FAMILY PLANNING METHODS - Christian Connections for ...

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FAMILY PLANNING METHODS - Christian Connections for ...































































 


FAMILY PLANNING METHODS:

HOW DO THEY WORK AND WHY DOES IT MATTER

Christian Connections for International Health (www.ccih.org)

Family Planning/Reproductive Health Working Group ∗

Christian Connections for International Health (CCIH) is aware that how family planning

methods work is a concern among a number of its member organizations (1). The decision about

which methods are acceptable varies widely among Christian organizations and individuals, and

is influenced for some by whether the method acts to prevent conception or is thought to act as

an abortifacient (capable of causing an abortion).

One of the objectives of CCIH is to provide updated, evidence-based information, resources and

viewpoints on a variety of pertinent international health topics to serve our member

organizations and affiliates. Because family planning is a topic of considerable interest, the

purpose of this paper is to primarily address how basic methods work and to clarify what is

currently known with respect to specific methods.

There is no universally accepted definition of precisely what constitutes abortion; however,

according to most legal, regulatory and medical authorities “abortion” is the termination of an

established pregnancy after implantation of a fertilized egg in the uterus (womb). Implantation

occurs at 5-7 days after ovulation (release of the egg) and fertilization (which typically occurs

within the first 12 hours after ovulation). Actions before implantation that prevent pregnancy are

“contraceptive”. This definition is used by the US Food and Drug Administration/National

Institutes of Health (2) and the American College of Gynecologists and Obstetricians (3).

Some faith communities and some individuals consider any action that prevents implantation of

a fertilized egg to be a very early abortion (4,5,6,7). For some in these communities, if the

primary mechanism of action is to prevent fertilization, this is acceptable. For others, any

possibility of a post-fertilization effect that would prevent implantation is problematic. CCIH

acknowledges and respects the differing views and values that result in different definitions of

abortion.

The information here is largely based on peer-reviewed documents and consensus material from

mainstream health sources (8,9,10) [Reference 10 is especially useful for description of terms

and basic reproductive processes]. Decisions regarding family planning methods are based on
































































∗ 
*By Douglas Huber, with contributions from Devina Patel, Victoria Jennings, Henry Mosley, Judith Brown,

Raymond Martin, Anne Wilson, Nancy Harris, Rose Nesbitt, and Michelle Fraser.

Contact: Douglas Huber, Co-Chair, Family Planning/Reproductive Health Working Group;

DouglasHuber777@yahoo.com.









































































several factors related to optimal health outcomes as well as the beliefs and values of

organizations and individuals. The mechanisms of action of family planning methods are only

one consideration in these decisions. Family planning choices often involve deciding where

individuals or couples are willing to make a compromise – effectiveness of the method, safety,

convenience, alignment with religious perspectives or some combination of these. CCIH

respects the different approaches by faith communities to enable couples to voluntarily achieve

their desired number and timing of pregnancies, consistent with the communities’ religious

teachings and values. We urge secular organizations to do the same.

Q1. What is family planning

A. “Family planning”, as used by CCIH, means enabling individuals and couples to determine

the frequency and timing of pregnancies, including the use of a variety of methods for

voluntary prevention of pregnancy.

Q2. What are the ways family planning methods can work

A. There are 5 primary ways: 1) block sperm from reaching the egg; 2) change the man’s sperm

so they cannot fertilize the egg; ; 3) prevent eggs from being released; 4) thicken mucus in the

cervix, preventing sperm from passing; 5) alter the lining of the uterus (womb) so the

fertilized egg does not attach or implant. Many methods have multiple actions, and it is

currently not possible to precisely determine the contribution of each. Periodic abstinence is

often a part of fertility awareness-based methods (natural family planning). These methods

can also be used to increase the chances of achieving a pregnancy.

