FAMILY PLANNING METHODS:

HOW DO THEY WORK AND WHY DOES IT MATTER?

Christian Connections for International Health (www.ccih.org)
Family Planning/Reproductive Health Working Group
Christian Connections for International Health (CCIH) is aware that how family planning
methods work is a concern among a number of its member organizations (1). The decision about
which methods are acceptable varies widely among Christian organizations and individuals, and
is influenced for some by whether the method acts to prevent conception or is thought to act as
an abortifacient (capable of causing an abortion).
One of the objectives of CCIH is to provide updated, evidence-based information, resources and
viewpoints on a variety of pertinent international health topics to serve our member
organizations and affiliates. Because family planning is a topic of considerable interest, the
purpose of this paper is to primarily address how basic methods work and to clarify what is
currently known with respect to specific methods.
There is no universally accepted definition of precisely what constitutes abortion; however,
according to most legal, regulatory and medical authorities abortion is the termination of an
established pregnancy after implantation of a fertilized egg in the uterus (womb). Implantation
occurs at 5-7 days after ovulation (release of the egg) and fertilization (which typically occurs
within the first 12 hours after ovulation). Actions before implantation that prevent pregnancy are
contraceptive. This definition is used by the US Food and Drug Administration/National
Institutes of Health (2) and the American College of Gynecologists and Obstetricians (3).
Some faith communities and some individuals consider any action that prevents implantation of
a fertilized egg to be a very early abortion (4,5,6,7). For some in these communities, if the
primary mechanism of action is to prevent fertilization, this is acceptable. For others, any
possibility of a post-fertilization effect that would prevent implantation is problematic. CCIH
acknowledges and respects the differing views and values that result in different definitions of
abortion.
The information here is largely based on peer-reviewed documents and consensus material from
mainstream health sources (8,9,10) [Reference 10 is especially useful for description of terms
and basic reproductive processes]. Decisions regarding family planning methods are based on

*By Douglas Huber, with contributions from Devina Patel, Victoria Jennings, Henry Mosley, Judith Brown,
Raymond Martin, Anne Wilson, Nancy Harris, Rose Nesbitt, and Michelle Fraser.

Contact: Douglas Huber, Co-Chair, Family Planning/Reproductive Health Working Group;

DouglasHuber777@yahoo.com.

several factors related to optimal health outcomes as well as the beliefs and values of
organizations and individuals. The mechanisms of action of family planning methods are only
one consideration in these decisions. Family planning choices often involve deciding where
individuals or couples are willing to make a compromise effectiveness of the method, safety,
convenience, alignment with religious perspectives or some combination of these. CCIH
respects the different approaches by faith communities to enable couples to voluntarily achieve
their desired number and timing of pregnancies, consistent with the communities religious
teachings and values. We urge secular organizations to do the same.
Q1. What is family planning?
A. Family planning, as used by CCIH, means enabling individuals and couples to determine
the frequency and timing of pregnancies, including the use of a variety of methods for
voluntary prevention of pregnancy.
Q2. What are the ways family planning methods can work?
A. There are 5 primary ways: 1) block sperm from reaching the egg; 2) change the mans sperm
so they cannot fertilize the egg; ; 3) prevent eggs from being released; 4) thicken mucus in the
cervix, preventing sperm from passing; 5) alter the lining of the uterus (womb) so the
fertilized egg does not attach or implant. Many methods have multiple actions, and it is
currently not possible to precisely determine the contribution of each. Periodic abstinence is
often a part of fertility awareness-based methods (natural family planning). These methods
can also be used to increase the chances of achieving a pregnancy.
Q3. There are a lot of different family planning methods. What are the specific ways each one
works so people can make better informed decisions?
A. The following table summarizes the main mechanisms of action and the relative strength of
each for preventing pregnancy (e.g., very strong, strong, moderate, weak). We comment on
the potential to have a post-fertilization effect that could prevent implantation. We make no
definitive statements on post-fertilization effects because failure of a fertilized egg to implant
cannot be directly assessed; however, when a method effectively prevents ovulation and/or
blocks/changes the mans sperm so fertilization does not occur, there is no fertilized egg that
could be prevented from implanting. [In this table, we assume methods are used consistently
and correctly. For complete information on the contraceptive effectiveness of methods as
commonly used, as well as when used correctly and consistently, see reference 9.]

Family Planning
Method

Mechanisms of Action
(Assuming correct and consistent use)

Pills (Combined estrogen

and progestin) (8,9)

Prevents ovulation (release of the egg)strong

Thickens cervical mucus to block the mans spermstrong
Post-fertilization effectin theory, could occur, but rarely (no actual
evidence that it does), due to high effectiveness in preventing ovulation
and fertilization. Missed pills increase chance of ovulation and
pregnancy.

