Birth control
Other names: Contraception, fertility control
A package ofbirth control pills
Specialty	Family medicine
Indications	Preventpregnancy[1]

Birth control, also known ascontraception andfertility control, is a method or device used to preventpregnancy.^[1] Birth control has been used since ancient times, but effective and safe methods of birth control only became available in the 20th century.^[2] Planning, making available, and using birth control is calledfamily planning.^[3][4] Some cultures limit or discourage access to birth control because they consider it to be morally, religiously, or politically undesirable.^[2]

The most effective methods of birth control aresterilization by means ofvasectomy in males andtubal ligation in females,intrauterine devices (IUDs), andimplantable birth control.^[5] This is followed by a number ofhormone-based methods includingoral pills,patches,vaginal rings, andinjections.^[5] Less effective methods includephysical barriers such ascondoms,diaphragms andbirth control sponges andfertility awareness methods.^[5] The least effective methods arespermicides andwithdrawal by the male before ejaculation.^[5] Sterilization, while highly effective, is not usually reversible; all other methods are reversible, most immediately upon stopping them.^[5]Safe sex practices, such as with the use of male orfemale condoms, can also help preventsexually transmitted infections.^[6] Other methods of birth control do not protect against sexually transmitted diseases.^[7]Emergency birth control can prevent pregnancy if taken within 72 to 120 hours after unprotected sex.^[8][9] Some arguenot having sex is also a form of birth control, butabstinence-only sex education may increaseteenage pregnancies if offered without birth control education, due to non-compliance.^[10][11]

Inteenagers, pregnancies are at greater risk of poor outcomes.^[12] Comprehensivesex education and access to birth control decreases the rate of unwanted pregnancies in this age group.^[12][13] While all forms of birth control can generally be used by young people,^[14]long-acting reversible birth control such as implants, IUDs, or vaginal rings are more successful in reducing rates of teenage pregnancy.^[13] After the delivery of a child, a woman who is not exclusively breastfeeding may become pregnant again after as few as four to six weeks.^[14] Some methods of birth control can be started immediately following the birth, while others require a delay of up to six months.^[14] In women who are breastfeeding,progestin-only methods are preferred overcombined oral birth control pills.^[14] In women who have reachedmenopause, it is recommended that birth control be continued for one year after the last period.^[14]

About 222 million women who want to avoid pregnancy indeveloping countries are not using a modern birth control method.^[15][16] Birth control use in developing countries has decreased the number ofdeaths during or around the time of pregnancy by 40% (about 270,000 deaths prevented in 2008) and could prevent 70% if the full demand for birth control were met.^[17][18] By lengthening the time between pregnancies, birth control can improve adult women's delivery outcomes and the survival of their children.^[17] In the developing world, women's earnings,assets, andweight, as well as their children's schooling and health, all improve with greater access to birth control.^[19] Birth control increaseseconomic growth because of fewer dependent children, more women participating in theworkforce, and less use of scarce resources.^[19][20]

Methods

Birth control methods includebarrier methods,hormonal birth control,intrauterine devices (IUDs),sterilization, and behavioral methods. They are used before or during sex whileemergency contraceptives are effective for up to five days after sex. Effectiveness is generally expressed as the percentage of women who become pregnant using a given method during the first year,^[25] and sometimes as a lifetime failure rate among methods with high effectiveness, such astubal ligation.^[26]

The most effective methods are those that are long acting and do not require ongoing health care visits.^[27] Surgical sterilization, implantable hormones, and intrauterine devices all have first-year failure rates of less than 1%.^[21] Hormonal birth control pills, patches or vaginal rings, and thelactational amenorrhea method (LAM), if adhered to strictly, can also have first-year (or for LAM, first-6-month) failure rates of less than 1%.^[27] With typical use, first-year failure rates are considerably high, at 9%, due to inconsistent use.^[21] Other methods such as condoms, diaphragms, and spermicides have higher first-year failure rates even with perfect usage.^[27] TheAmerican Academy of Pediatrics recommendslong acting reversible birth control as first line for young individuals.^[28]

While all methods of birth control have some potential adverse effects, the risk is less than that ofpregnancy.^[27] After stopping or removing many methods of birth control, including birth control pills, IUDs, implants and injections, the rate of pregnancy during the subsequent year is the same as for those who used no birth control.^[29]

For individuals with specific health problems, certain forms of birth control may require further investigations.^[30] For women who are otherwise healthy, many methods of birth control should not require amedical exam—including birth control pills, injectable or implantable birth control, and condoms.^[31] For example, apelvic exam,breast exam, or blood test before starting birth control pills does not appear to affect outcomes.^[32][33][34] In 2009, theWorld Health Organization (WHO) published a detailed list ofmedical eligibility criteria for each type of birth control.^[30]

