Birth control

Birth control

Birth control is an umbrella term for several techniques and methods used to prevent fertilization or to interrupt pregnancy at various stages. Birth control techniques and methods include contraception (the prevention of fertilization), contragestion (preventing the implantation of the blastocyst) and abortion (the removal or expulsion of a fetus or embryo from the uterus). Contraception includes barrier methods, such as condoms or diaphragm, hormonal contraception, also known as oral contraception, and injectable contraceptives.[1] Contragestives, also known as post-coital birth control, include intrauterine devices and what is known as the morning after pill.[2]


Mechanisms of action and terminology

The function of birth control can be classified by the stage of reproduction during which it is active. A form of birth control which prevents the sperm from fertilizing the egg is a contraceptive agent.[3][4] A form of birth control which acts after fertilization to prevent or interrupt the implantation of the embryo into the uterine lining is a contragestive agent.[5] After implantation has occurred, an agent which ends gestation by terminating the pregnancy is an abortifacient.[6][7]

The term contraception is a contraction of contra, which means against, and the word conception, meaning fertilization.[8] The word contragestion is likewise a combination of contra and gestation. French scientist Étienne-Émile Baulieu coined the word in 1985 because he felt that there was a need for a technical term to describe the prevention of implantation, which did not fit the traditional definitions of either contraception or abortion.[9] Since 18 U.S. states define pregnancy as beginning at conception,[10] describing methods of birth control in terms of their potential means of action allows one to be technically accurate while using language that is neutral with regard to the abortifacient versus contraceptive controversy.

These mechanisms of action are not always mutually exclusive. One substance or device can have more than one potential effect depending upon when it is used. For example, while mifepristone is best known as an abortifacient, it can also function as a contragestive agent.[11] Likewise, the IUD can be used as a contraceptive or a contragestive depending upon when it is inserted.[12]


A diaphragm (a type of physical barrier method) in its case, with a 0.25 U.S. dollar coin added for scale.
Condom (rolled-up).
Ortho Tri-cyclen, a U.S. brand of oral contraceptive, in a dial dispenser.

Contraception include barrier methods, such as condoms or diaphragm, injectable contraceptives,[1] and hormonal contraception, also known as oral contraception. The most common methods of hormonal contraception include the combined oral contraceptive pill and the minipill.[13] Hormonal emergency contraception can be both contraceptive and contragestive.


Contragestives include intrauterine devices placed inside the uterus and some forms of hormonal "emergency contraception".[14]

An intrauterine device.


Surgical sterilization is available in the form of tubal ligation for women and vasectomy for men. Although sterilization is considered a permanent procedure due to the uncertainty of reversal possibility, it is possible to attempt a tubal reversal to reconnect the Fallopian tubes in females or a vasectomy reversal to reconnect the vasa deferentia in males. The rate of success depends on the type of sterilization that was originally performed and damage done to the tubes as well as the patient's age.[15]

Behavioral methods

Behavioral methods involve regulating the timing or methods of intercourse to prevent the introduction of sperm into the female reproductive tract, either altogether or when an egg may be present.


From ancient times women tried to extend breastfeeding in order to avoid a new pregnancy. The lactational amenorrhea method, or LAM, gives guidelines for determining the length of a woman's period of breastfeeding infertility.

Fertility awareness

Symptoms-based methods of fertility awareness involve a woman's observation and charting of her body's fertility signs, to determine the fertile and infertile phases of her cycle. Charting may be done by hand or with the assistance of fertility monitors. Most methods track one or more of the three primary fertility signs:[16] changes in basal body temperature, in cervical mucus, and in cervical position. If a woman tracks both basal body temperature and another primary sign, the method is referred to as symptothermal. Other bodily cues such as mittelschmerz are considered secondary indicators.

Calendar-based methods such as the rhythm method and Standard Days Method estimate the likelihood of fertility based on the length of past menstrual cycles. To avoid pregnancy with fertility awareness, unprotected sex is restricted to the least fertile period. During the most fertile period, barrier methods may be availed, or she may abstain from intercourse.

