Contraceptives: Don't let pregnancy catch you off-guard

Jun 12, 2013

Birth control, also known as contraception, are methods or devices used to prevent pregnancy. While some people take the time to consult and understand the contraceptives that suit their bodies, others jump onto those methods that may seem convenient without first consulting a specialist.

Birth control, also known as contraception, are methods or devices used to prevent pregnancy. While some people take the time to consult and understand the contraceptives that suit their bodies, others jump onto those methods that may seem convenient without first consulting a specialist. Vicky Wandawa writes:  
 
 
Reallife: ‘I conceived while on birth control’
When my first born was only five months old, I discovered that I was seven weeks pregnant. I swore to start using contraceptives as soon as I had my second born.  Three weeks after delivering my second born, I went to a popular government health centre and asked to have an Intra-Uterine Device (IUD) inserted.
 
The procedure was a bit painful, but the doctors explained that it was because I had undergone a C-section and that my uterus had not healed well. I was so determined to first take care of my children, who were very often mistaken to be twins.
 
At four months, I felt like the coil was moving downwards so I went for a check-up and it was removed it. I suspected that it may have not been inserted well the first time, so I went to another specialist who was more experienced in family planning and he inserted another IUD. 
 
I had an ultra sound scan done to ascertain whether the coil had been inserted well and indeed it was, so I knew I was covered. About eight months down the road, I missed my periods and thought that it might have been because of change of diet since I had been fasting. Subsequently, I developed a bitter taste in my mouth.
 
At first, I suspected it was malaria, however, the test proved me wrong. A doctor recommended a urinalysis test to check if I had an infection in the urinary tract. But after revealing that I had missed my period, he recommended a pregnancy test. To my disbelief, I tested positive. I asked the doctor  a ‘thousand’  questions but he had no answer.
 
I was advised to do an ultra sound scan. The IUD had moved down and the foetus was in the right position. The device was removed. Luckily, my husband was so supportive. We thanked God for another gift of life and are ready to receive another member in our family.
 
 
What causes birth control failure?
It is definitely shocking when you test positive for pregnancy yet you have been using contraceptives (an agent or device intended to prevent conception). 
 
Dr. Evelyn Nabunya, a gynaecologist/obstetrician at Mulago Referral Hospital, defines birth control failure as a situation when a woman gets pregnant despite the use of contraceptives. Failure to follow the strict guidelines for a given method is the key cause, she says. 
 
“Some methods cause discomfort and are therefore not used for the duration they should be used, while others are used without following strict guidelines. However, some methods fail even when used perfectly. Up to 53% of unplanned pregnancies occur in women who are not using contraception,” she elaborates
 
Jamal Abduo, an obstetrician at Paragon Hospital in Bugolobi suburb, says amongst  all the methods of family planning, none is 100% effective. “It is only that some are more effective than the others,” he says. 
 
Abduo further adds that when choosing a method, one should go to a qualified health worker and have a comprehensive medical examination. In addition, one should provide all the details of their medical history, such that the most suitable method is recommended. 
 
Contraception can be reversible or permanent. Reversible contraceptives provide effective contraception for an extended period of time without requiring user action, for instance, the intrauterine contraceptive device (IUCD). Others are hormonal methods (to suppress ovulation), barrier methods (to block sperm from entering the uterus) and natural family planning, a method of working out when a woman is most fertile and then avoiding unprotected sex.
 
Permanent methods, on the other hand, include; vasectomy (to prevent the release of sperm when a man ejaculates), trans-cervical sterilisation and tubaligation (surgical procedure for female sterilisation that involves severing and tying the fallopian tubes).
 
Compliance is key
Abduo explains that pills, for example, should be taken daily at the same time. If one is using the cervical cap or diaphragm, it should completely cover the cervix before sexual intercourse. However, some users may not follow the guidelines, hence resulting in pregnancy.
 
Nabunya explains that IUCD users need to check that the device is in place every month. When it comes to condoms, they should be in good condition, properly packed and lubricated.
 
“After ejaculation, the penis should not be kept inside the vagina, or the possibility of sperm leaking from condom is raised, consequently resulting in pregnancy,” says Nabunya.
 
Inconsistent use of contraceptives
“Forgetting to take even just a pill increases risks of conceiving,” says Nabunya. She advises that when pills are not used as they should be, a barrier method, such as condoms, should be used every time you have sex.   

Condom breakage
Breakage or even the smallest tear can lead to pregnancy. Causes of condom breakage include; improper use, inadequate use of water-based lubricants, using expired condoms, improper storage, having jewelry on while handling condoms, long finger nails and other objects that may cause tears.
 
Certain drugs or herbs
Nabunya advises that people should check with a doctor if certain drugs or herbs may cause interactions that reduce the effectiveness of pills.
 
Fertile period mistake
Miscalculating that one is not in the fertile days can potentially lead to an unplanned pregnancy.

