Birth control is a basic health care need for all uterus-bearing people of reproductive age. But the science of contraception does not, and has never, lain strictly within the realm of women’s health. The choice of whether to become a mother, and when, is dependent on the birth control options that are available—which have been more influenced by politics, social mores, and even marketing than by medical research.
It’s hard to understate the importance and impact of the Pill. In just five years, 6.5 million women in the United States were using it to autonomously control their fertility, with no need for a man’s cooperation. Today, four out of five women have used the Pill at some point in their lives, according to the Guttmacher Institute; about 28 percent of women use it as their primary birth control.*
But since 1960 when that “miracle tablet” (to borrow Planned Parenthood founder Margaret Sanger’s words) came out, progress in the field has been minimal. According to a 2013 report by the Centers for Disease Control and Prevention, almost 50 percent of women surveyed had started and stopped using a form of birth control because they experienced or were concerned about negative side effects; one-third had tried five or more types of contraception. With so many ostensible options—the Pill, the patch, an IUD, condoms, injection—progress since the great leap forward of oral contraception has been more like baby steps.
In their “History of Contraception,” Malcolm Potts and Martha Campbell devote a chapter to the “historical diapause” of birth control development. “Despite the many biologic problems in the understanding of human reproduction,” the authors write, “it seems reasonable to assert that progress in the control of fertility could have been more rapid than it actually has been. Social factors, rather than an absence of scientific knowledge, proved the greatest barrier.” Detailing the history of contraceptive methods, they point out that by the time of Charles Darwin’s death, “a basic understanding has been established of the physiology of every body system,” including the cell theory of biology, evolution, anatomy as we know it today, bacteria as the cause of infection, and anesthesia. And yet, “the understanding of reproduction lagged behind that of other systems.”
People have been trying not to get pregnant since the beginning of time. Though poorly documented by historians, coitus interruptus as a means of preventing pregnancy has likely been happening since the beginning of modern humanity. There’s evidence that an herb called silphion was used in ancient Greece for either contraception or abortion; despite being worth its weight in silver, the herb was harvested to extinction. Then there was the medieval quackery to the tune of “jump five times backwards post-coitus,” and, all throughout history, a host of methods for inducing abortion surgically and medically. These reached their apogee in the Victorian era when back-alley abortion providers and pills of dubious origin cluttered the advertising pages of newspapers, often couching their very purpose as “warnings” in the copy (“A blessing to mothers … and although very mild and prompt in other operations, pregnant females should not use them, as they invariably produce a miscarriage,” read an ad for “Dr. Peter’s French Renovating Pills”).
Margaret Sanger is Planned Parenthood’s founder and patron saint. Sanger, a nurse by profession, came from impoverished beginnings that would inform her life’s mission of giving women reliable birth control—a term she coined—that they could control themselves. A fortuitous meeting led Sanger to Katherine McCormick, who would pick up the tab. McCormick came from a wealthy family and married even wealthier, studied biology (she was the first woman to earn the degree from MIT) and went on to make female reproductive health her life’s work. Through Sanger she met biologist Gregory Goodwin Pincus, a brilliant endocrinologist who had already been researching the relationship between hormones and fertility and who was to become the co-inventor of the Pill.
But biases were to make the development of oral contraception much more arduous than it might have been. In 1934, Pincus was called “Dr. Frankenstein” and denied tenure at Harvard after his test tube bunny made the cover of Look magazine, the result of his pioneering work in in-vitro fertilization. It was an era of “Big Brother” fears (“Brave New World” had just been published), and interwar, Depression-fueled conservatism. Sanger and her husband were convicted under the Comstock Act, known formally as the Act for the Suppression of Trade In and Circulation of Obscene Literature and Articles for Immoral Use. Passed in 1873 by a New England killjoy and dry goods salesman named Anthony Comstock, the act lumped together birth control and abortion with pornography and prostitution, and with Puritan fervor Comstock arrested anyone guilty of trying to procure or sell such materials. Thanks to these “chastity laws,” Sanger was arrested first in 1914 for publishing Family Limitation, a pamphlet describing birth control methods, and then again in 1916 after she opened America’s first birth control clinic in Brownsville, Brooklyn. The conviction was sustained until 1918 when a judge overturned it and ruled that condoms could be legally advertised and prescribed as tools for preventing disease (but not as birth control). It took decades for the country to overcome its prudish aversion to advertising birth control, with the Justice Department only overturning a late 50s ban against condom ads on TV in 1979.
