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1) What are natural
methods of family planning?
2) How important is it to
use pills correctly?
3) The female condom: what
do we know?
4) Breakage and slippage
of male condoms: what do we know?
5)
Diaphragm FAQ
What
are natural methods of family planning?
- Periodic
abstinence: A group of methods
that are based on
 avoiding
sexual intercourse during the fertile time (time when a woman can
conceive.) A woman's fertile time is identified through observing,
recording and interpreting natural signs and symptoms associated
with the menstrual cycle. These methods include the calendar
(rhythm) method, cervical mucus (or ovulation) method, and basal
body temperature method.
-
- Withdrawal
(coitus interruptus): A method
where sexual intercourse is interrupted and the penis is withdrawn
from the vagina before ejaculation.
How do natural
methods of family planning work? (mechanism of action)
They prevent sperm from
uniting with an egg by avoiding intercourse around the time of
ovulation or by withdrawing the penis from the vagina before
ejaculation.
For whom are
natural methods of family planning appropriate?
- Couples willing and
motivated to learn how to observe, record and interpret the
woman's fertility signs
- Couples who accept
the potential for unintended pregnancy
- Couples with
no/little access to modern contraceptive methods
- Couples with
religious/philosophical reasons not to use other methods
- Women with regular
menstrual cycles
- Women unable to use
other contraceptive methods
- Men willing to
practice withdrawal
Advantages
- Have no medical side
effects
- Immediate return to
fertility
- Free and readily
available
- Use increases
knowledge of female reproductive physiology
- Use may improve
communication between partners
Disadvantages
- High failure rate
- Require high
motivation and ability to follow instructions
- Require partner's
cooperation
- Couple practicing
periodic abstinence must abstain from intercourse for a
significant period of time every month
- No protection from
STDs/HIV
- May be difficult to
detect a woman's fertile period (close to menarche, close to
menopause, during breastfeeding, or in women with irregular
cycles)
Follow-up and
Counseling
- Initial counseling
involves detailed instructions on how to identify the fertile
period
Provide
follow-up/additional counseling:
- Anytime client has
questions or concerns
- Every visit
(correct use of the method should be reinforced and client's
satisfaction with the method reviewed)
- Initial counseling
involves detailed instructions on how to identify the
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How
important is it to use pills correctly?
More
than 80 million women worldwide take "the pill" to prevent pregnancy.
Pills containing a combination of the hormones estrogen and progestin
have an annual failure rate of less than 1% if taken perfectly, that
is, one pill each and every day without interruption. However, life is
not perfect and pill users are no exception. Typical failure rates
among pill users are as high as 12% to 20% in some surveys. The
importance of helping women take the pill correctly is clear. Reducing
the number of oral contraceptive (OC) failures by only 1% would mean
800,000 fewer accidental pregnancies each year.
Correct and consistent use is essential to the effectiveness of
oral contraceptives. Incorrect OC use (often called "poor compliance")
is not always due to a woman's conscious decision to skip pills or
forgetfulness. It may be due to confusing, incorrect, or incomplete
information about how to take the pill, or how to handle missed pills.
It may be due to a desire to reduce side effects, lack of supplies, or
the belief that it is not necessary to take OCs if no intercourse is
anticipated for a week or two.
The four most common pill-taking errors are:
- starting a pack late,
without using a back-up contraceptive method;
- taking the pills in
the wrong order, out of sequence;
- interrupting use for
any reason;
-
not
using additional, back-up contraception when two or more pills are
missed.
Increasing the Likelihood of Correct Use
Appropriate counseling and education are crucial to correct and
continued use, especially for women just beginning to use OCs. Women
need to know how OCs work, how to take them correctly, what to do in
case of missed pills, warning signs for complications, and common side
effects and how to manage them.
Stressing the safety of OCs and their protective effects against
anemia and endometrial and ovarian cancer is also important to
reassure women who may believe OCs are dangerous.
Service providers can
take these steps to encourage effective use of pills:
- Ensure that providers
have accurate, understandable information about the pill. This is
essential for correct OC use. Providers need thorough training about
OCs, with regular review of informational materials to stay
up-to-date.
