contraception

contraception Many social practices reduce the birth rate — delaying marriage, imposing taboos on the frequency of marital intercourse, and prolonged breastfeeding, for example. Contraception, however, is usually taken to mean deliberate resort to practices to prevent sexual intercourse resulting in the birth of a child, or, more strictly speaking, to preclude conception. Methods can be divided into ‘natural’ — those not requiring any apparatus — and ‘artificial’ means. The latter can be subdivided, though not entirely, into barrier and chemical methods locally applied to the genitals; intrauterine; surgical; and the more recent hormonal contraceptives. Magical prescriptions, of dubious efficacy, for the prevention of pregnancy have also proliferated.

Refraining from sexual intercourse may have been an underestimated element in attempts to restrict family size. A modification is indulgence only when the woman is believed to be infertile: however, the relationship between menstruation and ovulation was not reliably established until 1929, and many previous calculations of a ‘safe period’ were seriously in error — though, due to variation in the cycles of individual women, even an inaccurate idea may have been occasionally effective in delaying if not preventing conception. The independent discoveries of the Japanese K. Ogino and Austrian Hermann Knaus enabled more effective calculations, but nonetheless the ‘rhythm method’ is widely known as ‘Vatican roulette’ (as the only method, apart from abstention, approved by the Catholic Church) because of its unreliability. Recently developed devices, however, now enable extremely precise pinpointing of the actual period of fertility through hormonal analysis of the female urine.

Another possibility occurring to the ingenious very early in human history was the practice of coitus interruptus, whereby the man withdraws and ejaculates outside the vagina (cf. Onan — Genesis 38:9). To think of this method means that a connection must be made between emission of semen and conception. Another method requiring no appliances is anal intercourse.

Barrier methods

Barrier methods have a long history. Egyptian papyri describe pessaries and vaginal douches, which could have been effective. The pessaries both formed a barrier, and consisted of substances either spermicidal, or likely to slow sperm motility, while the douches could have altered the chemical balance of the vagina, rendering conception less likely. Many other societies are recorded as having had similar devices capable of lowering the probability of conception.

The condom, or male sheath, was quite a late development. It became more widely used following the discovery of the vulcanization of rubber in the 1840s, which also led to the development of various forms of occlusive cap for female use. These required, to be most effective, careful fitting — indeed, the first were custom-made for each individual. The most commonly used type is the ‘Dutch cap’ or diaphragm, invented by the German physician Wilhelm Mensinga of Flensburg in the 1870s, a domed rubber cap with a metallic spring in the rim, which comes in a range of sizes and is easier to fit than similar devices. Used conscientiously, with spermicide, and left in for several hours following intercourse, it has a success rate of around 95% in preventing pregnancy. The smaller cap, covering only the cervix, has had its advocates. Rubber itself tends to destroy sperm. Using sponges for birth control dates back probably to the eighteenth century, a method particularly efficacious if the sponge is soaked in some spermicidal or sperm-weakening substance, such as vinegar, olive oil, or even soapy water; modern sponges, for a single use only, are permeated with spermicide. The recently-promoted female condom, covering the entire interior surface of the vagina, has a longer history than often realized, and is primarily a protective against sexually transmitted disease.

Spermicides

The nineteenth century also saw the commercial development of chemical contraceptives, usually in the form of pessaries for insertion into the vagina. In theory these contained a spermicidal substance (though some worked because the greasy agents hindered the sperm), but in the unregulated industry of contraceptive manufacture, the unreliability of these products led to the belief (as with condoms) that the law required one ‘dud’ in every box. In Britain the issue of an ‘Approved List’ of effective products by the National Birth Control Association (later the Family Planning Association) led to improvement in standards, though spermicidal activity as measured in laboratory circumstances and in practice can still differ widely. Chemical contraceptives currently come as creams and jellies (specifically for use with a barrier method), pessaries, and foam and are recommended to be employed in conjunction with a barrier method.

IUD

As far as can be ascertained, the intrauterine device in its modern form dates back to the experiments of Gr̈afenburg and other German gynaecologists before World War I, although the British obstetrician C. H. F. Routh claimed in the 1870s that women were using uterine pessaries intended for gynaecological conditions for contraceptive purposes. Early IUDs were made of gold or silver; modern ones are made of plastic or copper. They work, it is believed, by irritating the uterus so that implantation of the fertilized ovum does not take place. The method has fallen into some disfavour following the highly damaging effects of the Dalkon Shield, which became apparent during the 1970s.

Sterilization

sterilization may be regarded as a contraceptive method, but unlike other methods it cannot be reversed, or not with any substantial probability of success. In women ligating the Fallopian tubes was originally a relatively major abdominal operation, carried out under general anaesthesia. More recently, sterilizations have been performed using a laparoscope, inserted through a small incision, to locate the tubes so that they can be cauterized; this can be done as an outpatient operation. Vasectomy is a much less serious operation.

The Pill

The greatest advance in contraceptive technology in the twentieth century was the female contraceptive pill. Ever since the discovery of the sex hormones and steroids there were hopes of a contraceptive which could be taken orally or injected. The earliest combination birth control pill, developed in the late 1950s, contained both oestrogen and progestin, and was taken for 21 days followed by a 5-day break during which menstruation occurred. It caused the suppression of ovulation and the thickening of the cervical mucus, hindering sperm from entering the uterus. The sequential pill (1965) consisted of oestrogen-only pills taken for the first 16 days of the cycle and combination oestrogen-progestin pills for the final five days, inhibiting ovulation but having no effect on the cervical mucus. The minipill, conversely, contains only progestin, is taken without breaks, and works by the constant production of thick cervical mucus which blocks the entry of the sperm. There are a number of other variations, and hormonal contraceptives are also given as implants or injections (e.g. Depo-Provera) with long-term efficacy. Related developments are the ‘morning after’ pill, a post-coital contraceptive, and the so-far unfulfilled hope of a ‘male pill’.

The Pill came into general use in the 1960s. It is an extremely reliable contraceptive method (97–99%) and has the important qualities of being totally detached from the genital organs, not requiring any dexterity to fit, and being unintrusive on the sexual act. This rendered it popular with both doctors and the general public. Side-effects, ranging from mild to extremely serious, and the implications for the dissemination of sexually transmitted disease of a reliable non-barrier method of contraception, have dimmed the initial glowing enthusiasm it generated, but it is still one of the most widely used methods of birth control.

Family limitation and society

Methods of birth control have been known from distant antiquity, but it is less easy to establish to what extent they may have been used. As Angus McLaren pointed out in A History of Contraception (1992), the desire of human couples to exercise control over their reproductive capacities may in some epochs veer towards the promotion of conception rather than its prevention. Many factors bear upon the possibility of even imagining that births might be restricted, and upon the putting of such a possibility into efficacious practice. Economic, social, and cultural factors led to increasing debate on the subject during the nineteenth century, particularly associated with the name of the political economist T. R. Malthus and his calculation that the population would always tend to outrun the means of subsistence — though he did not recommend artificial interference with this state of affairs. French peasants were apparently already limiting their families through coitus interruptus during the eighteenth century, because of their reluctance to let family holdings be divided between several heirs. The cause-and-effect relationship between the decline in infant mortality and the rise of family limitation is not clear: it is often claimed that the increased chances of child survival encouraged parents to reduce family size, but it can also be argued that infants born at wider intervals into smaller families have a better chance of survival through access to more maternal attention, and division of family resources between fewer family members.

In spite of the number of birth control methods available, they are still far from universally employed, due to simple lack of access; economic factors, either local factors encouraging large families, or the inability to afford the means; and in large areas of the world, because of religious objections.

Lesley A. Hall