Contraception

Christine R Rainey, Diane Sue Saylor, Margaret P. Battin. Encyclopedia of Sex and Gender. Editor: Fedwa Malti-Douglas. Volume 1. Detroit: Macmillan Reference USA, 2007.

Overview

Contraception is the prevention of conception or impregnation. This is in contrast to birth control, which is control of the number of children born. Conception is the process of becoming pregnant, whereas impregnation is fertilization (the union of two gametes; in the case of humans, a sperm and an egg).

The World Health Organization (WHO) categorizes current contraceptive devices and methods into eight classes:

Hormonal (includes oral, injectable, transdermal, and cervical delivery of contraceptive hormones; also includes emergency contraception [morning-after] pills)
Implants
Intrauterine devices (IUDs, including emergency contraception IUDs)
Barrier methods (includes male and female condoms, methods of spermicide delivery, diaphragms, and cervical caps)
Fertility awareness-based methods (the avoidance of conception/impregnation during fertile periods)
Lactational amenorrhea (lack of fertility caused by the hormonal changes of lactation)
Coitus interruptus (withdrawal of the penis from the vagina before ejaculation)
Surgical sterilization (male and female)

Effectiveness rates vary in the United States, ranging from 99.5 percent for sterilization, to 24 percent for cervical cap use in women who have previously given birth, to 15 percent for random chance alone (World Health Organization 2004, p. 6). The effectiveness of many forms of contraception is also affected by the technique of the person using it; for instance an improperly applied condom or improperly inserted diaphragm will increase the probability of conception.

It is likely that contraception has been practiced since the inception of humanity. First designed by trial and error and imbued with sacred, mystical, and political implications common to the period in which they were practiced, contraceptive methods became increasingly effective as a result of rational design arising from greater understanding of male and female reproductive anatomy in the 1850s.

Although religious and political factors impact the acceptance and utilization of contraception in the early twenty-first century, the medical, social, and political need for rational contraception is generally accepted.

Beliefs and Myths

Myths and beliefs about conception and contraception reflect the beliefs and mores of the culture of the society and the level of knowledge regarding reproductive anatomy. Anatomists and biologist supplanted the early influence of priests, shamans, and seers as reproductive anatomy was better defined.

Most early theories of male and female roles in contraception are linked to the existence and influence of outside entities; for instance one ancient belief held that a woman could become pregnant by bathing in a stream populated with eels. Similarly others believed that a male child entered its mother in the shape of a serpent, while a female child entered as a snail. Others believed that a wandering womb child, in the shape of a small frog, would leave the mother’s body at night in search of food and water. If the woman closed her mouth and the womb child was unable to return, the woman remained childless.

Belief in the spirit world often influenced opinions about conception and contraception. Ancient Nordic texts describe spirit children who resided in bodies of water or trees. A woman who swam or bathed in water or consumed fruit from a tree containing a spirit child would become pregnant.

Similarly other myths regarding conception were centered on then-current understanding of the uterus. Ancient Egyptians considered the uterus an independent animal capable of performing different types of movement within the woman’s body. Greco-Romans, notably Hippocrates, believed that if the uterus were not fed sufficient sperm it became feral within the woman’s body, wreaking havoc on other internal organs and unable to produce children.

Myths and beliefs surrounding contraception in the early twenty-first century, in many instances, continue to demonstrate a misunderstanding or lack of knowledge of the human reproductive system and functions.

Some common untrue myths and exaggerations about contraception include:

Breastfeeding is 100 percent effective for contraception
A woman cannot become pregnant without experiencing an orgasm
A man cannot impregnate a woman if he does not experience an orgasm
A woman cannot become pregnant the first time she has sex with a man
A woman has one fertile day monthly; sex on the other days is safe
Sex standing up, or sex with the woman on top, is effective for contraception
Plastic wrap or balloons are excellent substitutes for male condoms
Pregnancy will not occur if the man ejaculates outside the vagina
Douching after sex prevents pregnancy
A woman who showers, bathes, or urinates immediately after sex will not become pregnant
Oral contraceptives are immediately effective
Oral contraceptives can be used only for a short portion of the woman’s reproductive life
Oral contraceptives always cause weight gain
Oral contraceptives cause high blood pressure
Oral contraceptives cause fibroid tumors in women
Oral contraceptives are a treatment for endometriosis
Oral contraceptives cause acne
Intrauterine devices (IUDs) cause sterility or infertility

