Birth Control

contraceptive methodsstephanie b. teal

sociocultural and historical aspectsvern l. bullough

CONTRACEPTIVE METHODS

Contraception has been used worldwide since ancient times. Writings in Egyptian papyri, the Bible, and Greek and Roman texts indicate the usage of various herb and root preparations for contraception and abortion (Riddle 1992). Decisions regarding the timing of pregnancy and control over family size continue to be important issues for all adults.

An average woman in the developing world who wants four children must use effective contraception for sixteen years. The average U.S. woman who wants two children needs to effectively use contraception for twenty years to achieve her desired family size (Alan Guttmacher Institute 1999).

Worldwide, many contraceptive methods are available. Factors influencing the choice of method include availability, cost, reversibility, ease of use, cultural preferences, privacy, side effects, and medical risks. When evaluating risk, it is important to note that all available birth control methods carry lower risk of death than pregnancy, even in developed countries where maternal death rates are already low.

Patterns of use differ significantly internationally. The oral contraceptive pill accounts for 34 percent of contraceptive use in the Netherlands, but only 2 percent in Japan. The intrauterine device provides contraception for 19 percent of French women, but only 1 percent of U.S. women (Senanayake and Potts 1995). Conversely, the United States has the highest rate of female sterilization in the developed world.

Contraceptive methods have many different mechanisms of action, but may be generally grouped into hormonal or nonhormonal classes.

Hormonal Methods

Hormones are the chemical messengers the body uses to control and coordinate various physical processes. The major hormones influencing the female reproductive organs are estrogen and progesterone. Manipulation of these hormones may disrupt the normal processes required for fertility, such as ovulation, transport of egg and sperm in the Fallopian tubes, thinning of cervical mucus, and preparation of the uterine lining (endometrium) for implantation. Hormonal methods of contraception must affect these processes enough to prevent fertility, without causing too many other bothersome side effects or risks.

Combination oral contraceptive pills. The combination oral contraceptive (COC) pill is a highly effective, reversible female contraceptive. It contains both estrogen and progestin (a compound that mimics natural progesterone). Taken every day for three out of four weeks, it prevents ovulation by inhibiting the secretion of two regulatory hormones from the brain's pituitary gland. The estrogen suppresses follicle stimulating hormone (FSH) and thus prevents preparation of an egg for ovulation. The main contraceptive effect, however, is from the progestin, which suppresses luteinizing hormone (LH). The lack of the LH surge prevents ovulation. The progestin also has effects on the endometrium and cervical mucus. The endometrium becomes much less favorable to implantation due to thinning. Meanwhile, the cervical mucus becomes thick, limiting sperm penetration and transport into the uterine cavity. Even if ovulation occasionally occurs, these other effects contribute to the overall high contraceptive efficacy of 98 percent (Trussell and Vaughan 1999).

The COC pill has significant noncontraceptive benefits, including reduction of menstrual blood loss, reduction of cramps, and improved regularity of the menstrual cycle. It also significantly reduces the risks of ovarian and endometrial cancer, pelvic inflammatory disease, breast cysts, and endometriosis. Both acne and excessive hair growth are improved by COC pill use.

Although the COC pill has many contraceptive and noncontraceptive benefits, it is not appropriate for everyone. Contraindications include breast cancer, severe liver disease, and uncontrolled hypertension. Blood clots in the deep veins are a rare but sometimes serious risk associated with the pill. Women who smoke are already at higher risk of blood clots and heart attack due to their cigarette usage, and smokers are discouraged from COC use. In nonsmokers, however, the pill is safe to use through the age of menopause.

Depo-Provera. Depo-Provera (depot medroxyprogesterone acetate) is a long-acting, reversible injectable contraceptive available in many countries since the late 1970s and in the United States since 1992. It results in initially high progestin levels which taper off over the following weeks. It is given as an injection every twelve to thirteen weeks. The progestin dose results in thickening of cervical mucus and thinning of the endometrium, but also is high enough to suppress ovulation, leading to a high efficacy rate of 99 percent (Trussell and Vaughan 1999). Because of the lack of estrogen with this method, a common side effect is unscheduled irregular bleeding. This usually resolves over several months, and 50 percent of women have no bleeding at all after one year of use (Kaunitz 2001). In fact, this method may be beneficial to women who are troubled by heavy, prolonged menstrual periods. Depo-Provera is also an excellent contraceptive for those who cannot use estrogen, want a private method whose timing is not related to intercourse, or do not want to take a pill every day. Because it can have a prolonged effect on a woman's return to fertility, Depo-Provera is not a good option for women planning pregnancy within the next year. It is still controversial whether it promotes weight gain: this effect has only been noted in U.S. trials of this internationally popular method (Kaunitz 2001).

Lunelle. Lunelle, an injectable monthly contraceptive, contains one-sixth the dose of medroxyprogesterone acetate as Depo-Provera, and also contains estrogen. Lunelle is given by injection every twenty-three to thirty-three days. Like Depo-Provera, the progestin in Lunelle inhibits the secretion of the hormone LH, preventing ovulation. Because of the estrogen the bothersome unscheduled bleeding of Depo-Provera is much improved. In the first ninety days of use, 57 percent of Lunelle users report variations in their bleeding patterns, compared with 91 percent of Depo-Provera users (Hall 1998). However, long-term Lunelle users tend to see normalization of their bleeding patterns, and after a year, 70 percent report normal monthly bleeding. Lunelle is highly effective. In studies conducted by the World Health Organization, over 12,000 women in nine countries were followed for a total of 100,000 woman-months use: five pregnancies occurred (Hall 1998). The formulation in Lunelle has been used in some countries for twenty years prior to FDA (Food and Drug Administration) approval in the United States.

Implantables. Several sustained-release progestin-only contraceptives have been developed to reduce the frequency of administration and decrease the high progestin levels associated with Depo-Provera. Norplant consists of six capsules filled with the progestin levonorgestrel that are placed under the skin of the upper arm. The capsules release the hormone at a constant low rate, resulting in a daily dose about 25 to 50 percent that of low-dose COCs. Unscheduled bleeding does occur, especially during the first year, but women often return to a normal menstrual pattern thereafter. Norplant may be used for up to five years.

Implanon. A single capsule system which is effective for three years, Implanon's major benefit over Norplant is the ease of insertion and removal, which can be difficult if the capsules are placed too deeply or irregularly. One of the most obvious benefits of these implants is the low demand on the contraceptive user, especially as compared to daily pill use. Efficacy is also extremely high, with a failure rate of less than 1 percent per year.

Progestin Intrauterine Device. Widely used in Europe, the progestin intrauterine device (IUD) is a low-maintenance method that has high efficacy, rapid reversibility, and reduction of menstrual blood loss. The Mirena progestin IUD is a small, T-shaped flexible plastic device that slowly releases levonorgestrel contained in the long stem of the T. The contraceptive effect is primarily from the thickening of cervical mucus and alteration of sperm motility and function. Although ovulation is not usually inhibited, the failure rate is only 0.14 percent. After placement, the progestin IUD may be left in place up to five years, or removed when pregnancy is desired.

Nonhormonal Methods

Nonhormonal methods rely on prevention of contact of the egg and sperm. Many nonhormonal methods require implementation around the time of intercourse, or place restrictions on when or how intercourse may occur, whereas others require little maintenance. Because of this, these methods have a much wider range of contraceptive failure than the hormonal methods, ranging from as high as 25 percent for withdrawal and natural family planning, to as low as 0.5 to 1 percent for the IUD and sterilization.

Intrauterine Device. The intrauterine device is a highly effective, reversible, long-acting, nonhormonal method of contraception. It is popular in Europe, Asia, and South America. Nonhormonal IUDs come in many different forms, but the most common type in the United States is the TCu-380A, also known as Paraguard. The Paraguard IUD is a small plastic "T" wrapped with copper. It exerts its effect through several mechanisms: first, the copper significantly decreases sperm motility and lifespan, second, the IUD produces changes in the endometrium that are hostile to sperm. The IUD does not affect ovulation, nor does it cause abortions. The overall failure rate of the IUD is less than 1 percent per year, which is comparable to female sterilization (Meirik et al. 2001). After removal, a woman can become pregnant immediately. Despite its benefits, its popularity in the United States waned in the mid-1970s due to a rash of litigation related to reports of increased pelvic infection and infertility related to its use. Later studies largely refuted these concerns, but the bad publicity has lingered (Hubacher et al. 2001). Although slowly increasing, U.S. use rate of the IUD still lags far behind the rest of the world.

Condom: male and female. The male condom is a sheath of latex or polyurethane that is placed over the penis prior to intercourse as a barrier to sperm. It is inexpensive, readily available, and has the added health benefit of providing protection against sexually transmitted diseases, including HIV. Condoms may also be lubricated with a spermicide.

The female condom is a polyurethane sheath with two rings attached, which is placed in the vagina prior to intercourse. In clinical trials it has had high patient acceptance, and has the benefit of being a woman-controlled method of sexually transmitted disease protection. Couples should not use both a male and a female condom during an act of intercourse, as this increases the risk of breakage. The failure rate of condoms is 12 to 20 percent (Fu et al. 1999).

Diaphragm. The diaphragm is a rubber cupshaped device which is filled with spermicide and inserted into the vagina, creating a barrier in front of the cervix. Like the condom, the efficacy rate of the diaphragm is dependent on the user, but ranges from 80 to 90 percent. The diaphragm does provide some protection against gonorrhea and pelvic inflammatory disease, but has not been shown to reduce transmission of HIV or other viral sexually transmitted infections. Although it must be obtained by prescription, a diaphragm is relatively inexpensive, and with proper care lasts for several years. It may be combined with condom use for greater contraceptive efficacy and disease prevention.

Withdrawal. Also known as coitus interruptus, withdrawal requires the male partner to remove his penis from the woman's vagina prior to ejaculation. Although theoretically sperm should not enter the vagina and fertilization should be prevented, this method has a failure rate of up to 25 percent in typical use (Trussell and Vaughan 1999). Withdrawal is probably most useful as a back-up method for couples using, for example, periodic abstinence.

Natural family planning. Periodic abstinence, also known as natural family planning, depends on determining safe periods when conception is less likely, and using this information to avoid pregnancy. The various methods of natural family planning include the calendar, thermal shift, symptothermal, and cervical mucus methods. All of these methods require training in the recognition of the fertile phase of the menstrual cycle, as well as a mature commitment by both partners to abstain from intercourse during this time. If the woman does not have a predictable menstrual cycle, some of these methods are more difficult to use effectively. Although with perfect use the failure rate could be as low as 5 percent, actual failure rates are closer to 25 percent and above (Fu et al. 1999; Trussell and Vaughan 1999).

