective way of preventing pregnancy and STIs.

After stopping or removing many methods of birth control, including oral contraceptives, IUDs, implants and injections, the rate of pregnancy during the subsequent year is the same as for those who used no birth control.

Dual protection

Combining two birth control methods can increase their effectiveness to 95% or more, even for less effective methods. Using condoms with another birth control method is one of the recommended methods of reducing the risk of acquiring sexually transmitted diseases, including HIV. This approach is called a "dual protection" or "dual method" strategy to reduce such risk. Dual protection can be achieved by consistent use of condoms with another birth control method or by avoidance of penetrative sex.

Dual protection strategies may be aimed at avoiding pregnancy in dangerous medical situations. Using two forms of contraception is part of the risk management program for the anti-acne drug isotretinoin, which has an unusually high risk of causing birth defects if taken by pregnant women.

Health

Maternal mortality rate as of 2010

See also: Maternal health and Teenage pregnancy

Contraceptive use in developing countries has cut the number of maternal deaths by 44% (about 272,000 deaths averted in 2008) but could prevent 73% if the full demand for birth control were met. Birth control can also improve adult women's birth outcomes and child survival by lengthening the time between pregnancies.

Because teenage pregnancies, especially among younger teens, are at greater risk of many adverse outcomes including preterm birth, low birth weight, and infant mortality, adolescents need comprehensive sex education and access to reproductive health services, including contraception. Waiting until the mother is at least 18 years old before trying to have children improves maternal and child health. Also, if additional children are desired after a child is born, it is healthier for the mother and the child to wait at least 2 years after the previous birth before attempting to conceive (but not more than 5 years). After a miscarriage or abortion, it is healthier to wait at least 6 months.

Women who are over the age of 35 are at a higher risk of having a child with autism or Down syndrome. The chances of having multiple births increases, and they can cause further late-pregnancy risks. Older women have an increased chance of developing gestational diabetes, their need for a caesarian section is likely greater, and older women's bodies are not as well-suited for delivering a baby, as the risk of prolonged labor is higher.

Finances

Countries by fertility rate, according to the CIA World Factbook's 2012 data. (See List of countries and territories by fertility rate.)

  7–8 Children

  6–7 Children

  5–6 Children

  4–5 Children

  3–4 Children

  2–3 Children

  1–2 Children

  0–1 Children

See also: Family economics and Cost of raising a child

Birth control increases economic growth because of fewer dependent children, more women participating in the workforce, and less consumption of scarce resources. Women's earnings, assets, body mass indexes, and their children's schooling and body-mass indexes all substantially improve with greater access to contraception.

Family planning is among the most cost-effective of all health interventions. "The cost savings stem from a reduction in unintended pregnancy, as well as a reduction in transmission of sexually transmitted infections, including HIV." Childbirth and prenatal health care cost averaged US$7,090 for normal delivery in the US in 1996. US Department of Agriculture estimates that for a child born in 2007, a US family will spend an average of $11,000 to $23,000 per year for the first 17 years of child's life. (The total inflation adjusted estimated expenditure is $196,000 to $393,000, depending on household income.)

Providing the current level of contraceptive care in the developing world costs $4 billion yearly and saves $5.6 billion in maternal and newborn health service costs. To fully cover all need for modern contraceptive methods would cost $8.1 billion per year. . The effects of fulfilling the current unmet need for modern contraceptive methods would create a huge impact.

Prevalence

Percentage of women using modern contraception, according to the 2010 Save the Children State of the World's Mothers report. Each color represents a range of six percentage points, usage less than or equal to:

  6%

  12%

  18%

  24%

  30%

  36%

  42%

  48%

  54%

  60%

  66%

  72%

  78%

  84%

  86%

  No data

Globally approximately 45% of those who are married and able to have children use contraception. Avoiding sex when fertile is used by about 3.6% of women of child bearing age, with usage as high as 20% in areas of South America.

Developing countries

About 222 million women who want to avoid pregnancy in developing countries are not using a modern method of contraception. Many countries limit access to birth control due to the religious and political issues involved.