Out of the Lab,
Into the Magazines
Hormonal contraception exists because of the synthesis of progestin, used in combination with estrogen to simulate pregnancy in a woman’s body and thereby make it impossible for sperm to fertilize an egg and make her pregnant. Many scientists in the 1950s and 60s played a part in its creation: chemist Carl Djerassi and his two colleagues, who first synthesized progestin, along with Pincus, Min-Cheuh Chang, John Rock and others.
But since the groundbreaking oral contraceptive came out in 1960, there hasn’t been much by way of contraceptive development. The doses of hormones in the Pill have lowered, but the formula is fundamentally the same. Other non-barrier birth control methods rely on different delivery models of the same hormones. Though modern IUDs became available a few years after a Pill, they also simply improved on a technology first created in the 1920s.
“What has changed over the past several decades is how contraceptives—specifically, birth control pills—have been marketed,” writes researcher and writer Dr. Elizabeth Siegel Watkins in a 2012 article titled “How the Pill Became a Lifestyle Drug: The Pharmaceutical Industry and Birth Control in the United States Since 1960” published in the American Journal of Public Health. Reviewing the “stalled progress” in contraceptive development, notes that direct-to-consumer advertising of the Pill wasn’t even allowed until the mid-1980s, and until then, pharmaceutical companies advertised birth control in medical journals as purely a contraceptive. The marketing messages didn’t change until around 1990 as pharmaceutical companies responded to this new, direct marketing channel. “Lifestyle drugs,” a term coined in 1978 to describe drugs meant to improve one’s quality of life rather than address a medical need, helped mask the fact that as a form of contraception, birth control hadn’t changed much. This growing classification of drugs, however, provided a convenient way to market the pill for its positive side effects—acne control, PMS relief and the reduction of period frequency—rather than its primary purpose. Ironically, activists like Sanger ended up fighting for birth control to be legally advertised and sold, only for it to billed as a remedy for better skin.
Watkins cites another, related reason for the shift in focus from birth control’s efficacy to its secondary side effects: Big Pharma’s retreat from birth control research. Birth control progress has been stunted in part because pharmaceutical companies no longer research it, and they no longer research it because the past few decades of birth control developments have been marred by lawsuits, the result of malfunctioning products. The now-notorious Dalkon Shield, an I.U.D. that was designed to reduce the risk of expulsion by the uterus and intrauterine bleeding, led to 18 deaths and several more septic abortions and emergency hysterectomies. More recently, Bayer has been blasted for side effects of its birth control pill Yaz and its IUD Mirena, and Merck & Co. for complications related to the Nuva Ring. To drug companies, complications mean lawsuits, millions or even billions of dollars worth of settlements, and in the case of A.H. Robins, producers of the Dalkon Shield, bankruptcy.
In many cases, the companies came under fire for downplaying the possible risks and side effects of the product. Thus improvements have been minor, like the reduced dosage of hormones needed for the Pill or a safer design for the IUD.
Outside the lagging science of female-specific contraception, much has been said over the years about the “male pill,” which seems to be always just a few years away. Vasalgel is being developed as a “social venture” by the Parsemus Foundation, a small private foundation focused on seeing through ideas that have been cast aside by Big Pharma and making them affordable. Instead of a pill, Vasalgel is similar in concept and delivery, but not in formula, to a drug called RISUG that has been developed in India (though not yet on the market there). The concept is simple and involves no hormones: A polymer gel is injected into the man’s vas deferens, preventing sperm from passing through. But the road to market is long, as the company relies on relatively small investors and donations while adhering to increasingly complex FDA regulations. However, Paramus Foundation reports that over the next six months, they’ll be ratcheting up their preparation for human clinical trials.
There are a few other methods that are currently being explored for male birth control too, from an Indonesian herb to an ultrasound-based technique. Aaron Hamlin, executive director of the Male Contraception Initiative, told HealthDay that there is virtually no money out there, government or private, for the development of male contraceptives: “For the pill, that funding was through philanthropist Katharine McCormick. But we’ve yet to find our modern-day McCormick.”
In the U.S., contraception research largely comes from the government. However, funding for philanthropic foundations that do work in this field, like the Gates Foundation, is far less than what it used to be, while the number of pharmaceutical companies involved in birth control research has dwindled. In fact, most developments in contraception aren’t thanks to our advanced first-world medical system; they’re happening in developing countries to address the widespread lack of access to reproductive health tools and education.
