Effectiveness, Correct Usage, and Duration

While it is true the majority of birth control has high effectiveness at preventing pregnancy, that is only true if the user takes the birth control correctly every time.  No one is perfect, it is very difficult for many people to remember to take and use birth control correctly all the time.  Because of this, birth control effectiveness must consider "Perfect Use" and "Practical Use."  For example, Male Condoms, if used correctly every time, are 98% effective at preventing pregnancy.  However, because condoms require personal skill and accountability, their practical use effectiveness rate is only 82%.  This is a common theme with all the different methods; the more required from the user, the less effective the method.  This is why IUDs and Implants are the most effective forms of birth control, as these methods are very low maintenance--no daily pills to remember to take, no stopping before sex, no keeping track of cycles, and no trips to the pharmacy.  IUDs and Implants are the only forms of reversible birth control that have the same rates of Perfect and Practical use.  Sterilization also has the same rates of perfect/practical use, but is permanent. 

World Health Organization pregnancy rates, USA 2011

Percentage of women experiencing unintended pregnancy after one year of method use

 

Method                                    Practical Use                           Perfect Use                              % Cont. Use at 1 yr

None                                                       85                                            85                                   -

Spermicides                                            28                                            18                                  42

FABM                                                      24                                            -                                     47

Standard Days                                         -                                               5                                   -

2 Day Method                                          -                                               4                                    -

Ovulation Method                                    -                                               3                                    -

Sympo-Thermal                                       -                                               .4                                  -

Withdrawal                                               22                                            4                                   46

Sponge                                                    -                                               -                                    36

Parous Women                                        24                                            20                                 -

Nulliparous Women                                 12                                            9                                     -

Condom-Male                                          18                                            2                                    43

Condon-Female                                       21                                            5                                    41

Diaphragm                                               12                                            6                                    57

Oral Contraceptives                                  9                                              .3                                  67

Transdermal Patch                                   9                                              .3                                   67

Vaginal Ring                                             9                                              .3                                   67

Depo-Provera                                           6                                              .2                                   56

-------------------------------------------------------------------------------------------------------------------------------

IUD                                                        

Copper/Non-hormonal                            .8                                             .6                                    78

Mirena/Hormonal                                    .2                                             .2                                     80

Implant                                                    .05                                           .05                                   84

Female Sterilization                                .5                                             .5                                    100

Male Sterilization                                    .15                                           .10                                  100

 

Another variable that makes birth control more/less effective is its duration.  The longer the method lasts, the more effective it is at preventing pregnancy.  Sterilization and LARCs (Long Acting Reversible Contraceptives) and are the most effective forms of birth control, and they are both methods that last the longest, with sterilization lasting forever.  LARC users also have the highest rates of continuation.  That is, IUD and Implant users were more likely to stick with their method of birth control compared to other forms.  

Permanent Methods

After a woman has recovered from her sterilization, there is zero maintenance required from her.  Yearly wellness exams and routine pap and breast screenings are recommended for all women.

After a male has been cleared sterile, there is zero maintenance required from him.  Yearly wellness physicals and routine testicular checks are recommended for all men. 

Less than 1% of sterilized couples become pregnant within a year after surgery. 

Remember, sterilization is permanent.  Only use sterilization if you are absolutely sure you are done having children/do not want children.  Sterilization reversal surgery is sometimes possible, but odds greatly vary.  It is highly advised to view and treat any sterilization decision as permanent.

Long Acting Reversible Contraceptive (LARC) Methods

IUDs last a long time.  Copper/Non-Hormonal IUDs last for 10-12 years, and Hormonal IUDs lasts for 3-6 years.  After a woman has been seen for her follow up appointment after insertion, there is little maintenance required.  Women should check their IUD strings once per month to assure proper placement.  Yearly annual physicals are recommended for preventative care for all people, especially those using medication.  IUD users should continue their routine pap schedule per recommendation of their doctor.  Women should return for removal if they wish to become pregnant, or if it is time for a replacement.  Less than 1% of IUD users will become pregnant within one year of use.  The most common reason why IUD users become pregnant is expulsions without the woman's knowledge. 

Implants last 4 years.  A trained medical professional will numb the patient with local anesthesia and then insert the Implant into the upper arm.  The procedure is very quick.  Users should visit their doctor yearly, and return sooner if they have any undesired side effects or concerns. .05% of Implant users will become pregnant within one year of use.  The most common reason why Implant users become pregnant is incorrect placement/no placement at all. 