Other untrue myths and exaggerations include:

Women cannot become pregnant on a boat
Women cannot become pregnant if they consume large amounts of milk
Ingestion of folic acid increases the chance of becoming pregnant
A male is fertile only when his testicles feel cold to the touch
A male can decrease his sperm count by drinking large amounts of alcohol immediately before sex
Pregnancy occurs only if sex occurs daily
Cola soda douches are effective contraceptives

Methods of Contraception

The modern birth control movement began in 1912 when Margaret Sanger (1883–1966), a public health nurse, became concerned about the adverse health effects of frequent childbirth, miscarriages, and abortion. Challenging laws prohibiting distribution of information about (and access to) contraception, she opened the first family planning clinic in Brooklyn, New York, in 1916. The American Birth Control League, a precursor of the Planned Parenthood Federation, was founded in 1916 with the stated purpose, “To enlighten and educate all sections of the American public in the various aspects of the dangers of uncontrolled procreation and the imperative necessity of a world programme of birth control” (Sanger 2003).

Further legal actions during the 1920s and 1930s made contraceptive information and methods more accessible. In 1942 the American Birth Control League was reorganized and renamed the Planned Parenthood Federation of America. In 1960 the United States Food and Drug Administration (FDA) approved the first oral contraceptive, and the U.S. Supreme Court declared state laws banning contraceptive use by married couples unconstitutional (Griswald v. Connecticut, 381 U.S. 479 [1965]), clearing the way for further legal challenges and creating an environment that encouraged development of new birth control methods.

There are several mechanisms of birth control: hormonal manipulation, hormonal implants, intrauterine devices, emergency modes of preventing pregnancy, barrier methods, fertilization awareness methods, and surgical sterilization.

Hormonal (includes oral, injectable, transdermal, and cervical delivery of contraceptive hormones; also includes emergency contraception [morning-after] pills)

The reproductive cycle and fertility of a woman is under intricate hormonal control and can be manipulated by administration of estrogens, progestins, or a combination of both to modulate menstrual cycles and prevent ovulation. Oral contraceptives (birth control pills) are the most common method of female hormonal contraception. Following animal research in the 1930s and 1940s, a precursor of progesterone (a progestin) was discovered in Mexican yams. This discovery of a readily available, abundant source of progesterone precursor heralded the commercial development of progesterone tablets, which were initially approved by the FDA in 1957 for the treatment of gynecologic disorders. In 1960 the FDA approved the first preparations for contraceptive use.

Commercial development of a multitude of combination progestin/estrogen, progestin-only, and estrogen-only tablets, with varying formulas, strength combinations, and packaging, soon followed. All had in common two aspects: a cycle of twenty-one days of active hormonal ingredient(s), and the need for daily oral administration. Other regimens, including eighty-four days or twenty-four days of active hormone ingredient(s), have become available since 2000.

Contraceptive hormones can also be administered by long acting (depot) injection administered every three months, transdermally by use of a patch applied to the skin (typically weekly), or by the use of a hormone-infused flexible ring inserted around the edges of the cervix and left in place for one month.

Implants

Contraceptive implants were approved by the FDA for human use in 1990. Flexible, closed plastic capsules containing active hormones, they are inserted under the skin, eliminating the need for daily oral dosing. The composition and total number of capsules inserted vary by product; most capsules are between thirty and forty four millimeters long and are designed to provide contraception for a maximum of five years. Other capsules designed to provide up to three years of contraception are in development. All implants require insertion and removal by a healthcare provider in a minor surgical procedure. Biodegradable implants that will not require surgical removal also are in development.

Intrauterine Devices (IUDs, including emergency contraception IUDs)

IUDs are small objects inserted into the uterus. Although the exact mechanism for their effectiveness is not well understood, it is hypothesized that the IUD creates an inflammatory foreign body reaction in the uterus, creating a hostile environment for implantation of a fertilized ovum.