Age factor
A quarter of unplanned pregnancies occur in women below 20 years. Lack of experience or immaturity of adolescents is an important factor of contraception failure. 
 
Sickness
Sickness like vomiting or loose stool increase the chances of contraceptive pill coming out of the body without being absorbed.

Obesity in women
Women who are obese take longer to absorb the contraceptive pill, therefore reducing efficacy, Nabunya says.

Coitus interruptus (withdrawal)
The common, but risky form of birth control, is practiced by couples, the world over. “But accidents can occur. Even a drop of semen before withdrawal can result in pregnancy. Pre-ejaculatory fluid also contains sperm that can impregnate a woman,” says Nabunya.
 
Conceiving after IUCD and tubaligation
Abduo says although rare, women conceive even with IUCDs. “In case you conceive, you should have the device removed because it has the potential to perforate the uterus.”  
 
Regarding tubaligation, Abduo warns that in some women, the fallopian tubes can re-canalise, or join back together, hence allowing conception. Sometimes, the kind of stitch used after tubaligation may make it easier for recanalisation. 
 
Also, the wrong tissues, and not fallopian tube, could be mistakenly cut. “That is why it is advisable that the pieces cut from tubes should be taken for histology, to be studied in the laboratory so as to confirm that they are actually from the fallopian tube.”
 
What’s the best method?
The best method is one which works best for a couple. This is because what is convenient for one couple may not be for another. In addition, each method has its advantages, disadvantages and risks.
 
But ideally, one should be informed about all methods of family planning and the risks of conceiving, before they decide which to take on.
 
 
How do contraceptives work?
Intrauterine contraceptive device (IUCD)
The IUCD or ‘coil’ is a small device with a string, which is placed inside the uterus to prevent pregnancy. It should be inserted by a trained health worker. Abduo explains that there are two types; the copper-T and hormonal (also known as Mirena). 
Both types stop sperm from meeting the egg.
 
“The copper lasts up to 10 years. The hormonal method, which works by slowly releasing progestin into the uterus to prevent pregnancy, lasts up to five years,” says Nabunya.
 
One’s chance of getting pregnant will go back to normal as soon as the copper or hormonal IUCD has been taken out. The IUCD’s failure rate, according to Nabunya, is minimal, at only 0.2% for the hormonal and 0.8% for the copper T.

Hormonal methods 
 
Implants
These are small rods put underneath the skin on the inner part of a woman’s arm. “The single rod implants can be effective for three years, while the five-rod implants can be effective for five years,” says Nabunya.
 
They can actually be felt under the skin, she adds. They slowly release a hormone called progestin to prevent pregnancy.
When implants are inserted, periods are likely to change. 
 
A few women miss their periods, while others have their normal periods, but most women have a change in bleeding pattern, the experts reveal. However, one’s natural fertility returns as soon as the implant is removed.
 
It is suitable for women who may not find it convenient to take the pill, fulfil their injection appointments or who may have a medical reason that stops them from using the pill. 
 
Injection (Depo-Provera)
This is an injection given every three months. Some women have irregular or prolonged bleeding, especially in the first three to six months. Most women (70%) will have no periods after four injections. Natural fertility can take some time to return to normal — on average, six months, although it can take up to one year.  

Combined oral contraceptive pills
Nabunya emphasises that these should be taken daily at the same time to prevent pregnancy. The pill contains both progestin and oestrogen, which stop the eggs from developing. Abduo explains that the pill must be taken daily, whether sexual intercourse takes place or not.
 
“Unfortunately, some women opt for this method, but because they do not stay with their partners, they only remember to take the pill when their partners are around, which makes them ineffective,” says Abduo.
 
Progestin only pill (mini pill)
It is an oral contraceptive that contains the hormone, progestin. Nabunya advises that the mini pill should also be taken daily at the same time, for effectiveness. It is easily reversible and fertility can return as soon as one stops taking the pill. Some women may experience weight gain or irregular menstrual bleeding, among other effects. 

The patch
These are worn on the lower abdomen, buttocks or the upper body, but not on the breast. They contain both progestin and oestrogen. “They are worn once a week for three weeks, but not in the fourth week, to allow for menstrual periods,” says Nabunya. 
 
They are just like combined oral contraceptive pills, only that a patch is used instead of taking pills. The patch is stuck on to the skin so that the two hormones are continuously delivered to the body.
 
One does  not have to remember to take the pill every day, but has to remember to change the patch once a week. Some women have skin irritation when they use the contraceptive patch. 

Hormonal vaginal contraceptive ring
The plastic ring comprises both progestin and oestrogen, which are continuously released into the bloodstream. “It is placed in vagina for three weeks, but taken out during the fourth week for the menstrual period to take place, after which, a new ring is inserted,” Nabunya explains. 

