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Diaphragms were a rite of passage for the postwar baby boom generation and were one of the few contraceptives available before the Pill. However, diaphragms are simply impractical in countries such as Somalia, Ethiopia, and Afghanistan, where more than 70% of the population does not have access to clean water (Save the Children, 2005). Even those couples with access to clean running water must confront the diaphragm’s 6-20% failure rate (The National Women's Health Information Center, 2005). The same applies for the cervical cap, with its 10-40% failure rate.
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What about the Pill (and all its newer variants), one of the most popular methods in prosperous countries? The Pill can be appropriate for those who don’t have medical contraindications (such as a risk of heart disease or a family history of blood clots or stroke). However, side effects can include nausea, vomiting, headaches, moodiness, breakthrough bleeding, and breast tenderness (Hatcher, Trussell et al., 2004 p. 427-436). The Pill appears particularly problematic for South American women, who tend to experience more side effects because they tend to be significantly smaller, and have lower baseline hormone levels, than the North American women for whom the Pills are designed (Vitzthum & Ringheim, 2005).
Newer hormone delivery systems such as the vaginal ring are convenient and easier to remember to use, bringing the failure rate down to 1 or 2% or even lower. They can also permit a lower, steadier dose of hormones, which may mean fewer side effects (Dieben, Roumen, & Apter, 2002 p.259). Cardiovascular risk can also be lessened by lower doses. The vaginal ring is a good option for women who are comfortable enough with their bodies to insert it, able to afford the $40 per month, and not bothered by the remaining side effects.
The contraceptive patch was intended to have similar features (ease of use and steady dose). Unfortunately, the steady dose it delivers has turned out to be a high one (Ortho-McNeil, 2005). For details, click here.
Whatever the delivery system, the synthetic estrogens in contraceptives are causing increasing concern among environmentalists. Excess synthetic estrogens excreted in the urine pass unaffected through sewage treatment plants and feminize male fish and water mammals, reducing the fertility of these marine populations (Brian et al., 2005; Schultz et al., 2003). This effect is already apparent in the waters of industrialized countries, and it could be a tragic development in the rivers and seas of peoples directly dependent on marine life for subsistence and income. Mounting evidence indicates that hormones and hormone mimics in the food chain are starting to have a negative effect on human reproduction as well (Colborn, Dumanoski, & Myers, 1997). For details, click here.
Estrogen-containing hormonal methods are not safe for use by breastfeeding women, which limits their use for birth-spacing. U.S. health authorities recommend at least a year of breastfeeding per child; the World Health Organization encourages two or more years (CDC, 2005). In countries with high birthrates, breastfeeding can occupy 10 or more years of many women’s reproductive lives.
Cost can also be a limiting factor. Paying $10 per month for a pack of Pills through health insurance (or even the typical U.S. open-market price of $35-50 per month) is frustrating but manageable for most women when annual GDP (Gross Domestic Product) per person is measured in tens of thousands of dollars ($35,990 in the US, $22,820 in Canada) (The Economist, 2005 p. 28). However, even at discounted rates, the monthly purchase of hormones from pharmaceutical companies is out of reach of the world’s poorest women. For statistics on Pill prices versus incomes, click here.
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If methods that must be purchased every month are not ideal because of cost (and side effects), could a longer-term method, such as the long-acting progestin implants and injections, be preferable?
Norplant, a five-year dose of synthetic progestin implanted in tubes just under the skin of the upper arm, has been taken off the market in the United States. The tubes had a tendency to drift around to the other side of the arm and be difficult to remove when the five years were over.
Depo-Provera, a once-every-three-months progestin injection, has been aggressively marketed in the developing world. It is quite popular because of its low failure rate and because women can use it without their partners’ knowledge. Doctors often recommend Depo-Provera to young women whom they think will not reliably use other contraceptives. However, Depo-Provera is a substantial hormonal assault on the body (so much so that the manufacturer has recently introduced a 31% lower dose) and can wreak havoc with hard-to-measure factors such as mood. Furthermore, Depo-Provera is the one contraceptive definitively shown to thin bones and to cause weight gain (Clark et al., 2004; Pfizer, 2004).
About half the women who try Depo-Provera quit within the first year (Polaneczky et al., 1996; Trussell, 2004). For those who don’t quit, the manufacturer is now required to state “You should use Depo-Provera Contraceptive Injection long term (for example, more than 2 years) only if other methods of birth control are not right for you.” Given all these factors, this contraceptive should not be a first choice and does not deserve the enthusiasm with which doctors have prescribed it to teenagers and poor women.
The new single-rod implant “Implanon” lasts three years (or two for larger women) and may be a good choice for women who can tolerate progestin-based methods. It has been available in Europe for years, but was not approved in the United States until October 2004 (Azko Nobel, 2005). Health practitioners are eagerly awaiting its introduction. Its manufacturer, Organon, appears willing to sell it to public health services for as little as $3.70 (Royal Women's Hospital Clinical Practice Guideline Steering Committee, 2005). The most common side effects are changes in bleeding patterns (seen in about two-thirds of users), which may be more acceptable to the 21% of women who stop getting their periods than to the 18% who have frequent and/or prolonged bleeding (RWH 2005). Other side effects seen in 5-10% of users are breast tenderness, fluid retention, weight gain, skin disorders, and acne.
