Nearly one-fifth of the worldwide burden of illness and early death among all people – men and women – is due to poor sexual and reproductive health.  Worldwide, among women of reproductive age, it is one-third.  That’s one-third of all illness and early death, stemming largely from problems related to pregnancy and to sexually transmitted infections, including HIV/AIDS.[1]

 

I.                    Introduction

 

Contraception also known as birth control generally refers to any plan or method used to alter or avoid the body's natural state of fertility, thereby preventing or reducing the probability of pregnancy without abstaining from sexual intercourse; the term is also sometimes used to include abortion and natural family planning.[2] The term family planning is normally considered a synonym for the term birth control.[3] According to UNESCO, family planning is a health service that helps couples decide whether to have children, and if so, when and how many.[4]  Therefore, family planning encompasses a wide range of services and educational outreach which provide women and men more control over and knowledge about their sexual lives and reproductive goals as well as protecting themselves and their partner’s health and safety from unintended pregnancies and sexually transmitted diseases (STDs), particularly HIV/AIDS.  This chapter will provide a comprehensive overview of contraceptive technologies, what is available today and what is being researched.

 

II.                 Current contraceptive technologies

 

Successful prevention of unplanned pregnancies relies not only on access to available marketed products, but also on the products’ acceptability and couples’ willingness and ability to use them effectively.[5]  Due to the variety of side effects of the various products and cultural differences in terms of sexual preferences and what is appropriate, there are a number of different types of contraceptives available today. Most contraceptive methods fit into the following general categories: barrier method, natural method, hormonal method, and permanent method.[6] 

 

Barrier methods refer to methods such as the cervical cap, male and female condoms, diaphragms, spermicides, and sponges. These methods work by blocking the passage of the sperm to the egg.  Natural methods, on the other hand, do not require any devices, injectables, or oral ingestion.  These methods are also referred to as fertility awareness methods in which the days of the month when the woman is most likely to get pregnant is identified and sexual intercourse is abstained from on those days.  These natural or fertility awareness methods include cervical mucus method, symptothermal method, calendar (or rhythm) method, basal body temperature (BBT) method, and standard days method (SDM).  Hormonal methods refer to injectables, IUDs, implants, the combined hormonal pill, patch, and ring.  These methods work by releasing hormones into the woman’s body suppressing ovulation.  Permanent methods are surgical methods for people who do not wish to have any more children and include female sterilization and male sterilization also known as vasectomy.[7]  Table 1 displays the wide-range of contraceptive technologies that are available.

 

Table 1. Percentage of women experiencing an unintended pregnancy during the first year of use and its effectiveness against STD.

 

 

Failure Rate = % of Women Experiencing an Unintended Pregnancy within the First Year of Use[8]

Does the Method Protect against STDs?

Method

Typical          Perfect             

% Efficacy Rate (if known) 

  Use                  Use

No method

85                    85

No

Spermicides

29                    18

No

Withdrawal

     27                     4

No

Continuous abstinence

Not known*            0

100%

Periodic abstinence             (calendar/fertility awareness)

     25                     9

Not known

 

Cervical cap

32                    26

No

Sponge

32                    20

No

Diaphragm

16                     6

No

Male condom

21                     5

85-98%[9]

Female condom

15                     2

79-95%[10]

Combined pill

8                     .3

No

Combined hormonal patch (Evra)

8                     .3

No

Combined hormonal ring (NuvaRing)

6                     .3

No

DMPA (Depo-Provera)

3                     .3

No

Combined injectable (Lunelle)

3                     .05

No

IUD - ParaGard (copper T)

.8                     .6

No

IUD - Mirena (LNG IUS)

.1                     .1

No

Female Sterilization

.5                     .5

No

Male Sterilization

.10                  .15

No

* It is believed that typical use of continuous abstinence is similar to periodic abstinence once the person engages in sexual intercourse.

