ch. 6 and 7. Contraceptives and abortion

postabortion care

POSTABORTION CARE Abortion is a safe procedure, usually performed at an outpatient clinic or doctor's office rather than a hospital, and women go home shortly after the visit. Abortion does not cause infertility, jeopardize a woman's ability to have children in the future, compromise her reproductive organs, or increase her chances of cancer in any way. Furthermore, the recovery is rapid, usually lasting just a few days. Possible Physical Effects The incidence of immediate problems following an abortion (infection, bleeding, trauma to the cervix or uterus, and incomplete abortion requiring repeat curettage) is rare. The potential for problems is reduced significantly by a woman's good health, early timing of the abortion, use of the suction method compared to an older technique using sharp curettage, performance by a well-trained clinician, and the availability and use of prompt follow-up care. Problems related to infection can be minimized through preabortion testing and treatment for gonorrhea, chlamydia, and other infections. Also, women are given antibiotics at the time of the procedure to decrease the likelihood of infection. Post-abortion danger signs are as follows: Fever above 100°F Abdominal pain or swelling, cramping, or backache Abdominal tenderness (to pressure) Prolonged or heavy bleeding Foul-smelling vaginal discharge Vomiting or fainting Possible Emotional Effects Many women feel relief, guilt, regret, loss, or anger after an abortion. Some go through a period of sadness while making the decision to proceed with an abortion or shortly after it is performed. When a woman feels she was pressured into sexual intercourse or into the abortion, she may feel resentment. If she strongly believed abortion to be immoral, she may wonder if she is still a good person. Many of these feelings are strongest immediately after the abortion. Such feelings often pass rapidly. Others take time to resolve and fade only slowly. It is important for a woman to realize that a mixture of feelings is natural. Researchers have found that women with resilient personalities (high self-esteem, perceived control over the situation, optimism) tend to view the unintended pregnancy in a more positive light and to adjust better than women with less resilient personalities (see Chapter 2 for more on resilience). Between 2008 and 2010, the Turnaway Study recruited women seeking abortions across the United States, some of whom succeeded in undergoing the procedure and others who were "turned away" because their pregnancies were too far along. Researchers found that a person's feelings toward an unintended pregnancy and feelings toward having an abortion are mixed—many women felt regret about an unwanted pregnancy and felt that the decision to have an abortion was the right decision for them. Most women who were denied an abortion gave birth and adjusted to motherhood, happy to have a child. Nine percent of the women pursued adoption. Rates of mental health problems do not appear higher in those who had an abortion compared to those who gave birth or vice versa, suggesting that women are resilient despite their difficult circumstances. The most profound measurable effect observed in the group of women denied an abortion is that they were three times more likely to end up below the federal poverty line two years later compared to women who had abortions, though before the unintended pregnancy they had similar socioeconomic status. As many women predict when making a decision to have an abortion, having a child strains their resources to a significant degree.

How contraceptives work

HOW CONTRACEPTIVES WORK To understand how contraception works, you must first understand the process required for conception. A man's sperm must survive the acidic environment of the woman's vagina and pass through the thickened cervical mucus at the entrance to the uterus. The sperm must then travel into the fallopian tube to meet an unfertilized ovum (egg). As long as her hormones have supported the process of ovulation, a woman's ovaries release one egg each month into one of the fallopian tubes. Once fertilization occurs in the fallopian tube and a zygote is formed, the zygote must then travel back down the fallopian tube to implant within the endometrium (the lining of the inside of the uterus). Contraception can work at each of the points along this pathway by preventing sperm from entering the vagina or passing through the cervix, by preventing ovulation, by blocking the fallopian tubes, or by altering the endometrium to prevent implantation of a fertilized egg. Effective approaches to contraception include the following: Barrier methods work by physically blocking the sperm from reaching the egg. Condoms are the most popular method based on this principle. Hormonal methods, such as oral contraceptives (birth control pills), alter the biochemistry of the woman's body, preventing ovulation (the release of the egg) and producing changes that make it more difficult for the sperm to reach the egg if ovulation does occur. Intrauterine device methods prevent the sperm from reaching the egg through chemical or hormonal changes. Natural methods of contraception are based on the fact that the egg and the sperm have to be present at the same time for fertilization to occur; intercourse is avoided around the time of ovulation. Surgical methods—female and male sterilization—permanently prevent the union of sperm and eggs. Page 144All contraceptive methods have advantages and disadvantages that make them appropriate for some people but not for others, and the best choice during one period of life may not be the best in another (see the box "Contraception Use and Pregnancy among College Students"). Factors that affect the choice of method include effectiveness, convenience, cost, reversibility, side effects and risks, and protection against STIs. This chapter helps you sort through these factors to decide which contraceptive method is best for you. WELLNESS ON CAMPUS: Contraception Use and Pregnancy among College Students College is often a time of increased sexual activity for many young adults. Those who were sexually active in high school may have an increased number of partners or engage in riskier sexual behaviors once they enter college; those who abstained from intercourse during high school may begin to explore their sexuality once they enter this new environment. Surveys have shown that the majority of college students, up to 70%, engage in sexual activity, and some have more than one partner. Concern about pregnancy is on the minds of students: 75% of students report that preventing unplanned pregnancy is very important to them. However, a large percentage of students report not using contraception during their most recent sexual activity. The study cited above found that only 56% of students used contraception during their most recent intercourse. Oral contraceptive pills were the most commonly used contraceptive, with about 60% of women using a contraceptive selecting this method; males who used a contraceptive at last intercourse reported having used the male condom approximately 66% of the time. Of note, the withdrawal method was used by 27% of respondents; this method does not protect against STIs and has a high failure rate. Black and white college students differ somewhat in contraceptive use. Black students were more likely to have used a condom the last time they had vaginal intercourse, compared with white students (63% of blacks versus 58% of whites). White students were far more likely to use hormonal contraception than black students (66% versus 42%). Although the oral contraceptive pill is a highly effective form of contraception when used as directed, and the male condom is effective at preventing the transmission of a wide variety of STIs, they must be used together to provide simultaneous protection against both pregnancy and STIs. This is particularly important for couples who are not in a long-term, mutually monogamous relationship. However, surveys show that college students use a male condom plus another form of contraception only about 45% of the time. Around 2% of college women report having become pregnant in the prior year, many unintentionally. A disproportionate number of these pregnancies occur in students attending community colleges; a 2007 survey found that 5.3% of community college students reported a pregnancy during the year prior, whereas only 1.8% of students at four-year universities reported the same. Unintended pregnancies were nearly four times higher among black college students, compared with white students. The consequences of pregnancy among college students can be significant. For example, studies have demonstrated that 60% of women who became pregnant while attending community college subsequently dropped out. Those who continue their education face added expenses and stress. Given the importance of education in achieving long-term career and financial goals, the implementation of effective contraception during the college years can have a significant impact on the lives of young women. Unfortunately, only 42% of students report that their college provided any information about pregnancy prevention. sources: National Campaign to Prevent Teen and Unplanned Pregnancy. 2015. National College Health Assessment: Reference Group Executive Summary Spring 2011 (http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ExecutiveSummary_Spring2011.pdf); National Center for Health Statistics. 2011. National Survey of Family Growth (http://www.cdc.gov/nchs/nsfg/). Contraceptive effectiveness is determined partly by the reliability of the method itself—the failure rate if it were always used exactly as directed ("perfect use"). Effectiveness is also determined by user characteristics, including fertility of the individual, frequency of intercourse, and how consistently and correctly the method is used. This "typical use" contraceptive failure rate is based on studies that directly measure the percentage of women experiencing an unintended pregnancy in the first year of contraceptive use. For example, the 9% failure rate of oral contraceptives means 9 out of 100 typical users will become pregnant in the first year. This failure rate is likely to be lower for women who are consistently careful in following instructions and higher for those who are frequently careless; the "perfect use" failure rate of oral contraceptives is 0.3%. Another measure of effectiveness is the continuation rate—the percentage of people Page 145who continue to use the method after a specified period of time. This measure is important because many unintended pregnancies occur when a method is stopped and not immediately replaced with another. Thus a contraceptive with a high continuation rate would be more effective at preventing pregnancy than one with a low continuation rate. A high continuation rate also indicates user satisfaction with a particular method. Young women talks with doctor in patient room. A careful explanation by a health care professional will help this young woman choose a contraceptive method that is right for her. © Rocketclips, Inc./Shutterstock Contraception is often divided into categories, or tiers, based on efficacy. Figure 6.2 offers a graphic depiction of these tiers along with the typical use effectiveness ratings and tips on how to improve efficacy. Chart lists specifics on effectiveness and tips for making methods most effective. [D] FIGURE 6.2 Categorization of contraceptives based on efficacy. The percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the first year of typical use of each contraceptive method. source: Centers for Disease Control and Prevention. n.d. Effectiveness of family planning methods (http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/Contraceptive_methods_508.pdf). QUICK STATS About 400 eggs are released through ovulation during a woman's fertile life. —American Congress of Obstetricians and Gynecologists, 2012

permanent contraceptive

PERMANENT CONTRACEPTION Sterilization is permanent, and it is highly effective at preventing pregnancy. At present it is tied with the pill as the most commonly used contraceptive method in the United States and is by far the most common method used worldwide. It is especially popular among couples who have been married 10 or more years and have had all the children they intend to have. Sterilization does not protect against STIs. An important consideration in choosing sterilization is that, in most cases, it cannot be reversed. Although the chances of restoring fertility are being increased by modern surgical techniques, such operations are costly, and pregnancy can never be guaranteed. Many studies indicate that male sterilization is preferable to female sterilization for a variety of reasons. The overall cost of a female procedure is about four times that of a male procedure, the surgery itself is more complex, and women are much more likely than men to experience complications following the operation. Further, feelings of regret after sterilization seem to be more prevalent in women than in men. Before performing the procedure, most physicians require a thorough discussion with anyone considering sterilization. QUICK STATS Sterilization remains the most common method of permanent contraception, used by 47.3% of married couples (tubal occlusion: 30.2%; vasectomy: 17.1%). —American Congress of Obstetricians and Gynecologists, 2014 Male Sterilization: Vasectomy The procedure for male sterilization, vasectomy, involves severing the vasa deferentia, two tiny ducts that transport sperm from the testes to the seminal vesicles. After surgery, the testes continue to produce sperm, but the sperm are absorbed into the body. Because the testes contribute only about 10% of the total seminal fluid, the actual quantity of ejaculate is reduced only slightly. Hormone production from the testes continues with very little change, and secondary sex characteristics are not altered. Vasectomy is ordinarily performed in a physician's office and takes about 30 minutes. A local anesthetic is injected into the skin of the scrotum. Small incisions are made at the upper end of the scrotum where it joins the body, and the vas deferens on each side is exposed, severed, and tied off or sealed by electrocautery. Some doctors seal each of the vasa with a plastic clamp, which is the size of a grain of rice. The incisions are then closed with sutures, and a small dressing is applied (Figure 6.9). Pain and swelling are usually slight and can be relieved with ice compresses and a scrotal support. Bleeding and infection occasionally develop but can be treated easily. After the procedure most men can return to work in two days. In a vasectomy, an incision is made in the scrotum and the vas deferens (or sperm duct) is tied and cut. FIGURE 6.9 Vasectomy. This surgical procedure involves severing the vasa deferentia, thereby preventing sperm from being transported and ejaculated. Men can have sex after vasectomy as soon as they feel no discomfort, usually after about a week. Another method of contraception must be used for at least three months after vasectomy, however, because sperm produced before the operation may still be present in the semen. Microscopic examination of a semen sample, called semen analysis, is required to confirm that sperm are no longer present in the ejaculate. Most doctors recommend having the first semen analysis about three months after surgery, and a second test to confirm the results sometime in the future. Studies show that many men fail to complete follow-up testing after vasectomy. Fortunately, unintended pregnancies following vasectomy are rare, even when follow-up procedures are ignored. Page 162Vasectomy is highly effective. In a small number of cases, a severed vas rejoins itself. The overall failure rate for vasectomy is 0.15%. Vasectomy costs $400 to $1000 in the United States and is covered by Medicaid in most states, and by many private insurance companies. About one-half of vasectomy reversals are successful, though this rate can vary significantly depending on the number of years since the initial surgery. In at least half of all men who have had vasectomies, the process of absorbing sperm (instead of ejaculating it) results in antisperm antibodies that may interfere with later fertility. Vasectomy reversal costs between $5,000 and $15,000 in the United States. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION If you are sexually active, do you use any of the reversible methods described in the preceding sections? Based on the information given here, do you believe you are using your contraceptive perfectly, or in a way that increases your risk of an unintended pregnancy? Female Sterilization The most common method of female sterilization involves severing or blocking the oviducts, thereby preventing eggs from reaching the uterus, and sperm from entering the fallopian tubes. Ovulation and menstruation continue, but the unfertilized eggs are released into the abdominal cavity and absorbed. Hormone production by the ovaries and secondary sex characteristics are generally not affected. Tubal sterilization (also called tubal ligation) is most commonly performed by a method called laparoscopy. A laparoscope, a camera containing a small light, is inserted through a small abdominal incision, and the surgeon looks through it to locate the fallopian tubes. Instruments are passed either through the laparoscope or through a second small incision, and the two fallopian tubes are sealed off with ties or staples or by electrocautery (Figure 6.10). General anesthesia is usually used. The operation takes about 30 minutes, and women can usually leave the hospital two to four hours after surgery. Tubal sterilization can also be performed shortly after a vaginal delivery through a small incision, or in the case of cesarean section during the same surgery. FIGURE 6.10 Tubal sterilization. This procedure involves severing or blocking the fallopian tubes, thereby preventing eggs from traveling from the ovaries to the uterus. It is a more complex procedure than vasectomy. Although tubal sterilization is riskier than vasectomy, with a rate of minor complications of about 6-11%, it is the more common procedure. Potential problems include bowel injury, wound infection, and bleeding. Serious complications are rare, and the death rate is low. The failure rate for tubal sterilization is about 0.5%. When pregnancies occur, an increased percentage of them are ectopic (occurring outside the uterus). Ectopic pregnancy is dangerous and can even cause death, so any woman who suspects she might be pregnant after having tubal sterilization should seek medical help. Because successful reversal rates are low and the procedure is costly, female sterilization should be considered permanent. A new form of incision-free female sterilization has also become available. This procedure can be performed with local anesthetic in a doctor's office and has a short recovery time. Called the Essure system, it consists of tiny springlike metallic implants that are inserted through the vagina and into the fallopian tubes, using a special catheter. Within three months, scar tissue forms over the implants, blocking the tubes. A backup method must be used until a test shows that the tubes are occluded. Placement of the device doesn't require an incision or general anesthesia, and recovery time is quicker than that following tubal sterilization. Only clinicians with specialized training and equipment can perform this procedure. Hysterectomy, removal of the uterus, is the preferred method of sterilization for only a small number of women, usually those with preexisting menstrual or other uterine problems. Because of the risks involved, hysterectomy is not recommended as a form of contraception unless the woman has a disease of the uterus or the uterus has been damaged, and future surgery appears inevitable. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION What are your personal views on sterilization? Do you think it could be an option for you one day? Do you believe people should forgo considering sterilization until they have reached a certain point in their lives? When does sterilization become the best option?

