The practice of birth control preventsconception, thus limiting reproduction. The termbirth control, coined by Margaret SANGER in1914, usually refers specifically to methods ofcontraception, including STERILIZATION. Theterms family planning and planned parenthoodhave a broader application. METHODS OFBIRTH CONTROL Attempts to control fertilityhave been going on for thousands of years.References to preventing conception are found inthe writings of priests, philosophers, andphysicians of ancient Egypt and Greece.

Somemethods, though crude, were based on soundideas. For example, women were advised to puthoney, olive oil, or oil of cedar in their vaginas toact as barriers. The stickiness of these substanceswas thought to slow the movement of sperm intothe uterus. Wads of soft wool soaked in lemonjuice or vinegar were used as tampons, in thebelief that they would make the vagina sufficientlyacidic to kill the sperm.

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The Talmud mentionsusing a piece of sponge to block the cervix, theentrance to the uterus. Sperm Blockage Severalmodern methods of birth control are practiced bycreating a barrier between the sperm and the eggcell. This consists of the use of a chemical foam, acream, or a suppository. Each contains achemical, or spermicide that stops sperm. Theyare not harmful to vaginal tissue. Each must beinserted shortly before COITUS. Foams aresquirted from aerosol containers with nozzles orfrom applicators that dispense the correct amountof foam and spread it over the cervix; creams andjellies are squeezed from tubes and held in placesuppositories–small waxy pellets melted by bodyheat–are inserted by hand.

More effective atkeeping sperm and egg apart are mechanicalbarriers such as the diaphragm and cervical cap(both used with a spermicide), the sponge, and thecondom. A diaphragm is a shallow rubber cup thatis coated with a spermicide and positioned overthe cervix before intercourse. Size is important;women need to have a pelvic examination and geta prescription for the proper diaphragm. Thecervical cap, less than half the size but used in thesame way, has been available worldwide fordecades. It was not popular in the United States,however, and in 1977 it failed to gain approval bythe Food and Drug Administration (FDA); in1988, the FDA again permitted its sale. Thecontraceptive sponge, which keeps its spermidicalpotency for 48 hours after being inserted in thevagina, was approved in 1983. Like thediaphragm and cervical cap, the sponge has anestimated effectiveness rate of about 85%.

Thedevices only rarely produce side effects such asirritation and allergic reactions and, very rarely,infections. The condom, a rubber sheath, is rolledonto the erect penis so that sperm, whenejaculated, is trapped but care must be taken sothat the condom does not break or slip off. Afresh condom should be used for each sexual act.Condoms also help protect against the spread ofVENEREAL DISEASES, and, unlike otherbarrier devices, condoms made of latex dofoolproof–protection against AIDS (see AIDS).Another method of preventing the sperm fromreaching the egg is withdrawal by the man beforeejaculation. This is the oldest technique ofcontraception and, because of the uncertainty ofcontrolling the ejaculation, is considered one of theleast effective. Altering Body Functions Even inancient times, attempts were made to find amedicine that would prevent a woman’s body fromproducing a baby.

Only within the last century,however, have methods been developed thatsuccessfully interrupt the complex reproductivesystem of a woman’s body. The first attempt,made in the 19th century, was based on a legendthat camel drivers about to go on long journeys inthe desert put pebbles in the wombs of femalecamels to keep them from becoming pregnant.Researchers tried to find something that wouldwork similarly in a woman’s cervix. The earliestsuch objects were made of metal and were held inby prongs. Later, wire rings were placed beyondthe cervix, in the uterus itself, thus giving rise to theterm intrauterine device, or IUD.

IUDs appear towork by altering the necessary environment in theuterus for the fertilized egg. It was only with theintroduction of modern plastics such aspolyethylene, however, that IUDs were widelyaccepted. Their pliability led to simpler insertiontechniques, and they could be left in place untilpregnancy was desired unless a problem arosewith their use. Copper-containing IUDs, and thosethat slowly released the hormone progesterone,had to be replaced periodically. Some users ofIUDs, however, complained increasingly of theside effects of the devices. The most commonproblem was bleeding, and the devices could alsocause uterine infections. More dangerous was thepossible inducement of pelvic inflammatorydisease (see UROGENITAL DISEASES), aninfection that may lead to blockage of theFallopian tubes and eventual sterility or an ectopicpregnancy.