The term natural family planning (NFP) is sometimes used to refer to any use of fertility awareness methods. However, this term specifically refers to the practices that are permitted by the Roman Catholic Churchbreastfeeding infertility for example. FA methods may be used by NFP users to identify these fertile times.

Coitus interruptus

Coitus interruptus (literally "interrupted sexual intercourse"), also known as the withdrawal or pull-out method, is the practice of ending sexual intercourse ("pulling out") before ejaculation. The main risk of coitus interruptus is that the man may not perform the maneuver correctly, or may not perform the maneuver in a timely manner. Although concern has been raised about the risk of pregnancy from sperm in pre-ejaculate, several small studies[17][18] have failed to find any viable sperm in the fluid.

Avoiding semen near vagina

Non-penetrative sex is used to avoid pregnancy, but pregnancy can still occur with Intercrural sex and other forms of penis-near-vagina sex (genital rubbing, and the penis exiting from anal intercourse) where semen can be deposited near the entrance to the vagina and can itself travel along the vagina's lubricating fluids.

Sexual abstinence

Though some groups advocate total sexual abstinence, by which they mean the avoidance of all sexual activity, in the context of birth control the term usually means abstinence from vaginally penetrative sexual activity.[19] [20][21]

Abstinence is 100% effective in preventing pregnancy; however, not everyone who intends to be abstinent refrains from all sexual activity,[22] and in many populations there is a significant risk of pregnancy from nonconsensual sex.[23] As a public health measure, it is estimated that the protection provided by abstinence may be similar to that of condoms.[24] Some authorities recommend that those using abstinence as a primary method have backup method(s) available (such as condoms or emergency contraceptive pills).[25]


Surgical abortion methods include suction-aspiration abortion (used in the first trimester) or dilation and evacuation (used in the second trimester). Medical abortion methods involve the use of medication that is swallowed or inserted vaginally to induce abortion. Medical abortion can be used if the length of gestation has not exceeded 8 weeks.[citation needed] Some herbs are considered abortifacient.[26][27]

Methods in development

For females

  • Praneem is a polyherbal vaginal tablet being studied in India as a spermicide, and a microbicide active against HIV.[28]
  • BufferGel is a spermicidal gel being studied as a microbicide active against HIV.[29]
  • Duet is a disposable diaphragm in development that will be pre-filled with BufferGel.[30] It is designed to deliver microbicide to both the cervix and vagina. Unlike currently available diaphragms, the Duet will be manufactured in only one size and will not require a prescription, fitting, or a visit to a doctor.[29]
  • The SILCS diaphragm is a silicone barrier that is still in clinical testing. It has a finger cup molded on one end for easy removal. Unlike currently available diaphragms, the SILCS diaphragm will be available in only one size.
  • A longer acting vaginal ring is being developed that releases both estrogen and progesterone, and is effective for over 12 months.[31]
  • Two types of progestogen-only vaginal rings are being developed. Progestogen-only products may be particularly useful for women who are breastfeeding.[31] The rings may be used for four months at a time.[32]
  • A progesterone-only contraceptive is being developed that would be sprayed onto the skin once a day.[33]
  • Quinacrine sterilization (non-surgical) and the Adiana procedure (similar to Essure) are two permanent methods of birth control being developed.[34]

For males

Other than condoms and withdrawal, there is currently only one common method of birth control available. This option is undergoing a vasectomy, a minor surgical procedure wherein the vasa deferentia of a man are severed, and then tied/sealed in a manner which prevents sperm from entering the seminal stream (ejaculate). Several methods are in research and development:


See also the table at: Comparison of birth control methods

The effectiveness of a birth control method is generally expressed by how many women become pregnant using the method in the first year of use. Thus, if 100 women use a method that has a 0 percent first-year failure rate, then 0 of the women should become pregnant during the first year of use. This equals 0 pregnancies per 100 woman-years, an alternative unit. Sometimes the effectiveness is expressed in lifetime failure rate, more commonly among methods with high effectiveness, such as vasectomy after the appropriate negative semen analysis.[36]