Routine Methods

Depo-Provera is a highly effective form of birth control that lasts for three months.  One injection results in three months of pregnancy prevention.  A repeat injection is given every 12-13 weeks, totaling four injections per year.  As long as a woman returns for her next scheduled injection, she will receive continuous protection against pregnancy.  If a woman returns later than 15 weeks from her last injection, she is not protected against pregnancy.  6% of Depo Provera users become pregnant within one year of use.  The most common reason why a woman becomes pregnant while using Depo-Provera is because she returned too late for her next injection, or did not return at all.

Oral Contraceptives

Oral Contraceptives require daily administration.  Oral contraceptives can be purchased over the counter in Kosovo.  Women considering oral contraceptives should decide which type is best to fit her needs.  Reading all of the instructions and fine print, and paying attention to hormonal doses (lower doses tend to have less side effects) is important when deciding what type to try.  9% of oral contraceptive users will become pregnant within one year of use.  Inconsistent or incorrect use, or discontinuation of use was the most common reason for pregnancy.  Leaving your pills in an area where they could be damaged by heat or dampness is not recommended.  Some antibiotics can interfere with the effectiveness of oral contraceptives.  If a doctor prescribes you antibiotics, inform them immediately you are taking oral contraceptives.  It may be recommended to use condoms or abstinence until your have finished your antibiotics.  If a patient takes their pill every day, as directed, the effectiveness is over 99%. There are two main types of oral contraceptives:  Combined Oral Contraceptive (COC) and Progestin Only Pill (POP). 

Combined Oral Contraceptive (COC)

Combined Oral Contraceptives are the most common form of oral contraceptive pills.  COC contain the combination of Progestin and Estrogen. COCs can come in either 21 day, 28 day, or 91 day packs. Most COCs come in 28 day packs:  three weeks of active pills (pills containing estrogen/progestin), and one week of inactive/placebo pills.  The inactive/placebo week is when the woman will have her period, as there is no active ingredient in the pills taken during that week.  Pill users are still protected against pregnancy during their inactive week, as long as they start a new pack once their inactive week is over.  Taking one pill every day will prevent pregnancy.  A woman may begin taking COCs at any time in her cycle.  If a woman starts her COC within five days of when her period starts, she will be protected against pregnancy immediately.  For example, if a woman starts her period on Monday, that is Day 1.  As long as she starts her COC on days 1-5 (Monday-Friday), she will be protected against pregnancy immediately.  If a woman starts her COC any other time, she will not be protected for another seven days.  Using another form of birth control, like condoms, is recommended during the very first week of starting COCs.

Progestin Only Pills (POPs)

Progestin Only Pills contain no estrogen, but only progestin.  POPs only come in 28 day packs.  Every pill in a POP pack is active, which means every pill contains the active ingredient of progestin.  Because women using POPs are receiving a continuous supply of progestin, their period commonly lightens or discontinues altogether (similar to other progestin-only contraceptives, like hormonal IUDs and Implants).  POPs must be taken every day, at the same time. Women taking POPs must take their pill within three hours of the same time every day, otherwise she is risking pregnancy.  If you take your pill later than three hours past your usual time, use a backup method of birth control for the next 48 hours.  It is not advised to take POPs if remembering to take a pill at the same time every day is difficult for you.  POPs can be initiated at any time.  Pregnancy protection will begin 48 hours (two days) after starting POPs.

How do I take the pill?  What if I miss a dose?

            It is essential to take the pill every day.  POPs must be taken at the same time every day in order to be effective, whereas COCs are effective as long as a pill is taken each day.     Setting an alarm or keeping your pill pack next to things you use every day can help remind you to take your pill.  Contact your pharmacist/doctor if you are unsure how to take your birth control.  If you miss a pill, continue your next dose as usual, and contact your pharmacist/doctor/nurse.  They may ask when your last period started, or when you last had unprotected sex.  Use a condom until you are able to talk to them.  Make sure you know the exact name of your birth control when you call, as different brands and types require different instructions.  If you find yourself frequently missing your birth control pill, a more convenient method (like an IUD) may be a better option.  Contact your doctor/pharmacist if you vomit less than two hours after taking the pill. 

Any side effects?

