research paper topics on birth control

91 Birth control Essay Topic Ideas & Examples

🏆 best birth control topic ideas & essay examples, 📌 simple & easy birth control essay titles, 👍 good essay topics on birth control, ❓ research questions about birth control.

• Rhetoric: “The Morality of Birth Control” by Margaret Sanger In her speech, Sanger supports the argument that the American women should have the right to learn more about the birth control because of their responsibility for the personal health and happiness in contrast to […]
• Birth Control on the Level of Individual Woman It was not allowed up to the year 1938, that the court lifted the prohibition of birth control. In my opinion, all women should be allowed to have access to birth control methods.
• Population Increase and Birth Control The end of the 2oth century can be seen as a starting point to the global rivalry between nations, states and continents.
• Human Sexuality Birth Control They include tubal ligation that involves the cutting of the fallopian tube which supplies ova to the uterus for fertilization it can also be done on men through vasectomy which involves the cutting of the […]
• Birth Control, Pregnancy and Childbirth According to Priscilla Pardini who is a re-known scholar in this field of the study states that: “It is can be viewed as a selfish study in the way that an educational institution is studying […]
• Why Teenagers Must Be Allowed to Use Birth Control? It is the purpose of this paper to underscore why teenagers should be given the opportunity to use contraceptives. These findings point to the importance of contraceptives in solving the problem of teenage pregnancy in […]
• Abortions and Birth Control As a result the overall mortality of women increases in the countries where legal abortions take place. The general point of view in decreasing the number of abortions is the use of contraceptives as a […]
• Birth Control for Teenagers This is exactly the reason why the idea of using birth control should not be given to teenagers. The third reason why birth control should not be advocated for teenagers is that there are more […]
• The Birth Control: Safe Methods The first relates to a couple that uses the method correctly every time the couple has sexual intercourse and the latter is for an average couple who actually do not use the method every time […]
• Birth Control Education and Resource Availability for the Prevention of Teen Pregnancy The rationale for this position is mostly based on the fact that teen pregnancy tends to create more complex problems in the future pertaining to the education and literacy rate of the population, the increase […]
• Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
• Birth Control Methods & Options The male condom is one of the most popular and arguably the least complex methods of contraception. This leads to the prevention of fertilization and interferes with the movement of sperm and effects.
• Birth Control Against Overpopulation Based on the information presented, it can be seen that the current growth of the human population is unsustainable in the long run due to the finite resources on the planet.
• Giving Birth Control to Teenagers It is paramount to say that it is a significant problem that needs to be addressed because the number of cases of teenage childbearing is one of the highest in the United States compared to […]
• Population Growth Control From a perspective of political economy, control of the population is a matter that is in the sphere of women, and thus they deserve to have right to their sexuality and reproduction.
• Doctors’ Reluctance to Prescribe Birth Control Pills to Early Adolescents These are some of the proposed solutions that could help solve the problem of doctors not prescribing birth control pills to teenagers.
• Why The Regulation Of Birth Control Should Be The Health
• Understanding Your Birth Control Options
• Unaware And Unprotected: Misconceptions Of Birth Control
• The Different Methods of Birth Control in Our Modern Society
• Should Tennagers Be Allowed to Get Birth Control Without Parent Consent?
• The Birth of Birth Control: An essay on Margaret Sanger
• The Consequences of Using Birth Control on the Spread of HIV/AIDS in the United States
• The Effect of Sanger’s Birth Control Movement
• Talking To Your Folks About Starting Birth Control
• Why Birth Control Should Be Readily Accessible To Teenagers
• What You Ought To Know About Emergency Birth Control
• The African American Community and the Birth Control Movement
• Which is the Best Birth Control Method: Pills, Patch, Nuvaring, or Depo Shot
• The Ethical Debate of Free Contraception and Birth Control
• Various Options of Birth Control and Their Effectiveness
• Should High Schools Provide Birth Control Information And Condoms
• To Control or to Not Control: The Government and Birth Control
• Why Parents Should Obtain Birth Control
• Social and Political effects of Birth Control in England
• Uncertain Aims and Tacit Negotiation: Birth Control Practices in Britain, 1925-50
• Taste Buds Outside The Mouth And Male Birth Control
• The Cognitive Response Theory On Birth Control
• The Birth Control Pill: The Pill That Changed America
• Teens Getting Birth Control Without Parental Consent
• The Perspective of Margaret Sanger on Birth Control
• The History of Birth Control and Society
• The Negative Effects of Birth Control for Minors without Parental Consent
• Undergrad: Birth Control and Human Sexuality
• Teenage Girls Should Be Allowed For Get Birth Control Without
• The Misconceptions Of Birth Control In Developing Countries
• Television As Birth Control By Fred Pearce
• Women Have the Burden of Birth Control
• The Problems With the Birth Control Options for the Modern Society’s Teens
• The Pitfalls And Positives Of Abstinence Only Birth Control
• The Question of Whether the Use of Birth Control Increases Promiscuous Sexual Behanvor
• The Lack of Significant Advances for Men’s Health and Male Birth Control
• The Positive And Negative Effects Of Birth Control Pills
• The Pros and Cons of Over the Counter Birth Control Pills
• The Introduction of Birth Control in Things Fall Apart, a Novel by Chinua Achebe
• The Importance Of Educating Adolescents On Various Birth Control Methods
• The Significance of the Introduction of Birth Control for Teens to Prevent Teenage Pregnancy
• The Supply of Birth Control Methods, Education, and Fertility: Evidence from Romania
• The Social Impact of Birth Control in Germany
• The Sexual Activity and Birth Control Use of American Teenagers
• Why Should Birth Control Be Taught in Schools?
• Should Governments Provide Free Access to Birth Control?
• Why Isn’t Birth Control Education Being Taught in Schools?
• How Does Birth Control Affect Society?
• Should Americans Have Easier Access to Contraception?
• Why Should Parents Obtain Birth Control?
• Should Public School Students Be Given Birth Control Pills?
• Does Parental Consent for Birth Control Affect Underage Pregnancy Rates?
• Why Should Women Not Use Birth Control?
• Should Schools Distribute Birth Control?
• How Does Banning Birth Control Affect Women’s Lives?
• Should Birth Control Pills Be Available for Teenage Girls?
• How Does the Birth Control Pill Work?
• Should Birth Control Pills Be Sold Over the Counter?
• How Has Abortion and Birth Control Affected the 20th and 21st Century?
• Should High Schools Provide Birth Control Information and Condoms?
• What Should Women Know About Birth Control Pill?
• Should Teenagers Have Access to Birth Control Without Parent’s Consent?
• Why May Birth Control Patches Be More Dangerous Than Pills?
• Should Teenagers Have Access to Birth Control?
• Why Should Birth Control Be Readily Accessible to Teenagers?
• Should Health Insurance Companies Provide Complete Coverage for Birth Control?
• Does Learning About Birth Control in School Help Prevent Teen Pregnancy?
• Should Pharmacists Be Allowed to Refuse to Fill Emergency Contraception Prescriptions?
• What Are Some of the Current Birth Control Options?
• How Are Federal Reproductive Health Rights Legislation or Denied by State and Local Government?
• What Myths About Health Risks Associated With Contraceptive Devices?
• Should Birth Control Be Taught in School as a Way of Preventing Teen Pregnancy?
• What Are Some of the Religious/Ethical Issues Arising From the Usage of Birth Control?
• What Are Factors to Consider When Choosing the Right Birth Control?
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111 Birth control Essay Topic Ideas & Examples

Inside This Article

111 Birth Control Essay Topic Ideas & Examples

Birth control is a highly debated and controversial topic that has been discussed for decades. With its widespread availability and various methods, birth control has become a crucial aspect of reproductive health. If you are assigned an essay on birth control, it is essential to choose a compelling topic that will engage your readers and demonstrate your knowledge on the subject. To help you get started, here are 111 birth control essay topic ideas and examples:

• The evolution of birth control methods throughout history.
• The moral and ethical implications of birth control.
• The impact of birth control on women's empowerment.
• The correlation between access to birth control and reduced abortion rates.
• The effectiveness and safety of hormonal birth control methods.
• The cultural and societal attitudes towards birth control in different countries.
• The role of birth control in family planning.
• The influence of religion on birth control decisions.
• The relationship between birth control and population control.
• The impact of birth control on sexual behavior and attitudes.
• The accessibility and affordability of birth control in low-income communities.
• The controversy surrounding emergency contraception (the morning-after pill).
• The role of male contraception in preventing unwanted pregnancies.
• The impact of birth control on mental health.
• The correlation between birth control use and sexually transmitted infections (STIs).
• The benefits and drawbacks of long-acting reversible contraception (LARC) methods.
• The influence of pharmaceutical companies on birth control accessibility.
• The impact of birth control on economic stability and career advancement for women.
• The role of birth control education in schools.
• The relationship between birth control and reproductive rights.
• The impact of birth control on maternal and infant health outcomes.
• The effectiveness of natural birth control methods (e.g., fertility awareness).
• The influence of social media on birth control decisions among young adults.
• The impact of birth control on the LGBTQ+ community.
• The role of birth control in reducing teenage pregnancy rates.
• The impact of birth control on breastfeeding and lactation.
• The correlation between birth control use and reduced menstrual pain.
• The influence of cultural norms and traditions on birth control decisions.
• The role of birth control in reducing maternal mortality rates.
• The impact of birth control on sexual satisfaction and pleasure.
• The relationship between birth control and gender equality.
• The effectiveness of male sterilization (vasectomy) as a birth control method.
• The influence of political ideologies on birth control policies.
• The impact of birth control on the environment.
• The correlation between birth control use and educational attainment.
• The role of birth control in reducing infant mortality rates.
• The accessibility and usage of birth control among marginalized communities.
• The influence of media portrayal on birth control perceptions.
• The impact of birth control on menstrual irregularities.
• The effectiveness and acceptance of non-hormonal birth control methods.
• The relationship between birth control and sexual consent.
• The role of birth control in preventing reproductive coercion.
• The impact of birth control on gender dynamics within relationships.
• The correlation between birth control use and reduced teenage substance abuse.
• The influence of healthcare policies on birth control access.
• The impact of birth control on menstrual hygiene management.
• The effectiveness of birth control education programs in schools.
• The relationship between birth control and maternal mental health.
• The role of birth control in reducing unintended pregnancies among college students.
• The impact of birth control on body image and self-esteem.
• The correlation between birth control use and reduced domestic violence rates.
• The influence of peer pressure on birth control decisions.
• The impact of birth control on the LGBTQ+ youth mental health.
• The effectiveness of hormonal birth control methods in managing polycystic ovary syndrome (PCOS).
• The relationship between birth control and sexual consent among adolescents.
• The role of birth control in reducing child marriages.
• The impact of birth control on the gender wage gap.
• The correlation between birth control use and reduced maternal depression.
• The influence of sex education programs on birth control knowledge and usage.
• The impact of birth control on women's healthcare access in developing countries.
• The effectiveness of birth control in preventing ovarian and endometrial cancers.
• The relationship between birth control and body autonomy.
• The role of birth control in reducing infant mortality among minority communities.
• The impact of birth control on menstrual migraines.
• The correlation between birth control use and reduced HIV transmission rates.
• The influence of parental consent laws on birth control access for minors.
• The impact of birth control on male fertility and reproductive health.
• The effectiveness of birth control methods for women with disabilities.
• The relationship between birth control and sexual satisfaction among older adults.
• The role of birth control in reducing maternal disabilities.
• The impact of birth control on menstrual disorders (e.g., endometriosis, fibroids).
• The correlation between birth control use and reduced gender-based violence.
• The influence of abstinence-only education on birth control decisions.
• The impact of birth control on sexual desire and libido.
• The effectiveness of emergency contraception in preventing pregnancies.
• The relationship between birth control and reproductive justice.
• The role of birth control in reducing maternal substance abuse.
• The impact of birth control on menstrual-related absenteeism in schools and workplaces.
• The correlation between birth control use and reduced maternal stress.
• The influence of healthcare provider bias on birth control access.
• The impact of birth control on sexual consent in long-term relationships.
• The effectiveness of birth control in preventing cervical and uterine cancers.
• The relationship between birth control and body positivity.
• The role of birth control in reducing infant mortality among low-income families.
• The impact of birth control on menstrual-related mood disorders (e.g., PMDD).
• The correlation between birth control use and reduced sexual coercion rates.
• The influence of sex education on birth control decisions among teenagers.
• The impact of birth control on women's career choices and opportunities.
• The effectiveness of birth control methods for women with chronic illnesses.
• The relationship between birth control and sexual satisfaction among LGBTQ+ individuals.
• The role of birth control in reducing maternal malnutrition.
• The impact of birth control on menstrual-related chronic pain.
• The correlation between birth control use and reduced adolescent substance abuse.
• The influence of religious exemptions on birth control access.
• The impact of birth control on intergenerational poverty.
• The effectiveness of birth control in preventing sexually transmitted infections (STIs).
• The relationship between birth control and reproductive health disparities.
• The role of birth control in reducing maternal substance use disorders.
• The impact of birth control on menstrual-related sleep disorders.
• The correlation between birth control use and reduced maternal anxiety.
• The influence of cultural taboos on birth control decisions.
• The impact of birth control on menstrual-related eating disorders.
• The effectiveness of birth control methods in preventing ectopic pregnancies.
• The relationship between birth control and sexual satisfaction among survivors of sexual assault.

Remember to choose a topic that interests you and aligns with your essay's objective. Conduct thorough research, gather supporting evidence, and present a well-structured argument to effectively convey your ideas. Good luck with your birth control essay!

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• Published: 09 February 2021

A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya

• Susan Ontiri   ORCID: orcid.org/0000-0001-7622-5714 1 , 2 ,
• Lilian Mutea 3 ,
• Violet Naanyu 4 ,
• Mark Kabue 5 ,
• Regien Biesma 2 &
• Jelle Stekelenburg 2 , 6  

Reproductive Health volume  18 , Article number:  33 ( 2021 ) Cite this article

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Addressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives.

Qualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach.

Use of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods.

This study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users.

Peer Review reports

Use of contraceptive methods allows spacing of pregnancies or limiting family size, enabling individuals and couples to fulfill their fertility desire by choosing if and when to become pregnant. Contraceptive use not only has positive effects on health-related outcomes, such as improved maternal and child health [ 1 ] but also improves schooling and economic outcomes for girls and women [ 2 ]. Global trends have shown an increase in contraceptive uptake, however, many women, approximately one out of three, discontinue their method within a year [ 3 , 4 ]. Contraceptive discontinuation is an important determinant of contraceptive prevalence, as well as unintended pregnancies, and other demographic impacts as it increases the unmet need for family planning (FP). Several studies have found that contraceptive abandonment and failure contribute substantially to the total fertility rate, unwanted pregnancies, and induced abortions [ 3 , 4 , 5 ]. Analysis of data from 36 developing countries revealed that over one-third of unintended pregnancies resulted from women who had discontinued the use of contraception [ 5 ]. Unintended pregnancies have negative consequences on the health and well-being of women and their families as they can lead to maternal morbidities and even death. Besides, it is documented that children born from unintended pregnancies are: less likely to be breastfed, more likely to be stunted, at risk of a lack of parental love, and at higher risk of child mortality than children from wanted pregnancies [ 6 ].

An analysis of Demographic and Health Surveys conducted by Curtis et al. demonstrated that women’s socio-demographic characteristics—age, education, place of residence, and economic status—are the determinants associated with contraceptive discontinuation [ 7 ]. Even though studies indicate that women with higher levels of education and those residing in urban residences are more likely to discontinue their initial method, additional analyses reveal that these women are more likely to switch than stop after discontinuing a method [ 7 , 8 , 9 ]. This could be because they are enlightened on their contraceptive choices and will discontinue and switch if a particular method does not suit them since they can also easily access the contraceptive services due to shorter distances to health facilities.

Researchers continue to investigate why a woman or a couple would discontinue the use of modern contraception while still in need. Past studies show side effects and health concerns have been the main causes of contraceptive discontinuation [ 3 , 4 , 10 ]. Indeed, side effects account for more than half of the reasons for discontinuing contraceptives while still in need [ 9 , 11 ].

Kenya has implemented a strong national family planning (FP) program since it was launched in 1967 [ 12 ]. Over the past five decades, the country has developed FP/reproductive health policies, strategies, and guidelines and implemented programs aimed at increasing access and utilization of modern contraceptive methods among women of reproductive age and supporting men's involvement. These efforts have borne fruit; the current data estimates a contraceptive prevalence rate of 62.8%, which is mostly driven by the use of modern methods at 60.7% [ 13 ]. However, more than one-third of all pregnancies in Kenya are unintended and one in three women discontinue use of contraceptives by 12 months [ 14 ]. Like other countries, the main reason cited in Kenya for discontinuation is side effects, predominantly side effects associated with hormonal contraception [ 14 ]. Studies have linked poor quality of care, particularly inadequate counseling on side effects with contraceptive discontinuation [ 4 , 15 ]. For instance, data from round 5 to round 7 of Kenya’s Performance Monitoring and Accountability 2020 surveys indicate a glaring gap in the quality of FP services provided in health facilities. Only two-thirds of women were informed about side effects by service providers, with slightly more than half being informed about what to do in case of side effects [ 13 , 16 , 17 ].

Whereas the predictors of contraceptive counseling have been established by several quantitative studies [ 3 , 4 , 18 ], there is a paucity of information to understand the lived-in experiences of women who discontinue the use of contraceptives while still in need. This paper reports qualitative results from in-depth interviews and focus group discussions with discontinuers. The interviews and discussions explored experiences with previous use of modern contraceptives, reasons for discontinuation, and future intention to use contraceptives among discontinuers.

Study design and setting

A cross-sectional qualitative study was conducted as part of a formative assessment in a 24-month longitudinal study on evaluating the dynamics of contraceptive use, discontinuation, and switching in Kenya. The longitudinal study is being conducted in Kitui and Migori, rural counties in Kenya. The two counties have a diverse method mix; Migori’s mCPR is mostly driven by long-acting reversible contraceptives, at 72% while in Kitui, short-term methods are more popular, at 64% [ 14 ]. Details of the longitudinal study, including the study setting, have been published elsewhere [ 19 ]. Ten public health facilities, five in each county were purposively selected based on high FP caseload. The 10 facilities were located in 10 different sub-counties. Routine service statistics revealed that these facilities provided the highest number of contraceptive services in their respective sub-counties. Out of the ten facilities, 2 were county hospitals, 5 sub-county hospitals, 2 health centers, and 1 dispensary. The consolidated criteria for reporting qualitative research (COREQ) was used in this paper [ 20 ]. The completed checklist is available in Additional file 1 .

Study participants

Since the main objective of this study was to explore the experience with contraceptive use and discontinuation among discontinuers, participants who met the following inclusion criteria were selected: women of reproductive age between 15 and 49 years of age, who were sexually active, did not desire pregnancy, and had been but were currently not using modern contraception. The men who were interviewed to explore their perspective on contraceptive discontinuation were purposively selected since they were spouses of the women who met the inclusion criteria. Data collection included FGDs with adolescent mothers aged 15–19 years and women over 20 years and IDIs with couples and adolescent girls. Recruitment of study participants stopped once data saturation was achieved, that is when no new information was derived from the interviews and focus group discussions. In total, 42 data collection sessions (12 FGDs and 30 IDIs) were conducted with 135 study participants-105 in FGDs and 30 in IDIs. (Table 1 ).

Recruitment strategy

The study team selected community health volunteers (CHVs) who were providing health information including family planning to households within the catchment area of the study facilities. The CHVs were trained on the inclusion criteria and thereafter, mobilized and screened community members within their catchment area before referring them to the study staff who contacted, further screened, and recruited those eligible into the study. For couples, the CHV would approach the woman first to establish eligibility, before contacting the spouse. Both partners had to agree to participate before inclusion in the study.

Data collection

Data collection was conducted from May to July 2019. The data collection team was comprised of 10 research assistants, (seven females and three males) who had undergraduate training in Anthropology or Sociology. The team was selected based on their experience conducting qualitative studies. They further received an additional 5-day refresher training before data collection. They worked under the supervision of the lead author. Respondents were not known to the interviewers before the data collection sessions. Written consent was obtained from the participants to conduct and audio-record the data collection sessions. The time and place of the interviews were determined based on the convenience of the participants. The venue for the FGD data collection sessions was community halls while the IDIs were conducted at the participants’ homes. All participants were aware that the study was being conducted to explore their perspective and experience with contraceptive use and discontinuation as part of a formative assessment to improve the quality of family planning services provided.

Semi-structured topic guides covering FP topics for the various audiences were developed and piloted before use. The FGD guide included open-ended prompts related to knowledge and perception of contraceptives, use of FP with their community, and reasons for contraceptive discontinuation, including influencers. The study had IDI guides for the adolescent girls (15–19 years) and for married couples (18–49 years), husbands and wives were interviewed separately. The former group was asked about their knowledge and perceptions around sexual and reproductive health and contraceptive use, experience using contraceptives, and contraceptive discontinuation. The married couples shared their knowledge, perception, and decision-making experiences using contraceptives; FP use and discontinuation; and couple involvement in contraceptive use and discontinuation. The file showing the topic guides used in this study is provided in Additional file 2 .