Q3. There are a lot of different family planning methods. What are the specific ways each one

works so people can make better informed decisions

A. The following table summarizes the main mechanisms of action and the relative strength of

each for preventing pregnancy (e.g., very strong, strong, moderate, weak). We comment on

the potential to have a post-fertilization effect that could prevent implantation. We make no

definitive statements on post-fertilization effects because failure of a fertilized egg to implant

cannot be directly assessed; however, when a method effectively prevents ovulation and/or

blocks/changes the man’s sperm so fertilization does not occur, there is no fertilized egg that

could be prevented from implanting. [In this table, we assume methods are used consistently

and correctly. For complete information on the contraceptive effectiveness of methods as

commonly used, as well as when used correctly and consistently, see reference 9.]


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Family Planning

Method

Pills (Combined estrogen

and progestin) (8,9)

Patch, Ring, injections

(progestin plus estrogen)

(8,9)

Mechanisms of Action

(Assuming correct and consistent use)

Prevents ovulation (release of the egg)—strong

Thickens cervical mucus to block the man’s sperm—strong

Post-fertilization effect—in theory, could occur, but rarely (no actual

evidence that it does), due to high effectiveness in preventing ovulation

and fertilization. Missed pills increase chance of ovulation and

pregnancy.

Similar to combined pills

Progestin-only pills (POPs,

“minipills”) (8,9)

Injectables--progestin-only

(Depo-Provera and

Noristerat) (8,9)

Emergency contraceptive

pills (ECPs) (progestinonly

[levonorgestrel] pills).

ECPs are used after

unprotected sex to prevent

an unintended pregnancy

(8,9)

Thickens cervical mucus to block the man’s sperm—strong

Prevents ovulation—weak to moderate (ovulation may occur with 40%

of menstrual cycles)

Post-fertilization effect—may be rare or occasional, depending on

whether taken during breastfeeding. Probably rare when used during

breastfeeding when there is a dual effect from the pills and

breastfeeding to prevent ovulation. May be occasional when not

breastfeeding and ovulation is more common. Missed pills increase

chance of ovulation. POPs change lining of the uterus. Ectopic (tubal)

pregnancy can also occur; e.g. pregnancy develops in the woman’s tube

rather than the uterus (though the risk of ectopic pregnancy is lower

than if no method were used)

Prevents ovulation—very strong

Thickens cervical mucus to block the man’s sperm—strong

Post-fertilization effect—in theory could occur, but very rarely (no

actual evidence) due to very effective prevention of ovulation and

fertilization

Prevents ovulation—strong if taken before ovulation—does not work if

taken on day of ovulation

Thickens cervical mucus to block the man’s sperm—weak

Post-fertilization effect—unlikely, based on recent studies showing

ECPs work by preventing or delaying ovulation if taken before the

expected day of ovulation. If taken on day of ovulation or later,

implantation and pregnancy appear to occur at normal rates (11,12).

Note: A number of organizations are opposed to ECPs based on an

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Implants--progestin-only

(Jadelle, Implanon, Sinoimplant

II) (8,9)

Intra-uterine device (IUD)

(Copper T 380A) (9)

Intra-uterine device with

the progestin

levonorgestrel (Mirena)

(8,9,10)

Barrier methods—

condoms (male and

female), diaphragms, caps

understanding that the uterine lining is altered if ovulation occurs,

thereby preventing implantation of a fertilized egg. Complete absence

of a post-fertilization effect cannot be proven, but the available evidence

clearly shows prevention or delay of ovulation as the main (and possibly

the only) mechanism of action. ECPs have no effect on a pregnancy if

taken after implantation has already occurred.

Prevents ovulation— very strong

Effect on cervical mucus to block the man’s sperm—strong

Post-fertilization effect—in theory could occur but very rarely (no

actual evidence) due to very effective prevention of ovulation and

fertilization

Changes and inhibits sperm--very strong. The changes in the uterine

cavity (womb) due to the copper and presence of the IUD incapacitate

sperm, preventing migration and ability to fertilize the egg (8,13,14,15).