 

There are two additional methods of contraception that are for women in specific situations.  These methods include emergency contraception (EC) and lactational amenorrhea method (LAM).  EC can prevent pregnancy when used shortly after unprotected sex.  EC is oral contraceptive pills containing ethinyl estradiol and levonorgestrel that are taken for a short period of time in a higher dose than combined oral contraceptives, and is strongly recommended to be taken within 72 hours (three days) after unprotected sexual intercourse.[11]  LAM is a family planning method based on breastfeeding.  It is effective for up to six months after childbirth only if a woman has not had a period since the delivery of her child, her child receives predominantly breast milk, and the woman breastfeeds often, both day and night.[12]

 

III.               New Contraceptive Research and Product Development

According to the WHO, the priorities for new contraceptive technologies include the “development of methods and approaches that are easier to use, that improve service delivery, that have fewer side effects, that are affordable, and that respond to the needs of various groups of users, including men.”[13]  Over the past 30 years, there have been significant advances in the development of new contraceptive technologies, including transitions from high-dose to low-dose combined oral contraceptives, and from inert to copper- and levonorgestrel-releasing vaginal IUDs.[14]  However, the research and development has “failed to keep pace with the growing need for a variety of safe, effective and acceptable methods,” according to CONRAD’s Director Henry L. Gabelnick.[15]

 

Recent research in this field has largely focused on product development that will counter the devastation of HIV/AIDS.  Numerous promising microbicidal products are being investigated in Phase III trials.  They are believed to be ideal products for the potential protection and control of the virus since they will be female-controlled and enable women at risk of HIV to use them without partner consent.  Microbicides are formulated as foams, gels, creams, impregnated sponges, suppositories, and films.[16]  According to calculations by public health experts,

 

microbicides that are even 60 percent effective against HIV could avert at least 2.5 million infections over three years.  And because some women may wish to conceive a child while maintaining STI protection during sexual intercourse, noncontraceptive microbicidal formulations are also under development.[17]

 

According to Family Health International (FHI)’s scientific director Dr. Zeda Rosenberg, “all of these [microbidical] substances are active against microorganisms in the laboratory, and some animal studies and human safety trials are promising. But we still need more information from human efficacy trials.”[18]  For instance, PRO 2000, a microbicidal gel, inhibits sperm function and the attachment of pathogens to target epithelial cells. It appeared to be effective as a contraceptive in rabbits and was active against HIV, herpes simplex virus, chlamydia and gonorrhea in preclinical studies and was well tolerated in phase I trials.[19]  Cellulose sulfate, on the other hand, is an antifertility agent that does not destroy cells.  Results of phase I trials revealed that cellulose sulfate gel is as safe as inactive control K-Y Jelly.[20]  Table 2 provides a list of microbicides entering phase III and IV trials and how they work.

 

 

 

 

Table 2. Microbicides Approaching Efficacy & Effectiveness Trials.[21]

Researchers hope that the trials find various microbicidal products that are effective against pathogens other than just HIV, that are noncontraceptive formulations as well as contraceptive ones, that can protect against HIV infection when used postcoitally like EC, and that are effective for rectal use.[22]  According to FHI in 2000, “Topical application of microbicides to vaginal and rectal mucosal surfaces is the only method of application currently being considered.”  However, Swartz and Gabelnick report that the leading noncontraceptive microbicide, Carraguard, under development by the Population Council, was scheduled to enter a phase III trial in 2003 after data from a randomized, placebo-controlled, double-blinded safety trial in South Africa and Thailand was analyzed.[23]  This product is especially important since it would allow couples who are at risk for HIV or already have it to continue to have children while protecting themselves from transmission.  However, this product does not address the maternal to child transmission of HIV once the woman becomes pregnant.  More research needs to be done.

 

The urgency of the HIV crisis has accelerated the development of new contraceptive microbicides and even research into improvements for barrier methods, such as the diaphragm. However, this research has perhaps come at the expense of other novel contraceptive methods, which include research on new delivery systems and extended dosing of hormonal contraceptives that can lead to increased choice and improved compliance.[24]  However, no truly radical different methods have evolved.  

 

According to the WHO, “The public health benefits of increased male participation in family planning activities are becoming recognized among programme managers, policy-makers and donors.”[25]  A large, ongoing clinical trial is underway in China to assess the safety and efficacy of testosterone undecanoate, an injectable.  Studies are also being carried out to assess the acceptability of hormonal male contraceptive methods and their effects on behavior and sexual function.[26]  However, no new products have reached the market or are projected to. 

