Birth Control, History of

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BIRTH CONTROL, HISTORY OF

Evidence of attempts at contraception and induced abortion are found in many societies. Many preliterate societies used a variety of herbal remedies in attempts to suppress fertility or to induce menstruation. Literary evidence of contraception is found in the work of Egyptian, Classical, and Arabic writers, such as the Greek physicians Disocorides and Soranus (first–second centuries c.e.), the Roman historian Pliny the Elder (died 79 c.e.), and the Arabian physician and philosopher Avicenna (died 1037c.e.). Archaeological evidence of induced abortion has been found in a Romano-Gallic site in the Netherlands where the skeleton of a young a woman was discovered with a bone stylet, which was used to induce abortion, in the pelvis.

In classical times, the principal export of the Mediterranean port of Cyrene was a plant called silphion. Related plants demonstrate oxytocic properties, and sylphion seems to have been such an effective abortifacient that it was harvested to extinction. The oldest pictorial representation of a mechanical abortion is in a bas relief illustrating massage abortion in the great temples of Angkor Wat in Cambodia (1150 c.e.). The image depicts devils in masks pounding the abdomens of women who appear to be about 20 weeks pregnant. An identical procedure continues to be widely used in contemporary Southeast Asia.

The Judeo-Christian Tradition

Induced abortion is mentioned once in the Bible (Exod. 21:22), which categorizes it as a crime, but explicitly not as murder. Coitus interruptus is mentioned once in a passage in Genesis (38: 9). The story of Onan, "who spilled it [his seed] on the ground" is well known. Talmudic commentators are divided as whether God slew Onan because he practiced withdrawal, or because he disobeyed his father's command to make Tamar, his dead brother's wife, pregnant.

The New Testament makes no comment on any aspect of fertility regulation, but Saint Paul, in his letters, places women in an inferior position to men. The early fathers of the Church became increasingly conservative in their interpretation of human sexuality. Saint Augustine (died 430) had the same mistress for many years, with whom he had one child, and he may have practiced coitus interruptus. He taught that original sin had been passed down the generations in the semen, much like some precursor to the HIV virus, and therefore the unbaptized were condemned to eternal damnation. He argued that nocturnal erections were evidence of human sin because they were not under the control of the human will. Given such interpretations, Saint Augustine was led to conclude that the only justification for sexual intercourse was to perpetuate the human race. In his words, "that which is done for lust must be done in such a way that it is not for lust's sake" (Contra Julianum, 5, 9). Other western theologians constructed even more contrived restraints on human sexuality. By the later Middle Ages, intercourse was forbidden on Sundays, Fridays (the day when Christ died), feast days (which were numerous), and throughout the 40 days of Lent. In effect, intercourse was forbidden for approximately half the year. Women were told that if they had a congenitally abnormal baby it was because they had sex during menstruation or during some forbidden time.

Augustine condemned all types of artificial conception, including periodic abstinence. But in the late-nineteenth century, contrived exceptions began to be constructed to permit use of the rhythm method (abstinence limited to what was believed to be the fertile period of the woman's menstrual cycle). In 1920 the Lambeth Conference of Anglican Bishops moved to a cautious recognition of licitness of all artificial contraception. The Second Vatican Council (1962–1965), which marked a watershed in Catholic teaching in a variety of domains, was expected to move the Catholic Church in the same direction. Most people expected that the approval of contraception would be widened, at least to include the then newly available oral contraceptives. Pope Paul VI, who became pope in 1963, set up a commission to review the topic, which eventually included five women. The majority of the commission voted to revise the church teaching of birth control. However, Paul VI rejected these recommendations and published the encyclical Humanae vitae in 1968. It condemned any contraception, defined as "action, which is either before, at the moment of, or after sexual intercourse, that is specifically intended to prevent procreation–whether as an end or a means." It was a linear continuation of Augustine's teachings.

Only fragments of written information exist to illuminate the pain these teachings brought to countless women and their families over the centuries. An Inquisitor condemning Albigensian heretics to the stake (circa 1320) in Montaillou, France, interrogated one woman who had had a sexual relationship with a priest. "What shall I do if I become pregnant by you? I shall be ashamed and lost," she said. "I have a certain herb" responded her lover, "the one the cowherds hang over a cauldron of milk in which they have put some rennet to stop the milk curdling" (Le Roy Ladurie). Between 1647 and 1719, in Colyton (in Devon, England), the mean age of marriage for women rose to 29.6 years. In one parish in Somerset only one in 200 pregnancies was to women under age 17. Ecclesiastical court records show that while many women went to the altar pregnant, premarital sex was limited to a very short interval before marriage. Women who did bear a bastard child could be publicly whipped on market day–with extra stripes if they did not breastfeed their baby. In 1671, a French aristocrat, Madame de Sévigné wrote to her daughter, "I beg you, my love, do not trust to two beds; it is a subject of temptation. Have someone sleep in your room."