Studies in the 1980s confirmed thislink with the increased risk of infertility even in theabsence of apparent infections, especially withplastic IUDs. The A. H. Robins Company, inparticular, was ordered in 1987 to set aside nearly$2.5 billion to pay the many thousands of claimsfiled against it by women injured through use of itsDalkon Shield. By that time only a single,progesterone-releasing IUD remained on the U. S.

market, but a copper IUD later became availableand other steroid releasing devices were beingplanned for issue. The birth control pill, taken oncea day, has become the most popular birth controlcontraceptives are similar in composition to thehormones produced naturally in a woman’s body.Most pills prevent ovaries from producing eggs.Use of the pill, however, does not preventperiods to be more regular, with less cramps andblood loss.

Recent studies seem to indicate thatthe pill may also protect its users against severalrelatively common ailments, including irondeficiency anemia (the result of heavy menstrualbleeding), pelvic inflammatory disease, and somebenign breast disorders. In addition (and contraryto fears that were expressed when the pills werefirst marketed and contained much higher levels ofhormones), long-term statistical studies point to alower incidence of ovarian and uterine canceramong women who use contraceptive pills. Otherstudies, however, have linked its use with theincreased occurrence of breast cancer. Ongoingstudies by such organizations as the AmericanCancer Society continue to study a possible breastcancer link. For some users, the pill may haveundesirable and sometimes serious side effectssuch as weight gain, nausea, hypertension, or theformation of blood clots or noncancerous livertumors.

The risk of such effects increases abovethe age of 35 among women who smoke. Pills areobtainable only by prescription and after awoman’s medical history and check of her physicalcondition. In 1991 the FDA approved the use ofNorplant, a long-lasting contraceptive that isimplanted under the skin on the inside of awoman’s upper arm. The implant consists of sixmatchstick-size flexible tubes that contain asynthetic hormone called progestin.

Releasedslowly and steadily over a five-year period, thisdrug inhibits ovulation and thickens cervicalmucus, preventing sperm from reaching eggs.Avoiding Intercourse The time to avoid sex, whenconception is not desired, is about midway in awoman’s menstrual cycle; this was not discovereduntil the 1930s, when studies established that anegg is released (ovulation) from an ovary aboutonce a month, usually about 14 days before thenext menstrual flow. Conception may occur if theegg is fertilized during the next 24 hours or so or ifintercourse happens a day or two before or afterthe egg is released, because live sperm can still bepresent. Therefore, the days just before, during,and immediately following the ovulation areconsidered unsafe for unprotected intercourse;other days in the cycle are considered safe. Theavoidance of intercourse around ovulation, therhythm method, is the only birth control methodapproved by the Roman Catholic church.Maintenance of calendar records of menstrualcycles proved unreliable, because cycles may varydue to fatigue, colds, or physical or emotionalstress. A woman’s body temperature, however,rises slightly during ovulation and remains high untiljust before the next flow begins.

Immediatelypreceding the release of the egg, the mucus in thevagina becomes clear and the flow is heavier. Asthe quantity of mucus is reduced, it becomescloudy and viscous and may disappear. Thesesignals can help a woman determine the time whenshe must avoid intercourse to prevent pregnancy.Permanent Contraception Couples who wish tohave no more children or none at all may choosesterilization of the man or of the woman instead ofprolonged use of temporary methods. To beconsidered irreversible, sterilization blocks orseparates the tubes that carry the sperm or theeggs to the reproductive system. The man is stillcapable of ejaculating, but his semen no longercontains sperm. The woman continues tomenstruate and an egg is released each month, butit does not reach her uterus. Neither operationaffects hormone production, male or femalecharacteristics, sex drive, or orgasm.

Tubes maybe separated by surgically cutting them, they maybe blocked with clips or bands, or they may besealed using an electric current. The man’soperation, or VASECTOMY, is simpler and isusually performed in a doctor’s office or a clinic.The operation for women is usually performed in ahospital or an out-patient surgical center. Some ofthe most recent techniques require a stay of only afew hours.

Some soreness and discomfort may beexpected after surgery, occasionally with swelling,bleeding, or infection; the risk of seriouscomplication is slight. In the 1980s sterilizationbecame the preferred method among U.S. couplesdesiring no further children. The most optimisticprospects for reversing sterilization for women andmen exists when there is the least damage to theirtubes at the time of sterilization. It is estimated thatas many as 60 percent of reversals are successful(success is measured by a pregnancy).

