Objectives: Background-Contraception is the intentionalprevention of conception through the use of various devi-ces, sexual practices, chemicals, drugs or surgical proce-dures. An effective contraception allows a physicalrelationship without fear of an unwanted pregnancy andensures freedom to have children when desired. The aim isto achieve contraception in maximum comfort and privacy,with minimum cost and side effects. Some methods, likemale and female condoms, also provide twin advantage ofprotection from sexually transmitted diseases. The burdenof unsafe abortion lies primarily in developing countries.Here, contraceptive prevalence is measured among cur-rently married women of reproductive age, and levels havenot yet reached those that exist in developed countries.
Conclusion: In countries like India, there is a dire need forcontraceptive methods to be more women friendly, acces-sible and provide adequate privacy. Providers also need to be sensitive to special needs of adolescents as they are at acritically vulnerable segment.
Keywords : Contraception, Condoms, Vasectomy, Tubectomy, STDs
Contraception is defined as the intentional prevention ofconception through the use of various devices, sexual prac-tices, chemicals, drugs, or surgical procedures. Thus, anydevice or act whose purpose is to prevent a woman frombecoming pregnant can be considered as a contraceptive. Inany social context effective contraception allows a couple toenjoy a physical relationship without fear of an unwantedpregnancy and ensures enough freedom to have children whendesired. The aim is to achieve this with maximum comfort andprivacy, at the same time minimum cost and side effects.Some barrier methods, like male and female condoms, alsoprovide twin advantage of protection from sexually trans-mitted diseases (STDs).
Protection Against Unwanted Pregnancy
A growing number of women and men of reproductive agewish to regulate their fertility and have fewer children. Between the ages of 20 and 44, a fertile, sexually-activewoman is potentially capable of giving birth about 12times, even if she breastfeeds each baby for 1 year. Toavoid the need for an abortion, she has to successfullypractice birth control for 16–20 of her roughly 25 child-bearing years [1].
Couples are faced with conflicting goals of achievingsatisfying sex life and keeping a small family, failure to doso results in unwanted pregnancy and abortions. Whenabortion seeking is risky, late or in the hands of unsafeproviders or unhygienic conditions, it can lead to bothreproductive morbidity and maternal mortality. Worldover, if contraception is accessible and used consistentlyand correctly by women wanting to avoid pregnancy,maternal deaths would decline by an estimated 25–35%[2,3]. In India, the surveys suggest that abortions areresponsible for 10–20% of all maternal deaths [4]. There isa need for awareness regarding effective contraceptivemethods, their correct and consistent use.
Need for Protection Against Sexually TransmittedDiseases
The transmissibility of several STIs and HIV/AIDS isgreater from infected man to uninfected woman than thereverse [5]. The vagina offers a large mucosal surfaceexposed to the partner’s sexual secretions and a moreconducive environment for microbial growth than thepenile surface in men, therefore biologically, women aremore vulnerable to STIs than men. Since the infected semenstays in the vagina for a while, a man can infect the womanmore effectively. Also semen contains higher concentrationof virus than the woman’s sexual secretions. Thus, men aretwice more effective as transmitters of STIs than women.
Vulnerability of Adolescents
Usually younger women, married or unmarried, are lesslikely to be using contraception than older women, even incountries where contraceptive prevalence rate (CPR) ishigh [6]. At macro level, laws, regulations and socialpolicies that determine the access to contraception, affectadult and adolescent women alike in terms of the types ofcontraceptives that are permitted for distribution or pre-scription. But at the micro level, there are differencesbetween adolescents and adult women, in fertility level,maturity, knowledge, negotiation in sexual relations andexperience, coupled with social expectations affecting theirbehavioral patterns, as they relate to contraceptive accep-tance and use. This increases their vulnerability to unpro-tected sex and its adverse consequences manifold.
Early sexual debut for adolescent girls means that chan-ces of exposure to infections begin even before completingthe process of physiological maturation. Though the systemshave begun to function, the defense mechanisms are stillevolving, particularly of the cervix. The cervical mucus actsas non-specific barrier for various ascending organisms inadult women. Adolescents do not have the benefit of thismucosal defensive mechanism till several years after men-arche [7–9]. This increases their susceptibility to infectionup to six times compared to their adult counterparts, par-ticularly gonorrhoea, chlamydia and HIV [10].
