The pill is not the only answer

by Dr. Perle Feldman

Often when I ask women about contraception they will say “Oh I don’t use any birth control”. This surprises me because I know that these women are not planning pregnancies. What they mean is that they are not taking the pill, they are using other methods, such as condoms, withdrawal and rhythm, or breastfeeding as contraception. When I went to medical school we were taught that these methods were unreliable and undesirable. Women were encouraged to use what I now call “Doctor Centered” methods such as pills, Intrauterine devices and injections. While these methods have lower failure rates they are often unacceptable to women for a variety of reasons. The other more “free access” methods may have an inherently higher risk of pregnancy but for many they are the method, which suits the couple best, under the circumstances. What the alternative methods of contraception have in common is the need for a certain amount of skill and commitment in their use; thus they are often best for people in committed relationships for whom an unplanned pregnancy could be tolerated. In terms of risk to the life and health of the woman the best methods of birth control are conscientious use of a barrier method such as condom or diaphragm backed up with emergency contraception or early abortion. The average woman using these methods for her whole reproductive lifetime will have 2 unplanned pregnancies. The risk of pregnancy with any method of contraception decreases with the length of use, most unplanned pregnancies occurring in the first year.

To have reasonable success with alternative methods you have to use them properly. Let’s take breastfeeding. This is probably the most common method used by women around the world to space their pregnancies. Women who are not breastfeeding will have their first ovulation and be fertile as early as 3 weeks after giving birth. Several studies have demonstrated that if three criteria are fulfilled breastfeeding can be 98% effective: You must have the baby be completely or almost completely breastfed, on demand. The baby must be less than 6 months old and the mother should not yet have had a menstrual period. If any of these conditions are not met the risk of pregnancy increases.

The only male methods of contraception are included in the high skill, high motivation list. The most common male method, used around the world, is withdrawal. This is a method that is often quite ineffective with failure rates of up to 40% in the first year of use. However, skilled practitioners of this art, the “Servitore del Donna” as they used to be called in 17th Century Italy, can achieve rates close to that of the barrier methods, 4-5% failures. The problem with this method is that the man must be able to anticipate his ejaculation and withdraw far away from the woman’s vagina just at the moment when millions of years of evolution are urging him forward.

Condoms, which were completely out of favor in the late 60’s and early 70’s, are now of course, the method of choice for everyone who is not in a long-term committed relationship. Even people who are using other methods of contraception should probably continue to use condoms as well, until they are ready to commit to monogamy and perhaps until they are ready to have a first child. To be really safe the condom must be on during all genital contact, not just for that final moment of glory. It must be completely unrolled, and a little pinch must be pulled up at the end. After ejaculation the man must remove himself from danger immediately, holding on to prevent slippage. Latex condoms, used properly have a 3-5% failure rate. For those among you who are latex allergic there are natural membrane condoms such as “Fourex” and Naturalamb, which some people find more pleasant to use. These condoms are not proven protective, however, against the HIV virus.

If the condom is too small it causes a peculiar and unpleasant feeling during ejaculation; if it is too big it may slip during intercourse. Look around and experiment. Condoms come in a variety of shapes thickness and sizes, except small. Never in the history of mankind has a condom been marketed as being small; look for “slim”. Remember not to use oil based creams as lubricants with condoms, such as Vaseline or hand creams as they will melt the barrier.

Vaginal barrier methods, such as the female condom, the sponge, the cervical cap and the diaphragm are also useful methods of contraception for the right woman. Only the diaphragm is widely available in Montreal at this time. The diaphragm is basically a device for holding spermacide in place during intercourse. It must be fitted by a physician; proper use must be taught to the woman. The diaphragm must be refitted if the woman gains or loses more than 15 pounds or after pregnancy.

The main problem with barrier methods is that they never work when they are in the drawer. Since they must be used during every act of intercourse the temptation is always to use them next time, or later. This is the most common reason why these methods often slip up. There are of course method failures where the diaphragm slips or the condom breaks. The failure rate also increases with the number of acts of intercourse and these methods may not be appropriate as the only protection for people having sex more than 3 times a week.

One of the nice things about condoms, as opposed to the diaphragm, is that when they fail you can usually tell. If this happens you can get emergency contraception. The “morning after pill” which is available at almost all clinics and emergency rooms should be taken as soon as possible up to 72 hours later. IUD insertion may be effective up to 5 days after the slip-up. Immediate insertion of an nonoxyl-9 containing spermicide cream may decrease the risk of HIV transmission to the woman.

No discussion of alternative contraception is complete without talking about the various ways of using fertility awareness, the venerable “rhythm methods”. In this method women map their menstrual cycles and become aware of when they are ovulating. Remember that the first half of the cycle is more variable. A woman almost always gets her period 14 days after ovulation. Thus this method is best for women whose cycles are very stable. Many methods then use other ovulation predictors, such as the quality of the cervical mucous to help define the fertile period. Intercourse during the fertile period is avoided, replaced with other sexual activities or protected with another method of birth control. This method places a lot of emphasis on good couple relations and cooperation. It involves discipline and planning. The failure rate is quite variable, ranging from 3-9% in highly motivated, trained couples to a 25% failure rate among typical sloppy users. The Catholic Church offers training in the symptothermal or Serena method; the most highly effective form of this contraceptive. One of the advantages of this method is that it can be useful when couples are ready to conceive. They just use it in reverse.

The main thing in common among these alternate methods of contraception is that they are more the responsibility of the people using them. They are not methods put in place by doctors requiring little thought and motivation. They each have advantages and disadvantages. For many, if not most people the Birth control pill, the IUD or Depo Provera are simple and effective methods. But they do not suit everyone. Alternative methods are often cheap, accessible and “natural”, but they demand motivation and commitment on the part of their users.