            It is important to remember pregnancy typically has more serious side effects and complications than birth control.  Some users have headaches, nausea, sore breasts, gastrointestinal issues (like diarrhea), spotting between periods after starting the pill, or changes in mood.  Like most medications, side effects should subside after 2-3 months.  If a woman does not like the way the pill makes her feel, she should consult her doctor/pharmacist to see if there is an alternative brand (or different method) that may work better for her. Contact a doctor/nurse immediately if you experience any of the following:  chest pain, trouble breathing, repeat/intense headaches, yellowing of skin/eyes, sudden back/jaw pain combined with nausea and sweating. 

(US MEC--United States Medical Eligibility Criteria for Contraceptive Use, revised 2017)

^{*Planned Parenthood}

(Not offered in Kosovo)Transdermal Patches and Vaginal Rings require a yearly prescription renewal in some countries, and weekly administration.  One patch/ring is used per week.  After the week is over, a new patch/ring replaces the old.  Similar to COCs, the Patch and Ring come in three active weeks, and one inactive week.  During the inactive week, the user will simply not wear a patch or ring, and will have a period.  It is important the patch/ring is changed weekly and consistently.  The ring should be placed comfortably in the vagina, and the patch should be firmly in place on the skin.  9% of Patch and Ring users will become pregnant within one year of use.  The most common reason for becoming pregnant while taking these methods is inconsistent use and late replacements (users replacing patch and ring later than one week.)

Short Term Methods

Diaphragms, Condoms, Sponges, and Spermicides are all short term methods that are only used before sex.  It is essential to use these methods before intercourse occurs.  Any semen on the vagina, or PIV (penis in vagina) sex for any amount of time can result in pregnancy.  Each method has different requirements and tips to be more effective.  All methods require consistent and correct use.  Since condoms are the only form found in KS, we will focus on them. 

Like all short term methods, condoms require a lot of responsibility from the user. 

--If you are relying on condoms as your form of birth control, be sure you have an ample supply of them at all times.  Often people forego condom use simply because they did not have  any or they ran out.

--Store condoms in a cool, dark place away from sunlight.  Storing condoms in places like wallets, cars, bathrooms, pockets, etc for more than one month should be avoided, as heat, moisture, and pressure damages them. 

--Use your fingers to open a condom wrapper, do not use your teeth or scissors. 

--Examine condoms for holes before using, and throw away/do not use any condoms that are                 expired, torn, sticky, or stiff. 

--Roll the condom all the way to the base of the erect penis, leaving a little room at the tip for                    semen to deposit. 

--Only use one condom at a time. 

--Use a new condom every time you have sex.  If the man loses his erection, he should remove the condom and replace it with a new one once he becomes erect again.  New erection, new condom. 

--If you are using latex condoms, it is ok to place a small amount of lubricant inside/on the                        condom.  Do not use vaseline, lotion, baby oil, butter, or cooking oils as lubrication, as these can cause breakage.  Only use lubricants that are approved for latex, such as KY Jelly.  Some condoms are pre-lubricated. 

--There are a variety of brands, types, and sizes of condoms.  No brand is more effective at                    preventing pregnancy and STDs than another; proper and consistent use determines effectiveness, not brand.  

--Lambskin condoms only protect against pregnancy, not STDs.

--Most people fit the standard size.  If the condom feels too tight, try a larger size.  If the condom slips around or falls off during sex, try a smaller size. 

--Condoms can delay ejaculation, resulting in longer sex.  This is helpful for men who                               experience pre-mature ejaculation and wish to have longer intercourse. 

--Using condoms and another form of birth control is dual protection against STDs and                             pregnancy.  Dual protection is recommended for all people in non-mutually monogamous  relationships. 

--18% of women who only use condoms will become pregnant within one year of use.  The most             common reason for pregnancy is inconsistent or incorrect use. 

Other Methods

Withdrawal is a method used by many people.  Withdrawal is also called coitus interruptus, or simply "The Pull Out" method.  The Pull Out method is when the man removes his penis from the vagina before ejaculation.  This method requires a lot of personal restraint and self control.  It also requires trust between partners. This method is typically more difficult for young or sexually inexperienced males to execute correctly, as they are not as familiar with their sexual responses and boundaries compared to older and more experienced males.  Withdrawal is a great method to combine with other methods, but it not very effective on its own.  Some men pull out even when they wear condoms, or even if their female partner uses birth control, as it provides extra protection against pregnancy.  22% of women who only use this method will become pregnant within one year.  The most common reason for pregnancy with this use is the male being young or inexperienced, not withdrawing soon enough, or the man pre-ejaculating. 