Prevents ovulation—none

Thickens cervical mucus to block the man’s sperm—none

Post-fertilization effect—in theory could occur, but only rarely, due to

very effective prevention of fertilization. Ectopic (tubal) pregnancy

very rare. Note: Earlier generations of IUDs without copper (e.g. the

Lippes Loop) more often allowed fertilization, and were more likely to

prevent implantation if there was a fertilized egg. Ectopic pregnancy

was much more common than with currently available IUDs, though

still considerably less than would occur with no contraception.

As emergency contraception, the Copper T may be used for up to 5 days

after unprotected sex—it is very effective, even when inserted after

ovulation and fertilization. But in this case, it most likely has a postfertilization

effect that prevents implantation as one mechanism of

action when used for emergency contraception (12).

Thickens cervical mucus to block the man’s sperm--strong

Inhibits ability of sperm to migrate and capacity to fertilize the egg—

strong

Prevents ovulation—weak to moderate

Post-fertilization effect—in theory could occur, but rarely, (no actual

evidence) due to very effective blocking and impairing sperm, such that

fertilization is rare. Ectopic pregnancy is also very rare.

Blocks sperm from reaching egg—strong (when used correctly)

Post-fertilization effect—none


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Fertility awareness-based

methods (Standard Days

Method [CycleBeads],

Symptothermal Method,

Billings

Ovulation/Cervical Mucus

Method, TwoDay Method)

(8,9)

Breastfeeding and

lactational amenorrhea

method-(LAM) (9)

Postpartum infertility with

no breastfeeding (8)

Voluntary sterilization

(tubal ligation, “tying the

tubes” for women;

vasectomy for men)

(8,9,10)

Identifies fertile days during menstrual cycle so couple can avoid

unprotected sex-- by abstaining (if practicing natural family planning)

or using a barrier method.

Post-fertilization effect—no effect on lining of the uterus. Some

theoretical concerns (but no actual evidence) about whether fertilization

of a delayed ovulation could, on occasion, result in a fertilized egg

being impaired or unable to implant (4,16). Most research suggests this

is unlikely to be a common problem, though direct measurement cannot

be made (8).

Prevents ovulation up to 6 months—strong for LAM—variable if not

following the 3 LAM criteria, which are: 1) less than 6 mo. postpartum;

2) fully or nearly fully breastfeeding; 3) no return of menses

Post-fertilization effect—might occur, especially if breastfeeding

beyond 6 months. The first ovulation can precede the first menstruation,

especially with prolonged breastfeeding. These early ovulations are

typically followed by sub-normal amounts of the hormones needed to

prepare the lining of the uterus for implantation if the egg is fertilized

(8,17,18,19,20).

Prevention of ovulation—variable

Post-fertilization effect—might occur. Most non-breastfeeding women

in the postpartum period have their first ovulation at about 6 weeks.

First ovulations are most often followed by sub-normal amounts of

hormones, as are about 25% of second and third ovulations. Therefore,

a fertilized egg might not implant if fertilized during the first several

menstrual cycles after birth (8,21)

Blocks sperm from meeting the egg—very strong

Ectopic pregnancy—very rare (e.g., implantation in the woman’s tube)

can occur if female sterilization fails. No effect if vasectomy fails.

Vaginal spermicides (8,9)

Impairs the man’s sperm ability to migrate and fertilize the egg—

moderate

Post-fertilization effects—none

Q4. Why don’t we know accurately how often some family planning methods might prevent

implantation

A. There are two important reasons: 1) No practical test is available to detect fertilization of the

egg, that takes place in the tube before implantation. Most pregnancy tests turn positive after


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implantation, around the time the woman misses her menstrual period (about 12-14 days after

fertilization). 2) Many fertilized eggs among all couples, whether using a family planning

method or not, are abnormal (from 30-70%), and therefore do not divide and develop

normally. About 50% of fertilized eggs never progress to become a recognized pregnancy.

