Family Planning

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Family planning

The exaxt population of the world is unknown but believed at about 6.2 billion; it continues in its unrelenting growth especially in developing countries. Worldwide famine has been postponed thanks to modern agricultural procedures, known as the Green Revolution, which have greatly increased grain production. Nevertheless, with limited land and resources that can be devoted to food production—and increasing numbers of humans who need both space and food—there appears to be a significant risk of catastrophe by overpopulation. Because of this, there is increased interest in family planning. Family planning in this context means birth control to limit family size.

The subject of "family planning" is not limited to birth control but includes procedures designed to overcome difficulties in becoming pregnant. About 15% of couples are unable to conceive children after a year of sexual activity without using birth control. Many couples feel an intense desire and need to conceive children. Aid to these couples is thus a reasonable part of family planning. However, for most discussions of family planning, the emphasis is on limitation of family size, not augmentation.

Birth control procedures have evolved rapidly in this century. Further, utilization of existing procedures is changing with different age groups and different populations. Thus any account of birth control is likely to become rapidly obsolete. An example of the changing technology includes oral contraception with pills containing hormones. Birth control pills have been marketed in the United States since the 1960s. Since that time there have been many formulations with significant reductions in dosage. There was much greater acceptance of pills by American women under the age of 30. The intrauterine device (IUD) was much more popular in Sweden than in the United States whereas sterilization was more common in the United States than in Sweden.

A very common form of birth control is the condom, which is a thin rubber sheath worn by men during sexual intercourse. They are generally readily accessible, cheap, and convenient for those individuals who may not have sexual relations regularly. Sperm cannot penetrate the thin (0.3—0.8 mm thick) latex. Neither the human immunodeficiency virus (HIV) associated with AIDS nor the other pathogenic agents of sexually transmitted diseases (STDs) are able to penetrate the latex barrier. Some individuals are opposed to treating healthy bodies with drugs (hormones) for birth control, and for these individuals, condoms have a special appeal. Natural "skin" (lamb's intestine) condoms are still available for individuals who may be allergic to latex, but this product provides less protection to HIV and other STDs.

The reported failure rate of condoms is high and is most likely due to improper use. Yet during the Great Depression in the 1930s—when pills and other contemporary birth control procedures were not available—it is thought that the proper use of condoms caused the birth rate in the United States to plummet.

Spermicides—surface active agents which inactivate sperm and STD pathogens—can be placed in the vagina in jellies, foam, and suppositories. Condoms used in conjunction with spermicides have a failure rate lower than either method used alone and may provide added protection against some infectious agents.

Types of Contraceptives
Effectiveness	Predicted (%)	Actual (%)
Birth control pills	99.9	97
Condoms	98	88
Depo Provera	99.7	99.7
Diaphragm	94	82
IUDS	99.2	97
Norplant	99.7	99.7
Tubal sterilization	99.8	99.6
Spermicides	97	79
Vasectomy	99.9	99.9

The vaginal diaphragm, like the condom, is another form of barrier. The diaphragm was in use in World War I and was still used by about one third of couples by the time of World War II. However, because of the efficacy and ease of use of oral contraceptives, and perhaps because of the protection against disease by condoms, the use of vaginal diaphragms is down. The diaphragm, which must be fitted by a physician, is designed to prevent sperm access to the cervix and upper reproductive tract. It is used in conjunction with spermicides. Other similar barriers include the cervical cap and the contraceptive sponge. The cervical cap is smaller than the diaphragm and fits only around that portion of the uterus that protrudes into the vagina. The contraceptive sponge, which contains a spermicide, is inserted into the vagina prior to sexual intercourse and retained for several hours afterwards to insure that no living sperm remain.

Intrauterine devices (IUDs) were popular during the 1960s and 1970s in the United States, but their use today has dwindled. However in China, a nation which is rapidly attending to its population problems, about 60 million women use IUDs. The failure rate of IUDs in less developed countries is reported to be less than that with the pill. The devices may be plastic, copper , or stainless steel. The plastic versions may be impregnated with barium sulfate to permit visualization by x ray and also may slowly release hormones such as progesterone. Ovulation continues with IUD use. Efficacy probably results from a changed uterine environment which kills sperm.

Oral contraception is by means of the "pill." Pills contain an estrogen and a progestational agent, and current dosage is very low compared with several decades ago. The combination of these two agents is taken daily for three weeks followed by one week with neither hormone. Frequently a drug-free pill is taken for the last week to maintain the pill-taking habit and thus enhance the efficacy of the regimen. The estrogenic component prevents follicle maturation, and the progestational component prevents ovulation. Pill-taking women who have multiple sexual partners may wish to consider the addition of a barrier method to minimize risk for STDs. The reliability of the pill reduces the need for abortion or surgical sterilization. There may be other salutary health effects which include less endometrial and ovarian cancer as well as fewer uterine fibroids. Use of oral contraceptives in women over the age of 35 who also smoke is thought to increase the risk of heart and vascular disease.

Contraceptive hormones can be administered by routes other than oral. Subdermal implants of progestin-containing tubules have been available since 1990 in the United States. In this device familiarly known as Norplant, six tubules are surgically placed on the inside of the upper arm, and the hormone diffuses through the wall of the tubules to provide long term contraceptive activity. Another form of progestin-only contraception is by intramuscular injection which must be repeated every three months.

Fears engendered by IUD litigation are thought to have increased the reliance of many American women on surgical sterilization (tubal occlusion). Whatever the reason, more American women rely on the procedure than do their European counterparts. Tubal occlusion involves the mechanical disruption of the oviduct, the tube that leads from the ovary to the uterus, and prevents sperm from reaching the egg. Inasmuch as the fatality rate for the procedure is lower than that of childbirth, surgical sterilization is now the safest method of birth control. Tubal occlusion is far more common now that it was in the 1960s because of the lower cost and reduced surgical stress. Use of the laparoscope and very small incisions into the abdomen have allowed the procedure to be completed during an office visit.

Male sterilization, another method, involves severing the vas deferens, the tube that carries sperm from the testes to the penis. Sperm comprise only a small portion of the ejaculate volume, and thus ejaculation is little changed after vasectomy. The male hormone is produced by the testes and production of that hormone continues as does erection and orgasm.

Most abortions would be unnecessary if proper birth control measures were followed. That of course is not always the case. Legal abortion has become one of the leading surgical procedures in the United States. Morbidity and mortality associated with pregnancy have been reduced more with legal abortion than with any other event since the introduction of antibiotics to fight puerperal fever.

Other methods of birth control are used by individuals who do not wish to use mechanical barriers, devices, or drugs (hormones). One of the oldest of these methods is withdrawal (coitus interruptus ), in which the penis is removed from the vagina just before ejaculation. Withdrawal must be exquisitely timed, is probably frustrating to both partners, is not thought to be reliable, and provides no protection against HIV and other STD infections. Another barrier- and-drug-free procedure is natural family planning (also known as the rhythm method). Abstinence of sexual intercourse is scheduled for a period of time before and after ovulation. Ovulation is calculated by temperature change, careful record keeping of menstruation (the calendar method), or by vaginal mucous inspection. Natural family planning has appeal for individuals who wish to limit their exposure to drugs, but it provides no protection against HIV and other STDs.

The population of the world increases by about 140 million every year, while the world is unable to sustain its new residents adequately. That increase signals the need for family planning education and the continued development of ever more efficient birth control methods.

[Robert G. McKinnell ]