BY CORRESPONDING AUTHOR: EKEOCHA ONYINYE H.

INITIATOR: DR. (MRS.) CHINWEUBA ANTHONIA U.

DATE: JULY, 2019

 

INTRODUCTION

Evidence of contraception exists in some of the earliest written records. The practice of contraception is as old as human existence. For centuries, humans have relied on their imagination to avoid pregnancy. Ancient writings noted on the Kahun papyrus dating to 1850 BC refer to contraceptive techniques using a vaginal pessary of crocodile dung and fermented dough, which most likely created a hostile environment for sperm. The Kahun papyrus also refers to vaginal plugs of gum, honey, and acacia. During the early second century in Rome, Soranus of Ephesus created a highly acidic concoction of fruits, nuts, and wool that was placed at the cervical os to create a spermicidal barrier (Seregély, 1981). Many birth control methods have been used for hundreds of years: the condom since the 16th century; cervical cap since the 1820s; the diaphragm and vaginal spermicide since the late 19th century; and intrauterine contraceptive devices (IUCDs or IUDs) since the early 20th century. Today, the voluntary control of fertility is of paramount importance to modern society. From a global perspective, countries currently face the crisis of rapid population growth that has begun to threaten human survival. At the present rate, the population of the world will double in 40 years; in several of the more socioeconomically disadvantaged countries, populations will double in less than 20 years (WHO, 2015).

 

The effort by government and non-governmental agencies to promote the right of women and men to be informed, access and use safe, affordable and effective methods of fertility regulation has yielded only a marginal change over time (Creanga, Gillespie, Karklins & Tsui, 2011); (UNDESA, 2013). For instance, the Federal Government of Nigeria through the Federal Ministry of Health has continually made efforts to ensure widespread knowledge and access to contraceptives through advertisements and jingles in the mass media, incorporation of family planning into some secondary school subjects and distribution of free contraceptives (FMOH, 2013). These efforts resulted in an increase in the proportion of Nigerians who know at least a modern method of contraceptive, but usage has remained very low. Given the significance of contraceptive use for maternal and child health, family and national wellbeing (Sonfield, Hasstedt, Kavanaugh, & Anderson, 2013), the persistent gap between knowledge and use of contraceptives underscores the need for more research, particularly those that focus on couples.

 

The objectives of this paper are to;

1.explain the concept of contraception.

2.identify the similarities of users of orthodox and traditional methods of contraception

3.identify the differences of users of orthodox and traditional methods of contraception.

4.outline the defining characteristics of users of orthodox and traditional methods of contraception

5.outline the nursing implication.

 

CONCEPT OF CONTRACEPTION

Every month a woman's body begins the process that can potentially lead to pregnancy. An egg (ovum) matures, the mucus that is secreted by the cervix changes to be more inviting to sperm, and the lining of the uterus grows in preparation for receiving a fertilized egg. Contraception is designed to interfere with the normal process and prevent the pregnancy that could result. Contraception (birth control) prevents pregnancy by interfering with the normal process of ovulation, fertilization, and implantation by acting at different points in the process (WHO, 2015)

Samuel (2010), defined contraception as a deliberate use of techniques (natural or artificial) to prevent pregnancy by interfering with the normal process of ovulation, fertilization, and implantation. It is the use various devices, drugs, agents, sexual practices, or surgical procedures to prevent pregnancy. Somba, Mbonile, Obure, and Mahande, (2014) viewed contraception as family planning method which comprises the used of both scientific and traditional techniques such as injections, pills, condoms, spermicidal, Intra-Urine Devices (IUD), diaphragm, vaginal rings and other methods to prevent conception or pregnancy as well  as protection against sexually transmitted infections. The three main ways of birth control are: contraception (the prevention of fertilization of the ovum by sperm cells), contragestion (preventing the fertilized egg from implantation), and the chemical or surgical induction of abortion of the developing embryo. Unfortunately, there is no perfect form of birth control. Only abstinence (not having sexual intercourse) protects against unwanted pregnancy with 100 percent reliability. All forms of birth control have one feature in common. They are only effective if used faithfully (WHO, 2015)

 

 

Classification of contraceptives

The most common classification system for contraceptives involves dividing methods into the categories of modern and traditional methods (although there are inconsistencies in the definition and criteria for classifying methods as modern). Other classifications are based on;

Duration; comprising of permanent (irreversible) and temporal (reversible) methods. Permanent contraception include vasectomy and tubal ligation

Types/mode of action; made up of hormonal, mechanical, chemical, natural, surgical, mixed emergency or routine contraception.