Development of modern IUDs began in the early 1900s but faltered due to political and social pressures. The German physician Ernst Gräfenberg reported the clinical performance of an IUD in 1929; however reports of pelvic inflammatory disease (PID), combined with political pressures exerted by the Nazi party, stifled further research. Development continued until the 1950s, with researchers utilizing a variety of materials and conformations. In 1958 Lazar Margulies developed a plastic coil IUD, the Margulies coil, but this device was soon supplanted by the Lippes Loop, created by another American physician, Jack Lippes. The Lippes Loop became the most widely prescribed IUD in the United States during the 1970s.

Further refinements have since included design of the T-shape IUD and the addition of copper or progesterone to the device itself. The copper IUD is T-shaped, wound with fine copper wire, and can remain in place for ten years. The progesterone IUD is also T-shaped and contains a reservoir of progesterone for delayed release; it may be left in place for one year. The most common side effects include cramping, bleeding, and accidental expulsion of the IUD.

Emergency Contraception

Emergency contraception (EC) can be accomplished via the administration of EC pills (ECPs or morning after pills) or the insertion of a copper IUD. The term morning after pill is a misnomer. ECPs may be administered immediately after unprotected intercourse, or up to 120 hours after. Effectiveness is highest when taken as soon as possible. Two types of ECPs are available—progestin-only and a progestin-estrogen combination (oral contraceptives). The high-dose progestin-only pill has largely replaced the progestin-estrogen combination pills; it works by preventing the release of an ovum from the ovary and may prevent the fertilization of an ovum or attachment of the fertilized ovum to the uterus wall. The progestin-only pill will not affect a fertilized egg already attached to the uterus.

Copper-bearing IUDs may be inserted up to five to seven days after ovulation to prevent implantation of the fertilized ovum in the uterine wall. However difficulties in determining the exact time of ovulation make this method less dependable.

Barrier Methods

Barrier methods are those that physically prevent the union of egg and sperm. Methods include male and female condoms, spermicide (which also kills sperm), diaphragms, and cervical caps.

Male condoms are tubular sheaths applied over the penis to capture and store sperm during intercourse. They must be removed from the vagina intact and cannot be reused. Although condoms made of thin animal intestine were popular before the early 1980s, the possibility of AIDS transmission greatly diminished popularity. Latex has since become the most popular material for condoms. Men and women should use only water-based lubricants if necessary; oil-based lubricants degrade the integrity of the condom. Female condoms, much less common than male condoms, form a tubular corridor between the opening of the vagina and the cervical cap to prevent penetration of sperm into the cervix.

Spermicides are available as jellies, creams, ointments, and foams. In addition to presenting a physical barrier to the passage of sperm into the cervix, they contain chemicals designed to kill sperm.

Diaphragms are shallow latex domes or cups designed to fit snugly over the entire tip of the cervix. The outer ring is flexible to facilitate insertion through the vagina. Women should use diaphragms with spermicides to enhance effectiveness. They can be inserted up to two hours before sexual intercourse, and remain in place for at least six hours after.

Cervical caps resemble diaphragms but are smaller and designed to fit over the cervical opening (os) itself. The cap is filled approximately one-third full with spermicide before insertion through the vagina. The cap is inserted immediately before intercourse and must be left in place for at least eight hours.

Fertility Awareness-based Methods

Fertility awareness-based methods (the avoidance of conception/impregnation during fertile periods) are also known as rhythm methods. Fertile periods can be gauged by tracking menstrual cycles on a calendar; measurement of the woman’s basal body temperature; changes in viscosity of cervical mucus; or ovulation prediction kits.

In a woman with a regular twenty-eight-day menstrual cycle, ovulation occurs fourteen days prior to menstruation. By tracking menstrual cycles on a calendar couples can determine a woman’s fertile periods and avoid unprotected intercourse during that time.

A woman’s body temperature rises slightly (between 0.4 and 0.8 degrees Fahrenheit) immediately before, during, and after ovulation. Similarly the quantity of vaginal mucus increases and viscosity thins before ovulation. Ovulation prediction kits measure the quantity of leutenizing hormone (LH) in the woman’s urine. LH levels surge twelve to twenty-four hours before ovulation. Thus the couple is able to monitor the period during which fertilization is most likely.

