Hesperian Health Guides
Choosing a family planning method
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On the following pages we describe different family planning methods. Before recommending a method, find out about the woman’s needs.
- Does she want to be sure she will not get pregnant using this method?
- Is she concerned about side effects (uncomfortable and unintended effects)?
- Does she want a method she does not have to think about every day — or can she use a method that requires keeping charts or taking a pill each day?
- Is the woman’s partner willing to cooperate in using family planning?
- How much can this woman spend on family planning?
- Does the woman want a method that she can stop using if she wants to become pregnant — or one that is permanent?
- Does she need a method that prevents sexually transmitted infections (STIs)?
The methods described in this chapter work well to prevent pregnancy. Each of these methods also has disadvantages. The woman and her partner may need instruction on how to use the method. The method may cost something, it may require a medical visit, or it may have certain health risks. Make sure you understand how comfortable, safe, costly, or complicated each method is before you recommend it. Make sure the woman understands too.
Below is a chart that shows how well each method works to prevent pregnancy and to protect against STIs. The chart also shows what the possible side effects are for each method, and other important information about how the method must be used. Each method has stars to show how well it prevents pregnancy for the average user. When a man and a woman use a method correctly every time they have sex, the method will work better.
when used with spermicide and lubricant.
|Less effective when the woman is on top of the man during sex.|
|Most effective when when used with spermicide.|
|More effective when used with another barrier method like diaphragm or condom.|
Birth control pill, patch, injections
|These methods may be dangerous for women with certain health problems.|
|This method may be dangerous for women with certain health problems.|
|Sex without intercourse
(penis not inside vagina at all)
|Some couples, especially young people, may have a hard time using this method.|
(during the first 6 months only)
|To use this method, a woman must give her baby only breast milk, and her monthly bleeding must not have returned yet.|
|To use this method correctly, a woman must understand when she is fertile.|
|Women or men will never be able to have babies after this operation.|
|More effective when used with another method like spermicide or diaphragm.|
|Less effective for women who have had children.|
Condom for men (rubber or prophylactic)
A condom is a narrow bag of thin rubber that the man wears on his penis while having sex. The bag traps the man’s sperm (seed) so that it cannot get into the woman’s vagina or womb. Condoms work well to prevent pregnancy. Condoms also help prevent sexually transmitted infections (STIs), including HIV.
The most effective condoms are made from latex or polyurethane — not sheepskin.
A new condom must be used each time a couple has sex.
Lubricant can make sex feel better for both the woman and the man. It can also keep the condom from breaking. Use a water-based lubricant like saliva (spit), K-Y Jelly, or spermicide. Do not use oils, petroleum jelly (Vaseline), skin lotions, or butter. They can make the condom break. A drop of lubricant inside the tip of the condom makes it more comfortable on the penis. A little lubricant can also be rubbed on the outside of the condom after the man puts it on.
Condom for women (female condom)
A female condom fits into the vagina and covers the outer lips of the genitals. Each condom should be used only once, because it may break if it is reused. But if a woman does not have any other condoms, she can clean it and reuse it up to 5 times.
The female condom should not be used with a male condom. The female condom is the most effective of the methods controlled by women in preventing pregnancy and protecting against STIs, including HIV.
Female condoms can be expensive and take time to learn to use. They work best when the man is on top and the woman is on the bottom during sex.
3 types of female condoms are now available. The newest are less expensive. The VA female condom fits more closely to the woman's body, so it is more comfortable and makes less noise during sex.
How to use a male condom
A new condom should come rolled up inside a small packet that has not been opened. Be careful not to tear the condom as you open the packet. If the condom is stiff, hard or feels sticky, throw it away. It will not work.