Africa

Main article: Birth control in Africa

In Sub-Saharan Africa, extreme poverty, lack of access to birth control, and restrictive abortion laws cause many women to resort to clandestine abortion providers to avoid unintended pregnancy, resulting in about 3% obtaining unsafe abortions each year. South Africa, Botswana, and Zimbabwe have successful family planning programs, but other central and southern African countries continue to encounter extreme difficulties in achieving higher contraceptive prevalence and lower fertility for a wide variety of compounding reasons. However, contraceptive use among women in Sub-Saharan Africa has risen from about 5% in 1991 to about 30% in 2006.

China

The Red Triangle indicates family planning products and services in many developing countries

The "one-child policy" of the People's Republic of China requires couples to have no more than one child. Beginning in 1979, the policy was implemented to control rapid population growth. Chinese women receive free contraception and family planning services. Greater than 70% of those of childbearing age use contraception. Since the policy was put into place in 1979, over 400 million births have been prevented. Because of various exemptions, the actual current fertility rate is about 1.7 children per woman, down from 5.9 in the 1960s. A strong preference for boys and free access to fetus sex determination and abortion has resulted in a high artificial abundance of males in both rural and urban areas.

India

Awareness of contraception is near-universal among married women in India. However, the vast majority of married Indians (76% in a 2009 study) reported significant problems in accessing a choice of contraceptive methods. In 2009, 48.3% of married women were estimated to use a contraceptive method, i.e. more than half of all married women did not. About three-fourths of these were using female sterilization, which is by far the most prevalent birth-control method in India. Condoms, at a mere 3%, were the next most prevalent method. Meghalaya, Bihar and Uttar Pradesh had the lowest usage of contraception among all Indian states with rates below 30%.

Pakistan

Main article: Family planning in Pakistan

In 2011 just one in five Pakistani women aged 15 to 49 used modern birth control. In 1994, Pakistan pledged that by 2010 it would provide universal access to family planning. but contraception is shunned under traditional social mores that are fiercely defended as fundamentalist Islam gains strength. Most women who say they do not want any more children or would like to wait a period of time before their next pregnancy do not have the contraceptive resources available to them in order to do so. In the 1990s, women increasingly reported to wanting fewer children, and 24 percent of recent births were reported to be unwanted or mistimed. The rate of unwanted pregnancies is higher for women living in poor or rural environments; this is especially important since two-thirds of women live in rural areas. While 96 percent of married women were reported to know about at least one method of contraception, only half of them had ever used it. The most commonly reported reasons for married women electing not to use family planning methods include the belief that fertility should be determined by God (28 percent); opposition to use by the woman, her husband, others or a perceived religious prohibition (23 percent); infertility (15 percent); and concerns about health, side effects or the cost of family planning (12 percent).

Industrialized countries

United Kingdom

Contraception has been available for free under the National Health Service since 1974, and 74% of reproductive age women use some form of contraception. The levonorgestrel intrauterine system has been massively popular. Sterilization is popular in older age groups, among those 45-49, 29% of men and 21% of women have been sterilized. Female sterilization has been declining since 1996, when the intrauterine system was introduced. Emergency contraception has been available since the 1970s, a product was specifically licensed for emergency contraception in 1984, and emergency contraceptives became available over the counter in 2001. Since becoming available over the counter it has not reduced the use of other forms of contraception, as some moralists feared it might. In any year only 5% of women of childbearing age use emergency hormonal contraception. Despite widespread availability of contraceptives, almost half of pregnancies were unintended circa 2005. Abortion was legalized in 1967.

United States

Main article: Birth control in the United States

In the United States 98% of women have used birth control at some point in time and 62% of those of reproductive age are currently using birth control. The two most common methods are the pill (11 million) and sterilization (10 million). Despite the availability of highly effective contraceptives, about half of US pregnancies are unintended. In the United States, contraceptive use saves about $19 billion in direct medical costs each year.

Usage of the IUD more than tripled between 2002 and 2011 in the United States. During the year ending August 2011, IUDs were 10.4% of all birth control methods provided by doctors, as women increasingly view the IUD as the most convenient, safe, and most effective yet reversible form of contraception. Additional benefits from using an IUD for birth control include lower risk of developing endometrial and cervical cancer.

