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Barrier MethodsNote to presenter: Use this opportunity to make anycomments before beginning the presentation.Introduce yourself and the topic and be sure to let theaudience know how you would like to structure thediscussion (i.e., take questions during thepresentation or hold them until the end). There areseveral additional notes to the presenter that appearthroughout the narrative. These notes ofclarification may be of use to your audience. ■

Currently Available Barrier MethodsBarrier methods are among the oldest methods usedto prevent pregnancy and to prevent the sexualtransmission of diseases. Barrier methods includethe male condom and female-controlled methods —the female condom, diaphragm, cervical cap,spermicides and vaginal sponge.

As the name indicates, each method creates a barrierthat prevents sperm from reaching the egg orprevents the transmission of disease-causingmicroorganisms. Some do this primarily by creatinga physical barrier: the male and female condom,diaphragm and cervical cap. Spermicides and thevaginal sponge rely primarily on a chemical barrieragent that kills the sperm or microorganism.

Barrier methods can be used alone, in combinations,or with non-barrier types of contraception. ➔

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When used in combination, their overall effectivenessagainst pregnancy and infection increases.

According to surveys, about 45 million marriedcouples of reproductive age are using the malecondom for contraception worldwide. Millions morewho are not included in these surveys also use themale condom. About six million couples worldwidereport using either spermicides, the diaphragm or thecervical cap. The diaphragm, cervical cap and spongeare not generally available in developing countries,and the female condom is only now becomingavailable. ■

Barrier Methods ... Maintain GoodReproductive HealthTwo important aspects of good reproductive healthcare are prevention of unintended pregnancy andprevention of sexually transmitted diseases, or STDs.Barrier methods, especially condoms, are the onlycontraceptives recommended for prevention of STDs,including AIDS. As concern about AIDS and otherSTDs has increased in recent years, more people haveconsidered using barrier methods. Decisions aboutwhich method to choose have now begun to involveboth pregnancy and STD prevention.

The first section of this presentation will cover issuescommon to all barrier methods. Method-specificinformation is discussed in the middle section, andprogrammatic concerns about the use of barriermethods are addressed in the final section. ■

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General Characteristics of Barrier MethodsBarrier methods have some strengths and weaknesses,which we will discuss on this and the next slide.

All barrier methods are effective at preventingpregnancy and some STDs when used consistentlyand correctly. The degree of effectiveness varies bymethod. Barrier methods are very safe, and the rareside effects are usually mild. They have no systemiceffects. They are user-controlled and can be easilyinitiated and discontinued. They allow for immediatereturn of fertility.

Except for the diaphragm and cervical cap, barriermethods do not require a clinic visit and are availablewithout prescription. They are often available frompharmacies, community distributors and otherinformal outlets. ■

General Characteristics of Barrier Methods,continuedBarrier methods have some characteristics that maybe weaknesses or drawbacks for some users. Theymay not be as effective as other methods. This isprimarily due to the fact that some people find themdifficult to use consistently and correctly. Theyshould be used with every act of intercourse and,therefore, require substantial motivation for consistentand correct use. They also require partnerparticipation and communication. Some people areconcerned that use of barrier methods interruptssexual activity. In some cultures there may be otherobstacles, such as taboos on touching one’s owngenitalia. Proper storage is important to maintain thequality of the products, and a source of resupply isnecessary. Barrier methods may also be expensive insome settings, compared to other methods. ■

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Barrier Method UsersBarrier methods may be an especially good choice forcertain groups of people. Barrier methods,particularly condoms, are appropriate choices forpeople at increased risk of STDs. Women whocannot or do not want to use hormonal methods maychoose barrier methods. Barrier methods are a goodchoice for couples who need a back-up method whilewaiting for another method to take effect, or afterusing oral contraceptives inconsistently.

People who have sex infrequently may prefer to use amethod of contraception that is effective immediatelyand only used when intercourse occurs. Those whohave no access to other methods of contraception mayfind barrier methods a convenient option. For thesereasons, barrier methods may be a particularly goodchoice for young adults. Both men and women mayprefer a method of family planning they can controland can purchase privately rather than through ahealth-care facility. ■

Global Conditions Influencing IncreasedInterest in Barrier MethodsForty years ago, the male condom and femalediaphragm, along with traditional methods, such aswithdrawal, were the primary reversible methods forpregnancy prevention. But the development of oralcontraceptives, modern intrauterine devices and othermethods changed that. These newer methods haveusually been favored by family planning providers.However, interest in barrier methods has increased inrecent years for several reasons. The AIDS epidemicand high rates of other STDs have focused attentionon methods that can protect against these diseases.Community-based marketing campaigns have beenable to change people’s views about using condomson a broad scale, especially in Africa. Also, ➔

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family planning providers and users are recognizingthe importance of having a wide range ofcontraceptive choices to meet a variety ofreproductive health needs. ■

Contraceptive Pregnancy RatesBarrier methods can be very effective at preventingpregnancy when used consistently and correctly. Inthis slide, the yellow rectangles on the left show howeffective various methods can be when used bothconsistently and correctly. If used correctly at everyact of intercourse, barrier methods generally have lowpregnancy rates, about 3 percent for the male condomand 7 percent for spermicides. A 3 percent pregnancyrate means that three out of every 100 women usingthis method for a year would get pregnant.