-
- Counsel clients about
all types of contraceptive methods and let them know they have a
choice of methods. If the woman chooses OCs, counsel her
specifically about the benefits and side effects of this method and
its correct use. If she has trouble taking the pill regularly, help
her switch to another method.
-
- Emphasize to women
that pills must be taken every day (except during the pill-free week
for women using 21-day packs), preferably at the same time each day.
-
- Urge users to wait no
more than seven days between packs of 21 days pills and to start
each 28 day pack immediately after finishing the last one. This is
because ovulation and conception are most likely to occur if the
hormone-free week is extended beyond seven days.
-
- Emphasize that when
two or more pills are missed in a row a woman should use a back-up
contraceptive method until she has been taking active, hormonal
pills again for at least seven days.
-
- Keep records on
individual users. This allows follow-up of those who have problems
with OC use or who do not return regularly for supplies.
-
- Provide multiple packs
of pills at a time, as well as a back-up contraceptive method such
as condoms or foam. This can help to compensate if clients
experience periodic difficulties in obtaining supplies and can help
women be prepared if they miss pills.
-
- New OC users can be
counseled alone or in groups but should be provided with printed
materials to take home. Illiterate women should have someone read
the materials to them. During subsequent client visits, providers
should question clients to determine their understanding of OC use,
to assess the problems they have experienced, and to correct
misunderstandings about how to take the pill.
Recommended OC
Instructions
Simple, effective instructions were pilot tested by Family Health
International in Mexico. Following are instructions that providers can
give to clients, based on that pilot testing and USAID's guidelines:
Starting the pill
Start the first pack
of pills within seven days of starting your menstrual cycle or at any
other time your provider is reasonably sure that you are not pregnant.
If you do not start your pills within seven days of starting your
period, you will also need a back-up method of birth control for the
first 7 days you actually take the pill. Condoms, foaming tablets or
abstinence are all methods that can protect against pregnancy during
the first week of use.
Managing missed
pills
- If you miss
one active pill, take that pill as
soon as you remember, then continue taking your pills as usual.
The active pills are
the 21 [specify COLOR] pills that contain the birth control
hormones. The inactive pills are the 7 [specify COLOR] pills that do
not contain hormones. The 7 inactive pills, found only in 28-day
packs, often contain iron for your blood. However, missing an
inactive pill does not increase your risk of pregnancy.
- If you miss
two or more active pills, in a row:
- continue taking the
remaining pills in the current pack, one each day, until the pack
is empty.
- use another, back-up
method of contraception (eg, condoms or abstinence) until you have
taken active pills again for 7 days in a row. These may be from
the next pack.
Conclusion
No drug can work
well if it is used improperly. To be effective, oral contraceptives
require daily use. As part of a broad effort to ensure good quality of
care, providers should offer clear instructions on how and when to
take pills. Counseling and education can help women take the pills
correctly and avoid an unplanned pregnancy.
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The
female condom: what do we know?
Design of the Female
Condom
The female condom is a
thin, soft, loose-fitting polyurethane plastic pouch that lines the
vagina. It has two flexible rings: an inner ring at the closed end,
used to insert the device inside the vagina and to hold it in place,
and an outer ring which remains outside the vagina and covers the
external genitalia. Because the device is made from polyurethane,
the female condom can be used with any type of lubricant without
compromising the integrity of the device. This is advantageous in
countries where personal, water-based lubricants are hard to find or
non-existent.
Results of User
Acceptability Studies
Product acceptability
is critical to the correct and sustained use of any method. FHI
studies of the female condom found that many women liked the device
and would recommend it to others. Women tended to accept the device
more favorably than did men. While women in general would recommend
the device to other women and felt fairly positive about it, many of
the women in the studies discontinued use due to partner objections.
Overall, difficulties of insertion decreased as experience with the
device increased, and use became more comfortable and acceptable
with practice.
The acceptability of the female condom can also be assessed by
examining the advantages and disadvantages cited by FHI study
participants.