Female sterilization. Female sterilization is the most common method of birth control for married couples in the United States. The technique is performed surgically, through one or two incisions in the abdomen. The Fallopian tubes may be tied, cut, burnt, banded with rings, or blocked with clips. Sterilization should be considered final and irreversible, although expensive microsurgery can sometimes repair the tube enough to allow pregnancy. Some couples assume that because this method is irreversible, it has a perfect efficacy rate, but this is not true. Each method has a slightly different rate of failure or complication, but the overall failure rate for female sterilization is about 1 percent (Peterson et al. 1996). The failure rate of sterilization is also dependent on the age of the patient, with younger patients more likely to experience an unplanned pregnancy up to ten years after the procedure. Younger patients are also more likely to experience regret in the years following sterilization.

Male sterilization. Male sterilization (vasectomy) is also a highly effective, permanent method of contraception. It is accomplished by making a small hole on either side of the scrotum and tying off the spermatic cord which transports sperm into the semen just prior to ejaculation. Compared to female sterilization, it is less expensive, more effective, easier to do with less surgical risk, and is easier to reverse if necessary. Vasectomy has no effect on male sexual function, including erectile function, ejaculation, volume of semen, or sexual pleasure. However, vasectomy rates consistently lag far behind those of female sterilization in all parts of the world, due mainly to cultural factors.

Emergency Contraception

Emergency contraception, also known as post-coital contraception, includes any method that acts after intercourse to prevent pregnancy. The Yuzpe method uses COC pills to deliver two large doses of hormones, twelve hours apart. These must be taken within seventy-two hours of the unprotected intercourse to be effective. A prepackaged emergency contraceptive kit called Preven is also available. The kit contains a pregnancy test, instructions, and two pills with the appropriate doses of estrogen and progestin. Studies show a pregnancy rate of 3.2 percent for the cycle in which the woman took the emergency contraception, which is a 75 percent reduction of the 8 percent expected pregnancy rate per unprotected cycle (Ho 2000). The main side effects are nausea and possibly vomiting from the high dose of estrogen. Emergency contraception using a special progestin-only pill containing levonorgestrel avoids this side effect. It is marketed as Plan B. A study of 967 women using Plan B showed a pregnancy rate of 1.1 percent, or an 85 percent reduction. Both methods cause a 95 percent reduction in the risk of pregnancy if taken within the first twelve hours after unprotected intercourse (Nelson et al. 2000). The mechanism of action of the hormonal pills is probably the prevention of ovulation, with some contribution of changes in the endometrium. They do not cause abortion.

Conclusion

Control of family size is an important consideration for all adults, in every country. Many different contraceptive methods exist, and no single method is appropriate for all couples. When choosing a contraceptive method, factors such as effectiveness, reversibility, side effects, privacy, cost, and cultural preferences should be considered.

See also:Abortion; Abstinence; Assisted Reproductive Technologies; Birth Control: Sociocultural and Historical Aspects; Childlessness; Family Life Education; Family Planning; Fertility; Infanticide; Sexuality Education

Bibliography

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hubacher, d.; lara-ricalde, r.; taylor, d. j.; guerra-infante, f.; and guzman-rodriguez, r. (2001). "use of copper intrauterine devices and the risk of tubal infertility among nulligravid women." new england journal of medicine 345(8):561–567.

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meirik, o.; farley, t. m. m.; and sivin, i. (2001). "safety and efficacy of levonorgestrel implant, intrauterine device, and sterilization" obstetrics and gynecology 97(4):539–547.

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peterson, h. b.; xia, z.; hughes, j. m.; wilcox, l. s.; tylor,l. r.; and trussell, j. (1996). "the risk of pregnancy after tubal sterilization: findings from the u.s. collaborative review of sterilization." american journal of obstetrics and gynecology 174:1161–1170.

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other resource

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stephanie b. teal

SOCIOCULTURAL AND HISTORICAL ASPECTS

Birth control (a term popularized by Margaret Sanger, 1876–1966) refers to control over and decisions about the timing and number of births that a woman or couple has; it is a part of family planning and includes more than contraception.

People have used various forms of birth control throughout history, including abstinence (both short-term and, for some individuals, lifetime continence), abortion (abortifacients are common in both historical and oral sources), infanticide (disposing of unwanted infants), and surgical intervention (ranging from castration to creating a hypospadias condition in the male by making an exit for sperm and urine at the base of the penis). Forms of contraception have ranged from "natural" means, such as withdrawal or use of other orifices, to a variety of mechanical means including intrauterine devices (IUDs) and various barriers such as the condom or vaginal inserts.

Historically, however, birth control was not a general matter for public discourse. Although various medical writers described methods, some more effective than others, and theologians took conflicting stands about non-procreative sexual activities, most of the information was passed on informally among women themselves, some of it more accurate than others. Historians believe that the first really measurable efforts toward some form of fertility control, probably coitus interruptus, took place in France in the eighteenth century. Full scale debate on the issue, however, did not take place until the nineteenth century.

Widespread Public Discussion

Key to the emerging public discussion about birth control was concern with overpopulation, and only later did the feminist issue of right to plan families emerge. The population issue was first put before the public by the Reverend Thomas Robert Malthus (1766–1834) in his Essay on the Principle of Population (1708). The first edition was published anonymously, but Malthus signed his name to the second, expanded edition published in 1803. Malthus believed that human beings were possessed by a sexual urge that led them to multiply faster than their food supply, and unless some checks could somehow be applied, the inevitable results of such unlimited procreation were misery, war, and vice. Population, he argued, increased geometrically (1, 2, 4, 8, 16, 32 . . .) whereas food supply only increased arithmetically (1, 2, 3, 4, 5, 6, . . .) Malthus's only solution was to urge humans to exercise control over their sexual instincts (i.e., to abstain from sex except within marriage) and to marry as late as possible. Sexually, Malthus was an extreme conservative who went so far as to classify as vice all promiscuous intercourse, "unnatural" passions, violations of the marriage bed, use of mechanical contraceptives, and irregular sexual liaisons.

Many of those who agreed with Malthus about the threat of overpopulation disagreed with him on the solutions and instead advocated the use of contraceptives. Those who did so came to be known as neo-Malthusians. Much of the debate over birth control, however, came to be centered on attitudes toward sexuality. Malthus recognized the need of sexual activity for procreation but not for pleasure. The neo-Malthusians held that continence or abstinence was no solution because sex urges were too powerful and nonprocreative sex was as pleasurable as procreative sex.

To overcome the lack of public information about contraception, the neo-Malthusians felt it was essential to spread information about the methods of contraception. The person in the English speaking world generally given credit for first doing so was the English tailor, Francis Place (1771–1854). Place was concerned with the widespread poverty of his time, a poverty accentuated by the growth of industrialization and urbanization as well as the breakdown of the traditional village economy. Large families, he felt, were more likely to live in poverty than smaller ones, and to help overcome this state affairs, Place published in 1882 his Illustrations and Proofs of the Principle of Population. He urged married couples (not unmarried lovers) to use "precautionary" means to plan their families better, but he did not go into detail. To remedy this lack of instruction, he printed hand-bills in 1823 addressed simply To the Married of Both Sexes. In it he advocated the use of a dampened sponge which was to be inserted in the vagina with a string attached to it prior to "coition" as an effective method of birth control. Later pamphlets by Place and those who followed him added other methods, all involving the female. Pamphlets of the time, by Place and others, were never subject to any legal interference, although they were brought to the attention of the attorney general who did not take any action. Place ultimately turned to other issues, but his disciples, notably Richard Carlile (1790–1843), took up the cause. It became an increasingly controversial subject in part because Place and Carlile were social reformers as well as advocates of birth control. Carlile was the first man in England to put his name to a book devoted to the subject, Every Woman's Book (1826).

Early U.S. Birth Control Movement

In the United States, the movement for birth control may be said to have begun in 1831 with publication by Robert Dale Owen (1801–1877) of the booklet Moral Physiology. Following the model of Carlile, Owen advocated three methods of birth control, with coitus interruptus being his first choice. His second alternative was the vaginal sponge, and the third the condom. Ultimately far more influential was a Massachusetts physician, Charles Knowlton (1800–1850) who published his Fruits of Philosophy in 1832. In his first edition, Knowlton advocated a policy of douching, a not particularly effective contraceptive, but it was the controversy the book caused rather than its recommendation for which it is remembered. As he lectured on the topic through Massachusetts, he was jailed in Cambridge, fined in Taunton, and twice acquitted in trials in Greenfield. These actions increased public interest in contraception, and Knowlton had sold some 10,000 copies of his book by 1839. In subsequent editions of his book, Knowlton added other more reliable methods of contraception.

Once the barriers to publications describing methods of contraception had fallen, a number of other books appeared throughout the English-speaking world. The most widely read material was probably the brief descriptions included in Elements of Social Science (1854), a sex education book written by George Drysdale (1825–1901). Drysdale was convinced that the only cause of poverty was overpopulation, a concept that his more radical freethinking rivals did not fully accept. They were more interested in reforming society by eliminating the grosser inequities, and for them contraception was just one among many changes for which they campaigned.

Influence of Eugenics

Giving a further impetus to the more conservative voices in the birth control movement was the growth of the eugenics movement. The eugenicists, while concerned with the high birthrates among the poor and the illiterate, emphasized the problem of low birthrates among the more "intellectual" upper classes. Eugenics came to be defined as an applied biological science concerned with increasing the proportion of persons of better than average intellectual endowment in succeeding generations. The eugenicists threw themselves into the campaign for birth control among the poor and illiterate, while urging the "gifted" to produce more. The word eugenics had been coined by Francis Galton (1822–1911), a great believer in heredity, who also had many of the prejudices of an upper-class English gentleman in regard to social class and race. Galton's hypotheses were given further "academic" respectability by Karl Pearson (1857–1936), the first holder of the Galton endowed chair of eugenics at the University of London. Pearson believed that the high birthrate of the poor was a threat to civilization, and if members of the "higher" races did not make it their duty to reproduce, they would be supplanted in time by the members of the "lower races."

When put in this harsh light, eugenics gave "scientific" support to those who believed in racial and class superiority. It was just such ideas that Adolph Hitler attempted to implement in his "solution" to the "racial problem." Although Pearson's views were eventually opposed by the English Eugenics Society, the U.S. eugenics movement, founded in 1905, adopted his view. Inevitably, a large component of the organized family planning movement in the United States was made up of eugenicists. The fact that the Pearson-oriented eugenicists also advocated such beliefs as enforced sterilization of the "undesirables" inevitably tainted the group in which they were active even when they were not the dominant voices.

Dissemination of Information and Censorship

Population studies indicate that at least among the upper-classes in the United States and Britain, some form of population limitation was being practiced. Those active in the birth control movement, however, found it difficult to contact the people they most wanted to reach, namely the poor, overburdened mothers who did not want more children or who, in more affirmative terms, wanted to plan and space their children. The matter was complicated by the enactment of anti-pornography and anti-obscenity legislation which classed birth control information as obscene. In England, with the passage of the first laws on the subject in 1853, contraception was interpreted to be pornographic since of necessity it included discussion of sex. Books on contraception that earlier had been widely sold and distributed were seized and condemned. Such seizures were challenged in England in 1877 by Charles Bradlaugh (1833–1891) and Annie Besant (1847–1933). Bradlaugh and Besant were convicted by a jury that really wanted to acquit them, but the judgement was overturned on a technicality. In the aftermath, information on contraception circulated widely in Great Britain and its colonies.