History

Further information: Timeline of reproductive rights legislation

From ancient times women have extended breastfeeding induced lactational amenorrhea in an effort to avoid a new pregnancy.

Up to the 19th century

Ancient Mesopotamia, Egypt and Rome

Birth control and abortion are well documented in Mesopotamia and Ancient Egypt. One of the earliest documents explicitly referring to birth control methods is the Kahun Gynecological Papyrus from about 1850 BCE. It describes various contraceptive pessaries, including acacia gum, which recent research has confirmed to have spermatocidal qualities and is still used in contraceptive jellies. Other birth control methods mentioned in the papyrus include the application of gummy substances to cover the "mouth of the womb" (i.e. the cervix), a mixture of honey and sodium carbonate applied to the inside of the vagina, and a pessary made from crocodile dung. Lactation (breast-feeding) of up to three years was also used for birth control purposes in ancient Egypt.

Ancient silver coin from Cyrene depicting a stalk of silphium

Plants with contraceptive properties were used in Ancient Greece from the 7th century BCE onwards and documented by numerous ancient writers on gynaecology, such as Hippocrates. The botanist Theophrastus documented the use of Silphium, a plant well known for its contraceptive and abortifacient properties. The plant only grew on a small strip of land near the coastal city of Cyrene (located in modern day Libya), with attempts to cultivate it elsewhere failing. Its price increased due to high demand, leading to it being worth "more than its weight in silver" by the 1st century BC. The high demand eventually led to the extinction of Silphium during the third or 2nd century BC. Asafoetida, a close relative of siliphion, was also used for its contraceptive properties. Other plants commonly used for birth control in ancient Greece include Queen Anne's lace (Daucus carota), willow, date palm, pomegranate, pennyroyal, artemisia, myrrh, and rue. Some of these plants are toxic and ancient Greek documents specify safe dosages. Recent studies have confirmed the birth control properties of many of these plants, confirming for example that Queen Anne's lace has post coital anti-fertility properties. Queen Anne's lace is still used today for birth control in India. Like their neighboring ancient Greeks, Ancient Romans practiced contraception and abortion.

Religious texts

The Book of Genesis references withdrawal, or coitus interruptus, as a method of contraception when Onan "spills his seed" (ejaculates) on the ground so as to not father a child with his deceased brother's wife Tamar. The Talmud states that "there are three women that may cohabit with a sponge: a minor, a pregnant woman and one that nurses her child". Subsequent commentaries clarify that the "sponge" was an absorbent material, such as cotton or wool, intended to block sperm.

Ancient China

In the 7th century BC, the Chinese physician Master Tung-hsuan documented both coitus reservatus and coitus obstructus, which prevents the release of semen during intercourse. However, it is not known if these methods were used primarily as birth control methods or to preserve the man's yang. In the same century Sun Ssu-mo documented the "thousand of gold contraceptive prescription" for women who no longer want to bear children. This prescription, which was supposed to induce sterility, was made of oil and quicksilver heated together for one day and taken orally.

India

Indians used a variety of birth control methods since ancient times, including a potion made of powdered palm leaf and red chalk, as well as vaginal suppositories made of honey, ghee, rock salt or the seeds of the palasa tree. A variety of birth control prescriptions, mainly made up of herbs and other plants, are listed in the 12th century Ratirahasya ("Secret of Love") and the Anangaranga ("The Stage of the God of Love").

Early Islam

In the late 9th to early 10th century, the Persian physician Muhammad ibn Zakariya al-Razi documents coitus interruptus, preventing ejaculation and the use of suppositories to block the cervix as birth control methods. He describes a number of suppositories, including elephant dung, cabbages and pitch, used alone or in combination. During the same period Ali ibn Abbas al-Majusi documents the use of suppositories made of rock salt for women for whom pregnancy may be dangerous. In the early 10th century the Persian Polymath Abu Ali al-Hussain ibn Abdallah ibn Sina, known in Europe as Avicenna, included a chapter on birth control in his medical encyclopedia The Canon of Medicine, documenting 20 different methods of preventing conception.