Two trained interviewers were present at each FGD—one as a session moderator and the other as a note-taker. For the IDIs, only one trained moderator was present for the conversation. No observer was present during data collection. The FGDs and interviews were conducted in local dialect (Kamba and Dholuo) and Swahili. All the interviews were audio-recorded, and field notes were taken for each focus group session. The interview sessions lasted between 30 and 90 min. The data collection team debriefed after the end of each session. Interim findings were discussed weekly by the team and interview guides were modified and revised as needed. At the end of data collection, no new themes were emerging and data saturation had been achieved.

Data analysis

The digital recordings of IDIs and FGDs were transcribed verbatim, translated into English, and analyzed using NVivo 11. Data were analyzed thematically following the approach of Braun and Clarke to identify, analyze, and report patterns within the data [ 21 ]. Coding and theme development were directed by the content of the data (inductively) [ 21 ]. A final agreed thematic framework was applied to all interviews. Transcripts were not returned to participants in advance of coding. Data analyses were performed by two researchers (VN and SO) with in-depth knowledge of qualitative analysis who were supported by two analysts to ensure timely coding and validation of the coding frame. The team identified themes from reading and rereading the transcripts, noting any similarities and differences between and within participants’ accounts. The preliminary findings were shared with some of the study participants for validation.

Ethical considerations

This study was guided by a protocol that was approved by the Kenya Medical Research Institute Institutional Review Board and the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Participants gave informed written consent/assent to participate in the study. Protection and confidentiality of participants was ensured through conducting data collection sessions in private settings, maintaining confidentiality, and limiting access to study information to only authorized personnel.

The demographic characteristics of the 135 study participants are shown in Table 2 . The majority of the participants were adolescents and youth aged 15–24 years at 51%, had primary education 53%, were farmers 32%, and had one to two children (Table 2 ). The findings from the two study sites were comparable, with no major differences.

Study findings are provided in four themes below: (1) motivation for modern contraceptive use; (2) sources and decision-making for previous contraceptive used; (3) barriers to sustained use of contraceptives; and (4) future intention to use contraceptives.

Motivation for modern contraceptive use

The study explored the participant’s motivation for use of a contraceptive prior to discontinuation. Generally, there was strong consensus among all the study participants that the reasons for using contraceptives were to plan for the number of children they wished to have, and prevent pregnancy. Adolescent participants further noted that the greatest motivation for using contraceptives was to prevent pregnancy so as to pursue studies; they wanted to avoid unplanned pregnancies that might result in having to drop out of school and take on parental responsibilities they had not envisioned.

Economic reasons appeared to be the major impetus for use of contraceptives by adolescent mothers, older women, and married couples, as most participants shared similar sentiments on the need to have children they can manage to raise as illustrated by the following quote:

“We are able to space out the children and able to provide the right foods to the children so that they can be healthy because our incomes are low.” (FGD, Female).

Many participants reported that their motivation for use of contraceptives was to space their pregnancies to allow the healthy growth of children so they could get enough attention, nutrition, and care from their parents. A few married women noted, where couples were experiencing marital conflict, women used contraceptives to avoid getting additional children that they would need to support on their own.

Sources and decision-making for previous contraceptive used

The majority of participants interviewed indicated that they got their contraceptive method from public health facilities. Some, especially adolescents, got their contraceptive methods from private facilities, specifically chemists or pharmacists. Most older respondents indicated that they had opted for injectables and implants, while use of pills was mainly mentioned by adolescents.

“I bought my pills from the pharmacy shop in town” (IDI, Adolescent, Female).

The study findings revealed that before using contraception, most women sought the opinions of partners, peers, or family friends. For adolescent mothers, their mothers were mentioned as helpful in decision-making and accessing contraceptives. Most partners were involved in decision-making about uptake of FP before initiation of a method, while some were engaged after the FP method was started. However, some female participants stated that they had used contraception covertly due to non-supportive spouses or relatives, particularly the in-laws who threatened to report them to their partners.

Barriers to sustained use of contraception

The study further explored the reasons why women did not continue using a contraceptive method yet they still had a need for contraception. Reasons for discontinued use of contraceptives were manifold; five main sub-themes emerged: side effects, method efficacy, peer influence, gender-based violence, and health system factors.

Side effects of contraceptives

Across all the study groups, side effects resulting from use of contraception were repeatedly mentioned among the reasons for discontinuation. The leading side effect was irregular bleeding patterns presenting as menorrhagia (heavy menstrual bleeding) or amenorrhea (absence of menstrual bleeding). This was mainly experienced from the use of hormonal methods, and in particular injectables and implants. For example:

“When I used the three-months injection, I was bleeding excessively. Sometimes I would feel dizzy while walking. The bleeding would even continue for a month without stopping. So, I decided to stop using it.” (IDI, Female).

Heavy bleeding was cited to interfere with the participants’ social and economic lifestyle. The majority of the female participants who reported increased bleeding indicated that they were unable to carry out their economic activities since they were weak as a result of the increased menstrual flow. Another recurrent consequence of the increased bleeding was the interference with their sexual life:

“The reason I chose to stop using depo is for one reason. Sometimes my husband may have the desire to get intimate with you but you cannot, because of the bleeding. Whenever I want us to get intimate he declines because it is so much blood that is why he told me to try quitting it.” (IDI, Female).

On the contrary, some respondents reported that the absence of menstrual bleeding was what triggered discontinuation since they did not know whether they were still fertile or were pregnant.

“When I started using implants, my periods did not come for eight months, then it came back only for two days and disappeared again. I decided to stop using a contraceptive since I was always wondering whether I was pregnant.” (FGD, Adolescent).

Other side effects that led to discontinuation, albeit less frequently mentioned across the various study groups, included weight changes, dizziness, and low sexual libido.

“ My friend who was using the one for three years told me she stopped because she didn’t have an appetite for having sex, so it was raising issues between her and her husband.” (FGD, Adolescent).

Some study participants observed that experiences from other women influenced contraceptive use or discontinuation. Several FGD participants indicated that women discontinued the use of contraceptive methods after learning about side effects experienced by their friends. This prompted even those who were not experiencing the same to discontinue out of fear.

Contraceptive method efficacy

Contraceptive efficacy was a concern mentioned mostly by married couples. Respondents reported method failure whereby women got pregnant unexpectedly while still on a contraceptive method:

“One year after using an implant, I started becoming sick. When I went back to the hospital, I was tested and the results came out that I was four months pregnant, and at the same time I still had the implant in my arm.” (FGD, Female).

“I have a friend; she was using the one for 3 months. After sometime, she was shocked that she was pregnant. So, she decided that she will not use it because even if you use it you still get pregnant.” (FGD, Adolescent).

Several participants revealed that they decided to discontinue use of contraceptives after learning about cases of method failure among women who were using similar methods. On several instances, inconsistent use of contraceptive, especially short-term methods, that resulted in pregnancies were reported as method failure by some participants:

“The one for three months confused her a lot, it came to end without her knowing and she forgot to go back to the clinic for another injection. She became pregnant and then it surprised her. We had tried using it for a long time and I told her that she was using a method of a shorter duration and when it ended she became pregnant without planning.” (IDI, Male).

Covert use of contraception resulting in gender-based violence

Covert use of contraception was common due to lack of spousal support for use of a modern method. Across all the study groups, the participants shared their experiences or cases of other women who discontinued contraceptive use because their partners learned that they were using it covertly. Cases of gender-based violence directed at women by their partner after learning their use of modern contraceptive methods, further solidified their resolve to discontinue as illustrated by this experience:

“Another woman in our village went and got an implant without her husband’s knowledge. When the husband learned of this, he took a knife and removed it from her arm. This made my friends and me afraid, so we decided to just remove it for fear of what our husbands would do if they find out.” (FGD, Female).

Health system factors as a barrier to continuation

Health care system factors were repeatedly mentioned as reasons for discontinuation. Stock-outs of preferred methods during contraceptive initiation or resupply prompted women to either take alternative methods or leave without one. Provider bias that resulted in women taking up methods that they did not approve of came up as a sub-theme particularly by younger women, as shown in the quote below:

“I told him [the provider] I wanted depo and he said that the government does not advise the use of injection, and he refused to put it on me. He convinced me to take up an implant, which I did, but I went to another facility to have it removed.” (FGD, Female).

There were mixed experiences regarding FP counseling, particularly on side effects. Several respondents noted that they got adequate counseling by the health care providers during the initiation of a method; however, some mentioned that they were not informed of any potential side effects that could result from use of contraception.

“When I started using them, the doctor explained to me about the advantages and disadvantages of the various methods of family planning, such that, I know the goodness and effects of the method I am using.” (FGD, Female).

Future intentionality to use contraception

The study explored whether the respondents would consider using modern contraceptives again. Several respondents indicated willingness to use at some time, but some were hesitant. Those who would consider using an FP method again said they would consult widely, select a method with fewer side effects, and one with a longer duration. For those who were doubtful and not considering using FP, five reasons were provided.

First, there were fears about negative side effects. Women indicated that the fear of experiencing another side effect after discontinuation led them to decide not to take up any other modern method despite the counseling that they got from health care workers who were advising them on method switching. One woman shared her experience:

“These medicines bring problems. I stayed with the one injection for a while and every time I would feel sickly, weak, back pains at all times, bleeding from Monday to Monday. I came to the hospital and asked them to remove it. They asked me what the problem was, that they will give me another one, but I did not want one. So that is why I stopped using.” (FGD, Female).

Second, cost was cited as a barrier for continued use. Respondents indicated that the direct and indirect costs associated with uptake of contraceptive services hindered their intention to use. The cost barrier was mainly mentioned for short-term methods that require frequent resupply at facilities, hence, women had to make multiple visits to the facility. Several concerns were also raised regarding the removal of intrauterine contraceptive devices or implants after experiencing side effects. An important issue that participants highlighted was the cost incurred for the removal of a method, which caused women to fear the selection of another method in case they experienced side effects with that method.

“If you go to the facility before the expiry date, you are asked to pay 200 shillings, regardless of the side effects experienced. I wonder why they charge for removal yet they gave it for free. After that one fears to take up another method.” (FGD, Female).

Lastly, FP use caused conflicts in families. Women indicated lack of support from their partners and relatives impeded their intention to use contraception. It was evident that even though the women felt a need to space or limit their family size, that decision was mainly made by their partners. Other women, who had previously used the method covertly and had been discovered by their spouses or relatives, mentioned they could not use the method for fear of gender-based violence. This quote buttresses the point:

“My husband threatened to beat me also if he ever found me using a method. This was after he had observed a disagreement between our neighbors (couple), over the discreet use of contraceptives that ended up with the lady being hit by her husband. I decided to stop using to avoid such an occurrence. ” (IDI, Female).

This qualitative study aimed to explore the dynamics of contraceptive use and discontinuation among women with unmet need for contraceptives in the rural counties of Migori and Kitui, Kenya. A large and diverse group of adolescents, women, and couples who reported contraceptive discontinuation while still in need of a method provided insights on their experiences, perspectives with contraceptive use and reasons for discontinuation. Direct quotes of study participants about their experiences with FP use that culminated in discontinuation have been presented to deepen understanding of participants’ experiences [ 22 ]. From the study findings, it is evident that all the respondents chose to use contraceptives with the conviction that by using a modern method, they would be able to prevent pregnancy or plan when to have children, determine how far apart they want their children to be, and when to stop having children. However, this desire was not fully realized as they discontinued use of the contraceptives while still in need, which added to the pool of women of reproductive age with unmet need for FP.

There were numerous challenges faced by women using contraceptives that prompted them to discontinue their use. As noted in prior studies, side effects play a major role in reported decisions to discontinue [ 4 , 23 , 24 ]. Our study revealed that the most common side effect leading to contraceptive discontinuation were changes in users’ bleeding patterns, findings which are consistent with studies conducted across different parts of the world [ 18 , 25 , 26 ]. Irregularity of bleeding negatively impacts the well-being of women, mainly due to the social consequences, which could explain the low tolerance with contraception when such side effects are encountered. Studies have revealed that women, especially in the sub-Saharan region, believe that menstrual bleeding is a sign of fertility, hence any change that leads to reduced or no bleeding is frowned upon [ 27 , 28 ]. Conversely, increased bleeding impacts women’s socio-economic activities and sexual relationship with their partners [ 28 , 29 ].

Our findings thus provide strong support for addressing side effects experienced by women through management when they occur or being provided options for method switching to ensure the women continue to harness the full benefits of contraception. This can be achieved by conducting client follow-up by service providers to periodically assess the level of satisfaction with the contraceptive method while addressing issues that might prompt clients to discontinue. Proper counseling of clients, and their partners, is crucial to promote continuation with use of modern contraceptive methods as the users are made aware of the contraceptive’s mechanism of action, possible side effects, and what to do when they experience side effects. Helping women understand typical bleeding changes associated with their contraceptive methods could lead to greater acceptance of the changes, increased method uptake, improved satisfaction, and higher continuation rates [ 30 ]. Therefore, capacity building of health care providers on contraceptives should not just focus on the technical skills on insertion and removal (particularly for long-term methods), but also on contraceptives’ mechanisms, how they work, to ensure that providers are well versed on the potential side effects for each method. This is supported by evidence from studies in Madagascar and Ghana that revealed providers were not well informed on the physiological effects of contraception and how to manage side effects [ 4 ]. This resulted in inadequate counseling of women experiencing the side effects; women were counseled to switch to another method instead of being reassured that side effects would settle down over time or being offered medication to control some side effects [ 4 ]. This could be attributed to inadequate training content on side effects. A recent review of FP counseling, training, and reference materials revealed that bleeding changes are insufficiently addressed in capacity building resources and counseling tools for health care providers [ 29 ]. This is alarming, considering that the leading reason for discontinuation has been changes in bleeding pattern. Skilled counseling for side effects, particularly bleeding irregularities, can only be achieved if training materials for health care providers incorporate this information, information that will improve the quality of counseling by health care providers.

Contraceptive method failure was one of the reasons for discontinuation in this study. Method failure is a factor of either failure of a method to work as expected or incorrect/inconsistent use of a method by the user. In low- and middle-income countries, 74 million unintended pregnancies occur annually, of which a sizable share, 30%, are due to contraceptive failure among women using some type of contraceptive method [ 31 ]. Each contraceptive method has a Pearl Index number that reflects pregnancy rates during perfect and typical use, with use of long-term method conferring higher efficacy than short-term methods [ 32 ]. Whereas all contraceptive methods have some degree of failure, even during perfect use, failure rates can be reduced when individuals are sensitized on the proper use of contraception to ensure the method is used correctly and consistently. Provision of clear information about the risks and benefits of all available methods is crucial in facilitating informed contraceptive choice so women can make an educated choice for their preferred methods, which may reduce discontinuation.

Other reasons for contraceptive discontinuation, such as lack of support from partners and other social networks, are also corroborated in researches previously conducted in Kenya [ 28 , 33 ]. In our study, the decision to use or not use contraceptives was still primarily made by men. Although women made solo decisions on FP, they were heavily influenced by their spouses’ preference and would stop using if they thought it would bring marital conflicts. Opposition to contraceptive use by husbands appears to stem from the fear of side effects and the perception that women who use FP are more likely to be promiscuous. Additionally, Kenya being a highly patriarchal society, decision-making around the desired number of children mainly lies with the male partner. FP programs have mainly targeted women with information to promote uptake since they are the ones who face the risk of pregnancy and childbirth. Unfortunately, these programs have left out men, who are in most instances, the decision-makers in male-dominated societies, like most countries in the sub-Saharan region [ 34 ]. The findings from this study reveal the power dynamics when it comes to a couple’s decision to use contraception. This underscores the need to meaningfully involve men in FP programs by informing them of the health, economic, and social benefits realized from proper and consistent use of contraception so they can optimize use of FP services. Demand generation strategies that employ the use of positive deviants, satisfied users, and other key influencers, such as mothers-in-law, may lead to an increase in contraceptive uptake and enhance continuation.

This study indicates that the costs associated with consistent use of FP methods hinder their continued use. Promoting uptake of LARC methods will address the cost associated with the use of short-term method—LARCs have been shown to be more cost-effective and do not require frequent visits to facilities [ 35 ].

Our study also revealed punitive measures women faced, especially those on LARCs, when they wanted to switch to another method before its expiration. Allowing for method switching is indicative of strong FP programs that have an adequate range of methods and a flexible environment to meet women’s needs. Due to the health and social concerns that contraceptive use may confer on individuals, women may try different methods before settling for their preferred option. The health system should have a supportive policy environment that accommodates such needs of women by: instituting guidelines that prohibit penalization for method switching; addressing commodity stock-outs and ensuring sufficient method mix through increased financing of FP programs; and sensitizing providers on the importance of method switching by women who are not satisfied with their methods. Additional studies are needed to document the implications of frequent method switching on commodity security in countries that continue to face widespread stock-outs of contraceptive methods.

The study’s main strength was documenting the experiences of contraceptive use and discontinuation among discontinuers themselves. However, qualitative studies have limitations related to validity, subjectivity, and reliability. To address these issues, efforts were made to increase the rigor and trustworthiness of the findings through the selection of participants with a range of backgrounds and experiences with the guidance and supervision of experts, as well as external review. Information was not collected on the number of eligible participants who refused to participate in the study. Despite this, our study benefits from including a large number of participants, diverse in terms of age, gender, ethnicity, and location, and utilizing different data collection methodologies (FGDs and IDIs) to enrich the findings.

Conclusions

Our study, conducted in two rural counties in Kenya, revealed a number of important findings regarding factors influencing contraceptive use and discontinuation. The participants in this study had a common motivation for using contraception, to avoid pregnancies, however, side effects were a major hindrance in continued use of contraception. Covert use of contraception resulted in discontinuation when it was discovered and, in some instances, led to gender-based violence. Decision-making on contraception, method to use, and the number of children to have, was jointly done by couples or made by the husband. Reasons for discontinuation, specifically on side effects, were influenced by the husbands.

As contraceptive use in a population increases, success in avoiding unintended pregnancies depends less on initial contraceptive uptake and more on effective and persistent use. Enhanced efforts are needed to design and implement programs that focus on contraceptive discontinuation among women with unmet need for FP. Health care providers offering FP services should be well versed with the mechanism of action for the various contraceptive methods, and incorporate quality of care in the provision of contraceptive services. Additionally, contraception technological advancement is urgently needed to expand the method mix and to develop methods that have fewer side effects and side effects that can be more easily tolerated. This will go a long way in promoting continuation of contraceptive use, as indicated by a majority of our study participants who were willing to consider future use of contraception methods with fewer side effects. Findings from this study, as well as other studies, confirm the importance of engaging men and other social influencers in FP programs by educating them on the socio-economic and health benefits of family planning and dispelling any myths and misconceptions to create a social environment that supports use of modern contraception.

Availability of data and materials

The data used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Consolidated criteria for reporting qualitative studies

Community health volunteers

Focus group discussions

Family planning

In-depth interviews

Long-acting and reversible contraceptive

Total fertility rate

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Acknowledgements

The authors would like to acknowledge the generous contribution of time and expertise by those who participated in this study. We are grateful to Dr. Solomon Orero and Elizabeth Thompson from Jhpiego for reviewing the manuscript.

The study is funded by USAID Kenya and East Africa under Afya Halisi project, award number AID-615-A-17-00004. The funding institution did not play a role in the study design, implementation, in the writing of the manuscript, or in the decision to submit the article for publication.

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SO, LM, MK, RB and JS contributed to the design of the study. VN and SO performed data analysis. SO drafted the manuscript. All authors critically revised the manuscript and approved the final version. All authors read and approved the final manuscript.

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Ontiri, S., Mutea, L., Naanyu, V. et al. A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya. Reprod Health 18 , 33 (2021). https://doi.org/10.1186/s12978-021-01094-y

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Birth Control Essay Examples

Birth control essay topics and outline examples, essay title 1: birth control methods and their impact on reproductive health and family planning.

Thesis Statement: This essay explores various birth control methods, their effectiveness, and their impact on reproductive health and the ability to make informed family planning decisions.

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Thesis Statement: This essay advocates for comprehensive sexual health education programs that equip individuals with knowledge about birth control options, safe practices, and informed decision-making.