the public debate about abortion

THE PUBLIC DEBATE ABOUT ABORTION Abortion is one of the most polarized and politicized issues of our times and has been since the 1960s (see the box "Abortion around the World"). The American public has been willing to self-identify as "pro-life" or "pro-choice," though most hold middle-ground views and do not fall neatly into one of these two categories. A percentage of this middle-ground group instinctively feels that the fetus gains increasing human value as a pregnancy advances. In this view, first-trimester abortion is acceptable but later-term abortion should be performed only when the mother's health is in jeopardy. DIVERSITY MATTERS: Abortion around the World The top four causes of pregnancy-related deaths in the world are hemorrhage, infections, pregnancy-induced hypertension, and unsafe abortion. Unsafe abortions account for 13% of maternal deaths globally. An unsafe abortion is a procedure performed by a person without the appropriate training or in a setting that does not conform to medical standards. Of all induced abortions performed in industrialized countries, 1% are performed unsafely, in contrast to the 56% performed unsafely in developing countries. The wide majority of these unsafe abortions (98%) occur in developing countries with restrictive abortion laws and limited access to family planning and abortion services. Of the women who survive unsafe abortion, 5 million suffer long-term health complications such as injuries to the genitals, reproductive organs, intestines, and bladder—injuries that result in infertility, incontinence, and chronic pain. Anti-abortion Laws Many countries with strict anti-abortion laws have high abortion-related complications because women undergo abortions in secret and in unsafe conditions. Romania provides a stark example of how a ban on abortion can have devastating effects on a nation. Nicolae Ceauşescu came into power in 1965 and enforced pronatalist policies, including making abortion illegal unless a woman's life was endangered, one of the parents had a dangerous hereditary illness, the woman was over 40 years old, the woman had at least four children who were in her care, or the pregnancy was a result of rape or incest. The law was strictly enforced for the first two years with police present in hospitals monitoring physicians and patients. Abortion rates declined and birth rates increased. Once the police abandoned this monitoring policy, abortion rates rose. Contraceptives were neither manufactured nor imported. Although some women could afford an illegal abortion, the most economically disadvantaged women attempted abortions themselves. During the Ceauşescu regime, Romania had the highest recorded maternal mortality ratio in Europe: 170 maternal deaths per 100,000 births, 87% of which were attributed to abortion complications. Ceauşescu was executed in 1989 and the new government repealed the restrictive abortion law. By 1990, the proportion of maternal deaths due to unsafe abortion dropped to 69%. In subsequent years, abortion-related mortality continued to decline, as did overall maternal mortality, suggesting that the majority of maternal deaths during the restrictive time was due to unsafe abortions. By 2006, the abortion-related mortality ratio was becoming more comparable to those in other European countries. Other Considerations The status of laws is not the only factor that determines whether a woman has access to safe abortion services. The way laws are interpreted can be just as critical. For example, in some countries that allow abortion for mental health reasons, the law is interpreted to allow the majority of women seeking abortions to obtain them. Enforcement of abortion laws is also a factor and varies from country to country. The attitudes and beliefs of the medical community also influence the availability of abortion services. In Nigeria, for example, many physicians perform abortions despite legal bans because the medical community believes in the need for safe abortion services. In contrast, major medical associations in Poland and the Republic of Ireland have adopted guidelines that are stricter than their countries' laws. The number and location of abortion providers and the cost of abortion services also influence the true availability of abortion in a particular country, regardless of the procedure's legal status. Opposition to abortion among some physicians and communities has left parts of the United States, Austria, and Germany without abortion providers, even though abortion is legal in all three countries. In contrast, policies in Denmark go beyond just permitting safe abortion to ensuring that services are widely available. There, each county must have at least one hospital with the capability of providing abortion services, and the services are free. sources: Benson, J., et al. 2011. Reductions in abortion-related mortality following policy reform: Evidence from Romania, South Africa and Bangladesh. Reproductive Health 8(1): 39; Guttmacher Institute. 2012. In Brief: Facts on Induced Abortion Worldwide (http://www.guttmacher.org/pubs/fb_IAW.html); Singh, S., et al. 2009. Abortion Worldwide: A Decade of Uneven Progress. New York: Guttmacher Institute. Pro-life groups oppose abortion on the basis of their belief that life begins at conception. They believe that the fertilized egg must be afforded the same rights as a human being. This view holds that any woman who has sexual intercourse knows that pregnancy is a possibility; therefore, should she willingly Page 179have intercourse and get pregnant, she is morally obligated to carry the pregnancy through. For women who feel they are unable to raise a child, pro-life groups encourage adoption. Pro-choice groups support the view that the decision to continue or end a pregnancy is a personal matter and that a woman should not be compelled to carry a pregnancy to term if she does not want to have a child. This view holds that distinctions must be made between the stages of fetal development, that the fetus is part of the pregnant woman, and that she has priority over it. Members of this group argue that pregnancy can result from contraceptive failure or other factors out of a couple's control. (All contraceptive methods except abstinence have the potential for failure.) When pregnancy occurs, pro-choice supporters believe that the most moral decision possible must be determined according to each Page 180situation and that, in some cases, greater injustice could result if abortion were not an option. Opinions about abortion have remained generally consistent over time. Although nearly half of Americans feel that abortion is morally wrong, an overwhelming majority supports legal availability of abortion services in some circumstances (see Figure 7.5). Most Americans oppose governmental regulation of women's reproductive decisions and also feel that paying for an abortion should be an individual's responsibility. Most do not support the use of public funds to help poor women obtain abortions; they also do not support inclusion of abortion benefits in a national basic health care plan. 51% say abortion should be legal under certain circumstances; 21% say legal under any circumstances; 19% say illegal; and 1% no opinion. FIGURE 7.5 Public opinion about abortion. source: Gallup Inc. 2016. Public Opinion about Abortion (http://www.gallup.com/poll/1576/abortion.aspx). Copyright 2016 Gallup Inc. All rights reserved. The content is used with permission; however, Gallup retains all rights to publication. Although the most vocal groups in the abortion debate tend to paint a black-or-white picture, most Americans view abortion as a complex issue and prefer to focus on preventive strategies. If the most common reason for abortion is unintended pregnancy, then more effort should be dedicated to sex education and promotion of consistent and effective contraception use. Also, more effort should be dedicated to creating a society with policies that make it easier to raise a child. Examples of such policies include parental leave, child care programs for working parents, and reduced costs for education and health care. Pro-choice groups believe the decision to end or continue a pregnancy is a personal matter. Pro-life groups oppose abortion based on a belief that life begins at conception. © Drew Angerer/Getty Images QUICK STATS More than one in three American women has an abortion before they turn 45. —Guttmacher Institute, 2011

methods of abortion

METHODS OF ABORTION The way a pregnancy is ended depends on how far along a woman is in her pregnancy. Ultrasound (a device that shows an image of the developing fetus) is the most accurate way to determine this. If an ultrasound is not available, the date of the woman's last period provides an estimate. Abortion is an extremely safe process. To put it into perspective, it is safer than childbirth. First-Trimester Abortion As noted earlier, 90% of abortions in the United States take place in the first trimester. Women who are up to 2.5 months pregnant can choose between taking pills or having a procedure to end the pregnancy. Women who are 2.5-3.5 months pregnant undergo a procedure. Medical Abortion Medical abortion entails taking two medications, mifepristone and misoprostol. Medical abortion is not the same as emergency contraception, also known as the "morning-after pill." Emergency contraception is designed to prevent pregnancy, whereas medical abortion ends an already existing pregnancy. Women who have a medical abortion take mifepristone in a doctor's office and then go home. They take the second Page 175medication, misoprostol, on their own. This second medication causes period-like cramps and causes the pregnancy tissue to pass usually within 4 hours but up to 48 hours. The amount of bleeding is similar to that of a heavy period or miscarriage. Women return to see their provider 1-2 weeks later and have an ultrasound or a serum pregnancy test to confirm they are no longer pregnant. Medical abortion successfully ends pregnancies 95-97% of the time. If the woman continues to be pregnant, she may repeat the medications or undergo an aspiration procedure. Aspiration Abortion Page 176Aspiration abortion is another way to end a pregnancy in the first trimester. It is also known as "suction abortion," or dilation and curettage (D&C). This is a procedure performed in a medical facility (usually in the outpatient setting and rarely in a hospital) by a trained provider. The woman is usually awake, and the procedure is done through the vagina exclusively (no cut on the abdomen). The provider dilates the cervix (opening to the uterus) and inserts a slender tube (called a cannula or suction curette) into the uterus, which is attached to a vacuum device, and removes the pregnancy (Figure 7.4). The procedure may cause strong cramps and usually takes fewer than 10 minutes. Women undergoing the procedure receive a powerful oral or intravenous pain medication in addition to a numbing medication administered vaginally. The cramping subsides once the procedure is over. Women return home the same day—typically within 30 minutes to an hour after the pain medication has worn off. FIGURE 7.4 Suction curettage. This procedure takes 5-10 minutes and can be performed until the end of the first trimester of pregnancy. Aspiration abortions are successful 98% of the time. Many women receive contraception such as an intrauterine device right after the abortion is completed, saving them an extra visit and protecting them from future pregnancy. Medical vs. Aspiration Abortion in the First Trimester Some women may have the option of selecting either medical or aspiration abortion to end a first-trimester pregnancy. A number of women feel that medical abortion allows them to take more control of the process and gives them more privacy than an aspiration abortion. Additionally, some women feel it is a more "natural" process because it mimics a miscarriage. It is also a noninvasive alternative to aspiration abortion because no instruments are introduced into the uterus. Most women who select a medical abortion are satisfied with this method. A downside of medical abortion is that it takes longer to complete, typically at least 24 hours from the time the first pill is taken to the time the pregnancy passes, whereas an aspiration abortion takes about 10 minutes for the entire procedure. Side effects of one of the medications, misoprostol, include nausea, vomiting, diarrhea, fever, and abdominal pain for some women. Women undergoing a medical abortion are typically given additional medications to help with these symptoms. Medical abortion also generally requires more clinic visits, and there is a small risk of failure, which would then require another round of medications or an aspiration procedure. Vaginal bleeding is often more prolonged and in a few cases heavier than with aspiration abortion. The financial cost to the patient is generally about the same. QUICK STATS More than one-third of abortions that occur at up to 9 weeks of gestation involve early medication procedures. —Guttmacher Institute, 2014 Second-Trimester Abortion About 10% of abortions take place in the second trimester (greater than three months of pregnancy). Women who have an abortion at this stage in pregnancy may do so for a variety of reasons: They recognized they were pregnant later in the pregnancy; they had a difficult time finding a facility to have an abortion; they felt conflicted about ending the pregnancy and needed more time to decide; they discovered that the fetus had problems; or they became sick themselves, making it difficult or dangerous to continue the pregnancy. The approach to ending a second-trimester pregnancy depends on where the woman goes for care and how far along she is. Some medical facilities offer termination of pregnancy by inducing labor with medications, a process called induction abortion. Other facilities offer surgery called dilation and evacuation (D&E), the most common method of second-trimester pregnancy termination in the United States. While similar to a first-trimester abortion, a Page 177D&E may take longer, and women typically receive stronger pain medications. Dilation and evacuation is typically done as outpatient surgery, but a woman may need to visit the health care provider or clinic the day before to take medications or begin the process of dilating the cervix. Under general or regional anesthesia, the fetus is surgically removed through the vagina, and suction is used to remove any remaining tissue; women can usually go home the same day. Soreness and cramping may occur for a day or two after the procedure, and some bleeding may last for 1-2 weeks. Second-trimester pregnancy termination is also very safe. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION How may restrictive abortion laws increase the number of women who have second-trimester abortions? Do these laws affect poor women differently than they do more affluent women? What about the variation among states in abortion laws and number of providers?