 


IV.              The Importance of Contraception: Health Aspects and Social Consequences

According to WHO’s 2001 estimates, sexual and reproductive health problems account for 18 percent of the total global burden of disease and 32 percent of the burden among women of reproductive age (15-44) worldwide.[27]  Meeting sexual and reproductive health care needs can contribute to economic productivity inside and outside the home by preventing high risk pregnancies that may result in long-term disability.[28]  According to Population Action International, “More than 500,000 women die every year from pregnancy-related causes, and more than 99 percent of these deaths take place in the developing world.”[29]  Access to reproductive health services, including contraception, reduces a woman’s exposure to fatal obstetric complications, which account for approximately 80 percent of maternal deaths globally and enables a women to plan the timing and spacing of her children.[30]

 

The interactions between sexual and reproductive health and HIV/AIDS are deeply entwined and need to be addressed simultaneously.  The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding.[31]  Likewise, females are more vulnerable to STDs, and therefore HIV, because they often engage in sexual activity earlier than males, they have sex with older and more experienced partners, and biologically they are more vulnerable due to characteristics of the genital tract of young girls.[32]  Yet, more than 201 million women around the world do not have access to contraceptive supplies and services;[33] and, the WHO found that in most developing countries the best indicators of STD levels in women come from surveys taken at antenatal, family planning, or gynecological clinics.[34] 

 

Therefore, family planning services that incorporate contraception for both preventing unintended pregnancies and protecting couples from STDs and HIV will allow couples to realize their own childbearing intentions, promote less volatile age structures, enable slower urban population growth, promote economic productivity, and lessen pressure on limited natural resources.[35]  Furthermore, interventions to prevent HIV are at least 28 times more cost-effective than antiretroviral therapy.[36]  For these reasons, the availability of and access to culturally appropriate contraception is an important public health concern.

 

V.                 Barriers to Access and Development of New Contraceptive Technologies

 

According to Swartz and Gabelnick, “Financial factors, political pressures and legal concerns are among the obstacles that have impeded the research and development of new contraceptive products.”[37]  Microbicides research provides an excellent example of these obstacles.  Microbicide researchers need a large sample size of women at high risk for STDs in order to evaluate the products effectiveness.  Yet, they also need to provide trial participants with condoms and counsel them to use the condoms so the data about effectiveness is only available when a condom fails or is not used.  If condoms are used, then microbicides may not be necessary.  However, research from developing countries indicates that condoms are not normally or regularly used.  So microbicides would give women control in protecting herself; however, is a new product enough?  There are still issues of partner communication about sex and societal structures that position women in a subordinate and therefore disadvantaged role where their voices and actions are limited.  Likewise, the cost of a clinical trial is expensive and “pharmaceutical companies have little interest due to regulatory complexities, difficulties in securing patent protection, and product-liability suits.”[38] 

 

VI.              Public Health Programs and Policies Addressing Reproductive Health

Although there are many barriers to the development of new contraceptive technologies, many family planning programs exist due to the vast consequences of unmet need.  Many programs that implement current technologies and educational outreach have been invested in and found successful throughout the world. In the U.S., a family planning program, authorized under Title X of the Public Health Service Act, is administered within the OPA by the Office of Family Planning (OFP) with a budget of $288 million for fiscal year 2005. The Title X program is the only Federal program devoted solely to the provision of family planning and reproductive health care. The program supports a nationwide network of approximately 4,600 clinics and provides reproductive health services to approximately 5 million persons each year.

 

The program is designed to provide access to contraceptive supplies and information to all who want and need them with priority given to low-income persons. A broad range of effective and acceptable family planning methods and related preventive health services are available on a voluntary and confidential basis. In addition to contraceptive services and related counseling, Title X supported clinics also provide a number of preventive health services such as: patient education and counseling; breast and pelvic examinations; cervical cancer, STD and HIV screenings; and pregnancy diagnosis and counseling. For many clients, Title X clinics provide the only continuing source of health care and health education. [39]

 

However, the United States’ domestic and international policies related to family planning are very exclusive in terms of the range of services that funds can be directed towards. This exclusivity is apparent in its international policy known as the U.S. Global Gag Rule, which bars U.S. family planning assistance to foreign nongovernmental organizations (NGOs) who, with their own, non-U.S. funds, engage in abortion-related activities in their country. NGOs refusing to abide by these restrictions lose vital U.S. family planning funds and technical assistance. Organizations that do not sign the Global Gag Rule also lose access to U.S.-donated contraceptives, including condoms.[40]

 