The most effective methods in typical use are those that do not depend upon regular user action. Surgical sterilization, Depo-Provera, implants, and intrauterine devices (IUDs) all have first-year failure rates of less than one percent for perfect use. In reality, however, perfect use may not be the case, but still, sterilization, implants, and IUDs also have typical failure rates under one percent. The typical failure rate of Depo-Provera is disagreed upon, with figures ranging from less than one percent up to three percent.[37][38]

Other methods may be highly effective if used consistently and correctly, but can have typical use first-year failure rates that are considerably higher due to incorrect or ineffective usage by the user. Hormonal contraceptive pills, patches or rings, fertility awareness methods, and the lactational amenorrhea method (LAM), if used strictly, have first-year (or for LAM, first-6-month) failure rates of less than 1%.[39][40][41][42] In one survey, typical use first-year failure rates of hormonal contraceptive pills (and by extrapolation, patches or rings) were as high as five percent per year. Fertility awareness methods as a whole have typical use first-year failure rates as high as 25 percent per year; however, as stated above, perfect use of these methods reduces the first-year failure rate to less than 1%.[37]

Intrauterine devices (IUDs) were once associated with health risks, but most recent models of the IUD, including the ParaGard and Mirena, are both extremely safe and effective, and require very little maintenance.[43]

Condoms and cervical barriers such as the diaphragm have similar typical use first-year failure rates (14 and 20 percent, respectively), but perfect usage of the condom is more effective (three percent first-year failure vs six percent) and condoms have the additional feature of helping to prevent the spread of sexually transmitted diseases such as the HIV virus. The withdrawal method, if used consistently and correctly, has a first-year failure rate of four percent. Due to the difficulty of consistently using withdrawal correctly, it has a typical use first-year failure rate of 19 percent,[37] and is not recommended by some medical professionals.[44]

Combining two birth control methods, can increase their effectiveness to 95% or more for less effective methods.[45] Using condoms with another birth control method is also one of the recommended methods of reducing risk of getting sexually transmitted infections, including HIV. This approach is one of the dual protection strategies.[46]


Early history

Ancient Mesopotamia, Egypt and Rome

Birth control and infanticide are well documented in Mesopotamia and Ancient Egypt. One of the earliest documents explicitly referring to birth control methods is the Kahun Gynecological Papyrus from about 1850 BC. It describes various contraceptive pessaries, including acacia gum, which recent research has confirmed to have spermatocidal qualities and is still used in contraceptive jellies. Other birth control methods mentioned in the papyrus include the application of gummy substances to cover the "mouth of the womb", a mixture of honey and sodium carbonate applied to the inside of the vagina, and a pessary made from crocodile dung. Lactation of up to three years was also used for birth control purposes in ancient Egypt.[47]

Ancient silver coin from Cyrene depicting a stalk of Silphium.

Plants with contraceptive properties were used in Ancient Greece from the seventh century BC onwards and documented by numerous ancient writers on gynaecology, such as Hippocrates. The botanist Theophrastus documented the use of Silphium, a plant well known for its contraceptive and abortifacient properties. The plant only grew on a small strip of land near the coastal city of Cyrene (located in modern day Libya), with attempts to cultivate it elsewhere failing. Its price increased due to high demand, leading to it being worth "more than its weight in silver" by the first century BC. The high demand eventually led to the extinction of Silphium during the third or second century BC. Asafoetida, a close relative of siliphion, was also used for its contraceptive properties. Other plants commonly used for birth control in ancient Greece include Queen Anne's lace (Daucus carota), willow, date palm, pomegranate, pennyroyal, artemisia, myrrh, and rue. Some of these plants are toxic and ancient Greek documents specify safe dosages. Recent studies have confirmed the birth control properties of many of these plants, confirming for example that Queen Anne's lace has post coital anti-fertility properties. Queen Anne's lace is still used today for birth control in India. Like their neighboring ancient Greeks, Ancient Romans practiced contraception and abortion.[48]

Religious texts

The Book of Genesis references withdrawal, or coitus interruptus, as a method of contraception when Onan spills his semen on the ground so as to not father a child with his deceased brother's wife Tamar. The Talmud states that "there are three women that may cohabit with a sponge: a minor, a pregnant woman and one that nurses her child". Subsequent commentaries clarify that the "sponge" was an absorbent material, such as cotton or wool, intended to block sperm.[49]