The red rectangles on the right show how effectivethe methods are, based on actual or typical use duringone year. Typical users include those who may notuse the method consistently and correctly. Undertypical use, contraceptive pregnancy rates for somebarrier methods are 21 percent or higher. Thepregnancy rates for diaphragms that are used inconjunction with spermicides are slightly less thanthose of spermicides when used alone. Contraceptiveeffectiveness should improve when the male condomand vaginally inserted spermicides are used together,although data on this issue are not available.

Note that the difference between the rates forconsistent and correct use and the rates for typical useis large for certain methods, such as oralcontraceptives and barrier methods. This is becausethese methods depend heavily on the client to usethem consistently and correctly. Good counselingmay be able to influence use patterns. Notice alsothat the difference is small or non-existent for long-acting methods such as Norplant, IUDs, ➔

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Depo-Provera or female sterilization, which do notrequire much or any action by the client. ■

Note to presenter: Failure rates vary from country to countrybecause they are dependent on many factors. Thus, studiesreport varying rates and it is impossible to calculate oneprecise rate for any method. The three main factors thatinfluence the effectiveness of any contraceptive method includethe inherent effectiveness of the method itself, programmaticissues, and whether or not the method is used correctly andconsistently by users. Correct use is dependent not only on theuser, but is influenced by a variety of programmatic factors.To facilitate correct and consistent use of any contraceptivemethod, programs must offer a variety of contraceptive optionswith adequate counseling for clients and proper follow-upcare. Clients must also receive complete and instructiveinformation on how to use the method, and on the importanceof correct and consistent use. Some methods depend greatlyon the technical competence of the provider to administer themethod properly. All methods must also be accessible andaffordable to the user.

Prevention of Sexually Transmitted DiseaseThe male latex condom is the only barrier methodthat has been shown in human studies to prevent thetransmission of all types of STDs, including HIV, thevirus that leads to AIDS. The female condom mayprove to be as effective as the male condom, butstudies have not been completed.

Other female-controlled barrier methods protectagainst disease in varying degrees. Spermicidescontaining nonoxynol-9, or N-9, protect againstcommon bacterial STDs and have been found toinactivate HIV in the laboratory. Their effect on HIVtransmission in humans is under study. Thediaphragm with N-9 offers some protection againstbacterial STDs, while the cervical cap with N-9 mayalso offer such protection. The effect of thediaphragm and cervical cap on HIV transmission ➔

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is not known. The vaginal wall is still exposed whena diaphragm or cervical cap is in place and couldprovide points of entry for STDs, including HIV. ■

Effective Counseling for Barrier Method UseUsers of barrier methods are more likely to besuccessful when they receive effective counseling.Good initial counseling ensures that clientsunderstand the characteristics and potential sideeffects of a variety of family planning options. Thisallows women and men to make an informed choiceabout which method meets their specific needs. Forbarrier methods, counseling must emphasize theimportance of consistent and correct use.

Intensive counseling, which may involve teachingnew skills, is needed to facilitate consistent use.Partner communication and cooperation are alsorequired for effective use of barrier methods. Usingbarrier methods involves touching one’s own genitalsor the genitals of one’s partner. If culturallyappropriate, it is helpful to talk to clients about howto make the use of barrier methods a part of sexualactivities.

Clear and practical information on how to use themethod correctly, how to avoid common mistakes inuse and how to get more supplies is also essential.These factors will be discussed in detail later in thispresentation.

In the event of incorrect or inconsistent use of abarrier method, or if a condom slips or breaks, clientsshould be advised that emergency contraception maybe available. Clients should see a provider as soon aspossible. ■

Note to presenter: Emergency contraception is described inmore detail, including definition and dosage, in the textaccompanying slide 41.

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Client InstructionHealth-care providers can use a variety of counselingtechniques to teach couples how to be successfulusers of contraceptive methods. For barrier methods,samples of various types should be available forclients to see and handle. Anatomical models can beused to demonstrate how to use barrier methodscorrectly. A penis model can be used to show bothmale and female clients how the male condom isunrolled correctly as it is put on. Drawings orphotographs on wallcharts, flipcharts or booklets canbe used to show proper placement and use of male orfemale methods. Also, women who choose adiaphragm or cervical cap should have theopportunity to practice putting it in place while at theclinic. Informational pamphlets or booklets to takehome can be helpful for the client. Ideally, thepartner will be included in the counseling session.

Some clients need assistance learning the necessarycommunication skills, especially for condom use.Role-playing is one technique that can help. In somecases, it may be easier for a woman to get herpartner’s agreement to use female barrier methodsrather than male condoms. ■

Information on Each MethodWhat follows is a brief explanation of each type ofbarrier method. We discuss the mechanism of action,as well as characteristics, counseling issues andimportant research findings specific to each method.The male condom is discussed first, followed by thefemale condom, spermicides, diaphragm and cervicalcap, the vaginal sponge, and potential new barriermethods. ■

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Male CondomThe male condom fits over the man’s erect penis andforms a physical barrier between the vagina and thepenis. The condom serves as a receptacle for semenand prevents sperm and microorganisms fromentering a woman’s reproductive tract. It alsoprevents fluid and microorganisms from the femalepartner from coming into contact with the penis.

