| Selecting a
contraceptive method involves assessing each method
in terms of its characteristics and determining
which method offers the optimal combination of
characteristics, given the needs and desires of
the individuals making the decision. This task
is further complicated by the fact that these
characteristics cannot be independently selected
but rather must be chosen from the limited number
of currently available methods. When a couple
is making a contraceptive decision, the partners
may have different needs and desires and may not
assess method characteristics in the same way.
While most studies of contraceptive behavior
have acknowledged the importance of method characteristics,
only a few consider method characteristics as
outcomes. These can be classified into three general
types: studies that examine the characteristics
of persons using some contraceptive method but
do not differentiate among types; those that focus
exclusively on the characteristics of people who
use condoms; and a small number that consider
perceptions regarding the characteristics of an
expanded set of alternative method choices.
In research of the first type, the characteristics
of contraceptive use are generally measured in
terms of agreement or disagreement with statements
about the consequences of using some unspecified
form of contraception, such as a reduced risk
of unintended pregnancy.( Eisen 1985) Such studies
provide important information about which perceived
advantages and disadvantages of birth control
are important predictors of contraceptive use,
especially among adolescents. However, by defining
characteristics that are not specific to any method,
they offer little help in understanding the process
by which individuals choose among the array of
available methods.
Many of the studies focusing exclusively on the
characteristics of condom use are restricted to
identifying the perceived attributes of condoms
that may facilitate or prohibit use.( Baldwin
& Baldwin 1988) Such research offers a wealth
of information relevant to programs and policy
makers, but its usefulness is limited because
it remains unclear whether these perceptions are
generally shared, or whether they are the concern
of only specific subgroups of the population.
A few studies have explicitly examined the relationship
between individuals' characteristics and their
perceptions about condoms. (Brown 1984) However,
only three have explored the impact of gender.
Two found that females perceive the condom more
positively than males do with respect to both
its effects on sexual experience and its "interpersonal
impact."(Campbell et al 1992) In one of these
studies, women rated the condom's comfort and
convenience more positively than did men (Grady
et al 1993) In contrast, another found no significant
effect of gender on perceptions about the condom.(
Norris & Ford 1992)
While this research is important, its usefulness
is limited because the condom was considered in
isolation from all other methods. For example,
the study showing that women view the condom's
convenience more positively than men do could
not identify whether they perceive the condom
to be more or less convenient than other methods
with which it may compete. This limitation is
critical, because the decision that most individuals
face is not whether to use the condom, but rather
whether to use the condom, some other method or
no method.
Recognizing this problem, one researcher examined
how perceptions about the effectiveness, convenience
and "major" and "minor" health-related
side effects of the pill and diaphragm were related
to women's choices between those two methods.
(Condelli 1986) The choices made were related
to perceptions about both methods included in
the choice set, with the relative ratings of the
methods on each dimension having a critical effect.
For example, adopters of both methods perceived
the pill to be more effective and convenient than
the diaphragm, but those adopting the pill perceived
the method differences in these characteristics
to be much larger than those who chose the diaphragm.
Another analysis examined how young women's method
choices were related to their ratings of the pill,
IUD, condom, diaphragm and spermicides, in terms
of their safety, effectiveness, interference with
sexual intercourse, convenience and cost. (Tanfer
& Rosenbaum 1986) Women ranked the methods
similarly on each dimension, but those who chose
a particular method viewed it as having bigger
advantages and smaller disadvantages, relative
to other methods, than women who made other method
choices. Further, in multivariate analyses, perceptions
about the characteristics of one or more competing
methods were significant predictors of method
choice.
These and other analyses provide compelling evidence
that men and women evaluate alternative contraceptive
methods in terms of their perceived convenience,
effectiveness, health effects, interference with
sex and other characteristics.( Beckman et al
1992) However, in almost all studies in this area,
the effects of personal and couple characteristics
are of interest only to the extent that they are
viewed as capturing the demand for, or importance
of, certain contraceptive characteristics, such
as effectiveness. (Glor & Severy 1990) Such
valuations usually are not directly measured,
though, and seldom are empirically investigated.
In one exception, the authors listed general characteristics
on which individuals might compare contraceptive
methods (e.g., "Being able to control if
and when you have children") and asked individuals
to rate how "salient" each was to them
when considering specific methods. (Cohen 1978)
They also investigated gender differences in how
these ratings were related to attitudes toward
different methods. Unfortunately, by asking about
the salience of these characteristics for each
method, they obtained measures that combined valuations
and perceptions and could not uniquely identify
either.