which contraceptive method is right for you

WHICH CONTRACEPTIVE METHOD IS RIGHT FOR YOU? The process of choosing and using a contraceptive method can be complex and varies from one couple to another. Each person must consider many variables in deciding which method is most acceptable and appropriate for her or him. Key considerations include those listed here. (To help make a choice that's right for you, take the quiz in the box "Which Contraceptive Method Is Right for You and Your Partner?") The implications of an unplanned pregnancy and the efficacy of the method. Many teens and young adults fail to consider how their lives would be affected by an unexpected pregnancy. People who choose to be sexually active but would be negatively affected by an unplanned pregnancy need to use an effective means of birth control and use it consistently. Health risks. When considering any contraceptive method, determine whether it may pose a risk to your Page 167health. However, most women are candidates for most, if not all, methods of contraception. Remember that pregnancy carries significant health risks that are generally much greater than the risks of any method of contraception. STI risk. STIs are another potential consequence of sex. In fact, several activities besides vaginal intercourse (such as oral and anal sex) can put you at risk for an STI. Condom use is of critical importance whenever any risk of STIs is present, even if you are using another contraceptive method to prevent pregnancy. This is especially true whenever you are not in an exclusive, long-term relationship. Convenience and comfort level. The most convenient methods are the LARC methods (IUDs and implants) that do not require any work on the part of the user. Most women using hormonal methods also rank them high in convenience. If forgetting to take pills is a problem for you, a vaginal ring, contraceptive patch, implant, or injectable method may be a good alternative to the pill. For those who choose a barrier method, condoms are the most common. Some people think condom use disrupts spontaneity, but creative approaches to condom use can decrease these concerns. The diaphragm, cervical cap, contraceptive sponge, female condom, and spermicides can be inserted before intercourse begins, unlike condoms, which must be put on the erect penis. Type of relationship. Barrier methods require more motivation and sense of responsibility from each partner than hormonal methods do. When the method depends on the cooperation of one's partner, assertiveness is necessary, no matter how difficult. This is especially true in new relationships, when condom use is most important. Ease and cost of obtaining and maintaining each method. Investigate the costs of different methods. Under the Affordable Care Act, insurers (except for religious organizations) are required to cover the cost of contraception. On June 30, 2014, the Supreme Court ruled that closely held corporations with religious objections also may opt out of the contraception coverage. Remember that your student health clinic probably provides family planning services, and most communities have low-cost family planning clinics, such as Planned Parenthood. Religious or philosophical beliefs. For some people, abstinence and/or fertility awareness-based methods may be the only permissible contraceptive methods. Potential noncontraceptive benefits. Women with dysmenorrhea, irregular periods, acne, endometriosis, severe premenstrual syndrome (PMS), and other medical problems may benefit from using a particular method of contraception. Be sure to discuss these issues with your health care provider so that you can take advantage of the noncontraceptive benefits associated with many methods of birth control. ASSESS YOURSELF: Which Contraceptive Method Is Right for You and Your Partner? If you are sexually active, you need to use the contraceptive method that works best for you. The following questions will help you sort out factors that affect your choice and pick an appropriate contraceptive method. Answer yes or no for each statement. _____ 1. I like sexual spontaneity and don't want to be bothered with contraception at the time of sexual intercourse. _____ 2. I need a contraceptive immediately (today). _____ 3. It is very important that I (or my partner) do not become pregnant now. _____ 4. I want a contraceptive method that will protect me and my partner against sexually transmitted infections. _____ 5. I prefer a contraceptive method that requires the cooperation and involvement of both partners. _____ 6. I have sexual intercourse frequently. _____ 7. I have sexual intercourse infrequently. _____ 8. I am forgetful or have a variable daily routine. _____ 9. I have more than one sex partner. _____ 10. I have (or my partner has) heavy periods with cramps. _____ 11. I prefer a method that requires little or no action or bother on my part. _____ 12. I am (or my partner is) a nursing mother.* _____ 13. I want the option of conceiving immediately after discontinuing contraception. _____ 14. I want a contraceptive method with few or no side effects. _____ 15. I want a very effective contraceptive method that requires no work on my part (or my partner's part) for at least three years. If you answered yes to these statements: These contraceptive methods may be a good choice for you: 1, 3, 6, 10, 12, 13 Oral contraceptives 1, 3, 6, 8, 10, 13 Contraceptive patch, vaginal ring 1, 3, 6, 8, 10, 11, 12 Injectable contraceptive (Depo-Provera) 1, 3, 6, 8, 10, 11, 12, 15 Contraceptive implant (Implanon, Nexplanon) 1, 3, 6, 8, 10, 11, 12, 13, 14, 15 IUD (Mirena, Skyla) 1, 3, 6, 8, 11, 12, 13, 14, 15 IUD (ParaGard) 2, 4, 5, 7, 9, 12, 13, 14 Condoms (male and female) 2, 5, 7, 12, 13, 14 Vaginal spermicides and sponge 5, 7, 12, 13, 14 Diaphragm and spermicide, cervical cap *Progestin-only hormonal contraceptives (the minipill and Depo-Provera injections) are safe for use by nursing mothers; contraceptives that include estrogen are usually not recommended. Whatever your needs, circumstances, or beliefs, do make a choice about contraception. Not choosing anything is the one method known not to work. Contraception is an area in which taking charge of your health has immediate and profound implications for your future. The method you choose today won't necessarily be the one you'll want to use your whole life or even next year. But it should be one that works for you right now.

understanding abortion

UNDERSTANDING ABORTION The word abortion generally refers to a pregnancy ending. A spontaneous abortion, also called a miscarriage, is a pregnancy that ends on its own; it may be an emotionally trying event for some women and their families, and often experienced as a loss. About 15% of pregnant women experience spontaneous abortions, which occur most frequently during the first trimester. Generally, chromosomal abnormalities lead to an abnormal pregnancy that is incompatible with life and that the body ultimately detects and ends. Induced abortion, or pregnancy termination, is a pregnancy that is intentionally ended. The rest of this chapter focuses on induced abortion. Abortion Statistics The decision to have an abortion may be complex or emotional, and is usually in reaction to an unintended pregnancy. This is the reason for more than 95% of abortions. An unintended pregnancy includes pregnancies that are (1) mistimed, meaning that a woman or couple wanted to become pregnant but at a later date or (2) unwanted, meaning that a woman or couple had not wanted to become pregnant at that time at all. Mistimed pregnancies account Page 173for 65-75% of unintended pregnancies, a much larger percentage than unwanted pregnancies. More than half of women with unintended pregnancies continue their pregnancies and give birth. The remainder of women with unintended pregnancies have either an induced abortion or a miscarriage in relatively equal proportions. About 1 million abortions are performed in the United States each year, making abortion the most common procedure that women of reproductive age undergo. In fact, one in four women has an abortion by age 30, making it very likely that each of us knows someone who has had one. Women choosing to end their pregnancies will find a way to obtain an abortion; researchers estimated that about 800,000 illegal abortions were performed annually in the years before Roe v. Wade. The number of legal abortions rose after 1973, reaching a peak in the early 1980s and then declining fairly steadily; the rate in 2011 was the lowest since 1973 (Figure 7.1). Stricter laws that limit access to abortion do not appear to be responsible for the drop, as the decrease has occurred across the nation and not just in states with the most significant restrictions. Pregnancy and birth rates have also declined, most likely due to increased access to and use of contraception to prevent unintended pregnancy. The timing of abortions has shifted to earlier in pregnancy, with over 90% taking place within the first 13 weeks (Figure 7.2). FIGURE 7.1 Pregnancy (1976-2010), birth (1976-2014), and abortion (1976-2011). sources: Curtin S. C., J. C. Abma, and K. Kost. 2015. 2010 Pregnancy rates among U.S. women (http://www.cdc.gov/nchs/data/hestat/pregnancy/2010_pregnancy_rates.htm); Martin, J. A., et al. 2015. Births: Final data for 2013. National Vital Statistics Reports 64(1). Hyattsville, MD: National Center for Health Statistics; Jones, R. K., and J. Jerman. 2014. Abortion incidence and service availability in the United States, 2011. Perspectives on Sexual and Reproductive Health, 46(1): 3-14. Pie charts showing distribution by woman's age and by gestation period. [D] FIGURE 7.2 Distribution of abortions by the woman's age and by the weeks of gestation: 2012. source: Centers for Disease Control and Prevention. 2015. Abortion surveillance—United States, 2012. MMWR Surveillance Summaries 64(SS10): 1-40. Personal and Social Indicators Several personal and social indicators are commonly given as reasons for terminating a pregnancy (Figure 7.3). These reasons include lack of financial resources; interference with the woman's work, educational aspirations, or ability to care for dependents; reluctance to become a single mother; or problems in a relationship. Younger women who become pregnant often report Page 174that they are unprepared for the transition to motherhood, whereas older women regularly cite that a pregnancy would interfere with their responsibility to dependents. Bar graph showing percentage of women reporting specific reasons for deciding to have an abortion. [D] FIGURE 7.3 The reasons women have abortions. Researchers asked women to describe their reasons for deciding to have an abortion. source: Finer, L. B., et al. 2005. Reasons U.S. women have abortions. Quantitative and qualitative perspectives. Perspectives on Sexual and Reproductive Health 37(3): 110-118. Women who have abortions represent various ages, religions, races, and levels of education. Poverty has been identified as a key factor leading to an abortion. In 2008, 42% of women undergoing an abortion were poor by federal standards. Fetal and Maternal Indicators Women or couples with a planned pregnancy may ultimately decide to end it if they learn that the fetus has a significant abnormality. Two examples are Trisomy 18, which causes renal, cardiac, gastrointestinal, and musculoskeletal problems, or anencephaly, which means that major portions of the skull and brain do not form. Both conditions are usually fatal before or shortly after birth. Most abortions performed for fetal anomalies occur in the second trimester because fetal problems are typically discovered at this time through genetic testing and a detailed ultrasound. Due to risks to their own health, pregnant women with serious medical conditions sometimes need to end their pregnancies. These conditions might include severe high blood pressure, a lung disease called pulmonary hypertension, severe kidney disease, advanced diabetes, and severe cardiac disease. Some conditions that already exist can worsen in pregnancy and permanently injure a woman's health after pregnancy. If she knows that her health is at risk, ending the pregnancy before the fetus becomes viable (able to survive outside the womb) may prevent a life-threatening problem. Personal Considerations for the Woman For the pregnant woman with an unintended or abnormal pregnancy, the decision about how to proceed is not political, especially as she attempts to weigh the many short- and long-term ramifications for all those who are directly concerned. If she continues the pregnancy, how will her life change by having a child? Can she become a mother to this child? If she has other children, how will another child affect them? How does she feel about adoption? What are her long-term feelings likely to be? (The box "The Adoption Option" addresses some of these questions.) If she ends the pregnancy, can she accept the decision in terms of her own religious and moral beliefs? What are her partner's feelings about having this child? If he is unsupportive, does she have the social and emotional resources to raise the child without him? If she is young, what will be the effects on her own growth? Will she be able to continue with her educational and personal goals? What about the ongoing financial responsibilities? DIVERSITY MATTERS: The Adoption Option Before abortions were legal, women with unintended pregnancies had the legal options of becoming a parent or pursuing adoption. Before 1979, about 9% of babies born to never-married women were relinquished for adoption, and in the mid-1990s to early 2000s, the number dropped to 1%. This decline may be due to a variety of factors, including an easing of the social stigma of single parenthood. A drop in adoption rates in the 1970s probably reflected an increase in the abortion rate following the 1973 legalization of abortion. Since 1990, however, adoption rates have remained steady, whereas the abortion rate has declined, indicating that overall, women are not choosing abortion over adoption. Many children who are adopted are adopted by a relative or foster parent. Adoptions in which the child is not related to an adoptive parent(s) are more common among those with higher levels of income and educational attainment. © Design Pics /Darren Greenwood RF The decision to go through an unwanted pregnancy and then give the baby to another family may be emotionally difficult. Adoption is permanent: The adoptive parents will raise the child and have legal authority for his or her welfare. Many people can help a pregnant woman consider her options, including her partner; friends; family members; a professional counselor; a family planning clinic; or family services, social services, or adoption agencies. A counselor should always be respectful and willing to discuss all three options—continuing the pregnancy and becoming a parent, arranging an adoption, or ending the pregnancy. Adoptions can be open or closed, also known as confidential. In a confidential adoption, the birth parents and the adoptive parents never know each other. Adoptive parents receive any information that might help them take care of the child. A later meeting between the child and birth parents is possible in confidential adoption; laws vary by state, but in many, information about birth parents and adopted individuals can be released if both parties consent (visit childwelfare.gov for additional information). In an open adoption, the birth parents and adoptive parents know something about each other. The levels of openness range from reading a brief description of prospective adoptive parents to meeting them and sharing full information. Birth parents may also be able to stay in touch with the family by visiting, calling, or writing. In all states, a mother can work with a licensed child placement (adoption) agency. It may also be possible to work directly with an adopting couple or their attorney; this is called a private or independent adoption. A woman who places the child for adoption should also consider the reaction and rights of the biological father. A woman can choose to have an abortion without the consent or knowledge of the father, but once the baby is born, the father has certain rights. These rights vary from state to state, but at a minimum, most states require that the biological father be notified of the adoption. In some states, the biological father may be able to take the child even if the mother prefers that the child go to an adoptive family. Working with an adoption agency can help a person navigate the laws in each particular state. Throughout the adoption process, the mother should make sure she has the help she needs and that she carefully considers all her options. sources: Child Welfare Information Gateway. 2014. Are You Pregnant and Thinking about Adoption? (https://www.childwelfare.gov/pubs/f_pregna/f_pregna.pdf); Child Welfare Information Gateway. 2005. Voluntary Relinquishment for Adoption: Numbers and Trends (https://www.childwelfare.gov/pubs/s_place.pdf); Fisher, A. P. 2003. Still "not quite as good as having your own"? Toward a sociology of adoption. Annual Review of Sociology 29: 335-361. Personal Considerations for the Man Men are often involved in the decision-making process with their partners, and they may experience a range of emotions similar to those felt by women. Men may also accompany their partners during the abortion process. Accompaniment may reflect an effort to share responsibility for the pregnancy as well as to provide emotional and practical support by providing transportation or helping to pay for the abortion. Supporting each other through the abortion process may strengthen their relationship. In some instances, men disagree with the woman's decision, and they may try to control the outcome of the pregnancy or may be abusive to their partners. Many abortion facilities are sensitive to creating a safe space for women in such situations. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Suppose one of your friends has an unplanned pregnancy and does not know what to do. How would you begin discussing how she feels and what options are available to her? What kind of support would you be willing to offer?

