Chapter Thirteen Contraception and Abortion Agenda Discuss History and Considerations Associated with Methods Discuss Contraception Methods Discuss Abortion Class Exercise: Contraception Values Clarification Complete the handout entitled “Contraception Values Clarification. After you have completed the handout, discuss your response in small groups. Introduction Majority of U.S. pregnancies are not planned and most are a result of not using contraception Factors increasing motivation to use contraception: good communication with partner, lower cost, effectiveness rates, frequency of intercourse, motivation to avoid pregnancy, side effects, openness about sexuality Contraception: History Contraception in Ancient Times Contraception in the U.S.: 1800s and Early 1900s Contraception Outside the U.S. Contraception in Ancient Times Ancient Greeks: magic, superstition, herbs Egyptians: fumigating female genitalia, tampon soaked in herbal liquid & honey, inserting a mixture of crocodile feces, sour milk, & honey South Africa: insert vegetable seed pods Africa: insert a grassy cervical plug Persia: insert alcohol soaked sponges Greece: insert empty pomegranate halves Contraception in the U.S.: 1800s and Early 1900s Concern in early 1800s was to curb poverty by controlling fertility 1873 Comstock laws prohibited dispersing information about contraceptives, including by doctors Contraception use is affected by Social issues – e.g. desired family size Economic issues Knowledge & misinformation Religion Gender roles & power – in some areas, men make the contraceptive decisions; for some it is the responsibility of both Choosing a Method of Contraception FDA Approval Process Lifestyle Issues FDA Approval Process The U.S. Food and Drug Administration (FDA) must formally approve the method 10-14 year process to develop a new contraceptive drug Drug company submits a new drug application demonstrating safety in animal tests & a desire to conduct human trials FDA Approval Process 3 phases Phase 1: 20-80 volunteers to test effectiveness Phase 2: several hundred to test effectiveness, side effects, risks Phase 3: hundreds to thousands are tested for generalization Animal trials are conducted throughout the process Class Discussion: Lifestyle Issues Associated with Contraceptive The following factors seem to be associated with choosing a contraceptive method: Own health & risks Number of sexual partners Frequency of intercourse Risk of acquiring a STI Responsibility level Method cost Advantages & disadvantages of the method Discuss influence of each. Contraception Methods Barrier Methods: Condoms and Caps Prevent sperm from entering the uterus Barrier Methods: Condoms The Diaphragm The Contraceptive Sponge The Cervical Barriers Condoms 1850 – latex condoms available in the U.S. $10-$15/dozen Non-expired condom is rolled onto an erect penis (foreskin pulled back), ½-inch empty space at the tip Water-based lubricants for latex condoms Condom grasped at base when withdrawing Latex condoms have lower rates of slippage & breakage, and offer better STI protection Condoms In 1994, female polyurethane/nonlatex condoms were available $2 each 7 inches long with 2 flexible rings Inner ring squeezed and inserted close to the cervix Outer ring lies outside the vagina Adequate lubrication is necessary Condoms Effectiveness rates Latex condoms: 85-98% Female condoms: 79-95% Latex & polyurethane protect against STI transmission Lambskin condoms block sperm, but contain holes large enough for viruses to pass through Heat can damage condoms Condoms Advantages: STI protection Encourages male participation Inexpensive No prescription necessary Can reduce premature ejaculation Can reduce postcoital drip No medical side effects Condoms Disadvantages: Reduces spontaneity Can reduce sensation Female condoms can be difficult to use, uncomfortable, noisy Female & male condoms should never be used together Popular in some countries, not used in others The Diaphragm Not widely used, almost 0% in 2002 Made of latex or silicone Many sizes and shapes; a fitting by a health care provider is necessary $20-$35 diaphragm, $13 spermicidal jelly/cream, office visit charge They can last for many years Diaphragms come in a variety of different shapes and sizes and must be fitted by a health-care provider. The Diaphragm Diaphragm rim is covered in spermicidal jelly & a tablespoon of jelly is placed in the dome; it is folded in half and inserted into the vagina with the front rim tucked under the pubic bone It should not be felt & should cover the cervix It can be inserted up to 6 hours prior to intercourse Left in for at least 6-8 hours, no