In the United States, however, where similar legislation was enacted by various states and by the federal government, materials that contained information about birth control and that were distributed through the postal system or entered the country through customs ran into the censoring activities of Anthony Comstock (1844–1915) who had been appointed as a special postal agent in 1873. One of his first successful prosecutions was against a pamphlet on contraception by Edward Bliss Foote (1829–1906). As a result, information about contraceptives was driven underground, although since state regulations varied some states were more receptive to information about birth control. Only those people who went to Europe regularly kept up with contemporary developments such as the diaphragm, which began to be prescribed in Dutch clinics at the end of the nineteenth century. The few physicians who did keep current in the field tended to restrict their services to upper-class groups. The dominant voice of the physicians in the increasingly powerful American Medical Association was opposed to the use of contraceptives and considered them immoral. That this situation changed is generally credited to Sanger, a nurse.

In 1914, Sanger, then an active socialist, began to publish The Woman Rebel, a magazine designed to stimulate working women to think for themselves and to free themselves from bearing unwanted children. To educate women about the possibilities of birth control, Sanger decided to defy the laws pertaining to the dissemination of contraceptive information by publishing a small pamphlet, Family Limitation (1914), for which she was arrested. Before her formal trial, she fled to England, where she spent much of her time learning about European contraceptive methods, including the diaphragm. While she was absent her husband, William Sanger (1873–1961), who had little to do with his wife's publishing activities, was tricked into giving a copy of the pamphlet to a Comstock agent, and for this was arrested and convicted, an act that led to the almost immediate return of his wife. Before she was brought to trial, however, Comstock died. The zealousness of his methods had so alienated many prominent people that the government—without Comstock pushing for a conviction—simply decided not to prosecute Sanger, a decision which received widespread public support.

In part through her efforts, by 1917 another element had been added to the forces campaigning for more effective birth control information, namely the woman's movement (or at least certain segments of it). Women soon became the most vocal advocates and campaigners for effective birth control, joining "radical" reformers and eugenicists in an uneasy coalition.

Sanger, though relieved at being freed from prosecution, was still anxious to spread the message of birth control to the working women of New York. To reach them, she opened the first U.S. birth control clinic, which was patterned after the Dutch model. Since no physician would participate with her, she opened it with two other women, Ethel Byrne, her sister and also a nurse, and Fania Mindell, a social worker. The well-publicized opening attracted long lines of interested women—as well as several vice officers—and after some ten days of disseminating information and devices, Sanger and her two colleagues were arrested. Byrne, who was tried first and sentenced to thirty days in jail, promptly went on a hunger strike, attracting so much national attention that after eleven days she was pardoned by the governor of New York. Mindell, who was also convicted, was only fined $50. By the time of Sanger's trial, the prosecution was willing to drop charges provided she would agree not to open another clinic, a request she refused. She was sentenced to thirty days in jail and immediately appealed her conviction. The New York Court of Appeals rendered a rather ambiguous decision in acquitting her, holding that it was legal to disseminate contraceptive information for the "cure and prevention of disease," although they failed to specify the disease. Sanger, interpreting unwanted pregnancy as a disease, used this legal loophole and continued her campaign unchallenged.

New York, however, was just one state; there were many state laws to be overcome before information about contraceptives could be widely disseminated. Even after the legal barriers began to fall, the policies of many agencies made it difficult to distribute information. Volunteer birth control clinics were often prevented from publicly advertising their existence. It was not until 1965 that the U.S. Supreme Court, in Griswold v. Connecticut, removed the obstacle to the dissemination of contraceptive information to married women. It took several more years before dissemination of information to unmarried women was legal in every state.

In Europe, the battle, led by the Netherlands, for the dissemination of information about birth control methods took place during the first half of the twentieth century. It was not until after World War II when, under Sanger's leadership, the International Federation for Planned Parenthood was organized, that a worldwide campaign to spread the message took place. At the beginning of the twenty-first century two major countries, Japan and Russia, still used abortion as a major means of family planning. In many countries, more than 60 percent of women of childbearing age are using modern contraceptives, including Argentina, Australia, Austria, the Bahamas, Belgium, Brazil, Canada, China, Costa Rica, Cuba, Denmark, Finland, France, Hungary, Italy, Jamaica, Korea, New Zealand, Netherlands, Norway, Spain, Sweden, Switzerland, Singapore, Thailand, the United Kingdom, and the United States. Many other nations are approaching this rate of success, but much lower rates exist throughout Africa (where Tunisia seems to the highest at 49 percent), in most of the former areas of the Soviet Union and the eastern block countries, and in much of Asia and Latin America. The International Planned Parenthood Federation does periodic surveys of much of the world which are regularly updated on its website (see also Bullough 2001).

Teenagers and Birth Control

With legal obstacles for adults removed, and a variety of new contraceptives available, the remaining problems are to disseminate information and encourage people to use contraceptives for effective family planning. One of the more difficult audiences to reach has been teenagers. Many socalled family life or sex education programs refuse to deal with the issue of contraceptives and instead emphasize abstinence from sex until married. Unfortunately, abstinence—or continence as it is sometimes called—has the highest failure rate of any of the possible means of birth control since there is no protection against pregnancy if the will power for abstinence fails. The result was a significant increase in the 1990s of unmarried teenage mothers, although not of teenage mothers in general. The highest percentage of teenage mothers in the years the United States has been keeping statistics on such matters came in 1957, but the overwhelming majority of these were married women. Although the number of all teenage mothers has been declining ever since, reaching new lows in 1999–2000, an increased percentage of them are unmarried. In fact, it is the change in marriage patterns and in adoption patterns, more than the sexual activity of teenagers, that led to public concern over unmarried teenage mothers. Since societal belief patterns have increasingly frowned upon what might be called "forced marriages" of pregnant teenagers, and the welfare system itself was modified to offer support to single mothers, at least within certain limits, teenagers who earlier might have given up their children for adoption decided to keep them.

Many programs have been introduced since the federal government in 1997 created the abstinence-only-until-marriage program to teach those teenagers most at-risk to be more sexually responsible. Only a few of the programs included a component about contraceptives since the federally funded programs do not provide for it, and only a few states such as California have provided funds to do so. Most of the programs emphasize self-esteem, the need for adult responsibility, and the importance of continence, all important for teenage development, but almost all the research on the topic, summaries of which are regularly carried in issues of SIECUS Report, has found that the lack of specific mention of birth control methods has handicapped their effectiveness in curtailing teenage pregnancy. This deficiency has been somewhat compensated for by the development of more efficient and easy-to-use contraceptives and availability of information about them from other sources.

Still, although contraception and family planning increasingly have come to be part of the belief structure of the U.S. family, large segments of the population remain frightened by, unaware of, or unconvinced by discussion about birth control. Unfortunately, because much of public education about birth control for much of the twentieth century was aimed at the poor and minorities, some feel that birth control is a form of racial suicide. It takes a lot of time and much education to erase such fears and success can only come when such anxieties can be put to rest.

See also:Abortion; Abstinence; Adolescent Parenthood; Assisted Reproductive Technologies; Birth Control: Contraceptive Methods; Childlessness; Family Life Education; Family Planning; Fertility; Infanticide; Sexuality Education; Women's Movements

Bibliography

bullough, v. l., and bullough, b. contraception. (1997)buffalo, ny: prometheus.

bullough, v. l. (2001). encyclopedia of birth control.santa barbara, ca: abc-clio.

chandrasekhar, s. (1981). a dirty, filthy book: the writings of charles knowlton and annie besant on reproductive physiology and birth contol and an account of the bradlaugh-besant trial. berkeley and los angeles: university of california press.

fryer, p. (1965). the birth controllers. london: secker &warburg.

grossman, atina. (1995). reforming sex: the germanmovement for birth control and abortion reform. new york: oxford university press.

mclaren, angus. (1990). a history of contraception. london: blackwell.

new york university. margaret sanger papers project. new york: new york university department of history.

population information program. population reports. baltimore, md: johns hopkins university school of public health.

reed, j. (1978). from private vice to public virtue: thebirth control movement and american society since 1830. new york: basic books.

riddle, john m. (1997). eve's herbs: a history of contraception and abortion in the west. cambridge, ma: harvard university press.

solway, r. a. (1982). birth control and the populationquestion in england, 1877–1930. chapel hill: university of north carolina press.

case

griswold v. connecticut, 381 u.s. 479, 85 s.ct. 1678,14 l.ed.2d 510 (1965).

other resource

international planned parenthood federation. "countryprofiles." available from http://www.ippf.org/regions/country.

vern l. bullough

BIRTH CONTROL

Birth control, or contraception, is the practice of preventing or reducing the probability of pregnancy without abstaining from sexual intercourse. In premodern texts references to the enhancement of fertility and birth outweigh references to their restriction, and the development of contemporary contraceptive technologies emerged from work on fertility enhancement. Today, however, one of the most common ways in which scientific and technological advances are experienced is through people's control of fertility and birth.

History of Birth Control

The desire to control fertility has always existed in tension with the desire to procreate and with social motives to preserve population sizes. Infanticide and abortifacients were used frequently in premodern and early modern societies to control the number of offspring. However, diverse contraceptive techniques also existed, including the natural rhythm method (avoiding intercourse during ovulation), coitus interruptus (withdrawal before ejaculation), coitus obstructus (using pressure to block the male urethra), and coitus reservatus (avoiding ejaculation). Other methods included suppositories such as crocodile dung in ancient Egypt, cervical barriers, and intrauterine devices (IUDs).

Neither the ancient Greeks nor the Romans considereed contraception immoral. That also was the case among the Germanic, Celtic, and other non-Mediterranean peoples in much of the medieval period. It is not surprising that the Christian Church had difficulty enforcing rules and moral norms against contraception. Early Church fathers made the moral standing of sexual intercourse an important feature of their teachings. Most important, Augustine (354–430) saw the procreation of children as one of the three justifications for Christian marriage. If sexual intercourse was performed with the specific intent of engendering offspring, it was done without sin. Augustine's views influenced subsequent treatments of contraception in the Catholic Church (Dupré 1964), and certain medieval canons criminalized contraception.

Life in modern industrial societies removed the agrarian incentive to produce numerous children. Emerging individual perspectives on procreation clashed with received social norms and many religious teachings. Technological improvements in contraceptive techniques decreased their cost and increased their availability. For example, the vulcanization of rubber in the mid-nineteenth century by Charles Goodyear (1800–1860) led to the mass production of condoms, which were made from animal intestines in seventeenth-century Europe, and other birth control devices.

Although most Catholic authorities reacted with renewed criticism of contraception, several groups that were promoting birth control challenged them. For example, neo-Malthusians in England in the early nineteenth century wanted to increase the standard of living of the poor by reducing birth rates. Others argued that birth control techniques promoted greater sexual freedom or aided eugenic attempts to improve the hereditary "stock." Many women went to extreme lengths to avoid pregnancy because of the disproportionate burden it placed on them. Those efforts were made more difficult by the declining authority of midwives in the nineteenth century in favor of male doctors, many of whom did not recognize the right of women to terminate or prevent pregnancy.