Ancient China

In the seventh Century BC the Chinese physician Master Tung-hsuan documented both coitus reservatus and coitus obstructus, which prevents the release of semen during intercourse. However, it is not known if these methods were used primarily as birth control methods or to preserve the man's yang. In the same century Sun Ssu-mo documented the "thousand of gold contraceptive prescription" for women who no longer want to bear children. This prescription, which was supposed to induce sterility, was made of oil and quicksilver heated together for one day and taken orally.[49]


Indians used a variety of birth control methods since ancient times, including a potion made of powdered palm leaf and red chalk, as well as vaginal suppositories made of honey, ghee, rock salt or the seeds of palasa tree. A variety of birth control prescriptions, mainly made up of herbs and other plants, are listed in the 12th century Ratirahasya ("Secret of Love") and the Anangaranga ("The Stage of the God of Love").[49]

Early Islam

In the late ninth to early tenth century the Persian physician Muhammad ibn Zakariya al-Razi documents coitus interruptus, preventing ejaculation and the use of suppositories to block the cervix as birth control methods. He describes a number of suppositories, including elephant dung, cabbages and pitch, used alone or in combination[citation needed]. During the same period Ali ibn Abbas al-Majusi documents the use of suppositories made of rock salt for women for whom pregnancy may be dangerous. In the early tenth century the Persian Polymath Abu Ali al-Hussain ibn Abdallah ibn Sina, known in Europe as Avicenna, included a chapter on birth control in his medical encyclopedia The Canon of Medicine, documenting 20 different methods of preventing conception.[49]

Modern history

In modern Europe knowledge of herbal abortifacients and contraceptives to regulate fertility has largely been lost, resulting in the most extensive population growth in human history. Historian John M. Riddle found that this remarkable loss of basic knowledge can be attributed to attempts of the early modern European states to "repopulate" Europe after dramatic losses following the plague epidemics that started in 1348.[50] According to Riddle, one of the policies implemented by the church and supported by feudal lords to destroy the knowledge of birth control included the initiation of witch hunts against midwives, who had knowledge of herbal abortifacients and contraceptives.[50][51][52]

On December 5, 1484, Pope Innocent VIII issued the Summis desiderantes affectibus, a papal bull in which he recognized the existence of witches and gave full papal approval for the Inquisition to proceed "correcting, imprisoning, punishing and chastising" witches "according to their deserts." In the bull, which is sometimes referred to as the "Witch-Bull of 1484", the witches were explicitly accused of having "slain infants yet in the mother's womb" (abortion) and of "hindering men from performing the sexual act and women from conceiving" (contraception).[53] Famous texts that served to guide the witch hunt and instruct magistrates on how to find and convict so-called "witches" include the Malleus Maleficarum, and Jean Bodin's "De la demonomanie des sorciers".[54] The Malleus Maleficarum was written by the priest J. Sprenger (born in Rheinfelden, today Switzerland), who was appointed by Pope Innocent VIII as the General Inquisitor for Germany around 1475, and H. Institoris, who at the time was inquisitor for Tyrol, Salzburg, Bohemia and Moravia. The authors accused witches, among other things, of infanticide and having the power to steal men's penises.[55]

Birth control and public policy

Restrictive legislation on birth control was continually employed by European governments throughout the period of mercantilism and formed the backbone of the populationist strategy of this era. The mercantillists argued that a large population was a form of wealth, making it possible to create bigger markets and armies. The intense violence during the mercantilist era of the 17th and 18th centuries in Europe can be seen as a result of successful political implementation of population growth by means of restricting birth control, which created an enormous youth bulge. This youth bulge, as explained by youth bulge theory, in turn fueled imperialist expansion of the European empires.[citation needed]

In the Soviet Union, to facilitate social equality between men and women, birth control was made readily available. Alexandra Kollontai (1872–1952), commissar for public welfare during this time, also promoted birth control education for adults as well. In France, women fought for reproductive rights and they helped end the nation's ban on birth control in 1965. In Italy women gained the right to access birth control information in 1970.[56]

A recent, well-studied example of governmental restriction of birth control in order to promote higher birth rates was the post-World War II Nicolae Ceauşescu era in Romania.[57]

Birth control was a contested political issue in Britain during the 19th century. Malthusians were in favour of limiting population growth and therefore promoted birth control through organisations such as the Malthusian League, while the idea was opposed by a variety of groups such as socialists, and the regligious establishment.

