Executive Summary

One-third of women at risk of unintended pregnancy used coitus interruptus as a contraceptive method within the past 30 days, often in combination or rotation with more effective methods, according to findings from a new U.S. study.

  • The study, which looked at national data from 3,276 women ages 18-39 in 2012, found that among the one-third of women who had used withdrawal in the past 30 days, 12% reported using only withdrawal. The majority of women who practiced withdrawal also used a hormonal method (13%) or condoms (11%) within that same timeframe.
  • Withdrawal Has Perfect Use Failure Rates (4% Of Women Experiencing Unintended Pregnancy In First Year Of Use) And Typical Use Failure Rates (22% Of Women Experiencing Unintended Pregnancy In First Year Of Use) That Match Those For Condoms And Fertility-awareness Based Methods.

Don’t discount withdrawal as a form of contraception. One-third of women at risk of unintended pregnancy used coitus interruptus as a contraceptive method within the past 30 days, often in combination or rotation with more effective methods, according to findings from a new U.S. study.1

The study, which looked at national data from 3,276 women ages 18-39 in 2012, found that among the one-third of women who had used withdrawal in the past 30 days, 12% reported using only withdrawal. Most women who practiced withdrawal also used a hormonal method (13%) or condoms (11%) within that same timeframe.1

What prompted researchers to look into the use of withdrawal? When scientists undertook the study, they wanted to obtain the most accurate measures of recent contraceptive use available, explains Rachel Jones, PhD, senior research associate at the Guttmacher Institute in New York City. This goal led researchers to do two things differently on their survey, explains Jones, who served as senior author of the paper. “First, we asked about hormonal methods and coital methods separately,” Jones notes. “We adopted this strategy because women and couples use these methods in very different ways and sometimes for reasons unrelated to pregnancy prevention, such as to regulate their periods or to reduce the risk of sexually transmitted infection [STI] transmission.”

The researchers placed withdrawal first on the list of coital methods, states Jones. The researchers suspected that many women don’t consider withdrawal to be a “real” method and, by listing it first, it served as an indication that researchers wanted to know about use of this method as well, she says.

In the national sample of more than 4,500 adult women, researchers found that reliance on withdrawal was as common as reliance on condoms (33% versus 35%, respectively).

“This finding did not necessarily surprise us. We expected we would get higher incidence levels when we placed it first on the list,” observes Jones. “What did surprise us was the fact that most women who reported using withdrawal in the last 30 days also reported using a more effective method, most commonly the condom or the pill.”

Users of withdrawal might fall into two camps, says Jones: women/couples who are not particularly motivated to avoid pregnancy and rely only on withdrawal, and women/couples who are highly motivated to avoid pregnancy and use it as a second or backup method.

What to keep in mind

Don’t dismiss withdrawal, says Deborah Kowal, MA, PA, executive editor of Contraceptive Technology.

Findings from the National Survey of Family Growth, a national compilation of information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and men’s and women’s health, indicate that half of women report having used withdrawal at some time in their lives.2 But on closer examination, the extent of use seems greater, notes Kowal. In a study of low-income African-American adolescents, 60% reported having used withdrawal in the previous three months.3 Withdrawal is “the ever-present backup method,” she states.

Take the initiative in asking patients whether they sometimes rely on withdrawal, because many women won’t otherwise volunteer that they use it, notes Kowal. Since withdrawal falls on the bottom tier of effectiveness, couples need to be prepared for a potential failure. The method can effectively prevent pregnancy. Withdrawal has perfect use failure rates (4% of women experiencing unintended pregnancy in first year of use) and typical-use failure rates (22% of women experiencing unintended pregnancy in first year of use) that match those for condoms and fertility-awareness based methods.4

When used with a hormonal method, withdrawal adds protection, notes Kowal. When it is used with condoms or with fertility-awareness based methods during the fertile days, withdrawal doesn’t give added protection; it’s just a substitute for correct use or abstinence, she states.

If a patient says she uses condoms, it might not be the case, says Kowal. If her partner places the condom on after he’s already had vaginal penetration, then it is really withdrawal, she notes. Correct condom use requires that the condom be placed on the penis before any penile-vaginal contact. In one study of college males, 43% reported using withdrawal during initial phases of intercourse, then applying a condom for intravaginal ejaculation.5

Remind women that pre-ejaculate can contain sperm, though generally less than 23 million, says Kowal. The risk of pregnancy is still low, but it is not zero.6 Also counsel that withdrawal does not protect against STIs.

It is not helpful to tell women that withdrawal doesn’t work, says Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of iWomansHealth in Washington, DC, which focuses on information on women’s health issues for clinicians and consumers. “It’s much better than nothing,” states Wysocki. “It’s the one method you don’t leave home without.”

Using withdrawal as a method is a sign that the woman/couple is motivated to prevent pregnancy, states Wysocki. Clinicians can help by offering methods with a higher rate of effectiveness with a script such as, “I can see you are motivated not to become pregnant. I can provide you with other methods that are much more effective for preventing pregnancy.”

REFERENCES

  1. Jones RK, Lindberg LD, Higgins JA. Pull and pray or extra protection? Contraceptive strategies involving withdrawal among US adult women. Contraception 2014; 90(4):416-421.
  2. Mosher WD, Martinez GM, Chandra A, et al. Use of contraception and use of family planning services in the United States: 1982-2002. Adv Data 2004; 350:1-36.
  3. Sznitman SR, Romer D, Brown LK, et al. Prevalence, correlates, and sexually transmitted infection risk related to coitus interruptus among African-American adolescents. Sex Trans Dis 2009; 36(4):218-220.
  4. Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  5. Crosby RA, Sanders SA, Yarber WL, et al. Condom use errors and problems among college men. Sex Transm Dis 2002; 29:552-557.
  6. Killick SR, Leary C, Trussell J, et al. Sperm content of pre-ejaculatory fluid. Hum Fertil 2010; 14(1):48-52.

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