The questions, Why do there have to be so many abortions? Why don’t more women use contraception? are wrongly put. Most women who seek abortion are contraceptive users; they have not "substituted" abortion for contraception. The increase in abortions and the increase in contraceptive use in the 1970s occurred simultaneously. Until a "perfect" method of contraception is developed, which will probably never happen, periods of heightened consciousness and extended practice of birth control will inevitably mean a rise in abortions. One jarring reminder of this interdependence is the fact that clinical studies of new contraceptive methods cannot proceed under conditions in which abortion is illegal (as in the 1950s and 1960s) or federal funding for abortion is curtailed (as now) because human subjects will not accept the risk of unwanted pregnancy without the availability of abortion as a backup.2 Thus we have to expand our analysis of why abortion rates increased in the United States in the 1970s to include an important contributing factor: A uniquely effective, but not foolproof, method of contraception had been developed, distributed, and absorbed into popular practice on an unprecedented scale. What was the impact of the pill and the "pill culture" on rising abortion rates? To what extent did the reality and the "aura" of the pill—themselves the product at least as much as the cause of a growing demand—create changed expectations about reliable fertility control that helped also to legitimate abortion? On the other hand, to what extent did the pill’s failure to meet these expectations directly increase the need for abortion?
Feminist demographer Susan Scrimshaw has argued that the pill, with all its flaws, acted as a kind of catalyst that helped change women’s expectations to include the possibility and the right of reliable contraception: "It can be argued that even among women who discontinued or never initiated pill use, their heightened perception of the life alternatives open to them increased their motivation to use other contraceptive methods more effectively. This change in expectations has resulted in increased pressure from women for the development of a true contraceptive panacea."3 Scrimshaw credits "the advent of the pill" with having produced a whole range of "new" social forces: women’s greater sexual self — assertiveness, the increasing entrance of women into higher education and careers, the postponement and reduction of childbearing, an increased "honesty and joy in sex," and the development of aggressive feminist health networks. But the pill did not "cause" these changes, any more than the changes effected the "liberation" of most women. The case for the "contraceptive revolution" is reductionist; it ignores the fact that certain conditions and relationships created a pill "market" to begin with and that it was the conjunction of an effective new technology with other social conditions, such as an expanding job market for women, that led to changes in consciousness among women. As I suggested in Chapter 4, the evidence strongly supports the view that changing conditions of women (increased labor force participation, more schooling, delayed marriage) underlay their need for and consciousness about effective birth control. The successful marketing of the pill was a response to that need more than its "catalyst." (This interpretation is reinforced by the fact that the fertility decline started before the "pill era.")
But Scrimshaw reminds us that the pill, as a more effective method of reversible contraception than women had ever known, contributed to a climate of expectations that women need not and should not have to fear an unwanted pregnancy. Having a baby when you didn’t want a baby became "unthinkable" for new generations of women, or for older generations at new stages in their lives. This changed consciousness undoubtedly contributed to the rise in abortions, for women who did not use the pill as well as those who did. It meant that if there were not more unwanted pregnancies, there were at any rate more women willing and prepared to do something about them. It meant that the shadow of fear and furtiveness, sometimes of danger and death, that had surrounded abortion for a hundred years would increasingly become an anachronism. The pill, as the apparent embodiment of "perfect" birth control, helped propagate that idea among women, to close up the margin of uncertainty and fatalism that had previously clouded fertility control.
