Front Cover
 Title Page
 Table of Contents
 Concepts of contraception that...
 How good-or bad- are barrier...
 Current acceptability and emerging...
 Groups for whom barrier methods...
 Using science and technology to...
 Barrier methods in developoping...
 Recommendations for policy and...
 Back Cover

Group Title: public issues paper of the Population Council
Title: Contraceptives and common sense
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088808/00001
 Material Information
Title: Contraceptives and common sense conventional methods reconsidered
Series Title: A Public issues paper of the Population Council
Physical Description: ix, 125 p. : ; 23 cm.
Language: English
Creator: Bruce, Judith
Schearer, S. Bruce
Publisher: Population Council
Place of Publication: New York
Publication Date: c1979
Subject: Contraceptives   ( lcsh )
Natalidad, Limitación de la -- Métodos
Contraceptifs   ( rvm )
Contraception -- methods   ( mesh )
Contraceptive Agents -- standards   ( mesh )
Contraceptive Devices -- standards   ( mesh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Bibliography: Includes bibliographical references.
Statement of Responsibility: Judith Bruce, S. Bruce Schearer.
 Record Information
Bibliographic ID: UF00088808
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 05029325
lccn - 79015285
isbn - 0878340408

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
    Title Page
        Page i
        Page ii
        Page iii
        Page iv
    Table of Contents
        Page v
        Page vi
        Page vii
        Page viii
        Page ix
        Page x
        Page 1
        Page 2
        Page 3
        Page 4
    Concepts of contraception that meet modern needs
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
    How good-or bad- are barrier contraceptives?
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
    Current acceptability and emerging demand for barrier contraceptives
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
    Groups for whom barrier methods have special appeal
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54
        Page 55
        Page 56
    Using science and technology to improve barrier contraceptives
        Page 57
        Page 58
        Page 59
        Page 60
        Page 61
        Page 62
        Page 63
        Page 64
        Page 65
        Page 66
        Page 67
        Page 68
        Page 69
        Page 70
    Barrier methods in developoping countries
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
        Page 77
        Page 78
        Page 79
        Page 80
        Page 81
        Page 82
        Page 83
        Page 84
    Recommendations for policy and action
        Page 85
        Page 86
        Page 87
        Page 88
        Page 89
        Page 90
        Page 91
        Page 92
        Page 93
        Page 94
        Page 95
        Page 96
        Page 97
        Page 98
        Page 99
        Page 100
        Page 101
        Page 102
        Page 103
        Page 104
        Page 105
        Page 106
        Page 107
        Page 108
        Page 109
        Page 110
        Page 111
        Page 112
        Page 113
        Page 114
        Page 115
        Page 116
        Page 117
        Page 118
        Page 119
        Page 120
        Page 121
        Page 122
        Page 123
        Page 124
        Page 125
    Back Cover
        Page 126
        Page 127
Full Text

The Population Council is an independent, nonprofit organization established in 1952 at the initiative of
John D. Rockefeller 3rd. It is international in the composrton of its Board of Trustees and its staff, as well as
in the nature and deployment of its activities. The Council conducts murtdisaplinary research and provides
technical and professional services in the broad field of population. Its vanous activities reflect eight pnmary
program themes: interaction between population and development processes, poles, and programs;
demographic aspects of family and community behavior migration and urbanizabon; women in develop-
ment; contraceptive development, physiology of the reproductive system of the human mate; approaches to
birth planning; and monitoring the safety and health effects of methods of fertility regulation. In addition to
these eight themes, strengthening professional resources is an important element that runs through the
Councis programs. The Council maintains collaborative relationships wth insutions throughout the world
having similar interests. It awards grants and contracts both to extend and complement its own work and to
help build, enlarge, or strengthen professional resources elsewhere. In addition, the Council awards training
opportunities and fellowships of several kinds intended to increase the number of qualfied professionals in
the population field. The Cuncil disseminates publications and information on population matters to in-
terested individuals and groups.

Public issues papers of the Population Counci are a hybrid form of policy writing: part descripive of
current knowledge; part analytical in suggestng alternative interpretations of this knowledge; part pocy
directed in weighing possible responses and in suggestng direcbons for future acbon Public Issues papers
relate insights gained from Council staff research to issues of contemporary policy relevance, in the United
States and elsewhere, and present arguments in a condensed, nontechnical format Papers in this series do
not necessarily reflect the views of the Population Council.

Papers in the Public Issues series:
Toward Saf, Convenient, and Efective Cotraceptive: A Policy Perspectie
Stephen L Salyer and James J. Bausch
U.S. Immigration A PeAcy Analysi
Charles B. Keely
Contraceptives and Come Sense: Ceaventeaioa Mliethi nds n
Judith Bruce and S. Bruce Schearer

and Common Sense:

and Common Sense:

a Public Issues paper of
The Population Council

Judith Bruce
S. Bruce Schearer

The Population Council
One Dag Hammarskjold Plaza
New York, N.Y. 10017 U.S.A.

Library of Congress Cataloging in Publication Data
Bruce, Judith.
Contraception and common sense.
(A public issues paper of the Population Council ;
Includes bibliographical references.
1. Contraceptives. I. Schearer, S. Bruce.
II. Title. III. Series: Population Council, New York.
A public issues paper of the Population Council ; PI-03.
RG137.B78 613.9'43 79-15285
ISBN 0-87834-040-8

Quotation and translation from Papyrus Ebers (facing page 1)
reprinted with the permission of Geron-X, Inc., from Kenneth
K. Keown, Jr., "Historical perspectives on intravaginal contra-
ceptive sponges," Contraception 16, no. 1 (July 1977).

1979 by the Population Council, Inc.
All rights reserved
Printed in the United States of America


Foreword vii

Introduction 1

Part 1 Concepts of Contraception That Meet
MF1odern Needs 6

Part 2 Now Good-or Dad-Are Barrier
Contraceptives? 12
Effectiveness of Barrier Contraceptives 12
Factors That Determine Effectiveness 14
Safety of Barrier Contraceptives 19

Part 3 Current Acceptability and Emerging Demand
for Barrier Contraceptives 26
Current Acceptability and Use 26
The Role of Service Providers in Determining Acceptability 26
Emerging New Patterns of Demand 31

Part 4 Groups for WVhom Barrier Methods Have
Special Appeal 38
Adolescents 39
Women over 30 44
Men Who Want to Share Risks 48
Women Who Seek Self-Care and a Feminist Approach
to Health Care 51

Part 5 Using Science and Technology to Improve
Barrier Contraceptives 58
How Barrier Methods Can Be Improved 58
Status of Current Research Efforts 63
Special Research Needs 66
Consumer Participation in Future Research 68

Part 6 Barrier IPethods in developingg Countrios 72
Acceptability of Condoms 74
Acceptability of Other Barrier Methods 76
Barrier Method Effectiveness in Developing Countries 78
Barrier Method Safety in Developing Countries 80
Pilot Tests of Barrier Contraceptives 81

Part 7 Recommendations for Policy and Action 86
Providing Supportive Family Planning Services 86
Special Programs for Adolescents 89
Improvements in Packaging and Labeling 92
Increasing Applied and Basic Research 95
Pilot Tests in Developing Countries 99
A Call for Public Action 100

Notos 104

.c.rr i :.

My colleagues and I at the Population Council ask:
What can be done in the coming decade to bring
the interests of individuals who use (or want to use)
contraceptives closer to the center of attention in
the development and improvement of methods to
prevent pregnancy? In considering this question,
we accept two compelling arguments: that the per-
spective of the user-his or her perceived needs,
wants, concerns, and aspirations-is a point of view
that those who work in contraceptive development
must take increasingly into account; and that the
safety and health risks of using contraceptives, in-
cluding the risk-to-benefit ratios of using one type
over another and of contracepting rather than con-
ceiving, need greater and more continuous atten-
This is not intended to criticize any of the presently
available contraceptive methods. Every one of them
is important and, because people's needs vary so
greatly, their variety is desirable. In fact, it can be
argued that the range of available contraceptives
needs to be expanded to include substantially more
rather than fewer varieties for men and for women.
There is no doubt, however, that increasing knowl-
edge of the risks and side effects of some contra-
ceptives is, as an earlier Public Issues paper by
Stephen L. Salyer and James J. Bausch pointed out
in 1978, "encouraging a rising level of dissatisfac-
tion with current contraceptive technology. Signs
of concern and disenchantment are found ... in
indications that a shift away from pill use may be
under way .... The sexually active person is faced
with an uncomfortable choice between highly ef-
fective methods involving varying degrees of risk

and safe methods that may detract from sexual en-
joyment ." It seems evident that a considerable
expansion of effort to produce the widest range of
safe, convenient, and effective contraceptives must
be undertaken, and that the perceived needs and
concerns of the user must be kept centrally in mind
throughout every phase of this work.
Barrier, or conventional, methods of contra-
ception-those that physically block the passage of
sperm into the uterus or chemically inactivate the
sperm in the vagina-are an important group of
methods in need of further development. Most
have been around for decades. Some, like the con-
dom and the diaphragm, are familiar to many;
others, including cervical caps and spermicidal
suppositories, tablets, and foams, are becoming
more widely known. Often, however, these
methods are perceived as clumsy or inconvenient
to use, are believed to be ineffective, and are con-
sidered too plain and old-fashioned for this era.
Yet, as Judith Bruce and S. Bruce Schearer point
out in this paper, research shows that most of these
methods are capable of providing high use-
effectiveness, contrary to common views. The au-
thors' examination of social trends and the special
needs of many groups of current contraceptive
uses, including adolescents, women over 30, and
those worried about the health risks of the pill and
the intrauterine device (IUD), indicates that bar-
rier methods are increasingly perceived as a mod-
ern, safe, and common sense way to prevent preg-
nancy. They are, in this increasingly health-
conscious age, the only group of contraceptives of-
fering high effectiveness with the absence of any
known health hazards, and the option of complete
and instant freedom to try to conceive if and when
the users wish. For these reasons, nearly 20 percent
of contraception in the United States today is based
on the use of conventional methods.

In such a climate, one might expect developers of
contraceptives to be giving some priority to better
and more barrier methods, but one would be sur-
prised and disappointed: in 1977, while public
agencies spent some $9 million to test the safety
and effectiveness of oral contraceptives and $1 mil-
lion to test IUDs, no funds were allocated to test
currently available barrier methods. And while
these same agencies concurrently spent $5.7 mil-
lion to improve and develop new hormonal contra-
ceptives for women, $1.8 million on new ap-
proaches based on immunology, $1.5 million on
new hormonal contraceptives for men, and $1.3
million on new techniques of abortion, they spent
only $143,000 on the development of better barrier
contraceptives. This would appear to be out of
tune with the times and somewhat unheeding of
the message consumers are sending with increas-
ing clarity.
The authors persuasively argue that this important
area of contraception has been too long ignored,
that a large and sustained effort to develop new
and better barrier contraceptives is sensible and re-
quired, and that now is the time to begin. We need
to listen more attentively to the common sense of
the contraceptive user in this important field of
health technology.

New York City

_oo ii +o 1^ <^ rs

Here begin the medicines to be made whereby a woman might
cease to conceive for one, two, or three years: (mix a concoc-
tion of certain drugs and honey), moisten lint therewith, and
place it at her uterus.

Papyrus Ebers, P1. 93, 6-8
(c. 1550 B.C.)

The ancient Egyptians had a simple, if not always
effective way of preventing conception-crocodile
dung was put into the vagina to separate the sperm
from the egg. There are examples dating back al-
most half a million years of female-applied contra-
ceptive barriers using a full range of animal, vege-
table, and even mineral products: chopped grass,
spider webs, leaves, honey combined with sodium
carbonate. In ancient Greece, women used tanic
acid on their homemade tampons as a spermicide.
A bush tribe in northern South America has tradi-
tionally employed okralike seed pods with one end
snipped off as a kind of female-controlled vegeta-
ble condom held in place by the vagina.
The earliest condoms for men were made of ani-
mal skin formed into sheaths; they were used ini-
tially as protection against venereal disease and
later as a means of contraception. Both ancient and
modern preliterate peoples, as well as most of the
early literate civilizations, found the simplicity and
logic of placing a barrier between the sperm and the
opening of the uterus easy to comprehend. The
principle was handed down from generation to
generation and society to society until the latter
part of the nineteenth century, when the first mod-
ern barrier contraceptives were developed-
condoms made of vulcanized rubber, diaphragms,
cervical caps, and vaginal spermicides. Until the
1960s these methods-updates on the ancient
modes-were the most reliable and most widely
used means of birth control in the modern world.'
Since the 1960s the solution to the problems of
contraception have been based increasingly on
complexity, not simplicity. This is not surprising in

an age of computers, lasers, zero-based budgeting,
and high-technology medical treatment. The oral
contraceptive (the "pill") was developed in the late
1950s using newly discovered synthetic hormones
that act in intricate ways on glands at the base of
the human brain. Intrauterine devices (IUDs) were
widely introduced in the 1960s in a host of
scientifically engineered configurations that act in-
side a woman's uterus in ways that are still too com-
plex to be fully understood. Nearly half of all mar-
ried couples in the United States who use some
method of contraception-and most do during the
course of their marriage-now use either the pill
or IUD.
Both of these methods introduced new concepts
in contraception. They seemed significant break-
throughs at the time of their introduction. Our
hindsight permits us to see the limitations of
both methods, but the concept behind hormonal
contraceptives in particular dominates our vision
of future technology. We continue to invest almost
exclusively in research on hormonal methods of
contraception. Of the nearly $70 million spent by
public institutions on contraception research dur-
ing 1976, only around $50,000 was devoted to im-
proving barrier methods of contraception.2 The
low priority given to research on barrier methods
reflects a bias of reproductive scientists and health
professionals in favor of high technology, sophisti-
cation, and a belief that "science" will solve our
health problems. Barrier methods have simply be-
come too simple to capture our imaginations.
Yet, if we examine emerging social trends and con-
sider the special needs of some large groups for
better contraceptives-adolescents, women over
30, individuals concerned with health and safety-
in many respects barrier methods appear to offer
both a modern and a commonsense solution to an
age-old problem. They are, even with their present

disadvantages, the only methods that offer poten-
tially high contraceptive effectiveness combined
with freedom from any known short- or long-term
side effects and the freedom to be fertile in the
future if the user so desires.
Thus, we believe that the time is at hand for a
comprehensive reexamination of barrier tech-
niques for contraception. In this Public Issues pa-
per we examine in some detail how good or bad are
today's barrier contraceptives, how acceptable they
are, and how they can be used to make them as
close to the ideal concepts of modern contraception
as possible. We document new patterns of use and
demand for barrier contraceptives in this country,
and we consider the potential utility of these
methods for couples living in developing countries.
In view of the shortcomings of present-day barrier
methods, we review the opportunities for using sci-
ence and technology to develop new and improved
barrier contraceptives. Finally, we believe that our
assessments of current social trends in contracep-
tion hold implications for public policy, and we
briefly state these in the last part of this paper.