Known methods of contraception include the following:
Traditional Methods
Coitus Interruptus or Withdrawal
Involves withdrawal of penis from the vagina just beforeejaculation, thus preventing semen from entering thewoman. This is perhaps the oldest contraceptive methodknown to man, but it depends on the cooperation of themale partner. This is not a reliable method and may fail ifsemen escapes before ejaculation or is left on external sexorgans. Man needs good self-control, both emotionally andphysically, for this method to succeed.
Lactational Amenorrhoea Method
Nursing women secrete hormones that prevent conceptionfor about 6 months. It prevails if there is no menses andfull breast-feeding day and night is maintained. This ismore a myth as, breast-feeding is irregular, 60% womenstart menstruating by the third month. Not reliable ininstances where baby sleeps through the night, or in case ofsore, cracked or inverted nipples and breast abscess. Manyunsuspecting women conceive during this period beforereturn of menstruation.
Rhythm Method
This method requires predicting ovulation, the period whenthe woman is most fertile, by recording the menstrualpattern, or body temperature, or changes in cervical mucus,or a combination of these (symptom-thermal method).Intercourse is avoided on fertile days. Although a largenumber of people claim knowledge of this method, only asmall proportion can actually identify the fertile period ofthe month. It cannot be used by women who have irregularperiods, or after childbirth, or during menopausal years.Intercourse is limited to some days of the month only. The method requires careful record keeping for calculating thesafe period.
Modern Methods
Male Condom
In this, a thin rubber or latex sheath (condom) is rolled onthe erect penis before intercourse. It prevents semen(sperms) from entering the woman. The method is 95%effective if used correctly. It can be used by all age groups,safely. No prior medical examination is required and iseasily available without prescription. It serves as the mosteffective method in providing twin protection of contra-ception and STI disease. The major drawback in thismethod is related to compliance, inconsistency and incor-rect use. Total use by men in India varies from 2 to 14% inPunjab and 18% in Delhi [11]. There are disadvantagesintrinsic to this method, as it may tear or slip if not usedproperly. Expired or perforated condoms should not beused. Extra supply should be maintained in readinesswhenever required.
Female Condom
This is a vaginal pouch made of latex sheath, with one ringat each end. The closed end ring is inserted inside thevagina and works as the internal anchor. Outer portioncovers and protects the external genitalia. It is reliable,hypo-allergic with high acceptance in test groups althoughits cost could be a major deterrent to use. It is a femalecontrolled method and protects from both unwanted preg-nancy and STDs. Size and hardness of inner ring may beuncomfortable to some users. Extensive promotion andpersuasion among female users is required to make itpopular.
Oral Contraceptive Pills
The combined pill consists of two hormones: estrogen andprogesterone. This is to be taken everyday orally by thewoman. The pill works by preventing the release of theegg, thickening of cervical mucus and by altering tubalmotility. It is to be prescribed after a medical check-up.Almost 100% effective if taken regularly. It is an easy andconvenient, woman-controlled method and does not inter-fere with love-making. There is regular monthly cycleoften with reduced pain and bleeding. Can be discontinuedwhen pregnancy is desired. The pills must be taken regu-larly and do not work when consumed later than 12 h. Thepills are unsuitable for women over 35 years or those withfamily history of heart, liver diseases, hypertension, dia-betes or unexplained vaginal bleeding. Failure rates arehigher in younger, less educated women. Adolescents areless likely to take pills correctly and consistently.
Injectables
These inhibit ovulation and also increase the viscosity ofthe cervical secretions to form a barrier to sperms. It is a99% effective, easily administered method, suitable duringlactation too. It has non-contraceptive advantages, likerecession of ovarian cysts or breast lumps. Menstrual cyclemay become irregular, spotting or cease altogether as longas the injectables are used. There may be gain in weightand return to fertility may take time. Subsequent injectionsshould not be delayed more than 2 weeks from the pre-scribed date. Counseling and support are needed forwomen when this method is chosen.
Emergency Contraceptive Pill
Here, two doses of the pill, separated by 12 h, are takenwithin 3 days (72 h) of unprotected intercourse. Dependingon the time of menstruation it is taken, it can preventovulation, fertilization or implantation of the fertilized egg.It is available without prescription. Its uses include-pre-vention of pregnancy after condom tear/slips, when twooral pills are missed in succession, when an intra-uterinedevice is expelled and there is fear of conception, in caseinjectables are delayed by more than 2 weeks.
