Physicians, demographers, and epidemiologists often approach family planning as an issue of comparative risk and effectiveness of various contraceptive methods. But as the statistician Christopher Tietze (1908—84) wrote in the 1950s, any contraceptive approach succeeds only if it is “use-effective”—one which individual women (and men) find appropriate for use within their own lives. This idea, of course, has very different connotations in the developed countries of the world, where contraceptives are marketed products, and in developing countries, where they are often made available through government population control programmes. Let us consider a few historical instances from the USA in the mid-20th century that cast some light on the way women responded to using contraceptives.
In the late 1950s, Tietze, then at the National Committee for Maternal Health (NCMH) in New York, was working to improve the scientific legitimacy of contraception, both within US medical practice and for implementation in global population control programmes. With his ally Mary Calderone at the Planned Parenthood Federation of America, he embarked on a research study to compare diaphragms, Planned Parenthood's medically endorsed method of choice, with what they called “simple methods”—spermicidal creams, jellies, and foam products. Tietze and Calderone suspected that many women found these products, which were widely marketed not only through physicians but also available at pharmacies and even five-and-dime stores, easier to use than the diaphragm, and therefore more “use-effective”. Calderone lamented at one point that they could not gather data on condoms, also a simple, widely available method, but one that at the time was inaccessible to clinic-based research, since virtually all condoms were purchased by men in retail outlets.
Planned Parenthood's 3-year simple-method study and a concurrent project at the Cleveland Clinic had similar results. Although spermicides seemed to be effective when used consistently, Tietze found it impossible to draw significant conclusions, since more than 60% of the women who took part dropped out of the study within 18 months. Although each woman was allowed to choose her own method when enrolled, many would not use it regularly or even adhere to a single method or product for more than a few months; all failed the use-effectiveness test. Tietze noted ruefully that “consistent use of one method was often not compatible with their pattern of life as evidenced by the frequent comment that they liked variety”.
Tietze had meanwhile begun working with Frederick Osborn and the Population Council on what promised to be a method less subject to user whim: the intrauterine device (IUD). This inexpensive and apparently effective device, inserted and removed only by physicians, seemed to be an ideal solution for global population control. The Cooperative Statistical Program (CSP) designed by Tietze evaluated five different IUDs between 1963 and 1968. The final reports presented data on 31 767 women submitted by 33 researchers at 26 clinical sites. Some 45% of the participants dropped out before the study concluded, some because of personal choice, most for “medical reasons” (other than expulsion). Tietze noted, however, that “The distinction between medical and personal reasons was not always unequivocal; doubtful cases were classified as medical.” In order therefore to assess the contraceptive effectiveness of the IUD, Tietze developed a formula that assessed the experience of those who persisted, “the more determined contraceptors”, while excluding those who had not found the device as use-effective.
In 1960, of course, the IUD and all earlier methods of contraception were overtaken by the astonishing impact of the pill. Tietze, Calderone, Osborn, and their colleagues had known that Enovid (Conovid), the first oral contraceptive (a progestin-oestrogen compound), was in development, but at an NCMH conference in 1958, had agreed that most women would probably not find a medication that altered their physiological cycles acceptable. This was clearly a misconception. The freedom and personal control that the pill put into the hands of women was life-altering for many. As Loretta Lynn sang in 1975, “I'm making up for all those years since I've got the pill.”
Oral contraceptives proved not to be an unmixed blessing. In November, 1961, The Lancet reported the death from thrombosis of a young woman who was taking the pill; in less than a year, the US Food and Drug Administration (FDA) had received reports of six such deaths and 20 other non-fatal cases. Popular articles in newspapers and magazines began to ask, “How safe is the birth control pill?” Several years of uncertainty and controversy followed, culminating in 1967, when Martin Vessey, Richard Doll, and their colleagues published their epidemiological findings in the British Medical Journal. They estimated the pill's mortality risk at one in 67 000 for women aged 34 years and younger and one in 25 000 for those aged 35 and older. The American journalist Morton Mintz, who had broken the thalidomide story in the USA, charged Enovid's developers, Gregory Pincus and G D Searle and Company, with risking the lives of thousands of women, claiming erroneously that the pill had been tested on only 132 experimental subjects before FDA approval. The feminist writer Barbara Seaman's better-evidenced, but impassioned, book, The Doctors' Case Against the Pill, fuelled consumer and congressional concern, resulting in a series of hearings chaired by Senator Gaylord Nelson in 1969, and the strengthening of the consumer warnings inserted in each packet of oral contraceptives sold.