1. A condom should be put on the man’s penis when it is hard, and before it touches the woman’s genitals. An uncircumcised man should pull his foreskin back. The man should squeeze the tip of the condom and put it on the end of the penis.
|2. Unroll the condom until it covers all of the penis. Keep squeezing the tip of the condom while unrolling. Without this extra space at the tip for the sperm, the condom may break.|
|3. Right after the man ejaculates (comes) and before his penis gets soft, he should hold on to the rim of the condom while he pulls his penis out of the vagina. Then he should carefully take the condom off.|
|4. Tie the condom shut. Then throw it in the garbage or a latrine.|
How to use a female condom
1. Carefully open the packet without tearing the condom.
2. Find the smaller inner ring, which is at the closed end of the condom.
|3. Squeeze the inner ring together.|
|4. Put the inner ring in the vagina.|
|5. Use your finger to push the inner ring up into your vagina and over the cervix. The outer ring stays outside the vagina.|
6. Be sure to guide the penis through the outer ring when you have sex.
|7. Remove the female condom immediately after sex, before you stand up. Squeeze and twist the outer ring to keep the man’s sperm inside the condom. Pull the condom out gently, then bury it or throw it in a latrine. Do not flush it down the toilet.|
The diaphragm is a shallow cup of soft rubber that the woman wears in her vagina during sex. The diaphragm covers the cervix so that the man’s sperm cannot get into her womb. The diaphragm should be used with spermicide. When a diaphragm is used correctly, it is effective in preventing pregnancy and may also give some protection against STIs, like HIV.
Diaphragms come in different sizes. A health worker must help a woman find the right size. Midwives can learn to fit women for diaphragms. It is easy to do once you have been trained.
How to Use a Diaphragm
|1. Squeeze some spermicide into the center of the diaphragm. Then spread a little around the edge of the diaphragm. If you do not have spermicide, you can still use the diaphragm, but it may not work as well.||2. Squeeze the diaphragm in half.|
|3. Push the diaphragm into the vagina, right over the cervix.||If the diaphragm is in correctly, the woman can feel her cervix through it.||
4. Leave the diaphragm in place for at least 6 hours after sex. If the woman has sex again before 6 hours have passed, she should put more spermicide in her vagina first. |
After using the diaphragm, the woman should wash it in mild soap and water. Then she should dry it, dust it in cornstarch if she has any, and store it in a clean, closed container
Spermicide (foam, jelly, cream, or tablets)
A spermicide is a chemical that kills sperm after it comes out of the penis. Spermicides are fairly good at preventing pregnancy when used alone, and are very effective when used with a condom or diaphragm.
WARNING! A woman should use spermicide only if she knows that her partner does not have HIV. Most spermicide is made with a chemical called Nonoxynol 9. Nonoxynol 9 irritates the vagina, causing tiny cuts. These cuts allow HIV to pass more easily into the blood. So using spermicide, especially using it very often, may actually make HIV more likely to pass during sex.
How to Use Spermicide
cream or jelly
The woman puts the spermicide in her vagina. Foam or jelly is put in with an applicator. Tablets (suppositories) are put deep in the vagina with the fingers.Spermicides should be put in the vagina no more than half an hour before having sex. Spermicide must be left in the vagina for at least 6 hours after having sex. A woman needs to put in more spermicide each time she has sex.
Birth control pills, injections, and implants contain hormones. Hormones are chemicals that a woman’s body normally makes. Hormones regulate many processes in a woman’s body including her monthly bleeding and her ability to become pregnant. Hormonal methods of family planning prevent pregnancy by stopping the woman’s ovaries from releasing eggs into her womb. Some hormonal methods include:
New hormonal methods are still being invented. Some newer methods are a contraceptive patch, a ring (worn around the cervix), and a hormonal IUD.
Hormonal methods are very effective in preventing pregnancy. But none of them used alone protect women against HIV or other STIs.
Most birth control pills and some injections contain two hormones: estrogen and progestin. Implants, some pills, and some injections contain only progestin.
Hormonal methods sometimes have side effects. These effects are not dangerous, but they are often uncomfortable. Hormonal methods can make a woman have:
|nausea||headaches||weight gain||swelling of
These effects usually get better after a few months. If they do not get better, the woman can try a different family planning method.
Birth control pills (oral contraceptives or "the pill")
Birth control pills have all the benefits and problems of hormonal methods.
When a woman takes a birth control pill at the same time every day, this method is one of the most effective ways to avoid pregnancy.