A similar product, Jadelle, has been approved by the United States Food and Drug Administration (FDA) but has not been made available to American women by the manufacturer (Population Council, 2005). This is a particular shame because the research and development on Jadelle were done by the Population Council, a nonprofit institution, yet the marketing agreement with Wyeth Pharmaceuticals has allowed the product to be held hostage by the priorities of a for-profit corporation.
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An even longer-term method, the intrauterine device (IUD), has been out of favor with American women ever since a defective design was forced off the market with much publicity in the early 1970s. However, today’s progestin IUDs are much better contraceptives and deserve to be more widely used in the United States. IUD use is much higher in Europe — almost 20% of French women have IUDs, for example. Typical European country rates are 5-25%, and in some Eastern European countries women use very little else (World Health Organization, 2004a). Unfortunately, even the IUD has drawbacks.
The Copper-T IUD has been used by generations of women, lasts up to 10 years, and is extremely affordable. However, it has two big disadvantages: 1) it often causes heavier menstrual bleeding, especially in the first year (Andrade & Pizarro Orchard, 1987), and 2) it is not recommended for women at increased risk for sexually transmitted infections (STIs) (World Health Organization, 2004b). Worryingly, a recent study also showed that users of one of the most commonly prescribed IUDs had blood copper levels twice as high as nonusers, outside the normal range and within the range known to cause gastrointestinal symptoms and alterations of liver function (De la Cruz et al., 2005).
The Mirena progestin-releasing IUD (actually, IUS, or intrauterine system) is a more appealing option for many women. It is approved for five years’ use in the U.S. (seven years in Europe), and it tends to cause lighter rather than heavier bleeding — a helpful change particularly for the many women who are anemic. For details, click here.
The Mirena’s dose of progestin is low enough that frustrating hormonal side effects such as acne, weight gain, and depressed mood are not the norm. About 10-25% of women get their Mirena removed in the first year because of bleeding problems, pain, or acne (Diaz et al., 2000; Dubuisson & Mugnier, 2002). The remaining women often are very satisfied with the method. If properly counseled, women who stop having periods can be particularly pleased at this turn of events. For a variety of women’s experiences with IUDs, click here.
The Mirena IUS deserves more popularity and recognition. However, although the Mirena is cost-effective over the long term, its high wholesale price has kept it beyond the reach of many and excluded it from aid agencies’ contraceptive distribution programs. Many contraceptives are sold to governments at cost plus 5-10%; for example, one government pays as little as 5¢ each for copper IUDs. However, government health services have not been able to negotiate anything lower than about $160 apiece for Mirena, despite an estimated production cost between $10 and $40. In the private sector, Mirena costs even more: generally $400-$900 with insertion. To read more about the politics of Mirena pricing, click here.
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If the Mirena is not widely affordable, what methods remain to choose from?
• Continuous abstinence — not an easy sell to committed couples;
• Withdrawal — helpful on a population-wide level but not reliable on an individual level;
• Periodic abstinence/fertility awareness — free and quite effective if used correctly, but vulnerable to misuse because it requires the couple to abstain from sex the part of the month when the woman’s hormones lead her to be most interested;
• The female condom — a great barrier, but somewhat expensive, and even with perfect use has a 5% yearly pregnancy rate;
• Emergency contraception — an important new option, but a big hormonal assault on the body and only 89% effective, so not a long-term option (Hatcher, Trussell et al., 2004 p. 286).
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Finally we arrive at the permanent option for women: female sterilization. Great strides forward have been made in this area in the past two decades, and sterilization is now an easy and obvious choice for those who are sure they do not want any more children.
Female sterilization has become much more appealing with the recent approval of the “Essure” system. It is still costly — several thousand dollars versus a few hundred for a vasectomy — but now there is no surgery involved. Instead of opening a woman’s abdomen to access and cut the fallopian tubes, small coils are threaded through the vagina and uterus into the tubes. Once the coils are left in place in the fallopian tubes, the body surrounds them with scar tissue, gradually blocking the passageway for sperm and egg. A scan at a follow-up visit several months later checks for complete blockage and gives the woman the go-ahead to rely on the procedure for contraception. Recovery is much quicker than for traditional female sterilization, an important consideration for women caring for small children.
Essure should be a big advance for women whose husbands eschew vasectomy, but it doesn’t serve the billions of women who haven’t finished having children, especially the millions of women in the developing world who are just entering reproductive age. Many in aging prosperous countries may not realize how big this group of young people is. In most of the world’s poorest countries, 40-50% of the population is under age 15 (The Economist, 2005 p. 21), and worldwide that figure is 30% (Population Reference Bureau, 2004).
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