legan restrictions on abortion

LEGAL RESTRICTIONS ON ABORTION In 1973 in the landmark case of Roe v. Wade, the U.S. Supreme Court made abortion legal in every state in the United States. To replace the restrictions most states still imposed at Page 178that time, the justices devised new standards to govern abortion decisions. They divided pregnancy into three parts, or trimesters, giving a woman less choice about abortion as her pregnancy advances toward full term. According to Roe v. Wade, in the first trimester, the abortion decision must be left to the judgment of the pregnant woman and her physician. During the second trimester, similar rights remain up to the point when the fetus becomes viable. Today most clinicians define this point as 24 weeks of gestation. When the fetus is considered viable, a state may regulate and even bar all abortions except those considered necessary to preserve the mother's life or health. Three years after Roe v. Wade, Congress passed the Hyde Amendment, which prevents the use of federal funds (such as Medicaid) to pay for an abortion unless the pregnancy arises from incest or rape or if the woman's life is endangered. In practice, this amendment affects poor women (those who rely on Medicaid to pay for medical services). These women must pay out of pocket for abortion-related care, and if they are unable to pay or they take too long to raise funds, they may be compelled to continue their pregnancies. The Affordable Care Act (2010) explicitly permits states to dictate the circumstances under which abortions may be performed or insured. Currently 17 states provide nonfederal public money to assist some poor women seeking medically necessary abortions. Concerns have been raised that a two-tiered system has been created—one for women with means to pay for an abortion and another for those without. Since 1973 many campaigns have been waged to overturn the Roe v. Wade decision, whereas other campaigns have tried to strengthen the rights provided by the decision. Although abortion remains legal throughout the United States, subsequent rulings by the Supreme Court, starting with Planned Parenthood of Southeastern Pennsylvania v. Casey (1992), have allowed states to regulate abortion throughout pregnancy as long as no "undue burden" is imposed on women seeking these services. The following are examples of restrictive laws that exist on the state level: ∙ Physician and hospital requirements. Thirty-eight states require an abortion to be performed by a licensed physician. Nineteen states require an abortion to be performed in a hospital after a specified point in the pregnancy, and 18 states require the involvement of a second physician after a specified point. Studies show that other medical professionals such as nurse practitioners, nurse midwives, and physician assistants can safely provide abortions. Abortion is held to the same safety standards as all other medical treatments in the United States. ∙ State-mandated counseling. Seventeen states mandate that, before an abortion, women must be given counseling that includes information on at least one of the following: the purported link between abortion and breast cancer (5 states), the ability of a fetus to feel pain (12 states), or long-term mental health consequences for the woman (7 states). There is no evidence to suggest that abortions lead to breast cancer or have other long-term consequences for women, as discussed earlier in this chapter. Furthermore, there is no biological evidence that a fetus feels pain. ∙ Waiting periods. Twenty-eight states require a woman seeking an abortion to wait a specified period of time, usually 24 hours, between the time she receives counseling and when the procedure is performed. Fourteen of these states have laws that effectively require the woman to make two separate trips to the clinic to obtain the procedure. Strong evidence suggests that women have made up their minds to have an abortion prior to seeking an abortion and that it is not a decision taken lightly. Women seeking an abortion, as do all individuals seeking care, have the right to take some time to select a treatment. However, mandating a waiting time creates an extra hurdle to having an abortion and is not founded on a medical explanation. ∙ Parental involvement. Thirty-eight states require some type of parental involvement in a minor's decision to have an abortion. Twenty-five states require one or both parents to consent to the procedure, whereas 13 require that one or both parents be notified and 5 states require both parental consent and notification. Parental involvement has not been shown to protect minors as purported and may cause harm when a minor has abusive parents or is pregnant as a result of incest. Such regulation may also motivate a minor to travel out of state to get an abortion. These restrictions do not improve communication between minors and their parents because most minors already do tell their parents they are having an abortion, when they feel it is safe to do so. In general, mandatory delay laws like waiting periods and parental involvement have been found to delay access to abortion, resulting in abortions at later gestational ages.

long acting reversible contraceptive

Page 146 LONG-ACTING REVERSIBLE CONTRACEPTION Long-acting reversible contraception (LARC) consists of intrauterine devices (IUDs) and implants. These methods of contraception give very high satisfaction rates and have been shown to decrease instances of unintended pregnancy and abortion more than do other methods. According to the Institute of Medicine, "expanding access to LARC for all young women should be a national priority." The American College of Obstetricians and Gynecologists agrees that IUDs and implants should be encouraged for all appropriate candidates, including adolescents and women who have not yet given birth. Intrauterine Devices (IUDs) An intrauterine device (IUD) is a small plastic object placed in the uterus as a contraceptive. Three types of IUDs are now available in the United States: the Copper T-380A (also known as ParaGard), which provides protection for up to 12 years, and the Mirena and Skyla, both of which release small amounts of progestin (a synthetic progesterone) and remain effective for 5 and 3 years, respectively. Current evidence suggests that ParaGard works primarily by preventing fertilization. This IUD contains copper, which is thought to cause biochemical changes in the uterus that affect the movement of sperm and eggs. ParaGard may also interfere with implantation of fertilized eggs. Like ParaGard, Mirena and Skyla also work primarily by preventing fertilization. As a result of the slow release of very small amounts of progestin, the cervical mucus thickens and stops fertilization. An IUD must be inserted and removed by a trained professional. It can be inserted at any time during the menstrual cycle, as long as the woman is not pregnant. The device is threaded into a sterile inserter that is introduced through the cervix; a plunger pushes the IUD into the uterus. IUDs have two threads attached that protrude from the cervix into the vagina so that a woman can feel them to make sure the device is in place. These threads are trimmed so that only 1-1½ inches remain in the upper vagina (Figure 6.3). FIGURE 6.3 An IUD (Copper T-380A, or ParaGard) properly positioned in the uterus. QUICK STATS Use of long-acting reversible contraception (LARC) increased nearly fivefold in the past decade among women aged 15-44, from 1.5% in 2002 to 7.2% in 2011-2013. —Centers for Disease Control and Prevention, 2015 Advantages Intrauterine devices are highly reliable and are simple and convenient to use, requiring no attention. They do not require the woman to anticipate or interrupt sexual activity. IUDs have only local effects and tend to be very safe for all women, including those with complex medical problems. The long-term expense of using an IUD is also low. The main advantage is their low failure rate: Less than 1% of women using IUDs will get pregnant. In the absence of complications, they are also fully reversible, meaning that fertility is restored as soon as the IUD is removed. Following IUD removal, the risk of ectopic pregnancy is decreased. Mirena has the added advantage of greatly decreasing blood flow during menstruation and is often used as a treatment for excessive bleeding. In fact, after a year of using Mirena, menstrual bleeding is decreased by about 90%. Mirena generally reduces menstrual cramps and is often prescribed for that reason. The Mirena IUD has also been shown to prevent endometrial cancer (in the lining of the uterus) and even reverse the endometrial changes that precede endometrial cancer. ParaGard has been shown to decrease the risk of endometrial cancer, but the reasons for this are less clear. Disadvantages The IUD offers little to no protection against STIs. Most IUD side effects are limited to the genital tract. Side effects differ between the two types of IUD. Page 147Heavy menstrual flow and increased menstrual cramping sometimes occur with ParaGard, whereas Mirena causes a reduction in bleeding and cramping. Spontaneous expulsion of the IUD happens to 3% of women within the first year, most commonly during the first months after insertion. In rare cases, an IUD can puncture the uterine wall and migrate into the abdominal cavity. A serious but rare complication of IUD use is pelvic inflammatory disease (PID). Most pelvic infections among IUD users occur shortly after insertion, are relatively mild, and can be treated successfully with antibiotics. Early and adequate treatment is critical—a lingering infection can lead to tubal scarring and subsequent infertility. For many years, IUD use was not recommended for women who had never had a child. However, extensive research now reveals that the IUD is a safe and highly effective contraceptive in this patient population and therefore can be recommended. IUDs are not suitable for women with suspected pregnancy, large tumors of the uterus, other anatomical abnormalities, or unexplained bleeding; Mirena is also not to be used in women with certain hormonally responsive cancers. Early IUD danger signals include abdominal pain, fever, chills, foul-smelling vaginal discharge, and unusual vaginal bleeding. A change in string length may also be a sign of a problem. Because of the relatively high up-front costs associated with the IUDs, including the cost of the device as well as the practitioner's insertion fee, the IUD is typically most cost-effective for women who desire contraception for at least six months. The percentage of the cost covered by insurance plans varies greatly. Effectiveness The typical first-year failure rate of IUDs is 0.8% for ParaGard, 0.5% for Skyla, and 0.2% for Mirena. Effectiveness can be increased by periodically making sure that the device is in place and by using a backup method for the first week of IUD use. If pregnancy occurs, the IUD may need to be removed to safeguard the woman's health and to maintain the pregnancy; removal depends on the location of the IUD with respect to the pregnancy. If an IUD must be left in place during pregnancy, there is an increased risk of complications. Contraceptive Implants Contraceptive implants are placed under the skin of the upper arm and deliver a small but steady dose of progestin over a period of years. One such implant, called Nexplanon, is a single implant that is effective for three years and is considered to be one of the most effective forms of contraception (Figure 6.4). Implanon/Nexplanon implant device is placed under the skin on the inside of the arm between the armpit and elbow. FIGURE 6.4 Placement of contraceptive implant. The Implanon/Nexplanon implant device has to be placed and removed by a trained medical professional. The progestins in implants have several contraceptive effects. They cause hormonal shifts that may inhibit ovulation and affect development of the uterine lining. The hormones also thicken the cervical mucus, inhibiting the movement of sperm. Contraceptive implants are best suited for women who wish to have continuous, highly effective, and long-term protection against pregnancy. Advantages Contraceptive implants are highly effective, with a failure rate of less than 1%. After insertion of the implants, no further action is required; contraceptive effects are reversed quickly upon removal. Because implants contain no estrogen, they carry a lower risk of certain side effects, such as blood clots (venous thromboembolism) and other cardiovascular complications. Menstrual bleeding tends to decrease but becomes irregular. Women who are breastfeeding can use Nexplanon. Disadvantages An implant provides little to no protection against STIs. Although the implants are barely visible, their presence may bother some women. Only specially trained practitioners can insert or remove the implants. The up-front costs associated with the implant, including the cost of the device as well as the practitioner's fees, can be significant; therefore, the device is cost-effective only for users desiring more than six months of contraception. Common side effects of contraceptive implants are menstrual irregularities, including longer menstrual periods, spotting between periods, or having no bleeding at all. The menstrual cycle usually becomes more regular after one year of use. Less common side effects include headaches, weight gain, breast tenderness, nausea, acne, and mood swings. Effectiveness The overall failure rate for Nexplanon is estimated at about 0.05%. It is one of the most effective methods of contraception and also one of the most discreet.

