Module 5 – Contraceptives

One major challenge that adolescents and young people face is the possibility of unwanted pregnancy. While most young people are already sexually active, they are not yet ready to start families or to have children. Contraceptives are a good method to manage this predicament. Young people need to learn and understand the reality of conceiving, and the implications of unplanned and unwanted pregnancies, and they need to understand the various contraceptive methods available to manage the fear of unwanted pregnancy.

Contraception is defined as the intentional prevention of conception using various devices, sexual practices, chemicals, drugs, or surgical procedures. Contraception allows young people in particular young women to put off having children until their bodies are fully able to support a pregnancy. It can also prevent pregnancy for older people who face pregnancy-related risks or just do not want to have children.

Contraceptive use reduces the need for abortion by preventing unwanted pregnancies.
Young people need to learn and understand the reality that they can fall pregnant, the implications of unplanned and unwanted pregnancies, and they need to understand the various contraceptive methods available to manage the fear of unwanted pregnancy.

Topic objectives

• To discuss the prevalence and implications of unplanned and unwanted pregnancy among adolescents and young people.
• To explore the importance of family planning in the lives of adolescents and young people.
• To define and discuss the types, advantages, and disadvantages of various contraceptives.
• To increase the demand and use of contraceptive services among young people.

WHAT IS FAMILY PLANNING & WHY IS IT IMPORTANT?

Family planning is the voluntary use by an individual or a couple of different appropriate methods to anticipate and attain their desired number of children and the spacing and timing of their births. But it involves a lot more than using contraceptives:

1. The decision to have sex.

The decision to have sex is one aspect of family planning – no sex, no family. The longer you delay having sex, the better the position you find yourself in to make informed decisions and successfully plan your family.

2. The decision to have children.

Many young people believe that it is a must to have children when living in a relationship. This is not true, because the decision to become pregnant and give birth is at the discretion of a couple, and both partners should agree that they want children. Young people, especially young men, are not supposed to push for sex and pregnancy because girls as well have a decision to make; whether that is what they want or not.

3. Family size and frequency of childbearing.

It is the sole responsibility of the couple to decide how many children they want to have and how big they want their family to be. It is not the responsibility or right of the man or the woman alone to decide how many children the family should have. Neither is it the right of the man alone to decide how often his wife will be pregnant. They must decide together, and it is the right of women to resist any forced pregnancies and childbearing.

4. The decision to use contraceptives.

The use of contraceptives is a right of women as it is a right of men. Men should not only support their partners in matters related to contraception, but they should also in fact participate actively in family planning. Contraceptives work by preventing a man’s sperm from fertilizing a woman’s ovum and can be achieved in several ways. Condoms are a form of contraceptive that can also prevent the transmission of STIs including HIV. Unplanned pregnancies and STIs do not only disturb students’ studies but also have a bearing on their health and can threaten their lives.

In Zimbabwe, where abortion is illegal and access to treatment of STIs and HIV remains challenging, contraceptives remain the most viable option. Contraception, therefore, allows students to plan their lives without the obvious disruptions that come with unplanned pregnancies and the effects of STIs or induced abortions. Contraception ensures that students enjoy their sexual and reproductive health rights which include being free from diseases as well as planning for when and how often to have children.

Information on a wide range of contraceptives is important so that students can make informed choices about their sexuality. This module explores some of these contraception methods – particularly those that are popular and available to students and young people in Zimbabwe. Contraceptive methods are frequently referred to by the way they prevent pregnancy. They can be short term i.e., can be used for a short term up to 3 months and when stopped one can get pregnant, or long term i.e., last 6 months or longer but can be stopped and one still gets pregnant or permanent or irreversible.

THE CONTRACEPTIVE METHODS ARE:

• Barrier methods
• Intrauterine methods
• Hormonal methods
• Surgical (permanent) methods
• Natural methods
• Emergency contraception
• Traditional methods

How Do You Know Which One to Choose?

Different methods of contraception have their individual advantages and disadvantages. There’s no single ‘best’ method of contraception, so you must decide which is most suitable for you. A health worker can also assist with information so you can make an informed decision. Whatever your situation, there should be a contraception option that works for you. For many people, barrier methods of contraception are best, because they do not only prevent pregnancy but also prevent HIV and other sexually transmitted infections from being passed on during sexual intercourse.

Where Do You Get Contraceptives From?

Where you can get contraceptives depends on which type of contraceptive you’re looking for. Barrier methods such as condoms are available at health centers, clinics, some NGOs that offer clinical services, college clinics and pharmacies in Zimbabwe. They’re also available from most healthcare providers. There are many different condom brands that are distributed free of charge. Free, distributed condoms are equally as strong as the brands available for purchase in shops, contrary to the widely circulated myth that they are not safe to use. Hormonal methods are available with advice and counselling from qualified medical personnel.