Hormonal

Hormonal birth control is available in a number of different forms, includingbirth control pills,implants under the skin,injections,patches,IUDs and avaginal ring. They are currently available only for women, although hormonal contraceptives for men have been and are being clinically tested.^[35] There are two types of birth control pills, thecombined oral contraceptive pills (which contain bothestrogen and aprogestin) and theprogestogen-only pills (sometimes called minipills).^[36] If either is taken during pregnancy, they do not increase the risk ofmiscarriage nor causebirth defects.^[33] Both types of birth control pills preventfertilization mainly by inhibitingovulation and thickening cervical mucus.^[37][38] They may also change the lining of the uterus and thus decrease implantation.^[38] Their effectiveness depends on the user's adherence to taking the pills.^[33]

Combined hormonal birth control is associated with a slightly increased risk ofvenous andarterial blood clots.^[39] Venous clots, on average, increase from 2.8 to 9.8 per 10,000 women years^[40] which is still less than that associated with pregnancy.^[39] Due to this risk, they are not recommended in women over 35 years of age who continue to smoke.^[41] They are also not recommended in the 4 to 6 week period immediately after delivery of a baby; though progestin-only methods may be used.^[42] Due to the increased risk, they are included in decision tools such as theDASH score andPERC rule used to predict the risk of blood clots.^[43]

The effect on sexual desire is varied, with increase or decrease in some but with no effect in most.^[44] Combined oral contraceptives reduce the risk ofovarian cancer andendometrial cancer and do not change the risk ofbreast cancer.^[45][46] They often reduce menstrual bleeding andpainful menstruation cramps.^[33] The lower doses of estrogen released from the vaginal ring may reduce the risk of breast tenderness,nausea, and headache associated with higher dose estrogen products.^[45]

Progestin-only pills, injections and intrauterine devices are not associated with an increased risk of blood clots and may be used by women with a history of blood clots in their veins.^[39][47] In those with a history of arterial blood clots, non-hormonal birth control or a progestin-only method other than the injectable version should be used.^[39] Progestin-only pills may improve menstrual symptoms and can be used by breastfeeding women as they do not affectmilk production. Irregular bleeding may occur with progestin-only methods, with some users reportingno periods.^[48] The progestinsdrospirenone anddesogestrel minimize theandrogenic side effects but increase the risks of blood clots and are thus not first line.^[49] The perfect use first-year failure rate ofinjectable progestin is 0.2%; the typical use first failure rate is 6%.^[21]

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  Three varieties ofbirth control pills in calendar oriented packaging

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  Birth control pills

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  A transdermalcontraceptive patch

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  ANuvaRing vaginal ring

Barrier

Barrier contraceptives are devices that attempt to preventpregnancy by physically preventingsperm from entering theuterus.^[50] They include malecondoms,female condoms,cervical caps,diaphragms, andcontraceptive sponges withspermicide.^[50]

Globally, condoms are the most common method of birth control.^[51]Male condoms are put on a man's erectpenis and physically block ejaculated sperm from entering the body of a sexual partner.^[52] Modern condoms are most often made fromlatex, but some are made from other materials such aspolyurethane, or lamb's intestine.^[52]Female condoms are also available, most often made ofnitrile, latex or polyurethane.^[53] Male condoms have the advantage of being inexpensive, easy to use, and have few adverse effects.^[54] Making condoms available to teenagers does not appear to affect the age of onset of sexual activity or its frequency.^[55] In Japan, about 80% of couples who are using birth control use condoms, while in Germany this number is about 25%,^[56] and in the United States it is 18%.^[57]

Male condoms and the diaphragm with spermicide have typical use first-year failure rates of 18% and 12%, respectively.^[21] With perfect use condoms are more effective with a 2% first-year failure rate versus a 6% first-year rate with the diaphragm.^[21] Condoms have the additional benefit of helping to prevent the spread of some sexually transmitted infections such asHIV/AIDS, however, condoms made from animal intestine do not.^[5][58]

Contraceptive sponges combine a barrier with a spermicide.^[27] Like diaphragms, they are inserted vaginally before intercourse and must be placed over thecervix to be effective.^[27] Typical failure rates during the first year depend on whether or not a woman has previously given birth, being 24% in those who have and 12% in those who have not.^[21] The sponge can be inserted up to 24 hours before intercourse and must be left in place for at least six hours afterward.^[27] Allergic reactions^[59] and more severe adverse effects such astoxic shock syndrome have been reported.^[60]

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  A rolled up malecondom.

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  An unrolled malelatexcondom

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  A polyurethanefemale condom

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  Adiaphragm vaginal-cervicalbarrier, in its case with aquarter U.S. coin.

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  Acontraceptive sponge set inside its open package.