By the end of the nineteenth century many people were interpreting the increasing prevalence of birth control as a sign of social decadence and moral degradation. Some people in the United States argued that women, especially upper-class women, were shirking their "patriotic duty" to have children, sinning against nature, and committing "race suicide" (Reed 1978). Anthony Comstock (1844–1915) became the most eminent crusader against the dissemination of contraception literature. In 1873 Congress passed the Comstock Act, which defined information about contraception as obscene and prohibited the dissemination of contraceptives through the mail or across state lines. Several states also banned or restricted the dissemination of contraceptives. The strictest laws were passed by Connecticut, where married couples could be arrested for using birth control.

The most common arguments against birth control were that it promoted lewd or sinful behavior, weakened the stability provided by large families, signified a rebellion by women against their primary social role of motherhood, and undermined certain racial ideals. By contrast, those in favor of birth control argued that it promoted autonomy for women, stronger families and marriages, economic equality, and environmental health.

In the early twentieth century Margaret Sanger (1879–1966), an advocate for contraceptives who coined the phrase birth control, attempted to increase access to birth control by using arguments based primarily on socioeconomic justifications (Reed 1978). She crusaded against the Comstock Act, beginning with the creation of a birth control clinic in 1916. Sanger popularized the image of birth control as a means of individual freedom, self-determination, and gender equality. Legislative changes slowly followed, along with the growing legitimization of birth control methods by much of society, especially the medical community. Sanger's American Birth Control League and other organizations became known as Planned Parenthood in 1942.

In the 1960s population control became a popular movement to reduce poverty and conserve natural resources. Some anthropologists argued that irresistible reproductive pressures arising from the lack of safe, effective contraception had led all past cultures into a self-destructive pattern of production intensification and environmental degradation. Modern contraceptive technologies, however, offered an opportunity to alter that perennial pattern by lowering fertility rates (Segal 2003). The new emphasis on birth control in response to concerns about the disparity between lowered death rates and continued high birth rates in the developing world was made clear in the "Proclamation of Teheran" (paragraph 16) by the 1968 International Conference on Human Rights.

In the United States anticontraceptive laws remained in effect until the U.S. Supreme Court struck down the Comstock Act as unconstitutional in 1965. Until that time most pharmaceutical companies had refrained from investing in birth control technologies because of those laws and fear of religious objections, especially from the Catholic Church. The independent development of synthetic progesterone in the early 1950s by Frank Colton, a chemist at J. D. Searle Pharmaceutical, and Carl Djerassi, working for Syntex, a pharmaceutical company based in Mexico, allowed Gregory Pincus to create what would become known as the birth control pill. That development sparked a revolution in contraception.

The pill received approval from the U.S. Food and Drug Administration (FDA) as a contraceptive in 1960 after controversial research was done on women in third world nations. Five years later more than 6.5 million U.S. women were taking oral contraceptives. In the 1970s and 1980s contraceptive technologies continued to develop, including lower-dose birth control pills (the initial doses were found to be ten times higher than the necessary amount, causing many dangerous side effects) and a T-shaped IUD. The IUD fell out of favor because it was linked to pelvic inflammatory disease. In the 1990s the FDA approved the first hormone injections and emergency contraceptives.

The twenty-first century continues to bring new contraceptive technologies, including the birth control patch, continuous birth control pills that schedule fewer menstrual cycles per year, and male birth control pills. Despite the increased use of these technologies contraception still stimulates a wide range of ethical judgments that range from mortal sin to moral imperative. It also spans the legal and policy spectrum from laws that ban birth control to those, such as the 1979 "one child per couple" policy in China, that practically mandate it.

Issues of birth control and reproductive rights remain highly controversial elements of modern politics. Hence, whereas rising rates of teenage pregnancy lead many people to applaud the greater use of birth control, others have promoted abstinence. However, there were increasing debates about the abstinence-only education programs encouraged by the administration of U.S. President George W. Bush. Many critics argued that the administration was misusing science to promote an anticontraception moral agenda (Union of Concerned Scientists 2004).

Technological Methods

Contraceptive techniques can be divided into three categories: blockage of sperm transport to the ovum, prevention of ovulation, and blockage of implantation. Both men and women can use methods in the first category, whereas those in the latter two categories are available to women only. Each technique presents different tradeoffs among variables such as comfort, price, availability, safety, and effectiveness.

BLOCKAGE OF SPERM TRANSPORT TO THE OVUM. Natural contraception, also known as the rhythm method of birth control, relies on abstinence from intercourse during a woman's fertile period. Carefully tracking menstrual cycles and/or monitoring fluctuations in body temperature can predict ovulation. Neither method is very effective (average failure rates range from twenty to thirty annual pregnancies per hundred women) because of variability in ovarian cycles. Coitus interruptus has a similar failure rate.

Other techniques in this category involve chemical contraceptives such as spermicidal foams, sponges, creams, jellies, and suppositories. When inserted into the vagina, those contraceptives can remain toxic to sperm for roughly an hour. These techniques are usually not very effective and are used mostly in conjunction with barrier methods that mechanically prevent sperm transport to the oviduct. Those methods include condoms (thin, strong rubber or latex sheaths), which are available for both male and female use. Females also can use the diaphragm, which is a flexible rubber dome positioned over the cervix. An alternative to the diaphragm is the cervical cap, which is smaller and is held in place by suction. Sterilization is a more permanent and highly effective method of birth control. It involves the surgical disruption of the ductus deferens (vasectomy) in men and the oviduct (tubal ligation) in women.

PREVENTION OF OVULATION. Oral contraceptives, or birth control pills, function by manipulating the complex hormonal interactions in the ovarian cycle. They contain synthetic estrogen-like and progesterone-like steroids and are taken for three weeks and then discontinued for one week. The steroids inhibit the secretion of certain hormones, preventing follicle maturation and ovulation. The one-week period of discontinuation allows menstruation to occur, although without the presence of an ovum. Recent developments prolong the length of the menstrual cycle and thus can reduce the annual number of menstruations. Oral contraceptives also prevent pregnancy by increasing the viscosity of cervical mucus, making the uterus less likely to accept implantation, and decreasing muscular contractions in the female reproductive tract.

Birth control patches also have been developed. They are applied directly to the skin and secrete synthetic steroids that work in the same way as do those in the contraceptive pill. Also available are long-acting subcutaneous contraceptives such as NorplantÒ. NorplantÒ consists of six matchstick-size capsules that gradually release progestin. The patches are inserted under the skin in the inner arm above the elbow. Once implanted, these contraceptives are effective for roughly five years. Additionally, injectable time-release synthetic hormones, which provide contraceptive effects for one to three months depending on the product, can be obtained. In the United States all these methods are available only with a prescription and are quite effective, with average failure rates of less than one annual pregnancy per hundred women.

BLOCKAGE OF IMPLANTATION. These are the most controversial techniques because they act after fertilization has taken place by preventing the implantation of a fertilized ovum in the uterus. The most common technique in this category is the IUD, which is inserted into the uterus by a physician. The mechanism of action of the IUD is not completely understood, but evidence suggests that the presence of this foreign object in the uterus produces a local inflammatory response that prevents implantation of the fertilized ovum. Early IUD techniques were associated with serious complications. More recent methods are much safer, but the popularity of IUDs has waned.

Implantation also can be blocked by emergency contraception, or "morning-after" pills. These pills can prevent pregnancy when they are taken within seventy-two hours after intercourse. Often used in the case of rape, emergency contraceptive kits usually involve high doses of hormones that either suppress ovulation or cause premature degeneration of the corpus luteum. The latter effect removes the hormonal and nutritive support required by a fertilized ovum. The controversial "abortion pill" RU 486 (MifepristoneÒ) blocks the female hormone progesterone, making it impossible for the body to sustain a pregnancy. The association of this pill with abortion explains why it took twenty years after its invention in 1980 by a French pharmaceutical company for the FDA to approve it in 2000.

CURRENT RESEARCH. Research continues in all these categories, partly because unplanned pregnancies continue to present personal and public health problems (Institute of Medicine 2004). Advances in genome sequencing, materials science (a multidisciplinary field focused on the properties of functional solids), and drug delivery are important factors in new techniques. Longer-lasting hormone-releasing IUDs are being developed along with improved methods for inserting and removing them. Other techniques target chemical reactions between ova and sperm or manipulate the pituitary secretion of certain reproductive hormones in both males and females.

In 2005 researchers in the United States partnered with a European biotechnology company to develop a male contraceptive pill. Such contraceptives could be based on a variety of techniques, ranging from inhibiting spermatogenesis to disabling the motility of sperm. Research involving reversible chemical sterilization also is being carried out.

Additionally, efforts are under way to develop immunocontraception that would allow the use of vaccines that prod the immune system to produce antibodies targeted against a protein that is critical to the reproductive process (Ada and Griffin 1991). Such vaccines would work for both males and females. In males vaccines would create antibodies against the production of gonadotropin-releasing hormone (GnRH), which is essential for sperm production. In this case supplemental testosterone injections would be needed because of the loss of GnRH. In females some vaccines that are being tested induce the formation of antibodies against the creation of human chorionic gonadotropin (hCG), which is essential for supporting the corpus luteum during pregnancy. These techniques present concerns about endocrine disruption and autoimmune pathologies. Immunocontraception is fairly commonly used as a strategy for the control of wildlife populations. Although research on human applications has proceeded since a special working group was formed by the World Health Organization (WHO) in 1973, no safe and effective methods had been developed by 2004. Clinical trials continue.

Ethical and Political Issues

The association of contraceptive practices with prostitution, extramarital affairs, and the perceived breakdown of sexual mores is related directly to the discomfort with which most religious traditions have responded to these methods. Today, however, most laypeople, along with most scholars in different traditions, accept the morality of contraception within marriage. However, that acceptance has not extended to all religious traditions.

The clearest example of continuous opposition to the use of artificial birth control methods comes from official Roman Catholic teachings. Catholic teachings on contraception remain important for contemporary debates, especially the 1930 encyclical issued by Pope Pius XI titled Casti Cannubii [On Christian Marriage], which called birth control a sin and opposed birth control by artificial means. In 1968 Pope Paul VI condemned contraception but permitted the use of natural rhythm methods. Today, although Catholic doctrine still advocates the use of natural methods such as abstinence during fertile periods, it completely condemns the use of artificial contraception or voluntary sterilization. The grounds for this rejection are related to what is claimed to be an inseparable connection between the sexual and procreative acts. Because many developing countries have large Catholic communities, many have criticized the official position of the Catholic Church as insensitive to overpopulation problems and to the effects of continuous childbearing on the well-being of women and children. The spread of HIV and AIDS in many developing countries has provided an important reason for criticizing Catholic opposition to methods that can be effective in preventing the spread of a deadly disease.