Advantages
- Female-controlled
- More comfortable
to men, less decrease in sensation than with the male latex condom
- Offers greater
protection (covers both internal and external genitalia)
- More convenient
(can be inserted pre-coitus)
- Stronger
(polyurethane is 40% stronger than latex)
Historically,
contraceptive methods are more effective if they are controlled by
the woman with the support and acceptance of the method by the man.
Women in Cameroon, Kenya, Thailand and Malawi all cited control over
their own health as a positive aspect of the female condom. Female
condoms do not constrict the penis as do latex condoms. As a result,
sensitivity of the male partner may not be substantially reduced; no
loss of sensitivity was reported by study participants in Kenya and
Malawi. Since the device covers both the internal and much of the
external female genitalia, as well as providing a barrier between
the male and female sex organs, it may offer greater protection
against STD. Participants in Kenya, Thailand, and Cameroon all said
STD protection was important; those in the African studies also
perceived the device to be either durable, strong, efficacious, or
an effective alternative to the male condom, or some combination of
the four. Finally, the female condom was perceived as more
convenient because it can be inserted well in advance of
intercourse. For a woman at high risk of STD, the female condom
provides a prophylactic option should her partner refuse to use a
male condom.
Disadvantages
- Not aesthetically
pleasing
- Difficulties in
insertion/removal
The major disadvantages
of the device noted by study participants centered around one of the
female condom's major advantages; coverage of the external female
genitalia. This coverage had a decidedly negative impact on the
device's aesthetics and acceptance. Other problems related to
aesthetics included dislike of the appearance of the device, noise
associated with use, size and partner resistance. Some participants
noted difficulties associated with insertion or removal of the
female condom, discomfort, messiness and inconvenience associated
with use, and movement of the device during use. A few cases of the
penis slipping between the device and the woman's body, and slippage
and breakage of the device itself were also noted. While not a
factor in FHI studies, female condoms are relatively expensive. This
may be a factor limiting their acceptability for large numbers of
women.
Conclusions
While condoms are
becoming increasingly important as a method to slow sexually
transmitted disease, acceptance of the female condom is limited
because of real and perceived drawbacks inherent in the method. The
concept, appearance and use of the female condom is still unfamiliar
to most couples worldwide, and perceptions are apt to change
significantly as the female condom is more widely used. Attitudes
may become more favorable.
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Breakage and slippage of male condoms: what do we know?
How
frequent is condom breakage/slippage? Recent international research
indicates that male condom breakage ranges from zero to 12 percent,
with many of the US-based studies falling in the two to five percent
range. The percent of condoms that slip off the penis during or after
intercourse is in a similar range.
A Family Health International (FHI) study has shown that most condom
users rarely experience condom breakage and/or slippage. A small group
of users is often responsible for a majority of the breaks and slips.
In the study, 177 couples used 1,947 condoms and reported a combined
breakage/slippage rate of 8.7 percent. If every couple were equally
likely to experience condom breakage/slippage, then each couple would
have been expected to have about 1 out of 11 condoms either break or
slip off. However, in this study, 16 couples (less than 10 percent of
participants) were responsible for 50 percent of all the
breakage/slippage. Well over half the couples did not experience any
condom breakage/slippage among the 11 condoms each couple used.
In this study, four
factors for men were significantly associated with increased condom
breakage and slippage:
- no condom
experience in the past year;
- condom breakage in
the past year;
- not living with
partner;
- 12 or fewer years
of schooling.
Several other reasons
for condom failure have been mentioned in the literature:
- opening the
package with sharp objects or teeth;
- incorrect methods
of putting on the condom, such as pulling it on like a sock;
- use of oil-based
lubricant;
- lengthy and
vigorous intercourse;
- using condoms for
non-vaginal intercourse;
- not holding rim of
condom during withdrawal;
- re-use of condoms.
In addition to
presenting overall percentages of breakage and slippage, it also may
be informative to present their distribution among study
participants (i.e., the percentage of users with no breaks, the
percentage with one break, etc.). This illustrates that for a
majority of condom users, condom breakage and slippage are rare
events.