The Different types of contraceptives

1. Barrier Method – Male Condom

• It is a thin rubber cover that fits over the erect penis.
• It prevents pregnancy and sexually transmitted infections, including HIV.
• It is effective when used consistently and correctly every time you have sex.
• It can be used alone or with another method.
• It can be used by any couple who agrees to use it, including married couples.
• Students, especially female students should consider whether they can:
  • Negotiate condom use with their partners without threat of violence or manipulation especially if the partner is older and may have financial power over them.
  • Consistently use condoms to avoid transmission/acquisition of STIs/HIV
  • Emergency contraceptive pills (ECPs) can be used if condom breaks or slips.

 

How to use male condoms

2. Barrier Method – Female Condom

• It is a thin rubber lining that fits loosely inside a woman’s vagina.
• It prevents pregnancy and sexually transmitted infections including HIV.
• It is effective when used consistently and correctly every time you have sex.
• It can be used alone or with another method.
• It can be used by any couple who agrees to use it, including married couples.

Benefits—Female condoms can be inserted in advance. Feels more natural than male condoms.
Female students should consider whether they can: Negotiate female condom use with partner. Use emergency contraceptive pills (ECPs) if condom is used incorrectly.
Emergency contraceptive pills (ECPs) can be used if condom breaks or slips.

 

 

How to use female condom

3. Hormonal Methods – Oral Contraceptive pills

• It is a pill taken every day to prevent pregnancy.
• It can be a combined oral contraceptive (COC) pill i.e., contain estrogen and a progesterone, or it can be a progesterone only pill (POP). POP is suitable for breastfeeding women. It prevents eggs from leaving the ovaries. After stopping pills, you can get pregnant without a delay.
• It can be used safely by most women, including those living with HIV.
• It does not provide protection from HIV or other STIs; add other methods to protect yourself should be used (i.e., condoms or PrEP).

Benefits—COCs: Periods are usually very regular and light. Helps prevent certain types of cancer. Normal changes some women may have: Nausea, Headaches and dizziness, Breast tenderness or mood changes. Irregular spotting (rare).

Female students should consider whether they:

Can take a pill every day. Will an unpredictable school schedule, and/or use of alcohol/other drugs, make it harder to maintain a pill-taking routine? If you are on ART or being treated for TB, tell your provider which drugs you take because they may reduce COC effectiveness.

 

4. Hormonal Methods – Emergency Contraceptive pills (ECPs)

Pills taken to prevent pregnancy after unprotected sex (effective if taken within 5 days, the earlier, the better). ECP work by preventing or delaying the release of eggs. Is not a replacement for regular contraceptive methods. Safe for any woman including those with HIV or AIDS, and those on ART.

Benefits—ECPs: Can be used by women of any age. Second chance to prevent pregnancy; do not cause an abortion. Can be used more than once in a woman’s cycle. ECP May cause nausea and vomiting and light spotting for a few days. Next period may come a few days earlier or later.

Female students should consider whether they: Were exposed to HIV. While ECPs do not increase the risk for acquiring HIV, they provide no protection from HIV and other STIs. Should seek post-exposure prophylaxis (PEP) in addition to ECPs, if concerned about exposure to HIV due to unprotected intercourse. ECPs should not be used continuously, this can be hazardous to health.

5. Hormonal contraceptives – Injectables

The most used injectable in Zimbabwe is called Depo-Provera. Depo-Provera is a shot given every three months. It is a hormone, much like the progesterone a woman produces during the last two weeks of each monthly cycle. Injectables stop the woman’s ovaries from releasing an ovum and have other contraceptive effects.

Among typical couples who initiate use of injectables, about three percent of women will experience an accidental pregnancy in the first year.

For the most effective protection against sexually transmitted infections, condoms must be used in addition to getting the injection. Complete information about this contraceptive is available through a family planning clinic, local health department, or clinician. Injectable contraceptives are available from your clinician, health department, or family planning clinic.  Most clinics provide the first shot when a woman is on her period or within seven days of the start of the period. Be sure to use condoms or another method for added protection against pregnancy and the transmission of STIs including HIV.

1. Hormonal injectable- SAYANA PRESS

SAYANA PRESS is indicated for long-term female contraception. Each subcutaneous injection prevents ovulation and provides contraception for at least 13 weeks (+/- 1 week). However, it should be taken into consideration that the return to fertility (ovulation) may be delayed for up to one year. Sayana Press is a low-dose form of depot medroxyprogesterone (DMPA) prefilled for subcutaneous injection with Uniject, a prefilled easy-to-use injection device. Sayana Press has the same effectiveness and the same side effects as the intramuscular formulation of DMPA (depo-IM).