In spite of Catholic opposition to artificial contraception many other Christian churches have become more accepting of the role of birth control within marriage. In most cases the reasons for that openness are related to the consequences unlimited procreation can have on a marriage, other children, or the community in general. For many Christian denominations the use of both natural and artificial contraceptives methods is a way to express responsible parenthood. Other religion traditions, such as Islam, Orthodox Judaism, and Hinduism, also accept the morality of contraception as long as it is not harmful to the persons involved. Islamic teachings, for example, historically have been fairly tolerant of contraception. That allowed discussion and development of birth-control techniques by medieval Arabic writers, including the Muslim physician Ibn Sina (980–1037). The Jewish tradition also tends to support birth control, although with many qualifications, and makes it primarily the responsibility of women (Feldman 1968).

Feminists' attitudes toward artificial birth control methods are, as with many other reproductive technologies, ambivalent. On the one hand, contraception has freed women from unlimited reproduction, facilitated their incorporation into the labor force, and allowed them to make autonomous choices about whether and when to have children and about how many of them to bring into the world. On the other hand, birth control methods are developed, implemented, and used in the context of patriarchal societies that still are involved in controlling women's lives and in many cases continue to show little interest for women's well-being.

In this context the fact that most contraceptive methods have been developed for women is a matter of concern, especially because women rarely have been involved in making decisions about what technologies to develop. Also a matter of feminist concern is the fact that many contraceptive methods, such as those involving hormones, appear to have been developed with more interest in their efficacy than in their safety. Similarly, although male reproductive biology seems to be more difficult to interrupt, it appears that part of the scarcity of research in that area can be attributed to fear of affecting the male libido, a concern that has not affected research on female contraception.

Many feminists have objected to the testing of new contraceptives on women in developing countries and have expressed worries about possible social abuses in both industrialized and nonindustrialized nations arising from the use of long-acting implantable contraceptives such as NorplantÒ. Once implanted, NorplantÒ can be removed only surgically. That makes this contraceptive far more effective than many others in which compliance can be a problem. These worries are not easily dismissible in light of the fact that in the United States, for example, several state legislatures have considered regulations that would pay women on welfare to use NorplantÒ. Some judges have imposed the use of this drug as an alternative to a lengthy prison sentence for women convicted of child abuse.

In developing countries the likelihood of abuses resulting from the use of this type of contraceptive is even more obvious. Powerful population control interests can result in subtly or clearly coercive methods to assure women's use of birth control. The fact that NorplantÒ requires surgery, together with the scarcity of health care resources, makes concerns about the possibility of coercion even more pressing.

Also feeding feminists' worries about possible abuses of birth control methods were attempts by members of eugenics movements in the early twentieth century to control the reproductive activities of those considered undesirable. In most cases involuntary sterilization was the method of choice to prevent those with mental problems, criminals, immigrants, and poor and minority women from reproducing under the idea that if they were not stopped, lower-class offspring would outnumber the upper classes' progeny.

New demographic trends such as below-replacement birth rates in some European nations, together with what appears to be an environmentally caused decline in fertility among both men and women in industrialized countries, may put discussions of birth control in a different framework in the future, especially in nations with strong welfare systems. In those nations the aging population has been putting a serious strain on public resources. In this context some might argue for the need to encourage births rather than control them.

INMACULADA DE MELO-MARTÍN
ADAM BRIGGLE

SEE ALSO Bioethcs;Eugenics;Population.

BIBLIOGRAPHY

Ada, G. L., and P. D. Griffin, eds. (1991). Symposium on Assessing the Safety and Efficacy of Vaccines to Regulate Fertility. Cambridge, UK, and New York: Cambridge University Press. Sixteen essays collected by the Special Program of Research Development and Research Training in Human Reproduction at the World Health Organization.

Bullough, Vern. L., ed. (2001). Encyclopedia of Birth Control. Santa Barbara, CA: ABC-CLIO.

Dupré, Louis. (1964). Contraception and Catholics: A New Appraisal. Baltimore: Helicon. Examines the arguments that the Catholic Church has proposed against the use of artificial birth control.

Feldman, David M. (1968). Marital Relations, Birth Control, and Abortion in Jewish Law. New York: Schocken.

Holmes, Helen; Betty Hoskins; and Michael Gross, eds. (1980). Birth Control and Controlling Birth: Women-Centered Perspectives. Clifton, NJ: Humana Press.

Institute of Medicine. (2004). New Frontiers in Contraceptive Research: A Blueprint for Action. Washington, DC: National Academies Press. Provides recommendations on how science can best address concerns of fertility regulation and reproductive health.

Moskowitz, Ellen, and Bruce Jennings, eds. (1996). Coerced Contraception? Moral and Policy Challenges of Long-Acting Birth Control. Washington, DC: Georgetown University Press.

Reed, James. (1978). From Private Vice to Public Virtue: The Birth Control Movement and American Society since 1830. New York: Basic Books. Focuses on the strategies and efforts of a small group of U.S. citizens in the birth control movement.

Segal, Sheldon J. (2003). Under the Banyan Tree: A Population Scientist's Odyssey. New York: Oxford University Press. Stresses the importance of education in achieving population control and poverty reduction and chronicles personal experiences with international family-planning efforts to increase understanding about population issues.

INTERNET RESOURCE

Union of Concerned Scientists. (2004). Scientific Integrity in Policy Making: An Investigation of the Bush Administration's Misuse of Science. Cambridge, MA: Author. Available at http://www.ucsusa.org/documents/RSI_final_fullreport.pdf.

Birth Control

Human beings have sought to avoid child bearing since ancient times and have used many methods to prevent conception or to kill a developing fetus. Religious and secular authorities usually discouraged the separation of sexual intercourse from procreation because they believed that it violated natural law or deprived the state of human capital. Thus, while individuals pursued their self-interests through such practices as coitus interruptus or inducing abortion, they usually acted in flagrant violation of official standards of sexual conduct.

Falling Birth Rates and the Social Environment

The English economist and cleric Thomas Malthus brought reproductive behavior into public debates over the nature of poverty through his Essay on Population (1798). He argued that rapid population growth forced down the living standards of the working classes, whose only hope for amelioration lay in "moral restraint" or the prudent postponement of marriage. In the early nineteenth century, English labor organizer Francis Place and other champions of the poor advocated family limitation as a tool in the struggle for social justice and sometimes published descriptions of how to prevent conception. These neo-Malthusians found a growing audience during the nineteenth century as birth rates began to decline in many countries that were actively involved in the developing market economy of the Atlantic world. These secular declines in fertility resulted from the private efforts by the sexually active to avoid pregnancy and were routinely denounced by political leaders, who attempted to suppress information on fertility control techniques. The term birth control was coined in the June 1914 issue of The Woman Rebel, a militantly feminist journal published in New York by Margaret Sanger (1879-1966), who became the preeminent champion of reproductive autonomy for women through her campaigns to abolish the legal and social obstacles to contraceptive practice. Eventually the term birth control became a synonym for family planning and population control, but the term family planning was originally adopted by those who wished to disassociate the movement to control fertility from Sanger's feminism, and the phrase population control was largely a post–World War II movement led by social scientists and policy-making elites, who feared that rapid population growth in the non-Western world would undermine capitalist development.

The precise timing and social determinants of the demographic transition in western Europe and North America from a vital economy of high birth rates and high death rates to one of low fertility and low mortality is still much in dispute among demographers, perhaps because of class and geographical differences in motivation and behavior. While French peasants seem to have been pioneers in fertility restraint during the eighteenth century, a broad spectrum of native-born Protestants in the United States led the turn to family limitation during the nineteenth century. In the United States the average native-born white woman bore seven or eight children in the late eighteenth century, but by the middle of the nineteenth century she was the mother of five, by the early twentieth century the mother of three, and by the middle of the Great Depression of the 1930s the mother of two. One of the remarkable aspects of the American demographic transition is that there were no sustained declines in infant mortality before 1900. Several generations of American women had fewer children than their mothers despite high infant mortality and vigorous attempts by social leaders to encourage higher fertility.

The fertility decline is best understood as a response to a changing social environment. As the home ceased to be a unit of production, and as the manufacture of clothing and other goods moved to factories, children no longer provided necessary labor in the family economies of the emerging middle and white-collar classes. Rather, they became expensive investments, requiring education, capital, and an abundance of "Christian nurture" from mothers who measured respectability by the ability to stay home and efficiently manage the income won by their husbands in a separate, public sphere of work. Marriage manuals, some containing instructions for contraception, were prominent among the self-help books that became a staple of American culture after 1830. Romantic love became the rationale for marriage and religious leaders gave new prominence to the erotic bonds between husbands and wives. Thus, socially ambitious married couples bore the burden of reconciling sexual passion with a manageable number of children, whose socialization required more expensive and permissive nurture.

Historians now attribute the fertility decline to restrictive practices–contraception, abortion, and abstention from coitus–rather than biological changes or shifts in the percentage of individuals who married or their age at marriage. The efforts by individuals to control their fertility for personal reasons inspired the first self-conscious attempts to suppress birth control. Between 1840 and 1870, leaders of the medical profession organized successful campaigns to criminalize abortion through new state laws. The culmination of the campaigns against abortion in state legislatures coincided with the passage of the Comstock Act (1873) a strengthened national obscenity law in which no distinctions were made between smut, abortifacients, or contraceptives–all were prohibited.

During this period of legislative repression of contraception, Catholic theologians debated the moral implications of claims by experimental physiologists that there might be a naturally occurring sterile period in the female menstrual cycle. Church authorities quietly accepted the legitimacy of limiting coitus to periods of natural sterility, but the effectiveness of this "rhythm method" proved limited, and the Church's ancient prohibition on "artificial" contraception was reaffirmed by Pius XI in the encyclical Casti Connubi (December 1930).

Margaret Sanger

By the second decade of the twentieth century women in both Great Britain and the United States had begun to challenge the taboos on fertility control. Margaret Sanger won her place as the charismatic leader of the birth-control movement in the United States through her ability to develop a compelling rationale for the acceptance of contraception as an alternative to illegal abortion, since an appalling number of women died from septic abortions. Although she was influenced by the anarchist Emma Goldman and by trips to Europe, during which she was impressed by the sexual know-how of ordinary French women and by the birth-control advice stations operated by feminist physicians in the Netherlands, Sanger claimed that the death of one of her nursing clients from a self-induced abortion led her to focus all her energy on the single cause of reproductive autonomy for women. Sanger opened the first birth-control clinic in the United States in October 1916, in the Brownsville section of Brooklyn, New York. A police raid closed the clinic after ten days, but Sanger's trial and brief imprisonment made her a national figure, and in appealing her case she won a 1919 clarification of the New York State obscenity law that established the right of doctors to provide women with contraceptive advice for "the cure and prevention of disease."