Intrauterine devices

The currentintrauterine devices (IUD) are small devices, often 'T'-shaped, containing either copper orlevonorgestrel, which are inserted into the uterus. They are one form oflong-acting reversible contraception which are the most effective types of reversible birth control.^[61] Failure rates with thecopper IUD is about 0.8% while thelevonorgestrel IUD has a failure rates of 0.2% in the first year of use.^[62] Among types of birth control, they, along with birth control implants, result in the greatest satisfaction among users.^[63] As of 2007, IUDs are the most widely used form of reversible contraception, with more than 180 million users worldwide.^[64]

Evidence supports effectiveness and safety in adolescents^[63] and those who have and have not previously had children.^[65] IUDs do not affectbreastfeeding and can be inserted immediately after delivery.^[66] They may also be used immediately after anabortion.^[67][68] Once removed, even after long term use, fertility returns to normal immediately.^[69]

While copper IUDs may increase menstrual bleeding and result in more painful cramps,^[70] hormonal IUDs may reduce menstrual bleeding or stop menstruation altogether.^[66] Cramping can be treated with painkillers likenon-steroidal anti-inflammatory drugs.^[71] Other potential complications include expulsion (2–5%) and rarely perforation of the uterus (less than 0.7%).^[66][71] A previous model of the intrauterine device (theDalkon shield) was associated with an increased risk ofpelvic inflammatory disease, however the risk is not affected with current models in those withoutsexually transmitted infections around the time of insertion.^[72] IUDs appear to decrease the risk ofovarian cancer.^[73]

Sterilization

Surgical sterilization is available in the form oftubal ligation for women andvasectomy for men.^[2] There are no significant long term side effects, and tubal ligation decreases the risk ofovarian cancer.^[2] Short term complications are twenty times less likely from a vasectomy than a tubal ligation.^[2][74] After a vasectomy, there may be swelling and pain of the scrotum which usually resolves in one or two weeks.^[75] With tubal ligation, complications occur in 1 to 2 percent of procedures with serious complications usually due to theanesthesia.^[76] Neither method offers protection from sexually transmitted infections.^[2]

This decision may cause regret in some men and women. Of women aged over 30 who have undergone tubal ligation, about 5% regret their decision, as compared with 20% of women aged under 30.^[2] By contrast, less than 5% of men are likely to regret sterilization. Men who are more likely to regret sterilization are younger, have young or no children, or have an unstable marriage.^[77] In a survey of biological parents, 9% stated they would not have had children if they were able to do it over again.^[78]

Although sterilization is considered a permanent procedure,^[79] it is possible to attempt atubal reversal to reconnect thefallopian tubes or avasectomy reversal to reconnect thevasa deferentia. In women, the desire for a reversal is often associated with a change in spouse.^[79] Pregnancy success rates after tubal reversal are between 31 and 88 percent, with complications including an increased risk ofectopic pregnancy.^[79] The number of males who request reversal is between 2 and 6 percent.^[80] Rates of success in fathering another child after reversal are between 38 and 84 percent; with success being lower the longer the time period between the vasectomy and the reversal.^[80]Sperm extraction followed byin vitro fertilization may also be an option in men.^[81]

Behavioral

Behavioral methods involveregulating the timing or method of intercourse to prevent introduction of sperm into the female reproductive tract, either altogether or when an egg may be present.^[82] If used perfectly the first-year failure rate may be around 3.4%, however if used poorly first-year failure rates may approach 85%.^[83]

Fertility awareness

Fertility awareness methods involve determining the most fertile days of themenstrual cycle and avoiding unprotected intercourse.^[82] Techniques for determining fertility include monitoringbasal body temperature,cervical secretions, or the day of the cycle.^[82] They have typical first-year failure rates of 24%; perfect use first-year failure rates depend on which method is used and range from 0.4% to 5%.^[21] The evidence on which these estimates are based, however, is poor as the majority of people in trials stop their use early.^[82] Globally, they are used by about 3.6% of couples.^[84] If based on both basal body temperature and another primary sign, the method is referred to as symptothermal. First-year failure rates of 20% overall and 0.4% for perfect use have been reported in clinical studies of the symptothermal method.^[85][21] A number offertility tracking apps are available, as of 2016, but they are more commonly designed to assist those trying to get pregnant rather than prevent pregnancy.^[86]

Withdrawal

Thewithdrawal method (also known as coitus interruptus) is the practice of ending intercourse ("pulling out") before ejaculation.^[87] The main risk of the withdrawal method is that the man may not perform the maneuver correctly or in a timely manner.^[87] First-year failure rates vary from 4% with perfect usage to 22% with typical usage.^[21] It is not considered birth control by some medical professionals.^[27]

There is little data regarding the sperm content ofpre-ejaculatory fluid.^[88] While some tentative research did not find sperm,^[88] one trial found sperm present in 10 out of 27 volunteers.^[89] The withdrawal method is used as birth control by about 3% of couples.^[84]

Abstinence

Sexual abstinence may be used as a form of birth control, meaning either not engaging in any type of sexual activity, or specifically not engaging in vaginal intercourse, while engaging in other forms of non-vaginal sex.^[90][91] Complete sexual abstinence is 100% effective in preventing pregnancy.^[92][93] However, among those who take apledge to abstain frompremarital sex, as many as 88% who engage in sex, do so prior to marriage.^[94] The choice to abstain from sex cannot protect against pregnancy as a result ofrape, and public health efforts emphasizing abstinence to reduce unwanted pregnancy may have limited effectiveness, especially indeveloping countries and amongdisadvantaged groups.^[95][96]