 

Natural Family Planning

Natural family planning is one of the most widely used methods of fertility regulation, particularly for those whose religious or cultural beliefs do not permit devices or drugs for contraception. This method involves periodic abstinence, with couples attempting to avoid intercourse during a woman's fertile period, which is around the time of ovulation. They include;

 

Waist Beads

Beads are huge traditional symbols to represent many values. Among these values are the protections against pregnancy. Albert (2014) believes that, beads are used for traditional ceremony, music without beads is incomplete. He also asserted that, family planning method is promoted by the use of beads. Women wear beads to inform their husband that she is menstruating and not in the right time for sex. However, it is obvious that this method will be very effective, if only the husband will not force his wife to sex and not every man has that ability to subdue their hunger for taste just by seeing beads around his wife’s waist especially when they are drunk (Albert,2014).

 

Abstinence

This is the avoidance of sexual intercourse among married couples for a particular period of time. Samuel (2010) believes that, abstaining from sex is the commonest and most effective traditional family planning method which can also prevent sexually transmitted infections and HIV/AIDS provided it is strictly and honestly practiced. However, it is obvious that this method will be very effective, but the vital question is how long would they abstain from sex when sex is one of human’s psychological needs. Hence, it is difficult to practice.

Coitus Interruptus

Coitus interruptus involves withdrawal of the entire penis from the vagina before ejaculation. Thus, ejaculation should be away from the introitus. However, it requires extreme self -control on the part of the man. The man controls his emotion so as not to reach a climax during intercourse. Mobalanle, (2005) asserted that, the method is very unreliable as a small amount of semen may escape or ejaculation may occur unexpectedly. Not all men can control this and it could lead to emotional disturbances and psychological complication.

 

Lactational Amenorrhea

Elevated prolactin levels and a reduction of gonadotropin-releasing hormone from the hypothalamus during lactation suppress ovulation. This leads to a reduction in luteinizing hormone (LH) release and inhibition of follicular maturation. The duration of this suppression varies and is influenced by the frequency and duration of breastfeeding and the length of time since birth. The baby must be less than six months old for perfect use. (Alana, 2017).

 

Calendar method

The calendar method is based on 3 assumptions as follows: (1) A human ovum is capable of fertilization only for approximately 24 hours after ovulation, (2) spermatozoa can retain their fertilizing ability for only 48 hours after coitus, and (3) ovulation usually occurs 12-16 days before the onset of the subsequent menses etc. This is practicable in women with relatively regular cycles.  Sexual intercourse is avoided 3 days from the estimated ovulation date up to 3 days after the said date (a total of 7 days). The estimated date of ovulation is usually (not always) 14 days from the date of her expected next period. Alternative to calendar calculation is the rhythm method, which requires the woman to know her menstrual calendar for the past 6 months. Subtracting 18 from the shortest recorded cycle determines the estimated first day of fertile time (unsafe period). Subtracting 11 from the length of the longest cycle will determine the last day of fertile period.

For example, if the recorded menstrual cycle is 28 days, doing some counting:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18 19 20 21 22 23 24 25 26 27 28

 

To get the first day of the fertile (unsafe) period, count 18 backwards (starting from 28 and ending @ 11). And to get the last day of the fertile period, count 11 backwards (starting from 28 and ending @ 18). Abstinence from sex between day 11 to day 18 (9 days) is encouraged because these days are the fertile period and chances of getting pregnant is high. The billings method (calendar method) can also be used in 29-30, 31, 32, 33, 34 or 35 day cycle.