Condoms come in different sizes, colors, shapes andthicknesses. Some are lubricated with silicone orother water-based lubricants, and some havespermicides added to the lubrication. The malecondom can be used with other contraceptivemethods, including most barrier methods. However,the male condom should not be used with the femalecondom because friction could dislodge eitherdevice. ■

Properties of Condom MaterialsThere are three types of condom materials — naturalmaterials, latex rubber and plastic. The earliestcondoms were sheaths made from animal intestines,bladders and skins. These natural condoms have beenused for thousands of years and are still available insome countries. While they are an effective barrieragainst sperm and bacterial STDs, they are not aseffective against viral organisms such as HIV, whichare smaller than bacteria. Natural condoms allow thetransfer of body heat between partners.

Rubber condoms were developed in the 19th century,followed by latex rubber in the 20th century. Theyare less porous than natural condoms and, hence,form a more effective barrier that can block smallerorganisms, such as HIV. However, latex condomsreduce heat transfer, which may contribute to reducedsexual pleasure. ➔

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Various types of plastic male condoms are underdevelopment, and one brand is on the market in theUnited States and Europe. Plastic condoms providean effective barrier against HIV as well as bacterialSTDs, while at the same time allowing better transferof heat.

Since most condom users are still using latexcondoms, the information described in thispresentation refers to the latex rubber condom unlessotherwise specified. ■

Characteristics of the Male Latex CondomAs we have discussed, the male condom is the onlybarrier method that has been proven to protect againstthe transmission of all types of STDs, including HIV.However, STD transmission is possible if genitallesions are present outside the area covered by thecondom. The male condom is also known to have aprotective effect against cervical cancer, which hasbeen associated with human papillomavirus, asexually transmitted virus.

The male condom is safe for virtually everyone,except for the rare person who is allergic to latex.The male condom may reduce sensation to the penisdue to the lack of heat transfer and due to constrictionfrom the tight fit. This may pose a problem for menwho have difficulty maintaining an erection duringintercourse. However, it may help men who havepremature ejaculation.

Latex condoms can be damaged by exposure tooil-based lubricants, excessive heat, humidity or light.The male condom is widely available and accessiblein most parts of the world. ■

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Characteristics of the Male Plastic CondomThe male plastic condom has many of the samecharacteristics of the latex condom, including thedegree of protection against STDs. However, it hassome important differences. The plastic condoms arethinner and stronger. They are generally made larger,so they are less constrictive. Some designs allowgreater sensitivity during use than latex condoms.The material is more stable. They maintain theirstrength over time and are not as likely to break downwhen exposed to light or high temperatures. Theyalso will not break down when used with oil-basedlubricants, which is important in countries wherewater-based lubricants are not easily available. ■

Correct Use of the Male CondomThe following is information that should be given toclients regarding correct use of the male condom.

Open the package carefully to avoid tearing thecondom. To prevent sperm or microorganisms fromentering the woman’s reproductive tract, there shouldbe no genital contact before a condom is put on. Thecondom should be unrolled directly onto the erectpenis. Be sure to unroll it all the way to the base ofthe penis.

After ejaculation, withdraw the penis from the vaginawhile the penis is still erect. Hold onto the rim of thecondom while removing the penis to help prevent thecondom from slipping off and the semen spilling intothe vagina. After the condom is removed, genitalcontact should be avoided since this could allowresidual sperm or STD microorganisms on the glansor in the urethra to enter the woman.

To properly dispose of a condom, put it in a trashcontainer or bury it. It should not be flushed down atoilet. ■

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Male Condom Breakage and Slippage RatesIf male condoms break or slip, it is usually because ofhuman error. With modern technology and qualitycontrol, condom breakage is rarely due to faultymanufacturing. Studies have examined the incidenceof breakage, the term used when a condom develops ahole or tear, and slippage, the term used when thecondom comes off of the penis while it is in thevagina. Among experienced users, condom breakageor slippage is very rare. Among the majority of users,breakage rates are less than 5 percent.

In studies where higher rates of breakage have beenreported, a small number of users were found to beresponsible for most of the failures. This suggeststhat counseling can greatly improve an individual’ssuccessful use of condoms. Providers need to be ableto identify users who may be using condomsincorrectly and help them reduce their risk of condomfailure. The next two slides will discuss thebehaviors that are most likely to cause condombreakage or slippage. ■

Behaviors Likely to Cause Condom Breakageor SlippageResearch has identified four primary types of userbehaviors that can cause excessive breakage orslippage of condoms.

• Opening the package with sharp objects such asteeth, scissors, knives and pencils was associatedwith condom breakage.

• Unrolling condoms before putting them on alsoled to higher breakage and slippage rates.Condoms should always be unrolled onto thepenis, rather than pulled on like a sock. ➔

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• Having intercourse for more than 20 minutes ledto high rates of condom slippage.

• Having especially intense intercourse was alsoassociated with condom slippage. ■

Other Cautions for Correct Condom UseIn addition to the four behaviors described above,there are other behaviors that can lead to condombreakage, contamination, or slippage that should alsobe avoided.

• Carefully check the condom package to be surethat it is not torn or damaged. Check theexpiration or manufacturer’s date on the packageto be sure it is not expired. Do not use a condomthat is brittle or dry or if it has changed color.

• Use only water-based solutions such as K-Y jelly,spermicidal gels or creams, or saliva forlubrication. Oil-based products such as petroleumjelly, hand lotion, or mineral or vegetable oilsshould never be used because they can weakenlatex in just a few minutes, making the condommore likely to break.

• Use a new condom for each act of intercourse. Amale condom should never be washed and reusedas this also can substantially weaken the latex.