Deliberatenon-penetrative sex without vaginal sex or deliberateoral sex without vaginal sex are also sometimes considered birth control.^[90] While this generally avoids pregnancy, pregnancy can still occur withintercrural sex and other forms of penis-near-vagina sex (genital rubbing, and the penis exiting fromanal intercourse) where sperm can be deposited near the entrance to the vagina and can travel along the vagina's lubricating fluids.^[97][98]

Abstinence-only sex education does not reduceteenage pregnancy.^[7][99] Teen pregnancy rates and STI rates are generally the same or higher in states where students are given abstinence-only education, as compared withcomprehensive sex education.^[99] Some authorities recommend that those using abstinence as a primary method have backup methods available (such as condoms or emergency contraceptive pills).^[100]

Lactation

Thelactational amenorrhea method involves the use of a woman's naturalpostpartum infertility which occurs after delivery and may be extended bybreastfeeding.^[101] This usually requires the presence of noperiods, exclusively breastfeeding the infant, and a child younger than six months.^[24] TheWorld Health Organization states that if breastfeeding is the infant's only source of nutrition, the failure rate is 2% in the six months following delivery.^[102] Six uncontrolled studies of lactational amenorrhea method users found failure rates at 6 months postpartum between 0% and 7.5%.^{[103][needs update]} Failure rates increase to 4–7% at one year and 13% at two years.^[104] Feeding formula, pumping instead of nursing, the use of apacifier, and feeding solids all increase its failure rate.^[105] In those who are exclusively breastfeeding, about 10% begin having periods before three months and 20% before six months.^[104] In those who are not breastfeeding, fertility may return four weeks after delivery.^[104]

Emergency

Emergency contraceptive methods are medications (sometimes misleadingly referred to as "morning-after pills")^[106] or devices used after unprotected sexual intercourse with the hope of preventing pregnancy.^[8] They work primarily by preventing ovulation or fertilization.^[2][107] They are unlikely to affect implantation, but this has not been completely excluded.^[107] A number of options exist, includinghigh dose birth control pills,levonorgestrel,mifepristone,ulipristal and IUDs.^[108] Providing emergency contraceptive pills to women in advance does not affect rates of sexually transmitted infections, condom use, pregnancy rates, or sexual risk-taking behavior.^[109][110] All methods have minimal side effects.^[108]

Levonorgestrel pills, when used within 3 days, decrease the chance of pregnancy after a single episode of unprotected sex or condom failure by 70% (resulting in a pregnancy rate of 2.2%).^[8]Ulipristal, when used within 5 days, decreases the chance of pregnancy by about 85% (pregnancy rate 1.4%) and is more effective than levonorgestrel.^{[8][108][111]}Mifepristone is also more effective than levonorgestrel, while copper IUDs are the most effective method.^[108] IUDs can be inserted up to five days after intercourse and prevent about 99% of pregnancies after an episode of unprotected sex (pregnancy rate of 0.1 to 0.2%).^[2][112] This makes them the most effective form of emergency contraceptive.^[113] In those who areoverweight orobese, levonorgestrel is less effective and an IUD or ulipristal is recommended.^[114]

Dual protection

Dual protection is the use of methods that prevent bothsexually transmitted infections and pregnancy.^[115] This can be with condoms either alone or along with another birth control method or by the avoidance ofpenetrative sex.^[116][117]

If pregnancy is a high concern, using two methods at the same time is reasonable.^[116] For example, two forms of birth control are recommended in those taking the anti-acne drugisotretinoin oranti-epileptic drugs likecarbamazepine, due to the high risk ofbirth defects if taken during pregnancy.^[118][119]

Effects

Health

Contraceptive use indeveloping countries is estimated to have decreased the number ofmaternal deaths by 40% (about 270,000 deaths prevented in 2008) and could prevent 70% of deaths if the full demand for birth control were met.^[17][18] These benefits are achieved by reducing the number of unplanned pregnancies that subsequently result in unsafe abortions and by preventing pregnancies in those at high risk.^[17]

Birth control also improves child survival in the developing world by lengthening the time between pregnancies.^[17] In this population, outcomes are worse when a mother gets pregnant within eighteen months of a previous delivery.^[17][121] Delaying another pregnancy after amiscarriage however does not appear to alter risk and women are advised to attempt pregnancy in this situation whenever they are ready.^[121]

Teenage pregnancies, especially among younger teens, are at greater risk of adverse outcomes includingearly birth,low birth weight, anddeath of the infant.^[12] In the United States 82% of pregnancies in those between 15 and 19 are unplanned.^[71] Comprehensivesex education and access to birth control are effective in decreasing pregnancy rates in this age group.^[122]