 

 

Cervical mucus method

With the cervical mucus method, the woman attempts to predict her fertile period by quantifying the cervical mucus with her fingers. Under the influence of estrogen, the mucus increases in quantity and becomes progressively more elastic and copious until a peak day is reached. This is followed by scant and dry mucus, secondary to the influence of progesterone, which remains until the onset of the next menses. Intercourse is allowed 4 days after the maximal cervical mucus until menstruation. A woman using the traditional method of family planning in Nigeria must know how to check for daily cervical mucus, and softness. Immediately after the last flow, the cervix may be dry or the mucus will be scanty, cloudy and sticky for the first 3, 4, 5, 6 or even 7 days depending on the length of menstrual cycle. These days are safe. The body makes more mucus when an egg starts to ripen and ovulation is about to happen. This mucus will be yellow, white, or cloudy and it feels sticky or tacky. Ovulation starts when the mucus becomes slippery and looks like egg white and can be stretched between the fingers. These “slippery days” are the fertile (unsafe) days when pregnancy is most likely to occur. After about 4 slippery days, the mucus reduces and gets cloudy and sticky or even dry- this is another safe period. It will be best to have a chart to record the daily dry days, wet days, sticky days, cloudy days and slippery days. Cervical mucus is best tested between the thumb and the index finger.

 

Sympto-thermal method

The symptothermal method predicts the first day of abstinence by using either the calendar method or the first day mucus is detected, whichever is noted first. The end of the fertile period is predicted by measuring basal body temperature. The basal body temperature of a woman is relatively low during the follicular phase and rises in the luteal phase of the menstrual cycle in response to the thermogenic effect of progesterone. The rise in temperature can vary from 0.2-0.5°C. The elevated temperatures begin 1-2 days after ovulation and correspond to the rising level of progesterone. Intercourse can resume 3 days after the temperature rise (Trussell 2011).

 

Artificial methods

Amulet (traditional method)

Ojusanya (1984) described an amulet as an object whose most important characteristic is the power ascribed to it to protect its owner from getting pregnant. It also protects against getting harmed. Potential amulets include gems, especially engraved gems, statues, coins, drawings, pendants, rings, plants, animals, and even words in the form of a magical spell or incantation to repel evil or bad luck. Amulet is also for the protection of women against infertility and miscarriage, and of the newborn against "the evil lilith" on the eve of the ritual circumcision. The negative side of amulet is that difficult rules are ascribed to it in order to make it effective and most couples find these rules difficult to follow (Hanson, Burke &Anne 2010).

 

Mechanical Barriers

Condom

Samuel (2010) posits condom to consist of a thin sheath placed over the glans and the shaft of the penis that is applied before any vaginal insertion. Female condom, on the other hand is a polyurethane sheath intended for one-time use, similar to the male condom. It contains 2 flexible rings and measures 7.8 cm in diameter and 17 cm long. The ring at the closed end of the sheath serves as an insertion mechanism and internal anchor that is placed inside the vaginal canal. It is one of the most popular mechanical barriers. Among all of the barrier methods, the condom provides the most effective protection of the genital tract from STDs. It prevents pregnancy by acting as a barrier to the passage of semen into the vagina.

 

Diaphragm

The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina. Diaphragms are manufactured in various diameters. A pelvic examination and measurement of the diagonal length of the vaginal canal determines the correct diaphragm size. It is inserted before intercourse so that the posterior rim fits into the posterior fornix and the anterior rim is placed behind the pubic bone. Spermicidal cream or jelly is applied to the inside of the dome, which then covers the cervix. It prevents pregnancy by acting as a barrier to the passage of semen into the cervix. After intercourse, the diaphragm must be left in place for at least 6 hours (Idowu and Akinsanya, 2016).

 

Cervical Cap

The cervical cap is a cup-shaped latex device that fits over the base of the cervix. A cervical cap acts as both a mechanical barrier to sperm migration into the cervical canal and as a chemical agent with the use of spermicide. It is inserted as long as 8 hours before coitus and can be left in place for as long as 48 hours. A cervical cap acts as both a mechanical barrier to sperm migration into the cervical canal and as a chemical agent with the use of spermicide.