Manyindividuals, however, may not even be candidatesfor an attempt at reversal, especially women whohave undergone electrocauterization or surgicalcutting of their tubes. New or ExperimentalContraceptives Several new drugs andcontraceptive devices are at present undergoingexamination in the United States. Thus an injectionof the synthetic progesterone Depo-Provera(currently used in more than 90 countries)prevents ovulation for three months. Animal tests,however, suggest that the drug may induce somecancers, and have other undesirable side-effects.Also in use in several countries is a capsule,implanted beneath the skin of the upper arm, thatslowly releases the synthetic hormonelevonorgestrel over a period of five years.

Thecapsule, which was approved by the WorldHealth Organization in 1985 for distribution byUnited Nations agencies, has minimal known sideeffects but should not be used by women whohave liver disease or breast cancer. Anothercontraceptive approach, successful in animals andcurrently undergoing human trials, is vaccination.One vaccine delivers antibodies against a hormonethat plays a crucial role in pregnancy. A secondworks against a hormone in the matrix surroundingthe egg, blocking sperm from penetrating. Maleand unisex oral contraceptives are currently inresearch.

SOCIAL ISSUES Birth control, orlimiting reproduction, has become an issue ofmajor importance in the contemporary worldPOPULATION growth. Until relatively recently,however, most cultures have stressed increasing,rather than reducing, procreation. The Englisheconomist Thomas MALTHUS (1766-1834) wasthe first to warn that the population of the worldwas increasing at a faster rate than its means ofsupport.

However, 19th-century reformers whoadvocated birth control as a means of controllingpopulation growth met bitter opposition both fromthe churches and from physicians. The AmericanCharles Knowlton, author of an explicit treatise oncontraception entitled The Fruits of Philosophy(1832), was prosecuted for obscenity, and similarcharges were brought against the free-thinkersAnnie BESANT and Charles Bradlaugh, whodistributed the book in Britain. Nonetheless, themovement persisted, gathering strength at the endof the century from the WOMEN’S RIGHTSMOVEMENT. In Britain and continental Europe,Malthusian leagues were formed, and the Dutchleague opened the first birth control clinic in 1881.An English clinic was started by Dr. Marie Stopes(1882-1958) in 1921.

In the United States,Margaret Sanger’s first clinic (1916) was closedby the police, but Sanger opened another in 1923.Her National Birth Control League, founded in1915, became the Planned Parenthood Federationof America in 1942 and then, in 1963, the PlannedParenthood-World Population organization. InGRISWOLD V. CONNECTICUT (1965) the U.S.

Supreme Court struck down the last statestatute banning contraceptive use for marriedcouples, and in 1972 the Court struck downremaining legal restrictions on birth control forsingle people. The federal government begansystematically to fund family planning programs in1965. Contraceptive assistance was provided tominors without parental consent until Congressruled in 1981 that public health-service clinicsreceiving federal funds must notify parents ofminors for whom contraceptives have beenprescribed.

Suits challenging the regulation havebeen upheld; the government has announced plansto appeal. Despite the wide availability ofcontraceptives and birth control information, therate of childbirth among unmarried teenage girlsrose throughout the 1970s and 1980s. A majorfocus of current concern, therefore, is theadolescents. Other countries where the birthcontrol movement has been notably successfulinclude Sweden, the Netherlands, and Britain,where family planning associations early receivedgovernment support; Japan, which has markedlyreduced its birthrate since enacting facilitatinglegislation in 1952; and the Communist countries,which after some fluctuations in policy, nowprovide extensive contraceptive and abortionservices to their inhabitants. Many of the lessdeveloped countries are now promoting birthcontrol programs, supported by technical,educational, and financial assistance from variousUnited Nations agencies and the InternationalPlanned Parenthood Federation. A series ofWorld Population Conferences has sought tostrengthen the focus on population control as amajor international issue. At present the strongestopposition to birth control in the Western worldcomes from the Roman Catholic church, whichcontinues to ban the use of all methods exceptperiodic abstinence.

In Third World countriesresistance to birth control programs has arisenfrom both religious and political motives. In India,for example, a country whose population isincreasing at a net rate of 10-13 million a year, thetraditional Hindu emphasis on fertility has impededthe success of the birth control movement. SomeThird World countries continue to encouragepopulation growth for internal economic reasons,and a few radical spokespersons have alleged thatthe international birth control movement isattempting to curtail the population growth ofThird World countries for racist reasons. A similarargument has been heard within the United Stateswith regard to ethnic minorities; the latter,however, voluntarily seek family planning in anequal proportion to nonminorities. Despite sucharguments, most educated individuals andgovernments acknowledge that the health benefitsof regulating fertility and slowing the naturalexpansion of the world’s population are matters ofBibliography:Louise B. Tyrer, M.D.

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