Lactational amenorrhea (lack of fertility caused by the hormonal changes of lactation) is a contraceptive method based on the infertility of a woman who is fully breastfeeding. Prolactin released during suckling of the infant suppresses ovulation, thus preventing pregnancy.

Coitus interruptus is withdrawal of the penis from the vagina before ejaculation, preventing the deposition of semen in the vagina.

Surgical Sterilization (male and female)

Vasectomy is the most common method of male surgical sterilization. In a minor surgical procedure, the vas deferens is cut, a small section is removed, and the ends are tied off or cauterized. Sperm do not reach the urethra and are resorbed by the body. Vasectomy does not affect the male sex drive or sexual performance.

Tubal sterilization (tubal ligation or having one’s tubes tied) is the most common form of female sterilization. The fallopian tubes are tied off or clamped to prevent the union of sperm and ova. This is accomplished through a small incision in the abdomen in which the surgeon secures the fallopian tubes by hand or by use of a laparoscope. Tubal ligation does not affect sex drive or performance. Alternatively hysterectomy (a major surgical procedure in which the uterus is removed) renders a woman sterile. However, due to removal of the hormones manufactured by the uterus, hysterectomy can affect female sexual response and arousal.

Relation of Sexual Practices and Gender Roles

While the primary use for contraception is to prevent pregnancy, it also has many other applications. In particular, both condoms and birth control pills have non-contraceptive therapeutic uses.

Condoms

Though the surest way to avoid contracting or spreading sexually transmitted diseases (STDs) is to practice abstinence or limit sex to a monogamous, long-term relationship; when that is not practical, condoms provide an important form of defense. Consistent and proper use of latex condoms helps prevent the spread of diseases such as chlamydia, gonorrhea, trichomoniasis, and human immunodeficiency virus (HIV) but provide only limited protection against other diseases such as human papillomarvirus (HPV or genital warts), syphilis, and genital herpes because infective tissue or lesions may occur outside the area normally covered by a condom. Condoms should be used with water-based lubricant since oil or petroleum-based products can cause the latex to break down. Condoms with nonoxynol-9 (a spermicide) should be avoided since they may actually increase the chance of transmitting HIV between partners. In non-monogamous relationships, condom usage is advised even with sexual practices unlikely to result in pregnancy, including oral sex (fellatio, cunnilingus, or anilingus). To avoid spreading disease during oral sex, it is important to keep both semen and vaginal fluids out of the mouth. The use of an unlubricated, non-spermicidal condom will help prevent the transmission of disease in men. Flavored condoms, which help dispel the latex taste, are available. A dental dam (a square of latex or silicone) or a condom that has been cut into a square serves as a barrier between the mouth and the vagina or anus. Pre-made dental dams have the advantage of being larger and thus covering more surface area. Female condoms (a latex tube fitted with two rings at each end, which is inserted into the vagina—one ring fitting snuggly against the cervix and the other remaining outside and covering the vulva) are also helpful in preventing disease. The use of condoms in anal sex helps prevent urethritis (an infection of the urethra) by shielding the penis from exposure to residual fecal matter in the rectum. Condoms are the only form of contraception that offers protection against the spread of infection.

In addition, condom use is sometimes prescribed to treat cervical mucous incompatibility with the sperm, a condition where the woman manufactures antibodies to her partner’s sperm resulting in unwanted infertility in couples trying to conceive. In this case, condoms are not used to prevent conception but rather to facilitate it. After three to six months of condom usage during intercourse, the woman creates fewer antibodies thus allowing the sperm to pass through the cervix where it can then fertilize the egg.

Oral Contraceptives

Birth control pills have other therapeutic applications beyond pregnancy prevention. Oral contraceptives are frequently prescribed for medical conditions, especially those dealing with menstruation. They are helpful in the treatment of irregular menstrual cycles (oligo-ovulation), dysmenorrhea (lower abdominal pain and cramping associated with menstrual periods), and dysfunctional uterine bleeding (such as spotting between periods) by controlling the hormonal balance. Birth control pills also provide hormonal therapy for patients with endometriosis, a common and painful condition where endometrial cells from the inner lining of the uterus are regurgitated through the fallopian tubes during menstruation and implant in the abdominal or pelvic cavity. The main treatment is hormonal suppression with or without surgical excision of the ectopic (outside of the uterus) tissue. Because of the increased rate of cancer of endometrial tissue in women suffering from this condition, hormonal therapy with birth control pills (with both progesterone and estrogen) is often prescribed.