 

Spermicidal Agents

This is a contraceptive substance that destroys sperm and it is inserted vaginally prior to intercourse to prevent pregnancy. Bartman, Stolpen, Pretorious and Malamud (2001), believe that as contraceptives, spermicide may be used alone. Vaginal spermicides consist of a base combined with either nanoxynol-9 or octoxynol. The actual spermicidal agent consists of a surfactant that destroys the sperm cell membrane. Bases include vaginal foams, suppositories, jellies, films, foaming tablets, and creams. These must be inserted into the vagina prior to each coital act. Use of spermicidal agents also reduces the risk of infection by both viral and bacterial organisms that cause STDs; however, clinical data on their efficacy for preventing the transmission of HIV are limited. Nonoxynol-9 is toxic to the lactobacilli that are part of the normal vaginal flora. Adverse effects include increased vaginal colonization with the bacteria Escherichia coli, which may predispose to bacteriuria after intercourse. Spermicides prevent sperm from entering the cervical os by attacking the sperm's flagella and body, reducing their mobility, and disrupting their fructolytic activity, thereby inhibiting their nourishment.

 

Hormonal Contraceptives

Implants

This method consists of a single rod of ethylene vinylacetate copolymer, measuring 40 mm long and 2 mm in diameter and containing 68 mg of etonogestrel. A serum concentration of 0.09 ng/mL can inhibit ovulation in most women. The implant releases approximately 70 mcg of etonogestrel per 24 hours during the first year of use, achieving peak serum concentrations of 0.7-0.8 ng/mL within the first few weeks. The rate of release decreases to an average of 30 mcg/d in the latter years of use. Contraceptive protection begins within 24 hours of insertion if inserted during the first week of the menstrual cycle. The rod is inserted subcutaneously, usually in the woman's upper arm, where it is visible under the skin and can be easily palpated. The mechanism of action is a combination of suppression of the LH surge, suppression of ovulation, development of viscous and scant cervical mucus to deter sperm penetration, and prevention of endometrial growth and development.

 

Injectable Depomedroxyprogesterone Acetate

DMPA is a suspension of microcrystals of a synthetic progestin that is injected intramuscularly. Pharmacologically active levels are achieved within 24 hours after injection, and serum concentrations of 1 ng/mL are maintained for 3 months. During the fifth or sixth month after injection, the levels decrease to 0.2 ng/mL, and they become undetectable by 7-9 months after injection. DMPA acts by the inhibition of ovulation with the suppression of follicle-stimulating hormone (FSH) and LH levels and eliminates the LH surge. This results in a relative hypoestrogenic state. Single doses of 150 mg suppress ovulation in most women for as long as 15 weeks. The contraceptive regimen consists of 1 dose every 3 months.

 

Progestin-Only Oral Contraceptives

Progestin-only oral contraceptives are also known as minipills. Candidates for use include women who are breastfeeding and women with contraindications to estrogen use. Two formulations are available, both of which have lower doses of progestin than combined oral contraceptives. Prevention of conception involves a combination of mechanisms similar to, but not as efficacious as, combination oral contraceptives. Mechanisms of action include; suppression of ovulation (not uniformly in all cycles), a variable dampening effect on the mid-cycle peaks of LH and FSH, an increase in cervical mucus viscosity by a reduction in its volume and an alteration of its structure, a reduction in the number and size of endometrial glands, leading to an atrophic endometrium not suitable for ovum implantation; and a reduction in cilia motility in the fallopian tube, thus slowing the rate of ovum transport (Alana, 2017).