That women wanted and expected unfailing fertility control as a normal part of life, however, does not mean that they wanted or expected serious health risks and side effects in return. In fact, the actual circumstances in which the pill was developed and commercially introduced reinforce the claims of feminist health activists that the needs of women, especially Third World women, were not foremost in the minds of oral contraceptive researchers. Gregory Pincus, the biochemist who along with John Rock developed the first commercially successfully oral contraceptive, tells us that in 1951 he was visited by Margaret Sanger, who impressed upon him the gravity of the "population explosion" and urged that he use his research knowledge to devise a "foolproof method" for use in "underdeveloped areas of the world." Thus, during the height of the U. S. "baby boom," the pill was conceived as an instrument of population control in the Third World. The sources of funding for research included major pharmaceutical companies as well as every major international population control institution (Planned Parenthood, Population Council, Pathfinder Fund, etc.).4 And the populations among whom the initial clinical trials were conducted, using dosages and combinations now known to be extremely hazardous, were poor women in Haiti and Puerto Rico. The decision to manufacture a pill containing high dosages of estrogen was made in spite of the fact that clinical literature since the 1940s had linked estrogen to carcinogenesis. Moreover, case reports associating the pill with sometimes fatal thromboembolisms began to appear soon after the pill was marketed (1960); yet pharmaceutical companies, researchers, and physicians suppressed or downplayed this information until the press and the Congress made it public in the late 1960s.5
There is no denying that the health hazards of the pill are serious or that the history of the pill is sullied with racism, profiteering, and collusion among researchers and drug companies. But the tendency of some feminists to view the pill entirely as a male medical conspiracy seems unnecessarily crude. The self-interested motives of some physicians, the drug industry, or population controllers cannot explain the fact that by 1965 oral contraceptives had become the number-one method of fertility control in the United States any more than the existence of highly profitable, proprietary abortion clinics can explain women’s growing demand for abortion. In a capitalist economy, it is hardly surprising that commercial interests attempt to exploit and expand any potential market. But the market is never conjured up out of the air; it exists in a social context of relationships and needs that are distinct from it even as they become shaped by it.6 We have seen that, even when women have been aware of risks to their health and life, they have been willing to take those risks in order to assure their control over pregnancy; control, for most women, has historically taken priority over safety, and certainly over "sharing the responsibility." Where male partners are hostile to birth control or unwilling to take any responsibility, women may prefer the method (e. g., the pill or sterilization) that seems least conspicuous, surest, and least dependent on male cooperation. In middle — and working-class families where women are saddled with most of the responsibility for children as well as a job outside the home, this may be especially true. As a working-class wife put it in the 1950s:
He doesn’t care how many times I get that way; he’d never do anything. The wife [should be responsible] because after the first pleasure the man has no more to do. It’s the woman who carries the baby and goes through all the suffering at birth. He goes off to work or gets out of the house and that’s all he cares about. He wouldn’t use anything at all, he just lets fly.7
Similarly, in 1969, before knowledge of the pill’s health hazards was widespread, black feminist Toni Cade (Bambara) challenged the view of the pill as genocidal, emphasizing its importance for black women as a means of self-control:
… I would never agree that the pill really liberates women. It only helps. . . the pill gives her choice, gives her control over at least some of the major events in her life. And it gives her time to fight for liberation in those other areas.
I find it criminal of people on the podium or in print or wherever to tell young girls not to go to clinics, or advise welfare ladies to go on producing, or to suggest to women with flabby skills and uncertain options but who are trying to get up off their knees that the pill is counterrevolutionary. It would be a greater service to us all to introduce them to the pill first, to focus on preparation of the self, rather than on abandonment of controls.8
An argument that emphasizes the burdensome and inequitable side of women’s responsibility for contraception is made by Kristin Luker in her book Taking Chances. She asserts that the domination of the contraceptive field by the pill is the result of a "deliberate" clinical and research decision in the late 1950s to shift emphasis to "female-oriented methods" whose use would be removed from sexual intercourse. Before the pill, "virtually all contraceptives. . . were intercourse-related," meaning that they involved at least some degree of shared responsibility by men. The shift to "female methods" (the pill, IUD, and abortion) worked primarily to reinforce, through technology and clinical practice, the patriarchal ideology of women’s exclusive responsibility for reproduction.9 But Luker’s liberal feminist ("egalitarian") analysis of the pill’s advent and its impact suffers from technological determinism as well as romanticizing the past. It ignores the fact that some methods used "prior to the pill" were not "intercourse-related" (e. g., illegal abortion or sterilization) and that even those that were (e. g., the condom, abstinence, or withdrawal) may have been used effectively only when women asserted their own sense of need.10
In other words, the "male" or "female" responsibility involved in a fertility control method is not a question intrinsic to its technology or form but is determined by the social*relations of its use. (The question of risks to health is another matter.) Above all, Luker’s argument disregards women’s desire and need for control, even if it means assuming all the risks. This no doubt includes even single young women who may also feel resentful that the pill signals their "availability" and seems to get men "off the hook."11 Assuming such women would prefer to hand over their responsibility—and risks—to men conveniently overlooks the fact that the women Luker interviewed ended up, on their own steam, in an abortion clinic. It also glosses over the reality of "male responsibility" in the 1950s: women passively waiting for a man to "do something," to "pull out," or to wear a condom. Whatever the motives of the researchers, the pill met a ready and eager market. Finally, Luker’s position ignores the feminist understanding that pregnancy involves an irreducible biological dimension for which the experience, and therefore the responsibility, cannot totally be transferred. "Control over our bodies" is more than a slogan.