There are many brands of birth control pills. Pills should be “low-dose.” That means they should have 35 micrograms (mcg) or less of estrogen, and 1 milligram (mg) or less of progestin. Women should never use pills with more than 50 mcg of estrogen.
How to Take Birth Control Pills
A woman should take the first pill in a packet on the first day of monthly bleeding. If that is not possible, she should take the first pill anytime in the first 7 days after she starts her monthly bleeding.
Pills come in packets of 21 or 28 tablets. If a woman is using a 28-day packet, she should take one pill every day. Women will usually have light monthly bleeding during the last 7 days of a pill packet. As soon as she finishes one packet, she should begin taking a new one.
(The last 7 pills in a 28-day packet are made of sugar. They have no hormones in them. Women take these pills to remember to take a pill each day.)
If a woman prefers not to bleed every month, it is safe to take only the hormone pills continuously for up to 3 months. When the woman reaches week 4 of her packet (the sugar pills) she can immediately begin a new packet of pills instead of taking the sugar pills. Then continue taking the hormone pills in the usual order.
It is best to take the pill at about the same time every day. Many women take the pill with food, especially if they feel some nausea during the first few months that they take it.
The pills will not prevent pregnancy immediately. So during the first 7 days on pills, the woman should use condoms or some other backup method to avoid pregnancy.
What if a woman forgets to take her pill?
If a woman forgets to take 1 or 2 pills, she should take 1 as soon as she remembers. Then she should take the next pill at the regular time — even if she must take 2 pills in one day.
If a woman forgets to take 3 pills, 3 days in a row, she should take 1 pill right away. Then she should take 1 pill each day at her regular time.
If she is using a 28-day packet of pills, she should only take the hormonal pills, and should skip the sugar pills. If she is taking a 21-day packet of pills, she should start a new packet as soon as she finishes the one she is taking now.
To prevent pregnancy, she should use condoms any time she has sexual intercourse within 7 days of missing her pills.
WARNING! If a woman taking the pill gets any of these signs,
she should get medical advice right away:
- chest pain and shortness of breath
- strong headaches
- numbness in arms or legs
- strong pain in one leg
See more information about specific birth control pills.
With this method, a health worker gives a woman a hormone shot to keep her from getting pregnant. One shot lasts 1 to 3 months.
Injections are very effective. Very few women who use this method become pregnant. Another advantage to this method is that a woman does not have to do anything before having sex. And no one except her health worker needs to know she is using a family planning method.
The disadvantages are similar to those for birth control pills — some women have weight gain, sore breasts, nausea, or unusual monthly bleeding. Many women who have injections have no monthly bleeding at all. These effects are not dangerous, but they may be uncomfortable. Another disadvantage is the woman must go to a health worker once every 1 to 3 months to get the injection. And like other hormonal methods, injections do not protect against HIV or other STIs.
Most injections contain only progestin. Depo Provera and Noristerat are the most common brands. These injections are safe to use while breastfeeding, and are safe for other women who should not use estrogen.
Some injections contain estrogen, but they cost more and are hard to find. They must be injected once every month. A woman using these injections will usually have a normal monthly bleeding.
When a woman stops getting injections, it may take longer than usual (as much as a year or more) for her to get pregnant. Women should always be told this before getting injectable contraceptives. For this reason, injections are best for women who are sure they do not want to get pregnant in the next year or more.
With this method, a trained health worker puts small, soft tubes of progestin under the skin of a woman’s arm. The implant then prevents pregnancy for 3 to 5 years, depending on the type of implant. The implants must be replaced after those 3 to 5 years are over. If a woman wants to get pregnant before that time, the implant must be removed by a health worker.
|Implants||Implants are put under the skin...||...and can be removed by a trained health worker.|
A woman with implants does not have to do anything before sex to prevent pregnancy. Implants are very effective, although very fat women may not get the same protection from pregnancy as thin women. Implants only contain progestin — so they are safe for women who should not take estrogen. And they can be used safely while breastfeeding.
Implants have the same risks and side effects as other hormonal methods. Most women who use implants have very irregular monthly bleeding, with spotting and bleeding between monthly bleeding. This usually gets better after a year of using this method. And like any hormonal method, implants do not protect against HIV or other STIs.