The Vatican's opposition towards birth control continues to this day and has been a major influence on U.S. policies concerning the problem of population growth and unrestricted access to birth control.[58]

Barrier methods such as the condom have been around much longer, but were seen primarily as a means of preventing sexually transmitted diseases, not pregnancy. Casanova in the 18th century was one of the first reported using "assurance caps" to prevent impregnating his mistresses.[59]

Etymology and movement

The phrase "birth control" entered the English language in 1914 and was popularised by Margaret Sanger and Otto Bobsein.[60][61] Margaret Sanger was mainly active in the United States, but had gained an international reputation by the 1930s. The birth control campaigner Marie Stopes, who had opened Britain’s first birth control clinic in 1921 and made contraception acceptable in Britain during the 1920 by framing it in scientific terms, also gained an international reputation. Stopes was particularly influential in helping emerging birth control movements in a number of British colonies.[62]

"And the villain still pursues her", a satirical Victorian era postcard

"Birth control" was advanced as alternative to the then-fashionable terms "family limitation" and "voluntary motherhood."[60][61] Family limitation referred to deliberate attempts by couples to end childbearing after the desired number of children had been born.[63] Voluntary motherhood had been coined by feminists in the 1870s as a political critique of "involuntary motherhood"[64] and expressing a desire for women's emancipation.[65] Advocates for voluntary motherhood disapproved of contraception, arguing that women should only engage in sex for the purpose of procreation[66] and advocated for periodic or permanent abstinence. In contrast the birth control movement advocated for contraception so as to permit sexual intercourse as desired without the risk of pregnancy.[67] By emphasising "control" the birth control movement argued that women should have control over their reproduction and the movement had close ties to the feminist movement. Slogans such as "control over our own bodies" criticised male domination and demanded women's liberation, a connotation that is absent from family planning, population control and eugenics. Though in the 1980s birth control and population control organisations co-operated in demanding rights to contraception and abortion, with an increasing emphasis on "choice."[68]

The societal acceptance of birth control required the separation of sex from procreation, making birth control a highly controversial subject in the 20th Century.[69] Birth control has become a major theme in feminist politics who cited reproduction issues as examples of women's powerlessness to exercise their rights.[70] In the 1960s and 1970s the birth control movement advocated for the legalisation of abortion and large scale education campaigns about contraception by governments.[69] In a broader context birth control has become an arena for conflict between liberal and conservative values, raising questions about family, personal freedom, state intervention, religion in politics, sexual morality and social welfare.[70]

Society and culture

A world map showing countries by fertility rate. Period 2005–2010. (See List of countries and territories by fertility rate.)
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Legal status

United States

Some states formerly had laws prohibiting the use of contraception. In 1965, the Supreme Court of the United States ruled in the case Griswold v. Connecticut that a Connecticut law prohibiting the use of contraceptives violated the "right to marital privacy". In 1972, the case Eisenstadt v. Baird expanded the right to possess and use contraceptives to unmarried couples.


The 1920 Birth Law contained a clause that criminalizes dissemination of birth-control literature.[71] That law, however, was annulled in 1967 by the Neuwirth Law, thus authorizing contraception, which was followed in 1975 with the Veil Law. Only 5% of French women aged 18 to 45 do not use contraception.