The Nineteenth Century

With industrialization, urbanization, and some fall in infant mortality, the pressure to control family size grew. The first articulated efforts to disseminate knowledge about family planning technologies date from the early-nineteenth century. They began with English Free Thinkers such as Francis Place (1771–1854) and John Stuart Mill (1806–1873). Place had 15 children and he understood the sufferings of factory workers and servants in the big cities. He wrote what contemporaries called the Diabolical Handbills describing the use of a sponge inserted vaginally. In 1832, the American physician Charles Knowlton (1800–1850) published anonymously The Fruits ofPhilosophy, which described post-coital douching. Several publishers were prosecuted under obscenity laws in the United States and Britain for republishing Knowlton's work.

In 1871, Charles Bradlaugh (1833–1891), a Free Thinker who had been elected to the British Parliament, and Annie Besant (1847–1933), a writer who had rejected the conventions of marriage and joined the Secular movement, deliberately challenged the law by republishing The Fruits of Philosophy. Their trial was widely reported in daily papers and sales of the book rose from 1,000 a year to 100,000 in three months. Bradlaugh and Besant were acquitted on a technicality. A substantial and continued decline in the British birth rate began at that time, most likely driven by increasing use of withdrawal and rising abortion rates, along with the commercial availability–albeit under the counter–of condoms and spermicides. Historical demography suggests that withdrawal, along with delayed marriage, was being used to limit family size in Elizabethan England and coitus interruptus almost certainly played a major part in the decline in family size in France that began in the eighteenth century. Even in the mid-twentieth century coitus interruptus remained one of the most common methods of contraception in Europe.

In nineteenth-century England, abortion up to the time of quickening was legal. But in 1861, the Offenses Against Persons Act not only made abortion at any time during pregnancy a crime, but even the intention to commit an abortion became a felony. During the same period, every state in the United States passed a law against abortion, although women struggled to terminate unintended pregnancies. In 1871, Ely van de Warkle described abortion practices in Boston, Massachusetts. To test their safety, he purchased the many herbal remedies that were available at that time and either ate them, or gave them to his dog. "The luxury of an abortion," he wrote in the Journal of the Boston Obstetrical Society, "is now within the reach of the serving girl."

In America, a dry goods salesman named Anthony Comstock began a one-man crusade against obscenity. Amongst other things, the law he successfully lobbied Congress to pass in 1873 defined all types of contraception as pornographic. Comstock also persuaded his wife to visit a well-known New York abortionist who called herself Madame Restell. She begged her for an abortion, which Restell promised to provide. Comstock then had Restell arrested. She cut her throat the night before her trial was to begin. Comstock described this as a "bloody end to a bloody business."

Class differences in both attitudes to and practice of birth control persisted through the nineteenth century. By 1900, in England, clergymen and doctors were having families that were only one quarter the size of those of miners and dock laborers. Yet it was the professional classes that were most opposed to making family planning available to the working classes.

Twentieth Century

It is difficult to reconstruct the sexual conservatism of late-nineteenth century Europe and North America. Marie Stopes (1880–1958) was one of the first women with a Ph.D. in Britain. The daughter of a middle class Edinburgh family, she married a fellow botanist called Ruggles Gates. He proved to be impotent and it is a measure of the ignorance of the time that it seems to have taken some while for his wife to discover that something was missing from her marriage. As a divorced virgin in 1918, she penned a book called Married Love. In flowery and convoluted language, and without mention of any of the anatomy of the genitalia, she argued that woman had a right to enjoy sexual pleasure in marriage. This novel view helped make the book widely read–both in Britain and in many other countries.

World War I generated a lively debate between those interested in family planning and a body of militaristic lobbyists who argued that contraception was unacceptable because it interfered with the birth of the next generation of soldiers. In 1920, Russia under the leadership of Lenin became the first country to legalize abortion. Several Scandinavian countries passed tortuous and complicated abortion legislation between the 1930s and the late-1950s. In 1966, Britain struck down Queen Victoria's 1861 Offenses against Persons Act forbidding abortion. This example led to important changes in some of the countries of the British Commonwealth (including India, Singapore, and Zambia). Over the next 30 years, every European country, except Malta and Ireland, had passed legislation making safe abortion widely available. In Italy, the decision was the result of a nationwide referendum in 1974.