A woman cannot remove implants herself. They can only be removed by a trained health worker. And it may be difficult to find a health worker who knows how to remove them. Women should understand this before the implants are put in.
WARNING! Watch women with implants for these signs of dangerous health problems. Get medical help if you find any of these signs:
- arm pain near the implant
- pus, redness, or bleeding around the implant
- implant comes out
- monthly bleeding stops after being regular for several months
Intrauterine device (IUD, IUS)
out of the
The IUD is a small device made of plastic that is put inside the womb to prevent pregnancy. Different types of IUD have different names, such as IUCD, copper T, Mirena, or the loop. Chapter 21 explains more about IUDs and how to insert them.
Once the IUD is put in, it stays inside the womb until it is taken out by a trained person. IUDs must be replaced every few years. Different IUDs can be left in for different lengths of time.
Neither the woman nor man feel the IUD while having sex. A woman who uses an IUD does not have to do anything before having sex. And no one needs to know that the woman has an IUD inside.
The IUD often causes changes in monthly bleeding, depending on the type of IUD. The Copper T can cause heavier monthly bleeding with more painful cramping. This extra loss of blood can cause anemia. The Mirena causes monthly bleeding to become very light or stop altogether, but it can cause irregular bleeding and spotting. Women who have STIs, vaginal or womb infections, or HIV or AIDS, should not use the IUD. These are some of the disadvantages or risks of the IUD:
- The IUD does not protect against HIV or other STIs. If a woman already has an STI when an IUD is inserted, that infection can spread to her womb. Womb infection can lead to infertility or other serious health problems.
- The IUD can cause miscarriage if a woman gets pregnant while using an IUD or if she has one put in when she is pregnant.
- The woman cannot put in or take out the IUD herself. A health worker must do it.
For these reasons, it is best if a woman who uses an IUD lives close to medical center.
WARNING! A woman with an IUD should get medical help if any of these danger signs appear:
- late or missed monthly bleeding or unusual spotting between monthly bleeding
- pain in the belly that does not go away, or pain during sex
- signs of infection: unusual discharge or bad smell from the vagina, fever, chills, feeling ill
- IUD strings get shorter or longer, are missing, or the IUD can be felt in the vagina
A woman with an IUD must check every month to be sure it is still in place. The best time to check is after her monthly bleeding.
First she should wash her hands. Then she should reach into the vagina with 2 fingers and feel for the strings of the IUD. They should be the same length each month.
If the strings are shorter or longer, or if she cannot feel the strings at all, the strings may have moved up into the womb, or the IUD may have fallen out. In this case, the woman should use another method of family planning, and she should get medical help.
Sex without intercourse
There are many ways to have sex that do not cause pregnancy. Oral sex (mouth on genitals) and sexual touch (touching the genitals or other parts of the body) are both sexual activities that many couples enjoy. They have very low risk of passing HIV and other STIs and they cannot cause pregnancy. Anal sex also cannot cause pregnancy, although HIV and other STIs can pass very easily this way.
Avoiding all sexual intercourse is the most sure way to prevent pregnancy and can be a good way to reduce the risk of HIV and other STIs. Not having sexual intercourse may be very difficult for couples to practice for a long time.
In the first 6 months after birth, most women who breastfeed do not release eggs from their ovaries, and so they cannot get pregnant when they have sex. Women usually do not get pregnant if they are breastfeeding as often as the baby wants, including at night, and:
- the baby is less than 6 months old, and
- the woman has not had any monthly bleeding since giving birth, and
- the woman is giving the baby only breast milk.
The woman can easily get pregnant if she is giving the baby formula, water, or other drinks. She may get pregnant if the baby goes longer than 6 hours between breastfeeding times.
The breastfeeding method does not protect against HIV or other STIs. Also, getting infected with HIV while breastfeeding creates a danger of passing HIV to the baby. If there is any chance that the mother’s partner has HIV, they should use condoms each time they have sex.