short acting reversible contraceptive

Page 148 SHORT-ACTING REVERSIBLE CONTRACEPTION A variety of hormonal and barrier methods fall into the group of short-acting reversible contraceptives. For these methods, the user must take action on a daily, weekly, or monthly basis, or at the time of intercourse. Such short-acting methods include, among others, oral contraceptives, skin patches, and vaginal rings. Oral Contraceptives: The Pill About a century ago, a researcher noted that ovulation does not occur during pregnancy. Further research revealed the hormonal mechanism: During pregnancy, the corpus luteum secretes progesterone and estrogen in amounts high enough to suppress ovulation. (See Chapter 5 for a complete discussion of the menstrual cycle.) Oral contraceptives (OCs), also known as birth control pills or "the pill," prevent ovulation by mimicking the hormonal activity of the corpus luteum. The active ingredients in OCs are estrogen and progestins, laboratory-made compounds that are closely related to progesterone. Today OCs are the most widely used form of contraception among unmarried women and are second only to sterilization among married women. In addition to preventing ovulation, the birth control pill has other contraceptive effects. Its main mechanism of action is to inhibit the movement of sperm by thickening the cervical mucus. In the rare event that ovulation does occur, the pill alters the rate of ovum transport by means of its hormonal effects on the fallopian tubes, and it may prevent implantation by changing the lining of the uterus. The Combination Pill The most common type of OC is the combination pill, which contains varying amounts of estrogen and progestin. Traditionally each one-month packet contained a three-week supply of "active" pills that combine varying types and amounts of estrogen and progestin, as well as a one-week supply of "placebo" pills that do not contain hormones. Increasingly, however, combination pills are offering different schedules, including 24 active pills and 4 placebo pills, and 84 active pills and 7 placebo pills. During the time in which no hormones are taken, "your placebo week," a light menstrual period occurs. The newer schedules allow a decreased frequency of menstrual periods. However, a side effect of these extended-cycle regimens is unpredictable light bleeding (known as spotting). The Minipill A much less common type of OC is the minipill, a small dose of a synthetic progesterone taken every day of the month. Because the minipill contains no estrogen, it has fewer side effects and health risks, but it is less effective and is associated with more irregular bleeding patterns. Additionally, it must be taken at the same time every day to maintain efficacy. It is sometimes prescribed for women who are breastfeeding or have medical problems that make it unsafe for them to take estrogen. Reversible hormonal contraceptives are available in several forms. Shown here are the patch, the ring, and an implant. © Phanie/Photo Researchers, Inc. How Oral Contraceptives Are Used A woman is usually advised to start the first cycle of pills with a menstrual period to increase effectiveness and eliminate the possibility Page 149of unsuspected pregnancy. But if pregnancy has been ruled out, the pill can be started immediately, that is, at any time during the cycle. A backup contraceptive method, such as condoms, should also be used during the first week. She must take one pill every day. Taking a few pills just prior to having sexual intercourse does not provide effective contraception. Linking pill taking to part of their regular routine, such as teeth brushing, helps many women remember to take their pills the same time every day. During the first cycle or two, hormonal adjustments may cause slight bleeding between periods. This spotting is considered normal. If the pill is not started with a menstrual period, full effectiveness cannot be guaranteed during the first week. A backup contraceptive method is recommended during the first week and any subsequent cycle in which the woman forgets to take any pills. Advantages Oral contraceptives are fairly effective in preventing pregnancy. The majority of women who get pregnant while using the pill get pregnant because the pills were not taken as directed. The typical one-year failure rate is 9%. The pill is relatively simple to use and does not hinder sexual spontaneity. Most women also appreciate the predictable regularity of periods, as well as the reduction in cramps and blood loss. Women who have significant problems associated with menstruation may benefit from menstrual suppression with extended-cycle OCs. Finally, the pills are reversible and fertility returns shortly after stopping the pill. Medical advantages include a decreased incidence of benign breast disease, acne, iron-deficiency anemia, ectopic pregnancy, colon and rectal cancer, endometrial cancer, and ovarian cancer. Women who have ever taken the pill have a 50% lower risk of endometrial cancer, and those who use the pill long term (more than five years) reduce their risk even further. The risk of ovarian cancer drops by 20% for every five years of pill use, and some doctors recommend OC use as a preventive measure for women at high genetic risk for ovarian cancer. Some studies have shown that OCs also reduce the risk of colon cancer by about 18% in current and recent users. OC use reduces dysmenorrhea (painful periods), endometriosis, and polycystic ovary syndrome. Health care providers prescribe OCs to treat other medical problems such as menstrual migraine, adenomyosis, and heavy perimenopausal bleeding. Disadvantages Although simple to ingest, remembering to take a pill every single day can be challenging. Furthermore, OCs do not protect against STIs. In some studies, OCs have been associated with increased risk of cervical chlamydia. If you are using the pill, you should also be using condoms regularly (an exception could be if you have a long-term, mutually monogamous relationship with an uninfected partner). The hormones in birth control pills influence many tissues in the body and can lead to a variety of side effects, most of which are minor. The majority of women do not experience any side effects associated with OC use. Among women who experience problems with OCs, the most common issue is bleeding during midcycle (called breakthrough bleeding), which is usually slight and tends to disappear after a few cycles. Symptoms of early pregnancy—such as morning nausea and swollen breasts—may appear during the first few months of OC use, although these side effects are uncommon with the low-dose pills in current widespread use. Other side effects can include depression, nervousness, changes in sex drive, dizziness, generalized headaches, migraine, and vaginal discharge. Acne may develop or worsen when women take OCs, but most women find their acne improves when they take the pill. In fact, OCs are frequently prescribed as a treatment for acne. Research shows that currently used low-dose OCs do not, on average, cause weight gain. Most women experience no change in their weight, while a small percentage lose weight, and about an equal percentage gain weight while taking OCs. The myth that OCs cause women to gain weight is actually dangerous because many unintended pregnancies have resulted when women avoided taking OCs due to unfounded fear of weight gain. Another myth about OCs is that they can cause cancer. Actually, taking the pill greatly reduces a woman's risk for endometrial and ovarian cancers. OC use is associated with little, if any, increase in breast cancer and a slight increase in cervical cancer, but earlier detection and other variables (such as a woman's number of sexual partners) may account for much of this increase. QUICK STATS The percentage of teenagers who report having ever had sexual intercourse is less than 50% and has declined over the past 25 years by 14% for females and 22% for males. —Centers for Disease Control and Prevention, 2015 Serious OC side effects have been reported in a small number of women. These include blood clots, stroke, and heart attack, concentrated mostly in older women who smoke or have a history of circulatory disease. Recent studies have shown no increased risk of stroke or heart attack for healthy, young, nonsmoking women on lower-dosage pills. OC users may be slightly more prone to high blood pressure, gallbladder disease, and, very rarely, benign liver tumors. Birth control pills are not recommended for women with a history of blood clots (or a close family member with unexplained blood clots at an early age), heart disease or stroke, migraines with changes in vision, any form of cancer or liver tumor, or impaired liver function. Women with certain other health conditions or behaviors, including migraines without changes in vision, high blood pressure, cigarette smoking, and sickle-cell disease, require close monitoring when taking the pill. Page 150When deciding whether to use OCs, each woman needs to weigh the benefits against the risks. To make an informed decision, she should begin by getting advice from a health care professional (see the box "Obtaining a Contraceptive from a Health Clinic or Physician"). If you take the pill, you can take several steps to reduce the risks associated with OC use: Request a low-dosage pill. (OCs recommended for most new users contain 20-35 micrograms of estrogen.) Stop smoking. Follow the directions carefully and consistently, making sure to take the pills at the same time every day. Be alert to preliminary danger signals, which can be remembered by the word ACHES: Abdominal pain (severe) Chest pain (severe), cough, shortness of breath, or sharp pain on breathing in Headaches (severe), dizziness, weakness, or numbness, especially if one-sided Page 151Eye problems (vision loss or blurring) and/or speech problems Severe leg pain (calf or thigh) Make sure your health practitioner knows your personal and family medical history to help determine whether OCs may be unsafe for you. Have regular Pap tests, pelvic exams, and breast exams as recommended by your health practitioner. CRITICAL CONSUMER: Obtaining a Contraceptive from a Health Clinic or Physician If you are a woman considering a method of contraception that requires a prescription or professional fitting or insertion, you'll need to go to a health clinic or a physician to get it. Many of the female contraception methods—including hormonal methods, IUDs, diaphragms, and cervical caps—require at least an initial professional visit. An exception is that several states have passed laws allowing some pharmacists to provide hormonal methods without a prescription; for example, California (pills, patches, injections) and Oregon (pills, patches). Similar laws are being considered in other states. The thought of visiting a physician's office or health clinic to discuss and obtain contraception makes many people nervous. Remember that the people in the office are health care professionals who will not pass moral judgment on you. They are dedicated to meeting your health care needs. Knowing what to expect can help you get more from your visit. Before Your Visit Prepare for a successful visit by doing the following: Pull together your personal and family medical history. Make sure it's accurate and up-to-date. Review the section in this chapter titled "Which Contraceptive Method Is Right for You?" Carefully consider each topic, and discuss it with your partner if that would be helpful. Write down any questions you have. Decide what you need to learn about your contraceptive options. If you have questions about sexually transmitted infections or other aspects of sexuality, write those down, too. If you like, plan to have your partner, a friend, or a family member accompany you to your appointment. Remember that the more honest you are with your health care provider, the more helpful the advice can be. During Your Visit When you arrive, you'll probably be asked to fill out forms detailing your background and medical history. A physician or staff member will then review the various contraceptive methods with you and answer your questions. She or he can help you evaluate the key factors affecting your choice of method, including health risks, lifestyle factors, cost, and protection against STIs. Blood and urine samples may be taken for lab tests. The Physical Exam Your physical exam will probably include a check of your breasts, external genitals, and abdomen, plus a Pap test and possible screening for certain STIs. The exam will help ensure that you can safely use the contraceptive method you have chosen, as well as protect your overall health. If this is your first pelvic exam or you feel nervous or uncomfortable, tell the clinician, and ask her or him to explain each step of the examination. For the pelvic exam, you will be asked to lie on your back on an examination table, with your feet in stirrups and your knees bent and spread apart. The exam doesn't usually hurt. An instrument called a speculum will be inserted into the vagina to hold it open so that the clinician can look at the cervix and vaginal walls. For the Pap test, the clinician will scrape some cells from the cervix and place them on a glass slide. These cells will be analyzed for any signs of cancer. You may feel a slight pressure while the cells are collected. The clinician will also check your internal organs by placing two gloved fingers into the vagina and the other hand on the lower abdomen. He or she will palpate (examine by touching) the uterus and ovaries to check for any abnormalities. If you're getting a diaphragm or a cervical cap that is available in multiple sizes, you will be fitted for it at this time. The clinician will probably try different sizes to find the best fit and then will show you how to insert and remove it. Following Your Exam After your exam, a health care worker will provide you with your contraceptive, arrange for a further appointment (if necessary), or give you a prescription. Make sure you know exactly how to use the method you've chosen. Written instructions and information should be available. Be sure to ask for a phone number you can call if you have questions later—and don't forget to return to your health care provider for other health care and screenings. source: Kaiser Family Foundation. 2016. Women's Health Policy: Oral Contraceptive Pills (http://kff.org/womens-health-policy/fact-sheet/oral-contraceptive-pills). Overall, OC risks are generally very small unless you are over 35, are a smoker, or have specific medical problems. For the vast majority of young women, the known, directly associated risk of death from taking birth control pills is much, much lower than the risk of death from pregnancy (Table 6.1). Table 6.1 Risks of Contraception, Pregnancy, and Abortion CONTRACEPTION RISK OF DEATH Oral contraceptives Nonsmoker Ages 15-34 1 in 1,667,000 Ages 35-44 1 in 33,300 Smoker Ages 15-34 1 in 57,800 Ages 35-44 1 in 5,200 IUDs 1 in 10,000,000 Barrier methods, spermicides None Fertility awareness-based methods None Tubal ligation 1 in 66,700 PREGNANCY RISK OF DEATH Pregnancy 1 in 6,900 ABORTION RISK OF DEATH Spontaneous abortion 1 in 142,900 Medical abortion 1 in 200,000 Surgical abortion 1 in 142,900 source: Hatcher, R. A., et al. Contraceptive Technology, 20th revised ed. 2011, Ardent Media. Effectiveness Oral contraceptive effectiveness varies substantially because it depends so much on individual factors. If taken as directed, the failure rate is as low as 0.3%. However, the typical user has a 9% failure rate. The continuation rate for OCs also varies; the average rate is 67% after one year. Besides forgetting to take the pill, another reason for OC failure is poor absorption of the drug due to vomiting or diarrhea, or to interactions with other medicines (including certain antibiotics, antiseizure medications, and the commonly used herb St. John's wort). Contraceptive Skin Patch The contraceptive skin patch, Ortho Evra, is a thin, 1¾-inch square patch that slowly releases an estrogen and a progestin into the bloodstream. The contraceptive patch prevents pregnancy in the same way as combination OCs, following a similar schedule. Each patch is worn continuously for one week and is replaced on the same day of the week for three consecutive weeks. The fourth week is patch-free, allowing a woman to have her menstrual period. The contraceptive skin patch can be worn on several different parts of a woman's body; it remains on during bathing or swimming. © Bob Pardue-Medical Lifestyle/Alamy Stock Photo The patch can be worn on the upper outer arm, abdomen, buttocks, or upper torso (excluding the breasts); it is designed to stick to skin even during bathing or swimming. If a patch should fall off for more than a day, the U.S. Food and Drug Administration (FDA) advises starting a new four-week cycle of patches and using a backup method of contraception for the first week. Patches should be discarded according to the manufacturer's directions to avoid leakage of hormones into the environment. Advantages Because the patch provides the same combination of hormones as a combined birth control pill, the Page 152advantages are similar. The medical benefits of the patch include, but are not limited to, lighter, less painful menses; decreased risk of uterine and ovarian cancers; decreased anemia; and the ability to control your cycle. With both perfect and typical use, the patch is as effective as OCs in preventing pregnancy. Compliance seems to be higher with the patch than with OCs, probably because the patch requires weekly instead of daily action. Disadvantages Like other hormonal contraceptives, the patch doesn't protect against STIs. Patch users should also use condoms for STI protection unless they are in a long-term monogamous relationship with an uninfected partner. Minor side effects are similar to those of OCs, although breast discomfort may be more common in patch users. Some women also experience skin irritation around the patch. More serious complications are thought to be similar to those of OCs, including an increased risk of side effects among women who smoke. However, because Ortho Evra exposes users to higher doses of estrogen than most OCs, patch use may further increase the risk of blood clots. Recent studies show conflicting results regarding the risk of blood clots, but it is possible that the risk is slightly higher with the patch compared to low-dose OCs. Effectiveness With perfect use, the patch's failure rate is very low (0.3%) in the first year of use. The typical failure rate is approximately 9%, similar to that of the oral contraceptive pill. Failure rates have been shown to be higher in women weighing more than 198 pounds. Vaginal Contraceptive Ring The NuvaRing is a vaginal ring that is molded with a mixture of progestin and estrogen. The two-inch ring slowly releases hormones and maintains blood hormone levels comparable to those found with OC use. The ring prevents pregnancy in the same way as OCs. A woman inserts the ring anytime during the first five days of her menstrual cycle and leaves it in place for three weeks. During the fourth week, when the ring is removed, her next menstrual cycle occurs. A new ring is then inserted seven days later. Rings should be discarded according to the manufacturer's directions to avoid leakage of hormones into the environment. Backup contraception must be used for the first seven days of the first ring use or if the ring has been removed for more than three hours. Advantages The NuvaRing offers one month of protection with no daily or weekly action required. It does not require a fitting by a clinician, and exact placement in the vagina is not critical as it is with a diaphragm. Because the ring provides the same combination of hormones as a combined birth control pill, the advantages are similar. The medical benefits of the ring include, but are not limited to, lighter, less painful menses; decreased risk of uterine and ovarian cancer; decreased anemia; and the ability to control your cycle. The NuvaRing is worn inside the woman's vagina for three weeks at a time. © N. Aubrier/Getty Images Disadvantages The NuvaRing provides no protection against STIs. Side effects are roughly comparable to those seen with OC use, except for a lower incidence of nausea and vomiting. Other side effects may include vaginal discharge, vaginitis, and vaginal irritation. Medical risks also are similar to those found with OC use. Effectiveness As with the pill and patch, the perfect use failure rate is around 0.3%. The ring's typical use failure rate is similar to the pill's at 9%. Injectable Contraceptives Hormonal contraceptive injections were first developed in the 1960s. The first injectable contraceptive approved for use in the United States was Depo-Provera, which uses long-acting progestins. Injected into the arm or buttocks, Depo-Provera is usually given every 12 weeks, although it may provide effective contraception for a few weeks beyond that. The product prevents pregnancy by inhibiting ovulation.Page 153 Advantages Injectable contraceptives are highly effective and require little action on the part of the user. Because the injections leave no trace and involve no ongoing supplies, injectable contraceptives allow women almost total privacy in their decision to use contraception. Depo-Provera has no estrogen-related side effects. Disadvantages Injectable contraceptives provide no protection against STIs. A woman must visit a health care facility every three months to receive the injections. The side effects of Depo-Provera are similar to those of implants: Menstrual irregularities are the most common, and after one year of using Depo-Provera many women have no menstrual bleeding at all. Weight gain is a common side effect. After discontinuing the use of Depo-Provera, women may experience temporary infertility for up to 12 months, making it less ideal for women who plan on conceiving in the near future. Depo-Provera also has a unique risk: It can cause a reduction in bone density, especially in women who use it for an extended period. The rate of decline in bone density is most rapid in the first two years of use, but the good thing is that the bone density begins to increase shortly after discontinuation. Although decreased bone density is a risk factor for osteoporosis (see Chapter 12) and fractures, no studies have shown that this decreased density actually leads to increased fractures. Nonetheless, women who use Depo-Provera are advised to do weight-bearing exercise and ensure an adequate intake of dietary calcium. Due to conflicting data, the FDA states that women should use Depo-Provera as a long-term contraceptive (longer than two years, for example) only if other methods are inadequate. However, multiple gynecologic associations believe that the benefits of this highly effective contraception outweigh the theoretical risks, and continuation should not be denied due to concerns regarding bone density. Effectiveness The perfect use failure rate is 0.2% for Depo-Provera. With typical use, the failure rate increases to 6% in the first year of use. QUICK STATS More than 99% of women aged 15-44 who have ever had sexual intercourse have used at least one contraceptive method. —Guttmacher Institute, 2015 Male Condoms The male condom is a thin sheath designed to cover the penis during sexual intercourse. Most brands available in the United States are made of latex, although condoms made of polyurethane and polyisoprene are also available. Condoms prevent sperm from entering the vagina and provide protection against most STIs. Condoms are the most widely used barrier method and the third most popular of all contraceptive methods used in the United States, after the pill and female sterilization. Condom sales have increased dramatically in recent years, primarily because they are the only method of contraception that provides substantial protection against HIV infection as well as some protection against other STIs. At least one-third of all male condoms are bought by women. This figure will probably increase as more women assume the right to insist on condom use. Many couples combine various contraceptives, using condoms for STI protection and another contraceptive method for greater protection against pregnancy. Condoms come in a variety of sizes, textures, and colors. Some brands have a reservoir tip designed to collect semen. © Catherine Lane/Getty Images The man or his partner must put the condom on the penis before it is inserted into the vagina because the small amounts of fluid that may be secreted unnoticed prior to ejaculation often contain sperm capable of causing pregnancy. The rolled-up condom is placed over the head of the erect penis and unrolled down to the base of the penis, leaving a half-inch space (without air) at the tip to collect semen (Figure 6.5). Some brands of condoms have a reservoir tip designed for this purpose. Uncircumcised men must first pull back the foreskin of the penis. Partners must be careful not to damage the condom with fingernails, rings, or other rough objects. FIGURE 6.5 Use of the male condom. (a) Place the rolled-up condom over the head of the erect penis. Hold the top half-inch of the condom (with air squeezed out) to leave room for semen. (b) While holding the tip, unroll the condom onto the penis. Gently smooth out any air bubbles. (c) Unroll the condom down to the base of the penis. (d) To avoid spilling semen after ejaculation, hold the condom around the base of the penis as the penis is withdrawn. Remove the condom away from your partner, taking care not to spill any semen. Many condoms are prelubricated with water-based or silicone-based lubricants. These lubricants make the condom more comfortable and less likely to break. Many people find that using extra, non-oil-based lubricant can be helpful. Prelubricated condoms are also available containing the spermicide nonoxynol-9, the same Page 154agent found in many of the contraceptive creams that women use. However, spermicidal condoms are no more effective than condoms without spermicide. They cost more and have a shorter shelf life than most other condoms. Further, condoms with nonoxynol-9 have been associated with urinary tract infections in women and, if they cause tissue irritation, an increased risk of HIV transmission. Planned Parenthood and many other public health agencies advise against the use of condoms lubricated with nonoxynol-9. Water-based lubricants such as K-Y Brand Jelly or Astroglide can be used as needed. Any products that contain