Sanger interpreted this decision as a mandate for doctor-staffed birth-control clinics. Spurred by the emergence of an English rival, Marie Stopes, who opened a birth-control clinic in London in 1921, Sanger played down her radical past and found financial angels whose support allowed her to organize the American Birth Control League in 1921 and the Birth Control Clinical Research Bureau in New York City in 1923. The first doctor-staffed birth-control clinic in the United States, it provided case histories that demonstrated the safety and effectiveness of contraceptive practice and served as a model for a nationwide network of over 300 birth-control clinics by the late 1930s. In 1936 Sanger won an important revision in federal law with U.S. v. One Package (1936), which established the right of physicians to receive contraceptive materials. In 1937 the American Medical Association recognized contraception as an ethical medical service.

On the eve of World War II, the limits of the birth-control movement seemed to have been realized. A majority of Americans practiced some form of fertility control, but there was widespread concern about the low birth rate and little support for public subsidy of the services. Many social leaders were disturbed by the more permissive standards of sexual behavior that emerged during the first decades of the twentieth century as young women became increasingly visible as wage earners and as participants in an eroticized consumer culture. Alfred Kinsey and other pioneers in the survey of sexual behavior documented increases in premarital sexual activity that convinced some social conservatives that sexual liberation had gone too far. After World War II, however, influential social scientists such as Frank Notestein of Princeton University's Center for Population Research provided a new rationale for birth control by drawing attention to rapid population growth in the Third World and by arguing that the United States risked losing the Cold War because economic development compatible with capitalism might be impossible if the means were not found to curb birth rates.

Birth Control after World War II

John D. Rockefeller III became the leader of a revived movement to promote population control by founding the Population Council in 1952, after he failed to convince the directors of the Rockefeller Foundation that his interests warranted major new initiatives. The Population Council subsidized the development of academic demographic research in the United States and foreign universities and by the late 1950s was providing technical assistance to India and Pakistan for family planning programs. Concerned over the failure rates of the conventional barrier contraceptives such as condoms and diaphragms, the council invested in the clinical testing, improvement, and statistical evaluation of intrauterine devices (IUDs), that is, objects placed in the uterus to invoke an immune response that inhibits conception. A second major advance in contraceptive technology came with the marketing of an oral contraceptive by J. D. Searle and Company in 1960. "The pill" depended on recent advances in steroid chemistry, which provided orally active, and inexpensive, synthetic hormones. Margaret Sanger ensured that these new drugs would be exploited for birth control by recruiting Gregory Pincus of the Worcester Foundation for Experimental Biology for the work and introducing him to a feminist colleague, Katharine Dexter McCormick, who provided the funds Pincus needed to realize their dream of a female-controlled form of birth control that did not require specific preparation before sexual intercourse and thus made spontaneous sexual activity possible. The pill's rapid acceptance by the medical community and its female clients was enhanced by the growing use of synthetic hormones to treat a wide range of gynecological disorders so that contraception now appeared to be divorced from the "messy gadgets" of the past and was place in the context of modern therapeutics. In 1963 the Roman Catholic gynecologist John Rock, who had led the clinical trials of the first oral contraceptive, proclaimed, in The Time Has Come, that contraception was, thanks to the pill, now compatible with Catholic natural law theology. Rock's optimism proved false when Pope Paul VI's encyclical Humanae Vitae (July 1968) confirmed traditional teachings that prohibited artificial contracerpition, but by then a majority of married Catholics in the United States were practicing birth control.

A series of federal court decisions and new welfare policies reflected the changed status of birth control in public opinion. In 1965 the U.S. Supreme Court, in Griswold v. Connecticut, struck down a statute that prohibited contraceptive practice. The court continued to expand the rights of individuals to defy outdated restrictions in Eisenstadt v. Baird, (1972), which established the right of the unmarried to contraceptives. As President Lyndon Johnson's War on Poverty emerged from Congress, the Social Security Amendments of 1967 specified that at least 6 percent of expanding maternal and child health care funds were to be spent on family planning services. The Foreign Assistance Act of the same year provided aid for international programs, and contraceptives were removed from the list of materials that could not be purchased with Agency for International Development funds.

By the late 1960s feminists and population control advocates were successfully challenging state laws that limited access to abortion. In 1973 the U.S. Supreme Court attempted to forge a new consensus in Roe v. Wade, which recognized the right of abortion on demand during the first trimester of pregnancy. The Court's decision simply added fuel to an escalating firestorm of controversy as Roman Catholic leaders found common cause with Protestant fundamentalists and social conservative critics of the welfare state in a "right-to-life" and "family values" movement. From the left, groups such as the Committee to End Sterilization Abuse (founded in 1974) charged that minority women were being coerced by government maternal health programs that they viewed as genocidal. Revelations that disproportionate numbers of Hispanic and African-American women were sterilized in government programs that lacked adequate ethical guidelines supported complaints by such organizations as the National Women's Health Movement and the International Women's Health Coalition that the American health-care establishment had gone radically wrong in its high-tech, top-down, paternalistic approach to reproductive health issues.

At the 1974 United Nations World Population Conference, held in Bucharest, Rumania, John D. Rockefeller III recognized the criticisms of conventional family planning programs that had been mounted by feminists and the Population Council was reorganized to emphasize holistic approaches to women's health issues. New ethical guidelines were developed for federally sponsored maternal health programs as well, but deep social divisions remained between "pro-choice" and "pro-life" advocates, with the Democratic Party embracing the former and the Republican Party embracing the latter. Despite numerous challenges in state and federal courts and legislatures, Roe v. Wade remained the law of the land. In the late 1990s federal and state expenditures for subsidized family planning, including contraception, sterilization, and therapeutic abortion, exceeded $700 million annually, while the birth rate among the native-born was below the level needed to maintain the population, which continued to grow because of liberal immigration laws and mass immigration to the United States.

The birth rate was even lower in Europe, where in countries such as Spain and Italy reproduction was not at a rate high enough to maintain their populations. In many other parts of the world, including China, India, and the Middle East, previously high birth rates were also in decline.

See also: Conception and Birth; Eugenics; Fertility Rates; Obstetrics and Midwifery; Sexuality.

bibliography

Brodie, Janet Farrell. 1994. Contraception and Abortion in Nineteenth-Century America. Ithaca, NY: Cornell University Press.

Chesler, Ellen. 1992. Woman of Valor: Margaret Sanger and the Birth Control Movement in America. New York: Simon and Schuster.

Critchlow, Donald T. 1999. Intended Consequences: Birth Control, Abortion, and the Federal Government in Modern America. New York: Oxford University Press.

Critchlow, Donald T., ed. 1996. The Politics of Abortion and Birth Control in Historical Perspective. University Park: Pennsylvania State University Press.

Dixon-Mueller, Ruth. 1993. Population Policy and Women's Rights: Transforming Reproductive Choice. New York: Praeger.

Garrow, David J. 1994. Liberty and Sexuality: The Right to Privacy and the Making of Roe v. Wade. New York: Macmillan.

Gordon, Linda. 1990. Woman's Body, Woman's Right: A Social History of Birth Control in America. New York: Grossman. 1976. Revised, New York: Penguin.

Hull, N. E. H., and Peter C. Hoffer. 2001. Roe v. Wade: The Abortion Rights Controversy in American History. Lawrence: University Press of Kansas.

McCann, Carole R. 1994. Birth Control Politics in the United States, 1916-1945. Ithaca, NY: Cornell University Press.

McLaren, Angus. 1990. A History of Contraception: From Antiquity to the Present Day. Cambridge, MA: Blackwell.

Mohr, James C. 1988. Abortion in America: The Origins and Evolution of National Policy, 1800-1900. New York: Oxford University Press.

Reagan, Leslie J. 1997. When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867-1973. Berkeley: University of California Press.

Reed, James. 1984. The Birth Control Movement and American Society: From Private Vice to Public Virtue. New York: Basic Books. 1978. From Private Vice to Public Virtue: The Birth Control Movement and American Society since 1830. Reprint, Princeton NJ: Princeton University Press.

Tone, Andrea. 2001. Devices and Desires: A History of Contraceptives in America. New York: Hill and Wang.

James W. Reed

BIRTH CONTROL.

Efforts to control fertility are as old as human society itself. Traditional methods of birth control included abortion, infanticide, late marriage, prolonged sexual abstinence, extended nursing (to prevent ovulation), coitus interruptus (withdrawal), douching, and nonreproductive sexual practices such as masturbation. For hundreds of years, women used substances such as sponges to block conception and herbal potions to kill sperm or to cause miscarriages. Condoms (also known as sheaths), in use since the early modern era, were originally made of sheepskin, then of vulcanized rubber from the 1870s. Although various birth control technologies and practices had long existed, by the turn of the twentieth century, the most frequently used methods continued to be withdrawal—a method dependent on men—and abortion. But key changes were already underway that would ultimately produce revolutions in both technologies and practice. Between 1870 and 1914, fertility rates throughout Europe had declined dramatically, reflecting a major transformation in values about ideal family size and a stronger motivation to limit it. Although feminist movements did not officially advocate birth control, female emancipation of the late nineteenth century led many women to consider reproductive choice a personal right. At the same time, the science of sexology emerged, which led to new ways of thinking about, regulating, and intervening in sexuality. It also led to the eventual recognition that female sexual pleasure was important to marital happiness. These transformations took place in the broader context of the rise of strong nation-states and international competition, discourses about "racial purity," and governments and professional experts who viewed their populations as a resource whose health needed improvement and whose families needed stabilization. By the turn of the twentieth century, the confluence of these factors led to improved contraceptive devices intended specifically for women and a new ideology—neo-Malthusianism—that spawned movements to distribute them.

Improved methods for women included various types of pessaries, a generic term for blockage methods, which included thimble-shaped cervical caps made of rubber or of cellulose and metal. One version had sharp teeth around the inside edge to adhere better to the relatively insensate cervix. The diaphragm, also made of rubber but wider and shallower than the cap, was (and is) held in place with an encased metal spring and used with spermicide cream. Intrauterine devices (IUDs) also came into use, though they were expensive. One type consisted of a plate placed at the base of the cervix, with a stem that extended into its canal. Others had a V-shaped spring that extended into the uterus.

Despite the expressed need many women felt for birth control, the widespread adoption of appliance methods required new attitudes toward sexuality and sexual practices, as well as women's knowledge about and comfort with their own bodies, which was uncommon during the Victorian era. Appliance methods also required premeditation prior to the sexual act, a psychological state many women continued to lack in the second half of the twentieth century. For this reason abortion—an act of desperation after the sexual act—seemed more innocent for many women than did conscious actions in advance of coitus to prevent conception. Appliance devices themselves posed difficulties. Placing any object in the vagina unrelated to sex or childbirth seemed unnatural to both women and doctors. Health practitioners sometimes advised patients to keep cervical caps and diaphragms in place for weeks at a time, which produced infections. Not surprisingly, the cervical cap with teeth often caused inflammation of the cervix. Finally, because they required fitting, instruction, and privacy, poor women, especially in the countryside, had little access to them.