Finances

In the developing world, birth control increaseseconomic growth due to there being fewer dependent children and thus more women participating in or increased contribution to theworkforce.^[19] Women's earnings, assets,body mass index, and their children's schooling and body mass index all improve with greater access to birth control.^[19]Family planning, via the use of modern birth control, is one of the mostcost-effective health interventions.^[123] For every dollar spent, the United Nations estimates that two to six dollars are saved.^[16] These cost savings are related to preventing unplanned pregnancies and decreasing the spread of sexually transmitted illnesses.^[123] While all methods are beneficial financially, the use of copper IUDs resulted in the greatest savings.^[123]

The total medical cost for a pregnancy, delivery and care of a newborn in the United States is on average $21,000 for a vaginal delivery and $31,000 for acaesarean delivery as of 2012.^[124] In most other countries, the cost is less than half.^[124] For a child born in 2011, an average US family will spend $235,000 over 17 years to raise them.^[125]

Prevalence

Globally, as of 2009, approximately 60% of those who are married and able to have children use birth control.^[126] How frequently different methods are used varies widely between countries.^[126] The most common method in the developed world is condoms and oral contraceptives, while in Africa it is oral contraceptives and in Latin America and Asia it is sterilization.^[126] In the developing world overall, 35% of birth control is via female sterilization, 30% is via IUDs, 12% is via oral contraceptives, 11% is via condoms, and 4% is via male sterilization.^[126]

While less used in the developed countries than the developing world, the number of women using IUDs as of 2007 was more than 180 million.^[64] Avoiding sex when fertile is used by about 3.6% of women of childbearing age, with usage as high as 20% in areas of South America.^[127] As of 2005, 12% of couples are using a male form of birth control (either condoms or a vasectomy) with higher rates in the developed world.^[128] Usage of male forms of birth control has decreased between 1985 and 2009.^[126] Contraceptive use among women inSub-Saharan Africa has risen from about 5% in 1991 to about 30% in 2006.^[129]

As of 2012, 57% of women of childbearing age want to avoid pregnancy (867 of 1,520 million).^[130] About 222 million women however were not able to access birth control, 53 million of whom were in sub-Saharan Africa and 97 million of whom were in Asia.^[130] This results in 54 million unplanned pregnancies and nearly 80,000 maternal deaths a year.^[126] Part of the reason that many women are without birth control is that many countries limit access due to religious or political reasons,^[2] while another contributor ispoverty.^[131] Due to restrictiveabortion laws in Sub-Saharan Africa, many women turn to unlicensed abortion providers forunintended pregnancy, resulting in about 2–4% obtainingunsafe abortions each year.^[131]

• 
  World map colored according to modern birth control use. Each shading level represents a range of six percentage points, with usage less than or equal to:

    6%

    12%

    18%

    24%

    30%

    36%

    48%

    60%

    66%

    78%

    86%

    No data
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  Demand for family planning satisfied by modern methods as of 2017.^[132]

History

Early history

The EgyptianEbers Papyrus from 1550 BC and theKahun Papyrus from 1850 BC have within them some of the earliest documented descriptions of birth control: the use of honey,acacia leaves and lint to be placed in the vagina to block sperm.^[133][134]Silphium, a species ofgiant fennel native to north Africa, may have been used as birth control inancient Greece and theancient Near East.^[135][136] Due to its supposed desirability, by the first century AD, it had become so rare that it was worth more than its weight in silver and, by late antiquity, it was fully extinct.^[135] Most methods of birth control used in antiquity were probably ineffective.^[137]

Theancient Greek philosopherAristotle (c. 384–322 BC) recommended applyingcedar oil to the womb before intercourse, a method which was probably only effective on occasion.^[137] AHippocratic textOn the Nature of Women recommended that a woman drink a coppersalt dissolved in water, which it claimed would prevent pregnancy for a year.^[137] This method was not only ineffective, but also dangerous, as the later medical writerSoranus of Ephesus (c. 98–138 AD) pointed out.[137] Soranus attempted to list reliable methods of birth control based on rational principles.^[137] He rejected the use of superstition and amulets and instead prescribed mechanical methods such as vaginal plugs and pessaries using wool as a base covered in oils or other gummy substances.^[137] Many of Soranus's methods were probably also ineffective.^[137]

In medieval Europe, any effort to halt pregnancy was deemed immoral by theCatholic Church,^[133] although it is believed that women of the time still used a number of birth control measures, such ascoitus interruptus and inserting lily root andrue into the vagina.^[138] Women in the Middle Ages were also encouraged to tie weasel testicles around their thighs during sex to prevent pregnancy.^[139] The oldest condoms discovered to date were recovered in the ruins ofDudley Castle in England, and are dated back to 1640.^[139] They were made of animal gut, and were most likely used to prevent the spread of sexually transmitted diseases during theEnglish Civil War.^[139]Casanova, living in 18th centuryItaly, described the use of a lambskin covering to prevent pregnancy; however, condoms only became widely available in the 20th century.^[133]