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Birth Control - Free Essay Samples And Topic Ideas

Birth control, a critical aspect of reproductive health, enables individuals and couples to plan if or when they want to have children. Essays might explore the various methods of birth control, the history of birth control advocacy, and the societal implications of accessible contraception. Discussions could delve into the challenges faced in promoting birth control in different cultural or religious contexts, and the impacts of birth control on gender equality, economic stability, and public health. They might also discuss the controversial political and moral debates surrounding birth control, and the role of education in fostering informed decisions regarding reproductive health. We have collected a large number of free essay examples about Birth Control you can find at Papersowl. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

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Most believe that birth control serves one purpose to prevent pregnancy. While it's very effective compared to other forms of contraceptives, the effects aren't just limited to pregnancy prevention. Its also known to be used to help treat other health concerns such as menstrual relief, skin changes, and more. Birth control has different side effects on women because of different hormone levels and each birth control carries different level of progestin and/or estrogen. Given the grueling horror stories we hear […]

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How to Write an Essay About Birth Control

Understanding the concept of birth control.

Before writing an essay about birth control, it's important to understand what birth control is and the various methods available. Birth control, also known as contraception, refers to methods or devices used to prevent pregnancy. Start your essay by explaining the different types of birth control methods, including hormonal contraception (like pills, patches, and injections), barrier methods (such as condoms and diaphragms), intrauterine devices (IUDs), and natural methods. Discuss the effectiveness, accessibility, and suitability of these methods for different individuals. It’s also crucial to explore the historical development of birth control and its role in the sexual and reproductive health movement.

Developing a Thesis Statement

A strong essay on birth control should be centered around a clear, concise thesis statement. This statement should present a specific viewpoint or argument about birth control. For example, you might explore the impact of birth control on women's health and rights, analyze the social and political challenges surrounding access to contraception, or argue the need for improved sex education in schools. Your thesis will guide the direction of your essay and provide a structured approach to your topic.

Gathering Supporting Evidence

To support your thesis, gather evidence from a variety of sources, including medical studies, public health data, and historical texts. This might include statistics on birth control usage, research findings on the health benefits or risks associated with various contraception methods, or analysis of policy changes affecting birth control access. Use this evidence to support your thesis and build a persuasive argument. Remember to consider different perspectives, including cultural and ethical dimensions of birth control.

Analyzing the Impact of Birth Control

Dedicate a section of your essay to analyzing the impact of birth control on society. Discuss how birth control has transformed women’s health, empowerment, and socioeconomic status. Consider the role of birth control in family planning, population control, and sexual health. Explore the challenges faced in accessing birth control, such as legal restrictions, cultural stigmas, or economic barriers.

Concluding the Essay

Conclude your essay by summarizing the main points of your discussion and restating your thesis in light of the evidence provided. Your conclusion should tie together your analysis and emphasize the importance of birth control in contemporary society. You might also want to suggest areas for future research or action needed to improve access to and understanding of birth control.

Reviewing and Refining Your Essay

After completing your essay, review and refine it for clarity and coherence. Ensure that your arguments are well-structured and supported by evidence. Check for grammatical accuracy and ensure that your essay flows logically from one point to the next. Consider seeking feedback from peers, educators, or healthcare professionals to further improve your essay. A well-written essay on birth control will not only demonstrate your understanding of the topic but also your ability to engage with complex health and social issues.

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Research Paper

Birth control.

Birth control is the control of fertility, or the prevention of pregnancy, through one of several methods. Another common name for birth control is contraception, because that is precisely what the various birth control methods do; they prevent the viable sperm and egg from uniting to form a fertilized embryo. Though discussing birth control is no longer likely to lead to an arrest, as it did in the days of birth control pioneer Margaret Sanger, public debates remain. Some debates address which methods of birth control are the most effective at attaining one’s reproductive goals, while others address whether insurance benefits should include the cost of birth control, the likely long- and short-term effects of their use, how to increase the use of birth control among sexually active young people, and questions over why there are still so many more methods that focus on women’s fertility compared with those that focus on men’s fertility.

Introduction

Controlling fertility affects the well-being of women, men, children, families, and society by providing methods and strategies to prevent unplanned pregnancies. Planned fertility positively impacts the health of children, maternal longevity, and the empowerment of women. Access to birth control provides women and men with choices regarding family size, timing between pregnancies, and spacing of children. Additionally, controlling fertility reduces the prevalence of chronic illness and maternal death from pregnancy-related conditions.

Globally, approximately 210 million women become pregnant each year. Of these pregnancies, nearly 40 percent are unplanned. In the United States, 49 percent of pregnancies are estimated to be unplanned. Research shows that unintended pregnancies can have devastating impacts on not only women but also children and families. An unintended pregnancy places a woman at risk for depression, physical abuse, and the normal risks associated with pregnancy, including maternal death. Pregnancies that are spaced closely together present risks to children, including low birth weight, increased likelihood of death in the first year, and decreased access to resources necessary for healthy development. Unintended pregnancies can have devastating impacts on the well-being of the family unit. An unplanned pregnancy often pushes families with limited economic resources into a cycle of poverty that further limits their opportunities for success.

Although control of fertility spans approximately 30 years of men’s and women’s reproductive life, preferences for birth control methods and strategies vary among individuals and across the life course and are influenced by multiple social factors. These factors may include socioeconomic status, religious or moral beliefs, purpose for using birth control (permanent pregnancy prevention, delay of pregnancy, or spacing between births), availability of birth control products, access to medical care, willingness to use birth control consistently, concern over side effects, and variability in the failure rates of different types of birth control products. Although the primary purpose of birth control is to control fertility, increases in the prevalence of sexually transmitted infections (STIs) and the human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), have created pressures to develop new pregnancy prevention options that combine contraception and STI prevention. The availability of contraceptive options allows women and men the opportunity to maximize the benefits of birth control while minimizing the risks of contraceptive use according to their needs.

The availability of birth control has raised important questions about reproductive control and the relationships between men and women. Traditionalists argue that pregnancy and child rearing are the natural or biologically determined roles of women, given their capacity to become pregnant and give birth. Opponents of this view argue that reproduction and motherhood are one of many choices available to women. Providing options to women and men that allow them to control their fertility has shifted pregnancy and motherhood from a position of duty to one of choice. This shift is a consequence of changes to the work force, increased opportunities for women, and changes in the economic structure of contemporary families. These changes, along with ongoing developments in fertility control research, provide women and men today with many innovative choices concerning birth control. These choices allow women and men to tailor birth control to their individual needs and life circumstances.

Today, birth control debates focus on the advantages and disadvantages of different birth control methods. The most common debates focus on the merits of temporary versus permanent methods of pregnancy prevention. Other debates examine the benefits of natural versus barrier methods of controlling reproduction. Still other debates examine the advantages and disadvantages of male and female contraception. With the growing pandemic of AIDS in sub-Saharan Africa and Asia and the increasing prevalence of sexually transmitted diseases that threatens world health, contemporary debates about birth control focus on the feasibility and practicality of combining STI prevention and contraception.

Brief History of Birth Control

Although women have sought to control their fertility since ancient times, safe and effective contraception was not developed until the 20th century. The large influx of immigrants in the 1900s and the emergence of feminist groups working for women’s rights helped bring to the forefront large-scale birth control movements in the United States and abroad. Ancient forms of birth control included potions, charms, chants, and herbal recipes. Ancient recipes often featured leaves, hawthorn bark, ivy, willow, and poplar, believed to contain sterilizing agents. During the Middle Ages, potions containing lead, arsenic, or strychnine caused death to many women seeking to control their fertility. Additionally, crude barrier methods were used in which the genitals were covered with cedar gum or alum was applied to the uterus. Later, pessary mixtures of elephant dung, lime (mineral), and pomegranate seeds were inserted into a woman’s vagina to prevent pregnancy. Other barrier methods believed to prevent pregnancy included sicklewort leaves, wool tampons soaked in wine, and crudely fashioned vaginal sponges.

Later birth control developments were based on more accurate information concerning conception. Condoms were developed in the early 1700s by the physician to King Charles II. By the early 1800s, a contraceptive sponge and a contraceptive syringe were available. By the mid-1800s, a number of more modern barrier methods to control conception were available to women. However, it was illegal to advertise these options, and most were available only through physicians and only in cases that were clinically indicated. Thus, early modern conception was limited to health reasons.

Modern contraceptive devices such as the condom, diaphragm, cervical cap, and intrauterine device (IUD) were developed in the 20th century and represented a marked advance in medical technology. Effectiveness was largely dependent on user compliance. Although these methods represented a significant improvement over more archaic methods, contraceptive safety remained an issue. Other modern methods included the insertion of various substances (some toxic) into the vagina, resulting in inflammation or irritation of the vaginal walls, while other devices often caused discomfort.

The birth control pill, developed in the 1950s by biologist Charles Pincus, represented a major advance in fertility control. Pincus is credited with the discovery of the effects of combining estrogen and progesterone in an oral contraceptive that would prevent pregnancy. The development and mass marketing of the birth control pill provided women with a way to control not only their fertility but also their lives.

Overview of Traditional Contraceptive Methods

Traditional contraception includes both temporary and permanent methods of controlling fertility. Temporary contraception provides temporary or time-limited protection from becoming pregnant. Permanent contraception refers to surgical procedures that result in a lasting or permanent inability to become pregnant. The choice of contraception takes into consideration several biological and social factors, including age, lifestyle (frequency of sexual activity, monogamy or multiple partners), religious or moral beliefs, legal issues, family planning objectives, as well as medical history and concerns. These factors vary among individuals and across the life span.

Traditional Contraceptive Methods

Traditional contraceptive methods provide varying degrees of protection from becoming pregnant and protection from STIs. While some of these methods provide noncontraceptive benefits, they require consistent and appropriate use and are associated with varying degrees of risks. Traditional contraception includes both hormonal and non-hormonal methods of preventing pregnancy and sexually transmitted diseases. These methods provide protection as long as they are used correctly but their effects are temporary and reversible once discontinued. Traditional contraceptive methods include sexual abstinence, coitus interruptus, rhythm method, barrier methods, spermicides, male or female condoms, IUDs, and oral contraceptive pills.

Sexual abstinence refers to the voluntary practice of refraining from all forms of sexual activity that could result in pregnancy or the transmission of sexually transmitted diseases. Abstinence is commonly referred to as the only form of birth control that is 100 percent effective in preventing pregnancy and STIs; however, failed abstinence results in unprotected sex which increases the risks of unintended pregnancy and transmission of STIs.

Coitus interruptus is the oldest method of contraception and requires the man to withdraw his penis from the vagina just prior to ejaculation. Often referred to as a so-called natural method of birth control, coitus interruptus is highly unreliable because a small amount of seminal fluid, containing sperm, is secreted from the penis prior to ejaculation and can result in conception. This method offers no protection from sexually transmitted diseases.

The rhythm method of birth control developed in response to research on the timing of ovulation. Research findings indicate that women ovulate approximately 14 days before the onset of their menstrual cycle. The rhythm method assumes that a woman is the most fertile during ovulation. To determine an individual cycle of ovulation, this method requires a woman to count backward 14 days from the first day of her menstrual period. During this time period, a woman should abstain from sexual activity or use another form of birth control (such as condoms) to avoid pregnancy. The rhythm method is another natural form of birth control that is highly risky. Few women ovulate at the exact same time from month to month, making accurate calculations of ovulation difficult. Additionally, sperm can live inside a woman for up to seven days, further complicating the calculations of safe periods for sex. Finally, the rhythm method does not provide protection from sexually transmitted diseases.

Barrier methods of contraception prevent sperm from reaching the fallopian tubes and fertilizing an egg. Barrier methods include both male and female condoms, diaphragms, cervical caps, and vaginal sponges. With the exception of the male condom, these methods are exclusively used by women. Barrier contraception is most often used with a spermicide to increase effectiveness. Spermicides contain nonoxynol-9, a chemical that immobilizes sperm to prevent them from joining and fertilizing an egg. Barrier methods of contraception and spermicides provide moderate protection from pregnancy and sexually transmitted diseases although failure rates (incidence of pregnancy resulting from use) vary from 20 to 30 percent.

Condoms, a popular and non-prescription form of barrier contraception available to both men and women, provides moderate protection from pregnancy and STIs. The male condom is a latex, polyurethane, or natural skin sheath that covers the erect penis and traps semen before it enters the vagina. The female condom is a soft, loosely fitting polyurethane tube-like sheath that lines the vagina during sex. Female condoms have a closed end with rings at each end. The ring at the closed end is inserted deep into the vagina over the cervix to secure the tube in place. Female condoms protect against pregnancy by trapping sperm in the sheath and preventing entry into the vagina. Used correctly, condoms are between 80 and 85 percent effective in preventing pregnancy and the transmission of STIs. Risks that decrease the effectiveness of condoms include incorrect usage, slippage during sexual activity, and breakage. Natural skin condoms used by some males do not protect against the transmission of HIV and other STIs.

The female diaphragm is a shallow, dome-shaped, flexible rubber disk that fits inside the vagina to cover the cervix. The diaphragm prevents sperm from entering the uterus. Diaphragms are used with spermicide to immobilize or kill sperm and to prevent fertilization of the female egg. Diaphragms may be left inside the vagina for up to 24 hours but a spermicide should be used with each intercourse encounter. To be fully effective, the diaphragm should be left in place for six hours after intercourse before removal. Approximately 80 to 95 percent effective in preventing pregnancy and the transmission of gonorrhea and Chlamydia, the diaphragm does not protect against the transmission of herpes or HIV.

Cervical caps are small, soft rubber, thimble-shaped caps that are fitted inside the woman’s cervix. Cervical caps prevent pregnancy by blocking the entrance of the uterus. Approximately 80 to 95 percent effective when used alone, effectiveness is increased when used with spermicides. Unlike the diaphragm, the cervical cap may be left in place for up to 48 hours. Similar to the diaphragm, the cervical cap provides protection against gonorrhea and chlamydia but does not provide protection against herpes or HIV.

Vaginal sponges, removed from the market in 1995 due to concerns about possible contaminants, are round, donut-shaped polyurethane devices containing spermicides and a loop that hangs down in the vagina allowing for easy removal. Sponges prevent pregnancy by blocking the uterus and preventing fertilization of the egg. Vaginal sponges are approximately 70 to 80 percent effective in preventing pregnancy but provide no protection against STIs. Risks include toxic shock syndrome if left inside the vagina for more than 24 hours.

Barrier methods of birth control provide moderate protection from pregnancy and STIs but are not fail-safe. Effectiveness is dependent on consistency and proper use. Advantages include lower cost, availability without a prescription, and ease of use (with the exception of the diaphragm). Disadvantages include lowered effectiveness as compared to other forms of birth control and little or no protection against certain STIs.

Non-Barrier Contraceptive Methods

Two other traditional contraceptive methods are the IUD and oral contraceptive pills. Both of these methods are characterized by increased effectiveness if used properly. The IUD is a T-shaped device inserted into a woman’s vagina by a health professional. Inserted into the wall of the uterus, the IUD prevents pregnancy by changing the motility (movement) of the sperm and egg and by altering the lining of the uterus to prevent egg implantation. The effectiveness of IUDs in preventing pregnancy is approximately 98 percent, however, IUDs do not provide protection from STIs. Oral contraceptive pills are taken daily for 21 days each month. Oral contraceptives prevent pregnancy by preventing ovulation, the monthly release of an egg. This form of contraception does not interfere with the monthly menstrual cycle. Many birth control pills combine progesterone and estrogen, however, newer oral contraceptives contain progesterone only. Taken regularly, oral contraceptives are approximately 98 percent effective in preventing pregnancy but do not provide STI protection.

New Contraceptive Technologies

In spite of the availability of a broad range of contraceptive methods, the effectiveness of traditional contraceptive methods is largely dependent on user consistency and proper use. Even with consistent and proper use, each method is associated with varying degrees of risk. Risks include the likelihood of pregnancy, side effects, and possible STI transmission. New developments in contraceptive technology focus on improvement of side effects and the development of contraceptives that do not require users to adhere to a daily regiment. These new technologies are designed to make use simpler and more suitable to users’ lives. Additionally, many of the new technologies seek to combine fertility control with protection from STIs.

The vaginal contraceptive ring is inserted into a woman’s vagina for a period of three weeks and removed for one week. During the three week period, the ring releases small doses of progestin and estrogen, providing month-long contraception. The release of progestin and estrogen prevents the ovaries from releasing an egg and increases cervical mucus that helps to prevent sperm from entering the uterus. Fully effective after seven days, supplementary contraceptive methods should be used during the first week after insertion. Benefits include a high effectiveness rate, ease of use, shorter and lighter menstrual periods, and protection from ovarian cysts and from ovarian and uterine cancer. Disadvantages include spotting between menstrual periods for the first several months and no protection against STIs.

Hormonal implants provide highly effective, long-term, but reversible, protection from pregnancy. Particularly suitable for users who find it difficult to consistently take daily contraceptives, hormonal implants deliver progesterone by using a rod system inserted underneath the skin. Closely related to implants are hormonal injections that are administered monthly. Both hormonal implants and injections are highly effective in preventing pregnancy but may cause breakthrough bleeding. Neither provides protection from STIs at this stage of development.

Contraceptive patches deliver a combination of progestin and estrogen through an adhesive patch located on the upper arm, buttocks, lower abdomen or upper torso. Applied weekly for three weeks, followed by one week without, the contraceptive patch is highly effective in preventing pregnancy but does not protect against the transmission of STIs. The use of the patch is associated with withdrawal bleeding during the week that it is not worn. Compliance is reported to be higher than with oral contraceptive pills.

Levonorgestrel intrauterine systems provide long-term birth control without sterilization by delivering small amounts of the progestin levonorgestrel directly to the lining of the uterus to prevent pregnancy. Delivered through a small T-shaped intrauterine plastic device implanted by a health professional, the levonorgestrel system provides protection from pregnancy for up to five years. It does not currently offer protection from STIs.

New contraceptive technologies are designed to provide longer-term protection from pregnancy and to remove compliance obstacles that decrease effectiveness and increase the likelihood of unintended pregnancies. The availability of contraceptive options provides users with choices that assess not only fertility purposes but also variations in sexual activity. However, until new contraceptive technologies that combine pregnancy and STI prevention are readily available, proper use of male and female condoms provides the most effective strategy for prevention of sexually transmitted diseases and HIV.

Permanent Contraception

Permanent contraception refers to sterilization techniques that permanently prevent pregnancy. Frequently referred to as sterilization, permanent contraception prevents males from impregnating females and prevents females from becoming pregnant.

Tubal ligation refers to surgery to tie a woman’s fallopian tubes, preventing the movement of eggs from the ovaries to the uterus. The procedure is considered permanent and involves the cauterization of the fallopian tubes. However, some women who later choose to become pregnant have successfully had the procedure reversed. The reversal of tubal ligation procedures are successful in 50 to 80 percent of cases.

Hysterectomy refers to the complete removal of a woman’s uterus or the uterus and cervix, depending on the type of procedure performed, and results in permanent sterility. Hysterectomies may be performed through an incision in the abdominal wall, vaginally, or by using laparoscopic incisions on the abdomen.

Vasectomy refers to a surgical procedure for males in which the vas deferens are tied off and cut apart to prevent sperm from moving out of the testes. The procedure results in permanent sterility although the procedure may be reversed under certain conditions. Permanent contraception is generally recommended only in cases in which there is no desire for children, family size is complete, or in cases where medical concerns necessitate permanent prevention of pregnancy.

Emergency Contraception

Emergency contraception, commonly referred to as postcoital contraception or the so-called morning-after pill, encompasses a number of therapies designed to prevent pregnancy following unprotected sexual intercourse. Emergency contraception is also indicated when a condom slips or breaks, a diaphragm dislodges, two or more oral contraceptives are missed or the monthly regimen of birth control pills are begun two or more days late, a hormonal injection is two weeks overdue, or a woman has been raped. Emergency contraception prevents pregnancy by preventing the release of an egg from the ovary, by preventing fertilization, or by preventing attachment of an egg to the uterine wall. Most effective when used within 72 hours of unprotected sex, emergency contraception does not affect a fertilized egg already attached to the uterine wall. Emergency contraception does not induce an abortion or disrupt an existing pregnancy; it prevents a pregnancy from occurring following unprotected sexual intercourse.

Ideally, birth control should be a shared responsibility between a woman and her partner. In the U.S., approximately 1.6 million pregnancies each year are unplanned. Unplanned pregnancies position women, men, and families in a precarious situation that has social, economic, personal and health consequences. An unintended pregnancy leaves a woman and her partner facing pregnancy termination, adoption, or raising an unplanned child— often times under less-than-ideal conditions. Contraceptive technologies and research developments in the transmission of sexually transmitted diseases represent increased opportunities for not only controlling fertility but also improving safe sex practices.

Also check the list of 100 most popular argumentative research paper topics .

References:

• Caron, Simone M., Who Chooses? American Reproductive History since 1830. Gainsville, FL: University Press of Florida, 2008.
• Connell, Elizabeth B., The Contraception Sourcebook. New York: McGraw-Hill, 2002.
• Gebbie, Alisa E., and Katharine O’Connell White, Fast Facts: Contraception. Albuquerque, NM: Health Press, 2009.
• Glasier, Anna, and Alisa Gebbie, eds., Handbook of Family Planning and Reproductive Healthcare. New York: Churchill Livingstone/Elsevier, 2008.
• Lord, Alexandra M., Condom Nation: The U.S. Government’s Sex Education Campaign from World War I to the Internet. Baltimore: Johns Hopkins University Press, 2010.
• May, Elaine Tyler, America and the Pill: A History of Promise, Peril, and Liberation. New York: Basic Books, 2010.
• Weschler, Toni, Taking Charge of Your Fertility. New York: Harper Collins, 2006.