BIRTH CONTROL MOVEMENTS

Birth control movements in the early twentieth century originated with "neo-Malthusian" concerns about economic distress and other social evils caused by overpopulation. The eighteenth-century political economist Thomas Malthus, in An Essay on the Principle of Population (1798), warned that because food production could not keep pace with population growth, the latter had to be checked. To that end, he preached celibacy and delayed marriage. Neo-Malthusians, however, thought that the sexual instinct could not and should not be suppressed; they hoped to alleviate social ills through the use of contraception. Controlling population growth was not only a matter of food, wages, and prices, but also of the potential for human perfection and freedom. Neo-Malthusian doctrine contributed to eugenicist notions of using birth control for the purposes of improving the quality, not just reducing the quantity, of the population.

Neo-Malthusianism started in Great Britain, and spread to the Netherlands, France, and Italy. The movements mostly concerned themselves with the more prolific working classes—middle classes were already the ones to deliberately limit family size. With their focus on birth control primarily as a panacea for social and economic ills rather than sexual emancipation for women (though movements varied nationally), neo-Malthusian movements were primarily dominated by men. But there were important exceptions. The Dutch physician Aletta Henriëtte Jacobs (1854–1929) opened a birth control clinic in Amsterdam in the 1890s. The French feminist Nelly Roussel (1878–1922) widely campaigned in France for women's access to contraception and argued that reproductive choice was the centerpiece of female emancipation. The American Margaret Louise Sanger (1879–1966) coined the term birth control in 1914 as a substitute for the gloomy economic label neo-Malthusianism and as a deliberate effort to focus on the well-being of mothers and children. All three particularly reacted to the hardships of working-class women who suffered from repeated childbearing and poverty, but implicit in their work was a belief in women's reproductive autonomy. The Englishwoman Marie Charlotte Carmichael Stopes (1880–1958), through her marriage manual Married Love (1918), became famous for her focus on women's sexual pleasure. But readers' responses to the manual stressed how fears of pregnancy interfered with pleasure, so she quickly produced Wise Parenthood (1918) in which she provided descriptions of contraceptives and their use. Finding that she could not depend on medical professionals to dispense contraceptives, she opened her own birth control clinic in 1921.

By the 1930s the idea of birth control was widely accepted and practiced, and an increasing number of women sought female contraceptives. Nonetheless, their adoption was slow, and until the last third of the twentieth century, withdrawal continued to be the most commonly used method throughout much of Europe. Everywhere, those who sought to spread contraceptives for women met with resistance from the church, governments, the medical profession, moral reformers, and social activists across the political spectrum. In 1930 Pope Pius XI (r. 1922–1939) issued the encyclicalCasti Connubi (On Christian marriage) to concretize the Church's staunch opposition to any artificial control of fertility and to reinforce Church doctrine regarding women's proper role as mothers. The only method of birth control acceptable to the Church was the rhythm method, made possible when doctors finally discovered the pattern of ovulation in 1929. But this method was dubbed "Vatican roulette" since it had such a high failure rate.

Many others opposed birth control for secular reasons. National defense required large populations, pronatalists argued. Moralists believed that access to female contraceptives would make women into sex objects, render them promiscuous, and destroy the family. Both prostitution and venereal disease would spread. Many feminists believed that contraceptives would rob motherhood of its dignity and deny women their single most important excuse to resist sexual advances. Doctors and other health professionals justifiably thought that appliance methods were unnatural and dangerous to the female body. Although most advocates of birth control came from the left wing—many were anarchists and freethinkers—opposition also came from the Left. Socialists believed birth control was selfishly individualistic and bourgeois. Any improvement in living standards resulting from smaller families would divert the working classes from the only true source of emancipation—the overthrow of capitalism.

GOVERNMENT INTERVENTION AND NATIONAL VARIATIONS, 1920–1960

The massive disruptions of World War I had direct impacts on attitudes toward birth control that varied considerably by nation. Hardships and economic disruptions of everyday life did not end with the war. Everywhere, large families were simply impractical, even though many viewed them as a potential source of national regeneration. But accustomed to rationalized economies from the war years, politicians and health professionals generally came to accept the need to develop population policies and intervene in issues of birth control in order to reduce abortion and stabilize family life. Governments born of war and revolution, such as the Communist Soviet Union and the German Weimar Republic, were more open to sexual reform movements that advocated birth control than were Western democracies.

The Russian Revolution of 1917 brought unprecedented gender equality—at least in principle—and with it a new consciousness about women's double burden of work and motherhood. But the effort to address women's issues did not initially extend to reproductive rights. Official Communist doctrine opposed birth control as a product of Western capitalism, and a source of race suicide in a nation surrounded by anticommunist countries. But relatively backward in even traditional methods of family limitation, the USSR differed from Western countries in the persistence of high birth-rates. It also had very high abortion rates. In 1920 the government took the opposite path of other nations: it legalized abortion in order to reduce the mortality and illness resulting from illegal operations. This bold step did not mean that the government favored abortion as a means of birth control. But the effort to regulate abortion led to open discussion about birth control. At the same time, concerns about the health of mothers and children led the government to form the Department for the Protection of Motherhood and Infancy that, in the mid-1920s, formed a commission to research birth control methods. In 1925 the department officially endorsed birth control and its dissemination as a means to reduce abortion. Even before that endorsement, pharmacies openly displayed contraceptive devices and handed out instructions to use them.

What happened in the Soviet Union was crucial for other countries as well. Because of its advances in women's equality and reproductive freedom, numerous women from Europe and the United States visited the Soviet Union in the 1920s and 1930s. German women were particularly influenced by what they learned. The prewar German penal code prohibited abortion and outlawed the discussion, display, and advertisement of contraceptives, though their manufacture and sale continued to be legal. After the war, in the context of national defeat, economic crisis, and a new democratic government, German reformers became deeply worried about the health of families. Communists and Social Democrats, influenced by the Soviet model and by Margaret Sanger, joined representatives of the health professions in the belief that sexuality should be regulated even though birthrates were in decline. Rather than trying to raise the birthrate, they focused on the quality of children born. They believed that sex and birth control counseling would stabilize marriage and reduce illegal abortion, infant mortality, and babies born out of wedlock. Weimar Germany was unique in its grassroots birth control movement, and in the early establishment and large number of clinics and sex reform leagues. They also openly fought to legalize abortion. But like the earlier neo-Malthusians, they framed their vision in economic terms with the intent of improving domestic happiness among the working classes, a vision they linked strongly to eugenics.

Western democracies that had neo-Malthusian movements prior to World War I, afterward proved more conservative with regard to reproductive rights. Birth control propaganda had always remained legal in Britain as long as it was not judged "obscene." The church and the medical profession continued to oppose birth control in the 1920s. Doctors not only feared race suicide and a decline of the British Empire, but they also believed contraception would cause sterility, fibroid tumors, and a number of other gynecological disorders. Despite this resistance, the economic dislocations and the plight of the working classes helped advocates of family limitation prevail. In 1930 the Anglican Church announced its acceptance of birth control, and the Ministry of Health finally approved the distribution of contraceptive devices—but only with the advice of local medical officers, and only to married mothers whose further pregnancies would be harmful to their physical health.

The situations in France and Italy differed markedly from those in other countries where the toleration for birth control grew. Because of France's uniquely low birthrates for more than a hundred years, its government felt particularly threatened by neo-Malthusianism even prior to World War I. Pronatalists had fervently argued for the legal prohibition of birth control from 1909 and believed that low birthrates made them vulnerable to German aggression. The French, moreover, lost proportionally more of their mobilized soldiers than any other country in World War I and suffered the damages from the war having been fought on their soil. In July 1920 the government passed a law that prohibited the sale, advertisement, and public discussion of birth control devices, though condoms remained legal to prevent venereal disease. A law of 1923 made prosecution for abortion easier. These laws remained in place until 1967 and 1975, respectively.

Legislation prohibiting abortion and birth control became an important aspect of totalitarian doctrines and practices in the 1920s and 1930s and reflected newly conservative views about gender roles. Fathering large families became a sign of masculinity and an important element of Italian dictator Benito Mussolini's fascism after he came to power in 1922, even though he had supported neo-Malthusianism prior to the war. Women were expected to sacrifice themselves through childbearing. Birth control was outlawed as a crime against the state in 1926. In Germany the Nazi takeover in 1933 resulted in the closure of birth control clinics and marriage counseling centers. The Nazis used "birth control" for eugenic ends, forcing abortions and sterilization on Jews, Gypsies, non-Aryans, and others deemed a threat to the German race. In both Germany and Vichy France during World War II, abortion became punishable by death for those who performed it. Soviet policy regarding reproduction reversed direction in the 1930s under Joseph Stalin. Like the right-wing dictators, he too encouraged large families and maternal self-sacrifice; abortion was again prohibited, and birth control information became unavailable.

THE REVOLUTION IN BIRTH CONTROL, 1960 TO THE EARLY TWENTY-FIRST CENTURY

As these examples indicate, government population policies, traditional attitudes about gender and sexuality, and the difficulties contraceptive devices posed hindered their adoption through much of the twentieth century. Only in the 1960s did new technologies begin to change attitudes in fundamental ways. New, presumably safer forms of the IUD became available and relieved women of all the inconveniences of the earlier methods. More important, the oral contraceptive pill became available. At least five scientists contributed to the hormonal research that eventually led to the Pill, though contraception had not been their intent. The irrepressible Margaret Sanger convinced one of them, Gregory Goodwin Pincus, to apply his research to contraceptive purposes and secured funding for him. Having proved that progesterone inhibits ovulation in 1951, he undertook the task of developing a synthetic hormone. In 1960 the American Food and Drug Administration approved the Searle synthetic anovulent, and it quickly spread to Europe. Like the IUD, the Pill offered the obvious advantage that its use was completely separate from the sex act and required no messy, unromantic preparations. But its adoption nonetheless required approval of the medical profession, legal sanction, and attitudinal change among women. By 1970, for example, only 6 percent of French women used the Pill, in part because its distribution required a prescription and because it was initially withheld from unmarried women and minors. Today the oral contraceptive has been followed by other means of injecting hormones such as patches, shots, and suppositories. Other applications of hormones have also come into use, such as the postcoital "morning-after pill" that blocks implantation of a fertilized egg.

The myth most commonly associated with the Pill is that it caused the sexual revolution of the 1960s and 1970s. In fact, that revolution resulted from the complex confluence of other cultural factors beyond the scope of this entry. The Pill, however, remains controversial for other reasons. While for some women it seems like a more "natural" method of contraception than appliance devices such as the diaphragm, others fear it might have long-term effects such as cancer and wonder why only women are subjected to such "biointervention." Such fears led many women in the 1960s and 1970s to choose the IUD. But various versions of this device eventually proved to be damaging to the uterus. Finally, abortion rates remain high despite the wider availability of contraception.

Birth control—especially the availability of female forms of contraception—enabled a separation of reproduction from sexuality and had an enormous influence on the evolution of modern European society. The few examples of national variation offered here illustrate the complex interrelationships between technology, sexuality, gender relationships, and the overarching influence of social policy engineered by various national agendas. The Pill fostered dramatic change and resolved many problems women and married couples confronted in the past. It has also raised new questions about sexual and reproductive autonomy. Moreover, large segments of the European population still have little access to safe and effective forms of birth control.