Emergency contraception (Morning after pill)
Nabunya says that the emergency contraception pill is not a regular method and should only be used after failure of a regular method, for example, when a condom breaks during sexual intercourse.  
 
Barrier methods
Diaphragm or cervical cap
It is placed in the vagina to cover the cervix and block sperm. The diaphragm is inserted with spermicide to block or kill sperm. A woman can easily insert the diaphragm whenever she expects to have sex. 

Male condom
It should be used once. Nabunya warns against using condoms with oil-based lubricants like petroleum jelly and baby oil because these weaken condoms, causing breakage. 
 
Female condom
These can be inserted up to eight hours before sexual intercourse. 
 
Spermicides (foam, gel, cream, film, tablet) 
These kill sperm and are placed in vagina, not more than an hour before intercourse. “They should be left in place at least six to eight hours after intercourse. They can be used with the male condom, diaphragm or cervical cap,” says Nabunya. 
 
Natural family planning versus fertility awareness
“This involves understanding of one’s monthly fertility pattern in order to plan or prevent pregnancy. One has to abstain during fertile days or use a barrier method,” says Nabunya. The failure rate is 24% .
 
Permanent methods
“Here, the failure rate is less than 1%,” says Nabunya.
 
Female sterilisation 
Also known as tubaligation, the fallopian tubes are tied so as to prevent the sperms and eggs from meeting.  
 
Trans cervical sterilisation
A thin tube is used to place a tiny device inside a fallopian tube. It irritates the tubes and causes scar tissue to grow, hence permanently plugging the tubes. It takes about three months for scar tissue to grow, as other methods are used to prevent pregnancy. 
 
Male sterilisation/vasectomy
Vasectomy keeps a man’s sperms from going to his penis, such that when his ejaculates, there is no sperms to fertilise an egg. However, it takes about 12 weeks for the sperm count to drop to zero.
 
Men play key role in contraceptive use 
As we commemorate Father’s Day on June 16, Health & Beauty explores the role of men in choosing contraceptives. Agnes Kyotalengerire writes:
 
“I cannot waste time going to hospital to discuss the type of contraceptives to use. I believe it is up to my wife to decide what works best for her,” says a married man who prefers anonymity. 
 
Robert Okumu, a father of four, admits that in the last eight year of their marriage, he has not bothered to find out the kind of contraceptives his wife uses. 
 
“Sometimes I wonder how she has managed to space the children without giving birth every year,” Okumu wonders. 
Such is the poor mentality of men who still think that contraceptive use is a women’s affair.  
 
On the contrary, some men sabotage contraceptive use. Maria Waiswa a resident of Balawole sub-county in Kamuli district has had five children in five years. Waiswa says she would like to use contraceptives, but her husband is against the use of contraceptives. “Whenever I mention going to a health centre to pick some for myself, he reminds me of how he married me to give birth to children,” she says. 
 
Unlike Waiswa, some women stealthily take contraceptives without the knowledge of their husbands or opt for family planning methods that their husbands would not find out easily for fear of being reprimanded. 
 
It is such testimonies that contribute to the current unmet need (women who want to use contraceptives but cannot access the services) that amounts to 34% (UDHS Report 2011). 
 
The role of men 
Dr. Moses Muwonge, a reproductive health consultant at SAMASHA Medical Consult, an organisation that advocates for reproductive health in Uganda, says it is common practice for men to refuse accompany their wives to seek family planning services, claiming they are busy.
 
He says male participation starts with men sitting together with their wives and agreeing on how many children to have and what method of contraception to use to space the births.
 
Though some men still think contraceptive use is a women’s affair, Dr. Zainab Akol, the priniciple medical officer, Ministry of Health, says in a country with gender inequalities in family planning, there is need for men to play a greater role in the implementation of the family planning policy.
 
“Men should get involved even before their children are born, by accompanying their wives to access family planning services.”  
 
According to Akol, male participation should include agreeing together as a couple on how many children to have, the spacing and what method to use.
 
Deisy Ssenyonga, a senior nursing officer at Mengo Hospital, says mostly women alone seek family planning services.   
“Men claim not to have time to accompany their wives to seek family planning services,” Ssenyonga says.
 
She adds that it is important that men come along so as to understand the importance of family planning, which in essence reduces child and maternal mortality, partly due to failure to space childbirth. 
 
“During the counselling, men get to know how the methods work and the possible side-effects so that they can make an informed decision,” she adds. 
 
Aside, the men can play a supportive role of reminding their wives to take contraceptives, for example, pills or going for their next appointment to avoid unplanned pregnancies. 
 
 Akol says often many women want to use contraceptives but are limited by poverty. It is important that men provide financial support in form of transport facilitation to health centres to access services.  
 
Some studies reveal that husbands who are present during childbirth are more likely to use contraceptives than those whose husbands are not present. 
 
Men too can use short-term contraceptive methods such as condoms or long-term methods like vasectomy. 
 

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