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Exploring Readiness for Birth Control in Improving Women Health Status: Factors Influencing the Adoption of Modern Contraceptives Methods for Family Planning Practices

Adnan muhammad shah.

1 Department of Computing Engineering, Gachon University, Seoul 13120, Korea; [email protected]

2 Department of Management Sciences, Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Islamabad 44320, Pakistan

3 Charles E. Schmidt College of Science, Florida Atlantic University, Boca Raton, FL 33431, USA

KangYoon Lee

Javaria nisa mir.

4 Faculty of Management Science, Riphah International University, Rawalpindi 46000, Pakistan; moc.liamg@110rimairevaj

Associated Data

The data used to support the findings of this study are available from the corresponding author upon request.

Background: Pakistan is the world’s sixth most populated country, with a population of approximately 208 million people. Despite this, just 25% of legitimate couples say they have used modern contraceptive methods. A large body of literature has indicated that sexual satisfaction is a complex and multifaceted concept, since it involves physical and cultural components. The purpose of this study is to investigate the impact of influencing factors in terms of contraceptive self-efficacy (CSE), contraceptive knowledge, and spousal communication on the adoption of modern contraceptive methods for family planning (FP) under the moderating role of perceived barriers. Methods: Data were collected using an adopted questionnaire issued to married women of reproductive age belonging to the Rawalpindi and Neelum Valley regions in Pakistan. The sample consisted of 250 married women of reproductive age. SPSS was used to analyze the respondents’ feedback. Results: The findings draw public attention towards CSE, contraceptive knowledge, and spousal communication, because these factors can increase the usage of modern methods for FP among couples, leading to a reduction in unwanted pregnancies and associated risks. Regarding the significant moderation effect of perceived barriers, if individuals (women) are highly motivated (CSE) to overcome perceived barriers by convincing their husbands to use contraceptives, the probability to adopt modern contraceptive methods for FP practices is increased. Conclusions: Policymakers should formulate strategies for the involvement of males by designing male-oriented FP program interventions and incorporating male FP workers to reduce communication barriers between couples. Future research should address several other important variables, such as the desire for additional child, myths/misconceptions, fear of side effects, and partner/friend discouragement, which also affect the adoption of modern contraceptive methods for FP practices.

1. Background

Pakistan is the world’s sixth most populated country, with a population of 208 million people at the time of writing [ 1 ]. The Pakistani government is concerned about population growth because it is related to economic and social consequences of unrestrained expansion [ 2 , 3 ]. Failure to control the rate of reproduction and rapid population expansion has negative consequences for development indices such as education, poverty, and life expectancy, especially for mother and child health [ 4 ]. Beginning in the 1960s, the country became a pioneer in the field of family planning (FP) among developing countries. Fifty years later, the program is still struggling to increase the use of modern contraceptives. The current contraceptive prevalence rate in Pakistan is 34%, compared to 62% in India and 56% in Bangladesh [ 5 , 6 ]. For years, the low and stagnant prevalence of contraception in Pakistan has been a source of academic debate [ 7 ]. Much has been written about Pakistan’s sluggish adoption of modern contraception methods, highlighting cultural hurdles, inconsistent political support, and service delivery failures [ 7 , 8 ]. The majority of the research has focused on service delivery problems, with the assumption that increasing contraceptive provision would improve contraceptive use [ 8 , 9 , 10 , 11 ].

The gradual increase in contraceptive rates in Pakistan compared to other nations in the region has been a hotly debated topic among demographers and other academics, with many speculating that inconsistencies in political support and a lackluster FP policy are to blame [ 11 , 12 ]. Researchers recommend that communication between couples should be encouraged because it increases the adoption of FP practices [ 13 , 14 , 15 ]. A recent study indicated that there is a need for modern contraceptive prevalence in Pakistan, which requires an increased uptake of contraceptives (National Institute of Population Studies (NIPS)) [ 16 ]. Pakistan has been facing the issue of FP for decades [ 17 ]. About 17% of married women in Pakistan have modern contraceptive prevalence for FP, and this rate is higher among rural areas. The demand for FP has reduced over the last 5 years, currently at 52% whilst it was 55% in 2012–2013. Pakistan has a 34% contraceptive prevalence rate, and the use of modern contraceptive methods has not increased since 2013 [ 16 ]. The literature shows that knowledge on contraceptives has profound effects on the FP practices [ 18 ]. Due to a lack of appropriate knowledge about contraceptive methods, women cannot get desired results [ 19 ].

Women’s self-efficacy and knowledge about the appropriate use and the side effects of contraceptive methods, a couple’s communication, and combined decisions are positive predictors of contraceptive use [ 20 ]. Women’s education and power to make decisions are significantly associated with the use of contraceptives [ 21 ]. Previous literature has indicated low contraceptive use in Pakistan, and there is an urgent need to explore factors which can help to improve FP practices and modern contraceptive prevalence necessary for FP practices [ 22 ]. Contraceptive self-efficacy (CSE), contraceptive knowledge, and spousal communication are found to be associated with FP practices [ 23 ]. Self-efficacy theory suggests that an individual’s belief in his own competence to perfectly perform any behavior is affected by several moderators and barriers, either personal or social [ 24 ]. Therefore, researchers have suggested that while assessing self-efficacy, the impact of perceived barriers on health behavior estimation must be examined [ 25 ]. Researchers have also reported several reasons for why improving contraceptive knowledge might improve contraceptive use [ 26 ]. Spousal communication is the determinant of FP practices, but there is need to assess this connection in the context of developing countries [ 13 ]. Because a lack of communication and counselling is affecting couples’ and women’s decision-making ability regarding fertility preferences [ 14 ], the current study attempts to assess the impact of these variables on women’s perceptions regarding the adoption of modern contraceptive methods for FP practices.

Numerous economists and researchers continue to doubt Pakistan’s ability to significantly boost the adoption of modern FP practices because of religious norms, social liberalism, and preferences for large family systems. Therefore, several gaps are observed in the policies and structure of programs related to FP practices in Pakistan [ 8 , 11 ] and other developing regions [ 27 , 28 ]. The unavailability of contraceptives, especially in rural areas, users’ dissatisfaction, low service quality, lack of proper guidance concerning the methods selected, religious factors, and a lack of knowledge, funding, and collaboration between public and private sector facilities providing FP services have been quoted as barriers that cause a low prevalence of contraceptive measures [ 10 , 17 ]. Since the context of this study is Pakistan, it is worth noting that FP in Pakistan is entirely female-oriented [ 29 ]. Programs that target only a single sex tend to fail to achieve its targets [ 13 ]. Therefore, all these issues need to be investigated, because they are affecting population control activities in the country. The theoretical foundation of this study is based on a combined health belief model, social cognitive theory, and the theory of planned behavior. In this regard, this study attempts to examine different predictors in the adoption of modern contraceptive methods for FP practices. This study will provide a thorough understanding of these factors, which will be helpful for the control of fertility.

The current study aims to explore the impact of spousal communication, contraceptive knowledge, and CSE on the adoption of modern contraceptive methods for FP practices in a developing country context, such as Pakistan. In addition, the moderating role of perceived barriers is, for the first time, theorized and tested to determine the relationship between contraceptive knowledge, spousal communication, CSE, and the adoption of modern contraceptive methods for FP practices. The findings of the current study would be helpful for policymakers in implementing and revising policies to further improve FP programs.

The rest of the sections in the current study are arranged as follows: Section 2 presents a literature review and hypotheses; Section 3 covers the proposed methodology, including sample and data collection, the measurement of variables, common method bias, and control variables; Section 4 explains the data analysis and results; finally, Section 5 discusses the results of the study, sheds light on practical implications, and recommends a direction for future research.

2. Literature Review

2.1. contraceptive self-efficacy (cse) and family planning (fp) practices.

Levinson, as cited in [ 30 ], defined CSE as “it is the strength of a young woman’s conviction that she should and could exercise control within sexual and contraceptive situations to prevent an unintended pregnancy, if that is what she desires” (p. 9). Following the self-efficacy theory, the concept of CSE was developed to measure women’s self-efficacy and its impact on their reproductive health. The extant literature indicates that women with higher self-efficacy are more independent in the selection and practice of modern contraceptive methods [ 31 , 32 ]. CSE is important because it stimulates individual behavior related to the use of modern contraceptives, therefore helping to prevent major public health issues by prompting the use of modern contraceptives [ 31 ]. Contraceptive acceptance is higher among females with higher CSE [ 33 , 34 , 35 ]. CSE enables women to manage all resistance related to FP practices [ 25 ]. Findings from previous research also reveal that CSE increases contraceptive adherence [ 20 ]. The above explanations suggest that CSE is a strong predictor of the use of modern contraceptive for FP practices. Therefore, it can be hypothesized that:

Contraceptive self-efficacy has a positive impact on the adoption of modern contraceptive methods for FP practices .

2.2. Contraceptive Knowledge and Family Planning (FP) Practices

Contraceptive knowledge was defined by Nsubuga et al. [ 36 ] as “the state of awareness of contraceptive methods, any specific types and the source of contraceptive”. Contraceptive knowledge enables women to easily access FP services [ 37 ]. It is reported that counselling increases contraceptive awareness, which modifies people’s attitudes towards the use of contraceptives [ 38 ]. Efficient contraceptive knowledge helps in changing people’s perceptions and decisions about FP [ 39 ]. Researchers have also found that educated women are more aware of contraceptive methods and FP practices, which ultimately increases the use of contraceptives among females [ 40 ]. It is also reported that females with good contraceptive knowledge practiced different methods effectively [ 41 ]. In contrast, individuals with a lack of contraceptive knowledge will discontinue contraceptive use due to its side effects or method failures [ 42 ]. According to a recent survey, 3/4th of the overall urban population is aware of FP practices, but a low level of awareness among rural population was reported [ 16 ]. Well-aware and knowledgeable individuals regarding different contraceptive methods have a tendency to solve different FP issues [ 43 , 44 , 45 ], such as intercourse and the method not changing the woman’s menstrual periods [ 46 ], intrauterine device and implant [ 47 ], and female sterilization [ 48 ].

Contraceptive knowledge in terms of awareness about the available contraceptive methods helps people in choosing the best and effective contraceptives practices, and also changes people’s fertility preferences [ 49 ]. It has been noted that people who are aware of implants and breastfeeding as contraceptive methods were more interested in the adoption of modern contraceptive methods for FP practices [ 50 ]. Studies in the context of a developing country, such as Pakistan, highlighted the gap between contraceptive knowledge and FP practice [ 17 , 51 ]. This gap is because of a lack of knowledge about the benefits and availability, as well as misinformation, of modern contraceptive methods for FP practices. Major sources delivering contraceptive knowledge include healthcare centers, friends, family, and media [ 52 ]. Therefore, based on the available literature, it can be hypothesized that:

Contraceptive knowledge has a positive impact on the adoption of modern contraceptive methods for FP practices.

2.3. Spousal Communication and Family Planning (FP) Practices

Backman, as cited in [ 53 ], stated that “spousal communication in the marital dyad is generally defined as the frequency of discussion between spouses, as reported by one or both partners” (p. 5). Communication between spouses plays an important role in the continuous adoption of modern contraceptive methods for FP practices. Partner communication appeared as a topic of interest regarding FP practices. In this regard, researchers found a positive association between spousal communication and FP practices [ 54 , 55 , 56 ]. Another study reported husbands as key decision makers for getting access to health and FP services. A husband’s education level is significantly associated with the current use of contraceptives. The location of service providers, the quality of services, women’s age, and financial status also determine the use of contraceptives [ 4 ].

FALAH (Family Advancement for Life and Health) is already working on male involvement in FP programs. An analysis of program outcomes found that engaging Pakistani men in FP practices to support and encourage their wives to use FP services and introducing male contraceptive methods can increase the utilization and acceptance of FP practices among the population [ 57 ]. Similarly, Khan et al. [ 58 ] stated that husband approval is a strong predictor of the use of contraceptives. Spousal communication helps in coping with psychological barriers and reduces emotional strains that discourage the use of contraceptives [ 59 ]. It helps couples in decision making concerning an appropriate family size, and enhances positive intentions towards modern contraceptive methods for FP practices. Thus, it can be hypothesized that:

Spousal communication has a positive impact on the adoption of modern contraceptive methods for FP practices.

2.4. Moderating Role of Perceived Barriers

Glasgow [ 60 ] defined perceived barriers as “A person’s estimation of the level of challenge of social, personal, environmental, and economic obstacles to a specified behavior” (p. 1). In the literature, the concept of perceived barriers has been extensively used with the health belief model (HBM). Perceived barriers have been used in many theories, including HBM, social cognitive theory, and social-ecological theory [ 60 ]. The integrated impact of multiple barriers hamper women from accessing reproductive health services. The restricted mobility of women by family [ 42 ] and a lack of communication between couples are factors that hamper women from using contraceptives [ 61 ]. Additionally, barriers restrain women’s ability to practice contraceptive methods. Most of the time, women that desire to limit their fertility by using contraceptives are influenced by religious and cultural hindrances [ 11 , 62 ]. They have to face great resistance from social barriers comparative to financial issues [ 63 , 64 ].

Women’s perceptions about contraceptive use, fear of their husbands’ negative response, and FP practices are perceived as an unacceptable act by society; therefore, culture limits the use of contraceptives among women [ 65 ]. Another study conducted by researchers in Pakistan declared that reasons for not using contraceptives include a desire for a baby boy (19%), fear of a health risk (29%), and lack of partner support and consideration of them as un-Islamic (14%); similar findings were found in other studies [ 66 , 67 ]. Interpersonal violence [ 68 ], cost, shyness, desire for a baby boy and a large family size [ 69 ], fear of sin, sterility [ 70 ], misinterpretation, husband and in-laws disapproval, prevailing myths, and social norms are all factors that contribute to the low intention of adopting of FP practices [ 66 , 71 ].

Fear of privacy breach, stigmatization, and FP service providers’ attitudes negatively affect the adoption of modern FP practices among women, despite them having knowledge about contraceptive use [ 72 , 73 ]. Spousal communication increases FP practices, but in-laws’ pressure, low parity, and administrative issues weaken this relationship [ 74 ]. Men’s disinterest and lack of knowledge about contraceptives, female financially dependency, and physical violence discourage women to communicate with their husbands about FP practices, which ultimately causes the low prevalence or lack of use of contraceptive methods [ 75 ]. Despite having information about several available FP methods, a low use of contraceptives has been noted among couples of rural areas due to misconceptions about risks associated with contraceptive methods [ 76 ]. Family environments also define women’s behavior towards FP practices [ 77 ]. A woman’s autonomy to make decisions about any aspect of her life is strongly influenced by the stratified family structure [ 78 ]. All these barriers contribute towards modern contraceptive prevalence for FP practices, in which women do not want to conceive for a period of time but still do not use any contraceptives [ 79 ]. Based on the above literature, it is argued whether perceived barriers act as moderator in the relationship between CSE, contraceptive knowledge, spousal communication, and FP practices or not. Therefore, it can be hypothesized that:

Perceived barriers moderate the relationship between contraceptive self-efficacy and the adoption of modern contraceptive methods for FP practices.

Perceived barriers moderate the relationship between contraceptive knowledge and the adoption of modern contraceptive methods for FP practices.

Perceived barriers moderate the relationship between spousal communication and the adoption of modern contraceptive methods for FP practices .

The research model of the study is presented in Figure 1 .

Research model.

3. Methodology

3.1. sample and data collection.

Women of reproductive age are the main target of FP practices in Pakistan due to higher needs for the use of contraceptives at this age. The adoption of modern contraceptive methods for FP is a key variable in current research. Using a convenience sampling technique, data were collected from married women of reproductive age from the Rawalpindi and Neelum Valley regions in Pakistan through distributed questionnaires. Convenience sampling has the advantages of being inexpensive, efficient, and easy to use. We selected the aforementioned sampling locations because both these regions are highly prevalent in terms of FP practices. Additionally, the travel restrictions implemented during the COVID-19 outbreak made it difficult for the authors to visit other areas for data collection. We decided to collect data using both self-administered questionnaires and social circles from these areas to distribute our questionnaire to the relevant samples. A cover letter was attached, declaring the purpose of the research and asking participants at the time they join the study for relevant and historical information on spousal communication and decision making regarding FP practices. A screening question was also placed at the beginning of the survey to clearly ask whether respondents belonged to these regions and they knew the contraceptive methods used in FP practices. Confidentiality, anonymity, and voluntary participation were also ensured.

A total number of 340 questionnaires were distributed. The authors believe that the sampling size was appropriate due to the COVID-19 restrictions and respondents’ hesitation to respond to specific questions because of cultural and religious beliefs [ 11 ]. Out of the 292 questionnaires that were returned 42 were not useable, making the valid response rate 73.5%. The contraceptive prevalence rate in our sample was 41.28%.

As shown in Table 1 , the majority of the women participants were literate (86.8%), most were non-working (63.6%), the majority of the women were in the age range of 24 to 35 years (78.3%), and the majority of the women got married in the age range of 18–25 years (72%). Most of the participants were residents of a rural area (70%), and most were Muslim (95.6%). The majority of the participants’ husbands were literate (95.2%) and working (97.2%). Of the respondents, 48% of them had a maximum of two–three children and (25%) had four or more children. Of the women, 92% of them reported having a good health status and 72.4% reported that their husbands were the head of the household. Of the respondents, 62.3% responded that their husbands were highly involvement in decision making regarding pregnancy, while 64.8% responded that they have spousal communication regarding FP and birth spacing.

Socio-demographic characteristics of respondents.

3.2. Measurements

All the study variables were measured on a 5-point Likert scale. All constructs were measured on a Likert scale ranging from strongly disagree = 1 to strongly agree = 5.

Constructs such as contraceptive self-efficacy (CSE) were measured using a 7-item scale developed by Prata et al. [ 80 ]. One sample item which was measured was “I can use a modern contraceptive method to prevent pregnancy”. Contraceptive knowledge (CK) was measured by using a 7-item scale developed by Lincoln et al. [ 81 ]. One sample item which was measured was “I am aware that health education is important for women who want to use contraception”. Spousal communication (SC) was measured using a 5-item scale developed by Wegs et al. [ 82 ]. One sample item which was measured was “I and my spouse discuss things that happened during the day”. Modern FP practices were measured using a 7-item scale developed by Lincoln, Mohammadnezhad, and Khan [ 81 ]. One sample item which was measured was “I often use one of the contraceptives to prevent unplanned pregnancy”. Perceived barriers (PB) were measured using a 14-item scale developed by Sen et al. [ 83 ]. One sample item which was measured was “Contraceptive measures are too expensive for me”. The details of all constructs and their corresponding items are presented in Appendix A , Table A1 . According to the criteria defined by Fornell and Larcker [ 84 ], the composite reliability values for all constructs were above the threshold (i.e., 0.70).

3.3. Common Method Bias

A common bias test was performed by taking into account Harman’s single factor [ 85 ]. Five constructs with their corresponding non-removed items were tested using an exploratory factor analysis by Harman’s single-factor test and analyzed with an unrotated factor solution. It was shown that there is no question about the common method bias in the current research data due to no emerging factor being reported, and 41.451% (less than 50%) variance was documented for the first factor, as suggested by Podsakoff, MacKenzie, Lee, and Podsakoff [ 85 ].

3.4. Control Variables

A one-way ANOVA was performed to control the variation in the adoption of modern contraceptive methods for FP practices on the basis of demographic variables used in the study. Results obtained from one-way ANOVA (see Table 2 ) indicated no significant differences in the adoption of contraceptive methods for FP practices (dependent variable) across qualification (F = 0.880, p > 0.05), profession (F = 3.371, p > 0.05), age at time of marriage (F = 2.881, p > 0.05), religion (F = 1.495, p > 0.05), health status (F = 1.267, p > 0.05), husband’s qualification (F = 1.496, p > 0.05), husband’s profession (F = 0.897, p > 0.05), and head of household (F = 0.399, p > 0.05).

One-way ANOVA.

At the same time, the one-way ANOVA indicated significant differences in FP across region (F = 19.089, p < 0.05), area of residence (F = 19.089, p < 0.05), current age (F = 2.682, p < 0.05), and number of children (F = 7.984, p < 0.05). Subsequently, factors identified as significant were entered as control variables in step 1 of a regression analysis for a single dependent variable.