Middle ages through industrialization

In modern Europe, knowledge of herbal abortifacients and contraceptives to regulate fertility has largely been lost. Historian John M. Riddle found that this remarkable loss of basic knowledge can be attributed to attempts of the early modern European states to "repopulate" Europe after dramatic losses following the plague epidemics that started in 1348. According to Riddle, one of the policies implemented by the church and supported by feudal lords to destroy the knowledge of birth control included the initiation of witch hunts against midwives, who had knowledge of herbal abortifacients and contraceptives.

On December 5, 1484, Pope Innocent VIII issued the Summis desiderantes affectibus, a papal bull in which he recognized the existence of witches and gave full papal approval for the Inquisition to proceed "correcting, imprisoning, punishing and chastising" witches "according to their deserts." In the bull, which is sometimes referred to as the "Witch-Bull of 1484", the witches were explicitly accused of having "slain infants yet in the mother's womb" (abortion) and of "hindering men from performing the sexual act and women from conceiving" (contraception). Famous texts that served to guide the witch hunt and instruct magistrates on how to find and convict so-called "witches" include the Malleus Maleficarum, and Jean Bodin's De la demonomanie des sorciers. The Malleus Maleficarum was written by the priest J. Sprenger (born in Rheinfelden, today Switzerland), who was appointed by Pope Innocent VIII as the General Inquisitor for Germany around 1475, and H. Institoris, who at the time was inquisitor for Tyrol, Salzburg, Bohemia and Moravia. The authors accused witches, among other things, of infanticide and having the power to steal men's penises.

Barrier methods such as the condom have been around much longer, but were seen primarily as a means of preventing sexually transmitted diseases, not pregnancy. Casanova in the 18th century was one of the first reported using "assurance caps" to prevent impregnating his mistresses.

Restrictive legislation on birth control was continually employed by European governments throughout the period of mercantilism and formed the backbone of the populationist strategy of this era. The mercantilists argued that a large population was a form of wealth, making it possible to create bigger markets and armies. The intense violence during the mercantilist era of the 17th and 18th centuries in Europe can be seen as a result of successful political implementation of population growth by means of restricting birth control, which created an enormous youth bulge. This youth bulge, as explained by the theory of that name, in turn fueled imperialist expansion of the European empires.

Birth control was a contested political issue in Britain during the 19th century. Malthusians were in favour of limiting population growth and therefore promoted birth control through organisations such as the Malthusian League, while the idea was opposed by a variety of groups, for different reasons, from the socialists to the established church.

Birth control movement

See also: Birth control movement in the United States

"And the villain still pursues her", a satirical Victorian era postcard

In the United Kingdom, birth rates declined from almost 35.5 births per 1,000 in the 1870s to about 29 per 1,000 by 1900. While the cause is uncertain, the 29% decline within a generation shows that the birth control methods Victorian women used were effective. The trial of Charles Bradlaugh and Annie Besant for republishing Charles Knowlton's The Fruits of Philosophy popularized the book and taught many women about contraception and how to avoid pregnancy. While the rhythm method was not yet understood, condoms and diaphragms made of vulcanized rubber were reliable and inexpensive.

Contraception was legal in the United States throughout most of the 19th century, but in the 1870s the Comstock Act and various state Comstock laws outlawed the distribution of information about safe sex and contraception and the use of contraceptives.

The phrase "birth control" entered the English language in 1914 and was popularised by Margaret Sanger and Otto Bobsein. Sanger was mainly active in the United States, but had gained an international reputation by the 1930s. The birth control campaigner Marie Stopes, who had opened Britain's first birth control clinic in 1921 and made contraception acceptable during the 1920s by framing it in scientific terms, also gained an international reputation. On opening their birth control clinic on 9 November 1921 at 153a East Street, Walworth, the Malthusian League commented that the clinic which Marie Stopes 'and her equally courageous and public-spirited husband' opened nine months earlier was the first in the British Empire (but not the first in the world). However, the League always emphasised that theirs was the first English clinic where birth control instruction was given under medical supervision. Their honorary medical officer was the influential birth control crusader, Australian-born Norman Haire. Two American researchers, Norman Himes and his wife Vera, said these two clinics 'opened up a new period in the history of the movement aimed at the emancipation of women from their slavery to the reproductive function'. They helped relatively few patients in 1921 but this was a victory and, as two British historians (Clive Wood and Beryl Suitters) made clear, 'the year was one of the most important in the whole history of birth control simply because of their very existence'.' Stopes was particularly influential in helping emerging birth control movements in a number of British colonies.

