Behavioral Methods of Birth Control

Picture of a couple lying on the grass holding hands.

• The practice of birth control or prevention of pregnancy is as old as human existence. For centuries, humans have relied upon their imagination in order to avoid pregnancy.
• With no method of birth control during sexual intercourse, a woman of childbearing age with normal fertility has an 85% chance of conceiving within 1 year.
• Behavioral forms of birth control do not employ hormones (e.g. oral contraceptives or mechanical devices such as condoms). They are in use throughout the world, especially in underdevelopedd nations.
• They often have high failure rates, indicating that they do not work effectively, and the chances of an unwanted pregnancy are increased.

• Abstinence refers to complete avoidance of sexual intercourse.
• There are no hormonal side effects, and it is endorsed by many religious groups.
• This method is 100% effective in preventing pregnancy, and it also avoids sexually transmitted diseases (STDs).
• Women who are abstinent until their 20s and ultimately have fewer partners are less likely to get STDs, become infertile, or develop cervical cancer. Abstinence costs nothing.
• Abstinence may be difficult for some couples to maintain. It is important to discuss this decision with your partner before sexual situations arise.

Coitus interruptus involves withdrawal of the entire penis from the vagina before ejaculation (i.e. when sperm is released from the penis). Fertilization is prevented because sperm does not contact a woman’s egg. This method remains a significant means of fertility control in less advantaged countries.

• How effective: This depends largely on the capability of the man to withdraw prior to ejaculation. The failure rate is estimated to be approximately 4% during the first year of proper usage. In reality, the rate approaches 19% during that time period. The failure rate refers to how often the method is unsuccessful, and an unwanted pregnancy occurs. The higher the failure rate, the more likely a woman is to have an unintended pregnancy.
• Advantages: This method can be used at any time, as no devices or chemicals are employed. There is no cost.
• Disadvantages: There is a high risk for unintended pregnancy. This method does not protect against sexually transmitted diseases (STDs).

Natural Family Planning (NFP), endorsed by the Couple to Couple League, 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 birth control. This method involves periodic abstinence (no sexual intercourse), with couples attempting to avoid intercourse during a woman's fertile period (the time of ovulation). Ovulation refers to the release of an egg by the ovary.)

The current method of NFP taught by the Couple to Couple League and many other teaching organizations is the symptothermal method. Women who employ this method observe the changes in their cervical mucus, their basal body temperature (i.e. temperature on awakening), and the pattern of their menstrual cycle. They may also monitor physical changes in the cervix. This method divides a woman's menstrual cycle into 3 phases. Phase I is preovulation infertility, and it begins with the first day of menstruation. Phase II is the fertile period, in which conception may occur. Phase III refers to the period following ovulation when a woman is no longer fertile. It is best used by women who have consistent and regular menstrual cycles.

• The symptothermal method determines the first day when sexual activity should be avoided based on how many days have elapsed since the onset of menses (typically 7) or the first day when mucus is detected, whichever is noted first. The end of the fertile period (Phase II) is determined based on basal body temperature readings. The basal body temperature is relatively low during the follicular phase (first half) of the menstrual cycle, and it rises during the luteal phase of the cycle.  This temperature elevation occurs in response to the thermogenic (i.e. heat-producing) effect of progesterone, a hormone which is released from the ovary following ovulation. The temperature rise can vary from 0.2-0.5° C. The higher temperatures begin 1-2 days after ovulation and correspond to the rising level of progesterone. Intercourse can safely resume 3 days after the temperature rise.
• To monitor cervical mucus, a woman must assess her cervical mucus with her fingers. Under the influence of estrogen, the mucus increases in quantity and becomes progressively more elastic. This is followed by scant and dry mucus because of changes induced by the influence of progesterone.  This thick, scanty mucus remains until the onset of her next menses. Intercourse is allowed 4 days following the maximal cervical mucus production, coinciding with the rise in basal body temperature.  She is then considered to be safe until the onset of her next menses.

NFP has advantages and disadvantages:

• How effective: The American Journal of Obstetrics and Gynecology reported that "the Sympto-Thermal Method of Natural Family Planning can be used at the 99% level of effectiveness in avoiding pregnancy." If a couple takes chances and has intercourse during Phase II, the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the U.S. Food and Drug Administration (FDA) reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for the particular methods of periodic abstinence. The American College of Obstetricians and Gynecologists (ACOG) lists a higher failure rate for periodic abstinence of 25%. Again, this figure does not differentiate for type of periodic abstinence.
• Advantages: No harmful effects from hormone usage occur. This may be the only method acceptable to couples for cultural or religious reasons. NFP methods can also be used to achieve pregnancy.
• Disadvantages: This method is most suitable for women with regular and predictable menstrual cycles. Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper use. To employ this method effectively, a woman or couple should be trained by a medical professional or a qualified counselor. A relatively high failure rate has been reported. This method does not protect against STDs.

IWomen who use the Fertility Awareness Method (FAM) monitor body temperature and cervical signs of pregnancy similarly to those who practice NFP. However, women using FAM may either avoid intercourse or use a backup nonhormonal method of birth control, such as a condom, during the fertile period.

Women using FAM monitor 3 primary fertility signs: basal body (waking) body temperature, cervical mucus, and cervical position.

Basal body temperature before ovulation is considered to range from 97-97.5°F. After ovulation, temperatures rise to about 97.6-98.6°F and remain elevated until the next period begins, about 12-16 days later. Temperatures usually rise within a day or so after ovulation, so the rise in temperature generally means that ovulation has already occurred. A basal body temperature chart can be obtained from 4women.gov.