Where reproductive risks are concerned, however, we are dealing with a contradictory reality. I have tried to underline the persistent desire of women in nearly all circumstances to maintain and maximize control over their reproductive lives. If the planning and application of fertility control methods are sometimes shared with male partners, the relentless fact that the consequences of an unwanted pregnancy fall more heavily on the woman has meant that she would often rather assume the risks herself than trust the man, whose stakes are different. Yet it is also true that institutional and clinical practices have intensified the exclusivity of women’s burdens and reified the identification of reproduction as a female activity, for reasons that are historical rather than governed by biological necessity. With the exception of vasectomy, all the existing "medical" methods of contraception are geared toward females because females have been the traditional clientele of reproductive medicine since its inception in the nineteenth century. A "male pill," while technically possible, has never been developed for a number of telling reasons: (1) Much more is known about female reproductive biology than about male because women’s bodies have historically been the objects of (male-dominated) clinical practice and research; (2) insufficient numbers of men volunteer for clinical trials in fertility control studies, for similar reasons of gender-defined tradition; (3) both researchers and male subjects are extremely concerned about the possibilities of "undesirable side effects" that chemical contraceptives could cause in men, especially the risk of impotence and a "loss of male libido."12 Male researchers rarely express a similar concern for side effects and libidinal loss in women due to synthetic hormones, although they surely occur. One senses that where sex (as opposed to reproduction) is at issue, the male of the species is still regarded by a patriarchal culture and medicine as the delicate and vulnerable one.
If feminists remain distrustful of physicians’ and family planners’ assurances that lower-dosage pills are safe, except for women who are "predisposed" to risk (i. e., smokers, diabetics, or women with hypertension), it is because of a systematic history of careless experimentation with women’s bodies and denial of our reality by medical professionals.13 A striking example of the misogynistic values that shaped the original development of the pill can be found in Pincus’ account of it. Contrary to everything that would be revealed four years later, Pincus in 1956 flatly dismissed the issue of mortality related to clotting disorders: "… there is no proof of any causal relation between thrombotic disease and the use of oral contraceptives… no evidence for a role of either estrogen or progestin in thromboembolism in women."14 He glossed over the issue of carcinogenicity, saying the work had been too "exhaustive" even to summarize, and then attributed possible metabolic disorders, especially weight gain, to a "loss of anxiety about accidental pregnancy with consequent appetite improvement"!15 Noting women’s frequent complaints of nausea, headache, and malaise related to pill use, he called them "reactions" (in quotes) and suggested a "suspected. . . psychogenic basis," since the "reactions" are most severe in the earlier stages of pill use. To persuade us of the validity of this argument, he cited experiments done on Puerto Rican women who were unknowingly given placebos instead of contraceptive pills! He also mentioned, in passing, experiments done during the 1950s and 1960s in which synthetic hormones were administered to pregnant women with a history of miscarriage, resulting in "masculinizing effects on the female fetus"; to nursing mothers, who transmitted them through their milk; and even to "suppress menstruation in sexually precocious girls.. . At the same time, Pincus waxed ecstatic about the benefits of the pill in reducing menstrual flow and menstrual disorders, as well as causing "a definite improvement in sexual adjustment" in women.16
Misogynist and sexist attitudes among male clinicians and researchers, however, are less important in determining the oppressive features of contraceptive practice for women than are certain structural characteristics of today’s contraceptive market. For if that market exists only because of women’s socially determined need, if it is not the creature of a conspiracy, it is also true that a few powerful interests monopolize the fertility control "industry" and therefore subject it to distortions.
