1900's
The history of contraception begins in ancient history although more substantial movements began in the 20th century. There have been many controversy’s which have ultimately shaped the methods we have today, but by looking at the history of contraception this will help to identify the changing attitudes in contraception.
Huge developments began with pioneer Marie Stopes, who highlighted the need for a way for women to gain control over their body and the need for accessible contraception and education (Haste, 1992). She had monumental effects at a time when discussions about contraception and sex were highly controversial and taboo due to societies norms. She created particular controversy by her highlighting women’s right to sexual pleasure which had not previously been discussed until the publication of her book ‘Married Love’ (McLaren, 1990).
Her work in 1918 highlighted the burden uncontrolled fertility had on women’s marriages and freedom. this identified the need for family planning clinics for women to easily access methods such as the ‘cap’ and ‘sheath’ making contraception accessible to poorer class groups (ibid). There was also pressure from Stopes to create a new contraceptive option of a ‘simple pill’ an easier method to free women from ‘reproductive burden’ with the ability to have autonomy of their reproductive system but also did not interfere with sex; unlike the sheath and cap which were called ‘passion killers’ by some women (Marks, 2001, p. 183).
Margret Sanger and Marie Stopes were both pioneers in developing contraceptive methods and accessibility, but the underlying motivation behind their actions was population control and social cleansing (Marks, 2001). Sanger’s and Stopes motivation for finding a practical easy contraceptive method for women came from contraception being seen as a ‘eugenic tool’, as a way of reducing the number of poor women having ‘degenerate’ children (Carey, 2012)
In 1909 physician Dr Richard Ritcher was making discoveries in a ‘coil’ type method; out of a silkworm (Margulis, 1975). This later inspired the development of the ‘silver ring’ IUD from Dr Grafenberg in 1929. This method was brought to the UK by Marie Stopes however this was surrounded by controversy due to the reports of the ring causing pelvic inflammatory disease and use of this method was discontinued (Thiery, 1997). Stopes actively pushed the development of the IUD by looking at early models such as the ‘Gold Pin’, she backed the then-experimental method. Although she did face resistance by medical professionals such as Dr Norman, eventually he overcame his hesitancy and actively encouraged the introduction of IUDs in the UK (Neushul, 1998). This marked a huge development in contraceptive methods as previously only unreliable barrier methods had been accessible to women. In 1937, Japanese researcher Tenrei Ota created the Ota ring, which was smaller than other IUD’s previously made and more effective as it was less likely to be expelled from the body compared to other models (MUVS, 2020).
The 1950- 1970s
This pioneering research paved the way for the development of the modern plastic IUD’s we have today, in the 1960’s IUD’s rapidly developed thanks to the ‘Lippies loop’ which again in its new shape reduced the chance of the device being expelled (Aniulienė & Aniulis, 2014). In 1969 research conducted by Dr Howard Tatum saw him decrease the size of IUD’s creating the ‘T’ shape of IUD’s which are still used today, within the same year saw the discovery of copper being used in an IUD as a non-hormonal alternative for women (Reproductive Health Access Project, 2013). The Population Council were influential in encouraging the uptake of IUD’s, as they approved the safety of the method (Population Council, 2013). However, the 1960s were not just monumental in the development of LARC’s but also the development of the contraceptive pill.
After years of development, the pill was made available to married women in the UK in 1961. This saw a massive rise in the number of women being prescribed the pill, between 1961 to 1969 the number of women using the pill grew from 50,000 to 1 million (FPA, 2007). This rapid uptake is due to ease for women to use, it was vastly different from previous methods these women had used as it did not interfere with sex and was discreet to take. There were reports of women suffering from side effects at this time such as migraines and other debilitating side effects, however, women were willing to tolerate these side effects to have control over their fertility the side effects were seen as tolerable compared to an unplanned pregnancy (Cook, 2014). But some women were raising the concern about their symptoms to their GPs but they were dismissed and made to feel guilty or that their concerns were being ignored (ibid).