Patch, Ring, injections

(progestin plus estrogen)
(8,9)

Similar to combined pills

Progestin-only pills (POPs,

minipills) (8,9)

Thickens cervical mucus to block the mans spermstrong

Prevents ovulationweak to moderate (ovulation may occur with 40%
of menstrual cycles)
Post-fertilization effectmay be rare or occasional, depending on
whether taken during breastfeeding. Probably rare when used during
breastfeeding when there is a dual effect from the pills and
breastfeeding to prevent ovulation. May be occasional when not
breastfeeding and ovulation is more common. Missed pills increase
chance of ovulation. POPs change lining of the uterus. Ectopic (tubal)
pregnancy can also occur; e.g. pregnancy develops in the womans tube
rather than the uterus (though the risk of ectopic pregnancy is lower
than if no method were used)

Injectables--progestin-only
(Depo-Provera and
Noristerat) (8,9)

Prevents ovulationvery strong

Emergency contraceptive
pills (ECPs) (progestinonly [levonorgestrel] pills).
ECPs are used after
unprotected sex to prevent
an unintended pregnancy
(8,9)

Prevents ovulationstrong if taken before ovulationdoes not work if

taken on day of ovulation

Thickens cervical mucus to block the mans spermstrong

Post-fertilization effectin theory could occur, but very rarely (no
actual evidence) due to very effective prevention of ovulation and
fertilization

Thickens cervical mucus to block the mans spermweak

Post-fertilization effectunlikely, based on recent studies showing
ECPs work by preventing or delaying ovulation if taken before the
expected day of ovulation. If taken on day of ovulation or later,
implantation and pregnancy appear to occur at normal rates (11,12).
Note: A number of organizations are opposed to ECPs based on an
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understanding that the uterine lining is altered if ovulation occurs,

thereby preventing implantation of a fertilized egg. Complete absence
of a post-fertilization effect cannot be proven, but the available evidence
clearly shows prevention or delay of ovulation as the main (and possibly
the only) mechanism of action. ECPs have no effect on a pregnancy if
taken after implantation has already occurred.
Implants--progestin-only
(Jadelle, Implanon, Sinoimplant II) (8,9)

Prevents ovulation very strong

Intra-uterine device (IUD)

(Copper T 380A) (9)

Changes and inhibits sperm--very strong. The changes in the uterine

cavity (womb) due to the copper and presence of the IUD incapacitate
sperm, preventing migration and ability to fertilize the egg (8,13,14,15).

Effect on cervical mucus to block the mans spermstrong

Post-fertilization effectin theory could occur but very rarely (no
actual evidence) due to very effective prevention of ovulation and
fertilization

Prevents ovulationnone
Thickens cervical mucus to block the mans spermnone
Post-fertilization effectin theory could occur, but only rarely, due to
very effective prevention of fertilization. Ectopic (tubal) pregnancy
very rare. Note: Earlier generations of IUDs without copper (e.g. the
Lippes Loop) more often allowed fertilization, and were more likely to
prevent implantation if there was a fertilized egg. Ectopic pregnancy
was much more common than with currently available IUDs, though
still considerably less than would occur with no contraception.
As emergency contraception, the Copper T may be used for up to 5 days
after unprotected sexit is very effective, even when inserted after
ovulation and fertilization. But in this case, it most likely has a postfertilization effect that prevents implantation as one mechanism of
action when used for emergency contraception (12).
Intra-uterine device with
the progestin
levonorgestrel (Mirena)
(8,9,10)

Thickens cervical mucus to block the mans sperm--strong

Inhibits ability of sperm to migrate and capacity to fertilize the egg
strong
Prevents ovulationweak to moderate
Post-fertilization effectin theory could occur, but rarely, (no actual
evidence) due to very effective blocking and impairing sperm, such that
fertilization is rare. Ectopic pregnancy is also very rare.

Barrier methods
condoms (male and
female), diaphragms, caps

Blocks sperm from reaching eggstrong (when used correctly)

Post-fertilization effectnone

Fertility awareness-based
methods (Standard Days
Method [CycleBeads],
Symptothermal Method,
Billings
Ovulation/Cervical Mucus
Method, TwoDay Method)
(8,9)

Identifies fertile days during menstrual cycle so couple can avoid

unprotected sex-- by abstaining (if practicing natural family planning)
or using a barrier method.

Breastfeeding and
lactational amenorrhea
method-(LAM) (9)

Prevents ovulation up to 6 monthsstrong for LAMvariable if not

following the 3 LAM criteria, which are: 1) less than 6 mo. postpartum;
2) fully or nearly fully breastfeeding; 3) no return of menses

Post-fertilization effectno effect on lining of the uterus. Some

theoretical concerns (but no actual evidence) about whether fertilization
of a delayed ovulation could, on occasion, result in a fertilized egg
being impaired or unable to implant (4,16). Most research suggests this
is unlikely to be a common problem, though direct measurement cannot
be made (8).