more than 24 After use it is washed with soap & water Instructions for proper insertion of a diaphragm. The Diaphragm 84-94% effective, lower for those who have given birth Advantages: Increases spontaneity Some STI & PID protection Reduces risk of cervical dysplasia & cancer Does not affect hormonal levels Relatively inexpensive The Diaphragm Disadvantages: Physician fitting and prescription Insertion & removal involves touching the genitals Increased risk of toxic shock syndrome and urinary tract infection Postcoital drip Low usage outside the U.S. The Contraceptive Sponge The Today contraceptive sponge was taken off the market for a decade due to issues with the manufacturing plant; reintroduced in 2005 Available over the counter in one size The sponge covers the cervix & contains spermicide; it blocks, absorbs, & deactivates sperm One box of 3 sponges is $13 The Today contraceptive sponge was back on the market in late 2005 in the United States. The Diaphragm Sponge is moistened with water to activate the spermicide, folded in half, & inserted to cover the cervix Can be inserted up to 24 hours in advance, with intercourse occurring as many times as desirable in that time period Must be left in at least 6 hours after intercourse 75-89% effectiveness rates Instructions for proper insertion of a contraceptive sponge. The Diaphragm Advantages: No prescription necessary Can have intercourse several times within 24 hours Increase sexual spontaneity Do not affect hormonal levels Disposable The Diaphragm Disadvantages: Increased risk of toxic shock syndrome & urinary tract infection Cannot be used while menstruating Requires touching of the genitals High expense if frequently used Some men can feel it Low usage rates in other cultures The Cervical Barriers Thimble-shaped, silicone barriers that fit over the cervix Block entrance to the uterus & deactivate sperm with the spermicide Fitting by a health care provider is necessary Two types: FemCap Lea’s Shield The FemCap is a silicone cup shaped like a sailor’s hat that fits securely over the cervix. Lea’s Shield is a silicone cup with a one-way valve and a loop for easier removal. The Cervical Barriers $15-75 plus cost of spermicide Left in place for 8 hours after intercourse After use, it is washed with soap & water Not to be used during menstruation 86% effectiveness rate, lower for those who have had children The Cervical Barriers Advantages: Left in place for up to 48 hours Do not affect hormonal levels Immediately effective Not permanent One-way release valve in Lea’s Shield reduces risk of toxic shock syndrome The Cervical Barriers Disadvantages: Abnormal Pap smears Increased risk of urinary tract infections Increased vaginal odors Cervical damage Increased postcoital drip Fitting is necessary Some male partners feel it & may dislodge it The Cervical Barriers Widely used in England Lea’s Shield is available over the counter in Germany, Austria, Switzerland, & Canada Hormonal Methods for Women: The Pill, the Patch, and More Changing hormonal levels can deter production of ova, fertilization, and implantation Hormonal Methods for Women: The Pill, the Patch, and More Combined-Hormone Methods Birth Control Pills Hormonal Ring Hormonal Patch Progestin-Only Methods Subdermal Implants Hormonal Injectibles Combined-Hormone Methods Combination of estrogen & progesterone Can repress ovulation and thicken cervical mucus Birth Control Pills Federally approved in 1960 Most popular contraceptive in the U.S. and around the world Most studied type of medication Combination birth control pills are $12-25 per month Designed to mimic a menstrual cycle, with 21 days of hormones and one off week Bleeding is medically induced Birth Control Pills Some take 2 to 3 packs of active pills in a row to reduce the number of menstrual periods Seasonale – 84-day active pill with 7-day placebo Reducing periods can help those with heavy bleeding and cramping 60% of women prefer to not have a period Birth Control Pills Increase in estrogen & progesterone prevent the pituitary from sending hormones to ripen the ovaries Cervical mucus thickens & endometrium buildup is minimal The body is tricked into thinking it is pregnant May experience other signs of pregnancy that usually disappear within a few months Birth Control Pills Initially prescribed a low-dose estrogen pill; increased if breakthrough bleeding occurs Monophasic pills contain the same dose of hormones in each pill Multiphasic pills vary in hormone amount Triphasil pills have 3 sets, each week the hormonal dosage increases 92-99.7% effective Need to take it each day at the same time Birth Control Pills