"Birth control" was advanced as an alternative to the then-fashionable terms "family limitation" and "voluntary motherhood." Family limitation referred to deliberate attempts by couples to end childbearing after the desired number of children had been born. Voluntary motherhood had been coined by feminists in the 1870s as a political critique of "involuntary motherhood" and expressing a desire for women's emancipation. Advocates for voluntary motherhood disapproved of contraception, arguing that women should only engage in sex for the purpose of procreation and advocated for periodic or permanent abstinence. In contrast, the birth control movement advocated for contraception so as to permit sexual intercourse as desired without the risk of pregnancy. By emphasising "control", the birth control movement argued that women should have control over their reproduction; the movement had close ties to feminism. Slogans such as "control over our own bodies" criticised male domination and demanded women's liberation, a connotation that is absent from family planning, population control and eugenics. Though in the 1980s birth control and population control organisations co-operated in demanding rights to contraception and abortion, with an increasing emphasis on "choice."

The societal acceptance of birth control required the separation of sexual activity from procreation, making birth control a highly controversial subject in some countries at some points in the 20th century. Birth control has become a major theme in feminist politics; reproduction issues are cited as examples of women's powerlessness to exercise their rights. In the 1960s and 1970s the birth control movement advocated for the legalisation of abortion and large scale education campaigns about contraception by governments. In a broader context birth control has become an arena for conflict between liberal and conservative values, raising questions about family, personal freedom, state intervention, religion in politics, sexual morality and social welfare.

Late 20th century

In 1965, the Supreme Court of the United States ruled in the case Griswold v. Connecticut that a Connecticut law prohibiting the use of contraceptives violated the constitutional "right to marital privacy". In 1972, the case Eisenstadt v. Baird expanded the right to possess and use contraceptives to unmarried couples.

In France, the 1920 Birth Law contained a clause that criminalized dissemination of birth-control literature. That law, however, was annulled in 1967 by the Neuwirth Law, thus authorizing contraception, which was followed in 1975 with the Veil Law. Women fought for reproductive rights and they helped end the nation's ban on birth control in 1965. In 1994, 5% of French women aged 20 to 49 who were at risk of unintended pregnancy did not use contraception.

The availability of contraception in the Republic of Ireland was illegal in the Irish Free State (later the Republic of Ireland) from 1935 until 1980, when it was legalised with strong restrictions, later loosened. This reflected Catholic teachings on sexual morality. In Italy women gained the right to access birth control information in 1970.

In the Soviet Union birth control was made readily available to facilitate social equality between men and women. Alexandra Kollontai, USSR commissar for public welfare, promoted birth control education for adults. A recent, well-studied example of governmental restriction of birth control in order to promote higher birth rates was the post-World War II Nicolae Ceauşescu era in Romania. The surge in births resulting from Decree 770 lead to great hardships for children and parents. In Eastern Europe and Russia, natality fell abruptly after the end of the Soviet Union.

Society and culture

Sandra Fluke reading her U.S. congressional testimony on why her Catholic university should be required to offer contraceptives in spite of their opposition to artificial birth control

Public policy

The Vatican's opposition towards birth control continues to this day and has been a major influence on U.S. policies concerning the problem of population growth and unrestricted access to birth control.

Recently, as an implementation policy of the 2009 Affordable Health Care for America Act, the Department of Health and Human Services developed a mandate to require all insurance policies to provide free contraceptives. In 2012, the GOP led an attempt to exempt insurance policies sponsored or paid for by religious institutions opposed to birth control on religious or moral grounds, from the mandate to provide free contraceptive care. The GOP opposition to this mandate is based on the view that it violates the "Free Exercise Clause" of the First Amendment of the U.S. Constitution. The bill was dismissed by the U.S. Senate by a vote of 51-48 along largely partisan lines and is viewed as a victory for President Barack Obama's health care law.