See alsoAbortion; Feminism; Sexuality.

BIBLIOGRAPHY

Primary Sources

Sanger, Margaret. Margaret Sanger: An Autobiography. New York, 1938.

Smith, Jessica. Women in Soviet Russia. New York, 1928.

Stopes, Marie Carmichael. Married Love. London, 1918.

——. Wise Parenthood: A Practical Sequel to "Married Love"; A Book for Married People. London, 1919.

——. Contraception (Birth Control): Its Theory, History, and Practice; A Manual for the Medical and Legal Professions. London, 1923.

Secondary Sources

"Before the Pill: Preventing Fertility in Western Europe and Quebec." Special issue of The Journal of Interdisciplinary History 34, no. 2 (autumn 2003).

Cook, Hera. The Long Sexual Revolution: English Women, Sex, and Contraception, 1800–1975. Oxford, U.K., 2004.

Grossmann, Atina. Reforming Sex: The German Movement for Birth Control and Abortion Reform, 1920–1950. New York, 1995.

Heims, Norman. The Medical History of Contraception. Baltimore, Md., 1936.

Marks, Lara. Sexual Chemistry: A History of the Contraceptive Pill. New Haven, Conn., 2001.

McLaren, Angus. A History of Contraception: From Antiquity to the Present Day. Oxford, U.K., 1990.

——. Twentieth-Century Sexuality: A History. Oxford, U.K., 1999.

Soloway, Richard Allen. Birth Control and the Population Question in England, 1877–1930. Chapel Hill, N.C., 1982.

Elinor Accampo

BIRTH CONTROL

Control or regulation of conception and birth, either to limit population growth, to increase births among particular populations, or to enable conception through medical intervention.

The terms birth control and family planning (in the sense of limiting births) and the concept of population reduction are controversial in the Middle East. Population, its growth, reduction, and control are at the heart of some of the region's most volatile political conflicts, such as the Arab–Israel conflict and the civil war in Lebanon, a country founded on the notion of proportional power-sharing between Christians and Muslims. Issues related to birth control and contraception also serve as lightning rods for some of the sharper social, cultural, and ideological controversies in the contemporary Middle East, particularly those centering on secular versus religious modes of organization and frames of meaning, women's rights, and the tension between individual and collective rights. In attempting to alter, influence, or control the literal and figurative reproduction of the family as the region's basic social institution and moral structure, birth-control policies straddle political, moral, and religious fault lines, highlighting contending sources of authority and revealing ongoing challenges of national integration and identity in the region.

Advocated by the state and international organizations, birth-reduction campaigns usually target impoverished, powerless, and marginalized groups, thus drawing attention to long-standing socioeconomic inequalities and class-based tensions in major cities such as Cairo, Tehran, and Istanbul. But birth control is not only imposed from above or beyond the contemporary Middle East—it is also chosen in increasing numbers by those living in the region as part of a larger trend toward claiming rights, taking control of personal health and the body, and domestic decision making and financial planning for families' futures. As a facet of projects designed to ensure women's increasing agency in and control over their own lives, birth control has drawn the attention and earned the censure of conservative religious authorities, be they Christian, Muslim, or Jewish.

Manipulating Population Growth

Population growth results from increased birth rates and falling mortality rates, as well as migration. In the major cities of the Middle East, rapid urbanization and dramatic population increases have been a common feature of the last sixty years. Most countries in the region have just attained, or soon will attain, the demographic transition—the stage at which birth rates slow down to replacement levels, death rates having dropped earlier. Rapid population increases in the Middle East have affected patterns of urbanization, labor, and immigration, and have often strained the provision of education, health, and social services in resource-poor countries. For many, state-sponsored policies encouraging birth control symbolize interference in family matters and the negation of such traditional values as the importance of marriage and family. Women's control over their own bodies and their own fertility, afforded by birth control, conflicts with some communities' values concerning the importance of women's chastity, their role in the home, and their status as mothers and nurturers. Others view contraceptive technology as an important tool in areas ranging from national development policy to a woman's safeguarding of her health.

Although the region shares a common culture and a dominant religion (Islam), variations of geography and resource allocation have generated different policy responses to population growth. Whereas some countries seek to limit their populations, others seek to increase theirs. Egypt, Iran, Turkey, Tunisia, Lebanon, and Morocco, lacking a sufficient resource base to support their growing and largely young populations, have supported national family-planning programs designed to reduce population growth. Saudi Arabia, Kuwait, Libya, Iraq, and the Gulf oil states, on the other hand, lack sufficient populations to supply their labor needs and have had pronatalist (probirth) policies. Israel also has a pronatalist policy for its Jewish population, and actively encourages Jewish women to have many children. This policy, however, does not extend to Israel's Arab citizens, who, representing 20 percent of Israel's population, have a higher birth rate and a younger median age than do Israeli Jews. Assisted conception and infertility treatments in Israel are the most advanced in the region, and state subsidies render these services affordable for all Israeli citizens, Arabs and Jews alike.

Overall, the rapid growth of population in the Middle East is a matter of concern within as well as beyond the region. In 1993 the population of the Middle East was approximately 360 million; by 2025 it is expected to reach 700 million. The region's population is young: 41 percent are under 15 years of age. Fears that resources, particularly water, may not stretch to support populations have prompted many governments to make contraceptive use an integral part of their public-health programs and to mount campaigns to encourage the use of family-planning techniques and mechanisms. Yet, women's fertility rates are often influenced more by educational levels and employment than by access to birth-control pills, intrauterine devices, or condoms. Women's status and life possibilities greatly shape their reproductive behavior; women who complete high school and college tend to marry later, and thus give birth to fewer children. Trends toward later marriage in most countries of the region (with the exception of the Occupied Palestinian territories, Yemen, and Oman) should translate into lower birth rates in the coming decades.

Demographic evidence suggests that disease, poverty, and warfare combined to keep population figures relatively even and stable until the beginning of the twentieth century. The population of the central Middle East (excluding North Africa) is estimated to have been around 40 million at the beginning of the twentieth century. By 1950 it had doubled to 80 million (1993, 265 million; 1999, 380 million). Explosive growth followed the end of World War II, when greater emphasis upon public sanitation and healthcare reduced the death rate while the birth rate remained high. In the early 1960s Gamal Abdel Nasser of Egypt and Habib Bourguiba of Tunisia were the first national leaders to appreciate the potentially negative relationship between unrestricted population growth and socioeconomic development, and they feared that the resulting pressure could spur political unrest. The family-planning programs they initiated encountered opposition, but since about 1970 their programs, along with those of Lebanon, Turkey, Morocco, and Iran, have achieved limited success.

Cultural, Political, and Religious Opposition to Family Planning

Opposition has come from political, military, religious, and cultural quarters. Both the culture of the Middle East and the religions of the area—Islam, Christianity, and Judaism—encourage marriage and family. The term birth control (tahdid al-nasl) is considered highly perjorative because it connotes preventing the birth of children. Less objectionable terms are tanzim al-usra and takhtit al-aʾila (family planning), which connote organization and ordering rather than the outright limitation of progeny. Nations of the Middle East have historically sought to augment their strength against enemies by increasing their numbers. To many, birth control is suspect and assumed to be another facet of Western imperialism in disguise; family-planning programs are often considered Western impositions designed to weaken the Middle East.

Political parties and nationalist groups throughout the Middle East affirm that having children constitutes a national duty in order to supply a large population base for military endeavors. Following heavy military losses at the end of the Iran–Iraq War in 1988, both Iran and Iraq emphasized pronatalist policies. Competition among Middle Eastern nations for regional prominence has led them to discourage family planning and advocate high birth rates. National, ethnic, or religious factionalism often translates into lack of support for family planning as each group seeks to enlarge its numbers. European Community governments decided in the 1990s to attack root problems of immigration from the Middle East by initiating programs supporting family planning in North Africa.

Most of the major religious traditions of the area hold that contraception is permitted. Christians are divided on its permissibility. The traditions of Judaism differ, but largely consider it permissible. Islamic jurisprudence condemns a pre-Islamic form of birth control, waʿd (exposure of female infants), but, reasoning from hadith texts, Islam does permit contraceptive use as analogous to coitus interruptus (azl). This is a personal, mutual decision of the husband and wife. Muslim opponents of contraception see it as murdering a potential creation of God and as a denial of the will (irada) and sustaining power (rizq) of God. Furthermore, Islam acknowledges the importance of and the right to sexual fulfillment for both men and women, and thus does not teach that reproduction is the sole or primary justification for marital intercourse.

The continuing importance of family in the Middle East has proved to be the largest obstacle to family planning. Because the status of both spouses, particularly the wife, depends upon the birth of children, family-planning programs have had difficulty encouraging both men and women to consider contraceptive use. One important support has been the Qurʾan's injunction to nurse children for two years, and most women appreciate the risks of becoming pregnant while nursing. The spacing of children as an important contributor to a mother's health is becoming better understood. Children have traditionally been seen as providing economic support for the family and, in the absence of social-security programs, are considered guarantors of parents' financial security in their old age. Finally, children are loved and valued as a true blessing and a gift from God in all the faith traditions and cultures of the region.

Contraception

The most common methods of contraception used by women in the Middle East are birth-control pills and intrauterine devices (IUDs). Concern over sexually transmitted diseases and AIDS has led to increased use and availability of condoms. Much interest has been shown in injectable or implantable contraceptives. Nonreversible sterilization for men or women is prohibited by Islam. Tubal ligations, however, are increasingly common, and because new medical technology makes the procedure reversible, they can be considered religiously permissible. Abortion is frowned upon but permitted in particular situations, mostly those in which the mother's life is threatened. The majority of states ban abortion except when the health of the mother is endangered, at which point responsibility devolves onto the woman's doctor. Tunisia permits abortion.

Family planning and contraception in the Middle East was the subject of worldwide attention and debate at the 1994 International Conference on Population and Development (ICPD) in Cairo. That gathering, as well as the other United Nations conferences held in the 1990s—the 1995 Beijing Conference, the 1999 five-year review of the ICPD (ICPD+5), and the 2000 five-year review of the Beijing Conference (Beijing+5)—witnessed an alliance of conservative Catholic and Muslim religious authorities joining forces to oppose and restrict Middle Eastern women's right to control their own bodies and sexuality.

see also gender: gender and health; gender: gender and law; medicine and public health.

Bibliography

Ali, Kamram Asdar. Planning the Family in Egypt: New Bodies, New Selves. Austin: University of Texas Press, 2002.

Badran, Margot. Feminists, Islam, and Nation: Gender and the Making of Modern Egypt. Princeton, NJ: Princeton University Press, 1995.

Bayes, Jane H., and Tohidi, Nayrereh. "Introduction." In Globalization, Gender, and Religion: The Politics of Women's Rights in Catholic and Muslim Contexts, edited by Jane H. Bayes and Nayereh Tohidi. New York: Palgrave, 2001.

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Donna Lee Bowen

Updated by Laurie King-Irani