Concepts of
That Meet
Modern Needs

The introduction of
highly effective
contraceptives in the
1960s encouraged new
social demands by women.

During the 1960s four highly effective contracep-
tive techniques-oral contraceptives, intrauterine
devices, and male and female sterilization-be-
came widely available in the United States for the
first time. Their advent accelerated changes in
the basic nature of family life and in the roles of
women, changes that are still under way today. By
providing individuals with the capability to control
their fertility with nearly complete effectiveness,
these methods opened up a new range of oppor-
tunities for couples and for women in particular.
During the decade following their introduction,
the amount of childbearing by American women
was sharply reduced, and the time at which women
elected to bear their children shifted significantly
to older ages. These shifts were accompanied by
the entry of women into the labor force in large
numbers and by their increasing sense of entitle-
ment, at all ages, to a broader role in national life
beyond the domain of the family alone.3
In retrospect, it now seems clear that the wide
availability of effective new means of contraception
encouraged a wave of new social demands by
women. These demands-for personal growth and
fulfillment, for control over one's body and future,
for individual autonomy and expression within
family life, for equity and sharing between men
and women, for personal health and safety, and for
sexual equality and fulfillment-have gained wide
acceptance in contemporary social life. They are
altering relationships between men and women,
between parents and children, and between health
professionals and consumers. Individuals, particu-
larly women, are making increasingly independent
decisions about health technologies and health care
systems; their discontent is feeding a growing "al-
ternative" health care movement. A growing num-
ber of men want to participate more equally in de-
cisions about contraception, including sharing the
risks of contraception, but they have few acceptable

choices. More women over 30 are still building or
just starting their families. There is a striking in-
crease in the number of adolescents who are sexu-
ally active, and most wish both to delay child-
bearing and to safeguard their future fertility.
Among all age groups there is an increasing em-
phasis on preventive and curative self-health care,
a growing discomfort with the ingestion of syn-
thetic substances and systemic drugs, and an
enlarging definition of health that stresses physical
and sexual well-being.
Within the last five years, as these changes have
been taking place, an ironic development has oc-
curred. The very contraceptives that facilitated the
emergence of new social demands are beginning to
be perceived as hindering their realization. Sophis-
ticated health technologies that entail the risk of
long-term effects-particularly health effects and,
for the young, impaired fertility-are increasingly
perceived as closing off future options. Both the
pill and the IUD are coming to be viewed as exam-
ples of technologies that exceed our grasp, that
interfere too powerfully with basic life processes
in ways we do not fully comprehend, and that
consequently have a capacity to cause us harm in
ways that we can only partially predict and rarely
This shift in attitude shows little sign of reversing,
since its foundations are based on increasing
knowledge from medical studies about the health
hazards of modern contraceptive methods. Con-
sider these developments:

* In 1975, over one-third of all contraceptive
users in the United States employed oral contra-
ceptives as their method. Beginning in the same
year, new research findings began to show that
oral contraceptives can cause serious health
problems.4 In 1976, it was shown that these

Ironically, the very
contraceptives that
facilitated the
emergence of new social
demands are now
perceived by many
as hindering their

problems are serious enough to require hospi-
talization in over 0.5 percent of pill users each
year.5 Overall, these findings indicate that if a
woman takes oral contraceptives throughout
her reproductive years, interrupting use only
for childbearing, she has better than a 1-out-
of-10 chance of experiencing a stroke, heart at-
tack, other type of circulatory system disease,
gall bladder surgery, ulcerations of the cervix
serious enough to require hospitalization, or a
liver tumor caused by her use of the pill.6 Ac-
cording to more recent findings, the risk of
those side effects that are related to the circula-
tory system is much higher among women who
smoke and take oral contraceptives, but much
lower among contraceptive users who do not

SThe popularity of intrauterine devices in the
United States declined between 1973 and 1975,
despite the fact that overall use of contraception
showed a substantial increase. Research on IUD
safety over the past five years has demonstrated
that long-term use of this method may cause
pelvic infections, which, in turn, can lead to per-
manent sterility in some women.8

* Recent studies have found that vasectomized
rabbits and monkeys develop debilitating, often
fatal autoimmune diseases.9 Millions of Ameri-
can men have been vasectomized, with no signs
to date of any adverse health effects; it there-
fore seems unlikely that the findings from these
animal studies are directly applicable to hu-
mans. Nonetheless, the National Institute of
Health is now conducting extensive follow-up
studies of vasectomized men to determine
whether any long-term side effects do occur in

Female sterilization fortunately remains free from
such clouds of potential long-term health risks, but
in spite of its dramatic increase in popularity over
the past decade, its irreversibility is perceived by
many women as a major drawback that under-
mines control over their future.
Paradoxically, the impressive documentation of the
known risks of the pill and the IUD has increased
the anxiety of many people about the unknowns.
It is no longer enough for contraceptive methods
to be highly effective. Consumers want contracep-
tives that are effective, safe in the short and long
term, self-administered, and fully reversible. This
is the modern concept of contraception.
This concept is not fully met by any of the pres-
ently available contraceptives. However, one class
of contraceptives comes the closest: barrier meth-
ods. What is most modern about present-day bar-
rier techniques is the concept they embody: simple,
direct, and reversible contraception. It is a concept
in easy harmony with demands for personal con-
trol and freedom from domination by formal social
institutions. It sidesteps reliance on high technol-
ogy and ingested chemicals, as well as overdepen-
dence on science to solve health problems. To the
best of our knowledge, barrier methods are safe
and reversible.
What is least modern about barrier methods is
their still insufficient and variable effectiveness and
the feeling by many users that their application in-
terferes too significantly with sexual fulfillment.
We now examine these issues in greater detail.

Users increasingly want
their contraceptives to
be effective, safe,
self-administered, and
fully reversible.

How Good
-or Bad-
Are Barrier

No other class of contraceptives provokes such a
wide range of opinion about their value and effec-
tiveness as barrier methods. The diversity of views
about barrier techniques reflects contradictory
findings about their contraceptive performance in
different clinical studies, as well as strongly oppos-
ing emotional reactions to the coitus-related nature
of these methods.

of Dnrrlor

At first glance, the clinical data on the performance
of barrier methods are so contradictory as to offer
support for almost any point of view. For instance,
in studies carried out between 1938 and 1976 the
diaphragm has exhibited a failure rate in prevent-
ing pregnancies varying from over 30 to as low as 2
pregnancies per year per 100 users." At a preg-
nancy rate of 30, the diaphragm would be classified
as one of the least effective of all contraceptive
methods, comparable to reliance on postcoital
douching or on calendar rhythm. At a pregnancy
rate of 2, on the other hand, the diaphragm would
be classed as a highly effective method, slightly
more effective than most IUDs and only slightly
less effective than oral contraceptives. The situation
regarding the use of spermicides and condoms is
virtually identical: pregnancy rates range from a
low of 2-3 failures per 100 users per year to a high
of 20-30, depending on the study consulted.12
Part of the answer to these apparent discrepancies
in findings lies in the way the studies have been
conducted. But the same broad range in pregnancy
rates has been exhibited among those studies that
have employed the most rigorous scientific meth-
odology.13 Thus it appears that the good or bad
performance measured in the various studies of
barrier methods actually occurs among the differ-

ent populations studied. The fundamental conclu-
sion from the 100 or more clinical studies to date is
not that the studies have been improperly con-
ducted, nor that barrier methods perform well or
poorly. The inescapable conclusion is that some
populations can and do use barrier contra-
ceptives-the condom, the diaphragm, vaginal
spermicides-with extremely high effectiveness,
while other populations are able to obtain only low

Put somewhat differently, the available research
shows that barrier contraceptives of all types are
technologically capable of providing very high ef-
fectiveness. At best, if they are used with correct
technique at each coitus, barrier methods fail to
prevent pregnancy in about 2-3 out of every 100
users during each year of use. This protection is
about equivalent to that offered by an IUD. In-
terpreting these statistics into individual terms, a
woman who obtains the best level of performance
from barrier contraceptives over the course of her
reproductive years has about a 50 percent chance,
on the average, of experiencing one unplanned
pregnancy due to contraceptive failure. Among
present-day contraceptives, only oral contracep-
tives and sterilization can offer better protection.
(A lifetime oral contraceptive user has a 5-10 per-
cent chance of experiencing one unplanned preg-
nancy, on the average.)14

Unfortunately, according to many studies carried
out in this country, many, probably even most
users of barrier contraceptives do not obtain this
high level of performance from barrier methods.
In fact, among the overall population of married
contraceptive users in the United States, barrier
method users experience about three times as
many contraceptive failures as IUD users. Again in
average statistical terms, if a woman were to use

Research on the condom,
diaphragm, and vaginal
spermicides shows that
all of these methods
are technologically
capable of providing
very high effectiveness,
equivalent to that
provided by IUDs.

Some groups, however,
achieve only low
effectiveness because
they fail to use
barrier methods
consistently and

barrier methods at this low level of effectiveness
over the course of her fertile years, she would be
likely to have roughly two to three unplanned con-
traceptive failures. When barrier methods are used
with such poor effectiveness, they are similar in
performance to such traditional contraceptives as
postcoital douching, withdrawal, rhythm, or pro-
longed lactation.'5

That Determine

New users obtain high
effectiveness when
they are given full
information about
the advantages and
disadvantages of
barrier methods,
competent instruction
on how to use them,
and follow-up support.

What factors determine whether a couple-or a
population-will use barrier contraceptives with
low or high effectiveness? The research studies
show that confirmed, experienced users generally
use all types of barrier methods with high effective-
ness." New users have also been shown to obtain
high effectiveness if they are given full informa-
tion, competent instruction, and follow-up support
in their use of these methods.7 Poor effectiveness,
on the other hand, has usually been observed in
studies in which new users are given only limited
information and instructions on use and little or no
follow-up support.18 To some extent increasing
levels of educational and socioeconomic status of
the user appear to compensate for a lack of instruc-
tion and support, but not completely.
Instruction, information, and support for new
users are so important for effective use of barrier
methods because of the central role that sexual atti-
tudes and behavior play in the performance of
these methods.' Barrier methods, like oral contra-
ceptives, are self-administered. Unlike oral contra-
ceptives, however, their use is related to the sex act.
The condom and spermicides must be used just
before coitus. The diaphragm can be inserted for
as long as four hours before sexual activity, but it
too must be inserted immediately before coitus
when unplanned sexual activity takes place. All of

these methods therefore necessitate interruption
of ongoing sexual behavior, as well as touching of
sexual organs by either the man or woman.
Not all couples can accept these requirements. To
use barrier methods successfully, a couple must be
able to accept them psychologically and integrate
their use into their sexual behavior.20 Without
achieving this, they will use the method incorrectly
or will occasionally take chances in order to avoid
the emotional burden that use of the method
causes them. Under such circumstances, some cou-
ples will then blame the method for any unplanned
pregnancies. Hence, a precondition for the effec-
tive use of barrier methods is an acceptance by the
user of how the method mechanically relates to his
or her sexual practices, and an understanding of
how and when to employ it.

This explains the key role played by instruction,
information, and support. Full information allows
couples who cannot meet the psychological and be-
havioral demands of barrier methods to appreciate
this in advance and to select some other method of
contraception better suited to their needs. Addi-
tionally, for couples who are motivated to try bar-
rier methods, they offer both practical help and
psychological support for successfully and effica-
ciously incorporating barrier methods in their
sexual practice.

Numerous studies have documented the impor-
tance of information and support in determining
how effectively any particular population will use
barrier contraceptives.21 One of the most convinc-
ing is a study conducted in the early 1970s among
young, unmarried, childless white women from
predominantly lower socioeconomic groups in
New York City.22 These women selected the dia-
phragm for contraception after participating in a
half-hour discussion of the different contraceptives

To use a barrier method
successfully, a couple
must be able to accept
and adapt to the coitus-
related demands of
the method.

being offered by a low-cost family planning clinic
on Manhattan's Lower East Side. Although they
were new to diaphragm use, these young women
employed the method with very high effectiveness
-the overall contraceptive failure rate for the pop-
ulation was 2.2 pregnancies per 100 users per year.
This effective use was combined with strong accep-
tance of the method: 83 percent continued to use
the diaphragm after one year. The authors of the
study attributed this success to two factors:

* "the objectivity with which the [alternative]
methods were offered and the thoroughness
with which they were described [which] allowed
the full exercise of patient self-selection";
"the level of instruction, which bolstered the
patient's self-confidence, and a mechanism for
continuing supervision. The participation of
personnel who believed in the method and who
possessed the skill and patience to teach it was

The high effectiveness obtained by established
users-most of whom did not receive this kind of
information and instruction-presumably reflects
their having learned through trial and error how to
use these methods. Their continued use of a bar-
rier method reflects their successful adjustment to
the coitus-related demands of these methods. It
also reflects their motivation to avoid pregnancy, a
third key factor in determining how regularly and
effectively a couple will use barrier contraceptives.
In sum, three human factors exert paramount
influence in determining how effectively-or inef-
fectively-a couple will use barrier contraceptives:

* the capacity of both partners to adjust emotion-
ally and behaviorally to the coitus-related de-
mands of these methods;

* the level of motivation of both partners to avoid
* the quality of instruction and information the
new users receive about these methods.

These factors explain the key role played by the
attitudes and practices of service providers, health
specialists, and pharmacy personnel in the perfor-
mance of barrier methods. Some health profes-
sionals often see the coitus-related demands of bar-
rier methods as a major drawback, and they are
biased both against barrier methods and against
the potential ability of users to employ them reli-
ably.24 In contrast, other professionals regard the
users' participation as a positive feature that
reaffirms its voluntary nature. In their discussions
with prospective users of barrier methods, service
providers communicate their attitudes-negative
or positive-and thus either undermine or en-
hance the users' success in employing these contra-
ceptives.25 When the service provider is the family
doctor or a woman's gynecologist, these conveyed
attitudes can exert substantial authority and
influence. When the service provider is a pharma-
cist or clerk expressing a negative or mocking atti-
tude, the effect can be discouraging to the would-
be user of over-the-counter methods.

Technological factors also influence the effective-
ness of barrier methods, although to a lesser ex-
tent. The quality of barrier contraceptives varies,
and not all products of the same type are equally
effective. At the extreme, it is evident that condoms
manufactured with inferior latex or made too
thinly can rupture during coitus, and that spermi-
cides containing insufficient active ingredients or a
type of jelly, cream, or foam that fails to adequately
cover the interior of the vagina will not provide
high contraceptive efficacy. Since drug control
laws in most countries are lax in their regulation

Limited data suggest
that inherent
differences in
effectiveness between
the various types
of barrier methods
are slight.

of over-the-counter products, such instances of
grossly inferior quality do sometimes occur.