mineral or vegetable oil—including baby oil, many lotions, regular petroleum jelly, cooking oils (corn oil, shortening, butter, and so on), and some vaginal lubricants and antifungal or anti-itch creams—should not be used with latex condoms. Such products can cause latex to start disintegrating within 60 seconds, thus greatly increasing the chance of condom breakage. (Polyurethane is not affected by oil-based products.) When the man loses his erection after ejaculating, the condom loses its tight fit. To avoid spilling semen, the condom must be held around the base of the penis as the penis is withdrawn. If any semen is spilled on the vulva, sperm may find their way to the uterus. Advantages Condoms are easy to purchase and are available without prescription or medical supervision. In addition to being free of medical side effects (other than occasional allergic reactions), latex condoms help protect against STIs. A recent study determined that condoms may also protect women from human papillomavirus (HPV), which causes cervical cancer. Condoms made of polyurethane are appropriate for people who are allergic to latex. However, they are more likely to slip or break than latex condoms and therefore may give less protection against STIs and pregnancy. Polyisoprene condoms, marketed under the brand name SKYN, are safe for most people with latex allergies, stretchier, and less expensive than polyurethane condoms. Condoms made of lambskin are also available but permit the passage of HIV and other disease-causing organisms and are less effective for pregnancy prevention. Except for abstinence or intercourse within a monogamous relationship with an uninfected partner, the correct and consistent use of latex male condoms offers the most reliable available protection against the transmission of HIV. Disadvantages The two most common complaints about condoms are that they diminish sensation and interfere with spontaneity. Although some people find these drawbacks serious, others consider them only minor distractions. Many couples learn to creatively integrate condom use into their sexual practices. Indeed, condom use can be a way to improve communication and share responsibility in a relationship. Effectiveness During the first year of typical condom use among 100 users, approximately 18 pregnancies will occur. And even with perfect use, the first-year failure rate is about 2%. At least some pregnancies happen because the condom is removed carelessly after ejaculation. Some may also occur because of breakage or slippage. Other contributing factors include poorly fitting condoms, insufficient lubrication (which increases the risk of breakage), excessively vigorous sex, and improper storage. (Because heat destroys rubber, latex condoms should not be stored for long periods in a wallet or a car's glove compartment.) To help ensure quality, condoms should not be used past their expiration date or more than five years past their date of manufacture (two years for those with spermicide). If a condom breaks or is removed carelessly, a woman can reduce the risk of pregnancy somewhat by immediately taking an emergency contraceptive (discussed later in the chapter). By far the most common cause of pregnancy with condom users is "taking a chance"—that is, occasionally not using a condom at all—or waiting to use it until after preejaculatory fluid (which may contain some sperm) has already entered the vagina. Female Condoms The female condom is a clear, stretchy, disposable pouch with two rings that can be inserted into a woman's vagina. It was designed as an alternative to the male condom because Page 155the woman can control its use. It can be inserted up to eight hours before intercourse, so it need not interfere with the moment. It is about as effective in preventing pregnancy and the spread of STIs as the male condom. The one-size-fits-all condom, called the FC2, consists of a soft, loose-fitting, nonlatex rubber sheath with two flexible rings (Figure 6.6). The ring at the closed end is inserted into the vagina and placed at the cervix much like a diaphragm. The ring at the open end remains outside the vagina. The female condom protects the inside of the vagina and part of the external genitalia. FIGURE 6.6 The female condom properly positioned. The directions that accompany the FC2 should be followed closely. The manufacturer strongly recommends practicing inserting the female condom several times before actually using it for intercourse. Most women find that it is easy to use after they have practiced inserting the FC2 several times. The FC2 comes prelubricated with a silicone lubricant, but extra lubricant or a spermicide can be used if desired. As with male condoms, users need to take care not to tear the condom during insertion or removal. Following intercourse, the woman should remove the condom before standing up. By twisting and squeezing the outer ring, she can prevent the spilling of semen. A new condom should be used for each act of sexual intercourse. A female condom should not be used with a male condom because when the two are used together, tearing is more likely to occur. Advantages For many women, the greatest advantage of the female condom is the control it gives them over contraception and STI prevention. (Partner cooperation is still important, however.) Female condoms can be inserted up to eight hours before sexual activity and are thus less disruptive than male condoms. Because the outer part of the condom covers the area around the vaginal opening as well as the base of the penis during intercourse, it offers potentially better protection against genital warts or herpes. The synthetic rubber pouch can be used by people who are allergic to latex. Because the material is thin and pliable, there is little loss of sensation. The FC2 is generously lubricated and the material conducts heat well, increasing comfort and natural feel during intercourse. When used correctly, the female condom should theoretically provide protection against HIV transmission and STIs comparable to that of the latex male condom. However, in research involving typical users, the female condom was slightly less effective in preventing pregnancy and STIs. Effectiveness improves with careful practice and instruction. Disadvantages The female condom is unfamiliar to most people and requires practice to learn to use it effectively. The outer ring of the female condom, which hangs visibly outside the vagina, may be bothersome to some couples. During coitus, both partners must take care that the penis is inserted into the pouch, not outside it, and that the device does not slip inside the vagina. Female condoms, like male condoms, are made for one-time use. A single female condom costs about three to four times as much as a single male condom. Female condoms are harder to find than male condoms. Some pharmacies do not currently carry them. You can buy the FC2 at Planned Parenthood and online (see http://fc2femalecondom.com/). Effectiveness The typical first-year failure rate of the female condom is 21%. For women who follow instructions carefully and consistently, the failure rate is considerably lower—about 5%. Female condoms rarely break during use, but slippage occurs in nearly 10% of users. Having emergency contraception available is recommended. Diaphragm with Spermicide Before oral contraceptives were introduced, about 25% of all American couples who used any form of contraception relied on the diaphragm. Many diaphragm users subsequently switched to the pill or IUDs, and therefore the device is rarely used now. However, the diaphragm still offers advantages that are important to some couples. The diaphragm is a dome-shaped cup of silicone with a flexible rim. When correctly used with spermicidal cream or jelly, the diaphragm covers the cervix, blocking sperm from the uterus. There are two diaphragms available: The Milex, which comes in two styles and multiple sizes, and the single-size Caya, which became available in the United States in 2015. Diaphragms are available in the United States only by prescription. Because of individual anatomical differences among Page 156women, the round Milex diaphragm must be carefully fitted by a trained clinician to ensure both comfort and effectiveness. The fit should be checked with each routine annual medical examination, as well as after childbirth, abortion, abdominal or pelvic surgery, or a weight change of more than 10 pounds. Caya comes in only one size and does not require fitting; it is oval in shape and designed to fit most women. Caya is contoured for easier use and includes grip "dimples" on the sides to help with insertion and a small dome to aid in removal of the device. A diaphragm should be used with spermicidal jelly or cream on the diaphragm before inserting it and checking its placement (Figure 6.7). If more than six hours elapse between the time of insertion and the time of intercourse, additional spermicide must be applied. The diaphragm must be left in place for at least six hours after the last act of coitus to give the spermicide enough time to kill all the sperm. With repeated intercourse, a condom should be used for additional protection. FIGURE 6.7 Use of the diaphragm. Wash your hands with soap and water before inserting the diaphragm. It can be inserted while squatting, lying down, or standing with one foot raised. (a) Place about a tablespoon of spermicidal jelly or cream in the concave side of the diaphragm, and spread it around the inside of the diaphragm and around the rim. (b) Squeeze the diaphragm into a long, narrow shape between the thumb and forefinger. Insert it into the vagina, and push it up along the back wall of the vagina as far as it will go. For the Caya, use the grip nubs to fold and grasp the device during insertion. (c) Check its position to make sure the cervix is completely covered and that the front rim of the diaphragm is tucked behind the pubic bone. To remove the diaphragm, the woman hooks the front rim (Milex) or small removal dome (Caya) down from the pubic bone with one finger and pulls it out. After each use, a diaphragm should be washed with mild soap and water, rinsed, patted dry, and examined for holes or cracks. Defects would most likely develop near the rim and can be spotted by looking at the diaphragm in front of a bright light. A diaphragm should be stored in its case. Advantages Diaphragm use is less intrusive than male condom use because a diaphragm can be inserted up to six hours before intercourse. Its use can be limited to times of sexual activity only, and it allows for immediate and total reversibility. The diaphragm is free of medical side effects (other than rare allergic reactions) and increased risk of urinary tract infection. Disadvantages Diaphragms must always be used with a spermicide, so a woman must keep both of these supplies with her whenever she anticipates sexual activity. Diaphragms require extra attention because they must be cleaned and stored with care to preserve their effectiveness. Some women cannot wear a diaphragm because of their vaginal or uterine anatomy. In other women, diaphragm use can cause bladder infections and may need to be discontinued if repeated infections occur. Diaphragms have also been associated with a slightly increased risk of toxic shock syndrome (TSS), an occasionally fatal bacterial infection. To reduce the risk of TSS, a woman should wash her hands carefully with soap and water Page 157before inserting or removing the diaphragm, should not use the diaphragm during menstruation or when abnormal vaginal discharge is present, and should never leave the device in place for more than 24 hours. Effectiveness The diaphragm's effectiveness depends mainly on whether it is used properly. In actual practice, women rarely use it correctly every time they have intercourse and the typical failure rate is 12% during the first year of use. The main causes of failure are incorrect insertion, inconsistent use, and inaccurate fitting. If a diaphragm slips during intercourse, a woman should use emergency contraception. Cervical Cap The cervical cap, another barrier device, is a small flexible cup that fits snugly over the cervix and is held in place by suction. This cervical cap is a clear silicone cup with a brim around the dome to hold spermicide and trap sperm, and a removal strap over the dome. It comes in three sizes and must be fitted by a trained clinician. It is used like a diaphragm, with a small amount of spermicide placed in the cup and on the brim before insertion. The cervical cap is reusable but must be replaced annually. Advantages Advantages of the cervical cap are similar to those associated with diaphragm use. It is an alternative for women who cannot use a diaphragm because of anatomical reasons or recurrent urinary tract infections. The cap fits tightly, so it does not require backup condom use with repeated intercourse. It may be left in place for up to 48 hours. Disadvantages Along with most of the disadvantages associated with the diaphragm, difficulty with insertion and removal is more common for cervical cap users. Because there may be a slightly increased risk of TSS with prolonged use, the cap should not be left in place for more than 48 hours. Effectiveness Studies indicate that the average failure rate for the cervical cap is 16% for women who have never had a child and 32% for women who have had a child. Contraceptive Sponge The contraceptive sponge is a round, absorbent device about two inches in diameter with a polyester loop on one side (for removal) and a concave dimple on the other side, which helps it fit snugly over the cervix. The sponge is made of polyurethane and is presaturated with the same spermicide used in contraceptive creams and foams. The spermicide is activated when moistened with a small amount of water just before insertion. The sponge, which can be used only once, acts as a barrier and a spermicide and absorbs seminal fluid. Many contraceptive methods work by blocking sperm from entering the cervix. While not as widely used as the hormonal methods, the barrier methods shown here—Caya diaphragm, cervical cap, female condom, and sponge—are important options for some couples. © Phanie/Alamy; © McGraw-Hill Education/Christopher Kerrigan, photographer; © McGraw-Hill Education/Jill Braaten, photogapher Advantages The sponge offers advantages similar to those of the diaphragm and cervical cap. In addition, sponges can be obtained without a prescription or professional fitting, and they may be safely left in place for 24 hours without the addition of spermicide for repeated intercourse. Most women and men find the sponge to be comfortable and unobtrusive during sex. Disadvantages Reported disadvantages include difficulty with removal and an unpleasant odor if the sponge is left in place for more than 18 hours. Allergic reactions, such as irritation of the vagina, are more common with the sponge than with other spermicide products, probably because the overall dose of spermicide contained in each sponge is significantly higher than that used with other methods. (A sponge contains 1000 milligrams of spermicide compared with the 60-100 milligrams present in one application of other spermicidal products.) If irritation of the vaginal lining occurs, the risk of yeast infections and STIs (including HIV) may increase. The sponge is a single-use device and must be thrown away after each use. Additionally, the sponge cannot be used during menstruation. Page 158Because the sponge has also been associated with toxic shock syndrome, the same precautions must be taken as those described for diaphragm use. A sponge user should be especially alert for symptoms of TSS when the sponge has been difficult to remove or was not removed intact. Effectiveness The typical effectiveness of the sponge is the same as that of the diaphragm (12% failure rate during the first year of use) for women who have never experienced childbirth. For women who have had a child, however, the failure rate rises to 24%. One possible explanation is that the sponge's size may be insufficient to adequately cover the cervix after childbirth. The user should carefully check the expiration date on each sponge because shelf life is limited. Vaginal Spermicides Spermicidal compounds developed for use with a diaphragm have been adapted for use without a diaphragm by combining them with a bulky base. Foams, creams, jellies, suppositories, and films are all available. Spermicides alone are not very effective methods of contraception, so most people use them in combination with a barrier method, such as a condom. Foam is sold in an aerosol bottle or a metal container with an applicator that fits on the nozzle. Creams and jellies are sold in tubes with an applicator that can be screwed onto the opening of the tube (Figure 6.8). FIGURE 6.8 The application of vaginal spermicide. Foams, creams, and jellies must be placed deep in the vagina near the cervical entrance and must be inserted no more than 60 minutes before intercourse. After an hour, their effectiveness is reduced drastically, and a new dose must be inserted. Another application is also required before each repeated act of coitus. The spermicidal suppository is small and easily inserted like a tampon. Because body heat is needed to dissolve and activate the suppository, it is important to wait at least 15 minutes after insertion before having intercourse. The suppository's spermicidal effects are limited in time, and coitus should take place within one hour of insertion. A new suppository is required for every act of intercourse. The vaginal contraceptive film (VCF) is a paper-thin two-inch square of film that contains spermicide. It is folded over one or two fingers and placed high in the vagina, as close to the cervix as possible. In about 15 minutes the film dissolves into a spermicidal gel that is effective for up to one hour. A new film must be inserted for each act of intercourse. Advantages The use of vaginal spermicides is relatively simple and can be limited to times of sexual activity. They are readily available in most drugstores and do not require a prescription or a pelvic examination. Spermicides allow complete and immediate reversibility, and the only medical side effects are occasional allergic reactions. Disadvantages When used alone, vaginal spermicides must be inserted shortly before intercourse, so their use may be seen as an annoying disruption. Some women find the slight increase in vaginal fluids after spermicide use unpleasant. Also, spermicides can alter the balance of bacteria in the vagina. Because this may increase the occurrence of yeast infections and urinary tract infections, women who are especially prone to these infections may want to avoid spermicides. Also, this contraception method does not protect against STIs such as gonorrhea, chlamydia, or HIV. Overuse of spermicides can irritate vaginal tissues; if this occurs, the risk of HIV transmission may increase. Effectiveness Vaginal spermicides on their own are not very effective. The typical failure rate is about 28% during the first year of use. Spermicide is generally recommended only in combination with other barrier methods or as a backup to other contraceptives. Emergency contraceptives provide a better backup than spermicides, however. Abstinence, Fertility Awareness, and Withdrawal Millions of people worldwide do not use any of the contraceptive methods described earlier because of religious convictions, cultural prohibitions, poverty, or lack of information and supplies. If they use any method at all, they are likely to use one of the following relatively "natural" methods of attempting to prevent conception. Abstinence The decision not to engage in sexual intercourse for a chosen period of time, or abstinence, has Page 159been practiced throughout history for a variety of reasons. Until relatively recently, many people abstained because they had no other contraceptive measures. Concern about possible contraceptive side effects, STIs, and unwanted pregnancy may be factors. For others, the most important reason for choosing abstinence is a moral one, based on cultural or religious beliefs or strongly held personal values. Fertility Awareness-Based Methods Women who practice a fertility awareness-based method of contraception abstain from intercourse during the fertile phase of their menstrual cycle. Ordinarily only one egg is released by the ovaries each month, and it lives about 24 hours unless it is fertilized. Sperm deposited in the vagina may be capable of fertilizing an egg for up to six or seven days, so conception can theoretically occur only during six to eight days of any menstrual cycle. However, predicting which six to eight days is difficult. Recent studies show that even in women who have regular menstrual cycles, it is possible to become pregnant at any time during the menstrual cycle. It is even more difficult to predict the fertile time of the cycle in women who have irregular menses—a situation that is very common, especially in teenagers and women who are approaching menopause. Methods that attempt to predict the fertile times of a woman's cycle include calendar methods, temperature methods, and methods that rely on observation of the cyclical changes of the cervical mucus, as well as other characteristics of the cervix. Some women use a combination of methods to determine the time of ovulation. Calendar methods are based on the idea that the average woman releases an egg 14-16 days before her period begins. To avoid pregnancy, she should abstain from intercourse for about eight days during her cycle, beginning several days before and during the time that ovulation is most likely to occur. However, in one recent study only about 10% of women with regular 28-day cycles actually ovulated 14 days before the next period. The situation is complicated further by the fact that many women have somewhat or very irregular cycles; calendar methods are extremely unreliable for these women. Temperature methods are based on the knowledge that a woman's body temperature drops slightly just before ovulation and rises slightly after ovulation. A woman using the temperature method records her basal (resting) body temperature (BBT) every morning before getting out of bed and before eating or drinking anything. Once the temperature pattern is apparent (usually after about three months), the unsafe period for intercourse can be calculated as the interval from day 5 (day 1 is the first day of the period) until three days after the rise in BBT. To arrive at a shorter unsafe period, some women combine the calendar and temperature methods, calculating the first unsafe day from the shortest cycle of the calendar chart and the last unsafe day as the third day after a rise in BBT. The mucus method (or Billings method) is based on changes in the cervical secretions throughout the menstrual cycle. During the estrogenic phase, cervical mucus increases and is clear and slippery. At the time of ovulation, some women can detect a slight change in the texture of the mucus and find that it is more likely to form an elastic thread when stretched between thumb and finger. After ovulation, these secretions become cloudy and sticky and decrease in quantity. Infertile, safe days are likely to occur during the relatively dry days just before and after menstruation. These additional clues have been found to be helpful by some couples who rely on fertility awareness-based methods. One problem that may interfere with this method is that vaginal infections, vaginal products, or medication can also alter the cervical mucus. Any woman for whom pregnancy would be a serious problem should not rely on these methods alone because the failure rate is high—approximately 25% each year. Fertility awareness-based methods are not recommended for women who have very irregular cycles—about 15% of all menstruating women. Further, fertility awareness-based methods offer no protection against STIs. Some women use fertility awareness in combination with a barrier method to reduce their risk for unwanted pregnancy. Withdrawal In withdrawal, or coitus interruptus, the male removes his penis from the vagina just before he ejaculates. Withdrawal has a high failure rate because the male has to overcome a powerful biological urge. Further, because preejaculatory fluid may contain viable sperm, pregnancy can occur even if the man withdraws prior to ejaculation. Sexual pleasure is often affected because the man must remain in control and the sexual experience of both partners is interrupted. The failure rate for typical use is about 22% in the first year. Withdrawal does not protect against STIs. Combining Methods Couples can choose to combine the preceding methods in a variety of ways, both to add STI protection and to increase contraceptive effectiveness. For example, condoms are strongly recommended along with hormonal contraception whenever there is a risk of STIs (Table 6.2). For many couples, and especially for women, the added benefits far outweigh the extra effort and expense of using multiple methods. Table 6.2 Contraceptive Methods and STI Protection METHOD LEVEL OF PROTECTION Hormonal methods Do not protect against HIV or STIs in lower reproductive tract; may increase risk of cervical chlamydia; provide some protection against PID. IUD Does not protect against STIs. Latex, polyisoprene, or polyurethane male condom Best method for protection against STIs (if used correctly); does not protect against infections from lesions that are not covered by the condom. (Lambskin condoms do not protect against STIs.) Female condom Reduction of STI risk similar to that of male condom; may provide extra protection for external genitalia. Diaphragm, sponge, or cervical cap Provides some protection against cervical infections and PID. Diaphragms, sponges, and cervical caps should not be relied on for protection against HIV. Spermicide Modestly reduces the risk of some vaginal and cervical STIs; does not reduce the risk of HIV, chlamydia, or gonorrhea. If vaginal irritation occurs, infection risk may increase. Fertility awareness-based methods Do not protect against STIs. Sterilization Does not protect against STIs. Abstinence Complete protection against STIs (as long as all activities that involve the exchange of body fluids are avoided). Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Prior to reading this section, how familiar were you with the principles of contraception? Did you know as much as you thought? Were you aware of the large number of contraceptive options that are currently available?