Such a policy has not stopped many developing countries from initiating family planning clinics, services, and campaigns to increase access to reproductive health educational materials, promote access and use of screenings, and encourage the use of prevention methods, specifically the often free distribution of condoms.  Haiti began a project to increase access to reproductive health care with the training of 16 health promoters and the initiation of clinical services in Cange, Haiti, a rural area where only dirt roads connect villages.  During the project’s first year, a total of 698 contraceptive clients, mostly adults, were served.  By 2002, the program grew significantly serving nearly 2,000 clinic clients, expanded its adolescent services to include supplying 4,000 adolescents with community-based distribution of contraceptives, and reduced its cost per client by more than 50 percent.[41]

 

Adolescents are a substantial target of many family planning programs throughout the world, particularly in the developing world.  The devastation of HIV/AIDS has brought the youth’s presence and sexual decision-making to center stage.  Nations are losing their future generations of laborers and professionals.  For these reasons and others related to stages of development, programs focusing on adolescents are receiving a lot of attention and investment. 

 

Peer Outreach for Reproductive Health project in Thailand provided more than 50 youth in the community training as peer health educators.  Due to the peer to peer educational outreach concerning reproductive health issues, each year more and more young people are seeking contraceptive services offered at the various family planning clinics throughout Thailand.[42]  The Promotion of Youth Responsibility Project in Zimbabwe also targets the health needs of youth.  It is a six-month multimedia campaign directed toward young people and training health care providers in interpersonal communication and youth counseling skills. An evaluation of the project found that youth in campaign sites were more likely than youth in comparison sites to abstain from sex, have fewer recent sexual partners, and use contraceptives and clinic services.[43]  Another evaluation compared three youth-friendly pilot projects in Zamia. In each, peer educators and health care providers were trained; two of the projects included community outreach component designed to increase the project’s reach in the community.[44] 

 

Projects geared towards the youth are becoming more prevalent throughout the world.  Investment in healthy, viable futures for young people is likely to be the key to long-term progress and stability in much of the developing world.  For this reason, reproductive and sexual behavior interventions for adolescents are being tied with their educational and economic options.[45]

  

VII.            Conclusion

 

Family planning and reproductive health will continue to be a hot topic area in which investments will be made since HIV is a global pandemic.  Likewise, the benefits for meeting individuals’ reproductive health needs exceed the costs.  Current methods for evaluating the costs and benefits of contraceptive services undervalue its services because pregnancy the condition that contraception prevents is not a disease.  However, contraceptive services have important medical and non-medical benefits.  A woman’s ability to space or limit the number of her pregnancies has a direct impact on her health and well-being as well as the outcome of her pregnancy.[46]  In exercising their reproductive rights, women are safeguarding their own health and rights, preserving our planet’s resources, and improving the quality of life for themselves, their partners, and their children.[47]  For these reasons, the need for new pregnancy and STD/HIV prevention options that improve the currently available methods is an important public health endeavor. 

 

References



[1] Camp, Sharon, PhD. 2003.  Statement by Sharon Camp: Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. The Alan Guttmacher Institute (AGI). New York City, NY.

[2] Birth control. Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Contraception

[3] Ibid.

[5] Schwartz, Jill L. and Gabelnick, Henry L. Special Report: Current Contraceptive Research. Perspectives on Sexual and Reproductive Health, 2002, 34(6): 310-316.

[6] EngenderHealth. Family Planning. New York, NY. www.engenderhealth.org.

[7] Ibid.

[8] Trussell, J. Contraceptive efficacy. In: Hatcher, R. A., Trussell, J., Stewart, F., Nelson, A., Cates, W., Guest, F., Kowal, D. Contraceptive Technology. Eighteenth Revised Edition. New York, NY, Ardent Media, 2004.

[9] Feminist Women's Health Center. Birth Control Comparisons. Cedar Rivers Clinics. Seattle, WA. http://www.fwhc.org/birth-control/index.htm.

[10] Ibid.

[11] EngenderHealth. Emergency Contraception. New York, NY. http://www.engenderhealth.org/wh/fp/cemerg.html.

[12] Planned Parenthood Federation of America, Inc. Your Contraceptive Choices. September 2003.

[13] World Health Organization. Reproductive Health and Family Planning. http://www.who.int/reproductive-health/family_planning/methods.html.

[14] Ibid.

[15] Schwartz, Jill L. and Gabelnick, Henry L. Special Report: Current Contraceptive Research. Perspectives on Sexual and Reproductive Health, 2002, 34(6): 310-316.