Types of Contraceptives
contraceptive choices for women have increased
significantly. So how do you decide on the best
method for you? Research indicates that our primary
concerns are that contraception is effective,
but with minimal side effects. Generally, the
more effective it is, the greater the potential
for side effects. Contraception can be broadly
divided into hormonal and non-hormonal types.
Hormonal Methods The Combined Pill
The oral contraceptive combined pill, containing
oestrogen and progesterone, is the most popular
contraceptive for younger Australian women. It
stops the monthly release of an egg from the ovaries.
It's usually taken for 21 days, then a sugar pill
(or no pill) is taken for seven days.
The daily commitment of taking the pill can be
a problem for some women and newer, long-term
methods may be a better alternative. Used correctly,
however, it is more than 97% effective.
Side effects can include tender breasts, nausea,
breakthrough bleeding, weight gain, headaches
and changes in libido. Contraceptive pills with
newer types of progesterone are being developed
to reduce the possible side effects. (Bonnar 1999)
Opinion and research is divided as to whether
the combined pill increases the risk of breast
cancer; there is some evidence that cancer of
the ovaries and uterus is reduced. Women who smoke
or are at risk of deep vein thrombosis (blood
clots) will be advised of the risks. You can't
breastfeed while taking it.
The advantages are that you will have a regular
period, which is generally lighter. Some pills
can actually reduce acne and alleviate some of
the symptoms of PMS. If you are taking antibiotics
or some other drugs, or have vomiting or diarrhoea,
its effectiveness can be reduced. It is not effective
immediately, so another form of contraception
will be needed initially. (Alvarado et al 1993)
The Mini Pill
Tile Mini Pill contains only the hormone progesterone.
It changes the mucous at the entrance to the uterus,
making it difficult for sperm to fertilise an
egg. It also alters the lining of the uterus,
making implantation of a fertilised egg more difficult.
It needs to be taken at the same time every day.
Side effects can be irregular bleeding or missed
periods because of the effects it has on the lining
of the uterus. It is safe to take when breastfeeding
and is a good choice for women who cannot tolerate
oestrogen. However, it is slightly less effective
than the combined pill. (Cleland et al 1990)
Depo Provera
This is an injection of progesterone given every
12 weeks to prevent ovulation. It is more than
99% effective and can be used when breastfeeding.
The disadvantage is that side effects can last
up to 12 weeks without the option of removing
or ceasing the hormone. It can also take several
months after the last injection to become pregnant.
Side effects may include heavy bleeding, irregular
bleeding or no bleeding (this is not harmful).
Some women also report weight gain, headaches
and depression. (Feldblum & Joanis 1994)
Implanon
Implanon is a small plastic rod (4cm long) containing
synthetic progesterone implanted under the skin
of the upper arm. A local anaesthetic numbs the
area and the Implanon is inserted. It takes about
one minute to insert and about three minutes to
remove. Removal involves a small incision and
the rod being lifted out with forceps.
It prevents ovulation and also has a secondary
effect on the lining of the uterus and cervical
mucous. It is one of the most successful contraceptive
methods available -- more than 99% effective.
It needs to be replaced every three years and
is ideal for those women who want the option of
long-term contraception.
Implanon is also useful if you can't take oestrogen.
It is quickly reversible, with pregnancy possible
soon after removal. You can also breastfeed while
using it. Side effects may include changes in
menstruation or irregular bleeding. (McCann &
Potter 1994)
Mirena
Mirena is a small, plastic T-shaped device that
is inserted into the uterus. It carries the hormone
progesterone in a sleeve around its stem and has
two fine threads attached to its base. It is inserted
through the vagina using a thin tube. (This only
takes a few minutes.) The progesterone is gradually
released, causing the cervical mucous to thicken,
which inhibits the sperm's movement.
It also reduces the monthly lining of the uterus,
resulting in lighter, shorter periods. It is 98%
effective and lasts for five years before it needs
to be replaced, so it is ideal for women who prefer
long-term contraception. On removal, your usual
level of fertility should return quickly. Women
with painful or heavy periods may find it particularly
useful. You will generally have spotting or light
bleeding in addition to your periods for the first
three to six months after the device is fitted.
Overall, however, the amount of bleeding is reduced
and in some women periods stop altogether.
Mirena can be fitted from six weeks following
the birth of a baby and you can breastfeed with
it. (Senior 1996)
The Morning-After Pill
If you have had sex and either did not use contraception,
or the condom broke, you can take the emergency
pill, also known as the 'morning-after pill'.