Even among well-manufactured barrier contracep-
tive products marketed by major pharmaceutical
manufacturers, differences in inherent effective-
ness may exist between different types of products.
Among spermicides, the prospective user can
choose among vaginal jellies, creams, liquifying
vaginal suppositories, foaming vaginal tablets, and
aerosol foams.26 Based on very incomplete data
from clinical studies of effectiveness, which show
that jellies or creams used alone are less effective
than the other varieties of vaginal barrier meth-
ods,27 it is generally recommended that the creams
and jellies be used only in conjunction with a
Each of the other types of spermicides, along with
the condom or the diaphragm used with jelly or
cream, has demonstrated low pregnancy rates in
selected individual studies-as well as very high
pregnancy rates in many other studies.29 Unfor-
tunately, the comparative effectiveness of the sup-
positories, tablets, and foams-or of these spermi-
cides compared to the diaphragm used with either
jelly or cream-is virtually unknown because few
comparative studies have ever been undertaken to
answer this basic question. The limited data we
have suggest that inherent differences in effective-
ness between these methods are slight. One study
conducted in the early 1960s concluded that,
among new users, the diaphragm used with jelly or
cream was slightly more effective than foaming
vaginal tablets.30 A later study by the same investi-
gators showed that the diaphragm was appreciably
more effective among new users than aerosol vagi-
nal foam.31 In both studies, however, the differ-
ences in effectiveness either between the dia-
phragm (with jelly or cream) and foaming tablets

or between the diaphragm and aerosol foam were
insignificant among long-term users of these three
methods, suggesting little inherent difference in
efficacy between them.
Unfortunately, many of the spermicide products
on the market today remain untested under rigor-
ous scientific conditions, let alone in comparison
with alternative products. It is possible, therefore,
that some of these products may not be capable of
providing very high effectiveness. Until resear-
chers conduct carefully designed comparative
studies, the user has little guidance beyond the
findings reported here in selecting among the half-
dozen or more varieties of vaginal spermicides cur-
rently on the market.

Thus far, this examination of the utility of barrier Sfety oa BCar-rir
methods has focused exclusively on their contra- ?T ".'rcc'-"'c
ceptive performance. What about their side ef-
fects? How safe are they in comparison with other
types of contraceptives?
To varying extents, oral contraceptives, IUDs, and
surgical sterilization of women all infrequently
cause illnesses or injury sufficiently serious to re-
quire hospitalization. More rarely, they give rise to
fatal side effects.32 In contrast, barrier methods
cause no known illness, disease, or mortality. In-
deed, there is recent evidence that the diaphragm
may even offer the health benefit of a reduced risk
of cervical cancer.33
The only adverse health effects known to be asso-
ciated with barrier methods are rare instances of
allergic reactions to the rubber or dusting powder
used in condoms and diaphragms or to the chemi-

To varying extents
oral contraceptives,
IUDs, and female
infrequently cause
illness, injury, or
more rarely, death.
In contrast, barrier
methods cause no known
illness, disease,
or mortality.

cals present in spermicides.4 Some types of sper-
micides cause a sensation of warmth in the vagina
as they are dissolving, but this is not associated with
any adverse effect on vaginal tissues. Recently, it
has been realized that some of the chemicals in
spermicides are likely to be absorbed through
penile or vaginal tissues into the bloodstream.35 If
this happens-and it is not yet established to what
degree it does-these chemicals might exert toxic
effects on the body. Based on the little we know
about the toxicity of these chemicals and on the fact
that they are used only intermittently, significant
health hazards do not seem highly likely. In the
case of spermicidal jellies and creams used in con-
junction with the diaphragm, actual clinical data
over seven years of observation have revealed no
illness or disease caused by this method.36 Further
studies of these and other types of spermicides are
now being considered by various research groups
to provide more complete information about their
potential absorption and toxicity.

In comparing the relative safety of different con-
traceptives, the US Food and Drug Administration
and most physicians feel it is necessary to consider
one additional factor: the risk of illness or death
associated with any unplanned pregnancies that
may occur because of failures in the contraceptive
effectiveness of different methods. It should be
stressed that this factor is not always a relevant con-
cern to a woman using contraceptives. During cer-
tain times in their reproductive years, most women
are prepared to accept an unplanned pregnancy as
a wanted (albeit earlier than intended) pregnancy.
Under these circumstances, she is prepared to ac-
cept the health risks of pregnancy and childbirth.
During such periods in a woman's life, she would
not give much weight to the health risks of preg-
nancy in evaluating the relative safety of different
contraceptive methods. For such a woman, barrier

methods offer contraception free from known
health risks.
However, for women who are fully committed to
not becoming pregnant, health risks arising from
pregnancies due to inadequacies in their contra-
ceptive method are of concern. Figure 1 presents a
comparison of the relative safety of different re-
versible methods of contraception that takes into
account such risks of unwanted pregnancies. Bar-
rier methods are included in the figure with two
different levels of effectiveness-low (equivalent to
using these methods with an annual contraceptive
failure rate of 21.5 pregnancies per 100 users) and
high (equivalent to an annual failure rate of 2.5
pregnancies per 100 users). The figure also in-
cludes barrier methods used with low effectiveness
coupled with abortion of all contraceptive failures
that would occur under such circumstances. The
comparison is based on risks of death; no other
risks to health are taken into account. The data in
the figure are specific to Western women, and
would yield very different results if calculated for
women in developing countries.37
Figure 1 shows that even when the mortality risks
of unplanned pregnancies are taken into account,
all barrier methods are extremely safe contracep-
tives. Indeed, for women willing to use abortion to
terminate any unwanted pregnancies, or for cou-
ples who can use barrier methods with enough con-
sistency to obtain high contraceptive efficacy, bar-
rier contraceptives offer by far the greatest safety
of any reversible means available today.

A very important footnote to the safety of barrier
contraception-even when used with low effective-
ness-is the safety of abortion. Mortality risks asso-
ciated with abortion are extremely low.38 In ad-
dition, a series of recent international studies
organized by the World Health Organization and

Even when the mortality
risks of unplanned
pregnancies are taken
into account, all
barrier methods are
extremely safe

Ficlru I
z rt Iitn
bsOlincd Sit --
Use of Reversible
Contra Iiv
(r'! o U? c n
U.Ic~ s so EN ata

Barrier Methods, Low Effectiveness, with Abortion
of Accidental Pregnancies
Barrier Methods, High Effectiveness

M Intrauterine Devices

W Barrier Methods, Low Effectiveness

D Oral Contraception among Nonsmokers

SOral Contraception among Smokers
r-1 Deaths Resulting from Pregnancy and Childbirth If No
L-J Contraception or Abortion Is Used


r--- I I

In Ii




Age of Women
- i i i i .i i -- n l _ -- ^ ^ ^ ^_ _ ^ ^ ^ ^ ^








3 r

25 .

20 0

15 -


ii r-


_~~~g of Women _1



; m LJ

the US Center for Disease Control show that mod-
ern suction abortion has no effect on subsequent
fertility or pregnancies.39 There is evidence from
one of these studies (in Singapore) that abortion by
D&C dilatationn and curettage) may sometimes
cause an increase in subsequent miscarriages, but
this finding was not observed in a parallel study in
New York City. At any rate, the vast majority of all
legal abortions are now performed using the suc-
tion technique.
In addition to their intrinsic safety, barrier meth-
ods are the only contraceptives to offer some de-
gree of protection against sexually transmitted dis-
eases. While there is some uncertainty and, indeed,
scientific dispute about the extent of this protec-
tion,40 condoms clearly can prevent the transmis-
sion of gonorrhea and some other less common
venereal diseases if they are used with vigorous
care to avoid all skin contact between sexual part-
ners.41 The diaphragm used with jelly or cream
and spermicidal foams and suppositories used
alone appear to offer partial protection against
some types of venereal disease.42 In view of the
virtual epidemic of venereal disease that has oc-
curred during the past decade in the United
States,43 even such incomplete protection can have
considerable importance for teenagers and others
having varied sexual partners.

While the preceding discussion on the utility of
barrier contraceptives is pertinent to couples in
both industrialized and developing countries, those
living in developing countries face special prob-
lems. The reader is referred to Part 6 of this paper
for a more complete discussion of the utility of bar-
rier contraceptives for such couples.

A very important
footnote to the
safety of barrier
contraception for
couples who obtain only
low effectiveness is
the documented safety
of abortion.

and Emerging
for Barrier

According to national statistics, the popularity of
barrier contraceptives in the United States has de-
clined substantially over the past decade. Among
contraceptive developers, manufacturers, and ser-
vice providers there now exists a widespread con-
viction that these methods are no longer acceptable
to most couples.

and Use

The Role of
Service Providers
in Determining

Examination of the statistics shows clearly that this
conviction is incorrect. In spite of the sharp drop in
the use of barrier methods between 1965 and 1976,
very substantial numbers of couples continue to
use these methods. In 1976, 18-19 percent of all
couples practicing contraception used a barrier
method.44 Among those couples using reversible
contraceptives (i.e., excluding those who were steri-
lized), between 27 and 33 percent were using a
barrier method in 1976.45 It is interesting to note
that the levels of barrier method use are similarly
high throughout most of Europe.46 Statistics also
show that most of the loss in popularity of barrier
methods in the United States took place among
older couples who were firmly committed to no
further births and adopted sterilization.47 Among
younger married couples there was a slight overall
increase in popularity of these methods, mainly
due to an increased use of the diaphragm.48 (For
more on this see pp. 31ff.)

Service providers exert a major influence on the
acceptability of barrier contraceptives. Simply put,
motivation and knowledge being equal, a person
who visits a clinic that supports barrier methods is
more likely to use them. The current level of bar-

rier method use in the United States-nearly one-
third of all married couples who use some form of
reversible contraception-is probably a minimum
indication of the acceptability of these methods.
With appropriate support by service providers, ac-
ceptance would very likely be increased.49
Table 1 summarizes the percentage of patients us-
ing the diaphragm, drawn from three different
service provision settings: (1) publicly supported
organized family planning service providers, such
as Planned Parenthood and state health depart-

Table 1
Variation in Acceptance of the Diaphragm among Seven
Health Services in the United States, 1976
Percent of
Percent of New Patients
Approximate New Patients 19 and under
Annual Selecting Selecting
Clinic Case Load Diaphragm Diaphragm

1. A public clinic in the South over 15,000 2% 1%
2. A clinic operated by a
voluntary organization in
the Midwest over 10,000 6 3
3. A public clinic in the East over 20,000 18 18
4. A clinic operated by a
voluntary organization in
the West over 10,000 19 12
5. Three clinics operated by a
voluntary organization in
the East over 30,000 20 20
6. Combined data from three
women-run clinics 1,500 80 80
7. A privately and publicly
supported adolescent
health center over 3,500 NA 30

Sources: Planned Parenthood of New York City, three women's health services, and Aida
Torres of the Alan Guttmacher Institute. Project 7 is within "The Door-A Center of
Alternatives," in New York City.

Attitudes and practices
of service providers
exert a major influence
on the acceptability of
barrier contraceptives.

ments; (2) women-run health centers, which are all
private; and (3) a special teenage clinic. Within the
network of organized family planning services
there is wide variation in the proportion of women
using the diaphragm. In some of these clinics, as
many as 20 percent of all clients use barrier
methods, while as few as 2 percent use them in
others. Within the network of privately operated
women's health services (there are approximately
200 such health collectives in the United States),
the proportion of women selecting the diaphragm
or other barrier methods is extremely high; typical
clinics report that as many as 80 percent of their
clients select these methods.

As the preceding suggests, a significant number of
small and some large service providers do not find
the provision of barrier methods unusually diffi-
cult. However, some providers still argue that the
time required for an effective discussion of barrier
methods with a prospective user prevents them
from offering better services in this area. The in-
struction must deal with sensitive sexual topics and
requires 10 to 15 minutes of competently guided
discussion. Diaphragm users need fitting to deter-
mine the correct size of the device they should use.
They also need a demonstration on how to actually
insert and remove the device, following which the
new user may either disappear behind a curtain,
insert the diaphragm, and be assured that she has
put it in place properly, or return within a week
with the diaphragm in place to demonstrate her
competence.50 The time consumed in this initial
visit of the barrier method user is generally less
than that required to insert an IUD and only
slightly longer than required for a thorough dis-
cussion of the oral contraceptive.

The time and the quality and nature of the re-
quired discussions are often viewed as excessively
costly burdens in a busy clinic or private office

practice. If this perception is indeed correct (and it
may not be), the initial outlay of professional time
will be compensated for by fewer subsequent con-
sultations. Oral contraceptive and IUD patients re-
quire regular follow-up visits. IUD users should be
seen within six weeks of insertion and at least annu-
ally thereafter. Oral contraceptive users are usually
seen within three months of their first visit and in
many services are asked to return twice a year for
resupply and "discussion," if not examination.
Once a woman has obtained a diaphragm or sper-
micide and has learned how to use the method,
her need for further follow-up support or medical
review is minimal.51 A woman's diaphragm size
might change if she gains or loses 15 pounds or
gives birth. Otherwise, a diaphragm (and a dia-
phragm prescription) should last about three years.
In effect, the professional input required by bar-
rier method users is slightly higher at the begin-
ning, but over time the user is less physician-
dependent than the IUD or oral contraceptive
Less time and involvement by physicians in the
provision of barrier contraceptives might improve
the quality of services and lower the costs. Some
services use nurse/midwives or other trained health
care paraprofessionals to supplement physicians'
services, a practice often preferred by women.
Some services strive to reduce the distance between
"professional" and "user" by emphasizing that the
user's perceptions and motivations are the criti-
cal factors in making health technologies work.
They encourage greater participation by the user
through open-ended discussion, self-examination,
and the like. Both measures appear to improve in-
formation levels and foster the self-awareness that
makes effective use of barrier methods possible. A
recent study compared the knowledge levels of
women receiving contraceptive services from medi-
cal, paramedical, and self-help facilities (the third

Over time, users of
barrier methods are
less physician-
dependent than those
selecting the IUD or
oral contraceptives.

type is generally run by women who are specially
knowledgeable and committed, though not for-
mally trained as professionals or paraprofession-
als). As shown in Table 2, women receiving services
from conventional medical sources had the lowest
knowledge levels, while those receiving services
from self-help facilities had the highest.
A number of legal and practical obstacles also block
greater use of these methods. Some states, for ex-
ample, impose age restrictions on the purchase of
over-the-counter contraceptives. In some states, a
diaphragm prescription cannot be refilled without
a physician's review. Although it might make sense
to remind a woman to see a doctor at yearly inter-
vals, forbidding a reorder of a diaphragm without
physician participation inconveniences and costs

Table 2
Correct Scores on a Test of Knowledge among Women Using
Different Types of Medical Facilities (percentage)
Medical Paramedical Self-help
Knowledge Tested Facilities Facilities Facilities

Anatomy identification
(clitoris, uterus, vagina, os,
Fallopian tube, urethra, ovary, labia,
cervix, hymen) 46.2% 54.6% 72.2%
Definitions of gynecological procedures
(breast exam, Pap smear, speculum,
pelvic exam, D&C, biopsy) 82.0 85.6 98.0
Knowledge of appropriate frequency of
performing these procedures 60.0 67.6 73.2
Contraceptive contraindications, if any
(for the pill, IUD, diaphragm, foam,
condom) 22.0 39.2 39.2

Source: M. Reynard, "Gynecological self-help: An analysis of its impact on the delivery and
use of medical care for women." Master's thesis, State University of New York at Stonybrook,

the user senselessly. Because barrier methods have
traditionally been given a low marketing priority by
manufacturers, not only has the packaging and la-
beling suffered but in some cases products have
ceased to be available. The cervical cap, a small,
flexible cap that fits over the cervix and was used in
the 1930s and 1940s, is virtually impossible either
to have fitted or to find in a drugstore.52 The few
physicians who fit caps get their supplies from En-
gland and other European countries.
Despite a low interest in barrier contraceptives that
has prevailed among service delivery personnel
and pharmaceutical companies, there are indica-
tions, as the next section documents, that a resur-
gence in the popularity of such methods is under
way. If service providers respond positively to this
demand, it seems likely that the acceptability and
use of barrier methods will increase substantially in
the years ahead.