Surgical Methods
Intrauterine Devices (IUDs)
A small flexible, plastic device, usually with copper, isinserted into the womb by a qualified medical practitioner,after menstruation, abortion, or 4-6 weeks after delivery. Itprevents the fertilized egg from settling in the womb.Copper ions have spermicidal activity. It is 95–98%effective, does not interfere with love-making and can beremoved when pregnancy is desired. It may cause heavybleeding in some women. Pelvic inflammation in women,especially those exposed to STDs, may occur. Sometimesthe IUD loosens and detaches and hence should be checkedperiodically. It may increase risk of ectopic pregnancy. It isunsuitable for women with cervical or pelvic infection,uterine fibroids, heavy menstruation, or unexplained vagi-nal bleeding.
Female Sterilization (Tubectomy)
This is a permanent surgical method in which the fallopiantubes are cut and ends tied to prevent the sperms frommeeting the eggs. It is a very reliable method requiring only 1 day of hospitalization and can be performed anytime,preferably after last child’s birth. Rarely, the tubes may joinand fertility may return. A few women tend to have heavierperiods after this method. Though this is a permanentmethod, the operation can be reversed, though the resultsmay not be always successful. Hence the couple should befirm about their decision before opting for this method.
Male Sterilization (Vasectomy)
A permanent surgical method in which, the vasa deferentiawhich carry the sperms from the testes to the penis, areblocked. This prevents the sperms from being released intothe semen at the time of ejaculation. It is a simple andreliable method not requiring hospitalization. Contrary topopular belief, it does not affect health or sexual vigour,neither does it interfere with intercourse.
Methods Available in Many Developed Countries
Diaphragm and Spermicides (Barrier/Chemical Method)
A soft rubber cap is fitted into the vagina shortly before theintercourse, to cover the cervix, thus preventing spermsfrom entering the uterus. It must be left in place for at least6 h after intercourse. The method is much more effective,when used in combination with a spermicidal cream toinactivate the sperms. It does not interrupt love-making andcan be used a few hours before intercourse. Insertion andremoval are simple, once learnt from the doctor and thereare no complications after use. The user must use addi-tional spermicides if more than 3 h elapse between inser-tion and intercourse. The cap must be inserted before everyintercourse. Different sizes suit different women and acorrect size should be used. Size may change after child-birth or if there is weight gain or loss of more than threekilograms and so, must be checked every 6 months.Medical assistance is necessary to select right size andlearn how to insert and remove it.
Implants-Hormonal
The Norplant capsule is implanted below the skin by minorsurgery. It suppresses ovulation, creates thick cervicalmucus which prevents sperms from entering the cervix andalso creates a thin, atrophic endometrial lining. It is notrelated to coitus. It is suitable for women seeking contin-uous contraception. Its effect lasts for approximately5 years and therefore it becomes a long term birth spacingmethod. When the capsule is removed using minor surgery,fertility is restored in 2–4 months. The woman must visitthe clinic 2–3 times a year for periodic check-up. Notsuitable for women with threatened malignancy of breast,cervix, uterus or ovaries, those suffering from blood dis-orders or heart diseases, pregnant or suspected to bepregnant women and also those suffering from liverinfections and diseases.
Hormonal Contraception for Men
Hormonal approaches, which employ formulations of tes-tosterone administered in combination with other hor-mones, have shown considerable promise in clinical trials,and they are currently at the forefront of research anddevelopment. However, the long-term effects of usinghormones throughout a male’s reproductive life for con-traception are unknown, and it may take time before thisinformation becomes available [12].
Global Trends in Contraceptive Use
In many developing countries contraceptive prevalencemeasured among currently married women of reproductiveage have been growing rapidly, but have not yet reached thelevels that exist in the developed countries. Unsafe abortionrates are highest in Africa, Latin America and the Carib-bean, followed closely by South and South-East Asia, whilein Europe and North America the rates are negligible.
Traditional Methods
The proportion of traditional methods changed markedlyover time in Sub-Saharan Africa. In surveys conducted in1980–1984, 56% of users in this region reported employingtraditional methods, while in 2000–2005 it declined to31%. Traditional methods represented a much smallerproportion of the method mix in Asia (decreased from 13 to9%) and in Latin America and the Caribbean, where itdecreased from 18 to 12%, respectively. India’s currentdependence on traditional methods is comparable to theAsian figures at 7.8% (Fig.1).