It contains progesterone and can be used while
breastfeeding. Two tablets need to be taken together,
or at a 12-hour interval, within 24 hours of having
unprotected intercourse. The pill delays ovulation
and prevents implantation. It can cause irregular
bleeding and an increase in ectopic pregnancy
if it fails. (Severy 1982)
Non-Hormonal Methods Condoms
Condoms (male and female) have the advantage
of protecting against sexually transmitted diseases
as well as pregnancy. They can be 85-95% effective.
Most are supplied with lubrication, but using
an additional water-based lubricant such as KY
Jelly helps prevent it from breaking. Oil-based
products such as baby oil can cause the condom
to split. Condoms can be bought in a variety of
sizes and colours, are relatively inexpensive
and are available in supermarkets and chemists.
The only side effect of condom use can be latex
allergy. As latex is perishable, condoms should
be kept in a cool place and used by the expiry
date. People with more than one partner should
use condoms to reduce the risk of sexually transmitted
diseases.
The female condom suits women who like to be in
control of the contraception. The woman places
the condom inside her vagina before intercourse
and the penis goes inside the condom. It covers
some of the vulva so may provide better protection
against sexually transmitted infections such as
herpes and human papilloma virus.
Polyurethane condoms (male and female) have recently
become available. These have the benefits of not
containing latex allergens, being stronger than
the conventional condoms, and having better heat
transmission. They are more expensive. (Frezieres
et al 1999)
Intra-Uterine Devices (IUD)
The IUD is a plastic and copper device placed
in the uterus. It prevents the fertilised ovum
embedding in the uterus. It is about 98% effective,
but can cause heavier and longer periods and cramping.
There is also an increased risk of infection in
the uterus and tubes, which could lead to infertility.
For this mason some doctors are reluctant to insert
IUDs, particularly in women who have not had children
yet. Its advantages are that it is effective immediately
and can remain in place for 5 to 8 years.
Diaphragms
These are made out of a soft, flexible rubber.
The diaphragm is placed inside the vagina to cover
the cervix, thus preventing sperm from entering
the uterus. It is advisable to use a spermicidal
cream or jelly with it. They come in different
sizes and must be fitted by a trained doctor or
nurse. Your diaphragm will also need to be refitted
if you lose or gain 3kg or more in weight or have
a baby. A diaphragm can be fitted about six weeks
after birth and is 92-96% effective if used with
a spermicide. It is washed and reused and lasts
for about 1-2 years.
The advantage of a diaphragm is you only need
to use it when having sex. It can also be used
when you are having your period. The disadvantage
is that you have to put it in before sex and leave
it in for six hours afterwards. Some women find
insertion and removal difficult, while a few people
are allergic to rubber. Others, either for cultural
or personal reasons, don't like the fact that
they have to touch their genitals to insert it.
(Ballagh et al 1994)
Breastfeeding
Breastfeeding as contraception can be up to 98%
effective and is probably the most commonly used
method worldwide to space children. It works by
keeping levels of the hormone prolactin high,
which prevents women ovulating. For it to be effective
you need to exclusively breastfeed for six months,
and at regular intervals throughout the day and
night (around every four hours). The baby must
have no other food or drinks, and menstrual periods
must not have returned.
Women not wanting to get pregnant again under
any circumstance will also need to use an additional
form of birth control as a safeguard. (Bonnar
et al 1999)
Sterilization
In 2001, 9% of women and 11% of men opted for
a sterilisation procedure. For women, sterilisation
means cutting the fallopian tubes or using clips
to block them. This prevents the ovum passing
through the fallopian tube and being fertilised.
It is over 99%, effective. The decision for sterilisation
shouldn't be taken lightly, and young women with
years of childbearing potential will find doctors
reluctant to perform it.
Male sterilisation involves cutting the Vas deferens,
the tube that carries the sperm from the testicles
to the penis. It involves a local anaesthetic
and a small operation. Two negative specimens
are required before it is considered effective.
This can take as long as eight weeks after the
surgery. Vasectomy has an effectiveness of over
99%.
Successful reversal of male and female sterilisation
is low and should be carefully considered. Sterilisation
techniques are improving all the time to be less
invasive. (Feldblum & Joanis 1994)
Natural fertility methods
Rhythm, Billings, Mucous, Ovulation and Temperature
are names for methods women use to tell when they
are most fertile. These methods are harder to
use if you have irregular periods, but women of
some cultural and religious backgrounds prefer
them. They take practice, close monitoring and
a good knowledge of your body, so make sure you
get adequate information before embarking on them.
(Cleland et al 1990)
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