The spread of contraception and safe abortion between 1960 and 1990 facilitated–some would say, caused–the marked fall in the total fertility rate that took place in Western countries. Low fertility had been achieved in parts of Europe between World War I and World War II, when abortion–although illegal–became relatively widely available in some places. For example, knowledgeable sources estimated one abortion for every live birth in Hamburg in the 1930s. In Vienna the abortion rate was thought to be 20 for every 1,000 women and the very low total fertility rate of 1.2 was thought to be one-third the result of abortion and two-thirds the result of contraception–probably, mainly coitus interruptus. A generalized pattern of low fertility in the West was widely predicted in the 1930s by demographers, anticipating declining populations by the second part of the twentieth century. This was not to be: To demographers' surprise, the postwar decades first brought a baby boom that was followed by rapid decline of fertility to well below replacement levels in many European countries.

In the 1950s and 1960s, the lowest birth rates in the world were in Eastern Europe, again based on widespread use of withdrawal backed up by abortion. In the twenty-first century the total fertility rate of most Western countries is below 2. A similar rapid decline in fertility that has occurred in most other parts of the world also owes much to the improved availability and range of contraceptive choices and access to safe abortion; examples include South Korea, Taiwan, Thailand and Sri Lanka.

Historically, the twentieth century not only saw increasing access to reproductive choices, but also witnessed important reversals of this trend. It is no-table that many twentieth-century dictators took steps to restrict reproductive choices. One of the first moves that the Nazis made when Hitler came to power was to close down what had been a promising beginning to family planning services in Germany and Austria. It was in Nazi dominated Vichy France in 1942 that the last execution of an abortionist took place. Stalin in Russia and Nicolae Ceausescu in Romania both reversed previously liberal abortion laws.

The first family planning clinic to be established was in the Netherlands in the 1880s. Birth control leader Margaret Sanger (1883–1966) opened a clinic in Brooklyn, New York in 1917. Immediately, large numbers of women attended, but ten days later the police, enforcing the Comstock laws, closed it down. In Britain, Stopes opened her first family planning clinic in 1921. In the United States, precedents were developed that held that if physicians prescribed contraceptives "for the cure and prevention of disease" then their use was deemed to fall outside the Comstock laws. (Congressional Globe 1873: 1436). In 1937, this precedent was reinforced in the case of United States v. One Package of Japanese Pessaries, 13F. Supp. 334 (E.D.N.Y. 1936). These developments brought short-term relief to those trying to provide contraceptive services, but it also contributed to the undue medicalization of contraceptive practice, particularly as at that time the only clinical methods were vaginal barriers. The last of the U.S. Comstock laws were not struck down until the Supreme Court ruling of 1965 in Griswold v. Connecticut, 381 U.S. 479 (1965).

In 1966, the British abortion law was reformed to take into account the "woman's total environment" (The Abortion Act, 1967). Framing abortion as a medical problem helped dull political opposition, but the fine print of medical regulation in England delayed for decades the introduction of safe abortion that would require only day care. When Commonwealth countries such as India and Zambia adopted a version of the British Abortion Law, medical restrictions meant that the law had little or no effect on the frequency of unsafe abortions.

Griswold was based on the right to privacy and this also became the foundation of the unexpected decision of the U.S. Supreme Court in 1972 in Roev. Wade, 410 U.S. 113 (1973), to strike down the anti-abortion laws that remained across America. Roe v. Wade also framed abortion as a right to privacy and an issue of religious toleration rather than a medical issue. "We need not resolve the difficult question of when life begins," wrote the justices, "when those trained in the respective disciplines of medicine, philosophy and theology are unable to arrive at any conclusion."