Advantages: High effectiveness rate Doesn’t interfere with spontaneity Reduced menstrual flow, cramps, & PMS Increased menstrual regularity Reduced risk of ovarian cysts, uterine & breast fibroids, facial acne, ovarian & endometrial cancers, PID, benign breast disease Birth Control Pills Disadvantages: No STI protection Female’s responsibility; taken daily Can be expensive Lower effectiveness if overweight Not appropriate for smokers Used throughout the world, although not popular everywhere; some places have it over the counter Hormonal Ring NuvaRing introduced in 2003 Plastic ring inserted into the vagina once a month for 3 weeks, removed for 1 week Affects the body as combination pills do Body heat & moisture activate a constant dose of estrogen & progesterone; lower dose than pills $30-35 per month 99.7% effective The NuvaRing is inserted deep into the vagina; moisture and heat cause it to time-release hormones that inhibit ovulation. Hormonal Ring Advantages: High effectiveness Doesn’t interfere with spontaneity Reduces menstrual flow, cramps, PMS Increases menstrual regularity Protection from ovarian & endometrial cancer and ovarian cysts Fertility restored upon removal Hormonal Ring Disadvantages: Comfortable touching genitals No STI protection Side effects that typically disappear with regular use: breakthrough bleeding, weight change, breast tenderness, nausea, mood changes, changes in sexual desire, increased vaginal irritation & discharge No data on cross-cultural use Hormonal Patch Ortho Evra patch is a thin, peach colored sticker attached to the skin with time-released hormones Placed on buttock, stomach, or upper torso for 3 weeks, no patch for the 4th week Affects the body as combination pills do $30-35 per month 99.7% effective, lower if weigh more than 198 pounds The Ortho Evra patch is worn on the buttock, abdomen, or upper torso for three weeks each month. Hormonal Patch Advantages: High effectiveness Doesn’t interfere with spontaneity Reduces menstrual flow, cramps, PMS Increases menstrual regularity Protection from ovarian & endometrial cancer and ovarian cysts Hormonal Patch Disadvantages: No STI protection Side effects similar to hormonal ring Skin irritation Change in vision, discomfort to contact wearers Collects lint Nearly impossible to conceal from partner No data on cross-cultural use Progestin-Only Methods Do not contain estrogen and can be used by women that cannot take estrogen, such as those who are breastfeeding & smokers Over time, may eliminate periods May cause slight weight gain, bloatedness, & breast tenderness Progestin-Only Methods Minipill/POPs (progestin-only pills) Inhibit ovulation and thicken mucus Fewer side effects than combination pills 92-99.7% effective More expensive than combination pills Can cause irregular bleeding Higher rate of ectopic pregnancies if get pregnant while taking the minipill Subdermal Implants Constant dose of progestin is time released for up to 5 years Norplant is no longer available Jadelle is FDA approved but not marketed in the U.S. 2 silicone cylinders implanted in the forearm in a 10 minute procedure; $500+ Implanon is a single-rod approved in 2004 Fertility restored upon removal Subdermal Implants Suppresses ovulation, thickens cervical mucus, unreceptive endometrium 99.95% effective, decreases after the 3rd year Lower effectiveness rates if over 154 pounds Advantages: Effective, long-lasting, reversible Simple implantation procedure No estrogen side effects Decreased menstrual flow, cramping Subdermal Implants Disadvantages: Expensive implantation fees, arm pain, painful removal, possible scarring Irregular bleeding, cramping Headaches, nausea, dizziness, weight change, rash, acne, hair growth or loss Vision problems Popular in South Africa Hormonal Injectibles Depo-medroxyprogesterone acetate (Depo- Provera) – synthetic progesterone Most popular non-oral contraceptive Injected into the arm or buttock muscle every 3 months $30-125 per injection Works within 24 hours Fertility resumes 10 months after last injection Hormonal Injectibles 97-99.7% effective Advantages: Long lasting injection Moderately expensive No estrogen Decreased menstrual flow & cramping Decreased risk of endometrial & ovarian cancers Allows for spontaneity Hormonal Injectibles Disadvantages: Office visits every 3 months Irregular bleeding Fatigue, dizziness, weakness, headaches Appetite increases Decrease in bone density Risk of liver, cervical, and breast cancers Long return to fertility Low usage rates in many countries Chemical Methods for Women: Spermicides Spermicides come as foams, gels, suppositories, creams, foaming tablets, films, and