Means, standard deviations, scale reliabilities ( bold diagonal entries ) , and correlation matrices are presented in Table 3 . Reliabilities for all constructs were greater than the cutoff value (i.e., α ≥ 0.7), which indicates acceptable reliability [ 86 ]. The results also revealed that all the absolute values of the correlation coefficients and the VIF statistics for each individual variable are less than 0.5 and 10, respectively [ 86 ]. Hence, multicollinearity is not a serious problem in the study, and the results are reliable. Table 3 also indicates that CSE is significantly positively correlated with modern FP practices (r = 0.48, p < 0.01) providing support for proposed hypothesis 1. Contraceptive knowledge is significantly positively correlated with modern FP practices (r = 0.34, p < 0.01), which provides support for proposed hypothesis 2. Modern FP practices are significantly positively correlated with spousal communication (r = 0.22, p < 0.01), which provides support for proposed hypothesis 3. Perceived barriers are not correlated with modern FP practices (r = 0.092, p = ns). Control variables, such as area of residence, region, current age, and number of children are positively correlated with modern FP practices.

Means, standard deviations, correlations, and reliabilities.

Notes: n = 250; alpha reliabilities are given in parentheses. p < 0.05. S.D = standard deviation, CSE = contraceptive self-efficacy, CK = contraceptive knowledge, SC = spousal communication, PB = perceived barriers, Qual = qualification, Prof. = profession, AoR = area of residence, Reg. = region, CA = current age, ATM = age at time of marriage, Relig. = religion, HQ = husband’s qualification, HP = husband’s profession, NC = No. of children, HS = health status, and HH = head of household. **, correlation is significant at the 0.01 level; *, correlation is significant at the 0.05 level. ns = correlation is not significant.

A multiple regression analysis was run to check the relationship between variables in the proposed model of this study. Table 4 shows the results of the regression analysis for the controls, direct effects, and moderating variable. The findings reveal that control variables, such as area of residence (β = 0.126, p < 0.01), region (β = 0.256, p < 0.05), current age (β = 0.325, p < 0.01), and number of children (β = 0.258, p < 0.05) significantly influence modern FP practices. The results show a significant positive impact of CSE on the adoption of modern contraceptive methods for FP practices (β = 0.551, p < 0.001). Thus, hypothesis 1 is accepted. The regression analysis shows that there is a significant positive impact of contraceptive knowledge on the adoption of modern contraceptive methods for FP practices as (β = 0.226, p < 0.01); thus, hypothesis 2 is accepted. In addition, the results indicate that spousal communication has a significant positive impact on the adoption of modern contraceptive methods for FP practices as (β = 0.184, p < 0.01), thus leading towards the acceptance of hypothesis 3. Analysis shows that perceived barriers have no significant direct effect on the adoption of modern contraceptive methods for FP practices as (β = 0.049, p = ns).

Hierarchical moderated regression analysis.

Notes: ***, p < 0.001; **, p < 0.01; and *, p < 0.05. CSE = contraceptive self-efficacy, CK = contraceptive knowledge, SC = spousal communication, and PB = perceived barriers. ns = not significant.

Hypotheses 4, 5, and 6 were tested using moderated regression analysis. Where control variables were entered in step 1, independent and moderator variables were entered in step 2, and interaction terms were entered in step 3. Results show that in the third step after incorporating for interaction terms, such as contraceptive self-efficacy×perceived barriers, the results (β = 0.168, p < 0.05) lead to the rejection of hypothesis 4, that higher perceived barriers weaken the relationship between contraceptive self-efficacy and the adoption of modern contraceptive methods for FP practices in such a way that the relationship is weaker when the perceived barrier is high.

Result shows that FP practices in women with high CSE will be higher even in the presence of high perceived barriers. In addition, regression analysis shows that by incorporating interaction terms in the model for contraceptive knowledge×perceived barriers (β = −0.020, p = ns) and for spousal communication×perceived barriers (β = 0.037, p = ns) in the model, hypotheses 5 and 6 are not accepted. These results indicate that perceived barriers are not moderating the relationship between contraceptive knowledge and the adoption of modern contraceptive methods for FP practices or that between spousal communication and the adoption of modern contraceptive methods for FP practices.

The interaction effect in Figure 2 shows that the relationship between CSE and the adoption of modern FP practices was stronger in the presence of high perceived barriers (in dashed red line) than in the presence of low perceived barriers (in solid blue line); thus, hypothesis 4 is rejected.

Interactive effect of contraceptive self-efficacy and perceived barriers on FP practices. CSE = contraceptive self-efficacy; PB = perceived barriers.

5. Discussion

The purpose of this study was to investigate the causal effect of different factors (i.e., CSE, contraceptive knowledge, and spousal communication) that influence the adoption of modern contraceptive methods for FP practices. Additionally, the moderating role of perceived barriers was also examined in the relationships between aforementioned constructs [ 31 , 32 ]. The findings were in support of previous studies conducted by scholars [ 20 , 25 ], where similar findings were reported.

Contraceptive knowledge as awareness was found to have a significant positive impact on the adoption of modern contraceptive methods for FP practices. These findings were in line with previous studies findings [ 37 , 40 ]. This is because contraceptive knowledge among women encourages them to adopt modern methods for FP services and choose suitable method for practice. A good level of contraceptive knowledge improves the modern contraceptive prevalence. Contraceptive knowledge modifies people’s perceptions about FP practices [ 39 ]. Furthermore, the majority respondents were literate, so they valued contraceptive knowledge as an important factor for FP practices. Thus, it is quite logical to infer that the adoption of modern contraceptive methods for FP in Pakistan can be enhanced by increasing comprehensive knowledge about contraceptive measures among women.

Similarly, spousal communication also has a positive impact on the adoption of modern contraceptive methods for FP practices. Spousal communication is an effective way to involve males in FP practices and support women’s decisions about fertility preferences. Partner support and encouragement is a key determinant of FP practices [ 87 ]. The current findings were in line with previous studies [ 54 , 55 , 56 , 88 ]. As discussed in the literature, good spousal communication and encouragement by their partners allows women to make decisions about desired family size, usability, selection, and awareness of all available FP methods, which results in a reduction in contraceptive discontinuation and their low prevalence. This situation usually happens because of public dissatisfaction and a fear of opposition. Introducing male-oriented FP methods could help in increasing the uptake of FP practices by couples.

The results of moderated regression analysis show that the relationship between CSE and the adoption of modern contraceptive methods for FP practices is moderated by perceived barriers. Since the perceived barriers were used as moderators between the relationship of CSE and modern FP practices for the first time, the findings of the current study are supported by evidence from previous studies [ 20 , 25 , 61 ], where they declared that women with higher CSE are motivated and can convince men to use contraceptives. The adoption of any health behavior is dependent on individuals’ intentions to adopt that specific behavior. If an individual has strong intentions to practice or adopt a specific health behavior as well as the self-efficacy to overcome his/her perceived obstacles, the probability to adopt a specific health behavior increases [ 89 , 90 ]. As in the current study, participants reported higher CSE; therefore, the presence of barriers cannot reduce their intentions to practice modern FP methods.

The results of the interactive effect of perceived barriers and contraceptive knowledge show that perceived barriers do not moderate the relationship between contraceptive knowledge and the adoption of modern FP practices, which contradicts a proposed hypothesis. This result is in accordance with the common-sense model [ 91 ]. The model explains that human behavior is determined by the process of learning. Before adopting any health behavior, an individual assesses its pros and cons through cognition. For example, if individuals have to get treatment for a disease they will think about its cost, prognosis, and benefits, and then make decisions about action. Comprehensive knowledge about threats associated with health behavior reduces fear and leads to the adoption of that behavior [ 92 ]. As the participants of this study reported a higher level of contraceptive knowledge, it can thus be concluded, based on the previous literature, that high contraceptive knowledge among women helps them to make informed choices, overcome fears, and motivate them towards adopting modern FP practices.

The results of the interactive effect between perceived barriers and spousal communication were not significant, which shows that perceived barriers were not moderating the relationship between spousal communication and the adoption of modern FP practices. Since the literature shows that spousal communication about using contraceptives and involving the male partner in decision making about fertility preferences directly influences efforts for limiting fertility, they help women in overcoming perceived barriers as the fear of opposition is being shared by both partners [ 93 ]. Evidence from previous studies [ 94 , 95 ] also reveals that dynamics of spousal communication have a positive effect on contraceptive behavior; thus, these result are in line with the findings of the current study. Spousal discussion boosts modern FP use and consequently reduces fertility and maternal mortality rate.

5.1. Practical Implications

The findings provide several implications for practice. It is recommended that policymakers should incorporate modern contraceptive FP program models as a strategy to enhance the contraceptive prevalence rate. Special consideration should be given to spousal communication, and couples should be encouraged to discuss the adoption of modern contraceptive methods for FP practices. Awareness campaigns should be launched that highlight the benefits of spousal discussion about ideal family size, societal pressures, complications related to closely spaced deliveries, unsafe abortion, the risks of maternal and child mortality, malnutrition among children, and modern FP practices. Policymakers should also formulate policies for male involvement in modern FP programs across the country by introducing improved male-oriented methods and incorporating male FP workers to reduce communication barriers and shyness (as shown by a program that has been launched by FALAH in Pakistan and reported positive outcomes) [ 57 ]. FP program stakeholders should focus on promoting contraceptive knowledge among women to promote the adoption of modern contraceptive methods for FP practices.

Understanding different factors in the adoption of modern FP practices is necessary in formulating more suitable policies for public health [ 8 , 96 ]. As the use of FP is high in educated and urbanized people, there is a need to focus on slums and rural areas with a low literacy rate as well as how their perceptions about ideal family size change [ 88 ]. As the findings indicated that improving contraceptive knowledge leads towards FP practices, this study provides baseline information to policymakers towards the value of gaining comprehensive knowledge to increase the use of FP [ 97 ]. This study also draws public attention towards spousal discussion because it can increase the usage of modern methods for FP among couples, leading to a reduction in unwanted pregnancies and associated risks. In addition, our findings highlight the need for proper fund allocation as well as the provision of training and refresher courses for female health workers [ 98 ]. Furthermore, counselling intervention should be introduced to involve in-laws in programs to reduce barriers toward the adoption of modern methods for FP practices [ 99 , 100 ]. This study attempts to assist the Pakistani government in reaching its national development goals of enhancing maternal and reproductive health through the increased use of modern contraceptives.

5.2. Limitations and Directions for Future Research

This paper has several limitations. First, the findings of current study were predisposing to recall bias as data were self-reported by respondents rather than dyads, etc. Future studies should ensure that the way questions are worded does not influence the answers of participants due to the possible risk of recall bias. Second, as the majority of the respondents belonged to the Rawalpindi and Neelum Valley regions, the findings may not be generalizable due to the smaller sample size and convenience sampling technique using a specific targeted group, which lack external validity. Future studies should run the analysis using a larger dataset. Third, the current study is limited and not able to measure several other important variables (i.e., the desire for an additional child, myths/misconceptions, fear of side effects, and partner/friend discouragement) which also affect the use of contraceptives. Future researchers are required to conduct studies on the approval of modern FP practices by couples and their association with contraceptive knowledge and barriers in acquiring contraceptive knowledge. Fourth, since the current study employed a statistical method due to the authors’ limitations in using advanced statistical tools, future studies may use PLS-SEM as an advanced statistical tool, which seems much more appropriate, especially when analyzing possible moderation. Finally, for formulating comprehensive strategies about couple counselling to overcome the knowledge and practice gap and to dispel misconceptions about contraceptives, researchers should conduct qualitative studies on spousal communication and contraceptive knowledge.

6. Conclusions

To conclude, the empirical analysis supported three hypotheses proposed in this study. The results indicated that CSE, contraceptive knowledge, and spousal communication positively impact the adoption of modern contraceptive methods for FP practices. In particular, the higher CSE in women motivates them to adopt modern contraceptive methods for FP practices. It also encourages women to overcome all the barriers, which limit their access to FP services. CSE helps women to understand the importance of FP practices that are important in maintaining the gap between child births. It supports women in decision making about fertility preferences, which helps them to recover their health from previous pregnancies and provide better care to their children.

Constructs along with their corresponding items.

Contraceptive Methods (A): Pill, IUCD, condom, periodic abstinence, withdrawal, female sterilization, male sterilization, implants.

Author Contributions

Conceptualization, J.N.M.; methodology, J.N.M.; software, J.N.M.; validation, A.M.S. and K.L.; formal analysis, J.N.M.; investigation, J.N.M.; resources, A.M.S.; data curation, J.N.M. and A.M.S.; writing—original draft preparation, J.N.M. and A.M.S.; writing—review and editing, A.M.S.; visualization, K.L.; supervision, K.L.; project administration, K.L.; funding acquisition, K.L. All authors have read and agreed to the published version of the manuscript.

This research was supported by the MSIT (Ministry of Science and ICT), Korea, under the ITRC (Information Technology Research Center) support program (IITP-2021-2017-0-01630), and the work (No. 2020-0-01907, Development of Smart Signage Technology for Automatic Classification of Untact Examination and Patient Status Based on AI) was supervised by the IITP (Institute for Information and Communications Technology Promotion).

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Faculty of Management Sciences, Riphah International University, Islamabad, Pakistan (FMS/RSL/ERC/107 on 11 August 2020).

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

SYSTEMATIC REVIEW article

The effects of hormonal contraceptives on the brain: a systematic review of neuroimaging studies.

• 1 Center for Clinical Research in Psychosis (TIPS), Stavanger University Hospital, Stavanger, Norway
• 2 Department of Clinical Medicine, Center for Sexology Research, Aalborg University, Aalborg, Denmark
• 3 Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
• 4 Department for Caring and Ethics, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
• 5 SESAM, Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
• 6 Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway

Background: Hormonal contraceptive drugs are being used by adult and adolescent women all over the world. Convergent evidence from animal research indicates that contraceptive substances can alter both structure and function of the brain, yet such effects are not part of the public discourse or clinical decision-making concerning these drugs. We thus conducted a systematic review of the neuroimaging literature to assess the current evidence of hormonal contraceptive influence on the human brain.

Methods: The review was registered in PROSPERO and conducted in accordance with the PRISMA criteria for systematic reviews. Structural and functional neuroimaging studies concerning the use of hormonal contraceptives, indexed in Embase, PubMed and/or PsycINFO until February 2020 were included, following a comprehensive and systematic search based on predetermined selection criteria.

Results: A total of 33 articles met the inclusion criteria. Ten of these were structural studies, while 23 were functional investigations. Only one study investigated effects on an adolescent sample. The quality of the articles varied as many had methodological challenges as well as partially unfounded theoretical claims. However, most of the included neuroimaging studies found functional and/or structural brain changes associated with the use of hormonal contraceptives.

Conclusion: The included studies identified structural and functional changes in areas involved in affective and cognitive processing, such as the amygdala, hippocampus, prefrontal cortex and cingulate gyrus. However, only one study reported primary research on a purely adolescent sample. Thus, there is a need for further investigation of the implications of these findings, especially with regard to adolescent girls.

Introduction

Synthetic sex hormones became available as contraceptive drugs in the 1960's, and they are currently being used by more than 100 million women worldwide ( Christin-Maitre, 2013 ). In the US, it is estimated that 88% of all women of fertile age have utilized this type of birth control at some point in their lives ( Daniels and Jones, 2013 ). Sex hormones consist of androgens, estrogens and progesterone, and in vivo they are synthesized in the gonads, the adrenal glands and the brain. They profoundly impact the brain during fetal life , exerting epigenetic effects and directing development along male or female trajectories by influencing a variety of molecular and cellular processes. Moreover, they affect regional gray matter volumes and neural connectivity associated with psychosexual and other behavioral functions ( Hines, 2006 ; Josso, 2008 ; Peper et al., 2011 ; McCarthy and Nugent, 2015 ).

Converging lines of evidence from animal literature, as well as cognitive and affective neuroscience involving human subjects, suggest that these hormones continue to shape the brain postnatally , also during adolescence ( Herting et al., 2014 ; Schulz and Sisk, 2016 ). In adulthood, they modulate brain areas involved in cognitive and emotional processing, and they are implicated in mood and anxiety disorders ( Comasco et al., 2014 ; Toffoletto et al., 2014 ; Garcia et al., 2018 ). If the synthetic sex hormones contained within hormonal contraceptives (HC) ( Christin-Maitre, 2013 ) interact with sex hormone receptors in the brain, they have the potential to interfere with multiple neurohormonal regulatory mechanisms and neural structures involved in emotion, cognition and psychosexual behavior ( Fuhrmann et al., 2015 ; Schulz and Sisk, 2016 ). To date, neuroimaging research on the effects of HC use on the structure and function of the brain has not been systematically reviewed. The potential for influencing brain plasticity and hence altering brain structures and behavioral outcomes has therefore not been fully elucidated.

Plasticity represents an intrinsic ability of the nervous system to adapt its structure and function in response to endogenous and exogenous environmental demands. This ability persists throughout life ( Pascual-Leone et al., 2005 ). However, there are periods of life when the brain exhibits an increased degree of plasticity and is particularly vulnerable to environmental changes. The perinatal phase is such a period. In 1959, Phoenix et al. proposed that perinatal sex hormones exert an organizing effect on the brain, with ensuing consequences for behavior ( Phoenix et al., 1959 ). They found that prenatal exposure of female guinea pigs to testosterone masculinized their later mating behavior, and they went on to demonstrate similar findings in female rhesus monkeys, who displayed masculinized play patterns following prenatal testosterone treatment. Their claim was that, perinatally, testosterone has an organizing effect on the brain, while the hormonal events of puberty have an activating/deactivating effect on the anatomical structures previously organized.

Several researchers have since expanded on, and in part refuted, this theory. Schulz and Sisk presented evidence from animal studies suggesting that sex hormones may have an organizing effect on the brain long after birth, gradually declining and ending approximately at the resolution of puberty ( Schulz and Sisk, 2016 ). Beltz and Berenbaum (2013) provided further support for the theory of continued ability of sex hormones to exert permanent effects in humans by showing that early puberty, and thus early exposure to adult-levels of sex hormones, in men was associated with better performance in a mental rotation task ( Wai et al., 2010 ). Consequently, adolescence might also be a period sensitive to organizing effects of sex hormones; and the effects may be stronger, the younger the individual is when exposed.

During adolescence, several brain areas, in particular the prefrontal cortex (PFC), undergo extensive structural maturation through processes such as synaptic pruning, reorganization and myelination ( Petanjek et al., 2011 ; Blakemore, 2012 ). The brain's functional architecture also undergoes maturational processes of optimizing connectivity in functional networks ( Sherman et al., 2014 ). This prolonged developmental shaping and reorganization of neural circuits has implications for understanding the vulnerability of the brain during this period, as the plastic brain is the platform for learning and developing as well as for psychopathology and cerebral disease.

While endogenous sex hormones have well-documented effects on the brain, the influence of their synthetic counterparts, progestins and ethinylestradiol, which are most commonly used in oral contraceptive pills ( Christin-Maitre, 2013 ), has been less extensively explored. However, there is reason to believe that also synthetic sex hormones could have a significant neural impact, particularly if taken when the young female brain is developing into its adult form. Behavioral effects of HC have been shown in cognitive tasks such as mental rotation and verbal expressional fluency ( Beltz et al., 2015 ; Griksiene et al., 2018 ), and of more serious concern is the demonstrated association between these drugs and various affective adversities. Thus, Skovlund et al. conducted a large national cohort study in Denmark, where they collected and compared data from the National Prescription Register and the Psychiatric Central Research Register. They found a correlation between the use of HC and a subsequent first diagnosis of depression and the use of antidepressants. The increased risk of these adverse outcomes was noted to be the highest in adolescent women ( Skovlund et al., 2016 ). The Skovlund group also investigated associations between HC intake and suicidal behavior and they found an increased risk for both attempted and committed suicide. Again, the increased risk was highest in adolescent women, and it peaked within 2 months of intake debut ( Skovlund et al., 2018 ).

In order to assess the prevalence of HC use among Norwegian adolescents, we queried the Norwegian Prescription Database regarding usage of drugs ( Norwegian Prescription Database, 2019 ) according to the Anatomical Therapeutic Chemical (ATC) code G03A (Hormonal contraceptives for systemic use). This database provides data on these drugs from 2004 to 2018, and it is possible to query separately for age groups such as 10–14 and 15–19. The usage for girls between the ages of 10 and 14 has more than doubled from 2004 to 2018, and in 2018 about 1.2 percent of all 10–14-year-old girls used some form of systemic HC. The numbers for girls between the ages of 15 and 19 have been quite stable at about 40 percent throughout the same period. Thus, a substantial proportion of young girls use these drugs and the usage has increased rapidly among the youngest adolescent girls in Norway.

The central aim of this review was to identify and critically appraise all peer-reviewed empirical studies published in English concerning human subjects that have investigated the effects of HC on brain structure and function through digital neuroimaging techniques, such as magnetic resonance imaging (MRI) and functional MRI (fMRI), as well as positron emission tomography (PET), electroencephalography (EEG) and magnetoencephalography (MEG).