Religious views on birth control

Religions vary widely in their views of the ethics of birth control. The Roman Catholic Church accepts only Natural Family Planning and only for serious reasons,[72] while Protestants maintain a wide range of views from allowing none to very lenient.[73][dead link] Views in Judaism range from the stricter Orthodox sect to the more relaxed Reform sect.[74] Hindus may use both natural and artificial contraceptives.[75] A common Buddhist view of birth control is that preventing conception is ethically acceptable, while intervening after conception has occurred or may have occurred is not.[76]

In Islam, contraceptives are allowed if they do not threaten health, although their use is discouraged by some.[77] The Quran does not make any explicit statements about the morality of contraception, but contains statements encouraging procreation. Prophet Muhammad also is reported to have said "marry and procreate".[78]

Cultural attitudes

According to Peter Mulira, "Reproduction in Africa is a cultural issue in which large families are seen as a source of free labour and wealth."[79]

Many nations in Western Europe today would have declining populations if it were not for international immigration.[80] The feminist movement has affected change in Western society, including education; and the reproductive rights of women to make individual decisions on pregnancy (including access to contraceptives and abortion).[81]

A number of nations today are experiencing population decline.[82] Growing female participation in the work force and greater numbers of women going into further education has led to many women delaying or deciding against having children, or to not have as many.[83] In Eastern Europe and Russia, natality fell abruptly after the end of the Soviet Union.[84] The World Bank issued a report predicting that between 2007 and 2027 the populations of Georgia and Ukraine will decrease by 17% and 24% respectively.[85]

Sex education

Many teenagers, most commonly in developed countries, receive some form of sex education in school. What information should be provided in such programs is hotly contested, especially in the United States and United Kingdom. Topics include reproductive anatomy, human sexual behavior, information on sexually transmitted diseases (STDs), social aspects of sexual interaction, negotiating skills intended to help teens follow through with a decision to remain abstinent or to use birth control during sex, and information on birth control methods.

One type of sex education program used in some more conservative areas of the United States is called abstinence-only education, and it generally promotes complete sexual abstinence until marriage. The programs do not encourage birth control, often provide inaccurate information about contraceptives and sexuality,[86] stress failure rates of condoms and other contraceptives, and teach strategies for avoiding sexually intimate situations. Advocates of abstinence-only education believe that the programs will result in decreased rates of teenage pregnancy and STD infection.

Abstinence-only sex education programs show an increase the rates of pregnancy and STDs in the teenage population in randomized controlled trials.[87][88] Professional medical organizations, including the AMA, AAP, ACOG, APHA, APA, and Society for Adolescent Medicine, support comprehensive sex education (providing abstinence and contraceptive information) and oppose the sole use of abstinence-only sex education.[89][90]


Modern misconceptions and urban legends have given rise to a great many false claims:

  • The suggestion that douching with any substance immediately following intercourse works as a contraceptive is untrue. While it may seem like a sensible idea to try to wash the ejaculate out of the vagina, it is not likely to be effective. Due to the nature of the fluids and the structure of the female reproductive tract, douching most likely actually spreads semen further towards the uterus. Some slight spermicidal effect may occur if the douche solution is particularly acidic, but overall it is not scientifically observed to be a reliably effective method. Douching is neither a contraceptive nor a preventative measure against STDs or other infections.
  • It is untrue that a female cannot become pregnant as a result of the first time she engages in sexual intercourse.
  • While women are usually less fertile for the first few days of menstruation,[91] it is a myth that a woman absolutely cannot get pregnant if she has sex during her period.[citation needed]
  • Having sex in a hot tub does not prevent pregnancy, but may contribute to vaginal infections.[92]
  • There is no evidence that any particular sexual position is more likely to lead to conception[93] and no sexual position prevents pregnancy. Having sex while standing up or with a woman on top will not keep the sperm from entering the uterus. The force of ejaculation, the contractions of the uterus caused by prostaglandins[citation needed] in the semen, as well as ability of the sperm to swim overrides gravity.
  • Urinating after sex does not prevent pregnancy and is not a form of birth control, although it is often advised anyway to help prevent urinary tract infections.[94]
  • Toothpaste cannot be used as an effective contraceptive.[95]
  • Though intrauterine devices (IUDs) are popular in many parts of the world, many people in the United States believe they are dangerous, probably in large part due to the widely publicized health risks associated with an IUD model called the Dalkon Shield. In reality, the most recent models of the IUD, ParaGard and Mirena, are both extremely safe and effective.[96]

See also


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