[16] Family Health International. Microbicides. http://www.FHI.org/en/Topics/microbicide.htm.

[17] Ibid.

[18] Family Health International. Microbicide Products Enter Human Trials: A variety of experimental products use different mechanisms to protect against HIV and other diseases. Network, 2000, 20(2): 1-11.

[19] Schwartz, Jill L. and Gabelnick, Henry L. Special Report: Current Contraceptive Research. Perspectives on Sexual and Reproductive Health, 2002, 34(6): 310-316.

[20] Ibid.

[21] Schwartz, Jill L. and Gabelnick, Henry L. Special Report: Current Contraceptive Research. Perspectives on Sexual and Reproductive Health, 2002, 34(6): 310-316.

[22] Ibid.

[23] Schwartz, Jill L. and Gabelnick, Henry L. Special Report: Current Contraceptive Research. Perspectives on Sexual and Reproductive Health, 2002, 34(6): 310-316.

[24] Ibid.

[25] World Health Organization. Reproductive Health and Family Planning. http://www.who.int/reproductive-health/family_planning/methods.html.

[26] Ibid.

[27] WHO, Estimates of DALYs by sex, cause and WHO mortality sub-region, estimates for 2001, 2002. http://www3.who.int/whosis/menu.cfm?path=evidence,burden,burden_estimates_2001,burden_estimates_2001_subregion&language=english.

[28] Camp, Sharon, PhD. 2003.  Statement by Sharon Camp: Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. The Alan Guttmacher Institute (AGI). New York City, NY.

[29] Ibid.

[30] Ibid.

[31] World Health Organization (WHO), UNFPA, UNAIDS, and International Planned Parenthood Federation (IPPF). 2005. Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages.

[32] World Health Organization (WHO). 1995. Workbook 1: The Transmission and Control of STD/HIV. http://whqlibdoc.who.int/temp/Tomas/GPA%20Documents/STD-CaseMan-Wb1-E-Wh95e18b.pdf

[33] Singh, Susheela, Darroch, Jacqueline E., Vlassoff, Michael, Nadeau, Jennifer. 2003. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. The Alan Guttmacher Institute (AGI). New York City, NY.

[34] World Health Organization (WHO). 1995. Workbook 1: The Transmission and Control of STD/HIV. http://whqlibdoc.who.int/temp/Tomas/GPA%20Documents/STD-CaseMan-Wb1-E-Wh95e18b.pdf

[35] Population Action International. September 2005. Fact Sheet: How Access to Sexual & Reproductive Health Services is Key to the MDGs. Washington, DC.

[36] Marseille, E, et al., HIV prevention before HAART in sub-Saharan Africa. Lancet, 2002, 359(9320): 1851-56.

[37] Schwartz, Jill L. and Gabelnick, Henry L. Special Report: Current Contraceptive Research. Perspectives on Sexual and Reproductive Health, 2002, 34(6): 310-316.

[38] Family Health International. Microbicide Products Enter Human Trials: A variety of experimental products use different mechanisms to protect against HIV and other diseases. Network, 2000, 20(2): 1-11.

[39] Department of Health and Human Services: Office of Public Health and Science: Office of Population Affairs: Office of Family Planning. http://opa.osophs.dhhs.gov/titlex/ofp.html

[40] The Global Gag Rule Impact Project. The Global Gag Rule & Contraceptive Supplies. Population Action International, Ipas, Planned Parenthood Federation of America, EngenderHealth, and Pathfinder International.

[41] PPFA-International. Five years of achievement: 1998-2003. Planned Parenthood Federation of America, Inc. New York, NY.

[42] Ibid.

[43]Boonstra, H. October 2004. Issue in Brief: The Role of Reproductive Health Providers in Preventing HIV. The Gutmacher Report on Public Policy. The Alan Guttmacher Institute, UNAIDS, UNFPA, and International Planned Parenthood Federation.

[44] Ibid.

[45] Esim, S., Malhotra, A., Mathur, S., Duron, G., Johnson-Welch, C. 2001. Making It Work: Linking Youth Reproductive Health and Livelihoods. International Center for Research on Women (ICRW). Washington, DC.

[46] The Alan Guttmacher Institute and UNFPA. 2003. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. The Alan Guttmacher Institute (AGI). New York City, NY.

[47] EngenderHealth. Family Planning. New York, NY. www.engenderhealth.org.