Oral Pill
Overall, the proportion of all users relying on the pill fell,but the most dramatic decline—from 31 to 18%—occurredin Latin America and the Caribbean. In India utilization ofthis method is poor at 3%. In developed nations it is 25% ofcontraception.
Condoms
The proportion of married female contraceptive usersrelying on condoms rose in Latin America and the Carib-bean, as well as in Sub-Saharan Africa, from 3% in theearly 1980s to 7–8% in 2000–2005. While condom use is slowly increasing in developing countries, it has fallenfrom 8 to 7.7% in the developed world. India’s share toofalls below the figures of developing countries.
Intra Uterine Devices (IUDs)
The proportion of IUD use decreased in Asia from 27.9 to22.8%. According to NFHS 3 the IUD segment is currentlybeing used by only 1.7% of married women.
Injectables
There was a small increase in Asia, Latin America and theCaribbean. The proportion of users relying on injectablesclimbed steadily over those using the pill. But, in India it isgrossly underutilized at 0.1%.
Sterlization Male
Women’s reliance on male sterilization for contraceptionwas low in all periods, with figures below 3% for allperiods. In Asia, however, the proportion of users relyingon vasectomies rose to 9% in 1990–1994, before droppingback to 5% in 2000–2005. This drop is contributed by threeAsian countries (viz., from 9 to 4% in India, from 19 to16% in Nepal and from 8 to 6% in Sri Lanka.
Sterilization Female
For the past 26 years, female sterilization has accounted forat least one-third of all contraceptive use in Asia, LatinAmerica and the Caribbean (where it peaked at 48% in1990–1994). In Asia, female sterilization rose from 34% in1980–1984 to 42–43% in 1985–2005. In contrast, the shareof female sterilization remained fairly level at 5–8% inSub-Saharan Africa and developed countries. As is evidentit is the favoured method in India at 37. 3%.
In India, in order to achieve demographic targets the stressis on terminal surgical methods, applicable to women whohave finished their child-bearing. Sterilization particularlyof female, dominates all modern methods used [11–14].Adolescents on the other hand have their reproductivecareers ahead of them, their needs are rather to postpone orspace pregnancies, which requires reversible and non-invasive methods. There is a shift from terminal toreversible methods. The focus on termination of fertilityhas led to an induced reduction in reproductive span ofyoung Indian women.
The explanations for delaying, underutilization andfailure to use contraception appear to be numerous andcomplex (Fig.2).
Personal
The intrinsic characteristics of the adolescent associatedwith contraceptive decision-making:
Inadequate Cognitive Capacity
A relationship requires logical, systematic and deductivedecision-making to deal with various possibilities andconsequences. In pre-adolescence, concrete thinking doesnot allow for complete understanding of risks involved insexual indulgence. Only when the adolescent moves from concrete to more abstract thought processes, he or she isable to engage in responsible sexual decision-making.
Ego-Centric Thinking
Olson and Rollins [15] have used the Elkind theory, toargue that the very immature and impulsive adolescent islikely to be dominated by a form of egocentric thinking,which leads her to believe that ‘‘it can’t happen to her’’.This leads them to take chances that their older counter-parts will not take.
Lack of Contraceptive Knowledge
Chhabra in her study of abortion-seeking unmarried girlsreported that 88% did not know the link between sexualrelations and pregnancy [4]. Although most ever married adolescents know of at least one method of contraception(90%), this is most likely to be sterilization, which isunsuitable for the adolescents.
Anxiety
The cognitive problems are further accentuated by anxietyrelated to indulging in socially disapproved activity, whichprevents adolescents from seeking reliable advice. Lack ofessential sexual information increases anxiety and inter-feres with appropriate use of contraception resulting incontraceptive failure.
Misconceptions and Misinformation
Research on relation between adolescents’ knowledge ofbirth control and their utilization of contraception indicatesthat most sexually active adolescents in urban settingsknow about contraception but this apparent knowledgedoes not predict the actual use of birth control during coitalactivity [16]. Misconceptions about the safe period, pos-sibility of conceiving without breaking hymen or in singlechance are reasons for failure to use contraception.
