|Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)|
|Chapter 20 - FAMILY PLANNING - HAVING THE NUMBER OF CHILDREN YOU WANT|
BOTH THESE FAMILIES LIVE IN POOR COMMUNITIES:
Some mothers and fathers want a lot of children - especially in countries where poor people are denied a fair share of land, resources, and social benefits. This is because children help with work and provide care for their parents in old age. In such areas, having just a few children may be a privilege only wealthier people can afford.
The situation is different in poor countries where resources and benefits are fairly distributed. Where employment, housing, and health care are guaranteed and where women have equal opportunities for education and jobs, people usually choose to have smaller families. This is in part because they do not need to depend on their children for economic security.
But in any society, it helps if a family has control over how many children they have, and when they have them.
When a mother has child after child, without much space between, she often becomes weak. Her babies are more likely to die. Also, after many pregnancies the danger is greater that she will die in childbirth, leaving many motherless children. Therefore many couples now choose to allow two or more years to pass between pregnancies, and avoid having a very large number of children.
If a man and woman have a lot of children, when the children grow up there may not be enough land for all of them to grow the food their families need. Children may begin to die of hunger. This is already happening in many areas.
Although most, if not all, hunger in the world today could be prevented if land and wealth were distributed fairly, the growing number of people is part of the problem. But the solution is not to force the poor to limit the number of children they have. Instead, the challenge is for societies to provide enough security so that the poor can afford to have few children.
FAMILY PLANNING AND BIRTH CONTROL
Different parents have different reasons for wanting to limit the size of their family. Some young parents may decide to delay having any children until they have worked and saved enough so that they can afford to care for them well. Some parents may decide that a small number of children is enough, and they never want more. Others may want to space their children several years apart, so that both the children and their mother will be healthier. Some parents may feel they are too old to have more children.
Family planning is having the number of children you want, when you want them.
When a man and woman decide when they want to have children, and when they do not, they can choose one of several methods to prevent the woman from becoming pregnant, for as long as she wishes. These are methods of birth control or contraception.
Couples who want children but are not able to have them should see section: Men and Women Who are Not Able to Have Children (Infertility).
1. Is it good?
In some parts of the world there has been a lot of discussion about whether different forms of birth control are good or are safe. Some religions have been against any form of birth control except trying not to have sex together. But an increasing number of religious leaders are realizing how important it is to the health and well-being of families and communities that people be able to use easier and surer methods of birth control.
Also, in many places women who get pregnant when they do not want a child will go for an abortion, to have the pregnancy removed. Where these abortions are legal, they can be done in health centers under sanitary conditions, and they are not usually dangerous to the woman. But where abortions are not permitted, many women get abortions illegally and secretly, often in dirty conditions and performed by unskilled persons. Thousands of women die from such abortions. If women are given the chance to use birth control methods, and information to use them wisely, many abortions, legal and illegal, would not be necessary. Much needless suffering and death could be prevented. (See Complications from Abortion)
Some people feel that much of the push for family planning comes from rich countries or persons who want to keep their control over the poor by controlling their numbers. The rich and powerful find it hard to accept that the way they manage the earth's land and resources strongly contributes to world hunger. They see only the growing numbers of people. In some countries professionals sterilize poor women by force or experiment on them with new or unsafe methods. For all these reasons social reformers and spokespersons for the poor often protest against birth control.
This is unfortunate. The object of attack should not be birth control, but rather its misuse. The attack should be against social injustice and the unfair distribution of land and-wealth. If used well, birth control can in fact help the poor gain strength to work for their basic human rights. But the decisions and responsibility for family planning must be in the hands of the people themselves.
Decide for yourself if and how you want to plan your family. Do not let anyone else decide for you.
2. Is it safe?
Whether or not different forms of birth control are safe has been much discussed. Often those who are against birth control for religious or political reasons try to scare women by talking about the risks. Some methods do have certain risks. However, the important thing all women should realize is that birth control is safer than pregnancy, especially for women less than 20 or more than 35 years old, and for women who have had many children.
The risk of serious illness or death resulting from pregnancy is many times greater than the risks involved in using any of the common methods of birth control.
There is much talk about the risks of taking birth control pills. But the risks with pregnancy are many times greater. The pill works so well in preventing pregnancy that for most women it is safer - in terms of protecting their lives - than any of the other 'less risky' but less effective methods.
On the following pages several methods of birth control are described. Some work better for some people than others. Study these pages, and talk with your midwife, health worker, or doctor about what methods are available and are likely to work best for you. Differences in effectiveness, safety, convenience, availability, and cost should be considered. Husbands and wives should decide together, and share the responsibility.
* With sterilization, problems occasionally result from surgery but the method is permanent.