Most are incapable of implanting. Of those that do implant, many result in spontaneous

abortions (miscarriages) -- about 15% of all established pregnancies. A few result in live

births with congenital abnormalities (birth defects) -- about 3% of all births (22,23,24).

While science has learned much about our basic human reproduction and the mechanisms of

action for family planning methods, the wonder of how our reproduction works remains an

unfolding story, as it is in other areas of human biology.

Q5. It seems natural loss of fertilized eggs is very common and not really within our control.

Are there other factors within our control that cause failure of fertilized eggs to implant and

miscarriages

A. Several life style factors affect the chances of a fertilized egg being healthy and capable of

implanting and developing normally. Age of the woman affects the frequency of genetic

abnormalities and early miscarriage. Men who smoke have genetic damage to their sperm,

resulting in increased failure to implant, early miscarriages, birth defects and childhood

cancers. Obesity in women is associated with higher rates of miscarriage and intra-uterine

death. Sub-normal hormone levels are more common after ovulation for women experiencing

psychological stress, athletic training or abrupt weight loss; therefore, the lining of the uterus

would not be optimally prepared for implantation. Damage to a woman’s tubes due to

sexually transmitted infections, endometriosis, and fibroids in the uterus reduce chances of

implantation and normal development (25). Several of these factors are largely within our

control and the effects are better documented than the potential that some family planning

methods may prevent implantation. As we learn more about how we are created and live, it

seems much that affects our health and human wholeness is linked to our reproduction. As

people of faith, there are many factors that need to be addressed to minimize loss of fertilized

eggs, reduce miscarriages, and optimize the health of women and children. The choice of

family planning method is one of many considerations.

Conclusion

The need for family planning methods is greatest in the poorest countries where current lack of

family planning results in many women seeking unsafe abortions (26). Family planning is a

powerful way to prevent abortion. Reducing unintended pregnancies and the need for abortion

produces health benefits that are strongly embraced by both Christian and secular health

organizations. A maternal death from any cause is a tragedy—but when a woman dies from a

pregnancy she did not want, it is a double tragedy. As Christians we have an obligation to weigh

all the health consequences for those we serve when deciding to provide or omit any family

planning method, since all reduce untended pregnancies and abortion. We trust that CCIH will

be a forum where issues of reproduction can be faithfully and respectfully discussed in light of

our common desire to advance health and wholeness from a Christian perspective.


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References

1. Huber D, Yang ER, Brown J, Brown R. International Family Planning: Christian Actions and Attitudes: A

survey of Christian Connections for International Health Member Organizations. Christian Connections for

International Health, August 2008. http://www.ccih.org/Working_Groups/FP-RH_Survey_index.htm. Accessed 25

June 2010.

2. National Institutes of Health. Protection of Human Subjects, 45 C.F.R. Sect. 46.202 (2009).

3. Hughes EC (ed), Committee on Terminology, The American Congress of Obstetricians and Gynecologists,

Obstetric-Gynecologic Terminology. Philadelphia PA: F.A. Davis Company, 1972.

4. Cutrer WR, Glahn SL. The Contraception Guidebook: Options, Risks, and Answers for Christian Couples.

Christian Medical Association Resources, Zondervan, Grand Rapids, Michigan, 2005

5. Christian Medical & Dental Associations Position Statement, Possible Post-conceptional Effects of Hormonal

Birth Control. Approved by the Board of Trustees, September 1998.

http://www.cmda.org/AM/Template.cfmSection=Ethics_and_Position_Statements&Template=/CM/ContentDispla

y.cfm&ContentID=8158. Accessed 25 June 2010

6. Association of Prolife Physicians, Do Oral Contraceptives Cause Abortions January 1998.

http://www.prolifephysicians.org/abortifacient.htm. Accessed 24 June10

7. United States Conference of Catholic Bishops. Married Love and the Gift of Life. November 14, 2006.

http://www.usccb.org/laity/marriage/MarriedLove.pdf. Accessed 25 June 2010

8. Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology (19 th revised

edition). Ardent Media, New York 2007

9. World Health Organization. Global Handbook for Family Planning Providers. 2008.

http://www.infoforhealth.org/globalhandbook/.