Birth control movement

The birth control movement developed during the 19th and early 20th centuries.^[140] TheMalthusian League, based on the ideas ofThomas Malthus, was established in 1877 in the United Kingdom to educate the public about the importance offamily planning and to advocate for getting rid of penalties for promoting birth control.^[141] It was founded during the "Knowlton trial" ofAnnie Besant andCharles Bradlaugh, who were prosecuted for publishing on various methods of birth control.^[142]

In the United States,Margaret Sanger and Otto Bobsein popularized the phrase "birth control" in 1914.^[143][144] Sanger primarily advocated for birth control on the idea that it would prevent women from seeking unsafe abortions, but during her lifetime, she began to campaign for it on the grounds that it would reduce mental and physical defects.^[145][146] She was mainly active in the United States but had gained an international reputation by the 1930s. At the time, under theComstock Law, distribution of birth control information was illegal. Shejumped bail in 1914 after her arrest for distributing birth control information and left the United States for the United Kingdom.^[147] In the U.K., Sanger, influenced by Havelock Ellis, further developed her arguments for birth control. She believed women needed to enjoy sex without fearing a pregnancy. During her time abroad, Sanger also saw a more flexible diaphragm in a Dutch clinic, which she thought was a better form of contraceptive.^[146] Once Sanger returned to the United States, she established a short-lived birth-control clinic with the help of her sister, Ethel Bryne, based in the Brownville section ofBrooklyn, New York^[148] in 1916. It was shut down after eleven days and resulted in her arrest.^[149] The publicity surrounding the arrest, trial, and appeal sparked birth control activism across the United States.^[150] Besides her sister, Sanger was helped in the movement by her first husband, William Sanger, who distributed copies of “Family Limitation.” Sanger's second husband, James Noah H. Slee, would also later become involved in the movement, acting as its main funder.^[146]

The increased use of birth control was seen by some as a form of social decay.^[151] A decrease of fertility was seen as a negative. Throughout the Progressive Era (1890-1920), there was an increase of voluntary associations aiding the contraceptive movement.^[151] These organizations failed to enlist more than 100,000 women because the use of birth control was often compared to eugenics;^[151] however, there were women seeking a community with like-minded women. The ideology that surrounded birth control started to gain traction during the Progressive Era due to voluntary associations establishing community. Birth control was unlike the Victorian Era because women wanted to manage their sexuality. The use of birth control was another form of self-interest women clung to. This was seen as women began to gravitate towards strong figures, like theGibson girl.^[152]

The first permanent birth-control clinic was established in Britain in 1921 byMarie Stopes working with the Malthusian League.^[153] The clinic, run by midwives and supported by visiting doctors,^[154] offered women's birth-control advice and taught them the use of acervical cap. Her clinic made contraception acceptable during the 1920s by presenting it in scientific terms. In 1921, Sanger founded the American Birth Control League, which later became thePlanned Parenthood Federation of America.^[155] In 1924 the Society for the Provision of Birth Control Clinics was founded to campaign for municipal clinics; this led to the opening of a second clinic inGreengate, Salford in 1926.^[156] Throughout the 1920s, Stopes and otherfeminist pioneers, includingDora Russell andStella Browne, played a major role in breaking downtaboos about sex. In April 1930 the Birth Control Conference assembled 700 delegates and was successful in bringing birth control and abortion into the political sphere – three months later, theMinistry of Health, in the United Kingdom, allowed local authorities to give birth-control advice in welfare centres.^[157]

The National Birth Control Association was founded in Britain in 1931, and became theFamily Planning Association eight years later. The Association amalgamated several British birth control-focused groups into 'a central organisation' for administering and overseeing birth control in Britain. The group incorporated the Birth Control Investigation Committee, a collective of physicians and scientists that was founded to investigate scientific and medical aspects of contraception with 'neutrality and impartiality'.^[158] Subsequently, the Association effected a series of'pure' and'applied' product and safety standards that manufacturers must meet to ensure their contraceptives could be prescribed as part of the Association's standard two-part-technique combining ‘a rubber appliance to protect the mouth of the womb’ with a ‘chemical preparation capable of destroying... sperm’.^[159] Between 1931 and 1959, the Association founded and funded a series of tests to assess chemical efficacy and safety and rubber quality.^[160] These tests became the basis for the Association's Approved List of contraceptives, which was launched in 1937, and went on to become an annual publication that the expanding network of FPA clinics relied upon as a means to 'establish facts [about contraceptives] and to publish these facts as a basis on which a sound public and scientific opinion can be built'.^[161]

In 1936 the U.S. court ruled in U.S. v. One Package that medically prescribing contraception to save a person's life or well-being was not illegal under theComstock Law; following this decision, theAmerican Medical Association Committee on Contraception revoked its 1936 statement condemning birth control. A national survey in 1937 showed 71 percent of the adult population supported the use of contraception. By 1938 347 birth control clinics were running in the United States despite their advertisement still being illegal.First LadyEleanor Roosevelt publicly supported birth control and family planning.^[162] In 1966,President Lyndon B. Johnson started endorsing public funding for family planning services, and the Federal Government began subsidizing birth control services for low-income families.^[163]The Affordable Care Act, passed into law on March 23, 2010 under PresidentBarack Obama, requires all plans in the Health Insurance Marketplace to cover contraceptive methods. These include barrier methods, hormonal methods, implanted devices, emergency contraceptives, and sterilization procedures.^[164]