Birth control pills are made of chemicals (hormones) that normally occur in a woman's body. When taken correctly, the 'pill' is one of the most effective methods for avoiding pregnancy. However, certain women should not take birth control pills if they can use another method. Birth control pills do not prevent AIDS or any other sexually transmitted diseases. To prevent these diseases, use a condom. If possible, birth control pills should be given by health workers, midwives, or other persons trained in their use.
The pills usually come in packets of 21 or 28 tablets. The packets of 21 are often less expensive, and of these, some brands are cheaper than others. The amount of medicine differs in different brands. To pick the kind that is right for you, see the GREEN PAGES.
How to take the pills - packet of 21:
Take the first pill on the fifth day from the beginning of your period, counting the first day of the period as day 1. Then take 1 pill every day until the packet is finished (21 days). Take your pills at the same time each day.
After finishing the packet, wait 7 days before taking any more pills. Then begin another packet, 1 pill each day.
This way, you will take the pills for 3 weeks out of each month, then go 1 week without taking any. Normally, the menstrual period will come during the week when the pill is not taken. Even if the period does not come, start the new packet 7 days after finishing the last one.
If you do not want to get pregnant, it is important to take the pills as directed - 1 every day. If you forget to take the pill one day, take it as soon as you realize this, or take 2 the next day.
Packet of 28 pills:
Take the first pill on the fifth day of the period, just as with the packets of 21. Take 1 a day. Seven of the pills will probably be a different size and color. Take these pills last (one a day) after the others have all been taken. The day after you finish the packet of 28, start another packet. Take 1 a day without ever missing a day, packet after packet, for as long as you want not to get pregnant.
No special diet must be followed when taking the pill. Even if you happen to get sick with a cold or another common illness while taking birth control pills, go right on taking them. If you stop taking the pills before the packet is used up, you may become pregnant.
Some women get a little morning sickness, swelling of the breasts, or other signs of pregnancy when they first start taking the pill. This is because the pill contains the same chemicals (hormones) that a woman's body puts into her blood when she is pregnant. These signs do not mean she is unhealthy or should stop taking the pill. They usually go away after the first 2 or 3 months. If the signs do not go away, she may need to change to a kind with a different amount of hormone. This is discussed in the GREEN PAGES.
Most women bleed less than usual in their monthly period when they are taking the pill. This change is usually not important.
Is it dangerous to take oral contraceptives?
Like all medicines, birth control pills occasionally cause serious problems in certain persons. The most serious problems related to the pill are blood clots in the heart, lungs, or brain (see stroke). This occurs most often in women who smoke - especially if they are over 35. However, the chance of getting dangerous clots is higher when women get pregnant than when they take the pill.
Although it is rare, a woman may become pregnant while taking the pill. If this happens, immediately stop taking the pill because it can harm the developing baby.
Death related to taking the pill is rare. On the average, pregnancy and childbirth are 50 times as dangerous as taking the pill.
Of 15,000 women who become pregnant, this many are likely to die from problems of pregnancy or childbirth.
Of 15,000 women who take birth control pills, only 1 is likely to die from problems related to having taken the pills.
For most women, birth control pills are relatively safe. Certainly they are far safer than becoming pregnant. However, for some women both pregnancy and taking birth control pills have a higher risk. These women should use other methods of birth control.
Who Should Not Take Birth Control Pills?
A woman who has any of the following signs should not take oral (or injected) contraceptives:
· A woman, whose period is late, who thinks she might be pregnant.
· Deep or steady pain in one leg or hip. This may be caused by an inflamed vein (phlebitis or blood clot). Do not use birth control pills. (Women with varicose veins that are not inflamed can usually take birth control pills without problems. But they should stop taking them if the veins become inflamed.)
· Stroke. A woman who has had any signs of a stroke should not take the pill.
· Hepatitis, cirrhosis, or other liver disease. Women with these problems, or whose eyes had a yellow color during pregnancy, should not take the pill. It is better not to take oral contraceptives for one year after having hepatitis.
· Cancer. If you have had or suspect cancer of the breast or womb, do not use oral contraceptives. Before beginning oral contraceptives, examine your breasts carefully. In some health centers you may also be able to get a simple test (Pap smear) to check for cancer of the cervix or opening of the womb. Birth control pills have not been proven to cause cancer of the breasts or womb. But if cancer already exists, the pill can make it worse.
Some health problems maybe made worse by oral contraceptives. If you have any of the following problems, it is better to use another method if you can:
· Migraine. Women who suffer from true migraine should not take oral contraceptives. But simple headache that goes away with aspirin is no reason not to take the pill.
· Urinary infection with swelling of the feet.
· Heart disease.
· High blood pressure.