Our main hypotheses were that HC use affects both brain structure and function in humans, and that there are effects on brain structures known to differ statistically in men and women, such as the PFC, hypothalamus, amygdala and hippocampus ( Cahill, 2006 ), as well as on brain structures involved in visuospatial and verbal cognition. Additionally, we hypothesized that HC use have the most pronounced effects on brain structures if used during early adolescence.

This review was conducted in accordance with the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2009 ), and it was registered in the PROSPERO International Prospective Register of Systematic Reviews (Registration number: CRD42019142427).

Literature Search

Studies employing neuroimaging techniques to measure possible HC effects on either brain structure or function were considered. In order to be included, the studies should (a) be primary empirical studies, (b) be conducted on women of fertile age using HC, and (c) have either a separate control group of naturally cycling (NC) women of comparable age or have HC users constitute their own controls by performing repeated assessments under NC and HC conditions. Thus, case reports, literature reviews and experimental studies with no control group were excluded. We included articles published in English from 1990 and up until February 2020. Studies older than the 90's are based on imaging techniques not comparable to those of modern neuroimaging.

Stage One Search

The review was carried out in two stages. The first stage consisted of an exploratory search using PubMed and Google Scholar. PubMed covers most studies involving neuroscience and related fields, and Google Scholar indexes most broadly of all peer-review databases. We first combined the keyword “contraceptives” with “brain,” “cognition,” “emotion,” and “motivation” and searched the databases. We selected and read relevant review articles. The knowledge gained from this process was used to decide on keywords for the stage two searches.

Stage Two Search

Following the initial exploratory search, systematic searches were carried out, employing a two-pronged approach aiming to identify structural and functional neuroimaging studies separately. In Table 1 , the PICOS criteria for the searches are described.

Table 1 . PICOS search.

We first combined search terms such as “contraceptive agent” and “birth control” with terms descriptive of structural neuroimaging such as “magnetic resonance imaging,” “computed axial tomography,” and “diffusion tensor imaging.” We searched for these terms in titles, abstracts and keywords as well as MESH- and Emtree-terms. Titles and abstracts were scanned, excluding articles not meeting our inclusion criteria. Finally, full texts were read in order to identify measures and methodological detail, further excluding ineligible articles. See Appendix 1 for a comprehensive list of search terms.

The second systematic search was carried out using the same search terms describing HC, this time combining them with terms aiming to identify functional neuroimaging studies. Relevant terms were “functional magnetic resonance imaging,” “positron emission tomography,” “electroencephalography,” and “event related potentials.” The same procedures of selection were carried out and relevant articles were retrieved. The stage 2 searches were carried out in February 2020.

A final reference and citation search strategy was employed to ensure that all relevant studies were identified. This implied scanning reference lists in the included articles as well as articles that cited the included papers, after a consensus selection process as described below.

After completing the systematic searches, the authors MKB and KKB independently read the keywords, abstracts and titles and divided articles into “included,” “excluded,” and “undecided” categories. After the initial assessments, full texts were read, and the researchers discussed the criteria and revised the “undecided” articles until all citations were either included or excluded.

Quality assessment was not done using a rigid framework resulting in a single numeric score, as the studies differed regarding dependent variables and design. However, we applied the validity typology of Donald Campbell and Thomas D. Cook ( Cook et al., 1979 ) in order to assess threats to construct, internal, external and statistical conclusion validity. This was done as the study designs and outcome measures were heterogenous, necessitating a flexible approach for quality assessment. These dimensions of validity encompass most of the common causes of bias and validity threats regarding causal inference. Three levels of validity were applied: low, intermediate and high. Low validity implies that there was a validity threat serious enough to fundamentally invalidate the study. Intermediate implies that there were validity threats, but that they were outweighed or resolved to a degree that they were unlikely to seriously bias or confound the study. High means that there were no validity threats for the dimension in question. The assessment was done by authors KKB and MKB and in case of disagreement, consensus was reached through discussion and independent re-reading of the study in question. With regard to statistical power, the combination of small sample size and lack of assessment of statistical power implied a classification of low statistical conclusion validity. In neuroimaging studies, it is difficult to determine a general “too small” sample size, but in the absence of power analyses, we chose a cutoff of n < 20 within the HC group to classify sample size as small.

Structural Neuroimaging

Following the initial exploratory search, a systematic search for structural neuroimaging studies yielded a total of 11,228 hits from the different databases, after removing duplicates. After scanning titles and abstracts, 11,213 citations were excluded. Finally, the full texts were read in order to identify measures and methodological details, further excluding five articles. Thus, 10 articles were deemed eligible for inclusion, based on the aforementioned criteria. No additional articles were found after doing citation searches and reference list reviews. See Figure 1 .

Figure 1 . Flowchart Structural Search.

Functional Neuroimaging

A second systematic search pursuing functional neuroimaging studies yielded 572 articles, after removing duplicates. A total of 23 articles qualified for inclusion following the same procedures of selection. No additional articles were found after performing citation searches and reference list reviews. See Figure 2 .

Figure 2 . Flowchart functional search.

See Tables 2 , 3 for an overview of the included articles.

Table 2 . Overview of articles concerning the effect of HC on brain structure.

Table 3 . Overview of articles concerning the effect of HC on brain function.

Results From the Structural Studies

Most of the included structural studies reported differences between HC users and NC women, as reported in Table 2 .

Summary of the Structural Studies

All the structural studies tested differences in various brain structures in users of different types of HC as compared to present non-users. The studies were mostly cross-sectional and observational in nature, with the exception of one study ( Lisofsky et al., 2016 ) which was a quasi-experimental pre-post study where a self-selected group of women starting HC use was compared with non-users. However, even in this study, previous use was unaccounted for. Hence no study investigated HC naïve women. The sample size ranged from 14 to 60 in the HC groups and from 14 to 89 in the control groups. The age range was 18–40 years in both HC and control groups except for the study by Frokjaer et al. (2009) who reported an age range of 18–45 years in the HC group and 18–79 years in a female and male control group. De Bondt et al. (2015a) studied “young women” but did not specify age span. A variety of neuroimaging techniques were employed, including DTI-MRI, volumetric MRI, spectroscopy MRI and PET.

HC in Studies on Sex Differences

Several of the studies concerning brain structure were not primarily focused on HC effects on the brain per se . Rather, they included HC users in order to investigate whether HC use is an important confounder or moderator in studies on sex differences in the brain. Thus, the aims, methodologies and hypotheses were heterogeneous with regard to HC effects. Four studies ( Frokjaer et al., 2009 ; Pletzer et al., 2010 ; De Bondt et al., 2016 ; Pletzer, 2019 ) explicitly argued that earlier neuroimaging studies on sex differences in the brain did not account for potential confounding effects of HC use in women. These studies assessed brain morphology as related to differential vulnerability to mood and anxiety disorders in men and women. For instance Pletzer et al. (2010) , found that NC women had larger prefrontal brain volumes than both men and HC women, and that men had larger hippocampal and amygdalae volumes than women. In a more recent publication, Pletzer pooled and analyzed data from previous publications and noted smaller gray matter volumes in hippocampal and parahippocampal areas in HC users as compared to NC women ( Pletzer, 2019 ). De Bondt et al. (2016) noted that gray matter volumes and PMS symptoms correlated differently in NC and HC groups, whereas Frokjaer et al. (2009) used cortical serotonergic receptor binding as a measure of potential for affective disturbances but discovered no effects of neither sex nor HC use.

Furthermore, as related to whether HC masculinize or feminize brain structure, Pletzer et al. investigated HC effects on the brain depending on the androgenicity of the progestin component of the HC ( Pletzer et al., 2015 ). They found that anti-androgenic progestins promoted larger gray matter volumes in temporal areas such as the fusiform face area and the parahippocampal place area and further related these changes to improved performance in a face recognition task, when comparing with NC women. They also found that users of androgenic progestins had smaller frontal areas compared to NC women.

Brain Structures Involved in Cognition and Emotion

A couple of studies specifically focused on HC effects on brain structures known to participate in the processing of emotion and/or cognition. Lisofsky et al. (2016) , in a pre-post quasi-experiment with a control group, found decreased gray matter volumes in the amygdala after 3 months of contraceptive intake in women starting HC use after a period on not using HC. They noted that this structural alteration was related to positive affect, whereas no changes in cognitive performance were detected. One study ( Petersen et al., 2015 ) investigated areas involved in the salience network and found cortical thinning in such areas. They were not able, however, to determine whether these changes were causally or merely indirectly related to the use of HC.

The Effect of Menstrual Cycle and HC on Brain Structure

One research group has published a series of articles where HC effects were contextualized regarding natural hormonal variation in the menstrual cycle. All these articles had Timo DeBondt as first author. The articles were based on overlapping samples and all assessed the effects of HC as compared to hormonal effects in the menstrual cycle on brain structure ( De Bondt et al., 2013a , b , 2015a ). Using diffusion tensor imaging, they found a significant increase in mean diffusivity in the fornix in an HC group as compared to a group of NC women ( De Bondt et al., 2013b ). In the same sample, they also reported that gray matter volume in anterior cingulate cortex (ACC) was negatively associated with estradiol levels in the NC women, whereas this finding could not be replicated in the HC group ( De Bondt et al., 2013a ). De Bondt et al. (2015a) also examined gamma aminobutyric acid (GABA) concentrations, seeking to find possible correlations between GABA concentration in the PFC, menstrual cycle phase, HC use and premenstrual syndrome (PMS) symptoms. They did find increased prefrontal GABA in the NC group at ovulation, whereas no changes were seen during the cycle in the HC group. No significant correlations with endogenous hormones or PMS symptoms were detected.

Adolescent HC Users

None of the structural studies directly investigated effects of HC use on the adolescent brain. Most samples included teenagers from the age of 18, but results were not separated according to age, and as such intermingled with effects on adult brains. This makes it impossible to assess differential or graded effects on younger brains.

Results From the Functional Studies

Functional measures were reported in 21 different articles as summarized in Table 3 .

Summary of Functional Studies

Functional studies were mainly conducted using task based and/or resting state fMRI. In addition, one group used PET and one group EEG. The research groups evaluated cognitive tasks, emotion processing, fear learning, reward and motivation as well as pain inhibition and resting state networks, related to intake of various types of hormonal contraceptives. Only two studies were randomized controlled trials (RCTs) ( Gingnell et al., 2013 , 2016 ), whereas the rest were observational, quasi-experimental or observational with repeated measures within one menstrual cycle. Sample size range was 8–55 in both HC groups and female control groups. Age span was 16–45 years, except in three studies ( Vincent et al., 2013 ; De Bondt et al., 2015b ; Smith et al., 2018 ) which provided no information about age, and four studies where only mean age was provided ( Pletzer et al., 2014 ; Hwang et al., 2015 ; Scheele et al., 2016 ; Smith et al., 2018 ; Hornung et al., 2019 ). One study ( Mareckova et al., 2014 ) additionally assessed an adolescent sample aged 13.5–15.5 years with 55 participants in both the HC and the NC control group. The functional studies were also heterogenous with regard to aims and approaches as well as design and methodology.

Emotion Processing, Fear, Anxiety, and Stress

In line with the scope of some of the structural studies, several of the functional studies investigated brain functions involved in affective processing.

Gingnell et al. (2013) conducted an fMRI RCT with a sample of women with a previous history of HC-induced adverse mood. The subjects were assessed at baseline and once during the last week of the 21 day HC/placebo treatment period. An emotional facial expression matching task was administered. Hemodynamic BOLD (Blood-oxygen-level-dependent) responses to angry or fearful expressions differed between groups and within the HC group when comparing pre-treatment and treatment scans. During the last week of the treatment cycle, the HC group showed decreased reactivity in the bilateral frontal gyri, both compared to the placebo group and to the pre-treatment scans. They also showed decreased reactivity in the left middle frontal gyrus and left insula compared to the placebo women. The changes in brain reactivity were accompanied by more depressed mood, mood swings and fatigue, compared both to the control group and to pre-treatment. The placebo group also showed decreased amygdala reactivity in the last set of scans, whereas this change was not found in the HC group.

Altered amygdala reactivity was also found by Petersen and Cahill ( Petersen and Cahill, 2015 ) who used fMRI to compare reactions related to arousing, negatively valenced images in HC and NC women. They found that HC women had significantly lower amygdala reactivity upon viewing emotionally arousing images.

Investigating the interaction effects of sex hormones and cortisol, Merz et al. (2012) found fMRI activation differences in amygdala, hippocampus and the parahippocampal gyri as a function of interaction of HC use and cortisol administration on implicit emotional learning using a fear learning paradigm. Administration of cortisol reduced amygdala activation in all groups but dampened neural activation in the left hippocampus and in the left anterior parahippocampal gyrus only in NC women. In HC women, hippocampal and parahippocampal activation was enhanced with increased levels of cortisol. In a later study ( Merz et al., 2013 ) Merz et al. evaluated the interaction between endogenous cortisol and the neural correlates of fear expression. There was an interaction between cortisol and HC use, as cortisol levels correlated with BOLD contrasts in the amygdala between conditioned fear stimuli only in HC users.

Fear conditioning was also applied by Hwang et al. (2015) , studying fMRI fear responses as well as extinction learning and recall, as related to HC and sex hormone status. HC women had lower activation in the posterior insular cortex, middle cingulate cortex, hypothalamus and amygdala compared to NC women with high levels of estrogen during fear conditioning.

An fMRI “traumatic” film viewing paradigm was utilized by Miedl et al. (2018) to assess the effects of endogenous estradiol and synthetic sex hormones on the neural processing of trauma exposure using films depicting severe interpersonal violence vs. neutral films in NC and HC-using women. The HC group showed increased insula and dorsal ACC activity relative to NC women upon viewing traumatic films.

Two different fMRI studies investigated effects of the pheromone-like steroid androstadienone. Hornung et al. (2019) evaluated differences in attention bias in HC vs. NC women when presented with fearful, angry and happy faces in a “dot probe” task and whether androstadienone affects attention bias. There were no behavioral attentional bias differences, no BOLD response differences and no effects of androstadienone. Similarly, Chung et al. (2016) explored the influence of androstadienone during psychosocial stress in HC, NC and in men using the Montreal Imaging Stress Task. The NC women showed increased activation of the left somatosensory association cortex as well as right pre-motor and supplementary motor areas under the placebo treatment when faced with stress, as compared to HC women. Under treatment with androstadienone, no significant differences were observed between the female groups.

The only included event-related potential (ERP) study was published by Monciunskaite et al. (2019) and employed emotional visual stimuli when comparing women using anti-androgenic HC with NC women. The main finding was that the HC group showed blunted late ERP amplitudes to negative emotional stimuli when compared to NC women.

Reward and Motivation

fMRI effects of HC on erotic stimulation and monetary reward was investigated by Abler et al. (2013) and Bonenberger et al. (2013) , respectively. Abler et al. presented erotic videos and pictures to HC users and NC women. The MRI scans revealed no between- or within group differences upon viewing these. However, compared to HC users, the NC women in their follicular phase showed increased activation in the bilateral anterior insula, dorsomedial PFC and left inferior parietal lobe, as well as in the bilateral inferior precentral gyrus upon expectation of erotic stimuli. In their luteal phase they had higher activation in the anterior and posterior middle cingulate cortex. Bonenberger et al. examined how the use of HC might alter neural reward processing in a monetary incentive task. In whole-brain analyses, NC and HC women did not differ upon expectation of a monetary reward. An ROI analysis did, however, show enhanced activity in the left anterior insula and inferior lateral PFC in HC users, relative to NC women in their follicular phase.

The interaction of oxytocin and HC regarding perceived partner attractiveness in relation to HC use was studied by Scheele et al. (2016) . Subjects were randomized to receive either oxytocin or placebo prior to participating in a passive face-viewing fMRI paradigm. NC and HC pair-bonded women were shown photographs of their romantic partner, matched unknown men, a familiar woman, and a matched unfamiliar woman. Administration of oxytocin was found to enhance ratings of attractiveness of romantic partners compared to unknown men in the NC women, but not in the HC women. NC women showed increased activity in the nucleus accumbens and ventral tegmental area upon viewing their partners, relative to the HC women. The interpretation was that HC can disrupt romantic partner attachment.

HC modulation of fMRI activation upon seeing different food cues was investigated by Arnoni-Bauer et al. (2017) who hypothesized that there would be an association between sex hormones and eating behaviors. Participants were shown images of high calorie foods as well as non-edible items. fMRI activation in the HC group was similar to that of the luteal phase in the NC women. Food related brain activation was assessed also by Basu et al. (2016) who tested the effects of depot medroxyprogesterone acetate (DMPA) on food motivation using a quasi-experimental pre-post design with subjects acting as their own controls. Eight women were investigated with MRI while looking at images of high-calorie and low-calorie foods, as well as neutral, non-food objects. Eight weeks after the DMPA injection increased activation was observed in frontal and postcentral areas upon viewing food, when comparing to baseline. The high-calorie images induced highest activation in cingulate and frontal areas, when comparing to baseline.

A final study of motivational effects of HC was conducted by Smith et al. (2018) who performed a PET study to assess sex differences in dopamine release in inferior frontal areas as well as the dorsal and ventral striatum. They administered D-amphetamine to NC and HC women, as well as to men, to elucidate possible sexually dimorphic neural and hormonal contributions to addiction. They measured changes in dopamine D2 and D3 receptors in the participants, but found no significant effects of HC.

Perception of Pain

Vincent et al. (2013) delivered noxious thermal stimuli to HC and NC subjects while in an MRI scanner, aiming to establish whether there was a reduction in the descending pain inhibitory system in the HC group. Serum sex hormone levels were assessed, and participants were asked to rate the intensity of pain for each stimulus delivered. The researchers found that a subgroup of HC women who had decreased testosterone levels required significantly lower temperatures to feel pain, relative to the NC control group. Imaging data showed significantly reduced activity in the rostral ventromedial medulla in response to the noxious stimuli in the low testosterone women, suggesting that failure to engage pain inhibition at this level might be involved in the increased sensitivity to pain in this group. NC women showed higher amygdala activation when compared to high testosterone HC women, but this was not seen when comparing with the low testosterone HC women.

Cognitive Tasks

Gingnell et al. (2016) published an fMRI RCT on the effects of HC on brain reactivity during response inhibition, where participants were asked to complete a go/no-go inhibition task. All participants were scanned at baseline and again during the last week of a 21-day treatment cycle. Only the women in the HC group improved performance significantly. HC women showed decreased reactivity in the right orbitofrontal cortex during correct response inhibition. Based on these findings the authors suggest that the use of HC does not necessarily have a negative impact on cognitive control and that, if anything, it might lead to a slight improvement.

Pletzer et al. (2014) assessed fMRI activations during two different numerical tasks which in previous studies had shown systematic sex differences in behavioral performance. HC users were compared to NC women in the follicular and luteal phases of their menstrual cycles, as well as to a group of men. They tested the assumption that brain effects of the synthetic form of progesterone in HC could be induced either by androgenic influences of these progestins (HC group should resemble men), by progestogenic influences (HC group should resemble the luteal group) or through an attenuation of endogenous steroids (HC groups should resemble the follicular group). The HC women resembled the follicular women the most regarding behavioral performance, but their BOLD response resembled that of the men in both cognitive tasks. The main conclusion drawn by the authors was that brain activation patterns in the HC users resembled that of men, but that no behavioral resemblance could be established.

Also employing cognitive tasks in which sex differences have previously been shown, Rumberg et al. (2010) employed fMRi scanning during a verb generation task which consisted of thinking about verbs corresponding to nouns being presented. They found increased activation in the right superior temporal lobe in HC women compared with NC women in their menstrual phase, and in the right inferior frontal cortex comparing with NC women in their mid-cycle phase.

Social cognition was evaluated by Mareckova et al. (2014) in a study on the influence of hormones on face perception. They recruited women using HC as well as NC women and performed fMRI scans while the women were shown ambiguous and angry faces. Both groups underwent fMRI scanning twice, once during the mid-cycle phase and once in the menstrual phase in both groups. Scans revealed stronger BOLD activation in the right fusiform face area in response to both ambiguous and angry faces in the HC groups as compared to the NC group.

Resting State and Functional Connectivity

Two of the research groups employed resting state fMRI to study the brain in the absence of tasks. Petersen et al. (2014) measured salivary hormone levels and compared brain activity in the anterior default mode network (DMN) and executive control network (ECN) in early follicular NC women, luteal NC women, HC users in active and inactive pill phases. They found that both endogenous hormone fluctuations and administration of synthetic sex hormones were associated with changes in these networks. De Bondt et al. (2015b) assessed hormone levels as well as symptoms of PMS in NC and HC women in addition to conducting fMRI analyses, but found no significant alterations in the DMN or ECN as a result of neither menstrual cycle phase nor the use of HC. They did, however, observe a positive correlation between PMS-like symptoms in women using HC and functional connectivity in the posterior part of the DMN.

Only one functional study ( Mareckova et al., 2014 ) investigated HC effects on a purely adolescent sample. This sample included teenagers from the age of 13.5–15.5 years. In this study, ROI findings from experiments done on adult participants ( Mareckova et al., 2014 ) were replicated. The teenagers using HC showed increased activity in the left fusiform face area of the temporal lobe upon viewing video clips of faces with ambiguous facial expressions.