Post-fertilization effectmight occur, especially if breastfeeding

beyond 6 months. The first ovulation can precede the first menstruation,
especially with prolonged breastfeeding. These early ovulations are
typically followed by sub-normal amounts of the hormones needed to
prepare the lining of the uterus for implantation if the egg is fertilized
(8,17,18,19,20).
Postpartum infertility with Prevention of ovulationvariable
no breastfeeding (8)
Post-fertilization effectmight occur. Most non-breastfeeding women
in the postpartum period have their first ovulation at about 6 weeks.
First ovulations are most often followed by sub-normal amounts of
hormones, as are about 25% of second and third ovulations. Therefore,
a fertilized egg might not implant if fertilized during the first several
menstrual cycles after birth (8,21)
Voluntary sterilization
(tubal ligation, tying the
tubes for women;
vasectomy for men)
(8,9,10)

Blocks sperm from meeting the eggvery strong

Vaginal spermicides (8,9)

Impairs the mans sperm ability to migrate and fertilize the egg
moderate

Ectopic pregnancyvery rare (e.g., implantation in the womans tube)

can occur if female sterilization fails. No effect if vasectomy fails.

Post-fertilization effectsnone
Q4. Why dont we know accurately how often some family planning methods might prevent
implantation?
A. There are two important reasons: 1) No practical test is available to detect fertilization of the
egg, that takes place in the tube before implantation. Most pregnancy tests turn positive after
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implantation, around the time the woman misses her menstrual period (about 12-14 days after
fertilization). 2) Many fertilized eggs among all couples, whether using a family planning
method or not, are abnormal (from 30-70%), and therefore do not divide and develop
normally. About 50% of fertilized eggs never progress to become a recognized pregnancy.
Most are incapable of implanting. Of those that do implant, many result in spontaneous
abortions (miscarriages) -- about 15% of all established pregnancies. A few result in live
births with congenital abnormalities (birth defects) -- about 3% of all births (22,23,24).
While science has learned much about our basic human reproduction and the mechanisms of
action for family planning methods, the wonder of how our reproduction works remains an
unfolding story, as it is in other areas of human biology.
Q5. It seems natural loss of fertilized eggs is very common and not really within our control.
Are there other factors within our control that cause failure of fertilized eggs to implant and
miscarriages?
A. Several life style factors affect the chances of a fertilized egg being healthy and capable of
implanting and developing normally. Age of the woman affects the frequency of genetic
abnormalities and early miscarriage. Men who smoke have genetic damage to their sperm,
resulting in increased failure to implant, early miscarriages, birth defects and childhood
cancers. Obesity in women is associated with higher rates of miscarriage and intra-uterine
death. Sub-normal hormone levels are more common after ovulation for women experiencing
psychological stress, athletic training or abrupt weight loss; therefore, the lining of the uterus
would not be optimally prepared for implantation. Damage to a womans tubes due to
sexually transmitted infections, endometriosis, and fibroids in the uterus reduce chances of
implantation and normal development (25). Several of these factors are largely within our
control and the effects are better documented than the potential that some family planning
methods may prevent implantation. As we learn more about how we are created and live, it
seems much that affects our health and human wholeness is linked to our reproduction. As
people of faith, there are many factors that need to be addressed to minimize loss of fertilized
eggs, reduce miscarriages, and optimize the health of women and children. The choice of
family planning method is one of many considerations.
Conclusion
The need for family planning methods is greatest in the poorest countries where current lack of
family planning results in many women seeking unsafe abortions (26). Family planning is a
powerful way to prevent abortion. Reducing unintended pregnancies and the need for abortion
produces health benefits that are strongly embraced by both Christian and secular health
organizations. A maternal death from any cause is a tragedybut when a woman dies from a
pregnancy she did not want, it is a double tragedy. As Christians we have an obligation to weigh
all the health consequences for those we serve when deciding to provide or omit any family
planning method, since all reduce untended pregnancies and abortion. We trust that CCIH will
be a forum where issues of reproduction can be faithfully and respectfully discussed in light of
our common desire to advance health and wholeness from a Christian perspective.
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References
1. Huber D, Yang ER, Brown J, Brown R. International Family Planning: Christian Actions and Attitudes: A
survey of Christian Connections for International Health Member Organizations. Christian Connections for
International Health, August 2008. http://www.ccih.org/Working_Groups/FP-RH_Survey_index.htm. Accessed 25
June 2010.
2. National Institutes of Health. Protection of Human Subjects, 45 C.F.R. Sect. 46.202 (2009).
3. Hughes EC (ed), Committee on Terminology, The American Congress of Obstetricians and Gynecologists,
Obstetric-Gynecologic Terminology. Philadelphia PA: F.A. Davis Company, 1972.
4. Cutrer WR, Glahn SL. The Contraception Guidebook: Options, Risks, and Answers for Christian Couples.
Christian Medical Association Resources, Zondervan, Grand Rapids, Michigan, 2005
5. Christian Medical & Dental Associations Position Statement, Possible Post-conceptional Effects of Hormonal
Birth Control. Approved by the Board of Trustees, September 1998.
http://www.cmda.org/AM/Template.cfm?Section=Ethics_and_Position_Statements&Template=/CM/ContentDispla
y.cfm&ContentID=8158. Accessed 25 June 2010
6. Association of Prolife Physicians, Do Oral Contraceptives Cause Abortions? January 1998.
http://www.prolifephysicians.org/abortifacient.htm. Accessed 24 June10
7. United States Conference of Catholic Bishops. Married Love and the Gift of Life. November 14, 2006.
http://www.usccb.org/laity/marriage/MarriedLove.pdf. Accessed 25 June 2010
8. Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology (19th revised
edition). Ardent Media, New York 2007
9. World Health Organization. Global Handbook for Family Planning Providers. 2008.
http://www.infoforhealth.org/globalhandbook/.
10. American Congress of Obstetricians and Gynecologists. Patient Education Pamphlets: Birth Control (October
2007) (AB020English) (SB020Spanish) http://www.acog.org/publications/patient_education/. Accessed 25
June 2010.
11. International Consortium for Emergency Contraception and International Federation of Gynecology &
Obstetrics. Statement on Mechanism of Action. How do levonorgestrel-only emergency contraceptive pills prevent
pregnancy? October 2008.
http://www.figo.org/files/figocorp/International%20consortium%20for%20emergency%20contraception%20stateme
nt.pdf. Accessed 25 June 2010.
12. Trussell J, Raymond EG. Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy. June
2010. http://ec.princeton.edu/questions/ec-review.pdf. Accessed 25 June 2010.
13. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine
contraceptive devices. Am J Obstet Gynecol 1999; 181: 1263 1269
14. Mishell DR. Intrauterine devices: mechanisms of action, safety, and efficacy. Contraception.
1998;38(Suppl):458-538.
15. Family Health International: Fact Sheet: Mechanisms of the Contraceptive Action of Hormonal Methods and
Intrauterine Devices (IUDs). http://www.fhi.org/en/RH/Pubs/factsheets/mechact.htm. Accessed 24 June 2010