International law

Seven measures required by the human rights standards of international law for governments to eliminate unmet need for family planning and achieve universal access to contraceptive information and services have been put forwards:

Priority measures required by human rights standards and principles for governments to eliminate the unmet need for family planning:

National and sub-national plans for sexual and reproductive health education, information, and services, including family planning	Design plans, through a participatory process, to provide universal access (not only for married but also for unmarried people, adolescents, others marginalised by income, occupation, or other factors); to encompass all appropriate public, private, national, and international actors; and to include certain features, such as objectives and how they are to be achieved, timeframes, a detailed budget, financing, reporting, indicators, and benchmark measures.
Removal of legal and regulatory barriers	Remove barriers that impede access to sexual and reproductive health education, information, and services, including family planning, particularly by disadvantaged groups.
Commodities	Make available the widest feasible range of safe and effective modern contraceptives, including emergency contraception, as enumerated in a national List of Essential Medicines based on the WHO Model List and delivered through all appropriate public and private channels.
Community-based and clinic-based health workers	Train adequate numbers of health workers who are skilled and supervised to provide good quality sexual and reproductive health services, including full and accurate contraceptive information and modern contraceptives, using the local language and exercising respect for privacy, confidentiality, diversity, and other basic ethical and human rights values.
Health facilities	Provide health facilities that are clean, provide seating and privacy for user—provider interaction, are adequately stocked and equipped, adhere to published hours of services, and inform users of their rights.
Financial access	Provide state subsidies and community insurance schemes to allow access for people who would not otherwise be able to afford services.
Monitoring and accountability	Establish mechanisms that provide effective, accessible, transparent, and continuous review of the quality of services; assess progress toward equitable access and other objectives; and check that the commitments of all stakeholders are met.

Governments have a formal legal obligation to do all they reasonably can to put these measures in place as a matter of urgent priority, and failing to do so without a compelling reason places them in breach of binding international treaty obligations pertaining to health and human rights. Cottingham et al. recommend that governments, NGOs, health-care providers and citizen advocates act to compel enforcement of these obligations to secure the existence and support of effective and inclusive birth control policies, improve the quality of reproductive health services, and achieve universal access to reproductive health including family planning. Guidance and assistance are available to help meet these obligations. For example, a World Health Organization publication can help identify inconsistencies between national laws and international human rights obligations (e.g., denying unmarried women contraceptive services.) WHO staff can assist with removal of such barriers to access to and the provision of high quality sexual and reproductive health services, which can help meet the considerable remaining need for family planning.

The United Nations created the "Every Woman Every Child initiative" to asses the progress toward meeting women's contraceptive needs and modern family planning services. These initiatives have set their goals in terms of expected increases in the number of users of modern methods because this is a direct indicator that typically increases in response to interventions. In previous years, London began the London Summit on Family Planning in an effort to make modern contraceptive services accessible to an added 120 million women in the world's poorest 69 countries by the year 2020. A goal of this initiative is reduce the number of women who have an "unmet need" for modern methods. The Summit wants to eradicate discrimination or coercion against girls who seek contraceptives.

Another initiative is the Millennium Development Goals which was established in 2000 by 193 United Nations member states and 23 international organizations. There are eight goals aimed at reducing inequality. Of the 8 goals, the fifth is improving maternal health. The maternal mortality ratio in developing regions is still 15 times higher than in the developed regions. The maternal health initiative calls for countries to reduce their maternal mortality rate by three quarters by 2015. Eritrea is one of the four African countries said to be on track to achieve Millennium Development Goal. This means attaining a rate of less than 350 deaths per 100,000 births.

Sex education

Barbara Hastings-Asatourian of the University of Salford demonstrates "Contraception", a sex education board game played in UK schools.

Many teenagers, most commonly in developed countries, receive some form of sex education in school. What information should be provided in such programs is hotly contested, especially in the United States and United Kingdom. Topics include reproductive anatomy, human sexual behavior, information on sexually transmitted diseases (STDs), social aspects of sexual interaction, negotiating skills intended to help teens follow through with a decision to remain abstinent or to use birth control during sex, and information on birth control methods.