Depo-Provera is a four-times yearly progestin injection that women in many such countries take in lieu of the daily birth control pill and was the last major development in the field. A newer project is an evolution of that technology. Gates Foundation and USAID funded the development of Sayana Press by the drug company Pfizer: a portable, single-use contraceptive in a syringe, similar to the way diabetics self-administer insulin. Made particularly for women in rural areas of Africa and Asia, women can inject themselves with the contraceptive on their own without having to travel to a doctor, and they don’t have to tell their husbands that they are on birth control.
From Women’s Health
to “Pro Choice”
Regardless of what happens in the lab, the birth control options available today are still not 100 percent reliable, resulting in the most polarizing spoke in the wheel of women’s health—abortion.
“For many people, unplanned pregnancies are so common—there are 3 million a year—and it has that ability to shift a woman’s course in life,” says physician Sara Pentlicky, who works for Planned Parenthood of the Great Northwest and Hawaiian Islands. Raised in the New Jersey town in North Plainfield, it took doing a residency in Lexington, Ky., part of a Family Planning Fellowship with Planned Parenthood, to realize how little control many women felt they had over their own fertility.
She also realized that abortion was not a part of OB-GYN training, or other considerations related to it. “We often talk about how we’re going to tell someone they have a terminal illness or a new diagnosis,” she points out. “There was a range of training about having this conversation [about abortion] that was absent.”
A short research project in Barbados further informed Pentlicky’s understanding of the realities of reproductive health, which is continually enriched by her experience in the field in a variety of environments with different socioeconomic groups: at clinics in the city of Seattle, in a rural region north of the city, and at a large military base. No matter the population, though, Pentlicky sees the “same things that you see at any abortion clinic.” Some women are “determined not to be a parent right now” and feel only relief, while others are “just sad.” But the sadness tends to come from the knowledge that birth control failed, whether it was their fault or not.
“They’re more sad about the unplanned pregnancy than the abortion,” she says. “[I hear], ‘I can’t believe I let this happen to me, this is all my fault, I missed my pill.’”
Pentlicky points out that the idea of dividing up the abortion issues between party lines is historically new, only starting in the 80s, when the pro-life movement was born from religious conservatives and other groups protesting the procedure. In March of this year, the Supreme Court will hear Whole Women’s Health v. Cole, a case that challenges the legality of Texas’ limiting abortion laws. It’s the first Supreme Court abortion case in nearly a decade and is to be decided by Justice Anthony Kennedy, who in 2007 used the grounds that “some women come to regret their choice to abort the infant life they once created and sustained” in his majority opinion of the last abortion case, Gonzalez v. Carhart, which upheld the Partial-Birth Abortion Ban of 2003.
In response to the impending hearing of Whole Women’s Health, a group of 113 attorneys signed an amicus brief with the support of the Center for Reproductive Rights that explains why having an abortion was important to their lives and how doing so allowed them to continue to pursue a career in law. The stories come from women of diverse backgrounds, each and every one detailing how the woman became unexpectedly pregnant at a pivotal point in her studies or career (often despite using birth control correctly). Beyond the derailment of careers, some women’s stories also emphasized personal struggles, including the possibility of mothering a child with an abusive husband and a willingness to consider illegal abortions, despite the risks. The stories are inspiring and moving, but they also represent a bigger argument: whether feelings, religious or personal, should have a place in the legal debate in the first place.
While the relatively recent addition of abortion into public discourse has turned women’s bodily autonomy and access to medical services into a fiery debate, according to the most recent numbers from the Centers for Disease Control and Prevention, both abortions and pregnancies hit an all-time low in 2010, the latest year for which the agency has numbers. Abortion rates peaked in 1980 and have been on a steady decline since then, thanks in part to wider use of effective birth control. The numbers also reveal that while teen pregnancies have dropped precipitously, pregnancy rates for women 30 and older are going up—indicating that wanted, planned pregnancies are now the norm, with women using birth control for longer and longer before choosing to have children.
This trend is also tied to the economy. In 2014, the National Center for Health Statistics found that the national birth rate rose 1 percent, the first increase since the beginning of the Great Recession. The Pew Research Center had previously identified a link between the economy and the birth rate, further indicating that access to quality family planning is vital to helping people identify the best time, emotionally and economically, to have children if they choose to. The numbers indicate that U.S. women are now effectively, if imperfectly, controlling their reproductive health—a development that has been forever in the making.
* It is unclear whether this study included others concerned with reproductive issues, like trans men and non-binary people, whose use of the Pill may skew these numbers even higher.