• Starting to unroll the condom wrong side out onthe penis and then flipping it over to put it oncorrectly may contaminate the outside of thecondom with pre-ejaculatory fluid containing STDmicroorganisms. If this happens and it issuspected that contamination has occurred, thecondom should be thrown away and replaced witha new one. ➔

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• Many condoms have a receptacle on the end forsemen. If the condom does not have one, somerecommend holding the end of the condom whileunrolling it onto the penis. This creates a spacefor the semen. Some feel this could preventcondom breakage or slippage although clearresearch on this issue has not been done. ■

Condom Protection Against HIVMany studies have shown that male condom usedecreases the risk of HIV transmission. The studyshown on this slide measured the protective effect ofcondom use among commercial sex workers inrelation to how consistently they used condoms.Those who did not use condoms at all had a highpercentage of HIV infection. The percent of infectiondecreased as condom use increased. Those who usedcondoms 100 percent of the time had no HIVinfection.

Other studies show similar patterns. The level ofprotection against HIV is due to the degree ofconsistent and correct condom use, rather than tovariations among the condoms themselves. To bemost effective at disease prevention, condoms mustbe used consistently and correctly. ■

Female CondomIn recent years, a female condom was developed inresponse to the need for more female-controlledmethods. Like the male condom, it forms a physicalbarrier between the vagina and the penis. It serves asa receptacle for semen within the vagina. It preventssperm from entering a woman’s reproductive tractand, theoretically, protects both partners againsttransmission of STDs. ➔

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The female condom is a soft, loose-fitting plasticsheath with a flexible ring at each end. One ring is atthe closed end of the sheath and serves as an insertionmechanism and anchor over the cervix. The outerring forms the external edge of the device andremains outside the vagina after insertion, providingprotection to the labia and the base of the penisduring intercourse. This design may reduce thepotential for transfer of infectious organisms betweensex partners, particularly from genital ulcers.

The female condom has been approved for use byseveral regulatory agencies and is being marketed inEurope as Femidom and in North America as bothFemidom and Reality. ■

Characteristics of the Female CondomWhile female condoms have many similarities tomale condoms, they also have some unique features.An important feature of the female condom is that itprovides women with more control over use than themale condom. Thus, it is an option for women whowant to protect themselves with barrier methods.

As mentioned, the female condom is made of plastic,thus it is stronger and more durable than the latexcondom. It is also loose-fitting and may be morecomfortable for men who object to the tight-fittingmale condom. It can be inserted prior to the initiationof sexual activities and does not interrupt coitus.

The ability of the female condom to preventtransmission of HIV and other STDs is promising.Laboratory studies have found that the femalecondom is impermeable to various STD organisms,including HIV. Clinical trials are under way.

The female condom may be difficult to learn to insertfor first-time users. Women should practice insertionbefore using the method. ➔

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Currently, the female condom is only approved forone use for one act of intercourse. However, becausethe device is expensive, studies are under way todetermine if it can be rinsed and reused withoutlosing effectiveness or compromising safety.

In acceptability studies, many women have reportedthat they liked the device and would recommend it toothers. However, some women complained that theinner ring caused discomfort when the penis hit it andthat the movement of the device during intercoursewas bothersome. Other women mentioned that thedevice was noisy if not lubricated adequately. Menwere less enthusiastic about the device thanwomen. ■

Use of the Female CondomAs with the male condom, most breakage is due tohuman error, not to problems with the device.Couples should be careful with sharp objects such asrings, other jewelry, fingernails or teeth, which cantear or puncture female condoms. As with the malecondom, no genital contact should occur before thefemale condom is in place or after it is removed.

Note that the inner ring must be inserted high into thevagina, against the cervix. The outer ring must beproperly placed outside of the vagina. Duringintercourse, care should be taken to place the penisinside the female condom and not to the side of it.

The female condom can be used by a woman who ispregnant or menstruating, but should not be used if awoman has a tampon inserted. It also should not beused with the male condom.

The female condom is pre-lubricated with silicone,but more lubricant can be added to increase comfortand to reduce noise during use. ■

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SpermicidesWe will now discuss spermicides, which are chemicalbarriers. For thousands of years, women have putmaterials ranging from rags to herbal preparationsinto the vagina in an effort to prevent pregnancy.Modern science built on this approach and developedproducts that are proven to kill sperm.

Spermicides consist of two components, aspermicidal chemical and a delivery base for thechemical. The base can be a cream, jelly, foam, film,suppository or tablet. The spermicidal chemicalsmost often used today are nonoxynol-9 (N-9),menfegol and benzalkonium chloride (BZK).Comparative data on the relative effectiveness ofdifferent delivery systems or chemical formulationsare scarce. Most research has been done using N-9since it is the most common spermicide in the world.

The spermicidal agent kills sperm and STDmicroorganisms. Most spermicides are surfactants,which means they act on the membrane of the spermor microorganism. In addition, some of the deliverybases physically block the cervix to prevent spermand microorganisms from moving into the woman’suterus, providing a secondary mode of action.

Spermicides can be used alone or with anothercontraceptive method. They are available withoutprescription in most countries, but may be expensive. ■

Characteristics of SpermicidesN-9 spermicides help prevent the transmission ofgonorrhea and chlamydia. Some studies suggest thatN-9 also reduces the risk of other STDs, includingbacterial vaginosis, trichomoniasis and herpes.