Information from a number of sources-national
surveys, family planning service statistics, and com-
mercial data-demonstrate an increased demand
for barrier contraceptives:53

*Data compiled by the National Center for
Health Statistics on the practice of contracep-
tion by white, never-divorced, married couples
in the United States indicate a small increase in
the number and proportion of persons using
the diaphragm between 1973 and 1976.54 This
increase reverses a downward trend in dia-
phragm use that had been under way since
1965. These same statistics show that the in-
crease has occurred mainly among younger
couples married fewer than ten years.

Despite continued
demand for barrier
contraception, low
interest by service
delivery personnel
and manufacturers
perpetuates a limited
range of choices.

New Patterns
of Demand

* These statistics also show that condom and, to a
lesser extent, spermicide use has begun to in-
crease among younger black couples, while con-
dom use continued to decline among older
black couples.
* Many family planning clinics have noted steady
increases since 1975 in the demand for dia-
phragms and in the use of condoms and
foams.55 The Center for Family Planning Ser-
vice Statistics, which collects information from
clinical services such as those operated by
Planned Parenthood, public hospitals, and pub-
lic health departments, has documented this
trend (see Table 3).
* Indirect evidence suggests a resurgence in the
use of barrier contraception by couples who ob-
tain their contraceptives from drugstores and
private physicians. Suppliers of the latex used in
the diaphragm are reporting a demand they
cannot meet, and at least one major diaphragm
manufacturer reports difficulty in producing
sufficient quantities to meet the growing new
demand. Pharmacists are experiencing a short-
age of diaphragms and are sometimes out of
supply. At the same time, pill manufacturers
are seeing a decline in sales-according to one
company, by as much as 15 percent each year-
that appears to indicate a shift to other forms of
contraception. A number of pharmaceutical
companies are introducing new spermicidal
products to the over-the-counter market.

Among the reasons cited for this emerging new
demand are increased awareness of and concern
about the side effects of oral contraceptives; this
concern has been closely accompanied by a persis-
tent decline in the use of the pill and IUD. It has
also been assumed that the "return" to barrier
methods in the United States after 1971 was re-
lated to the liberalization of abortion laws in several

Tabl! 3
Porcont Distribution of Clinic Patients by f
r.Vothcd at Last Clinic Vicit, 1972 and 1976

.ard 8Contracptive

All Ages 19 or Younger 20-29 30 or Older
Method at Last
Clinic Visit 1972 1976 1972 1976 1972 1976 1972 1976

Diaphragm 2.3% 5.3% 1.0% 2.7% 2.2% 6.3% 4.8% 6.4%
Foam 4.0 5.6 3.3 4.6 3.6 5.1 6.6 9.8
Condom 0.7 2.0 0.4 1.5 0.6 1.7 1.6 3.8
Orals 70.3 67.2 81.3 78.1 70.3 67.0 53.1 47.2
IUD 15.5 9.6 7.9 4.1 16.5 10.1 23.5 17.8
Sterilization 1.0 1.7 0.1 0.4 0.9 1.4 2.5 5.3
Rhythm 0.2 0.3 0.1 0.3 0.2 0.3 0.4 0.5
Other 1.0 1.2 0.6 1.0 0.9 1.1 2.0 2.2
None 5.0 7.1 5.3 7.3 4.8 7.0 5.5 7.0
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Source: Aida Torres, "Organized family planning services in the
Family Planning Perspectives 10, no. 2 (March/April 1978): 86.

states (New York, Alaska, and Hawaii in 1970;
Washington in 1972). These liberalized state laws,
followed by the Supreme Court decision on 22
January 1973 that in effect legalized abortion,
enabled men and women to use what they regard
as less effective methods of contraception in the
secure knowledge that abortion was available as a
backup. While there is no doubt that legal abortion
is an extremely important factor in permitting peo-
ple to make choices about contraception solely on
the basis of health and safety concerns, it is also
possible that the trend to barrier methods would
have increased without the changed law. In Austra-
lia, for example, restrictive abortion laws have re-
mained in force for many years, yet a demonstrable

United States, 1968-1976,"

Use of barrier methods
is increasing among
young married couples
in the United States.

trend away from the use of oral contraceptives be-
gan in the late 1960s.56
Who are the new users of barrier methods? Na-
tional data indicate that younger couples are show-
ing a new and distinct preference for the dia-
phragm and, among some groups, spermicides and
the condom, while the popularity of all of these
methods has declined among couples married for
10 to 20 years.57 In short, it appears that the new
users of barrier methods are clustered primarily in
the younger age groups.
Data from England, Australia, and the United
States reveal that better-educated women and
women married to professionals on the whole have
been more likely to use barrier methods than other
groups.58 Recently, however, use of these methods
appears to be diffusing to groups with lower levels
of educational attainment. For example, the data
gathered by the National Center for Health Statis-
tics show that the trend toward increased use of
condoms and spermicides may be much more pro-
nounced among married black women than mar-
ried white women.59 Other data show that, in com-
munities where the proportion of women using the
diaphragm has been several times higher than the
national average, diaphragm use is becoming prev-
alent among all types of women.60
This last point bears importantly on how the new
patterns of use and demand for barrier contracep-
tives are developing in the United States. The ob-
served differences in patterns of contraceptive use
between various groups of people are not due sim-
ply to educational or age differences. They also
reflect important differences in social attitudes and
in access to information and services. Highly edu-
cated women are generally the first to adopt supe-
rior health technologies, in part because their rela-
tive privilege permits them to make informed
choices earlier than other women. There are other

elites among women whose health care practices
have not been systematically studied. For example,
women health care professionals and women mar-
ried to such professionals constitute a type of elite
group that may well have a different pattern of
contraceptive use than women more isolated from
full information. Indeed, evidence (surveys of phy-
sicians' wives and family planning professionals)
suggests a considerable difference between what
health professionals recommend to patients and
the methods they themselves use; a dispropor-
tionate number of physicians' wives use barrier
methods.61 A recent addition to the sociology of
contraceptive use among professionals is the re-
mark by the commissioner of the US Food and
Drug Administration that he would rather his wife
and daughter use some method other than the oral
contraceptive.62 In the long run the contraceptive
choices of professionals are likely to have a persua-
sive influence on their clients.

for Whom
Barrier Methods
Have Special

Increasing use of and demand for barrier contra-
ceptives seems to be a fact. Just how far this emerg-
ing demand will extend in the years ahead is uncer-
tain, but substantial increases in barrier method
use seem very likely. It is not likely, however, that
this new demand will extend equally to all social
groups. Rather, the specific characteristics of bar-
rier contraceptives are likely to make them espe-
cially suitable for and appealing to certain social
As documented in Part 3, the only group for which
a definite statistical increase in the use of barrier
methods has been demonstrated up until 1976 (the
last year for which national statistics are available)
is young married couples. This is not surprising in
view of the obvious advantages of barrier contra-
ceptives for this group. Most young married cou-
ples are planning to have children in the future,
and for many of them a slightly higher risk of preg-
nancy is more acceptable than unwanted risks to
health or fertility that may be associated with
more effective contraceptive methods. This is espe-
cially so since legal abortion is both available and
acceptable to the majority of these couples. Also,
sexual communication between these young people
is generally more open and easy than it was for
earlier generations, and barrier contraceptives are
therefore more easily and successfully accommoda-
ted as part of their sexual practices. The fact that
barrier method use is on the increase among both
white and black and upper- and lower-income
young couples (although with different types of
barrier methods being preferred by these differ-
ent subgroups) suggests that this is only the begin-
ning of an extended social trend.
Four additional groups stand out as important and
interested future "markets" for these types of con-
traceptives: adolescents, women over 30, men who
wish to share the health risks of contraception, and

women for whom self-care and feminist health care
is important. Taken together, these groups now
represent a large share of all contraceptive users.
Because of the postwar baby boom and present so-
cial trends in sex, marriage, and childbearing, the
overall size of these four groups will increase
significantly during the coming decade.
To some extent, growth in use of barrier methods
among these four groups seems inevitable, and in
the following discussion we document the evidence
that such growth is already taking place. But to
some degree, the amount of growth in barrier
method use will also depend upon policies and ac-
tions adopted by health authorities and pharma-
ceutical companies over the next several years. In
what follows, therefore, we assess the utility of bar-
rier contraceptives for these four groups and com-
ment on some of the policy implications of these

The most rapidly growing group of contraceptive
users in the United States is women under the age
of 20.63 This "audience" for contraception has been
expanding in two ways: (1) numbers-more and
more young women, perhaps as many as 4 million
teenage girls, are sexually active and in need of
contraception;64 and (2) age-almost half the teen-
agers seeking contraception today are under 17.65
Consider the following statistics:

*Between 1971 and 1976, the percentage of
never-married women aged 15-19 who had had
intercourse increased from 27 to 35 percent.
Among the youngest-the 15-year-olds-18
percent had had intercourse, up from 14 per-
cent in 1971. The median age at first inter-
course was 16.2 years.66


The most rapidly
growing group of
contraceptive users is
unmarried teenagers.

Despite the increased
popularity of the pill
among teenagers, use
of over-the-counter
barrier contraceptives
is significant and
is likely to increase.

* Use of contraception among these teenagers
dropped from 83 to 75 percent between 1971
and 1976. However, among those who are using
some type of contraceptive, use is much more
frequent. Yet only 30 percent of the users (22
percent of all sexually active teenagers) use a
contraceptive at each intercourse.67
* In 1976, half of all sexually active teenagers had
more than one sexual partner. But when sur-
veyed, almost 50 percent of unmarried, sexually
active women aged 15-19 reported no inter-
course in the four weeks preceding the inter-
view. In other words, sexual activity among ado-
lescents is very irregular.68
* The most dramatic changes in the types of con-
traceptives used by teenagers between 1971 and
1976 were large shifts toward oral contracep-
tives (from 24 to 47 percent) and large shifts
away from withdrawal (from 31 down to 17 per-
cent) and the condom (from 32 to 21 percent).
Fewer than 10 percent of adolescent contracep-
tors use spermicides or the diaphragm, and
there was a slight decline in use of these meth-
ods between 1971 and 1976.69
* Teenagers tend to try several different contra-
ceptive methods, and the youngest favor such
nonmedical methods as the condom, spermi-
cides, douching, and withdrawal.70

Thus, it is clear that despite increasing popularity
of the pill among teenagers, barrier contraceptives,
especially the over-the-counter methods, hold an
important place in adolescent contraceptive prac-
tice. As the number of sexually active adolescents
grows and as adolescent sex becomes more typical,
the use of over-the-counter barrier contraceptives
by this group is likely to increase.

But beyond the inherent demand among teenagers
for a wide variety of methods and, specifically, for
barrier contraceptives under some circumstances, a
number of important social and health policy issues
suggest that increased barrier method use by this
group should be encouraged. One of the most pos-
itive findings from a recent national survey of
teenagers is that they are becoming more effective
contraceptors and more of them are seeking to use
contraception earlier.71 However, there are costs as-
sociated with the use of more effective contracep-
tion when this is achieved primarily through use of
oral contraceptives or IUDs. The irregularity of
sexual activity among teenagers and their vulnera-
bility to adverse health effects that may take years
to become manifest argue against the use of these
methods by teenagers. Continuous use of oral con-
traceptives or an IUD among this age group can be
seen as overmedication that exposes users not only
to the inherent risks of these methods, but also to
additional unnecessary risks because the method is
being used for long periods with no purpose.72
This concern is now being expressed by many phy-
sicians, who note the following:

* Women who begin using oral contraceptives at a
young age will frequently go on using them for
many years continuously. This will expose them
to a substantial cumulative health risk, particu-
larly if they smoke, as many teenagers do.73
* Young women whose menstrual and ovulatory
cycles are not yet fully established are not a suit-
able population for oral contraceptives, since
these contraceptives contain powerful hor-
mones that could potentially disrupt the natural
biological establishment of their cycles.74
* Venereal disease rates have sharply increased
among sexually active young people;75 oral con-

traceptives and IUDs provide no protection
against sexually transmitted diseases and may
even promote certain types of infections.76
* Most configurations of the IUD are not well tol-
erated by women who have never had a child.
Those few that are should be made more avail-
able, but even these are often expelled or cause
distressing bleeding and pain, leading to their
removal, especially in young, never-pregnant
women. Further, all IUDs increase the risk of
pelvic inflammatory disease, especially among
young women who have a variety of sexual
partners (as is common among teenagers), thus
creating a risk of subsequent infertility.77

For these reasons, some members of the medical
community have apprehensions about the increas-
ing reliance of adolescents on the pill and IUD.
This apprehension, however, has not yet been
translated into enthusiasm for barrier methods.
The key issue here is whether adolescents can em-
ploy these methods with sufficient consistency to
obtain high effectiveness. Young men carry con-
doms. Young women could carry spermicides or
the diaphragm (and some do), although it would
help if the diaphragm were more portable and if
various spermicidal jellies, creams, and supposito-
ries were packaged in single applications. But,
clearly, many adolescents cannot always plan ahead
for sexual activity. And even with the best inten-
tions and advance planning, the application of
spermicides or a condom so close to the sex act can
be socially and emotionally difficult for adoles-
cents. To use them effectively, they must find a way
to incorporate barrier methods into their sexual
practices and-more important-their partner-
In spite of these problems, large providers in dif-
ferent parts of the country have begun to prescribe

diaphragms for as many as one-fifth of their teen-
age clients (see Table 1). Recent studies show that
with adequate instruction and support, these
young users are obtaining very high effective-
ness.78 Marketing of condoms and spermicides is
being increasingly directed to young people, and
drugstores in many states are selling these meth-
ods off-the-shelf in supermarket style.
These trends suggest that a positive shift in basic
policy regarding the provision of contraceptive ser-
vices to teenagers is under way. In the past there
has been a tendency for many private physicians
and organized family planning services concerned
with the "social" risks of teenage pregnancy to
make judgments on behalf of their adolescent cli-
ents and thus to promote the use of oral contracep-
tives and IUDS.79
Slowly it is being recognized that adolescents are a
heterogeneous group and that they will-and
should-seek individual solutions compatible with
their personal habits, preferences, and concerns
for safety and effectiveness.80 For some, oral con-
traceptives or the IUD will be the right choice. For
those who can adapt their behavior to meet the
requirements of barrier methods, these tech-
niques can offer full safety, high effectiveness,
full reversibility, ease of purchase, and freedom
from medical (and therefore very often parental)
Informed choice implies more than a review of
medical facts. Both organized family planning pro-
grams and private physicians should encourage
discussion of social issues with teenagers making
contraceptive choices. Drawing teenage males into
discussion of health and safety risks in coeduca-
tional and clinic settings may help raise the explicit
issues of male and female risk and responsibility in
a constructive way. For example, in wishing to take
increased responsibility for contraception, young

Given adequate
instruction and support,
adolescents can use
barrier methods
with very high

women may be expressing something positive
about the desire to control their own lives and their
intense motivation to avoid pregnancy. But they
may also be expressing a helpless acceptance of un-
wanted health risks associated with contraception
because they are afraid to ask the man to use the
condom. The attitudes of adolescents to abortion
and their access to it vary widely throughout the
United States and will likely be an important ele-
ment in the selection of a method. Unwanted preg-
nancy is a possible outcome of use of barrier meth-
ods, and for adolescents either unwilling or unable
to obtain abortions, it is a life-altering event.
These and other health and social issues need full
discussion with young people faced with a com-
plex and difficult decision. Service providers
should seek to create an environment that permits
an informed and individual choice. If they do, it is
likely that the use of barrier contraceptives by
adolescents-with high effectiveness-will become
more widespread.

