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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  • Withdrawal (coitus interruptus): A method where sexual intercourse is interrupted and the penis is withdrawn from the vagina before ejaculation.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:

  1. starting a pack late, without using a back-up contraceptive method;
  2. taking the pills in the wrong order, out of sequence;
  3. interrupting use for any reason;

  4. 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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