Certain cases of hirsutism (a condition noted by excessive facial and body hair caused by the over-production of male hormones or androgens) may benefit from the administration of oral contraceptives. The condition is often associated with anovulatory ovaries and the cessation of menstrual cycles. In severe cases, the clitoris enlarges, the voice deepens, and balding can occur. Because most cases involve excess androgen production, treatment is directed toward interfering with the hormonal imbalance. Oral contraceptives may work by inhibiting the hormones that stimulate the secretion of the androgens. In addition, birth control pills are useful in treating acne associated with hirsutism (as well as non-androgen related outbreaks).

Relation of Contraception to Gender Roles

As soon as people made the connection between sexual intercourse and pregnancy, undoubtedly, the search began for the safest and most reliable way to prevent it. Early methods of birth control were behavioral, such as abstinence, which needed to be practiced equally between male and female partners. The Bible mentions the sin of Onan or spilling the seed, which includes the withdrawal method of birth control (coitus interruptus) in which the man avoids ejaculation until after he withdraws his penis from the vagina.

Old folk remedies generally centered on the woman’s role in contraception. It is not surprising that women, who bore the risks of pregnancy and the subsequent care of the children, were eager to experiment through trial and error to find a way of controlling conception. Early Egyptian women douched with a wine and garlic mixture or inserted a plug of crocodile dung and sour milk into the vagina as an early barrier or spermicide (or merely to discourage sex through the presence of the concoction itself). Early Greeks and Romans placed absorbent material in the vagina to soak up the semen. Though penis sheaths were documented back to ancient Egypt, they were mainly decorative. Later linen versions were used (very often unsuccessfully) to prevent conception, an attempt at shared responsibility for pregnancy prevention between the sexes.

By the 1900s, contraceptive methods included vaginal sponges, douching, withdrawal, abstinence, and notably (owing to the invention of vulcanized rubber in 1842) the rubber condom. However these options became increasingly inaccessible to women as attitudes about contraception changed. Abortions were banned, owing in part to the danger they posed to women in pre-antibiotic days, but the subsequent prohibition on birth control or information about contraceptive methods (even for married women) was due to a certain degree of sexual politics since women had no say in legislation. Women’s access to birth control was severely limited in the United States in the late 1800s by the Comstock Act (1873), which made it illegal to distribute birth control information through the mail on the grounds that it was obscene. States passed other laws making it illegal for individuals to give information to each other, including physicians to their patients.

During this time, doctors (predominantly male) began to replace midwives in the management of pregnancy and birth, removing yet another possible avenue through which women could receive birth control specifics. A married woman (for it was illegal to dispense contraception to unmarried women) needed documented proof that pregnancy would endanger her life to acquire legal and medical permission for access to contraceptive advice or materials. Activists like Margaret Sanger (1883–1966) in the early twentieth century challenged the contraception laws, but it was not until 1965 that birth control was finally legally accessible to all adults.

In 1960 the first oral contraceptive for women was marketed, and the U.S. Supreme Court decision in Roe v. Wade (1973) made abortion legal during the first trimester of pregnancy. For the first time women had the means and the power to control their own fertility without relying on the compliance of their male partners. Nevertheless patriarchal institutions, such as the Catholic Church, continued to oppose the use of artificial contraception.

Contemporary Views on Contraception

In the early twenty-first century, the responsibility for birth control still lies predominately with women. Types of contraception for women far outnumber those for men. Except for the addition of vasectomy, the methods available to men have remained largely unchanged since the nineteenth century. Women’s options though have greatly improved in efficacy and convenience: IUDs, diaphragms, sponges, female condoms, vaginal spermicides, and, significantly, birth control pills. The introduction of birth control pills ushered in a revolution that included sexual freedom for women, though with a cost: Female methods of birth control come with a higher risk for potential health issues for the woman. Though researchers have worked on developing a male oral contraceptive, none exists, due in part to potential side-effects (including dizziness, drowsiness, constipation, impotence, and permanent infertility) and the reluctance of women to accept a form of birth control that relies exclusively on male compliance.