The number of users continued to grow until safety concerns surfaced, due to the high concentration of hormones causing some women to have life-threatening blood clots and other side effects (Liao & Dollion, 2012). This ultimately meant that in the 1960s IUD’s popularity was rapidly increasing due to reduced health risk to women with underlying health conditions, meaning for many women who could not take the oral contraceptive pill this was a safe alternative (Gabriel , et al., 2017).
Although in America there were controversies in the 1970s surrounding safety of the ‘Dalkon shield’ IUD, which was removed from use and it had long-term damaging effects on the uptake of IUD’s in America (Reproductive Health Access Project, 2013). Previous IUDs as well as the Dalkon Shield have been historically associated with causing pelvic inflammatory disease, spontaneous septic abortions and in some extreme cases death. In America the effects of the Dalkon Shield (IUD) have been long-lasting and hard to dispel, this method had a design flaw that meant that bacteria could travel up the strings of the device (Horwitz, 2019).
As the Dalkon Shield is not a medicine it meant the product did not have to go under the same Food and Drug Administration (FDA) testing as pharmaceuticals, meaning that it was not adequately tested before being inserted into women (Krismann, 2020). This method faced many lawsuits as a result, although now scientific methods have improved and so has the safety of IUDs. This method is even recommended by the World Health Organisation as a safe and effective contraceptive method for young women (World Health Organization, 2015). But ultimately this health panic damaged the reputation of the method in the long term.
Shortly after the development of the pill saw the development of the injection by Dr Junkman and his research team in 1957, this method used the same hormones of the pill to prevent ovulation from occurring (World Health Organisation, 1999). The development of both the pill and the injection coincide at a time when attitudes towards sex and the idea of ‘sexual freedom’ were evolving due to the sexual revolution in the 1960’s.
The pills were praised as providing women with control enabling women to have new career opportunities and freedom, increasing women’s participation in the labour market and career opportunities (Oreffice, 2016), (Parker, 2015). Although the development of these contraceptive methods was not caused by the revolution, it did trigger attitude shifts towards sex and accessibility to contraception (Cook, 2014). This was a major cultural shift, by 1967 women in the UK regardless of their marital status could access the pill (Goverenment, 1967).
In 1974 it was made accessible via NHS free of charge to women regardless of age or marital status under the Labour Government, this a part of the government’s new public health movement focusing on prevention (FPA Contraception, 2011). This ultimately moved contraception into being viewed in a more medicalised manner, with clinical contraceptive services being run by the NHS (Stacey, 2018). This was a huge milestone as it removed many of the class and educational barriers women previously experienced with contraception. Before the work of both Stopes and Sanger, contraception was a taboo subject and now was widely accessible to women. In the 1970s sprung the second feminist movement enabling the idea of the ‘empowered women’ taking charge of their own body (Liao & Dollion, 2012). At the same time, early developments were being made in the creation of the implant in the 1960s. In 1976, saw the use of silicone implants to release medication throughout the body, this was later adapted for distributing hormones throughout the body (FPA, 2010).
The 1990s-2010
The 1990s saw the release of the first contraceptive implant to women, the ‘Norplant’ was comprised of six rods implanted into a women’s upper arm. At the time the manufacturer called it ‘one of the most effective and practical forms of contraception for any woman who wants long-term reliability, convenience and the opportunity to change her mind’ (BMJ, 2007). This statement strengthens the confidence the manufacture had in this technology, identifying features of the contraception which policymakers also praise LARCs for.
However, by the end of the 1990s, this method was withdrawn after several lawsuits against the manufacture due to safety concerns and the difficultly involved in removing the implant (Watkins, 2010). At the same time there was growing concerns with the safety of the pill, in 1995 pills containing gestodene or desogestrel had been linked with putting a woman at increased risk of thromboembolism this was heavily featured in the media at the time (Bajos, et al., 2014) (Furedi, 1999). This had a damaging uptake in the pill and widespread discontinuation over safety concerns, resulting in increased unintended pregnancies which added financial pressure on the NHS to provide maternity care and additional abortions (ibid).
