Worldwide, there has been a dramatic increase in contraceptive useover the past thirty-five years. The number of couples using systems of fertility control (the prevalence rate) has increased more than tenfold. Indeveloping countries, the number of contraceptive users increased fromunder 30 million before 1960, to almost 400 million in 1996. The percent of couples in the reproductive age group using contraception has increased from 8 percent to over 50 percent and is continuing to rise in most of the developing world.
Consequently, fertility has been steadily declining. In developing countries, the number of children a woman will have in her lifetime has decreased from approximately six in the 1960s, to less than four today2Most industrialized countries are at, or even below, replacement levels of fertility.
National surveys have provided detailed information on the methodsthat people choose to prevent pregnancy. Around the world, contraceptionis practiced chiefly by women. Surgical sterilization, primarily tubal ligation, ranks first among methods chosen by American couples. Oral contraception is the most widely used reversible method. In other countries,the pattern is different. In Sweden and France, the intrauterine device (IUD)is the preferred reversible method. In Japan, modem hormonal methods for women are not openly available, and the predominant method of birth control is the condom. Given the high failure rate of condom use, this means that many women ultimately must resort to having an abortion. Over one quarter of pregnancies in Japan are voluntarily terminated.
In Latin America and Africa, male use of contraception is negligible. In India, on the other hand, where surgical sterilization is the chief method used to prevent pregnancy, there was a period in the recent past when vasectomy was emphasized. Presently, most sterilization operations are tubal ligations. Male methods account for about 15 percent of the contraceptive prevalence rate, which has climbed in recent years to about 40 percent of couples. Some provinces of China rely heavily on vasectomy. Nevertheless, in the developing world, as well as in most industrialized countries, when couples wish to prevent pregnancies, contraception usually involves methods that women use.
Even with the availability of so-called modem methods, contraceptive failure is not uncommon. Surgical sterilization by tubal ligation, for example, usually assumed to be the gold standard with respect to effectiveness, does not always succeed. During the first year after such procedures, about four women per thousand will become pregnant. Among reversible methods, failure rates for one year of typical use are lowest with copper-carrying IUDs or progestogen-releasing intrauterine systems, contraceptive implants, and injectable progestogens (in each case, less than 1 percent). The conventional pill, the mini-pill, and inert plastic IUDs fail at a rate of 3-5 percent. Failure rates with use of the condoms, vaginal sponges, spermicides, cervical caps, diaphragms, periodic abstinence and withdrawal.
In order to calculate the number of pregnancies that result from contraceptive failure, one need only multiply the number of users of each method by its annual failure rate. Of the 3.2 million pregnancies that occur annually in the United States, fully one half occur while a couple is using a method of contraception. Studies show that about half of these are carried to term and the other half are terminated by abortion.
Presently available methods of contraception are profoundly inadequate. Failure rates are unacceptably high and side effects are often severe. This article surveys the current landscape of contraceptive technology in an effort to illustrate the need for more research in this area.
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