Fertility Awareness Based Methods

Fertility Awareness Based Methods are a variety of methods used to prevent or achieve pregnancy by tracking when a woman is ovulating.  Women are only fertile for six days per menstrual cycle, the day she ovulates and the five days prior to ovulation.  During those fertile days, women using FABMs should abstain from sex.  This can sometimes be difficult, as many women report being more sexually aroused during their fertile time.  In the case a woman wishes to have sex during her fertile time, condoms should be used.  It is recommended to have 3-6 months of cycle information (to establish baselines and averages) before relying on these methods. Women using these methods should use an online app, a personal calendar, cycle beads, or a chart to track their individual cycle.

Standard Days Method

--Version of the "Rhythm Method" that relies on tracking a woman's monthly menstruation cycle.  --The first day of a woman's period is Day 1. 

--Standard Days Method recommends abstaining from sex or using condoms on days 8-19, as those are typically a woman's most fertile days. 

--Many woman ovulate on day 13, however every woman is different, and some ovulate sooner/later than Day 13. 

--Standard Days Method is based on women who menstruate every 26-32 days.  If a woman has shorter or longer cycles than that range, or inconsistent cycles, Standard Days Method may not be the most reliable method for her.

Ovulation Methods

--Relies on diligent daily tracking of a woman's discharge and cervix placement throughout her cycle. 

--During and right before ovulation, there is typically more cervical mucus.  Stretchy, clear, and slick discharge (similar to how uncooked egg whites look and feel) is a symptom of ovulation. A woman typically has this discharge mid cycle when she is most fertile. 

--This type of discharge allows for enhanced sperm mobility, making it naturally easier for a woman to become pregnant.  If a woman desires pregnancy, having intercourse when she displays this type of discharge is highly recommended. 

--If a woman wishes to prevent pregnancy, she should abstain from sex or use condoms during this time until symptoms subside.

--Women using this method should also note the placement of their cervix.  Women can touch their cervix by inserting their fingers to the back of the vagina, and feeling for the smooth, rounded shape of the cervix. When a woman is fertile, her cervix opens up and becomes softer.  It is also much higher and sometimes difficult to reach.  When a woman is non-fertile, her cervix is lower, harder, and closed.

--It may take a woman a few months to become familiar with her body and be able to note differences in discharge and cervical placement.  Many women who use this method feel it has helped them recognize normal/abnormal vaginal secretions; and have a better knowledge of their personal cycle and body--however, it takes time to learn and make these assessments.

--Medical guidance is highly recommended for all types of birth control, especially FABMs.

Temperature Method

--Relies on daily temperature checking. Women who use this method should use a Basal Thermometer every morning as soon as she awakes, and before she gets out of bed. 

--Documentation of daily temperatures is necessary to notice differences.  Women's body temperature changes very slightly throughout her cycle, staying around 96-98 F before ovulation, and raising to 97-99 F after ovulation. 

--There is typically a slow decrease before ovulation, and then a sharp increase after ovulation,

although changes can be subtle.

--Women should track their daily temperatures on a Fertility Awareness chart. 

--Temperature Method can be difficult, as sometimes the temperature changes are very minimal.  Consistent documentation is necessary to best assess temperature changes.

When the Ovulation Method and Temperature Method are used together, it is called the Sympto-Thermal method.  Many women naturally combine Standard Days and Ovulation method, and track their menstrual cycle and ovulation symptoms on the same chart.  Fertility Awareness methods work best when more than one is used.  Whatever method(s) a woman can routinely maintain is the best method for her. 

With diligence, education, and awareness, these methods can be very effective.  However, due to a variety of reasons (incorrect or discontinued charting, not abstaining/not using condoms, inconsistent menstrual cycles, general confusion, etc) 24% of women who use Fertility Awareness Based Methods will become pregnant after one year of use. 

*^{Planned Parenthood}

Emergency Methods

Mistakes and accidents can happen to anyone.  Emergency Contraception should be used in the event of an accident/mistake, such as if the first method of birth control fails (condom broke/fell off or was not worn, partner didn't pull out in time, forgot to take routine birth control pills, etc.), or if a woman is sexually assaulted*. 

*Inform women sexual assault/rape is about to be briefly discussed.  If any women feel they may be triggered or uncomfortable with this discussion, they are encouraged to step out of the room for 1-2 minutes until the discussion is over. 