'Jcmoen American women over 30 are not what they used to
over 30 be. Marriage and family building patterns are
changing dramatically. Compared with previous
decades, many more women over 30 in this country
are now just beginning or still building their fami-
lies.81 Childbearing is shifting to older ages: among
married couples in the United States, over half of
all births in 1975 were to women aged 25 or over.82
Much of this childbearing entailed the births of
first children among women over 30.83 In 1964
only 7 percent of all births to women aged 30-34
were first births; by 1976, this percentage had
more than doubled to 16 percent. A comparable
increase in first births occurred among women 35-
39 years of age.84

Although women over 30 are not the only ones
participating in these shifts in childbearing and
family formation, the postwar generation is excep-
tionally large. By 1980, there will be an estimated
15.7 million women in the United States between
the ages of 30 and 39.85 This group of women pos-
sesses a number of unique social characteristics:

* Since 1970 the percentage of single men and
women among those aged 25-29 has increased,
indicating not only that later marriage has
gained general acceptance, but also that high
proportions of adults may never marry.86 De-
mographers estimate that 7-9 percent of all
adults now in their late 20s will never marry."7
* In 1960 there were 35 divorced persons per
thousand married persons. By 1976, this figure
had more than doubled to 75 per thousand.
Moreover, the increase in the divorce rate rose
more between 1970 and 1976 than between
1960 and 1970.88 Four out of every ten first
marriages now end in divorce.
* Between 1970 and 1976 the number of house-
holds with males 25-44 living with women to
whom they were unrelated doubled.89
* Families headed by women who have no hus-
band present represent a growing proportion
of all families. Many more women are passing
through this increasingly common life-cycle
stage than in the past.90

Given the personal uncertainties that these changes
imply and the increasing need for flexibility in
partnership, marriage, and childbearing, irreversi-
ble methods of birth control are not an option for a
growing number of women over age 30. A great
many of these women have selected the oral con-
traceptive as their technique, and they now face a
serious dilemma: the risks of adverse health effects

Current trends in
divorce, later
marriage, and
later childbearing
make irreversible
contraceptives or
those with potential
adverse effects on
fertility unacceptable
to many women.

of the pill for women over 30 are significant. Worse
still, these risks increase with age, and the longer a
woman over 30 remains on the pill, the higher her
risk of experiencing a serious health problem.
These risks are particularly large for women over
30 who smoke, as about half of all oral contracep-
tive users do.91 In view of these risks, the US Food
and Drug Administration has recently stipulated
that women receive a written warning each time
they purchase oral contraceptives. The following
statements are excerpted directly from the insert
that the FDA now requires be included in every
package of oral contraceptives:92

* "Blood clots are the most common of the serious
side effects of oral contraceptives .... For
women aged 20 to 44, it is estimated that about
1 in 2,000 using oral contraceptives each year
will be hospitalized because of abnormal clot-
ting. The risk increases with age."
* "The risk of having a heart attack increases with
age and is also increased by such heart attack
risk factors as high blood pressure, high choles-
terol, obesity, diabetes, and cigarette smoking."
* "Studies have found that when certain animals
are given estrogen, cancers may develop. These
findings suggest that oral contraceptives may
cause cancer in humans."
* "Women who use oral contraceptives have a
greater risk than nonusers of having gall blad-
der disease requiring surgery."
* "Although it is your decision, since many risks
increase with age, birth control pills are not rec-
ommended for women past the age of 40."

Confronted with this information each time they
open a package of oral contraceptives, women over
30 will inevitably experience anxiety about their

use of this method. Among these women are a
large number who have used the pill for many
years. Some of these were among the initial users
of this method when it was introduced in the
1960s, and, as a group, they have experienced the
earliest and longest exposure to these hormones.
Anxiety among these long-term users will be espe-
cially high, since many are aware that sometime
between 1980 and 1990 sufficient time will have
elapsed to determine whether their use of oral con-
traceptives has increased their risk of breast cancer
or other cancers. In the meantime, these women
must live with the uncertainty that their long-term
use of oral contraceptives could be carcinogenic, an
action that biologically may take between 10 and 25
years to become manifest.93

In response, many of these women over 30 are now
switching from the pill to alternative methods of
contraception, a trend that is likely to increase as
the impact of the new package inserts begins to
take effect. In the past five years, much of this
switching has been to sterilization: in 1975 roughly
half of all married women over age 30 who had
completed their childbearing were relying on sur-
gical sterilization (of either the husband or the
wife) to avoid further pregnancies.94

But, as noted above, for increasing numbers of
these women, sterilization is not an acceptable al-
ternative. Many such women are reevaluating bar-
rier contraceptives. The safety of these methods,
the availability of abortion backup for any contra-
ceptive failures, and, for older couples whose sex-
ual activity may be decreasing, the suitability of
barrier methods for occasional or intermittent use
are attractive features.

Another reason for predicting an appreciable shift
toward barrier contraceptives by women over 30
during the next decade has to do with the very

Confronted with
mandatory warnings
about the risks of
using the pill, many
women over 30 are
likely to reconsider
barrier methods.

large increase in the numbers of such women that
will occur during this period, and with some of the
social characteristics of these women. Between now
and 1990, the number of women aged 30-39 will
grow by about 5 million to a total of nearly 20 mil-
lion, as women born in the postwar baby boom pass
into their 30s.95 The attitudes of this group of
young women-sometimes called the "revolution-
ary class of 1968"-have been shaking habit and
custom ever since they began to enter college in the
mid-1960s. The oldest members of this group, now
in their early 30s, were at the forefront of changing
sexual attitudes and practices, and many of them
came of age sexually as adolescents and young
adults just as the oral contraceptive (in a much
higher dosage than its current form) was being
made widely available. Their numbers, their
values, and their prior long-term use of hormonal
methods are likely to lead to a substantial shift to
barrier methods among this age group during the
first half of the 1980s.

Mr.en Who Want Women alone bear the health risks of conception-
to Share Riseks that is, the risks of pregnancy and childbirth. To
some extent, however, the health risks of contra-
ception can be shared between men and women.
This can be done in the following ways:

The man can accept all of the health risks of
contraception by having a vasectomy.
The man can free the woman from health risks
associated with contraception by using the con-
The man can support, assist, and encourage his
partner in the use of spermicides or the dia-
phragm, which may entail drawbacks and in-

conveniences for the man in comparison with
use of the pill or IUD, but which will reduce the
woman's contraceptive health risks.
Couples who wish to share risks can also alter-
nate the method they use. For example, the
man may use a condom for a period, after
which the woman could use the diaphragm.

Many American men appear to be highly motiva-
ted to share risks but are not ready to have a vasec-
tomy and are not disposed to use the condom. Al-
though advances in condom sensitivity have been
made over the last ten years, they are still unsatis-
factory to some men. How does such a man share
in the risks of contraception with his partner? Alan
Guttmacher recounted that he once asked a
woman to describe how she inserted a diaphragm
so that he could describe this to his patients. She
responded that in fact it was her husband who reg-
ularly inserted the diaphragm for her. As this anec-
dote illustrates, a fundamental way for the man to
share contraceptive responsibilities with his part-
ner is to be appreciative and supportive of the re-
sponsibility and demands the woman carries. Espe-
cially for the diaphragm and spermicides, this
includes a full understanding by the man of how
the method must be used to be effective, along with
his full adaptation to and acceptance of this in the
sex life he shares with the woman. As we stressed in
Part 2, a couple's motivation and ability to integrate
the coitus-related requirements of barrier methods
into their sexual activity is crucial to their accep-
tance and effective use of this type of contracep-
tive. Consequently, a man's emotional support and
participation in the use of female-controlled bar-
rier contraceptives is essential if his partner is to be
able to use these methods continuously and effec-
tively, and thus to gain freedom from the health
risks associated with other methods of contracep-

A man can encourage,
assist, and support his
partner in the use of
spermicides or the
diaphragm, thus reducing
her contraceptive
health risks.

Men wishing to minimize
women's risks and to
expand their own
options should press
public officials to
expand funding for
contraceptive research.

There are strong indications that men do wish to
share in the responsibilities and risks of contracep-
tion. In 1976, among all couples practicing contra-
ception, one-quarter employed vasectomy or the
condom.96 Older men involved in partnership with
older women are more likely to use the condom
than any other group, as reported by national sur-
veys and organized family planning services.97
Among married couples over age 35, 24 percent of
those using reversible contraception employ the
condom.98 Couples having a relationship of some
duration and depth are generally better able to
communicate about sex and contraception and
have more experience in sharing responsibilities in
other parts of their lives than young people just
beginning their sex lives. Younger couples who
wish to conceive together some time in the future
are often especially motivated to safeguard their
fertility, and they may select the condom particu-
larly for this reason. In fact condom use is increas-
ing among young black couples in the United
States, and its use has remained constant over the
past five years among young, unmarried, middle-
class white couples.99
But in spite of these trends, more direct sharing of
contraceptive responsibility by men on a large scale
will probably await the development of new, safe,
and acceptable male methods, such as male-applied
spermicides, more sensitive condoms, reversible
vasectomy, and, perhaps, male oral contraceptives.
A male oral contraceptive is now being tested, but
this hormone-based method unfortunately appears
to have some side effects and troubling unknowns
that may limit its eventual acceptability.100 Re-
search on male methods has lagged far behind
female methods, in part because scientists have de-
veloped a fuller understanding of the female re-
productive system and therefore are aware of a
greater number of points for intervention in that

system. The original emphasis by scientists on un-
derstanding female anatomy and on systemic inter-
vention in the female reproductive system reflects a
deeply held and continuing bias that reproduction
and all related tasks are "women's work." So in-
grained is this bias that the analysis of risks and
benefits of oral contraceptives conventionally cen-
ters solely on the woman, emphasizing the risk of
childbearing.'01 No attempt has yet been made to
take into account the fact that whereas the health
risks of childbearing are unavoidably sex-specific,
the health risks of contraception can be assumed by
either partner.
Men wishing to minimize women's risks and ex-
pand their own options thus have a very important
political and public way of sharing. They can be
more vocal with their elected officials, with the
health professions, and with the pharmaceutical in-
dustry about the need for more contraceptive re-
search on male methods and improved barrier
methods for both males and females.

There are about 200 women's health collectives in
the United States, serving approximately 10,000
women.102 The women organizing and receiving
these services have been dissatisfied with the es-
tablished health care system, which they consider
economically predatory and, more importantly, the
source of inferior medicine. The publication of
Our Bodies, Ourselves in 1971 heralded a new activ-
ist approach by women to their bodies and their
health.103 This book, authored by the Boston
Women's Health Book Collective, has sold over 2
million copies and has been translated into 13 lan-
guages. Its central ideas, which have helped to fuel
the growing alternative-care movement, have been

Vlomen VVIJho Scott
Sefl-Care alnd
n Feminist Appronch
to 1-lea, Ith Care

Women's health
collectives emphasize
barrier methods and
rhythm techniques
because these methods
are safe, voluntary,
and self-administered.

the emphasis on self-care, learning more about
one's body, communicating with other women
about health problems and their solutions, and
looking beyond and challenging professional ad-
vice that perpetuates negative or false concepts
about women and their bodies. One curious re-
sponse to this indigenous health care movement is
that of some family planning and health care pro-
fessionals who recognize the benefits of traditional
healing and health systems in developing countries
but exhibit far less certainty about these benefits
when offered on their own doorsteps. In several
instances professional associations have pressured
women's health care centers almost out of opera-
tion by challenging their licensing or discouraging
doctors from working with them.104 The history of
these alternative-care systems and the profes-
sional responses to them deserves more detail than
can be given here. The central fact is simply that
these new providers of information and service are
filling a deeply felt and growing need for women's
health care not now available from conventional
In many ways, these services are the contemporary
equivalent of the first "birth control" clinics or-
ganized by women 40 years ago. The marvelous
paradox is that both movements began by empha-
sizing the same technology-the diaphragm and
other types of barrier and so-called natural
methods-which were more generally understood
and of greater variety 40 years ago. The women's
health collectives emphasize barrier and natural
methods because they are safe, entirely voluntary,
and self-administered techniques. These collectives
are developing new and redeveloping old nonhor-
monal contraceptive methods. Among the old
"new" methods are the cervical cap and the contra-
ceptive sponge. Testing the cervical mucus as an
indication of ovulation is also receiving renewed
popularity as a means of contraception.105

Use of modern contraceptives does not necessarily
increase a woman's knowledge of her body. In con-
trast, barrier contraceptives and methods that rely
on observation of bodily changes give women an
active role in health and contraception that an in-
creasing number consider desirable. This suggests
that the ideal contraceptive is not necessarily one
that requires minimal participation. The contra-
ceptive implant, various types of contraceptive
injections, and the IUD-all of which rely on pro-
fessional administration and removal (with the ex-
ception of the injection, which cannot be "re-
moved" once it has been administered)-are not
advances when viewed in the light of the contem-
porary women's health movement. Self-care is seen
as more liberating and reliable.
Women's health care groups emphasize full educa-
tion of the prospective user. Group sessions are
held frequently so that women may share informa-
tion; many of the groups report that women al-
ready have a great deal of evidence and theory
about the interaction of different types of contra-
ceptives with their bodies (often passed from
woman to woman or mother to daughter). Women
in the past generally have not shared their
thoughts outside very tightly knit groups of friends,
largely because they have been made to believe that
these views and observations are inferior to profes-
sional advice and information. In addition to pro-
viding the published scientific information that is
available about the risks and benefits of different
methods, women's health care groups encourage
bodily and fertility awareness. Each woman is en-
couraged to examine herself, locate and see her
cervix, and note the.physical changes that identify
the onset of ovulation. Many alternative-care
groups do not recommend a particular method of
contraception. Most provide all legal methods, in-
cluding oral contraceptives under prescription and
insertion of IUDs for women who want them.