Worldwide, women assume a disproportionate share of the responsibility for the prevention of pregnancy compared to men. According to a 1998 United Nations study, 40 percent of couples rely on female-based contraceptive methods and only 8 percent on male-based methods (United Nations 1998, p. 175). Figures for elective sterilization follow a similar pattern. Though vasectomy is a quick, simple surgery that may be performed in a doctor’s office, more women undergo tubal ligation, which is more complicated and costly. Many insurance companies will pay for a woman’s elective sterilization but not for a man’s. Researchers suggest a variety of reasons for the imbalance between the genders in responsibility for birth control. One is the attitude that a women’s position is partially defined by her role as child bearer, and as such she must control her fertility. Also many women prefer a form of contraception that puts them in control. Ultimately the most convenient, reliable, nonsurgical methods of birth control are those used by women.

Policies and Effects

Contraception serves to control the reproductive outcome of sexual intercourse between a fertile male and a fertile female. As modern methods of contraception were being developed in the mid-twentieth century, many institutions began to formulate policies attempting to govern the use of “artificial” contraception, often linked with policies about abortion. These institutions included governments and government agencies, religious groups, and medical and professional organizations.

Governmental Policies

Governmental policies typically view contraception in the context of population increase or decrease, variously prohibiting, encouraging, or requiring the use of contraception to serve differing demographic, economic, political, and social agendas. Governments employ a variety of methods, including moral propaganda, economic incentives and disincentives, legal and administrative policies, and public-service advertising. Several examples from the late twentieth and early twenty-first centuries illustrate the variety of governmental policies, both in intended impact on fertility and in whether they were directed primarily at women or men.

India

In the mid-twentieth century population growth rates, especially in Asia, were perceived as skyrocketing in this region, contraceptive policy has been directed at curbing population growth. India’s initial population-control effort of 1964–1965 provides an example of a governmental contraception policy intended to decrease population growth rates by employing methods directed primarily at men. This program focused on vasectomy, using incentives for “adopters” (the notorious transistor radio for men who would submit to a vasectomy on the spot); “canvassers,” or recruiters paid to deliver vasectomy prospects to clinics (Repetto 1968); and penalties for men with more than a specified number of children. In some areas, vasectomy was forcibly imposed. This wildly unpopular program lasted only slightly over a year and contributed to the downfall of Indira Gandhi’s government. It is believed to have had little direct impact on population growth rates in India. A later statement of Indian government policy—promulgated April 16, 1976, and intended (as the statement put it) to secure the future of the nation, remove poverty, and counter a “population explosion of crisis dimensions” (Singh 1976, p. 309) that would dilute the country’s economic progress and continued to offer monetary compensation for sterilization (of both males and females) but also proposed other methods of promoting family planning.

China

A governmental policy intended to limit population growth by employing contraceptive methods focused primarily on women is to be found in China’s one-child policy, introduced in 1979 and, although eroding, is still officially in force. Aware that it had a quarter of the world’s population but only 7 percent of its arable land, China limited urban dwellers to only one child; rural residents in some areas were permitted a second child if the first has a disability or is a girl. China’s population-containment policy has made use of circumstantial controls as well as virtually universal access to modern contraception and abortion to limit fertility: The age of marriage was increased, spouses were sometimes assigned to work in different cities, women’s menstrual cycles were publicly monitored, and the use of contraception was encouraged or mandated. Penalties, including fines, loss of employment, and loss of housing and benefits, were imposed for excess births. The use of an intrauterine device (IUD) after the birth of a first child was required, and sterilization was required after a second; these two long-term methods have accounted for 90 percent of contraceptive methods used since the 1980s and have kept abortion rates to almost half that in the United States (Hesketh, Li, and Zhu 2005), although some choice in types of contraceptives is now permitted.

The one-child policy, maintained for more than two decades—the approximate duration of a generation—has had a dramatic impact on China’s growth rate. Growth rates had begun to decline before the one-child policy was put in place, but with its sustained imposition, growth rates dropped from a 1969 high of almost 6 children per woman to 1.7, below replacement rate, in 2004. The social impact of this policy is referred to as the “4:2:1′ phenomenon (Hesketh, Li, and Zhu 2005), describing the obligations of responsibility given the proportion of grandparents and parents for each child.