Perception of Dangers of Contraceptives
The beliefs regarding dangers of birth control are distinctfrom actual exposure to birth control information anddevices. Olson and Rollins [15] found that adolescentsbelieved that condoms and IUDs could move upwards inthe woman’s body and cause complications or pills causepermanent infertility.
Lack of Maturity to Follow a Method Sincerely
Most adolescents’ understanding of a method is usuallyincomplete and confused, contraceptive failure therefore ishigher in adolescents compared to adult women. Adolescentsfind it difficult to take a pill everyday, at the same time, in anorderly manner and maintain a continuous supply of pills.
Partner Related
Partner-related failure mostly pertains to condom use or anindifference towards what their girl friends or wives resort to,and disadvantages of these methods in disease protection.
Loss of Pleasure
Generally men report that condoms reduce the pleasure ofsexual intercourse [17,18]. Interruption in foreplay is asource of displeasure. The thickness of the sheath reducessensation and lack of lubrication makes it uncomfortable, and may cause vaginal irritation in female partners [19].Commercial brands have brought thinner, textured andbetter lubricated varieties but they are expensive. Thesefeatures, however, have increased acceptability in themiddle and upper income groups.
Ego-Centric Thinking (Male)
Like women, younger men, are also prone to unreasonableoptimism, a form of egocentric thinking which leads themto believe that they can avoid pregnancy solely dependingupon natural methods.
Lack of Knowledge Regarding Proper Use
Most men do not know the right method to put on and takeoff a condom, and are shy to ask reliable sources. Condomis perceived as required by men with deviant sexual ten-dencies or those frequenting sex workers [20].
Faulty Use
Use of condoms requires that the penis should enter thevagina only after being protected and left when it is stillerect and by holding the condom rim to avoid spillage backinto the vagina. Often men enter unprotected during fore-play during this period little quantity of semen is producedthat may cause pregnancy. Also condoms should be usedwith water-soluble lubricants. Petroleum jelly and Vaselineweaken or perforate the condom and render it useless [19].
Faulty Storage
People often hide condoms from children and family membersby storing in cupboards, under clothes or mattresses, where dueto pressure, heat and humidity, their quality deteriorates [19].
Perceived Unavailability
Young men usually express ignorance of places to findcondoms or that they cannot afford the expenditure, but failto access the public health facilities where these areavailable openly and free of cost [21].
Embarrassed to Buy
Partners often avoid use of condoms due to the embar-rassment of purchasing them.
Not Required With Wives or Steady Girlfriends
There is a general belief that condom need only be used inrisky relations like, with sex workers. Men rely mostly onnatural methods with wives and steady partners [19]. Attimes condoms are used in the beginning of the relationshipbut gradually women are persuaded to shift to femalemethods [22].
Interpersonal
There are several other reasons that influence the decisionto use or skip contraception.
Lack of Planning
The episodes of sex occur at times without planning, fol-lowing dates, parties or use of alcohol. Couples also forgetto carry condoms/pills when they travel.
Sex is not Regular but Episodic
At times when the male partner lives away, visits areerratic and pills are discontinued. [23].
Lack of Spontaneity
The adolescents complain that wearing a condom interruptslove-making and the spontaneity of the occasion is lost.
Social Implications
Women fear that asking a partner to use condom before sexwould imply she is loose. Male claims that carrying acondom gives an impression, as if he had planned to havesex and tricked the partner into it [24].
Poor Negotiation
Women are usually more motivated to protect themselvesagainst disease and pregnancy, yet men often return theirresistance to refuse unprotected sex, with emotional orphysical abuse [25]. Compared to sex workers, steadypartners resign because unmarried women cannot afford tolose the partner and married women are socially and eco-nomically dependent on them [26].
Method Related
Poor Quality of Condoms
Condoms may fail due to poor quality, faulty packaging orstorage and transit. Sometimes sealing machines might sealthe pack such that the condom is pressed too; at times sealis incomplete and lubricant dries up [21].
Disadvantages Intrinsic to Methods
Every method has some disadvantages associated with it,which interferes with people successfully using it andresult in discontinuation or faulty use.
Service Related
Actual Unavailability
Often there is erratic supply of condoms and pills at healthcenters [19].
Provider Stress on Terminal Methods
Providers are preoccupied with completing demographictargets and older clients are focused upon to accept ter-minal methods. They do not offer them complete infor-mation on choice of methods available [27–29].