The concepts advanced
by women's health care
groups are likely to
increase demands for
more sensitive
treatment from health
professionals and
for a more active
management by women
of their own fertility.

The women's groups document and publish their
work in a number of ways. Our Bodies, Ourselves has
been revised and continues to serve as a key re-
source. A number of providers publish newsletters,
such as Health Right (New York City), WomenWise
(New Hampshire), and the Tallahassee Examiner
(Florida). Networks of women concerned with
health issues put out such publications as the Na-
tional Women's Health Network News and Women's
Health Roundtable (both in Washington, D.C.), and
an international bulletin called ISIS has devoted
two issues to women's health care. In addition,
most women-run health services have developed
excellent educational materials for their members
and those who use their services.
One area in which this movement could be particu-
larly valuable is health care instruction. With in-
creased financial support, these groups could doc-
ument for wider dissemination their observations
and findings on women's health issues, including
their approaches to educating women about their
bodies. Perhaps ways could be developed in the
next few years to allow the systems and informa-
tion developed by women's health collectives to be
shared with those out of their direct reach. For
example, the bulletins of health professionals could
carry reprints of their articles. Medical schools and
other training facilities for health professionals
could incorporate materials from the self-care
movement into their textbooks and manuals.
With or without additional support and attention
from established professionals and providers, it is
likely that the concepts on which these women's
health care groups are based will attract a growing
number of women concerned with understanding
their bodies and actively managing their fertility.
The concepts advanced by women's health care
groups often strike very responsive chords in

women outside the network, and they are likely to
be an important stimulant during the coming dec-
ade in increasing demands for more knowledge-
able and sensitive treatment from health profes-
sionals, for emphasizing the prevention of disease
in "well women" rather than curing sick women,
and for a wider use of barrier contraceptives.

Using Science
and Technology
To Improve

If the concept of barrier contraception is a modern
one, the available techniques unfortunately are
not. For the most part, they are the products of
decades-old research and development that have
been handed down with only minor changes
through several generations of consumers. Barrier
methods have not benefited from the kind of
broad-scale application of modern science and
technology that other types of contraceptives have
received during the last several decades, and many
of the drawbacks of existing techniques reflect an
unnecessary obsolescence that could be overcome
through the application of sophisticated pharma-
ceutical research efforts.

Barrier Methods
Cnn Be

Diaphragms, for example, need to be fitted by a
physician, a drawback that could be overcome
through the design of "one-size-fits-all" devices.
Use of the diaphragm requires obtrusive para-
phernalia-a large, fragile plastic box for storage
and toothpaste-size tubes of spermicide-draw-
backs that it should be possible to change. Another
major drawback is the requirement that the dia-
phragm be used along with a spermicidal jelly or
cream. The existing jellies and creams are widely
felt to be aesthetically objectionable, and they are
not fully effective. Also, they have the serious in-
conveniences of needing to be left in the vagina
(with the diaphragm in place) for six hours after
coitus, to be applied only a short time before coitus,
and to be replenished before each subsequent ejac-
ulation during coitus.
A number of approaches could be explored for
eliminating these drawbacks. The simplest would
be to test whether a spermicidal jelly or cream is
required for full effectiveness of the diaphragm.

On the basis of experience with their own clients,
some physicians believe that the diaphragm is just
as effective when used alone as when it is used with
jelly or cream, but this proposition has never been
scientifically tested.106 If some type of spermici-
dal agent is in fact required, it might be possible to
develop a spermicide-impregnated diaphragm.
Another solution might be a universal-size dia-
phragm with a thick, compressible rim that would
adhere firmly to the sides of the vagina during
coitus, thus totally blocking the passage of sperm
and eliminating the need for spermicides. Also,
spermicides themselves could be improved, as dis-
cussed in more detail below.

In general, such improvements would appear to be
well within the technical competency of modern
pharmaceutical research-if sufficient research
monies were invested. With such effort, diaphragm-
like barriers could be developed that could be more
easily fitted, carried, stored, and inserted by
women under a variety of conditions and circum-

Condoms, especially, have suffered from the ne-
glect of pharmaceutical research efforts. As a con-
traceptive technique, the condom has one princi-
pal, perhaps even sole drawback: by reducing
tactile sensations, it detracts from the sexual enjoy-
ment of the man (and sometimes the woman) dur-
ing coitus. If this drawback could be overcome, the
method would undoubtedly gain a much wider ac-
ceptance, since it offers virtually perfect protection
against pregnancy, significant protection against
venereal disease, and convenience and ease of use.
For women, the condom offers tangible, visible
protection against both pregnancy and venereal dis-
ease with no accompanying risk of health, along
with the advantage that the method is employed by
the man.

Many of the drawbacks
of existing barrier
contraceptives reflect
an unnecessary
obsolescence that could
be overcome through
the application
of sophisticated
pharmaceutical research.

To improve condoms, a
tough, elastic membrane
capable of transmitting
heat and tactile
stimulation is needed.

To overcome the basic problem of a deadening of
physical sensation, what is needed is the develop-
ment of a tough, elastic membrane capable of
transmitting heat and tactile stimulation and physi-
cally and economically suitable for manufacturing
into condoms. Some very limited research toward
this objective has been carried out using new types
of materials that absorb moisture within their phys-
ical structure, thus allowing increased transmission
of heat.107 With adequate investments in basic ma-
terials research and development, radically new
types of condoms that would transmit sensation to
a far greater degree could probably be developed.
Spermicides have benefited from greater product
development activity than either condoms or dia-
phragms over the past two decades, but they have
important limitations. The greatest drawback is
their imperfect effectiveness as contraceptives.
Notwithstanding some limited research efforts to
develop more potent spermicidal chemicals and
carrier substances that effectively spread the
spermicide throughout the vagina so that it can
come into contact with sperm, users of current
products must accept a small but real risk that they
will become pregnant-even if they faithfully use
the products as instructed. Other limitations are
the messiness and smell of most spermicidal prod-
ucts, the physical difficulty of placing them in the
vagina, the requirement that they be placed shortly
before coitus, the need to replenish the application
of the spermicide after each coitus, and the need to
avoid washing or douching for at least six hours
after coitus. The excessive lubrication and the leak-
age of fluids from the vagina that accompany the
use of most spermicides are distasteful to many
users and often detract from sexual pleasure.
Itching, irritation, and the local sensation of heat
have been encountered with some formulations of
spermicides. A number of practical problems asso-

ciated with the packaging and informational com-
ponents of spermicides also need attention. For ex-
ample, many products on the market today employ
cumbersome vaginal inserters. Most are available
only in bulky containers too large for easy carrying.
The instructions for use of these over-the-counter
products are often vague and confusing and some-
times misleading.
All of these problems are susceptible to applied
research, some of it very simple and direct, some of
it highly complex and costly. Aside from straight-
forward improvements in packaging and labeling,
perhaps the greatest need is for more research
to develop better carrier substances for the
spermicides-that is, the jellies, creams, or foams
that are used to disperse the spermicidal chemical
within the vagina. These chemical vehicles need to
be improved so that they cover the cervical os more
thoroughly and uniformly, stay in place during
coitus, and remain in place for longer periods.
More potent spermicidal chemical agents also
might help to improve effectiveness, although the
potency of present agents would be sufficient if
they were dispersed adequately by the carrier sub-
stances. Using modern know-how in plastics and
other synthetics, it might even be possible to de-
velop a totally physical barrier to sperm that would
be applied in the form of a paste or cream to the
opening of the cervix at the rear of the vagina.
When first applied, the substance would have to
adhere to local tissues, thus effectively sealing off
the entrance to the uterus. Shortly after applica-
tion, it would have to rapidly lose its capacity to
adhere, except where bonding to the local tissues
has already occurred, and it would need to be elas-
tic, so that it would stretch during coitus. It would
also need to be either biodegradable or in some
other way unstable, so that it would dissolve and
be released from the local tissues after the sperm

Applied research on
plastics and other
synthetic materials
offers great promise
for the development of
new, highly superior
forms of barrier

Research and
development work is
needed to adapt barrier
contraceptives to the
special needs and
conditions of
developing countries.

Technologically, it
seems feasible to
incorporate highly
effective bactericidal
agents into spermicides
so that they can
protect users against
venereal disease.

had been inactivated or removed. Various synthetic
materials individually possess some of these pro-
perties, and they could be taken as the starting
point for such research. The main point is that, as
for condoms, sufficiently intensive applied mate-
rials research offers considerable promise for the
development of new, superior types of spermicidal
Another needed improvement is the adaptation of
all types of barrier contraceptives to the special
needs and conditions that prevail in developing
countries. Couples in these countries often live un-
der conditions where piped water and electricity
are not available and where coitus takes place ei-
ther surreptitiously at night in.a room crowded with
sleeping children and in-laws or during the day-
time in isolated spots outdoors. Under such condi-
tions, spermicides are needed that can be used
quickly, unobtrusively, and without the need for
running water. Most developing countries are loca-
ted in tropical zones, and present spermicides of-
ten melt or spoil at high temperatures. The high
humidity that often prevails in these countries
causes problems for foaming vaginal tablets, which
lose their capacity to effervesce when exposed to
moisture.108 With proper pharmaceutical formula-
tion work, more stable products could be devel-

A final area for improvement of barrier contracep-
tives particularly stands out because of its impor-
tance for public health. This is the need to enhance
the prophylactic properties of barrier contracep-
tives against venereal disease. Technologically, it
seems feasible to incorporate highly effective bac-
tericidal agents into spermicides in a manner that
would provide virtually complete protection
against the organisms that are responsible for caus-
ing most genitally transmitted venereal diseases.
New antibacterial agents may be needed for this

purpose, as well as new chemical substances that
can serve as vehicles to disperse both the bacteri-
cide and the spermicide. Basic laboratory research
and applied behavioral studies are likely to be
needed, along with costly and very complex epide-
miological investigations to ascertain the actual
efficacy of any new agents that are developed and
the behavioral conditions required for such effec-
tiveness. Although an adequate research program
to meet these needs would undoubtedly be sophis-
ticated and costly, successful efforts would achieve
major social benefits.

This brief outline demonstrates some of the ways Status
in which modern science and technology can be of Current
applied to improve barrier contraceptives. To what oReSarch
extent are such efforts being undertaken? or
Until very recently, the answer was to almost no
extent. The current latex condom was developed
in the early 1930s, the latex diaphragm at about the
same time. Few improvements have been made in
these products since then. Apart from ongoing re-
search by condom manufacturers to modernize
production processes for condoms and to develop
the thinnest latex membranes that can be used to
manufacture devices that will not rupture, little has
been done to create new types of condoms that
would provide greater tactile sensitivity for users.
After a brief, unsuccessful period of experimenta-
tion with various types of plastic condoms in the
early 1970s, condom manufacturers focused their
development efforts mainly on cosmetic changes-
such as variations in color and shape-that would
enhance the product's appeal to users without
changing its basic characteristics. Spermicides have
received somewhat more attention from pharma-
ceutical company research and development labs.

In view of the low cost
of much of the research
needed to improve
barrier methods and
the many possibilities
that have been
identified, it is hard
to understand the near
absence of work in
this area.

But while there has been some improvement in
their effectiveness, on the whole the basic tech-
nique has changed little in its convenience and ease
of use since spermicides were first widely marketed
in the 1940s and 1950s. The one exception is the
introduction of pressurized spermicidal foam in
the early 1960s, which brought the advantages of
increased product shelf-life, better distribution of
spermicide within the vagina, and immediate effec-
tiveness following application.

Yet, during these same decades, well over $100 mil-
lion was spent to develop and introduce new types
of oral contraceptives and intrauterine devices. As
a result of this large effort, around 70 different
types of oral contraceptive products and nearly 20
different types of IUDs are now being sold world-
wide (under some 250 brand names), while only
five basic types of condoms, three types of dia-
phragms, and roughly 20 different spermicidal
products are available.109 The reasons for this dis-
parity are complex, but the outcome is clear: the
development of improved techniques for barrier
contraception has lagged behind the development
of other new forms.

To complement private-sector efforts and to meet
the special needs of couples in developing coun-
tries for better contraceptives, public agencies in
the early 1970s decided to establish a number of
publicly funded and operated contraceptive pro-
grams. Currently these programs are operated by
the World Health Organization, the National Insti-
tute for Child Health and Human Development of
the Department of Health, Education, and Wel-
fare, the Population Council, the International
Fertility Research Program, the Program for Ap-
plied Research on Fertility Regulation, and the
Program for the Introduction and Adaptation of
Contraceptive Technology.110 Unfortunately, the
extent of research on barrier contraceptives by

these public-sector programs has been minimal.
According to questionnaires completed by these
groups and the principal agencies that fund them,
expenditures on all types of barrier contraceptive
research totaled only $50,000 in 1976 and
$143,000 in 1977, out of total applied contracep-
tive testing and development expenditures of
$30.2 million and $33.7 million for these years, re-
In view of the comparatively low cost of much of
the research needed to improve barrier methods
and the numerous avenues for improvement that
have been identified, the near absence of work in
this area by both private- and public-sector organi-
zations is difficult to understand.
In the past year there have been some encouraging
signs that this situation may be changing, at least
with respect to private pharmaceutical company
research. Scientists working in pharmaceutical
companies are reporting a dramatic upsurge in re-
search and development work on barrier contra-
ceptive products. For example, at least one large
pharmaceutical company is conducting research to
improve the diaphragm and to introduce a new
spermicide product in the United States. Another
large company with extensive experience in pack-
aging and marketing toiletries is considering ap-
plying its know-how and marketing research
techniques to improving the ease of use and accept-
ability of spermicides.
Although there is no way of estimating the extent
of commitment by private companies, the nature of
the work reported suggests that it is focused pri-
marily on developing improved versions of present
barrier methods. At least some of the work entails
the use of commercial marketing research tech-
niques to identify consumer preferences and ac-
ceptance and to study behavioral aspects of the im-
proved methods.

In the past year,
there has been an
upsurge in barrier
method research by
companies. Most of
this is being aimed
at highly applied
objectives, but
basic, long-term
research is still
being neglected.