Normal changes some women may have: Bleeding changes such as prolonged or heavy bleeding, irregular bleeding or spotting, or no bleeding at all. Headaches and dizziness. Abdominal bloating and discomfort. Changes in mood and sex drive. Weight gain in some females.

Female students should consider whether they can: Remember to come for re-injections on time. Return even if late. Cope with unpredictable bleeding. Go back to the health facility if they experience unpredictable and heavy bleeding, because injectables may cause changes in the menstrual cycle.

6. Hormonal Contraceptives – Implants

These are small plastic capsules or rods placed under the skin of the inside upper arm (1 or 2 capsules or rods depending on type). They prevent eggs from leaving the ovaries and thicken cervical mucus. Last 3 to 5 years; can be removed any time if you want to get pregnant.
Can be used safely by most women, including those with HIV or AIDS
No protection from HIV or other STIs; add other methods to protect yourself (i.e., condoms, PrEP).

Normal changes some women may have: Bleeding changes are common and may include irregular spotting or no bleeding, nausea, Headaches and dizziness, breast tenderness or mood changes, abdominal discomfort, and weight gain in some females.

Female students should consider whether they can: Cope with irregular bleeding and spotting. Accept that others may know she is using implants; the rods can be felt when touched and, in some women, are visible under the skin.

Other considerations for women living with HIV or AIDS: If you are on ART or being treated for TB, tell your provider which drugs you take because they may reduce the effectiveness of implants.

7. Intrauterine methods – can be hormonal or non-hormonal (copper)

• It is a small, plastic “T” wrapped in copper wire placed in the womb, which stops sperm from reaching egg.
• It can be used for up to 12 years; can be removed any time if you want to get pregnant.
• It must be inserted and removed by trained nurse or doctor.
• It does not provide protection from HIV or other STIs; add other methods to protect yourself (i.e., condoms, PrEP).

Female students who have a lot of sexual partners may not be good candidates for IUDs unless gonorrhea and chlamydia infection can be ruled out before insertion: Untreated gonorrhea or chlamydia increases the risk of developing a serious pelvic infection during the first month of IUD use.

 

Female students should consider whether they can cope with irregular bleeding and spotting (eventually, less bleeding or no bleeding at all becomes more common, which many women view as beneficial).

Benefits—IUDs can be used by women of any age. Helps prevent certain types of cancer. Does not require a woman to do anything. Can be used privately.

8. Permanent surgical methods or sterilization

Sterilization is a permanent form of contraception that is intended to be non-reversible. It involves blocking the reproductive tubes to stop the ova (eggs) and sperm coming together. For one to take up this method they must be 100% sure that they will not want to have any kids in the future. Some doctors may be reluctant to do the operation on younger people, especially those without children. It’s important to make sure that you are certain before making such a big decision. If you are considering sterilization, ask yourself: Why do you want sterilization? If you are in a current relationship and it ended, would your feelings change? How would you feel if something happened to the children you have now?

Vasectomy – Is the procedure that cuts the tube called the vas deferens so that sperm produced in the testes cannot get into the semen (cum). If there are no sperm in the semen, then pregnancy cannot occur.

Benefits— this is one of the few procedures that give males the opportunity to take charge of their family planning. The operation is considered a minor operation taking about 20 minutes and can be done under local anesthetic and doesn’t require an overnight stay at a hospital.

Things to consider – this is a permanent method and is irreversible, there is a small percentage of males who may still become fertile after a vasectomy – because the vas deference would not have been completely cut, after the operation there is some discomfort and swelling and one might have to still use other contraceptive methods up to 3 months after the operation to allow any semen in the duct to die.

Tubal ligation– This is a procedure to block the fallopian tubes so that the sperm cannot reach the egg and begin a pregnancy. You will need a general anesthetic for this operation. This can be done as a laparoscopy (keyhole surgery), where a small telescope is inserted to find the fallopian tubes. The tubes are then closed off by clips or rings. For most people this operation is performed as day surgery, although rest is needed the next day. Sometimes an operation called a laparotomy may be done. A single longer cut is made above the pubic hair line. The fallopian tubes are then closed off. This operation usually requires a 1 or 2 day stay in hospital.

Benefits – Tubal ligation is highly effective (99.5%). One does not have to worry about contraceptive’s anymore as it is a permanent method. It does not affect sexual intercourse, sex drive nor cause early menopause. It is no hormonal.

Things to consider – this is a permanent method, and one cannot reverse it. It can be an expensive procedure.