Modern methods

In 1909, Richard Richter developed the first intrauterine device made from silkworm gut, which was further developed and marketed in Germany byErnst Gräfenberg in the late 1920s.^[165] In 1951, a chemist, named Carl Djerassi from Mexico City made the hormones in progesterone pills using Mexican yams.^[166] Djerassi had chemically created the pill but was not equipped to distribute it to patients. Meanwhile,Gregory Pincus andJohn Rock with help from thePlanned Parenthood Federation of America developed the first birth control pills in the 1950s, such asmestranol/noretynodrel, which became publicly available in the 1960s through the Food and Drug Administration under the nameEnovid.^[155][167]Medical abortion became an alternative to surgical abortion with the availability ofprostaglandin analogs in the 1970s andmifepristone in the 1980s.^[168]

Society and culture

Legal positions

Human rights agreements require most governments to provide family planning and contraceptive information and services. These include the requirement to create a national plan for family planning services, remove laws that limit access to family planning, ensure that a wide variety of safe and effective birth control methods are available including emergency contraceptives, make sure there are appropriately trained healthcare providers and facilities at an affordable price, and create a process to review the programs implemented. If governments fail to do the above it may put them in breach of binding international treaty obligations.^[169]

In the United States, the 1965 Supreme Court decisionGriswold v. Connecticut overturned a state law prohibiting dissemination of contraception information based on a constitutional right to privacy for marital relationships. In 1971,Eisenstadt v. Baird extended this right to privacy to single people.^[170]

In 2010, the United Nations launched theEvery Woman Every Child movement to assess the progress toward meeting women's contraceptive needs. The initiative has set a goal of increasing the number of users of modern birth control by 120 million women in the world's 69 poorest countries by the year 2020. Additionally, they aim to eradicate discrimination against girls and young women who seek contraceptives.^[171] TheAmerican Congress of Obstetricians and Gynecologists (ACOG) recommended in 2014 that oral birth control pills should beover the counter medications.^[172]

Since at least the 1870s, American religious, medical, legislative, and legal commentators have debated contraception laws. Ana Garner and Angela Michel have found that in these discussions men often attach reproductive rights to moral and political matters, as part of an ongoing attempt to regulate human bodies. In press coverage between 1873–2013 they found a divide between institutional ideology and real-life experiences of women.^[173]

Religious views

Religions vary widely in their views of theethics of birth control.^[174] TheRoman Catholic Church officially only acceptsnatural family planning,^[175] although large numbers of Catholics indeveloped countries accept and use modern methods of birth control.^{[176][177][178]} AmongProtestants, there is a wide range of views from supporting none, such as in theQuiverfull movement, to allowing all methods of birth control.^[179] Views inJudaism range from the stricterOrthodox sect, which prohibits all methods of birth control, to the more relaxedReform sect, which allows most.^[180]Hindus may use both natural and modern contraceptives.^[181] A commonBuddhist view is that preventing conception is acceptable, while intervening after conception has occurred is not.^[182] InIslam, contraceptives are allowed if they do not threaten health, although their use is discouraged by some.^[183]

World Contraception Day

September 26 is World Contraception Day, devoted to raising awareness and improving education about sexual and reproductive health, with a vision ofa world where every pregnancy is wanted.^[184] It is supported by a group of governments and international NGOs, including theOffice of Population Affairs, the Asian Pacific Council on Contraception, Centro Latinamericano Salud y Mujer, the European Society of Contraception and Reproductive Health, theGerman Foundation for World Population, the International Federation of Pediatric and Adolescent Gynecology,International Planned Parenthood Federation, theMarie Stopes International,Population Services International, thePopulation Council, theUnited States Agency for International Development (USAID), andWomen Deliver.^[184]

Misconceptions

There are a number ofcommon misconceptions regarding sex and pregnancy.^[185]Douching after sexual intercourse is not an effective form of birth control.^[186] Additionally, it is associated with a number of health problems and thus is not recommended.^[187] Women can become pregnant the first time they have sexual intercourse^[188] and in anysexual position.^[189] It is possible, although not very likely, to become pregnant during menstruation.^[190]

Accessibility

Access to birth control may be affected by finances and the laws within a region or country.^[191] In the United States African American, Hispanic, and young women are disproportionately affected by limited access to birth control, as a result of financial disparity.^[192][193] For example Hispanic and African American women often lack insurance coverage and are more often poor.^[194] New immigrants in the United States are not offered preventive care such as birth control.^[195]