emergency contraceptive

Page 160 EMERGENCY CONTRACEPTION Emergency contraception (EC) refers to postcoital methods—those used after unprotected sexual intercourse. An emergency contraceptive may be appropriate if a regularly used method has failed (for example, if a condom breaks) or if unprotected sex has occurred. Sometimes called the "morning-after pill," emergency contraceptives are designed only for emergency use and should not be relied on as a regular birth control method; other methods of birth control are more effective. When emergency contraceptives were first approved by the FDA, opponents feared that they might act as an abortifacient—preventing implantation of a fertilized egg, theoretically causing abortion. However, recent evidence indicates that emergency contraceptives do not interrupt an established pregnancy. Next-day or after-sex pills work primarily by inhibiting or delaying ovulation and by blocking the transport of sperm and eggs. Plan B, Plan B One-Step, Next Choice One Dose, and Ella are now in common use and are more effective, with fewer side effects, than older methods of EC. Plan B One-Step, which replaced Plan B in 2009, contains a single progestin-only pill, whereas Next Choice One Dose has two pills that are taken 12 hours apart. The pills should be taken as soon as possible after inadequately protected sex. If taken within 24 hours after intercourse, emergency contraceptives may prevent as many as 75-95% of expected pregnancies. Overall they reduce pregnancy risk by about 89%. They are most effective if initiated in the first 12 hours, but they can be taken up to 120 hours (five days) after unprotected intercourse. Possible side effects include nausea, stomach pain, headache, dizziness, and breast tenderness. If a woman is already pregnant, these pills will not interfere with the pregnancy. Current emergency contraceptives are considered very safe. Plan B One-Step is available over the counter (no prescription required) for everyone. Next Choice One Dose is available for persons 17 and older. To buy an emergency contraceptive, you need to ask for it at the pharmacy counter. It is recommended that you call ahead to make sure your pharmacy has EC on hand. The vast majority of pharmacies, especially the larger chains, currently carry emergency contraceptives. Ella is available only by prescription. Some clinicians advise women to keep a package of emergency contraceptives on hand in case their regular contraception method fails or they have unprotected intercourse. Research has found that ready access to emergency contraception improves the rate of use as well as decreasing the time to use. However, it does not lead to an increase in unprotected intercourse or STIs. One reason women fail to take emergency contraceptives even when they have them may be that they underestimate their risk of pregnancy. Many women still believe that they can't get pregnant from a single act of intercourse. Expense is also an issue for some women. EC is covered by some health plans as well as by Medicaid in many states. However, many women must pay directly for EC, which costs about $50. Page 161To find out more about emergency contraception and how to obtain it in your area, visit the Emergency Contraception website at http://ec.princeton.edu. Planned Parenthood is a good source of information, as are most pharmacies. Plan B One-Step has a website (http://www.planbonestep.com) that, as of this printing, contains a card you can print and hand to the pharmacist as an easy way to request EC. Next Choice One Dose, which is slightly less expensive than Plan B One-Step, also has a website (http://www.mynextchoiceonedose.com/) where you can locate pharmacies in your area that carry the product. You can also call the Emergency Contraception Hotline (888-NOT-2-LATE) for more information about access. Intrauterine devices can also be used for emergency contraception. If inserted within five days of unprotected intercourse, the Copper T ParaGard IUD (discussed earlier) is even more effective than pills for emergency contraception. It has the added benefit of providing up to 12 years of contraception. QUICK STATS Use of emergency contraception by women who had sexual intercourse at least once increased from 4% in 2002 to 18% in 2011-2013. —National Center for Health Statistics, 2015