As Elizabeth Watkins has described, the debate over the pill and the Nelson hearings galvanised feminist health activism in the USA and elsewhere. On the one hand, women still wanted an easy-to-use contraceptive that allowed them to control their own sexuality and reproductive choices; on the other, some no longer fully trusted the medical profession to make decisions for them and they trusted the pharmaceutical industry even less. Features in the popular magazines now shifted emphasis from discussing the risks of the pill to comparing and contrasting various contraceptive methods available and describing the “lifestyle” that each would best fit—in other words, assessing their use-effectiveness.
As concerns focused on oral contraceptives in this period, the IUD seemed to be a safer alternative to many women and physicians. In 1971, however, A H Robins Company introduced the Dalkon Shield, a tiny triangle-shaped IUD with “fins” to prevent its expulsion; the company claimed that the Shield was 98·5% effective in preventing pregnancy. Over the next 3 years, some 3·7 million women chose to have this device inserted, including many young, single women, whom A H Robins specifically targeted in its marketing. But within a year physicians reported cases of severe pelvic inflammatory disease, leading to miscarriage, birth defects, infertility, and even death. A H Robins suspended sales in 1974 and stopped manufacture in 1976, with about 400 000 lawsuits in progress; the company was forced into bankruptcy in 1986.
The subsequent histories of oral contraceptives and the IUD are telling. Manufacturers of both types of product have undertaken extensive research and redesign efforts to address the identified risks and improve the safety profiles; the current formulations on the market are relatively low-risk and well-publicised so that both physicians and consumers are able to make informed choices. Many medical experts consider the newer IUDs safer for long-term use than oral contraceptives. But while women have continued to find oral contraceptives use effective, in the USA at least IUDs never seem to have fully regained the confidence of women after the 1970s. Indeed, IUDs became less available in the USA during the 1980s and 1990s, as manufacturers found the market too limited to invest their time and effort; only two devices, the copper-T Paragard and hormonal Mirena, are currently available. In most parts of Europe IUDs are used by a higher proportion of women than in the USA, although they are still less popular than oral contraceptives. By contrast, in many Asian and African countries, where it has often been endorsed by government programmes, IUD use predominates.
In 1990, the Population Council tried again with Norplant, an implantable device that slowly released progesterone over 5 years, a method designed to combine the best features of the pill and the IUD; but women in developed countries disliked the erratic menstrual cycles they experienced with it. Norplant disappeared from the US and UK markets by around 2000 and other new implant and injectable products have so far had only limited impact on patterns of use.
Watkins has explored the remarketing of the oral contraceptive as a “lifestyle” drug, one that may also relieve premenstrual mood changes, treat acne, and regulate menstruation. But popular writers have discussed the appropriate contraceptive for a given lifestyle since at least the 1970s. The ultimate message of much of this popular literature in western countries is that women who take the pill are characterised as young, intelligent, free-spirited, able to choose for themselves. Condoms, since the 1980s, are often presented as a prudent choice for those who want to have multiple partners or spontaneous sex. By contrast, the IUD is often represented as the choice of the woman who has had her family and no longer wants to think about contraception. But for these women IUDs compete with surgical sterilisation, which has become an increasingly popular choice in both the USA and the UK.
Many women's responses to contraception in the 21st century are clearly interwoven with feminism, concerns about pharmaceutical marketing, and the rising consciousness of women about their own health. But it is worth looking back to the 1950s and listening to Tietze's stubborn study participants who “liked variety”. Where they have options, women will make choices; that is where family planning policy must start.