Although N-9 kills HIV in laboratory tests, studiesinvolving humans are not conclusive. It has beenreported that repeated N-9 use in a short period oftime, such as multiple times in one day, may cause ➔

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vaginal and cervical abrasions. These abrasionscould, in theory, increase the risk of HIVtransmission. Use of spermicides alone is notcurrently recommended as a means of preventingHIV infection. Further studies are in progress.

Most spermicides can be stored for up to five yearswithout affecting their reliability. However, like mostproducts, they usually have an expiration date printedon the packages and may be damaged if stored inexcessively hot conditions.

Spermicides can be used shortly before intercourse.Some spermicidal products can be messy and causevaginal wetness for several hours after use. Some canproduce a minor allergic reaction, causing irritation ora burning sensation for some men and women. Thismay be mildly uncomfortable but is normally notharmful and disappears once spermicide use isdiscontinued. Also, some women who use suppositoriesor foaming tablets report a warm sensation in thevagina as the tablets dissolve. This is not harmful.Spermicide use over time can increase the number ofyeast and urinary tract infections among women, andthe incidence of bacterial vaginosis. ■

Correct Use of SpermicidesSpermicides should be placed high into the vagina,near the cervix, to provide maximum contraceptiveprotection. Foams, jellies and creams are effective assoon as inserted and require no waiting time.However, suppositories, tablets and film do require awaiting time, which varies from five to 15 minutes.The waiting period allows the spermicide to dissolveand disperse throughout the vagina. Once inserted,spermicides are effective for one to two hours.

Creams, jellies and foam require an applicator forinsertion. Jelly and cream should be squeezed intothe applicator until loaded to the proper level. ➔

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Foam containers should be shaken before loading theapplicator to the proper level. Film, tablets andsuppositories are inserted into the vagina by hand.Women should have clean, dry hands and a cleanapplicator when they insert spermicidal products.

Because directions vary among products, propercounseling about each method is important. Forexample, film must be folded in half and insertedwith dry fingers, or the film will stick to the fingersand not to the cervix.

If there are repeat acts of intercourse in the samesexual encounter, additional spermicide must beadded for each act. They can be used duringmenstruation. For maximum effectiveness, aspermicide should be used with another barriermethod, such as a diaphragm or condom. Afterintercourse, a woman may wash outside the vaginabut should not douche for at least six hours. ■

User Preferences for Different Types ofSpermicidesUsers may prefer different types of spermicidalproducts, depending on culture and personal taste.When making decisions about which spermicidalproducts to offer, providers should recognizeindividual preferences and offer various optionswhenever possible.

A study of 162 women in Kenya, Mexico and theDominican Republic found that vaginal film waspreferred over tablets. The portion preferring filmvaried significantly, however, from 86 percent inKenya to 58 percent in Mexico and only 52 percent inthe Dominican Republic. At each site, even though amajority preferred the film, a sizeable number had apreference for tablets. This emphasizes the need forprograms to offer a variety of barrier methods whenpossible. ■

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Diaphragm and Cervical CapWe will now discuss two other female barriermethods, the diaphragm and cervical cap. Both aremade of soft latex rubber and are inserted into thevagina, fitting over the woman’s cervix. A diaphragmcovers the entire upper part of the vagina includingthe cervix. It fits between the pubic bone and theposterior fornix of the vagina. Smaller than thediaphragm, a cap fits only over the cervix, wheresuction holds it in place. These devices do not makea perfect seal against the cervix, and it is possible forthem to dislodge during intercourse. Thus, spermmay get past the physical barrier. For this reason,both devices are used with spermicidal cream or jelly.

When used with spermicides, the diaphragm andcervical cap prevent pregnancy by serving both as aphysical and chemical barrier.

Neither the diaphragm nor the cervical cap is widelyused in developing countries and often neither isavailable. ■

Characteristics of the Diaphragm andCervical CapDiaphragms and cervical caps are the only barriermethods that must be fitted by a trained provider forproper sizing. When properly fitted, neither deviceshould be felt by the client or her partner duringintercourse. These devices can be inserted up to sixhours prior to intercourse. Both devices can bereused, but access to clean water is necessary forproper cleaning after use. A proper storage location isalso needed.

Diaphragms used with spermicides theoreticallyprotect against the transmission of cervical infections.However, diaphragm use has been associated withbacterial vaginosis due to changes in the vaginal ➔

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flora. The effect of diaphragms on viral STDs and ofthe cap on all STDs is not known.

Research has shown that the use of the diaphragmmay increase a woman’s risk for developing urinarytract infections. This is particularly true if thediaphragm is too large, which may cause thediaphragm to put pressure on the urethra.

The cervical cap appears to be less effective in parouswomen because of changes in the cervix as a result ofchildbirth. ■

Considerations for Potential Users of theDiaphragm and Cervical CapAccording to World Health Organization guidelines,these devices should not be used by women withcervical or vaginal abnormalities because they maynot fit properly. After childbirth, women should waitat least six weeks to be fitted or refitted for adiaphragm or cap, so that the cervix can return to itsnormal size.

Women with an allergy to latex or spermicidesusually should not use a cap or diaphragm. Womenwith a history of toxic shock syndrome, a very rarebut potentially fatal disease caused by bacteria,should usually use other contraceptive methods. ■

Correct Use of the Diaphragm andCervical CapBefore inserting a diaphragm or cap, a woman shouldcheck it for holes or tears by holding it up to the light.If it is defective, she should use a back-up methoduntil the device can be replaced. Spermicidal jelly orcream should be spread around the rim and on theinside portion of the dome with clean fingers. Thedevice should go all the way back against the cervix,so the cavity containing the spermicide covers the ➔

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cervical opening. A woman should check the positionof the device by feeling around the edge to be sure thecervix is completely covered.