Romania

In the wake of World War II, population growth rates in Eastern Europe dropped to the lowest in the world, and many Eastern European governments developed pronatalist policies governing contraception and abortion. Nicolae Ceausescu’s Romania, which in 1966 strictly limited abortion, provides an example of a governmental policy intended to increase a state’s population (and hence its workforce). Women were expected, indeed required, to have at least four children: This was “every healthy Romanian woman’s patriotic duty” (Legge and Alford 1986, p. 725). As in many other Eastern European countries (for example, Russia, Poland, and Yugoslavia, and to a lesser extent the German Democratic Republic, Hungary, and Czechoslovakia), artificial birth control and modern forms of contraception were not readily available or of very low quality. The impact of Romania’s 1966 abortion prohibition is well documented: The birthrate peaked sharply within a year, but the principal long-term effect was a dramatic rise in illegal abortion and maternal mortality. As in much of Eastern Europe, reliance on withdrawal and abortion has remained the primary means of fertility control.

Global Family Planning

Family planning programs have been instituted in the majority of the world’s nations. Although the early programs strongly emphasized contraception and population control, since the 4th International Conference on Population and Development in Cairo in 1994, greater emphasis has been placed on economic development, women’s education, employment for women, women’s access to health care, reduced infant and child mortality, and other noncoercive means of social change associated with reducing population growth rates. Modern contraception has been made widely available in many areas of the developing world, largely financed by foreign-aid programs, and enhanced methods of promoting knowledge, access, and practice are in place. The term birth control has been largely replaced by family planning. In the 1960s fewer than 10 percent of married women were using contraception; by 2003 the proportion was 60 percent (Cleland et al. 2006).

Despite these trends, population reduction programs in some nations, particularly China and India, have been sharply criticized where pressures to decrease family size combined with a strong preference for sons, result in “missing girls”—a sharp imbalance in gender ratios at birth. More focused contraception programs are sometimes also criticized for bias. For example, governmental programs that provide special access to contraception for specific population subgroups—inner-city adolescent girls, for example—are sometimes said to be racially biased. Some attack the use of contraceptive technology, such as that used in family-planning programs, as “a destructive and even deadly weapon in the war on population” (Hartmann 1995, pp. 173-174). In addition, government programs and even the open-market availability of contraception have also faced criticism: A Christian pregnancy-counseling organization, A Woman’s Concern, labels the distribution of contraceptives as “demeaning to women.”

Population Decline and Fertility Encouragement

Population decline, or perceived decline, is also of concern in many European and Asian countries, to some degree offsetting the attention paid to contraception. Governmental programs in some countries where fertility rates have been falling, such as Germany, provide special benefits for childbearing, including financial payments, maternity/paternity leave, home loans, and child care, although these countries continue to provide access to modern methods of contraception. Concern with high AIDS mortality rates in sub-Saharan Africa has deflected attention from family planning, and although condoms used for disease prevention also have a contraceptive effect, birthrates remain high: 5.9 children per woman in west Africa, 5.7 in east Africa, and 6.3 in middle Africa (Glasier et al. 2006), although these high birthrates may be accompanied by high death rates and particularly high rates of infant mortality. In some countries, high birthrates are encouraged by dissident or subordinate population subgroups, which are led to mistrust or reject contraception, or by groups that have been subject to population-reducing disasters such as ethnic massacres, wars and civil wars, refugee dislocations, epidemics of infectious disease, and natural disasters, including earthquakes and tsunamis.

Nevertheless, there remains a substantial “unmet need” for contraception, encompassing an estimated 120,000 couples in 2006, most but not all in developing countries. The fecund married women in these couples wish to avoid further childrearing or to postpone their next child for at least two years but are faced with an absence of contraception. Even in the developed world, including countries such as the United Kingdom where contraception is available free of charge, most pregnancies that end in abortion are conceived either without any contraception, with incorrect or inconsistent use, or with the use of less-effective methods (Glasier et al. 2006).