16. Bovens L. The rhythm method and embryonic death. J Med Ethics 2006;32:355-356.
http://jme.bmj.com/cgi/content/full/32/6/355.
17. Diaz S, Cardenas H, Brandeis A, Miranda P, Salvateirra AM, Croxatto HB. Relative contributions of
anovulation and luteal phase defect to the reduced pregnancy rate of breastfeeding women. Fertility and Sterility.
1992;58:498-503.
18. Lewis PR, Brown JB, Renfree MB, Short RV. The resumption of ovulation and menstruation in a wellnourished population of women breastfeeding for an extended period of time. Fertil Steril. 1991;55:529-36.
19. Brown JB, Harrisson P, Smith MA. A study of returning fertility after childbirth and during lactation by
measurement of urinary oestrogen and pregnanediol excretion and cervical mucus production. J. Biosoc Science.
1985;9(Suppl):5-23.
20. Gray RH, Campbell OM, Apelo R, Eslami SS, Zacur H, Ramos RM, Gehret JC, Labbok MH. Risk of ovulation
during lactation. Lancet. 1990;335:25-9
21. Gray RH, Campbell OM, Zacur H, Labbok MH, MacRae SL. Postpartum return to ovarian activity in nonbreastfeeding women monitored by urinary assays. J Clin Endocrinol Metab 1987;64:645-650.
22. Macklon NS, Geraedts JPM, Fauser BCJM. Conception ongoing pregnancy: the black box of early
pregnancy loss. Human Reproduction Update, 2002,Vol. 8,No.4;333-343
23. Sadler TW. Langmans Medical Embryology, 8th ed. Lippincott Williams & Wilkins, Philadelphia, 2000.
24. Schoenwolf GC, Bleyl SB, Brauer PR, Francis-West PH. Larsenss Human Embryology. Elsevier Churchill
Livingstone, Philadelphia 2009.
25. Macklon NS, Greer IA, Steegers EAP. Textbook of Periconceptional Medicine. Informa healthcare UK, 2009.
26. Family Planning/Reproductive Health Working Group. Family Planning Prevents Abortion: Fact Sheet.
Christian Connections for International Health, (in preparation, July 2010). [Lead writer, Judith Brown;
judithevansb@yahoo.com]

This publication was made possible by support from the Institute

for Reproductive Health at Georgetown University. The contents
are the responsibility of Christian Connections for International
Health.