 

Combined Oral Contraceptives

This method consists of the estrogenic component (ethinyl estradiol) and the progestin component (consisting of norethindrone, levonorgestrel, norgestrel, norethindrone acetate) Another recent development is the release of a combined oral contraceptive pill to raise folate serum levels. If a woman misses 1 pill, she should take her missed pill as soon as she remembers followed by her regularly scheduled pill. Women who have missed 2 or more consecutive pills should be advised to use a backup method of contraception and could require an emergency contraceptive method. Prevention of ovulation is considered the dominant mechanism of action. Either estrogen or progesterone alone is capable of inhibiting both FSH and LH sufficiently to prevent ovulation. The combination of the 2 steroids creates a synergistic effect that greatly increases their antigonadotropic and ovulation-inhibitory effects. They also alter the consistency of cervical mucus, affect the endometrial lining, and alter tubal transport (Alana, 2017).

 

Combination Patch Contraceptive

The contraceptive transdermal patch releases estrogen and progesterone directly into the skin. Each patch contains a 1-week supply of hormones of both norelgestromin and ethinyl estradiol. It releases a sustained low daily dose of steroids equivalent to the lowest-dose oral contraceptive. Advantages include greater compliance and decreased adverse effects, such as nausea and vomiting, due to the avoidance of the first-pass effect. However, the patch may cause skin irritation, and, if it is removed unnoticed, such as from showering, this may compromise efficacy. Disadvantages and contraindications are similar to those of combination oral contraceptives. 

 

Intrauterine Devices

The intrauterine device is one of the most effective contraceptive devices available with pregnancy. The copper and progesterone intrauterine devices available now are not associated with severe infections, but practitioners should screen for chlamydia and gonorrhea according to /CDC guidelines at time of placement to prevent development of pelvic inflammatory disease. The Copper T380 was introduced in 1988. The T-shaped IUD is made of polyethylene with fine copper wire wrapped around the vertical stem. The string is clear or white and hangs from the lower limb of the IUD. This device consists of 308 mg of copper covering portions of its stem and arms.  A foreign-body reaction creates a toxic intrauterine milieu, preventing fertilization. 

 

Surgical methods

Sterilization

Sterilization is considered an elective permanent method of contraception. Although both female and male sterilization procedures can be reversed surgically, the surgery is technically more difficult than the original procedure and may not be successful. In regard to reversal of sterilization, success is noted to be greater with tubal reanastomosis than with reanastomosis of the vas deferens.

 

 

Female Sterilization

Female sterilization prevents fertilization by interrupting the fallopian tubes. Sterilization can be performed surgically in the postpartum period with a small transverse infraumbilical incision or during the interval period. Sterilization during the interval period can be performed with laparoscopy, laparotomy, or colpotomy. The methods of fallopian tube sterilization include occlusion with Falope rings, clips, or bands; segmental destruction with electrocoagulation; or suture ligation with partial salpingectomy.

 

The latest form of female permanent sterilization is the Essure system. This form of sterilization prevents fertilization by interrupting the fallopian tubes; however, the Essure system does not require surgical incisions and can be performed with the patient under local anesthesia. It is performed hysteroscopically, and a microinsert is placed directly into the fallopian tubes. During the first 3 months after the procedure, the fallopian tube and the microinsert create a tissue barrier that prevents sperm from reaching the egg. After the 3-month period, patients must undergo a hysterosalpingogram to ensure placement..

 

Vasectomy

Vasectomy involves incision of the scrotal sac, transection of the vas deferens, and occlusion of both severed ends by suture ligation or fulguration. The procedure is usually performed with the patient under local anesthesia in an outpatient setting. Vasectomy prevents the passage of sperm into seminal fluid by blocking the vas deferens. Complications include hematoma formation, infection and sperm granulomas (1-2%). After sterilization, remnant sperm remains in the ejaculatory ducts (Alana, 2017)

 

Orthodox and traditional contraceptive methods

Orthodox or modern contraceptive methods were invented so couples could act on natural impulses and desires with diminished risks of pregnancy. Modern contraceptive methods are technological advances designed to overcome biology. In this regard, they must enable couples to have sexual intercourse at any mutually-desired time. The term modern contraceptive is rarely defined. Instead, organizations and individuals who use the term simply name contraceptives and approaches that fit into their perception of that label. Thus, researchers who measure levels of modern contraceptive prevalence often differ in how they categorize particular methods (Fabic & Choi, 2013)

 

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