One type of sex education program used in some more conservative areas of the United States is called abstinence-only education, and it generally promotes complete sexual abstinence until marriage. The programs do not encourage the use of birth control, often provide inaccurate information about contraceptives and sexuality, stress failure rates of condoms and other contraceptives, and teach strategies for avoiding sexually intimate situations. Teen pregnancy rates are higher in students given abstinence only education, compared to comprehensive sex education. Abstinence-only sex education programs show an increase in the rates of pregnancy and STDs of a teenage population in randomized controlled trials. Professional medical organizations, including the AMA, AAP, ACOG, APHA, APA, and Society for Adolescent Medicine, support comprehensive sex education (providing both abstinence and contraceptive information) and oppose the sole use of abstinence-only sex education.

Cultural attitudes

According to Peter Mulira, "Reproduction in Africa is a cultural issue in which large families are seen as a source of free labour and wealth."

Many nations in Western Europe today would have declining populations if it were not for international immigration. The feminist movement has affected change in Western society, including education; and the reproductive rights of women to make individual decisions on pregnancy (including access to contraceptives and abortion).

A number of nations today are experiencing population decline. Growing female participation in the work force and greater numbers of women going into further education has led to many women delaying or deciding against having children, or to not have as many. The World Bank issued a report predicting that between 2007 and 2027 the populations of Georgia and Ukraine will decrease by 17% and 24% respectively.

Religious views

Main article: Religious views on birth control

Religions vary widely in their views of the ethics of birth control. The Roman Catholic Church officially only accepts natural family planning in certain cases, although large numbers of Catholics in developed countries accept and use modern methods of birth control. Protestants maintain a wide range of views from allowing none to very lenient. Views in Judaism range from the stricter Orthodox sect to the more relaxed Reform sect. Hindus may use both natural and artificial contraceptives. A common Buddhist view of birth control is that preventing conception is ethically acceptable, while intervening after conception has occurred or may have occurred is not.

In Islam, contraceptives are allowed if they do not threaten health, although their use is discouraged by some. The Quran does not make any explicit statements about the morality of contraception, but contains statements encouraging procreation. Prophet Muhammad also is reported to have said "marry and procreate".

World Contraception Day

The 26th of September is World Contraception Day, devoted to raising awareness of contraception and improving education about sexual and reproductive health, with a vision of a world where every pregnancy is wanted. It is supported by a group of international governments and NGOs, including Asian Pacific Council on Contraception, Centro Latinamericano Salud y Mujer, European Society of Contraception and Reproductive Health, German Foundation for World Population, International Federation of Pediatric and Adolescent Gynecology, International Planned Parenthood Federation, Marie Stopes International, Population Services International, the Population Council, the United States Agency for International Development (USAID), and Women Deliver.

Misconceptions

Modern misconceptions and urban legends have given rise to false claims. Here are the arguments against those false claims:

Douching with any substance immediately following intercourse does not work as a contraceptive. While it may seem like a sensible idea to try to wash the ejaculate out of the vagina, it is not effective for birth control. Due to the nature of the fluids and the structure of the female reproductive tract, douching most likely actually spreads semen further towards the uterus. Douching is neither a contraceptive nor a preventative measure against STDs or other infections.

A female can become pregnant the first time she engages in sexual intercourse, even if she has not yet had her firstperiod.

While women are usually less fertile for the first few days of menstruation, a woman can get pregnant if she has sex during herperiod.

No sexual position is more likely to lead to conception and no sexual position prevents pregnancy. Having sex while standing up or with a woman on top will not keep the sperm from entering the uterus. The force of ejaculation, the contractions of the uterus caused by prostaglandins in the semen, as well as ability of the sperm to swim outweighs the effect of gravity on sperm.

Though intrauterine devices are popular in many parts of the world, many people in the United States believe they are dangerous, probably in large part due to the widely publicized health risks associated with an IUD model called the Dalkon Shield. Recent models of the IUD, ParaGard and Mirena, are both extremely safe and effective.