Within the last year or two there has also been a
small increase in research on barrier contraceptives
by public-sector contraceptive development pro-
grams. These programs have focused on such ap-
plied research approaches as the development of
spermicide-impregnated contraceptive sponges,
heat-stable vaginal suppositories for use in the
tropics, intracervical devices, spermicide-releasing
vaginal rings made of synthetic rubber, and flexi-
ble, dissolvable films placed in the vagina or over
the penis.112 Work on these ideas is going forward
very slowly because of the limited resources being
made available.

flesearch Nleeds

Unfortunately, most of the new activity in barrier
contraceptive research appears to be limited to ap-
proaches aimed at short-term payoffs, usually
through improvements in existing products. It is
important to recognize that none of these types of
research is likely to result in fundamentally new
techniques. The technological drawbacks of exist-
ing barrier products place inherent restrictions on
the extent to which they can be improved. For truly
innovative and superior barrier contraceptives to
be developed, there is a need for more basic re-
search on the biological and medical aspects of bar-
rier contraception, as well as in the area of mate-
rials technology. Pharmaceutical companies appear
to be unwilling or unable to invest the large sums of
research monies and the corresponding long-term
commitment of research personnel to carry out the
kind of basic research that would be needed to de-
velop radically new types of barrier contraceptives.
Nor is the public sector filling this need, despite the
fact that it constitutes by far the greatest source of

support for such basic research in the world to-

Nor is most of the new activity being accompanied
by a thorough program of behavioral research to
determine the acceptability of these approaches
and to incorporate users' preferences and needs
into the design of the methods. Barrier contracep-
tives, by their very nature, are directly linked to
sexual behavior, and many of the drawbacks of bar-
rier methods result from unwanted interference in
the sexual practices of the user. Consequently,
many, perhaps even most of the ideas for improve-
ments in these contraceptives deal specifically with
the manner in which they influence (or are
influenced by) sexual behavior. In order to design
and test such "behavioral improvements," some
type of applied social science research must be used
in conjunction with the biomedical and technologi-
cal research. Public-sector contraceptive develop-
ment programs are conducting some very limited
social science research in this area, most of it aca-
demic in nature.114 The pharmaceutical industry is
employing marketing research during some of the
later stages of product development and presenta-

But for the most part, biomedically trained profes-
sionals guide the contraceptive development work
in both the public and private sectors. As a rule,
they are not well equipped to intimately involve the
necessary behavioral research elements in all
phases of the development effort. There is a pres-
sing need to bring into this research flexible and
creative user-oriented approaches-such as the
group-session marketing research techniques used
by private industry-if the early phases of clinical
research and field evaluations are to result in use-
ful new barrier contraceptive products.

Many of the needed
improvements in barrier
contraceptives concern
the manner in which
these methods influence,
or are influenced by,
sexual behavior.

Real improvements in
barrier methods will
depend upon consumer
participation in
determining research
priorities and in the
research process

Consumer The almost total lack of interest in barrier methods
Participation by professional contraceptive developers during
in Future the past decade and the strong behavioral compo-
nents of these methods suggest that significant im-
provements are likely to depend on some form of
consumer participation in determining research
priorities and in the research process itself.

Various types of participation are possible-
through formal social science research, through
marketing research techniques, through the lobby-
ing activities of organized consumer groups-and
all can play a constructive role. One relatively un-
tried approach deserves special mention. The
women's health care collectives described in Part 4
could constitute an important resource for clinical
investigations on nonhormonal methods of contra-
ception, as well as on the sources and cures of va-
ginal infection. The investigations conducted by
these groups operate on very different principles
from those of conventional clinical research. In a
conventional research design, the population of
women or men using health services (often a public
clinic) are asked to give their informed consent to
participate in tests of effectiveness and safety of
various-sometimes experimental-contraceptive
methods. These experimental users are monitored
through interviews and examinations. Their rela-
tionship to the study ideally excludes contact with
other participants, while maintaining a highly
structured, formalized contact with the profes-
sionals conducting the study. Individuals participa-
ting in this type of research are contributing to the
"knowledge base of medical science," which is
objectified and is generally at some distance from
their personal goals.115
Women-run research begins with the purpose of
helping the participants find out more about their
bodies and health. Work and investigation on the
ovulation method of contraception illustrates how

their "research" operates. Women in health care
collectives begin by monitoring their own cervical
mucus, taking their temperatures, and keeping re-
cords of both objective and subjective information.
With personal experience gained, a study group is
organized of 10 to 30 women, who conduct the
same rigorous monitoring on themselves. This
group meets every week over several months. In
the first month all members of the group abstain
from intercourse and contraception in order to be
able to monitor bodily changes, which are often
masked by use of contraceptives. Once the women
have developed greater sensitivity to their monthly
"rhythm," some begin to use different types of con-
traceptives as "insurance" while they continue to
educate themselves about bodily changes.

Exchange of information among members of the
study group is a basic principle of this research, in
marked contrast to conventional research. In the
latter, great care is often taken to ensure that study
subjects are not told what the investigators are
looking for, lest suggestible subjects experience
psychologically induced side effects. Women-run
research encourages exchange in an environment
in which there is no obvious investment in either
identifying or denying responses and observations.
While personal subjectivity clearly influences the
outcomes of such research, this is a strong advan-
tage as well as a potential drawback of such an ap-
proach. These efforts often provide more rapid
collection of information because women are
highly motivated to contribute and develop useful
information for other women.
These groups could contribute to the development
of better contraceptives through first-hand, small-
scale investigations to test new ideas. With ap-
propriate technical as well as financial assistance
from professional contraceptive developers, these
groups might become a constructive new resource

Women's health care
groups could contribute
to developing better
barrier contraceptives
by participating in the
testing of new ideas.

for the development efforts being undertaken by
public agencies and the pharmaceutical industry.
Women's groups would clearly welcome legitimiza-
tion and support. For example, the National
Women's Health Network, an organization of
women's health collectives, health consumers, and
health workers, has begun to ask for recognition of
the important role women, both lay and profes-
sional, can play in contraceptive and other health
research. Testimony on behalf of the Network in
the 1978 hearings of the House Select Committee
on Population requested that women's health
groups be given funds to support their research on
contraceptive methods and informational mate-

Barrier Methods
in Developing

Most of the hundreds of
millions of dollars
spent each year to
provide contraceptives
to developing countries
has been devoted to
providing orals, IUDs,
and sterilization.

In a recent study carried out by the World Fertility
Survey in India, Panama, and Turkey,"1 over 800
randomly sampled married women who had some
knowledge of contraceptive methods were inter-
viewed to learn which contraceptives they used.
Twenty-four of the women reported their hus-
bands were currently using condoms. Only eight,
all living in urban areas, had ever used a dia-
phragm, but none was using the method at the
time of the study. The study did not inquire about
spermicide use. By way of comparison with these
figures, however, the study found that 316 of the
group were either sterilized (husband or wife) or
were currently using the pill or the IUD.
This profile of contraceptive use is typical for the
majority of developing countries. It illustrates the
minor role played by condoms and the negligible
role played by the diaphragm and spermicides in
most of these countries. For the most part, modern
barrier methods have been given very little empha-
sis by health and family planning personnel. Most
of the hundreds of millions of dollars spent each
year to provide contraceptives to people in devel-
oping countries has been devoted to supplying oral
contraceptives, IUDs, and sterilization.'18 Con-
doms, spermicides, and diaphragms are imported
into many developing countries and, in some cases,
are manufactured locally. The availability of dia-
phragms, for example, is illustrated by Table 4.
However, these methods-the diaphragm and
spermicides in particular-are not readily available
except to members of elite social groups, who ob-
tain them through private physicians or purchase
them from a very restricted number of outlets loca-
ted in well-to-do urban areas.
What accounts for this apparent lack of popularity
of barrier contraceptives in developing countries?
Is the emerging new demand for and use of barrier

Table 4
Commercial Availability
of Diaphragms
in Developing Countries
Brand of Diaphragm Countries Where Available
Durex India, Lebanon, Sri Lanka
'loromex Afghanistan, Argentina, Bangladesh, Barbados, Bolivia, Chile,
Colombia, Egypt, El Salvador, Ghana, Guatemala, Honduras,
Hong Kong, Iran, Iraq, Jamaica, Jordan, Kenya, Lebanon, Liberia,
Malaysia, Mauritius, Mexico, Nicaragua, Nigeria, Panama, Paraguay,
Peru, Philippines, Puerto Rico, Sierra Leone, Sri Lanka, Surinam,
Tanzania, Trinidad and Tobago, Uganda, Uruguay, Venezuela
Nahkayama Taiwan
Ortho Bahrain, Barbados, Belize, Botswana, Cyprus, Dominican Republic,
El Salvador, Ethiopia, French Polynesia, Guatemala, Guyana, Haiti,
Hong Kong, India, Iran, Iraq, Jamaica, Jordan, Kenya, Kuwait,
Lesotho, Libyan Arab Republic, Malaysia, Mauritius, Netherlands
Antilles, Nigeria, Pakistan, Panama, Philippines, Puerto Rico,
Rhodesia, Saudi Arabia, Singapore, Surinam, Taiwan, Thailand,
Trinidad and Tobago, United Arab Emirates, Venezuela, Zambia
Ortho-White Barbados, Ghana, Guyana, Mexico, Netherlands Antilles, Paraguay,
Puerto Rico, Singapore, Surinam, Trinidad and Tobago
Ramses Brazil, Chile, Hong Kong, India, Jamaica, Kenya, Liberia, Malaysia,
Mexico, Netherlands Antilles, Paraguay, St. Lucia, Tanzania, Trinidad
and Tobago, Uruguay, Venezuela
Ortho All-Flex Barbados, Dominican Republic, Guyana, Netherlands Antilles,
Puerto Rico, Trinidad and Tobago

Source: Philip Kestelman and Ronald K. Kleinman (eds.), Directory of Contraceptives
(London: International Planned Parenthood Federation, 1976).

methods strictly a developed-country phenome-
non, generated by the special social demands and
conditions that exist in these materially wealthy cul-
tures, or does it have international significance? A
brief look at condom use is instructive.

of Condoms

Although overall use of condoms in developing
countries is very low, a handful of countries have
experienced high acceptability and use of this bar-
rier method. India, for example, has undertaken a
vigorous and imaginative effort to distribute con-
doms commercially through such outlets as groce-
ries, tea shops, shops selling cigarettes and chewing
tobacco, soap and edible oil shops, and even stands
selling match boxes or battery cells.119 Sales of the
condom, called Nirodh (prevention), have in-
creased from 7 million pieces annually before the
program was initiated in 1968 to 280 million pieces
in 1976-77. Sales for 1978 were anticipated to
reach 350 million pieces. These sales have contin-
ued to increase despite sharp declines in the last
eighteen months in IUD insertions and steriliza-
tion operations. Both the IUD and the sterilization
programs met with popular dissatisfaction arising
from reports of insufficient attention to aftercare
and a sense of coercion on the part of some accep-
tors. This latter point is important because com-
mercial sales are a very good indicator of people's
voluntary acceptance of family planning. A recent
study of the Nirodh program estimated that a reg-
ular user consumes 72 Nirodh pieces a year and
that, on this basis, the program's impact on the
birth rate may exceed that of all of India's steriliza-
tions and IUD insertions combined. In India, com-
mercial sales of condoms are meeting a need and
providing a product that people are willing to
spend money for.
In Sri Lanka, a condom called "Preethi" was intro-
duced over a two-year period, beginning with a
nationwide distribution and mass media advertis-
ing campaign.120 This program included altera-
tions in the appearance of condoms to make them
more appealing: they now come in colors-blue,
red, black-and even in different textures. In
about a dozen developing countries, including In-
dia and Sri Lanka, the embarrassment associated

with condoms and their notoriety (associated with
their use in extramarital sex) have been deliber-
ately diminished through greater openness in their
advertisement, through marketing efforts aimed at
associating them with masculinity and responsibil-
ity, and through the willingness of prominent peo-
ple to identify themselves with the method. In
Thailand a well-known family planning figure goes
from village to village distributing condoms in a
carnival-like atmosphere.121 In these villages, con-
doms are called by his name, "Mechais." In all of
the countries where an open marketing approach
has been taken and sufficient time has elapsed to
evaluate the results-Bangladesh, Colombia, In-
dia, Indonesia, Jamaica, Kenya, Korea, and Thai-
land-the level of condom usage has increased

This phenomenon is particularly interesting be-
cause the increase in condom use has not appre-
ciably reduced usage levels of other available con-
traceptive methods. Rather, it has often gone hand
in hand with the increased use of other
methods.123 This is not surprising, however, in
view of the low continuation rates for oral contra-
ceptives and IUDs in most developing countries.
On the average in developing countries, out of ev-
ery 100 women who receive an IUD, 34 stop using
it within one year and another 10 during the sec-
ond year. Among every 100 pill users, 55 abandon
the method during the first year, and another 16
during the second.124 With dropout rates this high,
couples need other contraceptive options to turn
to, and if they are available and socially acceptable,
a barrier method such as the condom provides this

The experience with condoms summarized here
demonstrates their high potential acceptability in
Africa, Asia, and Latin America. In the absence of
intensive public education campaigns, a variety of

Campaigns directed at
publicly legitimizing
condoms and making them
widely available have
resulted in widespread
acceptability and use
of this method in at
least 10 developing

social taboos block this acceptance and use. While
these social barriers of course differ somewhat
from culture to culture, in many respects they are
quite similar to the taboos against condoms that
prevailed in Europe, Japan, and North America
several decades ago. In all of these regions, as well
as in the developing countries mentioned above,
campaigns directed at publicly legitimizing con-
doms and making them widely available through
commercial outlets have proven successful.125 At
least two dozen other developing countries are now
initiating such programs, and others are likely to
follow suit in years ahead. As these efforts move
forward, large increases in condom use in develop-
ing countries will occur.

of Other
Darrier Me1othods

The developing-country experience with condoms
suggests that other barrier methods might also be
well accepted if they were promoted and made
widely available. Certain inherent features of these
methods would also seem to favor their acceptabil-
ity. As with condoms, the way in which diaphragms
work is readily comprehensible and quite similar
to the indigenous barrier methods traditional
societies have been using for centuries.126 By
comparison, the mode of action of the oral contra-
ceptive is much more mysterious, even to highly
educated people.
Also, from a policy standpoint it is known that the
greater the range of contraceptive methods avail-
able in a country, the greater the use of contracep-
tion. This has been shown in several studies, most
recently in an analysis of data from 33 develop-
ing countries.127 Three factors are responsible for
this effect: (1) various subgroups in any popula-
tion hold differing preferences for contraceptive

methods; (2) a variety of methods permits dissat-
isfied users to seek out and switch to another
method; and (3) the more methods there are, the
greater the chance that couples will have access to
at least some methods. This third point is especially
important with respect to condoms and spermi-
cides, which can be made widely available without
participation by physicians, who are in extremely
short supply in many developing countries.