Fertility awareness (natural family planning)
A woman can only get pregnant during her fertile time when an egg comes from her ovary into her tubes and womb — about once a month. To use fertility awareness, a woman must watch her body’s signs to understand when she is fertile. During the fertile time she and her partner must not have sexual intercourse (the penis inside the vagina). At these times, they can try other types of sex like oral sex or sexual touching. Or they can prevent pregnancy by using condoms or a diaphragm during the fertile time.
Natural family planning costs nothing and has no side effects. But it can be difficult to use. Women do not always know when they are fertile, and if they have one irregular cycle, they can easily get pregnant. This method usually works best when couples receive training before using it. Natural family planning does not protect against HIV or other STIs.
Natural family planning does not work well for women who do not have control over when they have sex. During a woman’s fertile times, her partner must be willing to use condoms or a diaphragm — or not have sexual intercourse.
Women whose cycles are very different lengths each month should not use this method either. Women who recently gave birth or had an abortion should not use this method until their cycles are regular for several months.
There are many ways to use fertility awareness. In this book we talk about the mucus method and the counting days method. These methods work best when they are both used together. But one method alone is better than nothing.
The mucus method
With the mucus method, a woman checks the mucus from her vagina every day to see if she is fertile. On her fertile days, the mucus is stretchy and slimy, like raw egg.
To check the mucus, a woman should wipe the vagina with a clean finger, paper, or cloth. Then she should look for mucus.
|Clear, wet, slippery mucus comes during the fertile time.
Do not have sexual intercourse.
|White, dry, sticky mucus (or no mucus) comes during other times of the month. |
It is probably OK to have sexual intercourse 2 days after the first dry day.
|After 2 or 3 months of practice, a woman can easily recognize these changes in her mucus.|
How to Use the Mucus Method
- Check the mucus at the same time every day. Check before having sex.
- Do not have sexual intercourse on any day you feel slippery mucus. Or use a condom or diaphragm on those days.
- Do not have sexual intercourse until 2 days after the last day that you have clear, slippery mucus.
- Do not douche or wash out the vagina at any time. This will wash the mucus away.
The counting days method
With the counting days method, a woman does not have sexual intercourse during any time that she might be fertile. This method can only be used by women with regular cycles that last between 26 and 32 days. This means that the time from the first day of one monthly bleeding to the first day of her next monthly bleeding must be at least 26 days, and no more than 32 days.
This method will usually work for a woman who has nearly the same number of days from one monthly bleeding to the next (regular cycles). But if a woman has one cycle of a different length, she can easily get pregnant. It is common for a woman to have a cycle of a different length when she is sick or feeling a lot of stress. When a woman is sick or feeling stress, it is best for her to use a different family planning method until she is well and her cycle is normal.
How to use the counting days method
For this method to work, the woman cannot have sexual intercourse from the 8th day of her cycle through the 19th day of her cycle. If she has sexual intercourse during this time, she must use another method of family planning.
Sterilization is an operation that makes it almost impossible to have a baby. This method is permanent. It is only good for someone who never wants to have another baby.
These operations are done at medical centers. The surgery is fast and safe. Sterilization is almost always completely effective. A doctor can try to undo a sterilization, but that operation is expensive and often does not work.
Sterilization does not protect men or women against HIV and other STIs.
Sterilization for men (vasectomy)
A vasectomy is a simple operation. It takes only about 10 minutes. A health worker inserts a tool through the skin of the testicles to cut the tubes that carry sperm to the penis. The skin heals quickly and the testicles are not harmed.
The operation does not change a man’s ability to have sex or feel sexual pleasure. He still ejaculates (comes), but sperm cannot get from the testicles into the semen. For about 3 months, there are still sperm in the tubes, so the couple must use another method of family planning.
Sterilization for women (tubal ligation)
cut or tied
Tubal ligation is a little more complicated than vasectomy, but it is still very safe. A health worker inserts a tool through the skin near the belly button to cut or tie the tubes that carry the woman’s eggs to her womb. The operation takes about 30 minutes.
A new method called Essure does not require surgery. A tiny, flexible metal and plastic coil is inserted through the vagina and uterus into each tube. Scar tissue then grows over these inserts and permanently blocks the tubes.
Tubal ligation does not change a woman’s monthly bleeding or her ability to have sex and sexual pleasure.