After a diaphragm is inserted, if intercourse occursmore than one hour later or if multiple acts ofintercourse occur, an application of spermicide shouldbe inserted into the vagina without removing thedevice. The diaphragm should be left in place for atleast six hours following the last act of intercourse butnot more than 24 hours.

The cervical cap is effective against pregnancy formultiple acts of intercourse without additionalspermicide. The cap should be left in place for atleast six hours following the last act of intercourseand can remain in place for up to 48 hours, althoughthis might lead to a bad odor.

When removing these devices, the woman shouldtake care not to damage them or the cervix with herfingernails. The devices should be washed gently butthoroughly with soap and water, dried, and stored in acool, dry, dark place. ■

Fitting Diaphragms and Cervical CapsAny trained health-care provider can fit a woman forthese devices. The size of the diaphragm isdetermined by a measurement of the vagina taken bythe provider. It should be a secure fit that matches thedistance from the pubic bone to the posterior fornix ofthe vagina, or the largest size that is comfortable forthe client.

Currently, four sizes of cervical caps are available.The provider estimates the size of the cap andconfirms the fit manually after it is in place. The capshould be about the same size or only a fewmillimeters larger than the base of the cervix. A capthat is too small can injure the cervix, and one that istoo large can slip off during intercourse. ➔

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Careful aseptic medical practices are required whenfitting diaphragms or caps. Clients who wish to useeither a diaphragm or a cervical cap will needcounseling, instructions and practice in using thedevice. The woman should practice inserting itbefore leaving the clinic. Ideally, she should alsoreturn in about two weeks, with the device in place,for the provider to ensure she is inserting itcorrectly and is comfortable using it. ■

Follow-up Issues for the Diaphragm andCervical CapThe woman should return to the clinic for periodiccheck-ups or for any problems. The device may lasttwo to three years, depending on usage. The size,however, may need to be changed if the woman gainsor loses a significant amount of weight, has a baby, orhas a second or third trimester abortion. Also, rubberdeteriorates, so the device needs to be checked forsmall holes. A woman should return to her providerfor a replacement of a damaged device and useanother form of contraception in the meantime.

Both a diaphragm and cap should be comfortable iffitted properly. A woman with discomfort should beexamined for signs of irritation from the spermicideand for improper fitting. If the size is correct, theprovider should demonstrate again the method ofpreparing, inserting and removing the device. If thedevice remains uncomfortable, she should becounseled to use another method.

A woman with repeated urinary tract infections maybe helped by reducing the amount of time she wears adiaphragm, although she must wear it for at least sixhours after intercourse. She may also try being fittedfor a smaller size, urinating more often before andafter intercourse, or changing contraceptivemethods. ■

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Vaginal SpongeAnother type of female barrier method currentlyavailable is the vaginal sponge, which also contains aspermicide. The sponge prevents pregnancy byreleasing spermicide, and by absorbing and acting asa barrier to semen, thus preventing sperm fromentering the cervix. Sponges are inserted into thevagina in a manner similar to the diaphragm and cap.The sponge needs no fitting and can be obtainedwithout a visit to a clinic.

The sponge is effective for 24 hours and can be usedfor multiple acts of intercourse during this time. Itshould remain in place at least six hours after the lastact of intercourse. At the end of 24 hours, it shouldbe removed and discarded. If left in place too long, abad odor may develop. The sponge should not bereused. The sponge has been found to be lesseffective in parous women.

Availability of the sponge is limited in many places.Currently, there are two sponges on the market, one inEurope, called Pharmatex, that uses the spermicidebenzalkonium chloride (BZK). The other sponge,called Protectaid, is manufactured in Canada. It isdesigned to cause less irritation to the vagina byincorporating three different spermicides in lowconcentrations. ■

New Barrier MethodsNew barrier contraceptives are in various stages ofdevelopment. Some may be available in the nearfuture. The new types fall into four groups: newdevice designs, new materials, new delivery systems,and microbicides and spermicides.

New device designs. The Femcap is a new devicesimilar to a cervical cap. It is made of silicone rubberand can be worn for 48 hours. It may be effective ➔

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without spermicides. Human safety and efficacytrials are in progress.

Lea’s shield is a diaphragm-like device made ofsilicone rubber. It comes in one size and does notneed to be fitted by a provider. It has a loop for easyremoval and a one-way valve to allow passage ofcervical secretions. It can be worn for 48 hours.Early clinical trials have been completed.

Several new designs of the male plastic condom andthe female condom are under development. Theseinclude a new looser fitting male plastic condom, a“bikini” female condom, which is worn likeunderwear, and a female condom that is inserted withan applicator.

New materials. A silicone rubber diaphragm hasbeen developed, in contrast to the standard latexdevice. Women can wear it continuously, withapplications of spermicide before sexual intercourse.It is taken out for cleaning and during menstrualperiods. Study of its effectiveness and acceptabilityare under way.

New delivery systems. Preliminary research hasbeen done on a vaginal ring made of silicone, whichreleases N-9 spermicide at a constant rate for at least30 days.