Research

Females

• Praneem is a polyherbal vaginal tablet being studied in India as a spermicide, and a microbicide active against HIV.
• BufferGel is a spermicidal gel being studied as a microbicide active against HIV.
• Duet is a disposable diaphragm in development that will be pre-filled with BufferGel. It is designed to deliver microbicide to both the cervix and vagina. Unlike currently available diaphragms, the Duet will be manufactured in only one size and will not require a prescription, fitting, or a visit to a doctor.
• The SILCS diaphragm is a silicone barrier that is still in clinical testing. It has a finger cup molded on one end for easy removal. Unlike currently available diaphragms, the SILCS diaphragm will be available in only one size.
• A longer acting vaginal ring is being developed that releases both estrogen and progesterone, and is effective for over 12 months.
• Two types of progestogen-only vaginal rings are being developed. Progestogen-only products may be particularly useful for women who are breastfeeding. The rings may be used for four months at a time.
• A progesterone-only contraceptive is being developed that would be sprayed onto the skin once a day.
• Quinacrine sterilization (non-surgical) and the Adiana procedure (similar to Essure) are two permanent methods of birth control being developed.

Males

Main article: Male contraceptive

Other than condoms and withdrawal, there is currently only one common method of birth control available: undergoing a vasectomy, a minor surgical procedure wherein the vasa deferentia of a man are severed, and then tied/sealed in a manner which prevents sperm from entering the seminal stream (ejaculate). Several methods are in research and development:

• As of 2007, a chemical called Adjudin was in Phase II human trials as a male oral contraceptive.
• Reversible inhibition of sperm under guidance (RISUG) consists of injecting a polymer gel, styrene maleic anhydride in dimethyl sulfoxide, into the vas deferens. The polymer has a positive charge, and when negatively charged sperm pass through the vas deferens, the charge differential severely damages the sperm. An injection with sodium bicarbonate washes out the substance and restores fertility.
• Experiments in vas-occlusive contraception involve an implant placed in the vasa deferentia.
• Experiments in heat-based contraception involve heating the testicles to a high temperature for a short period of time. Ultrasound is the application of high-frequency sound waves to the testes, which can absorb the sound waves' energy as heat, leading to temporary infertility.
• Research on the safety and effectiveness of using ultrasound treatments to kill sperm has undergone since the idea originally came about following experiments in the 1970s by Mostafa S. Fahim which noticed ultrasound killed microbes and decreased fertility. As of 2012 a study conducted on rats found that two 15 minute treatments of ultrasound delivered 2 days apart in a warm salt bath effectively lowered their sperm count to below fertile levels. Further experiments on its effectiveness on humans, the longevity of the results, and its safety have yet to be conducted.

Other animals

Artificial contraception is now being considered as an alternative to hunting as a means of controlling the population of animals which overbreed.

Further reading

Note: courtesy links to titles may show a searchable edition earlier than the most recent published edition.

• Speroff, Leon; Darney, Philip D. (November 22, 2010). A clinical guide for contraception (5th ed.). Philadelphia, Pa.: Lippincott Williams & Wilkins. ISBN 978-1-60831-610-6.
• Hatcher, Robert A.; Trussell, James; Nelson, Anita L.; Cates, Willard Jr.; Kowal, Deborah; Policar, Michael S. (eds.) (November 1, 2011). Contraceptive Technology, 20th revised ed. New York: Ardent Media, 906 pages, ISBN 978-1-59708-004-0, ISSN 0091-9721, OCLC 781956734.
• Stubblefield, Phillip G.; Roncari, Danielle M. (December 12, 2011). "Family Planning", pp. 211–269, in Berek, Jonathan S. (ed.) Berek & Novak's Gynecology, 15th ed. Philadelphia: Lippincott Williams & Wilkins, ISBN 978-1-4511-1433-1.
• Jensen, Jeffrey T.; Mishell, Daniel R. Jr. (March 19, 2012). "Family Planning: Contraception, Sterilization, and Pregnancy Termination", pp. 215–272, in Lentz, Gretchen M.; Lobo, Rogerio A.; Gershenson, David M.; Katz, Vern L. (eds.) Comprehensive Gynecology, 6th ed. Philadelphia: Mosby Elsevier, ISBN 978-0-323-06986-1.
• World Health Organization, UNICEF, UNFPA, The World Bank (2012) Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA, and The World Bank Estimates. ISBN 978-92-4-150363-1

External links

• Birth control at Curlie
• Family Planning: A Global Handbook for Providers USAID, WHO, Johns Hopkins INFO Project, 2007
• Phisick Pictures and information about antique contraceptive methods
• Birth Control Comparison Chart 2008