Emergency contraception is a way to avoid pregnancy after having sex. If a woman has sex without using a family planning method, and she does not wish to get pregnant, she can take a high dose of birth control pills as soon as possible — within 5 days of having sex. The sooner a woman takes the pills, the more likely they are to work.
This is not a good method to use every time a woman has sex. Emergency contraception often causes nausea or headaches. It is not as dependable as other methods.
|How to give emergency contraceptive pills|
|Most birth control pills contain ethinyl estradiol (estrogen) and levonorgestrel (progestin). The number of pills you take depends on how much ethinyl estradiol the pill contains.|
|Using low-dose pills (with 30 to 35 mcg ethinyl estradiol)|
|Using high-dose pills (with 50 mcg ethinyl estradiol)|
|Emergency pills can give women headaches or severe nausea. Some women have less nausea if they eat something at the same time as taking the pills. If a woman vomits within 2 hours of taking the pills, she should take the same dose again by placing the pills high in her vagina.|
|In some communities, women can buy pills specially made for emergency contraception. They have a higher dose of hormones, so women do not have to take as many pills. They may be made with only progesterone and no estrogen. Progesterone-only pills do not usually cause nausea.|
An IUD can also be used as emergency contraception. A trained health worker must insert the IUD within 5 days of a woman having sex. This will usually prevent a pregnancy. The IUD can then be left in to prevent future pregnancies. But this method should not be used by a woman who might have an STI.
Pulling out (withdrawal)
In this method, a man pulls his penis out of the woman’s vagina and away from her genitals before he ejaculates. This prevents sperm from getting inside the vagina.
If a man is willing and able to pull out every time before he ejaculates, this method can work reasonably well. It costs nothing and is always available. But a man may not want to or be able to pull out before the sperm comes. This means the woman may get pregnant. Also, a woman may worry about whether the man will pull out in time, and feel less pleasure because of that worry. This method is more effective when combined with another method like spermicide or a diaphragm.
This method may give some protection against HIV and other STIs.
The contraceptive sponge is a round circle of foam that is soaked in spermicide. It should be wet with clean water before inserting it deep in the vagina with a finger. It should be left in place for at least 6 hours after sex but not longer than 24 hours. It can be removed by reaching in and pulling the attached loop. This method does not protect against STIs and should be used only by women who know their partner does not have HIV, as the spermicide in the sponge can irritate the skin of the vagina and allow the virus to enter the body more easily. Women may also get more yeast or bladder infections with this method.
Homemade sponge method
With this method, a woman puts a sponge soaked in vinegar, lemon, or salt deep in the vagina before having sex. This method is not very effective, but it may prevent some pregnancies. It provides no protection against HIV or other STIs.
How to make a homemade sponge
|1. Mix: 2 tablespoons of vinegar with 1 cup of clean boiled water||or||1 teaspoon of lemon juice with 1 cup of clean boiled water||or||1 spoon of salt with 4 spoons of clean boiled water|
|2. Wet a boiled piece of sponge about the size of an egg with one of these liquids.|
|3. Push the sponge deep into the vagina no more than 1 hour before having sex.|
|4. Leave the sponge in for at least 6 hours after having sex. Then take it out.|
This method may irritate the vagina, which can make it easier for a woman to get STIs. The woman should stop using this method if it makes her vagina dry, sore, or itchy.
The sponge can be difficult to take out, but it cannot get lost in the vagina. It may be easier to take out if the woman squats and pushes down as if she is passing stool, while she reaches into her vagina. If she has trouble taking it out, she can tie a clean ribbon or string around it for the next time.
The sponge can be washed, boiled, and used again many times. Keep it in a clean, dry place. The liquid can be made ahead of time and kept in a bottle.
Methods that do not prevent pregnancy
These are some commonly used family planning methods that do not work. Some are also dangerous.
- Wearing charms will not prevent pregnancy. Neither will spells or prayers.
- Urinating after sex will not prevent pregnancy (though it may help prevent urinary tract infections).
- Washing out the vagina (douching) after sex does not prevent pregnancy. Some herbs or harsh chemicals used for douching can also injure the vagina.