In summary, most of the identified neuroimaging studies found effects of HC usage on the female brain, mainly in areas involved in emotional and cognitive processing. However, methodological challenges in almost all the included studies limit our ability to accurately interpret their results and render our main hypotheses to some extent unresolved. The studies by Gingnell et al. (2013 , 2016) were the only RCTs concerning the effects of HC. The sample consisted of women with previously reported HC-induced adverse mood, and the articles demonstrated that in women with adverse mood effects, HC may influence negative emotional reactivity and neural networks involved in cognitive inhibition.

Most of the other studies also found effects of HC use on brain structure or function, but these studies had major methodological problems with regard to internal validity or statistical conclusion validity resulting from using familywise uncorrected analyses of MRI-images or small sample sizes. Thus, although we discuss the possible implications of the findings, the reader should keep in mind that these studies are potentially biased. An overview of bias can be found in Supplementary Table 1 and methodological limitations are described in detail in a concluding section. Further, there was only one study with a sample of women in early adolescence, and this was a self-selected convenience sample and hence it may be biased. Thus, our hypothesis regarding effects in adolescence remains unresolved.

Implications of Structural and Functional Alterations

Most of the included studies indicate that several brain alterations are associated with the use of HC substances. We will discuss the most robust and convergent findings.

Several studies showed effects in areas of the brain known to be implicated in affective processing. Brain mechanisms involving affective changes caused by using of HC are crucial, due to their direct implications for mental health. This point is made convincingly by the register studies by Skovlund et al. showing that HC usage increases depression and suicide risk and that the effects are larger for the youngest women ( Skovlund et al., 2016 , 2018 ). According to Gingnell et al. (2013) the use of a combined HC has the potential to negatively affect mood and to induce changes in brain reactivity in structures involved in the processing of fear and other forms of negative affect. In the present review, their studies ( Gingnell et al., 2013 , 2016 ) were the strongest in terms of design, and are the only neuroimaging RCTs ever to be performed on functional brain effects of HC. The studies' risk of bias were small, but the researchers only included women with previously reported negative affect in response to the use of HC. Consequently, their sample is not representative for the general female population and external validity is hence limited. However, the study does contribute explanatory findings that are valid for women who experience adverse mood as a side effect of HC use. The women randomized to receive HC showed depressed mood after 1 month of use. This was linked to lower activity in frontal and insular brain areas upon viewing images of angry and fearful facial expressions, as compared to women randomized to receive placebo drugs. In the latter group, less amygdala reactivity was seen in response to images of emotional facial expressions upon a second exposure to these stimuli, whereas a difference upon re-exposure was not seen in women randomized to receive HC drugs. The researchers hypothesized that this might be indicative of decreased amygdala habituation in HC women, and as such attributed the deteriorated mood to an increased vigilance to emotional stimuli.

Further, several other studies in this review, shown in Tables 2 , 3 , indicate that HC use may affect structures in fear detecting and fear learning circuits in the brain, such as the amygdala. Amygdala functioning is strongly related to fear and learning of fear responses. This is clinically relevant, as fear learning is involved in phobias and other anxiety disorders ( Phelps and LeDoux, 2005 ; Adhikari et al., 2015 ; Hu et al., 2017 ). However, the findings are inconsistent, and the studies are heterogenous and confounded by lack of control regarding the androgenic and anti-androgenic effects of the progestins involved. Thus, a balanced interpretation would be that HC use likely affects fear circuits, but that the underlying mechanisms of such effects are not yet understood.

Several studies focused on cognition. The inferior and middle frontal gyri, in particular on the right side of the brain, are associated with inhibition and attentional control ( Booth et al., 2005 ; Aron et al., 2014 ). In a 2016 RCT, Gingnell et al. (2016) found decreased activity in the right middle frontal gyrus in HC women during a repeated go/no-go inhibition task, both comparing to the pre-treatment cycle and to the NC women. No difference in performance was detected at baseline, but the behavioral performance of the HC women improved more than that of the NC women in the retest session. The authors speculated that this might mean reduced effort in maintaining inhibitory control in the HC women leading to an enhanced inhibitory control in women taking these drugs. Thus, the reduced BOLD activations may be interpreted as increased efficiency and not as an expression of behavioral disinhibition.

Many of the included studies showed effects on the parahippocampal gyrus, both structurally ( Pletzer et al., 2010 , 2015 ; Lisofsky et al., 2016 ) and functionally ( Merz et al., 2012 ; Lisofsky et al., 2016 ). The parahippocampal gyrus is highly interesting in the context of sex hormones, as it is involved in encoding spatial layout of three-dimensional “scenes” ( Furuya et al., 2014 ). Spatial cognitive ability is one of the cognitive functions where the largest sex differences have been shown ( Voyer et al., 1995 ). However, none of the included studies focused on visuospatial cognition, where functional effects of the identified structural findings would be expected. The structural findings are inconsistent, as Lisofsky et al. (2016) found decreased parahippocampal volume in HC users, whereas Pletzer et al. (2010) found increased volume. Pletzer et al. suggest that an explanation may be that some progestins in HC are androgenic while others are anti-androgenic. They found larger gray matter volumes in the parahippocampal gyri in users of anti-androgenic progestins, but not in users of androgenic progestins, both compared to NC women. The Lisofsky article did not report the specific type of progestin, leaving this inconsistency unresolved.

Facial perception is a process considered to be important for social cognition which is a cognitive function where sex-differences have been found. The fusiform face area plays a role in facial recognition ( Axelrod and Yovel, 2015 ) and effects in this area was reported in the structural studies by Pletzer et al. (2010 , 2015) as well as the functional Marečková studies ( Mareckova et al., 2014 ) conducted with adult and adolescent samples. These studies found increased BOLD response in the fusiform face area upon viewing ambiguous and angry faces. The Marečková findings also provide a link between duration of HC use and extent of impact on the brain, as the activity in this area was increased as a function of length of use. The authors suggest a long-term plastic adaptation of the brain related to the use of HC. Thus, HC may influence social cognition, although the functional implications are unresolved.

Several research groups found functional effects of HC use in areas involved in the regulation of reward and motivation. The researchers used food-related, romantic, and sexual as well as monetary stimuli as a means of measuring such effects. The most important areas in the brain regarding reward, involve the dopaminergic mesolimbic structures such as nucleus accumbens in the striatum as well as the ventral tegmental area (VTA) ( Arias-Carrion et al., 2010 ). Oxytocin-releasing neurons terminate on these areas and oxytocin is thought to mediate reward ( Peris et al., 2017 ). Changes in these systems may affect all forms of motivated behaviors, thus having important effects in all areas of life. For instance, the study by Scheele et al. (2016) which assessed perceived partner attractiveness, found that upon viewing the partner's face, treatment with oxytocin increased the behavioral evaluation of partner attractiveness as well as BOLD responses in the nucleus accumbens and the VTA, in the NC group. This was not found in the HC group. The possible implication is that HC may attenuate partner-bonding. This remains speculative but should be explored further due to the seriousness of the potential consequences. The studies on sexual, monetary and food-related rewards ( Abler et al., 2013 ; Bonenberger et al., 2013 ; Basu et al., 2016 ) suffer from possible retest effects in only some of the subjects, post-hoc finding present only in an ROI based analysis and a small sample, respectively, thus presenting with reduced validity.

Lack of Pure Adolescent Samples

In addition to hypothesizing about the ability of HC to affect structural and functional aspects of the brain, we expected effects to be larger in adolescent subjects than in adult subjects. However, as we identified only one neuroimaging study ever to be performed on a purely adolescent sample, this hypothesis remains unresolved and the effects of such drugs on developing brains remain undetermined. The studies included many older subjects, making it impossible to disentangle potential differences between effects on the adolescent brain and effects on the adult brain. None of the studies investigated structural changes related to the use of HC in drug-naïve teenagers, but rather included convenience samples with mostly adult subjects. Only one functional study ( Mareckova et al., 2014 ) included a strictly adolescent sample, but there was no direct comparison with older subjects, nor any statistical test of age-covariates.

Given the evidence from the animal literature, as well as clinical registry studies such as that by Skovlund et al. (2016 , 2018) , which strongly indicate an increased vulnerability of the brain during adolescence, combined with the fact that girls are using these substances from an early adolescent age, we argue that there is a strong need for future studies to be carried out on adolescent use of HC.

Methodological Limitations in the Included Studies

We applied the validity typology of Donald Campbell and Thomas D. Cook ( Cook et al., 1979 ) which encompasses 4 types of validity threats with regard to our ability to make causal inferences: Internal validity, external validity, statistical conclusion validity and construct validity. While all types are important, low internal validity is paramount as is concerns whether an intervention was the likely cause of an effect. Thus, internal validity mainly encompasses confounders. See Supplementary Table 1 for a summary of the quality evaluation.

With the exception of Gingnell et al. (2013 , 2016) , none of the studies randomized participants to receive either HC or placebo, and most of the studies were observational with no inclusion of HC-naïve women. Hence, only the Gingnell studies reached high internal validity. The combined structural and functional MRI study by Lisofsky et al. (2016) achieved intermediate internal validity as they employed a pre-post quasi-experiment with control group, because even though the subjects self-selected to use HC, risk of bias was lowered due to the longitudinal design, enabling comparisons of within and between group effects. Yet, this design cannot control for effects of previous use. While this is true also for Gingnell, they explicitly aimed to generalize to a population of previous users. Thus, as stated previously, the Gingnell study cannot be generalized to the population of all women.

The conclusion regarding internal validity is that all studies, except the ones by Gingnell et al. were susceptible to bias and confounding due to selection phenomena and unobserved variables. Convenience sampling without disclosed detail concerning recruitment, as well as lack of randomization and control groups in almost all of the included studies, makes it impossible to ascertain causality.

Furthermore, most studies had poor control regarding type of substance currently or previously used, and no control for age at start of previous use, leading to low external validity. This critique also pertain to the Gingnell RCTs, as it is only possible to generalize to women with previous negative mood effects while using HC.

Most studies had low statistical conclusion validity, with small samples, resulting in low statistical power, making negative findings difficult to interpret, but also to an increased risk of false positive results ( Button et al., 2013 ). Many of the findings were also based on ROI analyses without familywise error (FWE) corrected whole brain analyses. ROI areas can be chosen based on post-hoc considerations, and so there should be a strong theoretical and/or empirical basis for choice of ROI areas. Several studies also employed whole brain analyses without correction for FWE. This may have led to type 1 errors.

Thus, while most studies found effects of HC on brain function or structure, confounding cannot be ruled out. While different studies had different methodological problems, the main source of low validity was self-selection in all of these studies, with the exception of the Gingnell studies. Thus, we discuss the effects of self-selection in the next paragraph.

The Impact of Sampling Bias and Self-Selection

Self-selection is a major internal validity threat in all of the non-randomized studies and is highly problematic in the present context. Choosing or not choosing to use HC may be influenced by various psychological factors that are associated with differences in brain structure and function. Mental and behavioral functions are, to a large extent, determined by brain function which ultimately is determined by brain structure. Thus, in the absence of randomization, self-selection by choosing or not choosing to use contraceptive drugs could be caused by psychological factors that are at least partly determined by brain function or structure. This could lead to serious confounding that could threaten internal validity.

Delayed sexual debut or sexual abstinence are examples of behaviors that may in part be determined by differences in brain function or structure when contrasted with being sexually active. Personality factors such as extraversion are central in this regard. In a large Dutch study, extraversion was found to affect friendships which again affected sexual debut and behavior ( van Leeuwen and Mace, 2016 ). A meta-analysis including altogether 420,595 subjects showed that extraversion was clearly positively associated with sexual activity ( Allen and Walter, 2018 ). Extraversion is further associated with distinct resting state fMRI patterns, such as increased long-range functional connectivity ( Pang et al., 2017 ). Structurally, it is associated with smaller gray matter volumes in the bilateral basal ganglia and increased dopamine receptor density in the striatum ( Baik et al., 2012 ). Also, negative associations with right PFC volumes have been found ( Forsman et al., 2012 ). This exemplifies how closely sexual activity is related to personality, which is further associated with differences both in brain function and structure. It thus illustrates how self-selection may have seriously confounded the included studies.

Another important source of possible bias is discontinued use of HC due to negative side effects. Different women may experience different side effects, and if such effects are not independent from brain function or structure, this will bias the finding. Thus, women who have chosen not to continue using HC will not be included in studies on effects of such drugs, unless the design of the study is a randomized design, and not based on self-selection.

As almost all the included studies were non-randomized case control-studies they might have ignored factors like these, and this might have introduced a strong sampling or selection bias. If the researchers had used only drug-naïve subjects for both controls and HC users, one could eliminate possible confounding effects of earlier use on their brains. By also employing longitudinal designs with drug-naïve subjects and pre-usage measures of brain-behavior relationships, validity could be further increased.

Contraceptive Content and Routes of Administration

There is a wide variety of HC drugs available, and these might affect the female brain in different ways. The orally administered drugs can be combination pills that commonly consist of ethinylestradiol and a progestin, or progestin-only formulations. They may have different cycle regimens, such as mono-, bi-, tri-, and quadriphasic as well as flexible regimens. Both the estrogen and the progestin contents of these pills have been gradually lowered over the years in an effort to reduce side effects ( Christin-Maitre, 2013 ).

Different types of formulation may also be associated with different side effects. Some progestins are considered to have androgenic properties, while others may have anti-androgenic effects on brain and behavior ( Pletzer and Kerschbaum, 2014 ; Giatti et al., 2016 ). Progesterone may lead to reduced testosterone action due to affinity for the enzyme 5α-reductase, and this may reduce conversion of testosterone into the more potent dihydrotestosterone ( Pletzer and Kerschbaum, 2014 ). Combined oral contraceptives with a progestin content considered to be anti-androgenic, such as drospirenone and desogestrel, have been postulated to be favorable in terms of mood symptoms in comparison with progestins displaying an androgenic profile ( Poromaa and Segebladh, 2012 ).

Alternative administration routes have also been developed over the years, such as vaginal or transdermal. Long-acting reversible contraception (LARC) such as progestogen-releasing intrauterine devices as well as injectable substances and implantable devices are effective contraceptive options that have become increasingly popular in the past decades ( Kavanaugh et al., 2015 ). Several of the included studies have recruited participants not using the same drug and/or using different routes of administration, and other studies do not provide information about these variables. This introduces the chance of committing type II errors and hence neglecting to uncover effects of the given drugs, since other drugs studied simultaneously, but having a different profile, may have counteracted or canceled out the effects on a group level.

Conclusions

This review found evidence that the use of HC can alter both structure and function of the brain. Furthermore, it contributed to accentuating the need for future research on HC and the ways in which they may affect the brain. There is a need for systematic research that considers the differences in formulation and administration of the various contraceptive drugs, employing a longitudinal, within-subject design with matched and randomized control groups consisting of HC-naïve subjects.

The impact of structural changes in the brain on functional outcomes such as motivational factors, affective phenomena and cognitive abilities should indeed be further investigated. Given the well-known sex hormone-dependent brain plasticity ( Schulz and Sisk, 2016 ), adolescence may be seen as a window of both increased opportunity and increased vulnerability, where implications of interference with endogenous processes could be far-reaching and affect emotional, relational, educational and vocational aspects of life. As a substantial number of women start using HC at a young age ( Martinez et al., 2020 ), these are issues that need to be scientifically addressed in order to provide female adolescents with individualized and informed contraceptive choices.

Author Contributions

MB: initial draft. MB and KB: conception/design and acquisition. All authors: analysis, interpretation of data, revision, final approval, and agreement to be accountable for all aspects of the work.

This project was partially funded by a research grant provided to author MB by Stavanger University Hospital, Psychiatric Division.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.556577/full#supplementary-material

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Keywords: hormonal contraceptives, brain, neuroimaging, MRI, PET, EEG

Citation: Brønnick MK, Økland I, Graugaard C and Brønnick KK (2020) The Effects of Hormonal Contraceptives on the Brain: A Systematic Review of Neuroimaging Studies. Front. Psychol. 11:556577. doi: 10.3389/fpsyg.2020.556577

Received: 28 April 2020; Accepted: 25 September 2020; Published: 27 October 2020.

Reviewed by:

Copyright © 2020 Brønnick, Økland, Graugaard and Brønnick. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Marita Kallesten Brønnick, mk.bronnick@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Permanent Birth Control—Vasectomies and Tubal Ligations—Up following Supreme Court Abortion Ruling

Researchers find dobbs decision ending right to abortion spiked use of permanent contraception.

After the Supreme Court’s Dobbs ruling, many public health experts expected women to take their healthcare into “their own hands, if need be, to maintain autonomy over their own bodies,” says BU researcher Jake Morgan. Photo by China News Service via Getty Images

Permanent Birth Control Up following Supreme Court Abortion Ruling

Researchers find dobbs decision ending right to abortion spiked use of permanent contraception—vasectomies and tubal ligations, rich barlow.

When the Supreme Court overturned the national right to abortion in June 2022, some friends and family of Jacqueline Ellison (SPH’20) underwent or considered “permanent contraception”—vasectomies and tubal ligations. Suspecting similar effects nationally, Ellison, a health sciences researcher, pulled together a team to study voluntary sterilization rates pre- and post- Dobbs v. Jackson Women’s Health Organization .

Among those she turned to was an expert from her alma mater who specializes in using data to answer public health questions: Jake Morgan , a Boston University School of Public Health research assistant professor of health law, policy, and management. Together, the team found that among 18- to 30-year-old men, post- Dobbs vasectomies leapt by about 27 additional procedures per 100,000 outpatient visits. The increase in tubal ligations among women of the same age roughly doubled the spike among men: about 58 per 100,000.

The study, published in April in JAMA Health Forum , used anonymized data involving 113 million patients nationwide at academic medical centers and clinics, including Boston Medical Center, BU’s primary teaching hospital. To get a before-and-after look, the researchers reviewed the period from June 2019—three years before the Dobbs decision—to September 2023, covering a year and a few months following the ruling.

”Permanent contraception procedures were on the rise even before Dobbs ,” says Ellison, who earned a PhD in health services research at BU and is now an assistant professor at the University of Pittsburgh . She speculates that rise was owed in part to millennials’ and Gen Z’s precarious finances, compared with previous generations’ finances.

For those who are hoping abortion bans will reverse declining birth rates, Morgan says the study offers a cautionary yellow light. He spoke with The Brink about the research and its implications as states debate abortion bans.

with Jake Morgan

The brink: did the magnitude of the greater spike in procedures among women surprise you.

Jake Morgan: I don’t think that I was surprised, because we know that women tend to bear the burden of reproductive planning a lot more than men. Even pre- Dobbs , the rate of tubal ligation was a lot higher than vasectomy. The change in the rate at which sterilization was increasing post- Dobbs [being] greater for women corresponds to what we have always known about how the world works, and who is disproportionately taking on the burden of making those choices. Is there a benefit in educating men more or creating better access to vasectomies? Both procedures are safe and effective, but a vasectomy is quicker, cheaper, less invasive. From a healthcare perspective, that might be an interesting thing to study in the future.

The Brink: Any idea about the socioeconomic traits of the typical person who received these sterilization procedures?

Jake Morgan: There’s a mix of effects going on. There are systematic barriers built into healthcare that make it difficult for low-income people, people of color, to access healthcare. That could be getting the bus fare to get there, finding child care, getting time off from work. So, it can both be true that poor women are sort of nudged to this option, but also that it’s harder for them to get into the healthcare system to begin with.  Everyone should have options to any sort of procedure that they and their doctor decide is right for them. But what we’ve seen with Dobbs is that people are being shunted into this option that may not have been their first choice, but they’re trying to do what they can to preserve autonomy over their own reproduction—i.e., with permanent contraception. So, while we think that everyone should be able to choose sterilization, the concerning point with this increase is that clearly this was not the first choice of folks.

The Brink: Are a heavy proportion of people who opt for permanent contraception from marginalized or disadvantaged groups?

Jake Morgan: There’s a long history of sterilization being forced on minority communities, either through pressure from doctors or sometimes the courts.    For example, you’re a poor woman with lots of kids, maybe you go to get healthcare, and your doctor is like, “You really should consider this procedure.” There is research about that.

The Brink: What are the implications of your findings, as states debate their individual abortion policies?

Jake Morgan: A legislature or policymaker needs to carefully consider expected benefits [and] the implications for patients. In the case of abortion, if you are pro-life, you are happy that fewer abortions are taking place. But if one of the reasons you’re against abortion is because you believe that we need to procreate, this should be concerning, because people are getting sterilized.    People have been debating population collapse or population explosion for hundreds of years. Just because you ban abortion does not mean that the demand for services related to not having a child is going to go away. Sterilization is definitely not the most common choice: you can cross state lines [to get abortions where they’re legal]; people are getting mail-order medications. The people that you’re targeting with these policies are still going to work to maintain their autonomy to the extent that they can. My academic career is focused on empowering people to make choices for their own healthcare and their own bodies. I hope that policymakers, when they pass laws that shrink autonomy, are really sure why they want to do that and what they think is going to happen. People who study this, I think, knew that there would be repercussions. Whether that is underground—back-alley abortions—or crossing state lines or sterilization, women will take this into their own hands, if need be, to maintain autonomy over their own bodies.