Furthermore, in response to the growing number of unintended pregnancies particularly in teenage girls, the government made a report in response. Later creating a strategy response to decrease teen pregnancies by half in the next 10 years (Hadley, Ingham, & Chandra-Mouli, 2016). This strategy set out a multifaceted approach to tackling the growing problem. The Labour government emphasised the importance of better sex education and access to contraception for young people (ibid).
In 2002 saw rising concern in the safety of the injection ‘Depo- Provera’, in particular with the concern about the effects it was having on bone density. Latest recommendations suggest that women under the age of 19 should only use Depro Provera when they are not suitable for another method; in addition, all women using the injection should review their risk factors for osteoporosis when using the injection for two or more years (Royal Osteoporosis Society , 2020). This means that it is not a suitable method for all women to use. However, this injection has not been discontinued like other methods of contraception with safety concerns, it does advise for regular review with a GP. Moving forward to 2010 saw the review of the teenage pregnancy strategy (1999), although it did not achieve the targeting drop in teenage pregnancies it did manage to decrease them (Hadley, Ingham, & Chandra-Mouli, 2016). Since 2010 the government has continued to focus on improved sexual health services and reducing the rates of unintended pregnancies and abortions.
Now: LARCs are the gold standard
In the UK the injection, the implant and IUDs are now labelled as the gold standard of contraception for women. As they are seen they have a higher level of efficacy because they remove the chances of human error. These LARC methods have a 99% effectiveness compared to short term methods like the pill and condom have a 94% effectiveness (NHS Digital, 2020). These methods are in particular promoted to women aged between 20-29 years in particular, as this group of women have the greatest number of unintended pregnancies (BPAS, 2018). By using LARCs to reduce the rates of unintended pregnancy alleviates financial pressure on the NHS.
However, by removing the element of human error they are also removing women’s decision making when using other contraception, meaning with LARCs they lose the choice to discontinue use on their terms. Zeal, Higgins and Newtons (2018) research has suggested that women place high importance on their ability to control their reproduction, although some women felt as if LARCs were negative external agents which can reduce their perceived autonomy.
As mentioned throughout the history of contraception side effects have always been problematic for women, at one-point women were happy to tolerate the side effects to be autonomous decision-maker over their bodies. But what is happening today is a new wave of women no longer want to tolerate these sides effects and are turning their backs on hormonal contraception.
With a new wave rhythm method tracking of fertility on apps, although not as accurate they do not induce any side effects on women or feel comfortable with interfering with their bodies with additional hormones (Zeal, Higgins, & Newton, 2018), (Whelan, 2018). But as well this research suggests that women are conflicted about being signed into long term contraceptive methods, many women are aware that LARC methods are more effective than the pill however with LARCs women have reported feeling as if their autonomy was threatened (ibid).
What this suggests that women are frustrated with contraceptive options and are more conscious and concerned about the side effects they are experiencing, in particular the impact hormonal contraceptive can have on woman’s mood and weight (Grigg-Spall, 2013). These are not new complainants from women they emerged with developed of the pill but what has changed is women’s tolerance for putting up with side effects, with many news stories emerging supporting this (Silman, 2019). Women’s opinions of contraception are heavily shaped by hearing the experiences of offers when considering a contraceptive method, it has been suggested that it can make women 69% less likely to consider a LARC method (Brown, Chor, Hebert, Webb, & Whitaker, 2019).
This growing frustration can be seen in the low uptake of LARCs in women under the age of 24, even though they are recommended to be the best method for these women (National Statistics, 2019). What has now emerged is tension between women and contraception, these methods were once seen as revolutionary and a powerful liberating tool but has now become something which women see as being limiting as many women do not feel as if they have control with these methods.
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