It is equally important to understand that not all breakage/slippage
exposes the condom user to the same risks. Researchers have begun to
distinguish between clinical and non-clinical breakage. Clinical
breakage occurs when condoms break during intercourse or withdrawal
and are the only type of break that directly put the couple at risk
of pregnancy and/or sexually transmitted diseases (STD). Nonclinical
breaks occur when opening the package and putting on the condom and
do not expose the couple to pregnancy or STD. In a recent review of
ten FHI condom studies, about one-third of the breaks were
classified as non-clinical.
Although the condom literature mentions relatively high breakage and
slippage rates, it is important to remember that:
- these rates may be
caused by certain behaviors and certain characteristics of a very
small proportion of users;
- about one-third of
the breaks do not put the users at risk of pregnancy and disease
transmission because they occur prior to intercourse.
Condoms are an
effective method of preventing pregnancy and sexually transmitted
diseases if they are used correctly and consistently during each act
of intercourse. The dissemination of condom use instructions must be
a high priority in service delivery programs to assure that maximum
protection is provided by the use of condoms.
Condom Instructions
A multitude of
condom instructions have been developed over the years by various
organizations. The following instructions are based on recent FHI
research findings.
Follow these guidelines for proper use:
- Carefully open
package so condom does not tear.
- Do not unroll
condom before putting it on.
- Put the condom on
end of hard penis.
- Unroll condom
until it covers all of penis.
- Always put condom
on before entering partner.
- After ejaculation
(coming), hold rim of condom and pull penis out before penis gets
soft.
- Slide condom off
without spilling liquid (semen or come) inside.
- Throw away or bury
condom.
Other
considerations:
- Do not use grease,
oils, lotions or petroleum jelly to make condoms slippery, only
use a jelly or cream that does not have oil in it.
- Use a condom each
time you have sex.
- Use a condom only
once.
- Store condoms in a
cool, dry place.
- Do not use condoms
that may be old or damaged; do not use a condom if:
- the package is
broken
- the condom is
brittle or dried out
- the color is
uneven or changed
-
it is
unusually sticky
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Diaphragm FAQ
What is a diaphragm?
The diaphragm is a
soft latex rubber cup that should be used with spermicidal jelly or
cream. A woman inserts a diaphragm into her vagina, fitting it over
the cervix, shortly before sexual intercourse and leaves it in place
for at least 6 hours after intercourse.
How does a diaphragm
work? (Mechanism of action)
- The diaphragm
blocks sperm from entering the uterine cavity
- Spermicides
provide additional protection by damaging the sperm
Who can use a
diaphragm?
Women of any
reproductive age and parity who:
- Want to use this
method of contraception
- Have no
contraindications
Who should not use a
diaphragm?
(For more information
see WHO eligibility criteria)
Women who have the
following conditions (contraindications):
- Are less than 6
weeks postpartum
- Allergy to latex
- History of toxic
shock syndrome
- Certain anatomical
abnormalities of the cervix and vagina
Advantages
- Woman-controlled
method
- Possible to use
without a male partner's knowledge
- Offers contraception
only when needed
- Effective if used
correctly with every act of sexual intercourse
- Has no systemic side
effects
- No impact on
lactation
- Can be stopped any
time
- Can be inserted up
to 6 hours before sex to avoid interrupting sex
- Provides some
protection from STDs
- Reduces risk of
cervical neoplasia
- Contains menstrual
flow when used during menses
Disadvantages
- Requires fitting by
a family planning provider, involving a pelvic examination
- A woman may need a
different size diaphragm after childbirth
- Requires having the
method on hand and taking correct action before each act of sexual
intercourse
- Less effective
contraception than IUDs or systemic methods
- Interrupts sex if
not inserted beforehand
- May be messy to use
- Possible side
effects (usually local irritation) or allergic reaction to latex
(rare)
- Should be washed
with soap and clean water after each use
- Needs careful
storage to avoid developing holes
- Requires a steady
supply of spermicide
Possible side
effects
- Can cause local
irritation, itching, vaginal wall lesions if ill-fitting
- Increases risk of
urinary tract infections
Provide follow-up
and counseling for:
- Any client concern
- Possible side
effects
- Importance of
correct and consistent use
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