Sexual assault is any forced or coerced sex--rape.  If you are forced to have vaginal sex, or if semen is left on/near your vagina, there is risk of pregnancy.  If you are correctly taking birth control, there is little risk of pregnancy.  If not, you may want to consider emergency contraception before it is too late (3-5 days).  If you are forced to engage in any other forms of sex (anal, oral, manual, etc), and no semen is left on/near the vagina, there is no risk of pregnancy. 

All forms of sexual assault are a major offense, regardless of what type of assault occurred, or who the perpetrator is--this includes husbands/boyfriends/life partners/friends.  If you have been sexually assaulted, know you are not alone, and it is NOT you fault.  Assault is always the fault of the perpetrator, as there is never a reason to assault someone.  Victims may choose to press charges against their assaulter.  It is recommended for victims of sexual assault to be seen by a doctor to ensure a pregnancy does not occur, and also to test if any STIs have been transmitted.  Remember, STIs can be transferred through any type of genital contact; sex does not have to be vaginal for an STI to be passed.  Finding someone you trust, seeing a qualified therapist, or talking to other assault victims may help in the emotional recovery after an assault.  Remember, assault is NEVER the victim's fault.  If you were a victim of war rape, please contact Center for Promotion of Women's Rights in the Drenas municipality to receive reparations. 

[Welcome any women who may have stepped out to re-enter the classroom/discussion.  Continue material on EC]

Emergency contraception is not intended to be used as a first form of birth control; that is, emergency contraception should not be taken as a replacement to more routine methods of birth control.  Emergency contraception is not an abortion, and cannot terminate an existing pregnancy.  Emergency contraception can only prevent a pregnancy if administered within 3-5 days of unprotected sex.  Typically, "unprotected sex" is defined as sex without a condom, however in regard to emergency contraception, "unprotected sex" means any sex that did not involve a means to prevent pregnancy.  For example, if a woman has sex without a condom, but is correctly taking her birth control pills every day, she is protected against pregnancy, thus she is having "protected sex."  If that same woman forgets to take her birth control pill, she is now unprotected against pregnancy, and thus having "unprotected sex."  If a woman is unsure if she is protected against pregnancy, she should contact her doctor/nurse/pharmacist immediately. 

There are two types of emergency contraception, a non-hormonal IUD and pills.

            1.  IUD:  Non-hormonal/Copper IUD is the most effective form of emergency contraception.  If this type of IUD is inserted within 120 hours (5 days) after having unprotected sex, it will prevent a pregnancy from occurring.  This is a great method to choose if a woman needs emergency contraception and continued pregnancy prevention.  Non-hormonal IUDs can last 10-12 years and can be removed at any time. 

            2.  Pill:  Emergency contraceptive (EC) pills are most common type of emergency contraception.  There are different brands and types of EC pills.  Only take one dose of EC pills; more doses will not give you more protection, and do not mix brands, as they may interfere with each other and become less effective.  A second dose will be required if you throw up less than two hours after taking your EC pill.  Read all instructions on/in the packaging carefully, and contact your doctor/pharmacist with the name of EC pill you took if you have any questions.                 

Levonorgestrel EC pills:  The most common types of EC pills contain Levonorgestrel and work best when taken within 72 hours (3 days) after unprotected sex.  The sooner these types of EC pills are taken after unprotected sex, the better they work.  Some brands of EC pills can be taken up to 120 hours (5 days) after unprotected sex.  Most brands of this type of EC pill can be purchased over the counter at a pharmacy. 

Remember, emergency contraception is not intended to be a first form of birth control, but rather used for accidents.  If a woman wishes to prevent pregnancy, she should receive a more routine form of birth control, as routine forms are more effective at preventing pregnancy, are less expensive that routinely purchasing EC, and tend to have less side effects.  EC pills are safe, but can contain high amounts of hormones, which can result in a variety of unpleasant side effects, like unusual periods or nausea.  Emergency contraception should not be taken if pregnant, however, if a woman takes an EC pill while unknowingly pregnant, it will not harm the baby.  Emergency contraception is not an abortion and will not terminate an existing pregnancy.  If a woman needs/decides to terminate a pregnancy, she should see a qualified health professional. 

*Planned Parenthood

Article written by

Ryann Qavdarbasha

 

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Category: Pregnancy