Religious Groups

The policies of religious groups concerning contraception range from condemnation to celebration. Among Protestant groups, the Episcopal Church, the Presbyterian Church (U.S.A.), the United Methodist Church, and the Unitarian Universalist Church support the use of contraception as a component of responsible family planning, variously emphasizing the importance of strong and stable families, healthy and wanted children, and the sexual expression of love between married couples. Some also accept the use of contraception in relationships outside marriage. Southern Baptists and Evangelical Lutherans accept the use of contraception by married couples. Many other Protestant groups encourage individual decision-making about contraception.

Judaism’s three principal branches differ in attitudes about contraception. Orthodox Judaism discourages contraception, permitting abstinence only, except for health reasons, and indeed the Orthodox practice of restraint from intercourse for a specified number of days after the menses serves to encourage intercourse at the time of ovulation, ensuring maximum fertility. Reform Judaism’s view is much like that of the liberal Protestant groups, supporting contraception for responsible family planning and other reasons. Islam also exhibits a wide variety of views: Some traditions insist that all family planning methods are prohibited; others point out that male withdrawal is clearly permitted in the Koran; and others accept contraception in general, especially to protect the health of the woman or the well-being of the family. Islam encourages procreation; so do Hinduism, Catholicism, evangelical Christianity, and Mormonism.

The Roman Catholic Church holds one of the most strongly prohibitive teachings concerning contraception. As articulated in Pope Paul VI’s 1968 encyclical letter, Humanae Vitae, Catholicism condemns the use of all forms of artificial contraception and all sterilization “permanent or temporary,” or “any act specifically intended to prevent procreation,” insisting that the sexual act of a married couple must be capable of being both “unitive” and “procreative.” Catholicism does accept the use of “natural” family planning based on rhythm methods. Adherence to the teaching varies. In the United States, Catholic women (of non-Hispanic ethnicity) use artificial contraception at the same rate as do Protestants and Jews.

While religious teaching concerning contraception is usually presented as a matter of individual spiritual commitment, some critics insist that the rejection of contraception by specific religious groups (such as Catholicism and Islam) is a pronatalist policy in disguise—a matter of sectarian arithmetic intended to increase the number of that group’s adherents.

Medical and Social Policies

Medical and social policies have often focused on the role of contraception in promoting individual and community health. Traditional medical policy in the United States was highly paternalistic, holding that a woman’s request for fertility control by means of sterilization could be honored only if her age, multiplied by the number of living children she already had, reached an adequate figure. This rule is no longer invoked, but physicians remain reluctant to use irreversible sterilization procedures for young adults without children. Contemporary medical policy has focused on the importance of effective contraception in preventing unwanted pregnancy, on making a wide range of types of contraception available to women, and on encouraging informed, reliable use. Noting that in the developing world, unsafe sex is the second most important risk factor for disability and death and the ninth most important in the developing world (Glasier et al. 2006), calls have been issued for universal, reliable access to modern methods to prevent both unintended pregnancy and sexually transmitted diseases.

Political friction has surrounded several forms of contraception. Controversial events have included the manufacturer’s concealment in the early 1970s of the safety risks of the Dalkon Shield IUD (Hartmann 1995), friction over suggestions for nonvoluntary implantation of Norplant in women receiving welfare (Moskowitz and Jennings 1996), disputes over abstinence-only programs as politically motivated in both domestic and international contexts (Fathalla et al. 2006), disagreement over whether health insurance policies should be required to cover contraception for women, and disputes over the refusal of some pharmacists to dispense the so-called morning-after pill and/or contraception in general. Data bearing on some disputes has been assembled: For example, in the United States 77 percent of the drop in pregnancy rates among younger teens, ages fifteen to seventeen, is due to improved contraceptive use and 23 percent to abstinence; in eighteen- and nineteen-year-olds, better contraceptive use is responsible for 100 percent of the decline (Santelli et al. 2007). In general, medical and global-health organizations stress the importance of the revitalization of political commitment to improving sexual and reproductive health for all, including access to safe and reliable contraception.

The Future

Governmental policies, religious teachings, and medical and institutional policies variously cover female and male natural family planning, withdrawal, condom use, male and female sterilization, and “artificial” or technologically advanced female contraception. But few governmental, religious, or medical entities have developed policies concerning new technologies for long-term male contraception. It remains to be seen whether such technologies will be successfully developed and if so, whether governmental, religious, and medical and policies will generally track policies concerning “artificial” female contraception.