MISCONCEPTION: FERTILITY CONTROL BEGAN WITH THE PILL

Timothy W. Guinnane

Professor of Economics
Yale University

Popular accounts often assume that fertility control was not possible until the development of the contraceptive pill. The historical record shows this is not true: much of Europe and the United States witnessed a sharp reduction in fertility in the 19th century. In 1800, a married woman in the West could expect to have 8 children during her lifetime. By the early twentieth century, this figure had declined to 3 in many cities. These developments mostly pre-date the Pill, which was not widely used until the 1960s. The first stages of the fertility decline even predate the first inexpensive condoms, which first appeared in the 1850s.

How did they (not) do it, before the condom, the Pill, and other modern contraceptive methods? Most of the evidence points to a combination of withdrawal and various forms of abstinence. These methods have failure rates that are unacceptably high for modern couples, but are fully capable of accounting for the fertility declines seen in the past.

The historical example could suggest that the current focus on spreading modern contraceptive methods in developing countries is misplaced, at least as far as population growth is concerned (STDs, of course, are another matter). The more important question is why couples decide to have smaller families. Scholars do not agree on why the European and American fertility decline occurred when it did. But our history suggests that once small families become attractive, couples will find a way to limit their fertility.

MISCONCEPTION: CONDOMS ARE FOR MEN

Zena Stein

Professor of Public Health and Psychiatry
Columbia University

The female condom is currently the only woman-initiated barrier that can claim proven effectiveness in preventing sexually transmitted infections. In this age of rapidly increasing infections among women across the globe, we have to ask why it has not been made more available. Last September, a meeting was held in Baltimore to address and explain this gap in protection for women. One explanation was that women fear to introduce the device because men object to its use; experience from the field, however supported a view that such problems can usually be overcome. Cost was raised as an issue, but was also felt to be far from insuperable. But another reason given, and always based on insufficient evidence, is what is called “the migration from the male condom theory.” According to this theory, those women who respond to the offer of the female condom will, in the main, be those who already use the male condom; the corollary being that when the female condom is introduced, there will be no overall increase in the proportion of protected encounters.

Neither this theory, nor its corollary, is founded on trials or systematic observations, and it well deserves to be listed high up among MISCONCEPTIONS. A careful review of all reasonably well-conducted studies has concluded that yes, there is sometimes “migration”, but there is also a considerable overall increase in protected encounters. In an STD clinic-based study in Alabama, six months after female condom introduction, 66% of sex occasions were protected relative to 38% at baseline. In developing country studies, reports also show increases in protected sex, with little evidence of migration from the male condom.

Misconceptions such as these are serious, acting as impediments to one of the very few programs that we currently have in our hands to make a difference in our struggle with HIV/AIDS, a struggle particularly urgent for women in high prevalence/low resource countries.