Finally, actual experience with spermicides in sev-
eral developing countries has demonstrated their
acceptability. In one of these countries, the
Dominican Republic, two types of spermicides-
vaginal foam and vaginal tablets-have been intro-
duced as standard methods offered countrywide
by the government-sponsored family planning
program.128 Acceptance has been high, and use of
the tablets in particular (often referred to as va-
ginal foaming suppositories) is increasing rapidly.
High acceptance has also been found in a large-
scale program in Colombia and in pilot studies in
the Philippines..29
But despite all of these indications of potential ac-
ceptability of spermicides and, possibly, of dia-
phragms in developing countries, very few family
planning programs offer these methods and use is
very low. Strong professional opposition blocks wi-
der availability and promotion in most such coun-
tries. There seems to be little doubt that many of
the reasons for this strong bias against barrier con-
traceptives are similar to those at work in the
United States (see Part 2). Some health care policy-
makers in developing countries perceive barrier
methods as outmoded, second-class technology,
and they are highly skeptical about the capacity of
impoverished and poorly educated couples to use
barrier methods reliably. They believe these
methods are inefficacious and have low appeal for
potential users. Many of these officials and health

In the few countries
where they have been
vigorously introduced
and promoted,
spermicides have
proven popular.

workers also believe that dispensing barrier
methods takes too much time and consumes too
much of their clinical resources. They often feel
that extensive promotion of these methods will de-
tract from their efforts to create efficient new
health systems utilizing the same kind of "modern"
contraceptive technologies employed in more
highly industrialized developed countries. Also,
the open discussion of sexuality is generally re-
stricted in most developing countries. Personnel at
all levels of policymaking and service delivery tend
to be more comfortable in discussing, promoting,
and providing such comparatively asexual methods
as the pill, the IUD, and sterilization, rather than
the coitus-related methods. That condoms have es-
caped some of the negative attitudes associated
with female-controlled barrier methods and have
been given more attention by family planning pro-
grams in a number of countries may reflect the fact
that male sexuality is more openly a topic of discus-
sion than female sexuality in most developing-
country cultures.

Carrier Method
in Developing

A key obstacle to wider acceptance and use of bar-
rier contraceptives in developing countries is the
belief that barrier methods, especially the female-
controlled methods, cannot be used effectively by
poor women because of their lack of motivation
and their particular lifestyles. As happens in re-
gard to adolescents in the United States, many poli-
cymakers and professionals in developing coun-
tries regard traditional women as unable to make
informed choices and to use contraceptive methods
These convictions are in part self-fulfilling. The
policymakers' prophecies of the incompetence of
poor women are confirmed by the results that oc-

cur when barrier methods are introduced with lit-
tle or no understanding of rural women's culture,
and without thorough education and follow-up.
Not surprisingly, therefore, much of the limited
data on the effectiveness of condoms, spermicides,
and the diaphragm in developing countries indi-
cates that moderate to high contraceptive failure
rates are observed. A study in India, for example,
shows that some segments of populations use the
diaphragm with moderate effectiveness.130 The In-
dia study was conducted in ten family planning
clinics in Bombay, which provided almost exclu-
sively the diaphragm with jelly to low-income
women. The women's return to the clinic was well
correlated with the extent of use and satisfaction
with the method. This return rate showed no rela-
tionship to the woman's income level, education,
mother tongue, or the availability of tap, latrine, or
bathroom facilities. This last finding suggests that
women motivated to use the diaphragm find ways
to insert it and clean it that do not require modern
sanitary facilities. Of those who maintained contact
with the clinic (generally those who lived closer to
it), the cumulative pregnancy rate was 10 percent
(excluding loss to follow-up) over a 12-month pe-
There has been some experience indicating that
high effectiveness can be achieved with barrier
contraceptives in developing countries.132 In gen-
eral, however, effective use of barrier methods by
women in developing countries can be expected
only if adequate training and psychological sup-
port are provided to new users, along the lines de-
scribed in Part 2. Until these methods have been
tested in developing countries under conditions in
which thorough, supportive instruction, informa-
tion, and counseling have been given to new users
by appropriately trained service providers, their ef-
fectiveness in these settings must remain a matter
of debate and conjecture.

Until barrier methods
have been tested under
conditions of thorough,
supportive instruction
and counseling, their
effectiveness in
developing countries
will remain unknown.

Darrior rMothod
in Developing

Barrier contraceptives
offer the greatest
safety of all reversible
methods for women who
can use them with high
effectiveness and are
willing to obtain a legal
abortion for any
accidental pregnancies.

Tests of how effectively barrier methods can be
used by developing-country couples are especially
important because effectiveness of use bears di-
rectly on the health and welfare of women who
practice contraception in these settings. Maternal
deaths associated with pregnancy and childbearing
among low-income groups in developing countries
are extremely high.133 Despite these high risks,
most low-income women want several or some-
times even many children. But for those who do
not want another child or who fear the health risks
of pregnancy, ineffective contraception poses a se-
rious problem-especially since legal, high-quality
abortion is rarely available in developing countries.
A woman in this circumstance who experiences a
contraceptive failure because she is unable to use a
barrier method effectively will generally have little
choice but to obtain an illegal (often dangerous)
abortion or to bear the child, thus running the high
risk of pregnancy-related maternal mortality. For
this reason, if a woman who wants no more chil-
dren finds the pill, the IUD, or sterilization (for
herself or her spouse) acceptable, she would be tak-
ing an unreasonable health risk if she chose a bar-
rier method and used it with poor effectiveness.134
On the other hand, for a woman who can use bar-
rier methods with high effectiveness-or, if she
uses them with low effectiveness, is willing and able
to obtain a legal abortion for any accidental
pregnancies-barrier methods offer greater safety
than any other type of reversible contraceptive.
Barrier methods are also a safe alternative for cer-
tain groups of women in developing countries who
may be able to use them with only moderate effec-
tiveness and who cannot rely on abortion for con-
traceptive failures. One such group is women who
are spacing births. Such women want more chil-
dren in the future and are prepared to accept the
health risks associated with pregnancy. While only

partially effective use of barrier methods by such
women might result in childbirth earlier than they
intended, they would still achieve a substantial de-
lay between births and at the same time avoid the
side effects of other types of contraceptives during
the intervals between pregnancies.
Another such group is women who have no access
to sterilization, oral contraceptives, or the IUD or
who find these methods unacceptable and have dis-
continued their use. For such women, barrier
methods, even if used only with low effectiveness,
are far more effective than no method at all. A
family planning project in the Sialkot District of
Pakistan offered barrier methods to women on the
same terms as the IUD or the oral contraceptive.
This was done because the project staff observed
the high concern of users for health and safety and
believed that all users should be properly intro-
duced to barrier contraceptives as either a fallback
choice or, for many, the most acceptable first

Whether barrier contraceptives can be effective,
acceptable contraceptives for a large number of
couples in developing countries is unknown be-
cause these methods have been virtually untried.
The positive response by low-income couples in
several developing countries is no guarantee that
wide acceptance and effective use will occur every-
where, but it is a signal that much wider promotion
and delivery of these methods should be at-
tempted, at least on a pilot basis. Pilot studies need
to be carried out locally to find out which barrier
contraceptives and service delivery techniques
work in different settings.

Min'; Tetst
of Dnrrior

Pilot studies should
be carried out to
determine which barrier
methods and service
delivery techniques
work in various

Traditional birth
attendants could be
trained to fit the
diaphragm, as well
as provide other
barrier contraceptives.

These pilot studies should use trained and commit-
ted paramedical workers wherever possible, since
these personnel are the most readily available and,
for barrier contraceptives, probably the most effec-
tive. A great number of programs around the
world are training traditional birth attendants, or-
ganizing group meetings of rural traditional
women, and setting up "mothers' clubs" and other
local women's organizations.136 Tests of effective
use of barrier methods could be developed within
these group settings. For example, it might be
worthwhile to solicit the views of traditional birth
attendants on these methods. They would be likely
to understand how the diaphragm, condom, and
spermicides work, since these are often similar to
traditional methods. In fact, traditional birth atten-
dants may be more favorably disposed to provid-
ing barrier methods than oral contraceptives be-
cause of the tangibility of their mode of action,137
the fact that these methods add to their "equip-
ment," and the likelihood that fitting the dia-
phragm or providing instruction on the use of
other barrier methods would reinforce their per-
sonal relationship to the women being served.
Some types of traditional birth attendants could
undoubtedly be trained to fit the diaphragm, just
as paraprofessionals in the United States now do.
There is some experience from developing coun-
tries in doing this. Under the Sialkot Project of
Pakistan, lady family planning visitors (who were
matriculate level and drawn from the community)
were trained to fit diaphragms successfully.138 A
project now in the planning stage in Egypt139 may
include traditional birth attendants, along with
paramedical staff, among those whose skill in dia-
phragm fitting is developed and tested. Unlike
IUD insertion, there is no mortality risk from the
diaphragm-fitting procedure, and the familiarity
with anatomy required for diaphragm fitting is
likely to be part of the traditional birth attendant's

In conducting field studies it is important to
select communities that have a history of using tra-
ditional barrier methods and a tradition of involve-
ment of local indigenous female health workers
who are able to openly discuss sexual topics with
women. Women's comfort with their bodies varies
tremendously from society to society. In many tra-
ditional societies (e.g., in parts of West Africa),
women focus sharply on their sexual attributes and
derive a sense of power from their sexuality. In
other societies women regard their menstruation
and sexuality negatively. Women's body images
(how they regard and understand their bodies) and
their willingness to put foreign objects into their
bodies also vary from society to society. Suitable
anthropological tools are available to determine
how women perceive their bodies and to antici-
pate some of their basic responses to different
Field studies should also examine the proposition
that the mode of use of the diaphragm or spermi-
cides requires that the woman be comfortable han-
dling herself and have some privacy. While the
Bombay study cited above suggested that availabil-
ity of hygiene facilities may not influence the
diaphragm's acceptability, these are real concerns.
For some women, the visibility of barrier methods
could be a problem. Packages containing spermi-
cides or a diaphragm are often more conspicuous
than packages of oral contraceptives; thus women
may be better able to use the latter with greater
privacy. Use of a diaphragm or a spermicide is visi-
ble. The insertion and removal procedures may be
noticed in a small household, and the sexual part-
ner is often aware during coitus that the method is
being used. Most women will probably desire pri-
vacy, at least from children and in-laws. All barrier
methods also require a degree of positive commu-
nication between a woman and her sexual partner,
a requirement that will rarely be met in a number
of developing countries.

For barrier methods to
be acceptable to rural,
traditional people,
they must be available
at low cost and without

Finally, where these methods have been shown to
be acceptable to rural, traditional people, they
must be made available through local community
outlets at low cost and without embarrassment.
Condoms are being introduced into village phar-
macies; however, the spermicides used either alone
or with the diaphragm are rarely available. Cost
and packaging are also issues needing further con-
sideration in field tests. Condoms cost only several
cents each; each application of a spermicide should
be of comparably low cost. Condoms often come
individually packaged, and it has been suggested
that spermicidal tablets could be similarly packaged
in single applications.
Pilot tests of the acceptability of spermicidal tablets
in developing countries are about to be carried out
with funding from the US Agency for Interna-
tional Development, which is purchasing a supply
of 10 million vaginal foaming tablets for this pur-
pose.141 Other international agencies and govern-
mental bodies concerned with family planning
need to give similar priority to pilot studies of dif-
ferent types of barrier contraceptives. It has not
been simple to develop clinical procedures, user
education, and follow-up to maximize the accept-
ability and safety of hormonal contraceptives in de-
veloping countries, but governments and interna-
tional agencies have successfully accomplished
these steps. Such action should now be extended to
barrier methods.

for Policy
and Action

The trends and opportunities that we have iden-
tified in the foregoing sections of this paper point
to the desirability of increased use of barrier
methods in the years ahead. The past experience
and problems we have discussed point to a down-
grading of barrier contraceptives by some health
policymakers and family planning service pro-
viders and to profound neglect of these methods
by contraceptive developers in both the public and
private sectors.
This leads us in this section to a call for new policies
and action to remove existing biases and other
practical obstacles that still prevent a wider use of
barrier contraceptives in the United States and in
developing countries.

Providing The ability of all types of contraceptive providers
Supportive and counselors to introduce prospective users to
Family Planning barrier methods should be enhanced. Organized
family planning services should take steps to
eliminate biases against barrier contraceptives.

As we discussed in detail in Part 2, no other single
practical step is likely to do more to increase the
contraceptive effectiveness of barrier methods
than establishment of supportive, fully informative
counseling services for prospective users of these
A concerted effort should be made to develop spe-
cial in-service training programs for the staff of
organized health and family planning services.
These staff badly need more complete and accu-
rate information about barrier methods. They
should be encouraged to adopt a more positive atti-
tude toward these methods and to develop the ca-
pacity to discuss them fully, empathetically, and

frankly with prospective users. Their in-service
training should include an open discussion of pro-
viders' attitudes about users' sexuality and of the
relationship of barrier techniques to sexuality. It
should include training in discussion techniques
that staff can use to achieve more effective commu-
nication with prospective users. Finally, such train-
ing should include information about emerging
trends in the use of barrier methods and
identification of groups (as in Parts 3 and 4 above)
to whom they might be particularly attractive.
The development of visual aids would assist health
workers to communicate more effectively with po-
tential users. These aids should include pictorial
representations of male and female anatomy that
show how (and when) barrier methods are used.
Public agencies that now operate contraceptive ser-
vice delivery programs could test the effectiveness
and acceptability of different visual materials
through their own programs and by funding pri-
vate groups, such as the Planned Parenthood asso-
ciations. Manufacturers of barrier contraceptives
should be encouraged to apply their considerable
expertise in communications and marketing to
creating materials for use in commercial displays
and in clinics. Properly done, these could include
such basic facts about human reproduction as
when ovulation occurs and the risk of pregnancy is
the highest, as well as more specific information
about the range of available barrier methods and
what makes them effective.
If such training programs and visual aids are to be
developed, federal agencies and private, nonprofit
organizations must make substantial new funding
available. Congress, the Department of Health,
Education, and Welfare, and, for military health
services, the Department of Defense should be en-
couraged to do this. The assistance of private foun-
dations concerned with health care should be solici-

ted, as well as the support and assistance of such
professional health care associations as the Ameri-
can Medical Association, the American Public
Health Association, and the various nursing associ-
ations. Both private and public hospitals and clinics
that offer family planning services should be en-
couraged to seek funding from all these sources to
devise and implement suitable training programs.
Funds are also needed to organize local and re-
gional workshops to provide this training. Such
workshops could be held in conjunction with family
planning conferences and meetings of medical and
nursing associations. These conferences and meet-
ings already take place on a regular basis for the
purpose of discussing medical and service-delivery
concerns, and special workshops related to barrier
methods could be easily appended. The partici-
pants should include staff of federally and
privately funded family planning services, state-
supported health services, women's health collec-
tives, and private physicians.
It is also essential to incorporate scientific and ser-
vice-delivery presentations on barrier contracep-
tives directly into the programs of professional
meetings held by obstetrician-gynecologists, gen-
eral practitioners, nurses, nurse-midwives, and
other groups involved in the first line of health
care. Many of those attending such conferences
will be highly influential in spreading more objec-
tive and positive views about barrier methods
among the private health care community.
These information-dissemination efforts could be
supplemented through existing newsletters and
bulletins that reach particular constituencies, such
as professional journals for physicians, nurse-
midwifery journals, and the like. These journals
and newsletters could feature the proceedings of
conferences, document in-service experiences, and
present the findings of studies on barrier methods.

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