3.1 Methods

+ Condom

It is a sheath or covering, made to fit over a man’s erect penis before penetration and prevents semen from coming in contact with cervix and vagina. Various types of condoms are :

• natural skin condom : made from lamb intestine, rarely used nowadays. It provides better sensation, but does not protect from infection. Most viruses can cross natural membrane

• latex condoms : 0.3 - 0.8 mm thick - sperms and organisms causing STIs cannot pass through these condoms.

• poly-urethane condoms : These are odourless, have greater sensitivity and resistance to deterioration from storage and lubricants. Individuals with latex allergy can use poly-urethane condoms.

• silicon rubber condoms : thicker and less popular.

+ Female condom (vaginal pouch)

It is a poly-urethane sheath with one flexible polyurethane ring at each end. The open ring remains outside the vagina and the symphysis like a diaphragm. It has a 0.6% breakage rate. The slippage and displacement rate is about 3%
compared to 8% for male condoms. The pregnancy rate with perfect use is 5% as compared to 3% with male condom. Female condom is also available as a ‘Bikini Condom’ which covers the perineal area and has a rolled up sheath which is pushed into the vagina during intercourse..

+ Spermicides

Foaming tablets or suppositories, melting suppositories, soluble films, jellies, and creams are used as vehicles for chemical agents that inactivate sperms in the vagina. Nonoxynol-9 is the commonest chemical agent used in these preparations.

+ Diaphragm

This is a soft rubber cup that covers the cervix to act as a barrier. Efficacy increases when it is used with spermicidal jelly or cream.

+ Cervical cap

It is like the diaphragm but smaller and fits over the cervix. These caps are not widely available outside North America, Europe, Australia and New Zealand. It is less effective in parous women.

+ Sponge

It is a physical as well as a chemical barrier with a sustained release system for spermicide. The sponge absorbs semen and blocks the cervical canal. Commonest available preparation is “TODAY” containing 1 gm of nonoxynol - 9. It may cause allergic reaction in about 4% of users and vaginal dryness, soreness and itching in 8% of users. It does not cause toxic shock syndrome. It may enhance HIV transmission by damaging the vaginal mucosa.

3.2 Advantages of barrier methods

• safe, non-hormonal methods that almost every couple can use easily

• prevent some STIs and allied conditions - pelvic inflammatory disease (PID), infertility, ectopic pregnancy and possibly cervical cancer

• offer contraception just when needed

• prevent pregnancy effectively if used correctly with every act of sexual intercourse

• can be used by lactating mothers

• can be used and discontinued without seeking a health care provider

+ Additional advantages of condom

• encourages male participation in preventing pregnancy and infection

• prevents HIV/AIDS when used correctly and consistently with every act of intercourse

• can be used immediately after childbirth or abortion

+ Additional advantages of spermicide

• can be inserted as much as one hour before sex to avoid interrupting sex

• may increase vaginal lubrication

• can be used immediately after childbirth

+ Additional advantages of diaphragm or cervical cap

• diaphragm can be inserted up to 6 hours before sex to avoid interrupting sex. Cap may be inserted even earlier since it protects for up to 48 hours after insertion.

3.3 Disadvantages of barrier methods

• require a high degree of motivation for regular use

• effectiveness requires having method at hand and taking correct action before each act of sexual intercourse

• difficult to conceal from partner

• allergic reactions may occur in some couples with use of spermicides, latex condoms, diaphragms and caps

• urinary tract infections are more common with the use of diaphragm and spermicides

• accidents like slippage, breakage during coitus necessitate a `back-up’ use of emergency contraception

• careful storage is required from heat, sunlight or excessive humidity

• may embarrass some people to buy and ask partner to use these methods.

• diaphragms and cervical caps do not protect against HIV/AIDS

• diaphragm and cervical cap require pelvic examination by family planning provider to assess size and fitting which may change after childbirth.

• accidents like slippage or breakage during coitus necessitate a ‘back-up’ use of emergency contraception

3.4 Contraindications to barrier methods

• diaphragm and cervical cap should not be fitted until 6-12 weeks after childbirth or second trimester abortion. This relates to the involution time of genital tract. These women can use spermicides and/or partners can use condoms during this period.

• latex condoms, diaphragm or cap should not be used by couples with history of latex allergy

• women with history of toxic shock syndrome should not use diaphragm or cervical cap but may use spermicides.

• women with anatomical defects of genital tract may have higher failure rates with diaphragm and cervical cap.

3.5 EC as ‘back-up’ for barrier methods

The main advantage of barrier methods like condom is protection against sexually transmitted infections and HIV/AIDS. For individuals at risk of STIs, the condom use is critical. Women and men may feel more confident in relying on condoms for birth-control, if emergency contraception is available to them as a ‘back-up’.

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