This interview was edited for clarity and brevity.

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Rich Barlow is a senior writer at BU Today and  Bostonia  magazine. Perhaps the only native of Trenton, N.J., who will volunteer his birthplace without police interrogation, he graduated from Dartmouth College, spent 20 years as a small-town newspaper reporter, and is a former  Boston Globe  religion columnist, book reviewer, and occasional op-ed contributor. Profile

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The Pill Makes Some Women Miserable. But Are They Really Quitting It en Masse?

The internet is awash with stories of women throwing out their oral contraception. New data suggests a different narrative.

Credit... Eric Helgas for The New York Times

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By Alisha Haridasani Gupta

• May 16, 2024

The woman in the video looks resolute, and a little sad, as she cuts up a pack of birth control pills. “These silly little pills have literally ruined me as a person,” reads the caption. The clip , which is on TikTok, has 1.1 million likes. It’s one of thousands that have proliferated on social media in recent years with virtually the same message: The pill causes terrible, sometimes irreversible side effects, and women should free themselves from it.

Anecdotal reports from news outlets have suggested that women are quitting the pill in large numbers because of this type of online post. “We’ve known for a long time that people really rely on their social circles to help them with medical decision making as it relates to contraception,” said Dr. Deborah Bartz, an obstetrician-gynecologist at Brigham and Women’s Hospital. Against a backdrop of increasingly restrictive abortion access, the idea that women might be giving up a reliable form of contraception because of social media hype has concerned researchers and doctors.

But, according to initial data, prescriptions for the birth control pill are not actually declining at all. An analysis by Trilliant Health, an analytics firm that provides health care companies with industry insights, found that usage has been steadily trending upward in the United States; 10 percent of women had prescriptions in 2023, up from 7.1 percent in 2018. The analysis looked at prescriptions for the pill that were written and picked up. Even among those aged 15 to 34, who would be most likely to see negative social media posts, Trilliant found prescriptions had increased.

The analysis was done at the request of The New York Times, and drew on Trilliant’s database of medical and pharmacy claims. It looked at a nationally representative sample of roughly 40 million women, aged 15 to 44, who used either Medicaid or commercial insurance. It doesn’t account for people who might get their birth control from telehealth providers that don’t take insurance, but that group most likely represents a small slice of the American population, said Sanjula Jain, chief research officer at Trilliant. Several of those telehealth companies also reported double-digit increases in birth control pill purchases in the past two years. The data also doesn’t include sales of the over-the-counter birth control pill, Opill , which has been available in stores in the U.S. since March .

Ten percent of women had prescriptions for the pill in 2023, up from 7.1 percent in 2018. Source: Trilliant Health

The pill has a reputation as a reliable, if flawed, form of birth control. Its known side effects — including blood clots, weight gain, a loss of libido and mood disruptions — have in fact been the main reason that some women do eventually quit the pill, Dr. Bartz said. When patients raise those concerns with physicians, they are often dismissed, she added, which can erode people’s trust in their doctors, and in health care institutions.

Online, that mistrust has bloomed. In two separate papers, published in 2021 and 2024 , Dr. Bartz analyzed the tone of birth control-related posts on Twitter. In the first study, researchers found that almost a third of posts about the pill from 2006 to 2019 were negative. In the second study, the team found that one of the major focus points of posts about the pill was its side effects. Another analysis from 2023 found that 74 percent of a sample of YouTube videos posted between 2019 and 2021 discussed discontinuing hormonal birth control methods because of side effects.

But the side effects of the pill don’t override its utility for many women. It is often seen as an easy point of entry for people newly considering continuous birth control because it can be started and stopped at any point, rather than requiring a painful procedure , said Dr. Cherise Felix, an obstetrician and gynecologist at Planned Parenthood’s south, east and north Florida chapters.

It is also more than 90 percent effective at preventing pregnancies, and can be used to help manage a range of health conditions, like endometriosis and polycystic ovarian syndrome.

What the analysis from Trilliant also underscores is that perhaps women are not so easily swayed by what they see online, said Dr. Felix, who reviewed the findings but was not involved in the analysis. If anything, they end up discussing it with their doctors to make more informed decisions. “I have not once had a patient start a conversation with ‘I stopped using my birth control because I saw this on TikTok,’” Dr. Felix said. “But I can tell you that just over the course of my career, I am having better-quality discussions with my patients.”

Nine states with some of the most restrictive abortion laws had bigger-than-average growth in pill prescriptions. Source: Trilliant Health

Several experts also pointed to increasingly restrictive abortion laws as a reason for the pill’s staying power. Trilliant’s analysis found that nine states with some of the most restrictive abortion laws saw bigger-than-average growth in prescriptions. For example, in Alabama, where abortion is completely banned with few exceptions, and South Carolina, which restricts abortions after six weeks, prescriptions increased by almost 5 percentage points between 2018 and 2023, compared with a national increase of 3 percentage points in that same time frame.

Women began stocking up on the birth control pill after the June 2022 Supreme Court ruling that ended the constitutional right to abortion, said Julia Strasser, director of the Jacobs Institute of Women’s Health at George Washington University and co-author of a recent study looking at contraception use. In 2019, roughly 32 percent of initial prescriptions were for more than one month; by 2022, more than half of initial prescriptions were for a greater supply of “two months, three months, six months and sometimes even 12,” Dr. Strasser said.

So if more women are relying on the pill, why does social media seem to tell a different story? One explanation, Dr. Bartz said, is what’s known as a negativity bias. Consumers are “much more inclined to complain and say ‘oh my gosh, let me tell you about all this bleeding that I’m having on my pill’ or ‘let me tell you about my weight gain,’ ” she said, and far less likely to post positive reviews.

She’s seen something very different in her clinical practice: Patients valuing their birth control options more than ever. “Post-Dobbs,” Dr. Bartz said, “there has been a heightened recognition of the need to be very proactive in preventing pregnancy.”

Alisha Haridasani Gupta is a Times reporter covering women’s health and health inequities. More about Alisha Haridasani Gupta

Birth Control Methods

A medication called Opill will soon become the most effective birth control method  available over the counter . Here’s what to know .

Seven gynecologists and reproductive health experts told us about the types of contraceptives currently available  and the risks they carry.

The birth control pill is known for having ushered in a sexual revolution. But for some, it can dampen libido .

The hormonal implant called Nexplanon, a long-acting reversible contraceptive, is an increasingly popular choice among teenagers. How does it work ?

The intrauterine device, or IUD, is one of the most effective birth control options, but inserting one can be excruciatingly painful. Why don’t more doctors offer effective relief ?

A generation of women grew up with hormones as the default option for birth control. The makers of Phexxi, a non-hormonal contraceptive gel , are trying to appeal to them.

Despite encouraging research, here’s why male birth control methods  remain elusive.

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BERNIE BULLERT , CEGE benefactor and MN Water Research Fund founder, was profiled on the website of the University of Minnesota Foundation (UMF). There you can read more about his mission to share clean water technologies with smaller communities in Minnesota. Many have joined Bullert in this mission. MWRF Recognizes their Generous 2024 Partners. Gold Partners: Bernie Bullert, Hawkins, Inc., Minnesota Department of Health, Minnesota Pollution Control Agency, and SL-serco. Silver Partners: ISG, Karl and Pam Streed, Kasco, Kelly Lange-Haider and Mark Haider, ME Simpson, Naeem Qureshi, Dr. Paul H. Boening, TKDA, and Waterous. Bronze Partners: Bruce R. Bullert; Brenda Lenz, Ph.D., APRN FNP-C, CNE; CDM Smith; Central States Water Environment Association (CSWEA MN); Heidi and Steve Hamilton; Jim “Bulldog” Sadler; Lisa and Del Cerney; Magney Construction; Sambatek; Shannon and John Wolkerstorfer; Stantec; and Tenon Systems.

After retiring from Baker-Tilly,  NICK DRAGISICH  (BCE 1977) has taken on a new role: City Council member in Lake Elmo, Minnesota. After earning his BCE from the University of Minnesota, Dragisich earned a master’s degree in business administration from the University of St. Thomas. Dragisich retired in May from his position as managing director at Baker Tilly, where he had previously served as firm director. Prior to that, he served as assistant city manager in Spokane, Washington, was the city administrator and city engineer in Virginia, Minnesota, and was mayor of Chisholm, Minnesota—all adding up to more than 40 years of experience in local government. Dragisich was selected by a unanimous vote. His current term expires in December 2024.

PAUL F. GNIRK  (Ph.D. 1966) passed away January 29, 2024, at the age of 86. A memorial service was held Saturday, February 24, at the South Dakota School of Mines and Technology (SDSM&T), where he started and ended his teaching career, though he had many other positions, professional and voluntary. In 2018 Paul was inducted into the SDSM&T Hardrocker Hall of Fame, and in 2022, he was inducted into the South Dakota Hall of Fame, joining his mother Adeline S. Gnirk, who had been inducted in 1987 for her work authoring nine books on the history of south central South Dakota.

ROGER M. HILL  (BCE 1957) passed away on January 13, 2024, at the age of 90. His daughter, Kelly Robinson, wrote to CEGE that Roger was “a dedicated Gopher fan until the end, and we enjoyed many football games together in recent years. Thank you for everything.”

KAUSER JAHAN  (Ph.D. 1993, advised by Walter Maier), PE, is now a civil and environmental engineering professor and department head at Henry M. Rowan College of Engineering. Jahan was awarded a 3-year (2022- 2025), $500,000 grant from the U.S. Department of Environmental Protection Agency (USEPA). The grant supports her project, “WaterWorks: Developing the New Generation of Workforce for Water/Wastewater Utilities,” for the development of educational tools that will expose and prepare today’s students for careers in water and wastewater utilities.

SAURA JOST  (BCE 2010, advised by Timothy LaPara) was elected to the St. Paul City Council for Ward 3. She is part of the historic group of women that make up the nation’s first all-female city council in a large city.

The 2024 ASCE Western Great Lakes Student Symposium combines several competitions for students involved in ASCE. CEGE sent a large contingent of competitors to Chicago. Each of the competition groups won awards: Ethics Paper 1st place Hans Lagerquist; Sustainable Solutions team 1st place overall in (qualifying them for the National competition in Utah in June); GeoWall 2nd place overall; Men’s Sprint for Concrete Canoe with rowers Sakthi Sundaram Saravanan and Owen McDonald 2nd place; Product Prototype for Concrete Canoe 2nd place; Steel Bridge (200 lb bridge weight) 2nd place in lightness; Scavenger Hunt 3rd place; and Aesthetics and Structural Efficiency for Steel Bridge 4th place.

Students competing on the Minnesota Environmental Engineers, Scientists, and Enthusiasts (MEESE) team earned second place in the Conference on the Environment undergraduate student design competition in November 2023. Erin Surdo is the MEESE Faculty Adviser. Pictured are NIKO DESHPANDE, ANNA RETTLER, and SYDNEY OLSON.

The CEGE CLASS OF 2023 raised money to help reduce the financial barrier for fellow students taking the Fundamentals of Engineering exam, a cost of $175 per test taker. As a result of this gift, they were able to make the exam more affordable for 15 current CEGE seniors. CEGE students who take the FE exam pass the first time at a rate well above national averages, demonstrating that CEGE does a great job of teaching engineering fundamentals. In 2023, 46 of 50 students passed the challenging exam on the first try.

This winter break, four CEGE students joined 10 other students from the College of Science and Engineering for the global seminar, Design for Life: Water in Tanzania. The students visited numerous sites in Tanzania, collected water source samples, designed rural water systems, and went on safari. Read the trip blog: http://globalblogs.cse.umn.edu/search/label/Tanzania%202024

Undergraduate Honor Student  MALIK KHADAR  (advised by Dr. Paul Capel) received honorable mention for the Computing Research Association (CRA) Outstanding Undergraduate Research Award for undergraduate students who show outstanding research potential in an area of computing research.

GRADUATE STUDENTS

AKASH BHAT  (advised by William Arnold) presented his Ph.D. defense on Friday, October 27, 2023. Bhat’s thesis is “Photolysis of fluorochemicals: Tracking fluorine, use of UV-LEDs, and computational insights.” Bhat’s work investigating the degradation of fluorinated compounds will assist in the future design of fluorinated chemicals such that persistent and/or toxic byproducts are not formed in the environment.

ETHAN BOTMEN  (advised by Bill Arnold) completed his Master of Science Final Exam February 28, 2024. His research topic was Degradation of Fluorinated Compounds by Nucleophilic Attack of Organo-fluorine Functional Groups.

XIATING CHEN , Ph.D. Candidate in Water Resources Engineering at the Saint Anthony Falls Laboratory is the recipient of the 2023 Nels Nelson Memorial Fellowship Award. Chen (advised by Xue Feng) is researching eco-hydrological functions of urban trees and other green infrastructure at both the local and watershed scale, through combined field observations and modeling approaches.

ALICE PRATES BISSO DAMBROZ  has been a Visiting Student Researcher at the University of Minnesota since last August, on a Doctoral Dissertation Research Award from Fulbright. Her CEGE advisor is Dr. Paul Capel. Dambroz is a fourth year Ph.D. student in Soil Science at Universidade Federal de Santa Maria in Brazil, where she studies with her adviser Jean Minella. Her research focuses on the hydrological monitoring of a small agricultural watershed in Southern Brazil, which is located on a transition area between volcanic and sedimentary rocks. Its topography, shallow soils, and land use make it prone to runoff and erosion processes.

Yielding to people in crosswalks should be a very pedestrian topic. Yet graduate student researchers  TIANYI LI, JOSHUA KLAVINS, TE XU, NIAZ MAHMUD ZAFRI  (Dept.of Urban and Regional Planning at Bangladesh University of Engineering and Technology), and Professor Raphael Stern found that drivers often do not yield to pedestrians, but they are influenced by the markings around a crosswalk. Their work was picked up by the  Minnesota Reformer.

TIANYI LI  (Ph.D. student advised by Raphael Stern) also won the Dwight David Eisenhower Transportation (DDET) Fellowship for the third time! Li (center) and Stern (right) are pictured at the Federal Highway Administration with Latoya Jones, the program manager for the DDET Fellowship.

The Three Minute Thesis Contest and the Minnesota Nice trophy has become an annual tradition in CEGE. 2023’s winner was  EHSANUR RAHMAN , a Ph.D. student advised by Boya Xiong.

GUANJU (WILLIAM) WEI , a Ph.D. student advised by Judy Yang, is the recipient of the 2023 Heinz G. Stefan Fellowship. He presented his research entitled Microfluidic Investigation of the Biofilm Growth under Dynamic Fluid Environments and received his award at the St. Anthony Falls Research Laboratory April 9. The results of Wei's research can be used in industrial, medical, and scientific fields to control biofilm growth.

BILL ARNOLD  stars in an award-winning video about prairie potholes. The Prairie Potholes Project film was made with the University of Delaware and highlights Arnold’s NSF research. The official winners of the 2024 Environmental Communications Awards Competition Grand Prize are Jon Cox and Ben Hemmings who produced and directed the film. Graduate student Marcia Pacheco (CFANS/LAAS) and Bill Arnold are the on-screen stars.

Four faculty from CEGE join the Center for Transportation Studies Faculty and Research Scholars for FY24–25:  SEONGJIN CHOI, KETSON ROBERTO MAXIMIANO DOS SANTOS, PEDRAM MORTAZAVI,  and  BENJAMIN WORSFOLD . CTS Scholars are drawn from diverse fields including engineering, planning, computer science, environmental studies, and public policy.

XUE FENG  is coauthor on an article in  Nature Reviews Earth and Environment . The authors evaluate global plant responses to changing rainfall regimes that are now characterized by fewer and larger rainfall events. A news release written at Univ. of Maryland can be found here: https://webhost.essic. umd.edu/april-showers-bring-mayflowers- but-with-drizzles-or-downpours/ A long-running series of U of M research projects aimed at improving stormwater quality are beginning to see practical application by stormwater specialists from the Twin Cities metro area and beyond. JOHN GULLIVER has been studying best practices for stormwater management for about 16 years. Lately, he has focused specifically on mitigating phosphorous contamination. His research was highlighted by the Center for Transportation Studies.

JIAQI LI, BILL ARNOLD,  and  RAYMOND HOZALSKI  published a paper on N-nitrosodimethylamine (NDMA) precursors in Minnesota rivers. “Animal Feedlots and Domestic Wastewater Discharges are Likely Sources of N-Nitrosodimethylamine (NDMA) Precursors in Midwestern Watersheds,” Environmental Science and Technology (January 2024) doi: 10.1021/acs. est.3c09251

ALIREZA KHANI  contributed to MnDOT research on Optimizing Charging Infrastructure for Electric Trucks. Electric options for medium- and heavy-duty electric trucks (e-trucks) are still largely in development. These trucks account for a substantial percentage of transportation greenhouse gas emissions. They have greater power needs and different charging needs than personal EVs. Proactively planning for e-truck charging stations will support MnDOT in helping to achieve the state’s greenhouse gas reduction goals. This research was featured in the webinar “Electrification of the Freight System in Minnesota,” hosted by the University of Minnesota’s Center for Transportation Studies. A recording of the event is now available online.

MICHAEL LEVIN  has developed a unique course for CEGE students on Air Transportation Systems. It is the only class at UMN studying air transportation systems from an infrastructure design and management perspective. Spring 2024 saw the third offering of this course, which is offered for juniors, seniors, and graduate students.

Research Professor  SOFIA (SONIA) MOGILEVSKAYA  has been developing international connections. She visited the University of Seville, Spain, November 13–26, 2023, where she taught a short course titled “Fundamentals of Homogenization in Composites.” She also met with the graduate students to discuss collaborative research with Prof. Vladislav Mantic, from the Group of Continuum Mechanics and Structural Analysis at the University of Seville. Her visit was a part of planned activities within the DIAGONAL Consortium funded by the European Commission. CEGE UMN is a partner organization within DIAGONAL, represented by CEGE professors Mogilevskaya and Joseph Labuz. Mantic will visit CEGE summer 2024 to follow up on research developments and discuss plans for future collaboration and organization of short-term exchange visits for the graduate students from each institution. 

DAVID NEWCOMB  passed away in March. He was a professor in CEGE from 1989–99 in the area of pavement engineering. Newcomb led the research program on asphalt materials characterization. He was the technical director of Mn/ROAD pavement research facility, and he started an enduring collaboration with MnDOT that continues today. In 2000, he moved from Minnesota to become vice-president for Research and Technology at the National Asphalt Pavement Association. Later he moved to his native Texas, where he was appointed to the division head of Materials and Pavement at the Texas A&M Transportation Institute, a position from which he recently retired. He will be greatly missed.

PAIGE NOVAK  won Minnesota ASCE’s 2023 Distinguished Engineer of the Year Award for her contributions to society through her engineering achievements and professional experiences.

The National Science Foundation (NSF) announced ten inaugural (NSF) Regional Innovation Engines awards, with a potential $1.6 billion investment nationally over the next decade. Great Lakes ReNEW is led by the Chicago-based water innovation hub,  Current,  and includes a team from the University of Minnesota, including PAIGE NOVAK. Current will receive $15 mil for the first two years, and up to $160 million over ten years to develop and grow a water-focused innovation engine in the Great Lakes region. The project’s ambitious plan is to create a decarbonized circular “blue economy” to leverage the region’s extraordinary water resources to transform the upper Midwest—Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Brewing one pint of beer generates seven pints of wastewater, on average. So what can you do with that wastewater?  PAIGE NOVAK  and her team are exploring the possibilities of capturing pollutants in wastewater and using bacteria to transform them into energy.

BOYA XIONG  has been selected as a recipient of the 2024 40 Under 40 Recognition Program by the American Academy of Environmental Engineers and Scientists. The award was presented at the 2024 AAEES Awards Ceremony, April 11, 2024, at the historic Howard University in Washington, D.C. 

JUDY Q. YANG  received a McKnight Land-Grant Professorship Award. This two-year award recognizes promising assistant professors and is intended to advance the careers of individuals who have the potential to make significant contributions to their departments and their scholarly fields. 

Professor Emeritus CHARLES FAIRHURST , his son CHARLES EDWARD FAIRHURST , and his daughter MARGARET FAIRHURST DURENBERGER were on campus recently to present Department Head Paige Novak with a check for $25,000 for the Charles Fairhurst Fellowship in Earth Resources Engineering in support of graduate students studying geomechanics. The life of Charles Fairhurst through a discussion with his children is featured on the Engineering and Technology History Wiki at https://ethw.org/Oral-History:Charles_Fairhurst#00:00:14_INTRODUCTION

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