Contraception

For centuries, limited knowledge of women's physiology slowed the development of effective contraceptives. There was no understanding of the accurate relationship between menstruation and ovulation until the early twentieth century. Yet contraceptive developers did make progress in the nineteenth century.

One major area was in updating the vaginal pessary. The rubber diaphragm and the rubber cervical cap, developed in the nineteenth century, are still in use today. The diaphragm is a disc-shaped object inserted into the vagina designed to prevent the passage of sperm while the cervical cap fits over the cervix.

Spermicides, substances developed to kill sperm, were mass produced by the late 1880s for use alone or for greater effectiveness with other devices such as the diaphragm. Vaginal sponges were also developed for contraceptive use in the late 1800s. Another popular nineteenth century method was douching, the use of a substance in the vagina following intercourse to remove sperm.

Contemporary use of these methods yields varying pregnancy rates. The diaphragm was used by 1.9% of American women who used contraceptives in 1995, down from 5% in 1988. In 1994, a total of 18% of women who used diaphragms with spermicide experienced accidental pregnancy in their first year of use. Women who depended on spermicides—1.3% of women using contraceptives—experienced a 21% accidental pregnancy rate in their first year of use. The cervical cap had an accidental pregnancy rate of 36% in 1995 among women who had previously given birth. The sponge, which had a first-year accidental pregnancy rate of 18% in 1990 among women who had never given birth, was take off the market in the mid-1990s.

While types of birth control increased in the nineteenth century, the topic of contraception was still considered sordid and unsuitable for public discourse. In the United States, the Comstock Law of 1873 declared all contraceptive devices obscene. The law prevented the mailing, interstate transportation, and importation of contraceptive devices. One effect of this was to eliminate contraceptive information from medical journals sent through the mail.

The social movement to make birth control legal and available challenged the Comstock Law and other restrictions against contraception. By the 1930s, the movement led by Margaret Sanger (1883-1966) had successfully challenged the Comstock Law, and the mailing and transportation of contraceptive devices was no longer illegal. Sanger was also instrumental in developing clinics to distribute birth control devices.

Advances in medical knowledge generated new contraceptive methods. The first intrauterine device (IUD), designed to be placed in the uterus, was described in 1909. The IUD was not used widely in the United States until the 1960s when new models were introduced. The copper IUD and the IUD with progesterone made the IUD more effective. A 1994 study found the typical accidental pregnancy rate in the first year of use was 3%.

The IUD works by causing a local inflammatory reaction within the uterus causing an increase in leukocytes, white blood cells, in the area. The product which results when the leukocytes break down is deadly to spermatozoa cells, greatly reducing the risk of pregnancy. The IUD devices available in the United States must be inserted by a health provider and typically must be replaced after one to four years. Possible dangers include bleeding, perforation of the uterus, and infection.

Use of the IUD fell from 2.0% in 1988 to 0.08% in 1995. One reason for this may be fear of lawsuits due to complications. In the United States, government officials pulled the Dalkon Shield IUD off the market in 1974, following reports of pelvic infections and other problems in women using the device. A second explanation may stem from the decision by two major IUD manufacturers to pull back from the U.S. market in the 1980s.

Another method which emerged in the early twentieth century was the rhythm method, which was approved for use by Catholics by Pope Pius XII in 1951. For centuries, various experts on birth control had speculated that certain periods during a woman's cycle were more fertile than others. But they often were wrong. For example, Soranos, a Greek who practiced medicine in second century Rome, believed a woman's fertile period occurred during her menstrual period.

As researchers learned more about female reproductive physiology in the early twentieth century, they learned that ovulation usually takes place about 14 days before a woman's next menstrual period. They also learned that an egg could only be fertilized within 24 hours of ovulation. The so-called calendar rhythm method calculates "safe" and "unsafe" days based on a woman's average menstrual cycle, and calls for abstinence during her fertile period. The method is limited by the difficulty of abstinence for many couples and the irregularity of menstrual cycles.

Several contemporary methods of natural contraception still used. Together, they are referred to as Periodic Abstinence and Fertility Awareness Methods, or natural family planning techniques. They include the rhythm method; the basal body temperature method, which requires the woman to take her temperature daily as temperature varies depending on time of ovulation; the cervical mucus method, which tracks the ovulation cycle based on the way a woman's cervical mucus looks; the symptothermal method, which combines all three; and the post-ovulation method, where abstinence or a barrier is used from the beginning of the period until the morning of the fourth day after predicted ovulation—approximately half the menstrual cycle. Accidental pregnancy rates for these methods were 20% in the first year of use. A total of 2.3% Americans used these methods in 1995.

As birth control became more acceptable in the twentieth century, major controversies grew about its social use. A series of mixed court decisions considered whether it is right to force an individual who is mentally deficient to be sterilized. In the 1970s, national controversy erupted over evidence that low-income women and girls had been sterilized under the federal Medicaid program. Federal regulations were added to prohibit the forced sterilization of women under the Medicaid program. Legal debates still continue on the issue of whether certain individuals, such as convicted child abusers, should be required to use contraceptives.