The Pill Is 1965 Technology

Futurist Sara Robinson has called modern contraception the most disruptive technology of the last hundred years. From the time our ancestors first walked out of the Great Rift Valley—perhaps even before—culture, religion, and division of labor enshrined the simple, universal fact that women had little control over their fertility. When modern contraception arrived in the middle of the 20^th Century, it triggered a tidal wave of culture change that left the guardians of tradition frantically trying to shore up their aging structures. Now, a second wave of contraceptive technologies is further threatening the notion that women must allow gods and men to decide whether they end up pregnant.

Today, the most widely used contraceptive in the US is the Pill, released almost half a century ago and refined in intervening years to reduce the hormone load and side effects. For two generations, the Pill has been a game changer. But it is far from perfect. Very few human beings are able to take a daily medication with perfect consistency, and that fact alone largely accounts for an annual pregnancy rate of 1 in 12 for women on the Pill. (For couples using condoms, the rate is 1 in 8. With no contraception, it is over 8 in 10.)

One of the most carefully controlled studies of Pill use required women to keep diaries and remove each pill from a container that electronically recorded missed doses. The participants reported missing only one pill per month on average; the boxes recorded an average of four missed pills per month! Only 16 percent of women in the study kept missed pills down to one per month or less. An estimated 750,000 American women get pregnant each year while on the Pill. With failure rates like that, a woman can plan for her future and her children with confidence only if she has access to abortion as a back-up plan. More than half of women seeking an abortion say that they were using a contraceptive method in the month they got pregnant.

Family planning doctors and researchers recognized the limitations of the Pill almost immediately, but early stage contraceptive research is a risky endeavor. It’s not appealing to most pharmaceutical companies, which have mostly been content to reformulate and repackage Pills. The gap was filled by, among others, the Population Council, a global not-for-profit that channels money into research about reproductive health technologies and programs. (The council’s latest contraceptive technology, now in clinical trials, is a ring that lasts a year and also protects against HIV.) In the 1970s and 1980s, the Population Council pioneered two IUDs, one copper and one hormonal, which it then licensed to pharmaceutical companies. These two went on to become Paragard and Mirena, both currently available on the US market. In the 1980s, the council developed the first widely adopted implant, now sold internationally (but not in the US or Canada) as Jadelle. In November 2011, the FDA approved the latest generation of implant, known as Nexplanon. Canadian women do not yet have access to contraceptive implants.

Long acting reversible contraceptives like IUDs and implants are known as LARCs. They have 1/10 to 1/50^th the failure rate of Pills, and they are cheaper in the long run. Both the Centers for Disease Control and World Health Organization consider them the top tier of contraceptive methods. In October 2012, the American Congress of Obstetricians and Gynecologists issued new practice recommendations stating that “counseling about LARC methods should occur at all health care provider visits with sexually active adolescents, including preventive health, abortion, prenatal, and postpartum visits.”

Why are LARCs so much better?

• Traditional reversible contraceptives have a big gap between “perfect use” and “real world.” Short-acting hormonal methods such as pills and patches and barrier methods such as diaphragms and condoms all have major gaps between how well they work in laboratory conditions and how well they work in normal circumstances. For timing methods such as Natural Family Planning, withdrawal, and abstinence the gap can be enormous, because they require a level of knowledge, self-awareness, control and communication that is beyond most people. By contrast, with a LARC, what you see is what you get. Once a LARC is in place, it works in the real world just like it works in the lab.
• LARCs are better at blocking pregnancy, even in the laboratory. Some 85 women out of 100 will get pregnant in a year of unprotected sex. Compared with that, the contraceptive effect of the Pill is dramatic. In a perfect world where women never missed a pill — where checks never bounced, memories never failed, and couples never argued — only 2 of 100 women would get pregnant on the Pill. That’s not bad, unless you’re one of the two. Still, it’s nowhere near as good as LARCs’ statistics: of women using copper IUDs for a year, just 2 in 800 get pregnant. Only 2 of 5,000 women will get pregnant during a year of using an implant.
• Fewer side effects mean higher continuation. In the St. Louis study, over 80 percent of women who chose a LARC were still using it a year later. About half of those who chose a short-acting method such as the Pill, ring or patch did the same. Part of the difference may be the hassle factor, but also, short-acting methods require bigger doses of hormones than do IUDs. Lower doses usually mean fewer side effects, and fewer side effects mean women are less likely to stop using the method.
• LARCs toggle the fertility default. Imagine if the light switches in your house all turned themselves back on after a certain amount of time whether you wanted them on or not. That’s how fertility works. It turns on at adolescence and stays on for the next 40 years whether a woman wants it on or not. During that time, she may want to have one child or four or none. The rest of those 40 years, almost 500 reproductive cycles, she has to either switch it back off or avoid having a fertile egg come in contact with sperm. The Pill requires her to flip the switch off every day. A LARC means she can hit it as infrequently as once every twelve years and still flip it back on when she wants to have a child. In recent years, behavioral scientists have learned quite a bit about default effects—how much human behavior is driven not by choice but by indecision or inattention or inconvenience or inertia or impulse. LARCs take these factors out of the equation for long periods, making pregnancy an active and more-often mutual decision.

It all adds up to a technology leap that pays huge dividends in human wellbeing, especially for people who are already up against the hard edges of life: teenage girls who haven’t quite figured out what they want for themselves or how to say no; families that are struggling to make ends meet; fundamentalist women for whom either another baby or an abortion would feel like a nightmare; and tired moms who just want to relax about sex, confident that intimacy won’t mean another 6,000 diapers.

The American teen pregnancy rate is higher than any other developed country, more than double Canada’s rate. In 2010, the teen birth rate in the US fell to a record low of 34 per 1,000; the rate in many of Europe’s social democracies is less than 10. America’s high rates of teen pregnancy and unintended pregnancy (and consequent need for abortion) have been blamed on a number of factors including Puritan sexual sensibilities that prevent candid conversations about sexuality; a “virginity myth” that inclines Christian girls to prefer impulsive, unsafe sex over “premeditated” sex; and a wobbly ladder of opportunity that makes childbearing seem no worse and often better than realistic alternatives for disadvantaged young women. All of these may be real, but it is striking that a simple shift in access to better technologies trumps them all, producing a dramatic drop in pregnancy rates.

Why aren’t more women reaping the benefits of this technology revolution? That’s what I’ll discuss next time.

Valerie Tarico, Ph.D., a trustee of Sightline, is a psychologist and writer in Seattle. She is the author of Trusting Doubt and Deas and Other Imaginings and the founder of WisdomCommons.org. Her articles can be found at Awaypoint.Wordpress.com.