Fertility Regulation Methods

All the methods of contraception now in use, except for systemically active oral contraceptives, implants, and injections, were available and documented by the end of the nineteenth century. Condoms made from sheep caeca, which date back to the seventeenth century, have been discovered by archaeologists. Famed diarist James Boswell describes using a condom with a prostitute in London in 1763. Condoms became widely available with the invention of vulcanization of rubber by Charles Goodyear and Thomas Hancock in 1844. The cervical cap was described in the early nineteenth century in Germany and the diaphragm was available by the turn of the twentieth century. The manufacturing and distribution of contraceptives was poorly regulated until well into the second half of the twentieth century. Sales were illegal in the United States, France, and several other European countries. In Britain sales were "under the counter." Intrauterine Devices (IUDs) began to be used in the late-nineteenth century. In the 1920s Ernst Grafenberg, a German gynecologist, did extensive work on IUDs, but after fleeing Nazi persecution he found that political freedom in America did not entail the freedom to continue his research. IUDs went through a renaissance of interest in the 1960s, when flexible plastic devices, such as the Lippes Loop, replaced the metal rings used previously. In 1971, Hugh Davis launched the Dalkon Shield. He claimed very low pregnancy rates without revealing that he counseled the clinical trialists also to use spermicides with the device. Deaths occurred due to rapidly spreading septicemia in pregnant women with a Dalkon Shield in situ. The legal cases that followed bankrupted the A. H. Robbins Company that had marketed the device, and led to a great reluctance to use any type of IUD in the United States. In Finland, obstetric and gynecological specialist Tapani Lukkenian devised the first hormone-releasing IUDs; in Chile, obstetric and gynecological specialist Jaime Zipper devised the first copper-releasing IUDs.

James Young Simpson, Queen Victoria's gynecologist, describes what twenty-first century society would call manual vacuum aspiration, a method of abortion, but the method was lost. The current method of manual vacuum aspiration, used for abortions up to the tenth week of pregnancy, was described by Harvey Karman in 1972.

In the 1920s, reproductive physiologist Ludwig Hablandt described the physiological basis of oral contraception. But the method made no progress, partly because of the lack of a cheap source of steroid and also because contraceptive research was not academically acceptable. The U.S. National Institutes of Health was forbidden by congressional mandate to support contraceptive research and, until the 1960s, the Vatican blocked any assistance from the World Health Organization in family planning. When Gregory Pincus, John Rock, and M.C. Chang, working in the Worcester Institute outside Boston, finally developed the Pill in the 1950s, contraception was still illegal in Massachusetts. For this reason, the initial large-scale trials were conducted in Puerto Rico. In 1963, American obstetrician and gynecologist John Rock, a devout Catholic, wrote The Time Has Come: A Catholic Doctor's Proposal to End the Battle over Birth Control. Rock argued that hormonal contraceptives should be licit because they imitated the natural processes whereby pregnancy and lactation inhibited ovulation. He died an embittered member of his Church. In 1966, obstetrician and gynecologist Elismar Coutino in Brazil demonstrated that an injectable form of progesterone, administered every three months, was a highly effective contraceptive.

One of the few genuine advances in birth control technology in the late-twentieth century was the discovery by reproductive physiologist ÉtienneÉmile Baulieu in France of the anti-progestigen Mifepristone (RU-486), an abortifacient effective if used during the first 50 days of pregnancy. Although Mifepristone is widely available in Europe, the controversy surrounding its development and use delayed its introduction in the United States.

Conclusion

The history of birth control is one of controversy, of slow progress in technology and scientific analysis, of legal restraints, and of medical conservatism. It is a tale of two steps forward and one step backward.

The twenty-first century has opened with a serious demographic divide. The Western nations and the emerging economies of Latin America and Asia have total fertility rates of 2.5 or less, while much of sub-Saharan Africa, Pakistan, and parts of northern India have total fertility rates of 5 or more. The legal and social attitudes toward family planning and abortion in the remaining high fertility countries has similarities to the situation in Europe and North America in the early twentieth century, in that contraception is not readily accessible to much of the population and abortion is illegal (or legal but difficult to get, as in India). Interestingly, countries furthest removed from the western cultural influence have had the most rapid fertility transitions; one was communist China in the 1970s and 1980s, and the other the Islamic Republic of Iran in the 1980s and 1990s. Undoubtedly, there were sad cases of coercion in China, although a plausible case can be made that if a national program had been started a decade earlier, a purely voluntary decline might have occurred as in South Korea and Taiwan. Iran shows that making family planning choices available leads to rapid fertility decline, even in a conservative religious theocracy.

Much of the proximate cause of the demographic divide within the contemporary world can be traced back to the uneven rate in which fertility regulation technologies have spread around the world. While the British Empire introduced significant public health measures, such as vaccination, clean water, and sewage treatment to many parts of the world, it opposed family planning. Birth control organizations began in the 1930s in India, as did an awareness of rapid population growth, but the country had to wait until independence before it could put in place any birth control policies. Many high fertility nations still have anti-abortion legislation that has existed since colonial times.