Action Durango Herald Medical Population

Include Men

How can we influence more people to use modern contraception? The answer is simple—include male partners in making family planning decisions. This ploy works in many different cultures.
Why have men been left out of family planning? In the past, planners have focused on women since only they get pregnant. The family planning movement started with Margaret Sanger over 75 years ago. For many years clinics catered to women’s needs, and only recently have they started to provide reproductive health care for men. There is another reason, too. Men make millions of sperm, but women only make one egg a month. It is easier to stop the production of a single egg than of all those sperm.
Furthermore, demographic studies of fertility usually focus on women. This is because it is easier to trace the parentage of a child to the mother. For example, the total fertility rate is defined as the number of children per woman. Only recently have demographers studied the fathering of children.
Now we acknowledge the importance of men in family planning. Especially in “macho” societies where men tend to be the decision-makers, women don’t have much control over the use of contraception unless their husbands concur.
Worldwide there are successes when men are included in family planning decisions. One comes from Ethiopia. Community family planning workers visited two different groups of married couples at home. In one group only the wife was present. The husbands also were present with the other half of the couples. Few of these couples were already using modern contraception.
Did these visits make a difference? Yes! One or two visits increased the use of pills, IUD’s or condoms. Did the presence of the husband improve the acceptance of contraception? You bet it did! At the end of a year, a third of couples were still using a method if their husbands had participated in the contraceptive decision. Only half that many used family planning where the husband was excluded.
Here in the United States the story is similar. Education, along with the AIDS scare, has doubled teens’ use of condoms in the past decade. In the past men assumed that women would take full responsibility for contraception. Now guys are more likely to share this responsibility and to use condoms. The availability of clinics where men feel comfortable has helped catalyze this change. Whether they attend alone or with their partners, it is important to involve men.

When asked, most males believe that preventing pregnancy is partly a male responsibility. Sad to say, only 2% of federal family planning dollars are allocated to reproductive services for men. Fortunately, some programs succeed in reaching young men.
Male service providers have found several steps to build successful programs. They use mass media to reach young men and to encourage them to communicate with their partners. Then they provide information about condoms and vasectomy where men tend to gather—a favorite place is in barbershops.

Teens on Track (TNT) is a program sponsored by Planned Parenthood of Southern New Jersey. Their first step was to hire male clinic workers. Then they built a program that incorporates recreation, education and medical care. The local YMCA hosts “Teen Night”. An hour of education on male health and sexuality is followed by sports—swimming or basketball. Attendance has been excellent.
In Houston the Baylor Teen Health Clinic hired a sports medicine physician to help draw teens to their “Males Only” program. Outreach workers recruit young men from housing projects and juvenile probation centers. The programs have helped the guys stay in school, improve academic performance and prevent unplanned pregnancies.
In one of the poorest countries of Africa “…men are deliberately constructing their family sizes and structure.” Researchers conclude: “Our perception is that in the communities studied in the rural Gambia, men’s contribution to the costs of bearing and raising their children is smaller than that of their wives…. It may be that the key shift precipitating fertility transition in high fertility societies in West Africa will be the growing financial burden of fatherhood.” The Gambia has one of the highest growth rates in the world. We can only hope that the men sense this burden quickly and plan for smaller families.
It is possible to change attitudes. Including men in family planning decisions increases their use of male methods, and improves their cooperation with their partners’ use of contraception. The result is fewer unplanned pregnancies, and better communication between men and women.
© Richard Grossman MD, 2005

Durango Herald Medical Population Public Health

Pick Mirena

If you were designing a perfect family planning method, what characteristics should it have? Certainly, the method would be highly effective and safe. Probably it should be designed for women, since they are usually more interested than men in controlling fertility. It would be nice if the method also had some beneficial side effects such as making periods lighter and less painful. Fortunately such a method is now available!
I have known about Mirena® for several years. Doctors in other countries, who have many years’ experience with it, have raved about it. The FDA finally approved it for use in the United States in 2000. It is wonderful to have another option for American women. As effective as tubal ligation, it is temporary and can be removed easily if a woman wishes to conceive.
Mirena® is made out of soft plastic in the shape of a “T”. The stem is filled with levonorgestrel, a potent form of progesterone—the hormone of pregnancy. A tiny amount of the hormone passes continually through the plastic into the uterus. It contains enough to last five years. Fortunately, although the levonorgestrel has a direct effect on the uterine lining, very little gets into the woman’s blood stream. Most women have no generalized symptoms from the hormone.
But isn’t this an Intrauterine Device (IUD)? Aren’t IUDs dangerous? Well, one IUD—the Dalkon Shield—was a disaster. Many years ago it was rushed to market before they had sufficient time to test it well. It made women vulnerable to serious infections, and some became infertile from the Dalkon Shield.
Two IUDs are now available in the United States, and both are amazingly safe. A woman who is in a mutually monogamous relationship is the best candidate for an IUD. Furthermore, IUDs work best for women who have given birth, since pregnancy stretches the uterus a bit. A potential user should be well informed about IUDs, and she should learn how to check that it is in the proper position. The device must be inserted skillfully by a qualified doctor or nurse.
How does Mirena® function? The levonorgestrel makes it more effective than other IUDs. Because the hormone causes the uterine muscle to relax, it also decreases cramps. The hormone prevents pregnancy in at least two ways. The principal way that it works is that it makes cervical mucus thick and sticky so that sperm cannot pass through. It also thins out the lining of the uterus. If a sperm got past the inhospitable cervical mucus and an egg did get fertilized, it would be unlikely to implant. This thinning effect also makes bleeding lighter or stops it completely.
One way of looking at Mirena® is that it is a means of getting the hormone where it can work most effectively. Because the hormone is released inside the target organ, only a tiny amount is needed, and side effects are minimized. One advantage of any IUD is that the user is constantly protected against pregnancy without having to do anything on a regular basis.
Levonorgestrel can cause a few annoying side effects. Certain women complain of increased acne or headaches, and rarely they will have breast tenderness or nausea. Some women stop having periods entirely, which is normal for a Mirena® user, as long as the device is in place. Fortunately, it does not cause weight gain.
Mirena® is small and flexible, which makes it well tolerated even by women who haven’t had a baby. The other popular IUD, Paragard®, is a bit larger and stiffer. Although Paragard® lasts longer than Mirena®—ten years versus five—women do not tolerate it as well if they haven’t started their family yet. In fact, young, childless women have requested many of the Mirenas® that I have placed so far.
Mirena® is called an IntraUterine System (IUS). I think that this is a marketing ploy to distinguish it from other IUDs. It is also possible that the manufacturer is preparing to market it for other indications. In many countries it has been used to help women who suffer from excessive bleeding or bad menstrual cramps. In addition, it prevents abnormalities of the lining of the uterus (including cancer), especially in menopausal women on estrogen. Although the FDA hasn’t approved Mirena® by for noncontraceptive uses, women welcome it for help with these problems.
At last we have an IUD that has a very low failure rate, few side effects and many benefits. Mirena® has great potential to help women control their fertility and deal with other problems.
© Richard Grossman MD, 2005