Research directions

Females

Improvements of existing birth control methods are needed, as around half of those who get pregnant unintentionally are using birth control at the time.^[27] A number of alterations of existing contraceptive methods are being studied, including a better female condom, an improveddiaphragm, a patch containing only progestin, and a vaginal ring containing long-acting progesterone.^[196] This vaginal ring appears to be effective for three or four months and is currently available in some areas of the world.^[196] For women who rarely have sex, the taking of the hormonal birth controllevonorgestrel around the time of sex looks promising.^[197]

A number of methods to perform sterilization via the cervix are being studied. One involves puttingquinacrine in the uterus which causes scarring and infertility. While the procedure is inexpensive and does not require surgical skills, there are concerns regarding long-term side effects.^[198] Another substance,polidocanol, which functions in the same manner is being looked at.^[196] A device calledEssure, which expands when placed in the fallopian tubes and blocks them, was approved in the United States in 2002.^[198] In 2016, ablack boxed warning regarding potentially serious side effects was added,^[199][200] and in 2018, the device was discontinued.^[201]

Males

Methods of male birth control include condoms, vasectomies and withdrawal.^[202][203] Between 25 and 75% of males who are sexually active would use hormonal birth control if it was available for them.^[128][202] A number of hormonal and non-hormonal methods are in trials,^[128] and there is some research looking at the possibility ofcontraceptive vaccines.^[204]

A reversible surgical method under investigation isreversible inhibition of sperm under guidance (RISUG) which consists of injecting a polymer gel,styrene maleic anhydride indimethyl sulfoxide, into thevas deferens. An injection with sodium bicarbonate washes out the substance and restores fertility. Another is anintravas device which involves putting aurethane plug into thevas deferens to block it. A combination of anandrogen and aprogestin seems promising, as doselective androgen receptor modulators.^[128]Ultrasound and methods to heat the testicles have undergone preliminary studies.^[205]

Other animals

Neutering or spaying, which involves removing some of the reproductive organs, is often carried out as a method of birth control in household pets. Manyanimal shelters require these procedures as part of adoption agreements.^[206] In large animals the surgery is known ascastration.^[207]

Birth control is also being considered as an alternative to hunting as a means of controllingoverpopulation in wild animals.^[208]Contraceptive vaccines have been found to be effective in a number of different animal populations.^[209][210] Kenyan goat herders fix a skirt, called anolor, to male goats to prevent them from impregnating female goats.^[211]

References

Further reading

• Speroff, Leon; Darney, Philip D. (2010).A clinical guide for contraceptionArchived 2020-07-27 at theWayback Machine (5th ed.). Philadelphia: Lippincott Williams & Wilkins.ISBN 978-1-60831-610-6.
• Stubblefield, Phillip G.; Roncari, Danielle M. (2011)."Family Planning"Archived 2020-08-03 at theWayback Machine, pp. 211–69, in Berek, Jonathan S. (ed.)Berek & Novak's Gynecology, 15th ed. Philadelphia: Lippincott Williams & Wilkins,ISBN 978-1-4511-1433-1.
• Jensen, Jeffrey T.; Mishell, Daniel R. Jr. (March 19, 2012)."Family Planning: Contraception, Sterilization, and Pregnancy Termination"Archived 2020-07-27 at theWayback Machine, pp. 215–72, in Lentz, Gretchen M.; Lobo, Rogerio A.; Gershenson, David M.; Katz, Vern L. (eds.)Comprehensive Gynecology, 6th ed. Philadelphia: Mosby Elsevier,ISBN 978-0-323-06986-1.
• Gavin, L; Moskosky, S; Carter, M; Curtis, K; Glass, E (Apr 25, 2014). Godfrey, E; Marcell, A; Mautone-Smith, N; Pazol, K; Tepper, N; Zapata, L; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs".MMWR Recommendations and Reports.63 (RR-04): 1–54.PMID 24759690.

External links

• Birth control atCurlie
• "WHO Fact Sheet". July 2017.Archived from the original on 19 April 2018. Retrieved23 July 2017.
• World Health Organization Department of Reproductive Health and Research and Johns Hopkins Bloomberg School of Public Health (2011).Family planning: A global handbook for providers: Evidence-based guidance developed through worldwide collaboration(PDF) (Rev. and Updated ed.). Geneva: WHO and Center for Communication Programs.ISBN 978-0-9788563-7-3.Archived(PDF) from the original on 2013-09-21. Retrieved2020-08-08.
• Curtis, Kathryn M.; Jatlaoui, Tara C.; Tepper, Naomi K.; Zapata, Lauren B.; Horton, Leah G.; Jamieson, Denise J.; Whiteman, Maura K. (29 July 2016)."U.S. Selected Practice Recommendations for Contraceptive Use".MMWR Recommendations and Reports.65 (4): 1–66.doi:10.15585/mmwr.rr6504a1.PMID 27467319.
• "Birth Control Comparison Chart". Cedar River Clinics.Archived from the original on 2014-03-29. Retrieved2020-08-08.
• Bulk procurement of birth controlArchived 2014-03-03 at theWayback Machine by the World Health Organization

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