capsules Inserted into vagina with applicator or finger 10-30 minutes prior to intercourse $5-10 over the counter Can also help reduce STIs Likely to see microbicides introduced that will protect from HIV & other STIs Chemical Methods for Women: Spermicides 71-82% effective Effectiveness is reduced if tampons or douches are used within 6-8 hours Foam is more effective than other varieties Advantages: Over the counter Provide lubrication Some protection from STIs No serious side effects Chemical Methods for Women: Spermicides Disadvantages: Used each time Increased postcoital drip May produce allergic reactions, skin irritations Increased risk of urinary tract infections Unpleasant taste Widely used in some countries, and not used much in other countries Intrauterine Methods for Women: IUDs and IUSs Intrauterine Device (IUD) ParaGard Copper T – can be left in for 12 years Intrauterine System (IUS) Mirena – IUD that contains time-released progestin; can be left in for 5 years Most IUD & IUS users are 35 or older $150-300 plus office visit Intrauterine Methods for Women: IUDs and IUSs IUDs & IUSs create a slight infection in the uterus that obstructs sperm mobility Progesterone from the IUS also affects the endometrium, hampering implantation Health care providers insert the IUD Each month the woman must check for the string to assure it is still in place 99.2-99.9% effective, lower if never pregnant Insertion of an IUD. Intrauterine Methods for Women: IUDs and IUSs Advantages: Least expensive method over time Allows for spontaneity Decreases menstrual flow (Mirena) Long lasting effects Intrauterine Methods for Women: IUDs and IUSs Disadvantages: No STI protection Risk of uterine perforation and PID Irregular bleeding Painful insertion & removal Increased menstrual flow and cramping May be expelled from uterus May cause discomfort to the partner Widely used through most of the world Natural Methods for Women and Men Natural Family Planning and Fertility Awareness Withdrawal Abstinence Natural Family Planning and Fertility Awareness Involves a woman charting her menstrual periods and determining ovulation by daily monitoring of basal body temperature and checking cervical mucus Body temperature rises 0.4-0.8°F before ovulation & remains elevated until menstruation Cervical mucus is thin, stretchy during ovulation Natural Family Planning and Fertility Awareness Abstinence is practiced during ovulation Or a form of birth control is used during ovulation (fertility awareness) Mostly used by women spacing pregnancies that are not as concerned about prevention Ovulation kits can also be used 75-99% effective Natural Family Planning and Fertility Awareness Advantages: Useful if other methods are not acceptable for religious reasons Inexpensive Educates about the menstrual cycle Encourages partner communication No side effects Natural Family Planning and Fertility Awareness Disadvantages: No STI protection Restricts spontaneity Low effectiveness Takes time & commitment Several cycles need to be recorded before it is reliable Widely used in many countries, particularly Catholic countries Withdrawal Also called coitus interruptus Just before ejaculation, the male withdraws his penis and ejaculates outside of the woman 73-96% effective Sperm may remain in urethra from previous ejaculations & impregnate without the male ejaculating inside of the woman Withdrawal Advantages: Useful if other methods are not acceptable for religious reasons No costs Good if couples aren’t concerned about prevention Withdrawal Disadvantages: No STI protection Low effectiveness May lead to premature ejaculation May be stressful Requires trust & restraint Widely used in many countries Abstinence Refraining from sexual intercourse 100% effective Protects against STIs Permanent (Surgical) Methods A woman may be fertile until 50-51 years A man may be fertile most of his life Sterilization in one of the safest & most effective contraceptive methods Surgery that is typically irreversible Two types: Female Sterilization Male Sterilization Female Sterilization Also called tubal sterilization or getting “tubes tied” A small incision is made under the navel or lower in the abdomen Both Fallopian tubes are blocked through cauterization, rings, bands, clips, plugs, or clamps, or the tubes may be cut This procedure uses general anesthesia as outpatient surgery or after childbirth Essure is a permanent method of contraception. Female Sterilization A woman still ovulates, but the egg can’t enter the uterus $2000-5000 Risks: anesthesia side effects, bleeding, infection, injury to other organs Reduces risk of ovarian cancer Most