If you suffer from asthma, tuberculosis, diabetes or epilepsy, it is best to get medical advice before taking birth control pills. However, most women with these diseases can take oral contraceptives without harm.
Precautions Women Should Take when Using Birth Control Pills
4. Watch for any of the problems mentioned in section Who Should Not Take Birth Control Pills?, especially:
· Severe and frequent migraine headaches.
· Dizziness, headache, or loss of consciousness that results in difficulty in seeing, speaking, or moving part of the face or body (see Stroke).
· Pain with inflammation in a leg or hip (chance of a blood clot).
· Severe or repeated pain in the chest (see Heart Problems).
If one of these problems develops, stop taking the pill and get medical advice. Avoid pregnancy by using another method, as these problems also make pregnancy especially dangerous.
Questions and Answers about Birth Control Pills
Some people claim birth control pills cause cancer. Is this true?
No! However, if cancer of the breast or womb already exists, taking the pill may make the tumor grow faster.
Can a woman have children again if she stops taking the pill?
Yes. (Sometimes there is a delay of 1 or 2 months before she can become pregnant.)
Is the chance of having twins or defective children greater if a woman has used oral contraceptives?
No. The chances are the same as for women who have not taken the pill.
Is it true that a mother's women breasts will dry up if she starts taking birth control pills?
Some women will produce less milk when taking the pill. So it is best to use another method of birth control while nursing, and later change to the pill. Or she can take the 'mini-pill', which contains so little hormone that it usually does not affect the milk.
THE CONDOM (also called 'prophylactic', 'rubber', or 'sheath') is a narrow rubber or latex bag that the man wears on his penis while having sex. Usually it works well to prevent pregnancy. It is also the only effective method for preventing AIDS, and other sexually transmitted diseases, but is not a complete safeguard.
Put on the condom while the penis is stiff, and leave space at the tip for sperm. The man should hold on to the condom when he pulls out his penis.
You can buy condoms in most pharmacies. Some are cheaper than others. Condoms are sometimes given away free at health clinics or family planning clinics. It is best to use a condom only once. (However, a washed and re-used condom, although not as safe, may be better than none. Fill with water to check for leaks.)
THE DIAPHRAGM is a shallow cup made of soft rubber, A woman wears it in her vagina while having sexual relations. It should be left in for at least 6 hours afterward. It is a fairly sure method if used together with a contraceptive cream or jelly. A health worker or midwife should help fit the diaphragm, as different women need different sizes. Check the diaphragm regularly for holes and cracks by holding it up to the light. If there is even a tiny hole, get a new one. They usually last a year or longer. After use, wash it in warm soapy water, rinse, and dry. Keep in a clean, dry place.
CONTRACEPTIVE FOAM comes in a tube or can. The woman puts it into her vagina with a special applicator. It must be applied no longer than 1 hour before having sex, and left in for at least 6 hours afterward. The application should be repeated before each time the couple has sex, even if this is several times in one night. It is a fairly sure method if used correctly.
THE INTRAUTERINE DEVICE (IUD) is a plastic (or sometimes metal) object that a specially trained health worker or midwife places inside the womb. While in the womb, it prevents pregnancy. IUDs fall out of some women. In others they cause pain, discomfort, heavy bleeding during periods, and sometimes serious problems, but for some women they give no trouble, at all. For these women, the IUD may be the simplest and most economical method.
WITHDRAWAL OR PULLING OUT (COITUS INTERRUPTUS) is a method in which the man pulls his penis out of the woman before the sperm comes. This method is perhaps better than none, but may be disturbing to the couple and does not always work, because some men do not pull out in time, especially if they have been drinking.
THE RHYTHM METHOD
This method is not very sure to prevent pregnancy, but it has the advantage of not costing anything. It is more likely to work for a woman whose periods come very regularly, more or less once every 28 days. Also, the husband and wife must be willing to pass one week out of each month without having sex the regular way.
Usually a woman has a chance of becoming pregnant only during 8 days of her monthly cycle - her 'fertile days'. These 8 days come midway between her periods, beginning 10 days after the first day of menstrual bleeding. To avoid getting pregnant, a woman should not have sex with her man during these 8 days. During the rest of the month, she is not likely to get pregnant.
To avoid confusion the woman should mark on a calendar the 8 days she is not to have sex.
If the woman and her husband carefully avoid having sex together during these 8 days of each month, it is possible that they will go years without having another child. However, few couples are successful for very long. This is not a very sure method, unless used in combination with another method such as a diaphragm or condoms, especially during the days from the end of the menstrual period until the fertile days are over.