issues in contraception

Page 163 ISSUES IN CONTRACEPTION The subject of contraception is closely tied to several issues that receive a lot of attention in the United States, such as premarital sexual relations, gender and ethnic differences, and sexuality education for teens (see the box "Barriers to Contraceptive Use"). DIVERSITY MATTERS: Barriers to Contraceptive Use Even in ideal circumstances, raising children is challenging as well as exciting. The ideal situation is that a woman becomes pregnant only when she is ready to start a family. Why, then, when the stakes are so high, do so many unintended pregnancies occur? Well into the late 1960s birth control was barely adequate. But now, people have so many choices for effective contraception. Why doesn't everyone who wishes to prevent pregnancy use contraception consistently? Here are some of the reasons. Long-acting reversible contraception (LARC) methods, such as implants and IUDs, are very effective, but some doctors have discouraged younger women from using them. Some reports indicate reasons that date back to 1980, when the most frequently used IUD, the Dalkon Shield, was recalled after it was linked to infertility and even death. Studies on current IUDs, however, have shown that they do not increase risk of death or infertility, and in fact, data suggest that Mirena (discussed earlier in the section on LARC) protects against STIs. Economic and ethnic background as well as age are all factors that influence our behavior, and these factors often become difficult to disentangle. The cost for the medical exam, the IUD, the insertion of the IUD, and follow-up visits to a health care provider can range up to $1,000, depending on health insurance. This cost may deter some candidates. Studies show that ethnic and racial differences are significant in women under age 25 or who are unmarried: among sexually active single women aged 20-24, 4% of whites used no method of contraception, compared with 18% of blacks and 15% of Hispanics. In turn, the number of unintended pregnancies for black and Hispanic women is more than double that for white women, and the number of teen pregnancies is also much higher. In general, both LARC methods and sterilization are much more common among older women, particularly those who are over 35 years of age or who have had children. Cofounder of the Women of Color Sexual Health Network, Bianca Laureano, writes about other barriers young women may face when choosing a method of contraception. For example, they may be monitored by parents or guardians who do not believe in birth control. Laureano herself grew up in a Puerto Rican family who advised her that birth control kills Puerto Rican women. Young women who are being closely monitored by anti-birth-control families must continue having a menstrual cycle, so they cannot use Depo-Provera, which, in some cases, causes menstrual bleeding to stop; they cannot wear a visible patch; and they cannot use a method that requires visits to a physician, especially if a parent or guardian attends their physical exams. In addition, some young people do not want a contraceptive method that requires them to remember to take a pill each day (oral birth control pills) or to touch their genitals (for example, the NuvaRing). Although some health providers discourage LARC methods, many health advocates promote them among women seeking to avoid pregnancy. However, some observers are concerned that campaigns targeting "at-risk" women focus too much on minority, poor, and young women. In her book Exposing Prejudice: Puerto Rican Experiences of Language, Race, and Class, Bonnie Urciuoli gives a history of U.S. policies toward Puerto Rican immigrants, which included controlling their population through sterilization, enforced contraception, and migration. In Killing the Black Body, Dorothy Roberts describes the experiences of black women throughout U.S. history—from being forced to bear children during slavery to having their fertility controlled by modern-day welfare policies. Thus, one reason women of color may not use LARC methods can be medical mistrust; another, as noted, may be having less access to these methods. In general, contraception use has increased and teen pregnancies have decreased in recent decades. A study covering the years 2006 to 2010 found that about 89% of sexually active, single white teens aged 15-19 had used a form of contraception in the past three months. Among single, sexually active black teens of the same age, 81% had used contraception, as had 80% of Hispanic teens. Although the latter two groups are less likely to use the most effective forms of contraception, there is a movement toward LARC usage. A study comparing 2009 and 2012 found that women from all populations increasingly chose LARC methods but particularly Hispanic women, those with private insurance, those with fewer than two sexual partners in the previous year, and those who were nulliparous (had never given birth). Overall, then, a complex mix of factors relating to age, financial status, culture, history, and policy can create barriers to effective contraception. sources: England, P., et al. 2016. Why do young, unmarried women who do not want to get pregnant contracept inconsistently? Mixed-method evidence for the role of efficacy. Socius: Sociological Research for a Dynamic World 2. doi: 10.1177/2378023116629464; Kavanaugh, M. L., J. Jerman, and L. B. Finer. 2015. Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009-2012. Obstetrics & Gynecology 126 (5): 917-927; Laureano, B. 2010. How accessible are IUDs? Rewire, April 19 (https://rewire.news/article/2010/04/19/accessible-iuds-0/); Melnick, M. 2010. The IUD makes a comeback. Newsweek, April 5 (http://www.newsweek.com/iud-makes-comeback-70545); Roberts, D. 1997. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon; Sweeney, M. M., and R. Kelly Raley. 2014. Race, ethnicity, and the changing context of childbearing in the United States. Annual Review of Sociology 40: 539-558; and Urciuoli, B. 1996. Exposing Prejudice: Puerto Rican Experiences of Language, Race, and Class. Boulder, CO: Westview. When Is It OK to Begin Having Sexual Relations? Answers to this question strongly affect a society's approach to contraception. Opinions on the appropriate age or time to begin having sex often determine people's views on sexuality education and contraception accessibility. Americans have a wide range of opinions on this issue: only after marriage; when 18 years or older; when in a loving, stable relationship; when the partners have completed their education or could support a child; whenever both partners feel ready and are using protection against pregnancy and STIs. As the average age of first marriage increases (currently ages 27 for women and 29 for men), young people typically experience a decade or more between puberty and marriage, making sex outside marriage and sex with multiple partners more likely. As a result, decisions about sexual activity, contraception, and STI prevention become even more important for young people (see the box "Talking with a Partner about Contraception"). TAKE CHARGE: Talking with a Partner about Contraception Many people have a difficult time talking about contraception with a potential sex partner. How should you bring it up? And whose responsibility is it? Talking about the subject may be embarrassing at first, but imagine the possible consequences of not talking about it. An unintended pregnancy or an STI could profoundly affect you for the rest of your life. Talking about contraception is one way of showing that you care about yourself, your partner, and your future. Before you talk with your partner, explore your own thoughts and feelings. Find out the facts about different methods of contraception, and decide which one you think would be most appropriate for you. If you're nervous about having this discussion with your partner, it may help to practice with a friend. Pick a good time to bring up the subject. It makes sense to have this discussion before you start having sex, but even if you've already had intercourse with your partner, it's important to be on the same page about contraception. A time when you're both feeling comfortable and relaxed will improve your chances of having a good discussion. Tell your partner what you know about contraception and how you feel about using it, and talk about what steps you both need to take to get and use a method you can live with. Listen to what your partner has to say, and try to understand his or her point of view. You may need to have more than one discussion, and it may take some time for both of you to feel comfortable with the subject. If you want your partner to be involved but he or she isn't interested in talking about contraception, you may want to enlist the support of a friend, family member, or health care provider to help you make and implement decisions about contraception. If you have been involved in hooking up with people you don't know well and are not having an ongoing relationship with, discussions about contraception may seem unrealistic. At a minimum, refuse to have sex with anyone who won't use a condom. If you are a woman, purchase emergency contraception ahead of time, and don't hesitate to use it. Both men and women should carefully consider the risks involved in hooking up. Remember that no contraceptive method can completely protect you from the potential consequences of being intimate with a person you do not know well. Contraception and Gender Differences The consequences of not using contraception are markedly different for men and women. At the most basic level, women have greater personal investment in preventing pregnancy because they bear the risk of pregnancy. Furthermore, women have accepted the primary responsibility for contraception along with its related side effects and health risks in part because of the wider spectrum of methods available to them. Men still have few contraceptive options, with condoms being the only reversible method currently available. However, men's participation is critical because condom use is central to the prevention of STI transmission even when women are using other methods for contraception. Although condom use and the prevention of STIs involves men's cooperation, women must also take responsibility for them. Whereas men may suffer only local and short-term effects from the most common diseases (not including HIV infection), women face an increased risk of serious long-term effects, such as cervical cancer and/or pelvic infection with associated infertility, from these same prevalent STIs. In addition, women are more likely than men to contract HIV from an infected partner. In other words, although condom use is dependent on men, it is also an important issue for women. Because women often must deal with greater consequences associated with inadequate contraceptive use, health care professionals are increasingly seeing the importance of involving male partners in the selection and use of contraceptives. Multiple methods have been identified to encourage shared responsibility, including expanding educational material and clinical programs that focus on the male's role in contraception, and encouraging males to share in the responsibility of using contraception. Scientists have attempted to develop a hormonal contraceptive for males for many years. Though progress has been made in identifying hormonal alterations that inhibit sperm formation, no treatment has been identified that suppresses this process entirely and still has a favorable side effect profile. Research has also focused on vas deferens implants to block the passage of sperm out of the testicle, but this remains in the experimental stages. Page 165Worldwide, condom use is increasing, but it remains low in developing countries, where it is often difficult for women to negotiate safer sex and condom use. The World Health Organization reports that the main factor in poor sexual health around the world is gender inequality. The experience of an unintended pregnancy is also very different for men and women. Although men suffer emotional stress from such an unexpected occurrence (and sometimes share financial and/or custodial responsibilities), women are much more intimately affected, obviously by the biological process of pregnancy itself as well as the outcome: abortion, adoption, or parenting. In addition, our societal attitudes are more severely punitive toward the woman and place much greater responsibility and blame on her when an unintended pregnancy occurs. Fortunately, there is growing interest in the roles and responsibilities of men in family planning. Sexuality and Contraception Education for Teenagers Sexuality education and pregnancy prevention programs for teenagers are an important, though controversial, issue. Opinion in the United States is sharply divided on this subject. Certain groups are concerned that more sexuality education and especially the availability of contraceptives will lead to more sexual activity and promiscuity. However, countless studies have shown this not to be the case. Contraception and safe sex practices are a joint responsibility for any sexually active couple. The health care community is taking steps to educate young men on their role in avoiding pregnancies and STIs. Sexuality and contraceptive education remains a volatile issue. The vast majority of research on teen sexual behavior shows that sexually active students who receive comprehensive sexuality education (where both abstinence and contraceptive use are taught) are more likely to use contraceptives. Moreover, research also shows that teens who are not yet sexually active do not start having sex sooner as a result of attending comprehensive sex education programs. Conversely, most studies show that abstinence-only school programs do not appear to reduce the number of teens who are having sex, and they also lead to decreased rates of contraception use. Although a great deal of focus has been placed on HIV and STI prevention, the nearly half a million U.S. teenage pregnancies that occur each year are a serious public health problem and warrant much greater national attention. The federal government has identified the issue of teen pregnancy as an urgent issue, and therefore is providing funding Page 166to programs that provide factual information about STIs and pregnancy prevention while also addressing issues of sexuality and abstinence. The American Academy of Pediatrics also supports the provision of factual, comprehensive sexual education in all schools as part of a standard curriculum. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Do you feel your sexual education up to this point in your life has been complete? Do you feel it has prepared you to have a healthy, safe, and responsible sexual life?

abortion in the united states since the 19th century

ABORTION IN THE UNITED STATES SINCE THE 19TH CENTURY The first anti-abortion campaign was launched in the mid-19th century; the result was that most abortion care provided at that time became criminalized. Physicians were at the forefront of this movement. They intended to raise the standard of abortion care, mandating that abortions should be provided only by physicians in a hospital setting for medical indications. For instance, a woman with a large family lacking the means to have another child did not qualify for an abortion unless it could be demonstrated that another pregnancy was life-threatening. Although improved safety was a goal, the techniques used by physicians in hospitals to terminate Page 172pregnancies were not necessarily safer than techniques used by nonphysicians in the community. The new policies criminalizing much of abortion care greatly limited the supply of abortion services, but the demand did not change. During this time, there were few options to prevent pregnancy; methods of contraception were much less effective than the methods we have today, and women continued to have unintended pregnancies. Many women did not have an obvious medical indication to justify an abortion or could not pay for an abortion in the hospital. Consequently, thousands of women who sought to end their pregnancies had no choice but to seek illegal abortions. In desperation, many found themselves using the services of unskilled individuals in unsanitary conditions, and suffered injury, subsequent infertility, or death. By the mid-20th century, the medical profession started to recognize the harms of criminalizing abortion. Also during this time, women's status improved as they entered the labor force and demanded a say over reproductive decisions and access to safe abortion. Abortion was legalized in the United States in 1973 with the landmark Supreme Court decision in Roe v. Wade, determining with the following language that abortion is a fundamental right under the due process clause of the 14th Amendment: "Right of privacy...is broad enough to encompass a woman's decision whether or not to terminate her pregnancy.... The decision vindicates the right of the physician to administer medical treatment according to his professional judgment up to the points where important state interests provide compelling justifications for intervention." Subsequently, legalization allowed significant improvements in abortion safety and technique. From a public health perspective, legalization of abortion ranks with the discovery of antibiotics in decreasing the overall death rate. New technologies expanded the provision of abortion in clinics rather than in hospitals exclusively, lowering cost and improving access for women nationwide. As a result, the abortion care we have today looks very different from pre-Roe v. Wade: The majority of women who obtain abortions do so in clinics specialized in abortion care. Abortions are rarely performed in the hospital as they once were, and it has become an extremely safe and effective process. In terms of safety, the evolution of abortion care in the United States is overall a great success and has influenced abortion care worldwide; however, it is not without challenges. The biggest problem created by the current model is the separation of abortion care from other reproductive health care services. This problem is multidimensional: Few women turn to their primary care physicians or obstetricians/gynecologists to end a pregnancy, although they obtain other reproductive health services from these providers. Most clinicians in women's health do not offer abortion services even though they have the skills and medical equipment to do so. Some clinicians abstain for personal reasons, but a majority are not able to provide abortions even if they want to because institutional rules or logistics make it extremely difficult or impossible to do so. Restricting abortion care to abortion clinics has perpetuated stigma for women seeking abortion and clinicians who perform them, implying that abortion is somehow different from other reproductive services. Furthermore, it has made abortion clinics vulnerable to attacks by extremist individuals and groups that oppose abortion. Since the early 1990s there has been an increase in violence against abortion providers and abortion clinics, including vandalism, bombing, arson, and shootings. Using the legal system to restrict abortion has become an important strategy in state and national politics by groups opposed to abortion and has shifted the conversation away from the area of health and status of women in society. Over the past 40 years, some federal and many state laws have tested the limits of Roe v. Wade by making it more difficult for a woman to obtain an abortion, even if her decision to have one is not violated. The Texas law limiting abortions by requiring burdensome rules for abortion clinics was, however, struck down by the Supreme Court in 2016. This ruling may now deter other states from passing "clinic shut-down" laws.