Kim Jansen talks to obstetrician and gynaecologist Dr Patricia Okeyo about various birth control methods, and the pros and cons associated with them.
KJ: Before we delve into the details of birth control, we need to determine what influences the way women choose contraceptives, correct?
Dr O: Absolutely! From a postnatal perspective, there are a couple of things you need to take into consideration to ascertain which birth control would work for you. First, if you’ve delivered via C-section, you are required to wait at least six weeks before resuming intercourse; that in itself is a contraceptive. If you’ve had a vaginal delivery, (and depending on what’s happened in the perineal area), you can resume intercourse as soon as the lochia has stopped flowing and when you feel ready. The second aspect you would need to take into consideration is whether or not you’re breastfeeding, as this will play a large role in determining what contraceptive method is used. As a rule, contraceptives are discussed at the six-week postnatal check-up, as most women aren’t having intercourse prior to six weeks after delivery.
Third, there is another really significant aspect to take into consideration and that is whether or not you’re planning on having more children. This will also influence the type of contraceptive method that you would ultimately decide to use.
KJ: That being said, would you separate the different contraceptive methods into permanent and temporary?
Dr O: Certainly. There are simple barrier methods and hormonal methods, and then your implants and tubal ligation. Let’s take a look at them.
Barrier methods: The condom is a barrier method of contraception, which, although effective, shouldn’t be used alone as a form of birth control. I normally recommend that this is used in conjunction with another contraceptive, like the pill. It works well to prevent sexually transmitted infections, but a condom can tear if handled incorrectly, so it’s not 100% effective as birth control.
Hormonal methods: If you’re breastfeeding, you need to take birth control that’s pure progesterone – so that your milk production is not affected – such as Microval or what’s commonly known as the mini pill. The mini pill contains no placebos and it must be taken at precisely the same time every day otherwise its effectiveness drops quite significantly and quickly. For instance, if you take the mini pill at 21h00, you need to ensure you don’t take it later than that every night. There is a very small window period of three hours to take advantage of – it’s not as nearly as forgiving as the combined pill.
The efficacy rate is about 96%, but if you’re breastfeeding exclusively and taking the mini pill, it’s slightly higher. Once you stop breastfeeding, you should change to something more reliable.
Injectable hormone: This is either the Depo-Prevera® injected every 12 weeks – or Noristerat® injected every eight weeks. These are progesterone-only contraceptives and quite safe while breastfeeding, with a 98% efficacy rate. This progesterone is injected into a muscle and is then gradually released into the bloodstream. The advantages are that you only have to think about contraception every two to three months rather than every day; it doesn’t interfere with sex or breastfeeding; it can reduce the chances of getting ovarian or endometrial cancer; and lastly, you do not have to wait to go to a doctor to stop it, you simply wait for the effects to wear off.
The main disadvantages are that it cannot be retracted once injected; you have to wait for it to wear off, which means that fertility may take some time to return after you stop using it. This is a residual effect and some literature suggests a return to fertility can be anything from six months to a year.
Implanon: This is a progesterone-releasing hormone that is 99% effective. It’s a matchstick-sized rod that is implanted in the non-dominant inner arm, around 8cm above the elbow – it can be felt, but no one can see it. Its efficacy lasts around three years, or until you’re ready to have another baby.
Intrauterine devices: These are the older methods of contraception that most women are familiar with. The Copper T device is inserted and can last up to five years. It’s a tried and tested method that’s about 97% effective, and it doesn’t release hormones. The main disadvantage is that it can result in a substantially increased menstrual flow and increased menstrual cramps, and unfortunately may lead to anaemia.
The Mirena is inserted into the uterus and releases a hormone every day for five years. The hormone release is a mere fraction of what you would be getting from an oral contraceptive. It works in the uterine area and the hormone is small enough to not suppress your ovulation and is about 99% effective. With any foreign object, you may have abnormal bleeding for the first six months, but the rule of thumb is that it does get progressively better and eventually settles down.
Neither of these intrauterine devices has a long-term effect on fertility. When you remove either of these devices, the return to fertility is immediate.
Oestrogen-containing birth control: These include the Evra® Patch, the combination pill, or the Nuvaring®, which we will not offer you until you stop breastfeeding. The patch is replaced weekly, the combination pill is taken daily, and the Nuvaring® is replaced monthly. All of these have a placebo week, and stop the release of eggs from your ovaries, which prevents pregnancy.
A risk with the Evra® Patch is that it may fall off, but it can be replaced as soon as you notice. In some instances, you could experience breast tenderness or nausea, weight gain or mood swings, but it’s rare and gets progressively better. Some women have reported vaginal irritation with the Nuvaring®.
With these three contraceptive methods many women have experienced a lighter flow, which lowers the risk of anaemia; reduced acne; and reduced risk of pelvic inflammatory disease. A big advantage of the patch and the Nuvaring® is that you don’t have to remember to take it daily.
KJ: There are actually quite a few options available to us. Now that we have a good idea of these temporary methods, please explain what tubal ligation is.
Dr O: There are many options available, which is why we strongly recommend seeing your licensed healthcare practitioner. Find what works for you with the advice of an expert who knows your health history.
We only recommend tubal ligation to parents who are 1 000% certain that they do not want any more children, as it’s a permanent method of contraception. Don’t opt for this and think that you would like to change your mind in future – if you haven’t decided on whether you want more children or not, this is not the option for you. Personally, I will not perform this procedure on anyone who has not had children because she may change her mind.
If you’re having a C-section, open tubal ligation (or laparotomy) may be performed simultaneously. This is when we can clip the fallopian tube with a titanium clip that’s completely inert. The clip strangulates the tissue and after a few months there is no more tissue. It’s like having a valley with no bridge, so the sperm can’t cross over to meet with your egg. This can be reversed, but it’s not ideal.
If you’ve had a vaginal delivery, a tubal ligation can be performed by inserting a viewing instrument and surgical tools through two small incisions (laparoscopy). This is generally the procedure that is used to tie the tubes. It is 100% effective, but we have had miraculous situations where one or two women have fallen pregnant after having had tubal ligation, though this is incredibly unlikely. Again, we will not touch you with a permanent procedure if you’re not sure.
KJ: Finally, what about the dads – can they contribute to birth control?
Dr O: Of course. Dads can undergo a vasectomy, which is perfectly safe and reversible. Most dads don’t really like the idea as they think it will have an impact on their functioning or performance, but it will not. It’s a much easier operation than tubal ligation for mums.
Because dads are often not comfortable with this, I do tell mums to look at it positively: this is your opportunity to take control of your fertility. Plan your family as best you can – take back the control by ensuring you’re taking birth control methods that work for you.