THE MUCUS METHOD
This is a variation of the rhythm method. A woman finds out when she could become pregnant by checking the mucus in her vagina every day. It works fairly well for some couples but not for others. In general it cannot be considered a very sure way of preventing pregnancy, but' it costs nothing and has no risks other than those that come with pregnancy itself. However, it is more difficult to do if the woman has a vaginal infection with a lot of discharge, if her periods are not regular, or if she douches often.
Every day, except during her period, the woman should examine the mucus from her vagina. Take a little mucus out of your vagina with a clean finger and try to make it stretch between your thumb and forefinger, like this:
As long as the mucus is sticky like paste - not slippery or slimy - you probably cannot become pregnant, and can continue to have sexual relations.
When the mucus begins to get slippery or slimy, like raw egg, or if it stretches between your fingers, you may become pregnant if you have sexual relations. So, do not have sex when the mucus is slippery or stretches, or until 4 days after it has stopped being slippery or stretchy and has become sticky again.
The mucus will usually become slippery during a few days midway between your periods. These are the same days you would not have sex with your man if you were using the rhythm method.
To be more sure, use the mucus and rhythm methods together. To be still more sure, see below.
If you want to be more certain not to become pregnant, it often helps to use 2 methods at the same time. The rhythm or mucus method combined with the use of a condom, diaphragm, foam, or sponge is surer than any of these methods alone. Likewise, if a man uses condoms and the woman a diaphragm or foam, the chance of pregnancy is very low.
INJECTIONS. There are special injections to prevent pregnancy. Depo-Provera is one. An injection is usually given every 3 months. Side effects and precautions are similar to those for birth control pills: After a woman stops getting injections, it can take a year or more for her to become pregnant. But to avoid pregnancy, it is wise to use another form of birth control.
IMPLANTS. With this method, 6 small tubes are put under the skin. If left there, they can prevent pregnancy for up to 5 years. Menstrual bleeding may be heavy during the first year. Return to the clinic if this happens.
Injections and implants are useful for women who have trouble remembering to take pills, or who run into problems using other kinds of birth control.
STERILIZATION. For those who never want to have more children, there are fairly safe, simple operations for both men and women. In many countries these operations are free. Ask at the health center.
· For men, the operation is called a vasectomy. It can be done simply and quickly in a doctor's office or a health center, usually without putting the man to sleep. Small cuts are made here so (1) that the tubes from the man's testicles can be cut and tied. The testicles are not removed.
The operation has no effect on the man's sexual ability or pleasure. His fluid comes just the same, but has no sperm in it.
· For women, the operation is called a tubal ligation, which means to tie the tubes. One method is to make a small cut in the lower (2) belly so that the tubes coming from the ovaries, or egg-makers, can be cut and tied. It can usually be done in a doctor's office or health center without putting the woman to sleep. Although usually successful, there is a higher risk of infection in the operation for women than for men.
This operation has no effect on the woman's menstrual periods or sexual ability, and may make having sex more pleasant because she does not have to worry about pregnancy.
Every land has 'home remedies' for preventing or interrupting pregnancy. Unfortunately, most either do not work or are dangerous,. For example, some women think that to wash out the vagina or to urinate after having sex will prevent pregnancy, but this is not true.
BREAST FEEDING. While a woman is breast feeding her baby she is less likely to become pregnant - especially when breast milk is the only food her baby receives. The chance of her becoming pregnant is much greater after 4 to 6 months, when the baby begins to get other foods in addition to breast milk. Even then, breast feeding can help prevent pregnancy if she breast feeds frequently, both day and night, and gives breast milk as the main food. (But if her periods start, she cannot depend on breast feeding to prevent pregnancy.)
To be more sure she will not become pregnant, the mother who is breast feeding should begin some method of birth control when the baby is 3 to 4 months old. A method other than birth control pills is better because the pills cause some women to produce less milk. (The 'mini-pill' causes less of a problem.)
THE SPONGE METHOD. Here is a home method that is not harmful and sometimes works. You cannot be sure it will prevent pregnancy every time, but it can be used when no other method is available.
You will need a sponge and either vinegar, lemons, or salt. Either a sea sponge or an artificial sponge will work. If you do not have a sponge, try a ball of cotton, wild kapok, or soft cloth.
2 tablespoons vinegar in 1 cup clean water
1 teaspoon lemon juice in 1 cup clean water
1 spoon of salt in 4 spoons clean water
· Wet the sponge with one of these liquids.
· Push the wet sponge deep into your vagina before having sex. You can put it in up to an hour before.
· Leave the sponge in at least 6 hours after having sex. Then take it out. If you have trouble getting it out, next time tie a ribbon or piece of string to it that you can pull.
The sponge can be washed and used again, many times. Keep it in a clean place.
You can make up the liquid in advance and keep it in a bottle.