Microbicides and spermicides. Various substancesare under study for their effectiveness andacceptability as microbicides, which would protectagainst STDs but allow pregnancy. Other newspermicides are under development that would killsperm but be less irritating to the vagina. ■

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Barrier Methods and Reproductive HealthNow that we have reviewed all types of barriermethods, we will discuss in more detail why barriermethods are important for good reproductive health.Good reproductive health includes the prevention ofunintended pregnancies and STDs, including AIDS.Barrier methods, particularly condoms, have thepotential for accomplishing both these purposes, andare currently the only contraceptive methodsrecommended for disease prevention.

The slides in this section discuss issues that programsmay need to consider in providing barrier methods.These include: where barrier methods can beobtained, possible use of two methods to preventpregnancy and STDs, STD prevention services,promotion and distribution through social marketingand through community-based programs, STDdiagnosis and treatment, and logistics of storage andsupply. ■

Where Can Barrier Methods Be Obtained?Many types of programs provide barrier methods, andthe number has expanded greatly, especially for themale condom.

• Family planning programs can provide all barriermethods at clinics, including diaphragms andcervical caps, and are increasingly distributingcondoms and, to a lesser extent, spermicidesthrough community-based family planningservices.

• Family planning and AIDS prevention projectsalso distribute condoms through differentcommunity programs that utilize alternativeoutlets, such as markets, hotels, bars, restaurants,the workplace and entertainment events. ➔

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• STD clinics promote and distribute condoms aftertreating patients.

• Programs working with youth are distributingcondoms as part of teenage pregnancy and STD/AIDS prevention campaigns. This includesschool-based programs in some countries.

• The private/commercial sector increasinglymarkets condoms and, to a lesser extent,spermicides in many “over the counter” locationssuch as pharmacies, retail shops and vendingmachines. ■

Using One Method for Pregnancy and STDPreventionAwareness of the risks of STDs and potentialexposure to STDs has increased rapidly in recentyears, making barrier methods an important methodfor consideration. A growing number of individualswish to have protection both for pregnancy and STDs.

When used consistently and correctly, condoms canbe used for the dual purpose of preventing pregnancyand STDs, including HIV. For women at increasedrisk of STDs who cannot persuade their male partnersto use a male condom, spermicides, the femalecondom and the diaphragm with spermicide arepossible choices for both pregnancy and diseaseprevention. Barrier methods can also be used incombinations, providing more protection. ■

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Using Two Methods: Dual-Method UseBarrier methods are difficult to use consistently andcorrectly. Therefore, in typical use, barrier methodsare not as effective at preventing pregnancy as someother methods. Hormonal contraceptives, intrauterinedevices and sterilization are very effective atpreventing pregnancy but offer no protection againstthe transmission of STDs.

If a person is at increased risk of STD/HIV infection,providers have a responsibility to help clients decidewhich method or methods to use, given this dilemmabetween emphasizing pregnancy prevention ordisease prevention. To address this dilemma, somefamily planning programs are beginning torecommend using two methods, or “dual-method” use— one for pregnancy prevention and the second forSTD prevention. ■

Choices for Dual-Method UseWhen considering dual-method use, the provider andthe client must deal with the question of what is theprimary method. Most family planning programs thatrecommend dual-method use offer a primary methodthat is highly effective for pregnancy prevention andadd a barrier method, usually the male condom, forSTD prevention.

Important challenges exist for this approach to dual-method use. Providing two methods is more costly;even one method may be expensive for manyprograms and couples. Clients may not understandthe need to use both methods consistently andcorrectly. In order for dual-method use to beeffective, counseling is needed for both methods, anda high degree of user motivation is required.

Another approach to dual-method use is to use themale condom as the primary method for both STDand pregnancy prevention. A back-up method, ➔

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emergency contraception, can be added if the condomis not used or if it breaks or slips off duringintercourse. Emergency contraception is usuallyprovided in the form of low-dose combined oralcontraceptives. The current recommended regimen isto take four low-dose combined pills within 72 hoursafter unprotected intercourse, and repeat the samedose 12 hours later. A woman must have easy accessto emergency contraception and be counseled to use itif she chooses this option. ■

Note to presenter: The most commonly used pills are thosecontaining levonorgestrel (LNG) and 30 µg of ethinylestradiol.

STD Prevention ServicesWhen programs evaluate the reproductive healthservice needs of their clients, they should considerSTD prevention services. These basic servicesinclude: providing information on STDs, assessingclients’ risks for STDs, counseling clients about safesexual behaviors, and promoting and distributingcondoms. Further STD services, including diagnosisand treatment, will be discussed in a moment.

To provide these services, family planning programsneed to train staff in how to assess clients’ risks forSTDs and to counsel them regarding method choice.Good materials explaining the risks of STDs areneeded. Unfortunately, many people seeking familyplanning services are not aware of their partner’ssexual activities outside the relationship. This meansthey may not know that they are at increased risk. Ifthey suspect they may be at risk, they may want touse barrier methods as a precaution.

Training in counseling can help providers understandhow to address these sensitive issues. Counselingshould address changing unsafe sexual behaviorsamong clients and their partners. Although this ➔

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type of counseling may initially be uncomfortable forboth clients and providers, it is extremely importantto assist clients at risk of STDs. It also may becomforting to some clients to be able to talk aboutthese issues.

The safest sexual behavior is abstaining from sex.For those who are sexually active, safe behaviorsinclude using condoms, reducing the number ofpartners, choosing partners carefully and engaging inlow-risk sexual practices.