widely used birth control method in the world Male Sterilization A vasectomy impedes the travel of sperm through the vas deferens Cheaper, safer, & simpler than tubal sterilization Two ¼ to ½ inch incisions are made in the scrotum and the vas deferens is snipped, clipped, or cauterized under local anesthesia 20 minute procedure The man ejaculates semen without sperm In a vasectomy, each vas deferens is clipped, cut, or cauterized. A vasclip uses a flexible plastic clip to block the vas deferens. Male Sterilization After surgery, sperm for 20 more ejaculations remains Sperm counts are checked 2-3 months later to check sterility $300-750 Risks: swelling, bruising, internal bleeding, infection 99-99.9% effective Permanent (Surgical) Methods Advantages: High effectiveness Permanent Allows for spontaneity Disadvantages: Expensive, irreversible surgery No STI protection Widely used throughout the world Abortion The Abortion Debate Why Do Women Have Abortions? Abortion Procedures Reactions to Abortion Teens and Abortion Cross-Cultural Aspects of Abortion Class Exercise: Abortion A fertilized egg is a human being from the moment the sperm and egg unite. The rights of the fetus always take precedence over the rights of the mother. Parental consent should be required for teenagers seeking abortion. Spousal consent should be required for married women seeking abortion. I support a woman’s right to choose in any and all circumstances. I support a woman’s right to choose if the pregnancy resulted from a rape. I support a woman’s right to choose if the pregnancy resulted from contraceptive failure. Exercise (cont.) I believe abortion is justified if the woman feels that she is not ready for this child. I believe abortion is justified if a serious birth defect has been detected via amniocentesis. I believe abortion is justified if the couple already has 5 children and the woman unexpectedly becomes pregnant again. I believe abortion is justified if parents of two boys discover they are pregnant again with a third boy, and they were really hoping for a girl. I believe abortion should be legal. There should be a mandatory 24-hour waiting period for all women seeking an abortion. Adoption could solve the problem of “unwanted children.” The Abortion Debate Pro-Life versus Pro-Choice Historical Perspectives Legal versus Illegal Abortions Pro-Life versus Pro-Choice Pro-life supporters: an embryo at any stage of development is a person and aborting a fetus is murder Pro-choice supporters: it is a woman’s choice and the government should not control her body No gender differences in abortion attitudes Historical Perspectives Abortion has been practiced throughout time in many societies Religion has determined attitudes for most of western history In 1965, all U.S. states banned abortion with some exceptions Illegal (back-alley) abortions were often performed in unsanitary conditions and produced many complications, even death Historical Perspectives In 1973, Roe v. Wade protected a woman’s right to have an abortion in the 1st trimester 2nd trimester abortions regulated by states 3rd trimester abortions can be limited or banned by states, unless a woman is at risk In 1992, the Supreme Court gave states the right to restrict abortions through waiting periods, mandatory counseling, parental consent, public funding limitations Historical Perspectives In 1994, Supreme Court barred anti-abortion demonstrators from getting within 36 feet of an abortion clinic Louisiana has the most restrictions New York, California, & Washington state have been most protective of their abortion laws Legal versus Illegal Abortions Since legalization in 1973, deaths from abortion decreased significantly Video: “If these Walls Could Talk” Why Do Women Have Abortions? Baby would interfere with life goals Lack financial resources Poor relationship with the father Don't want others to know they had sex Partner and/or family pressure Fetal deformity or risk to mother’s health Rape 54% of women who had an abortion used contraception when they became pregnant Abortion Procedures One of the most common surgical procedures in the U.S.; most performed in abortion clinics Surgery involves risks Most serious risks are uterine perforation, hemorrhaging, cervical laceration, infection, complications with anesthesia, death Risks increase with the use of general anesthesia and the further along the pregnancy is Abortion Procedures First-trimester Surgical Abortion Second-trimester Surgical Abortion Medical Abortion Mifepristone (RU-486) Methotrexate First-Trimester Surgical Abortion Vacuum aspiration – before 14 weeks gestation Usually an