South Florida Sun-Sentinel (Sunday)
Post Roe, bigger risks for birth control failures
No contraception is able to completely prevent pregnancy
Birth control options have improved over the decades. Oral contraceptives are now safer, with fewer side effects. Intrauterine devices can prevent pregnancy 99.6% of the time. But no prescription drug or medical device works flawlessly, and people’s use of contraception is inexact.
“There is no such thing as perfect use, we are all real-life users,” said Dr. Mitchell Creinin, an OB-GYN and a professor at the University of California, Davis.
Even when the odds of contraception failure are small, incidents can add up. More than 47 million women of reproductive age in the U.S. use contraception and, depending on the birth control method, hundreds of thousands of unplanned pregnancies can occur each year. With most abortions outlawed in more than a dozen states, contraceptive failures now carry bigger stakes for tens of millions of Americans.
Researchers distinguish between the perfect use of birth control, when a method is used consistently and correctly every time, and typical use, when a method is used in real-life circumstances. No birth control, short of a complete female sterilization, has a
0% failure rate.
The failure rate for typical use of birth control pills is 7%. For every million women taking pills, 70,000 unplanned pregnancies could occur in a year. According to the most recent data, more than 6.5 million women ages 15 to
49 use oral contraceptives, leading to about 460,000 unplanned pregnancies.
Even seemingly minuscule failure rates of IUDs and birth control implants can lead to surprises.
An IUD releases a hormone that thickens the mucus in the cervix. Sperm hit the wall of mucus and are unable to pass through. Implants are small plastic rods placed under the skin that send a steady, low dose of hormone into the body that also thickens the cervical mucus and prevents the ovaries from releasing an egg. But not always. The hormonal IUD and implants fail to prevent pregnancy 0.1% to 0.4% of the time.
Some 4.8 million women use IUDs or implants in the U.S., leading to as many as 5,000 to 20,000 unplanned pregnancies a year.
“We’ve had women come through here for abortions who had an IUD, and they were the one in a thousand,” said Gordon Low, a nurse practitioner at the Planned Parenthood in Little Rock, Arkansas.
Abortion has been outlawed in Arkansas since the Supreme Court’s ruling on Dobbs v. Jackson Women’s Health Organization in late June. The only exception is when a patient’s death is imminent.
Those stakes are the new backdrop for couples making decisions about which contraception to choose or calculating the chances of pregnancy.
Another complication is the belief among many that contraceptives should work all the time, every time.
“In medicine, there is never anything that is 100%,” said Dr. Regine Sitruk-Ware, a reproductive endocrinologist at the Population Council, a nonprofit research organization.
All sorts of factors interfere with contraceptive efficacy, said Sitruk-Ware. Certain medications for HIV and tuberculosis and the herbal supplement St. John’s wort can disrupt the liver’s processing of birth control pills. A medical provider might insert an IUD imprecisely into the uterus. Emergency contraception, including Plan B, is less effective in women weighing more than
165 pounds because the hormone in the medication is weight-dependent. And life is hectic. “You may have a delay in taking your next pill,” said Sitruk-Ware, or getting to the doctor to insert “your next vaginal ring.”
Using contraception consistently and correctly lessens the chance for a failure, but Alina Salganicoff, Kaiser Family Foundation’s director of women’s health policy, said that for many, access to birth control is anything but dependable. Birth control pills are needed month after month, year after year, but “the vast majority of women can only get a oneto two-month supply,” she said.
Even vasectomies can fail. During a vasectomy, the surgeon cuts the vas deferens, the tube that carries sperm to the semen. The procedure is one of the most effective methods of birth control — the failure rate is 0.15%. But even after the vas deferens is cut, cells in the body can heal, including after a vasectomy.
“If you get a cut on your finger, the skin covers it back up,” said Creinin. “Depending on how big the gap is and how the procedure is done, that tube may grow back together, and that’s one of the ways in which it fails.”
Researchers are testing reversible birth control methods for men, including a hormonal gel applied to the shoulders that suppresses sperm production. Among the 350 participants and their partners in the trial, zero pregnancies have occurred so far. It’s expected to take years for the new methods to be available to consumers. Meanwhile, vasectomies and condoms remain the only contraception for men, who are fertile for much of their lives.
At 13%, the typical-use failure rate of condoms is among the highest of birth control methods. Condoms are vital in stopping the spread of HIV and other sexually transmitted infections, but they are often misused or tear. The typical-use failure rate means that for 1 million couples using condoms, 130,000 unplanned pregnancies could occur in a year.
Navigating the failure rates of birth control medicines and medical devices is just one aspect of preventing pregnancy. Ensuring a male sexual partner uses a condom can require negotiation or persuasion skills that can be difficult to navigate, said Jennifer Evans, an assistant teaching professor and health education specialist at Northeastern University.
Historically, women have had little to no say in whether to engage in sexual intercourse and limited autonomy over their bodies, complicating sexual-negotiation skills today, said Evans.
Part of Evans’ research focuses on men who coerce women into sex without a condom. One tactic known as “stealthing” occurs when a man puts on a condom but then removes it either before or during intercourse without the other person’s knowledge or consent.
“In a lot of these stealthing cases, women don’t necessarily know the condom has been used improperly,” said Evans. “It means they can’t engage in any kind of preventative behaviors like taking a Plan B or even going and getting an abortion in a timely manner.”
Evans has found that heterosexual men who engage in stealthing often have hostile attitudes toward women. They report that sex without a condom feels better or say they do it “for the thrill of engaging in a behavior they know is not OK,” she said. Evans cautions women who suspect a sexual partner will not use a condom correctly to not have sex with that person.
“The consequences were already severe before,” said Evans, “but now that Roe v. Wade has been overturned, they’re even more right now.”