Cervical mucus qualities are also charted throughout the menstrual cycle. Cervical mucus qualities during the menstrual cycle are designated as absent, dry, sticky, creamy, or egg-white. A woman is most fertile when her cervical mucus has the consistency of a raw egg-white. During this time the cervical mucus is clear and elastic.

The cervix becomes softer near the time of ovulation, and this change facilitates the passage of sperm upward through the uterus to the fallopian tubes. The cervix also moves forward during this time because of the effects of estrogen on the ligaments that suspend the uterus.

For maximum effectiveness, FAM users follow 4 rules:

1. Intercourse is allowed in the first 5 days of the menstrual cycle (beginning with the first day of menses) if an obvious temperature shift occurred 12-16 days previously.
2. Prior to ovulation, intercourse is allowed the evening of every dry cervical mucus day.
3. Intercourse can resume the evening of the third consecutive day your temperature rises to postovulatory levels (i.e. after the thermal shift).
4. Intercourse can resume the evening of the fourth consecutive day the day of peak cervical mucus production and elasticity.

Intercourse is not considered "safe" for avoiding pregnancy unless all of these rules are followed. It is recommended that 2 full cycles be charted before relying on this method.

FAM has advantages and disadvantages.

• How effective: If a couple takes chances and has intercourse without backup contraception during the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the FDA reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular types of periodic abstinence. ACOG lists a higher failure rate for periodic abstinence of 25%. Again, this figure did not differentiate for method of periodic abstinence.
• Advantages: No harmful effects from hormone usage can occur. FAM methods can also be used to achieve pregnancy.
• Disadvantages: Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper usage. For maximal effectiveness, a woman or couple should be trained by a medical professional or qualified counselor. A relatively high failure rate has been reported. This method does not protect against STDs.

Immediately after childbirth the release of certain hormones from a woman’s pituitary gland is inhibited.  As these hormones are required for ovulation to occur, pregnancy becomes much less likely. The length of the period of hormonal suppression varies widely.  Consistent suppression of ovulation depends upon how often the woman breastfeeds and the length of time since her delivery. Despite continuous nursing, ovulation usually returns within 6 months of delivery.

Breastfeeding used for birth control is also called the lactational amenorrhea method (LAM). This method is based on the principle that breastfeeding prevents your body from producing the hormones required for ovulation and thus, a return to fertility. Some women feel this is a satisfactory form of birth control. ACOG states, "Exclusive breastfeeding helps prevent pregnancy for the first 6 months after delivery, but should be relied on only temporarily and when it meets carefully observed criteria of the lactational amenorrhea method (LAM)."

ACOG recommends that for the best impact on fertility, women should breast feed at least every 4 hours during the day and every 6 hours at night. Any feedings the infant is given aside from breastfeeding should not be more than 5%-10% of its total consumption.  For instance, one formula feeding out of every 10 might increase the chance of failure of LAM failure. If this schedule cannot be followed consistently, then an additional form of birth control should be considered. When the menstrual period returns following delivery, another form of birth control should be employed.

• How effective: ACOG reports this method to be 98% effective in the first 6 months after delivery if the above criteria are met. Once menstrual bleeding resumes, the risk of pregnancy increases greatly.
• Advantages: A woman has no menses for several months after this method is initiated.
• Disadvantages: When a woman is fertile again is uncertain. Frequent breastfeeding may be inconvenient. This method should not be used if the mother is HIV positive. This method does not protect against STDs.

Several other methods of periodic abstinence exist.

• Rhythm method: Couples who practice the rhythm method, also called the calendar method, decide when to abstain from intercourse based on calendar calculations of the past 6 menstrual cycles. However, allowances are not made for the normal variations in the menstrual cycle that many women experience. This method is not as reliable as the symptothermal method of NFP or FAM.
• Cervical mucus method: Also called the ovulation method, the cervical mucus method involves monitoring cervical mucus only, without also recording basal body temperature or menstrual history. The safe period is considered to be any dry mucus days just after menstruation and the 10 or 11 days toward the end of the cycle. Days of menstrual bleeding are deemed infertile; however, conception may infrequently occur occur during menstruation. Vaginal infections, sexual excitement, lubricants, and certain medications can significantly diminish the accuracy of cervical mucus assessment.
• Basal body temperature method: This method involves monitoring basal body temperature only, without also recording cervical mucus or other signs. Sex is avoided from the end of the menstrual period until 3 days after the increase in temperature.

Douching is a term which refers to rinsing of the vagina. Many women use water, vinegar, or commercially available products purchased at a pharmacy.  These are then introduced into the vagina with a squeeze bottle or tubing. It has long been thought that women needed to clean their vaginas, in part because of odor. Some women douche after their menstrual periods or after sex to avoid getting an STD. Some actually think douching after sex will prevent pregnancy.

• Douching is not recommended. Douching can alter the delicate chemical balance and bacteriological environment within the vagina. This may allow a new infection to develop or spread a pre-existing infection into other pelvic organs such as the uterus. This method does not protect against STDs. It may actually increase the chance of developing pelvic inflammatory disease and transmitting sexually transmitted diseases.
• Douching after sex does not prevent pregnancy. In fact, the practice can increase a woman’s chance for developing an ectopic pregnancy, which may represent a life-threatening condition.