outpatient surgery with local anesthesia 88% of abortions Woman lies on examining table, feet in stirrups Speculum is placed in the vagina, cervix is anesthetized, & dilation rods open the cervix First-Trimester Surgical Abortion A cannula that is attached to a vacuum aspirator is put into the cervix, the content of the uterus is emptied Takes 4-6 minutes, with a few hour stay after After she needs to rest, bleeding and cramping is likely Risks: excessive bleeding, infection, uterine perforation Second-Trimester Surgical Abortion Between 14-21 weeks 11% of abortions Reasons for a late abortion: medical complications, fetal deformity, divorce/marital problems, miscalculation of due date, financial or geographic problems Second-Trimester Surgical Abortion Dilation & evacuation procedure: 13-16 weeks Similar to vacuum aspiration, but in a hospital under general anesthesia 15-30 minute procedure More complicated than 1st trimester, with more pain, blood loss, & cervical trauma Second-Trimester Surgical Abortion Induced labor procedure used in late 2nd trimester Needle inserted into amniotic sac and drains the fluid; the sac is injected with saline or prostaglandin Fetus is delivered 19-22 hours later Can be painful emotionally & physically Risks: nausea, diarrhea, cervical problems, uterine rupture, risk of death Second-Trimester Surgical Abortion Hysterotomy – used in emergency situations Abdomen is opened to remove the fetus Similar to a cesarean section, with a 5-7 day hospital stay Hysterectomy – removal of the fetus and uterus Rarely used Medical Abortion Two drugs: Mifepristone (RU-486) Methotrexate They are used with a prostaglandin to produce contractions and expel the contents 2-3 office visits are required; $350-650 Advantages over surgical abortion: no anesthesia; it seems more like a miscarriage Increased risk of bacterial infection RU-486 An antiprogestin that inhibits progesterone production, breaking down the uterine lining 3 RU-486 pills are taken; 2 days later the prostaglandin is taken, which produces uterine contractions 95-97% effective Can be used up to 9 weeks gestation Mifepristone produces bleeding within 4-5 hours, and it continues for up to 13 days Methotrexate Methotrexate produces bleeding that may last 1 month or more It is injected and ceases the development of the zygote cells The prostaglandin produces contractions and expels the uterine contents Can be used up to 9 weeks gestation Reactions to Abortion Women’s Reactions Physiological Symptoms Psychological Symptoms Men’s Reactions Women’s Reactions Physiological symptoms: Surgeon General’s report found physiological health consequences (infertility, miscarriage, premature birth, low birth weight) no more common in women who have had abortions compared to the general population of women Immediately following the procedure: cramping, heavy bleeding, nausea Women’s Reactions Psychological symptoms: A woman’s feelings are often correlated with her society’s views on abortion There is little known about reactions to medical abortions Many women cycle through feelings of relief, happiness, shame, guilt, fear of disapproval, regret, anxiety, depression, doubt, anger, sense of loss, sadness Women’s Reactions 10% of cases a woman has severe feelings Factors in severe psychological symptoms: Young Lack family or partner support Persuaded to have an abortion or difficult time making the decision Strong religious & moral background Medical or genetic reasons for abortion History of psychiatric problems Men’s Reactions Abortion may cause couples to break up or may increase communication in a relationship and strengthen it Supportive partners are more positive following the procedure Men can feel sadness, a sense of loss, fear for partner’s well being, isolated, angry Men lack counseling services to help them through this time Teens and Abortion Some states require parental notification or consent In lieu of that, they may request a judicial bypass option In states without mandatory parental involvement, 75% of minors involve at least one parent in the process Cross-Cultural Aspects of Abortion About 40% of worldwide pregnancies are unplanned 20% are aborted Lowest abortion rates are in Ireland, Netherlands, Belgium, & Spain Highest abortion rates are in Cuba, Vietnam, Romania, & India 1.3 million abortions each year in the U.S. Cross-Cultural Aspects of Abortion 25% of countries have strong restrictions on abortion 20 million unsafe abortions occur each year by taking drugs, inserting objects into the vagina or flushing it with liquids, or forcefully massaging the abdomen Medical abortion is widely used outside the U.S.