How Contraceptives Work and Why No Method Is Perfect

Reproductive health is about far more than avoiding disease. It covers safe pregnancy and childbirth, informed choices about family size, and a society in which people understand their bodies without fear or stigma.

This part covers the meaning of reproductive health and India's programmes, population growth and its control, and the main methods of contraception.

The World Health Organization defines reproductive health as total well-being in all aspects of reproduction — physical, emotional, behavioural and social — and India's family planning and Reproductive and Child Health (RCH) programmes aim to build such a reproductively healthy society through awareness and services.

Aims and actions of the programmes:

- Awareness — through print and audio-visual media and government and non-government agencies, about reproductive organs, adolescence and hygienic practices
- Sex education in schools — correct information that discourages myths and misconceptions
- Information for couples — birth control, care of pregnant mothers, post-natal care of mother and child, breastfeeding, and equal opportunities for boys and girls
- Medical help — for pregnancy, delivery, sexually transmitted infections, abortion, contraception, infertility and menstrual problems

An everyday example. Anganwadi centres and primary health centres give pregnant mothers check-ups, vaccinations and nutrition advice as part of these programmes.

The substance. Sex education is part of reproductive health, not separate from it — accurate information prevents both unsafe practices and harmful myths.

Population explosion results from a rapid fall in the death rate, maternal mortality rate and infant mortality rate, together with more people of reproducible age; it strains food, housing, water and jobs, and it is tackled by motivating smaller families, raising the marriageable age and making contraception widely available.

Causes:

- Better health facilities and living conditions have lowered the death rate
- The maternal mortality rate (MMR) and infant mortality rate (IMR) have fallen sharply
- More people are now of reproducible age, while birth rates have not fallen as quickly

Consequences:

- Shortages of food, shelter, clothing and water
- Pressure on schools, hospitals, transport and jobs

Measures for stabilisation:

- Motivating smaller families through the use of contraceptive methods
- Raising the legal marriageable age to $18$ for women and $21$ for men
- Incentives for couples with small families

An everyday example. Crowded local trains and long queues for water in growing cities show how a rising population strains everyday services.

The substance. Falling death rates, not rising birth rates, drove the rapid growth — which is why better health care must go hand in hand with family planning.

Natural methods prevent sperm meeting the ovum by timing or behaviour, barrier methods physically stop sperm reaching the ovum, and intra-uterine devices placed in the uterus make it unsuitable for sperm or for implantation.

Natural (traditional) methods:

- Periodic abstinence — avoiding coitus from about day $10$ to day $17$ of the cycle, when ovulation is expected
- Coitus interruptus — withdrawal before ejaculation
- Lactational amenorrhea — ovulation and menstruation are usually absent during intense breastfeeding, so conception is less likely; effective only up to about six months after childbirth
- These have no side effects but a high failure rate

Barrier methods:

- Condoms — thin rubber or latex sheaths used by men or women; they also protect against sexually transmitted infections, including HIV
- Diaphragms, cervical caps and vaults — reusable rubber barriers inserted to cover the cervix

Intra-uterine devices (IUDs), inserted by doctors:

- Non-medicated IUDs — plastic devices placed in the uterus
- Copper-releasing IUDs such as the copper-T — copper ions suppress sperm motility and fertilising capacity
- Hormone-releasing IUDs — make the uterus unsuitable for implantation and the cervix hostile to sperm

An everyday example. The copper-T is a common spacing method offered free at government hospitals for couples who want to delay their next child.

The substance. Among these methods, only condoms also protect against sexually transmitted infections.

Oral pills, injections and implants use progestogens, alone or with oestrogen, to inhibit ovulation and implantation and thicken cervical mucus; surgical sterilisation — vasectomy in men and tubectomy in women — blocks the passage of gametes; and methods differ in effectiveness, reversibility and side effects.

Hormonal methods:

- Oral pills — progestogen or progestogen–oestrogen combinations taken daily for $21$ days, starting within the first five days of the cycle; they inhibit ovulation and implantation and change cervical mucus to block sperm
- Centchroman — a non-steroidal pill taken once a week, with very few side effects
- Injections and implants under the skin — act like pills but work for much longer
- Emergency contraception — progestogens, progestogen–oestrogen combinations or an IUD within 72 hours of unprotected coitus

Surgical methods:

- Vasectomy — a small part of the vas deferens is removed or tied through a small cut on the scrotum
- Tubectomy — a small part of the fallopian tube is removed or tied through a small cut in the abdomen or through the vagina
- Both are highly effective, but reversibility is very poor

Comparing methods:

- Most effective — sterilisation, IUDs and hormonal methods
- Possible side effects — nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding and, rarely, breast cancer, so methods should be chosen with medical advice

An everyday example. Government family welfare centres offer free sterilisation as well as spacing methods, letting couples choose what suits them.

The substance. The ideal contraceptive would be user-friendly, easily available, effective and reversible with no side effects — and no single method meets every one of these conditions.