Programs need to promote condoms, including theirconsistent and correct use, and make them readilyavailable to those who need them. Promotion anddistribution may involve many types of outreachefforts. Two particularly important approaches aresocial marketing and community-based distributionefforts, which we will discuss in the next twoslides. ■

Promotion and Distribution: Social MarketingSocial marketing has been a highly successful methodfor distributing the male condom, especially in theAIDS era. Spermicides have also been distributedthrough social marketing programs but on a muchsmaller scale.

“Social marketing” refers to the application ofcommercial marketing techniques to achieve asocially beneficial goal by using advertising, productpromotions and attractive pricing structures. Socialmarketing programs, which are generally subsidized,work around the so-called four “p’s”: products,prices, places and promotion. That is, these programsprovide products at locally affordable prices, inreadily available places, using creative promotiontechniques. In designing social marketing programs,the products, prices, places and promotion must becarefully considered. The involvement of the ➔

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potential clients in the design of strategies andmaterials for the campaign is essential for success.

This approach, which was used as early as the 1970sin parts of Asia, has been widely expanded in recentyears, focusing on HIV prevention. Even in theseAIDS prevention campaigns, promotion has oftenemphasized family planning as well. In countrieswhere aggressive condom social marketingcampaigns have been developed, the number ofcondoms distributed has skyrocketed. For example,in Zaire, condom sales increased from 300,000 in1987 to 18.3 million in 1991. In one study, three ofevery four persons reported that they bought thecondoms for AIDS prevention as well as familyplanning. ■

Promotion and Distribution:Community-based Distribution (CBD)Community-based distribution (CBD) programs areused to increase accessibility of products, particularlyto people in remote rural locations or urban slums.CBD programs have been used widely in distributingoral contraceptives and many other products,including barrier methods.

When sponsored by family planning programs, CBDworkers are usually women, going door-to-door invillages and urban slums. They counsel women andsometimes couples on family planning options. Theylearn to screen for potential problems using achecklist so that women can be referred if necessaryto the appropriate provider. Most CBD workersdistribute condoms, spermicides and pills. Usually, anurse, nurse-midwife or physician supervises CBDworkers.

Family planning programs are beginning toemphasize male condom distribution in new types ofCBD programs. These new programs are often ➔

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prompted by efforts to integrate family planningservices with STD prevention. The Jamaica FamilyPlanning Association, for example, has emphasizedcondom distribution in its outreach program intocommunities, workplaces and rural areas. Even theprogram’s staff drivers have been trained to promoteand distribute condoms. In one year, about half of thenew family planning acceptors in this outreachproject were men.

AIDS prevention projects have also used many typesof community-based approaches to promote anddistribute condoms. These are usually targeted toparticular populations, including men at theworkplace, youth at schools or community locations,people at marketplaces, and individuals in otheroutlets. ■

Beyond STD Prevention: STD ManagementServicesSTD management is an important part of maintaininggood reproductive health. STD management involvesdiagnosis of STDs, treatment, and partner notificationand treatment. If a program cannot offer STDmanagement services, it should consider adding aformal referral program when screening andcounseling indicate that a client may be infected.When possible, such programs should follow up witha client who has been referred to another clinic forSTD diagnosis and treatment.

Compared to counseling services alone, moreextensive staff training and additional staff time arerequired for diagnosis and treatment of STDs.Diagnosis of symptomatic persons can be done inmany cases without laboratory facilities. Becauseinfected women are often asymptomatic, detectinginfected persons may require laboratory referrals.Detecting STDs in asymptomatic persons, while ➔

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difficult, can help prevent infections from gettingworse in individuals and also help preventtransmission in the community.

Treating STDs requires knowledge of the prevalenceof STDs in an area, including the types ofmicroorganisms and their potential resistance tocertain antibiotics. Maintaining an adequate supplyof appropriate antibiotics is essential for STDmanagement and may require budgeting foradditional resources.

STD management services also benefit fromcounseling and treating partners. This is an essentialstep in breaking the infection chain. Even if a clientis treated for an STD, it may be a wasted effort unlessthe partner or partners are also treated, because theclient is likely to be re-infected. Hence, programsshould encourage clients to bring in their partners fortreatment. ■

Logistics of Storage and SupplyStorage of barrier methods is an importantconsideration for family planning programs, just as itis for individuals. It is important to protect the stockfrom heat, light, water, pests or pollution, usingproper storage techniques, illustrated in this slide.This is especially true for latex condoms.

When properly stored in temperate climates, mostbarrier method products will last up to five years.This is true for latex condoms as well if they weregood quality when manufactured and if the packagingremains intact. The quality of the product graduallydeclines with age, so it is best to use stock withinthree years if possible. ➔

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The best way to ensure that barrier methods are nottoo old to use safely is to monitor the supplycarefully. Because the use of barrier methodsrequires continuous resupply, programs need to besure to keep adequate amounts of stock available atall distribution sites. Careful planning is necessary toestimate quantities of supplies required. Accuraterecord-keeping and good stock rotation are alsonecessary. Training staff in all the steps of supply,resupply, stock rotation, storage and record-keeping isessential. ■

Remember...Barrier methods need to be available in all familyplanning programs in a variety of delivery sites. Forindividual users of barrier methods, the mostimportant thing to remember is to use themconsistently and correctly. This requires goodcounseling, instruction and user motivation. Barriermethods are the only contraceptive methodsrecommended for prevention of STDs. And, if usedcorrectly in every act of intercourse, barrier methodsare also highly effective at preventing pregnancy.But, for them to be effective, they must be used. ■

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