 

9. Other Contraceptive methods

a. Abstinence

Abstaining means you’ve decided not to have sex – this includes vaginal, and oral sex. This is the only form of birth control that always prevents pregnancy 100% because there is no chance for sperm to fertilize an egg. Secondary abstinence – In a case where you have already had sex and are no longer a virgin but choose to stop having sex and wait for a while until you are ready, this is called secondary abstinence. Sometimes we rush into sexual activity or sexual relationships before we are emotionally or physically prepared and we decide to stop having sex after such a sexual encounter. It is okay and safe and even encouraged to practice secondary abstinence.

Benefits – It is 100% effective at preventing unwanted pregnancies and STIs, there are no medical or hormonal side effects, it doesn’t cost anything.

Things to consider – It may be difficult to practice abstinence for long periods of time, it can be difficult to follow through with if your partner is not on board, if you have not had sexual education or been given information about contraception, you may not be prepared to protect yourself from pregnancy or sexually transmitted infections if/when you choose to have sex.

b. Outercourse

“Alternatives to sexual intercourse”— refers to types of sexual intimacy which does not involve oral, or vaginal sex. This may include Holding hands, Hugs, Kisses, Petting above the belt, Mutual masturbation.

Outercourse does take some discipline! Both partners must be committed to this method or else these exciting forms of sexual intimacy can lead to sexual intercourse. It is not an extremist position to practice only outercourse in this age of viral infections. It works better if there has been communication in advance. Decide in advance what sexual activities you will say “yes” to and discuss these with your partner. Tell your partner, very clearly and in advance, not at the last minute, what activities you will not do. At the same time learn more about the methods of birth control and safer sex so that you will be ready if you change your mind.

Benefits – It is free! There is no risk of pregnancy. No fluid is exchanged, providing protection against sexually transmitted infections. It can increase emotional closeness between individuals.

Things to consider – Touching your partner’s genitals during masturbation could possibly result in transmitting STIs. You may want to use some method of protection, such as latex gloves. For some partners, the desire to have intercourse can cause stress. This method may have either partner thinking, “Is this going to go farther than I want?” This concern may decrease enjoyment.

c. Withdrawal

(Coitus Interruptus) is when the man withdrawals his penis from the vagina when he senses that he is about to ejaculate (come). He ejaculates outside of the vagina.
This takes a lot of discipline! If the woman has not had an orgasm, the man can stimulate her in other ways after withdrawal. It works best if the couple has agreed to use this method in advance. Among typical couples who initiate use of withdrawal, about 27 percent of women will experience an accidental pregnancy in the first year. If withdrawal is used consistently and correctly, about 4 percent of women will become pregnant. The withdrawal method should be used in combination with spermicides for increased effectiveness.

Benefits – It is completely private. It is better than no method at all. No fluid or less fluid is deposited in the woman’s vagina. This means that there is somewhat less chance of infection spreading from a man to a woman. It has no medical complications, no hormones, no supplies, and is free.

Things to consider – provides poor to no protection against STIs, including HIV. The desire to keep thrusting when it is time for the man to withdrawal. May decrease enjoyment of intercourse because the man is thinking: “Will I withdraw in time?” And the woman is thinking “Will he withdraw in time?”. Semen may be present in the fluid that comes out of the penis before ejaculation.

d. Calendar method

Calendar method is since ovulation occurs from 12 to 16 days before the onset of mensuration. The days on which conception is likely to occur are calculated as shown in the diagram below.

Before you can use the calendar method as contraception, a female will need to keep track of the length of their menstrual cycles for at least 6 periods. There are tracking apps that can be downloaded on phone to help you with this. As shown in the graph days 1 to 7 are the days when a woman is menstruating, between days 8 and 19 a woman can fall pregnant because they ovulate during these days, days 20 to 26 are safe days to have sexual intercourse as they fall just before the menstruation.

Other techniques that can be used together with the calendar method are basal body temperature (monitoring the body’s temperature when a woman’s basal temperature is high it indicates that they are highly fertile) as well as cervical mucus monitoring (a woman can try to predict when they ovulate by tracking the changes in cervical mucus or vaginal discharge throughout the menstrual cycle)

Benefits – Low to no cost, no medical complications, no hormones, no supplies, no side effects.

Things to consider – This requires the understanding of the sexual partner; it is difficult to implement if a woman has an irregular period and is therefore no dependable.

DUAL PROTECTION

Protection given for both STIs/HIV, and pregnancy. Condoms are the main method of family planning that offers dual protection.

Final word – young people should consider the three key health outcomes of sexual activity – pregnancy, STIs and HIV.