It's an old contraception joke: What do you call people who practice the withdrawal method of birth control? Parents.
However, a spate of recent articles and books suggest women are rejecting the pill in favor of other contraceptive measures, including the age-old (and often derided) withdrawal method. In her book Sweetening the Pill: or How We Got Hooked on Hormonal Birth Control, Holly Grigg-Spall offers what she calls a "feminist critique" of hormonal contraception, arguing it is bad for women and represents a form of misogyny. A September article in New York magazine dubbed women who eschew hormonal birth control "The Pullout Generation."
Are women deserting the pill and starting to rely on nonhormonal methods such as withdrawal or rhythm?
The evidence does not show that, despite a recent flurry of articles suggesting it is so. According to the Centers for Disease Control and Prevention (CDC), about four of every five sexually active women have used the pill, a percentage that has remained constant since 1995.
In fact, the CDC's data shows that the use of other forms of hormonal birth control, such as injectables, patches, rings, implants and intrauterine devices (IUDs) has risen. The drop in teenage pregnancies (and abortions) has partly been credited to the increase in pill use by that age group.
Dr. Jennifer Brunet, an Ochsner OB-GYN, has also seen no evidence of patients dropping hormonal birth control. "Once in a while, I'll have a woman come in and ask about rhythm (a calendar-based method), but I certainly haven't seen a trend or people leaving the pill," she says. "It still is the most popular form of birth control."
What has changed, according to the CDC, is that the use of barrier and spermicidal periodic methods, such as the diaphragm, the cervical cap, foam, etc. has remained low or declined.
"The use of those methods has definitely fallen," Brunet says. "For example, I've only had four patients in three years choose a diaphragm — and only one who is still using it."
The use of condoms also has increased, a shift believed to have resulted from STD and HIV prevention efforts. Along with that increase has come a rise in the number of women who said they have relied on withdrawal at some point. The CDC states the two may be associated, since 60 percent of the women interviewed about current birth control usage in the month of the interview had used condoms and withdrawal together.
The news also was stirred by a recent study by Dr. Annie Dude, an OB-GYN resident at Duke University Medical Center, which found one in three young women (ages 15 to 24) relies on withdrawal as their only form of birth control, and about 22 percent will unintentionally become pregnant.
It is clear the use of withdrawal has increased, with data showing that younger women often rely on it in the absence of contraceptive methods that require planning, i.e. buying condoms or getting an IUD — and that they are using it without much success.
As for the women who rejected hormonal contraception in these recent articles, they tend to be older, in steady relationships (implying partner support and men they trust will "pull out") and they use withdrawal in conjunction with other forms of contraception such as condoms and fertility awareness — typically called rhythm or natural family planning (NFP).
Only 1.1 percent of all U.S. women who practice contraception rely on the rhythm method or NFP, a number that does not change much even among Catholics, where church teachings say NFP is the only form of acceptable birth control, though only 2 percent practice it.
That lack of reliance on fertility awareness is due to several reasons. To practice it properly, experts say the woman needs to have a regular cycle and consistently track her basal body temperature (waking temperature before moving, eating, etc.), the days of her menstrual cycle and her cervical mucus. It also requires partner cooperation.
However, the U.S. Department of Health & Human Services says most women don't have totally regular cycles, while Brunet notes that a third of her patients don't. "If you're not on a 28-day cycle, it is more difficult to pick up on changes," she said. "Plus, with the growth in obesity, irregular cycles have become more common."
Brunet says the change one looks for when tracking basal body temperature is extremely subtle and difficult to read. "It is as little as .4 degrees, so you need to know your normal basal temperature, which can change on a day-to-day basis and which can have other things come into play too."
"The bottom line is that those of us who are loath to make personal observations are an awful lot less likely to succeed in collecting and interpreting data than our scientist sisters," writes Danielle Bean, a Catholic writer, NFP advocate and mother of eight. "It should be noted (but too seldom is) that some of us are better at abstaining than others."
These issues lead natural family planning to have one of the highest contraceptive failure rates at 24 percent in typical use. Perfect use raisees that percentage to less than 1 percent, but that is rare, which is why health experts rely on typical use data.
Can fertility monitors, ovulation kits, period tracker applications and other products in the market help women leave hormonal contraception behind? At this point, Brunet says, most are designed to aid conception, not avoid it, and there is little evidence as to their effectiveness.
There are other issues. Women with irregular cycles pose problems. People often misread or get incorrect results. And many of these aids are expensive and not covered by insurance, unlike contraception, which under the Affordable Care Act, must now be covered.
So where does this leave women like Grigg-Spall who feel physically unwell when they take hormonal contraceptives or have other concerns?
Health practitioners note there are different contraceptive formulations and modes of delivery (oral, implants, etc.), so switching might help. There also are nonhormonal methods such as the copper IUD. Using two nonhormonal methods together increases contraceptive effectiveness as well.
Ultimately, people are more likely to comply and adhere to protocols that are easy to use and follow, which tends to make hormonal contraception a winner for most women.
But Everyone must weigh her own feelings, circumstances, partners and ability to follow through. They must also understand that as far as risk goes, pregnancy generally poses more risk than any form of contraception. According to the World Health Organization, 800 women worldwide die each day in childbirth. In the U.S., it's 1,000 women a year.
Finally, unintended pregnancy means unwanted kids, and those are the ones who are most likely to be unhealthy, abused, do poorly in school, commit crimes, and live in poverty, That is a risk everyone should understand.