10. American Congress of Obstetricians and Gynecologists. Patient Education Pamphlets: Birth Control (October

2007) (AB020—English) (SB020—Spanish) http://www.acog.org/publications/patient_education/. Accessed 25

June 2010.

11. International Consortium for Emergency Contraception and International Federation of Gynecology &

Obstetrics. Statement on Mechanism of Action. How do levonorgestrel-only emergency contraceptive pills prevent

pregnancy October 2008.

http://www.figo.org/files/figocorp/International%20consortium%20for%20emergency%20contraception%20stateme

nt.pdf. Accessed 25 June 2010.

12. Trussell J, Raymond EG. Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy. June

2010. http://ec.princeton.edu/questions/ec-review.pdf. Accessed 25 June 2010.

13. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine

contraceptive devices. Am J Obstet Gynecol 1999; 181: 1263 – 1269

14. Mishell DR. Intrauterine devices: mechanisms of action, safety, and efficacy. Contraception.

1998;38(Suppl):458-538.

15. Family Health International: Fact Sheet: Mechanisms of the Contraceptive Action of Hormonal Methods and

Intrauterine Devices (IUDs). http://www.fhi.org/en/RH/Pubs/factsheets/mechact.htm. Accessed 24 June 2010


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16. Bovens L. The rhythm method and embryonic death. J Med Ethics 2006;32:355-356.

http://jme.bmj.com/cgi/content/full/32/6/355.

17. Diaz S, Cardenas H, Brandeis A, Miranda P, Salvateirra AM, Croxatto HB. Relative contributions of

anovulation and luteal phase defect to the reduced pregnancy rate of breastfeeding women. Fertility and Sterility.

1992;58:498-503.

18. Lewis PR, Brown JB, Renfree MB, Short RV. The resumption of ovulation and menstruation in a wellnourished

population of women breastfeeding for an extended period of time. Fertil Steril. 1991;55:529-36.

19. Brown JB, Harrisson P, Smith MA. A study of returning fertility after childbirth and during lactation by

measurement of urinary oestrogen and pregnanediol excretion and cervical mucus production. J. Biosoc Science.

1985;9(Suppl):5-23.

20. Gray RH, Campbell OM, Apelo R, Eslami SS, Zacur H, Ramos RM, Gehret JC, Labbok MH. Risk of ovulation

during lactation. Lancet. 1990;335:25-9

21. Gray RH, Campbell OM, Zacur H, Labbok MH, MacRae SL. Postpartum return to ovarian activity in nonbreastfeeding

women monitored by urinary assays. J Clin Endocrinol Metab 1987;64:645-650.

22. Macklon NS, Geraedts JPM, Fauser BCJM. Conception ongoing pregnancy: the “black box” of early

pregnancy loss. Human Reproduction Update, 2002,Vol. 8,No.4;333-343

23. Sadler TW. Langman’s Medical Embryology, 8 th ed. Lippincott Williams & Wilkins, Philadelphia, 2000.

24. Schoenwolf GC, Bleyl SB, Brauer PR, Francis-West PH. Larsens’s Human Embryology. Elsevier Churchill

Livingstone, Philadelphia 2009.

25. Macklon NS, Greer IA, Steegers EAP. Textbook of Periconceptional Medicine. Informa healthcare UK, 2009.

26. Family Planning/Reproductive Health Working Group. Family Planning Prevents Abortion: Fact Sheet.

Christian Connections for International Health, (in preparation, July 2010). [Lead writer, Judith Brown;

judithevansb@yahoo.com]


This publication was made possible by support from the Institute

for Reproductive Health at Georgetown University. The contents

are the responsibility of Christian Connections for International

Health.

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