The consumer market in contraceptives is dominated by two methods: the pill, which involves serious health hazards; and sterilization, which, for women, involves major surgery and is irreversible. This extremely narrow range of choice reflects both the medicalization and the commercialization of birth control in the mid-twentieth century—two processes that are closely related. The proclivity of male-dominated U. S. medicine to "treat disease" rather than sustain health has had a particularly distorting impact on reproduction. Natural or daily maintenance processes such as childbirth, fertility control, and prenatal and infant care either are fitted into an inappropriate model of pathology—hence subjected to "heroic" interventions, surgery, or chemical regulation—or are disregarded altogether as "health needs" and as a result are denied reimbursement.17 Procedures that most readily assume a commodity form in an advanced capitalist market (costly, rapidly consumed, or highly technologized) become "preferred" birth control methods. Indeed, untold millions of women throughout the world, who need an item for daily consumption over fifteen or twenty years of their lives, constitute an ideal consumer market, as the vast pharmaceutical industry is well aware.
It is the ordinary dynamics of the capitalist market that in some ways determine the narrowness of contraceptive choices. But it is also the nature of health-care institutions in our society as ones that are hierarchically organized and geared toward managerial models of control. The pill and the IUD in part function as means to connect women patients on a regular basis to the medical-care system, since they can be acquired only by prescription (this is true of the diaphragm as well) and must be periodically renewed or checked by a doctor. They require little time or instruction to be administered and thus may be rapidly processed, with little need for auxiliary services or counseling. Private doctors are notoriously unwilling (and also untrained) to take the time necessary to instruct teenagers or poor women in the use of a diaphragm or condom. Clinics, in addition to the predilections of their medical personnel, have other structural constraints that operate to reinforce "pill pushing." In particular, their dependence on federal reimbursements, which are tied to total numbers of cases processed, results in a relentless pressure on birth control counselors to process cases quickly and thus to recommend the method that is most time effective from a managerial point of view.18 Thus, in both the private and the public sector, birth control patients become not simply users of a service but routinely integrated objects in a system of social intervention designed to control population.
The symbiosis between an increasingly hierarchical and elite medical profession and a multinational pharmaceutical industry is mirrored in the tendency of insurance companies to reimburse only those procedures that qualify as "medical" (i. e., that require a prescription, surgery, or hospitalization) and in the medical profession’s increasing reliance for its profits on third-party payments. At the same time, as we saw earlier, birth control organizations in this country began in the 1920s and 1930s to look to the medical profession and to the imprimatur of medical procedures for their legitimation; they succeeded in forging this alliance by yielding both to medical control over procedures and to eugenicist ideas, convincing the (white upper-middle-class) clinicians that birth control was an expedient way to limit the numbers of the poor. Thus, the commoditization of birth control reflects the ideological perspectives and interests of a network of power centers that includes physicians, pharmaceutical companies, and family planning and population control agencies. Generally speaking, these groups share an acceptance of population control as a major political priority and family planning as a means to deal with poverty and social instability, a definition of "efficacy" in terms of control by physicians and technicians rather than the health and safety of users, and a preference for methods that are the most technologically sophisticated, the most cost effective, and therefore the most profitable and efficient. Hence the predominance of the so-called medically effective methods.
A vivid example of the alignment of interests around contraceptive politics is the recent struggle over the injectable synthetic hormone (progestin) known as Depo-Provera. Manufactured by the Upjohn Company and administered as a contraceptive to some 10 million women throughout the Third World and in Western Europe over the past decade,19 Depo — Provera is a highly effective contraceptive that keeps women sterile for up to six months. It was banned by the FDA in 1978 for distribution as a contraceptive in the United States because of studies linking it to breast cancer in dogs and endometrial cancer in monkeys, and after evidence of congenital malformation of infants accidentally exposed to it in utero. Feminists in organizations like the National Women’s Health Network and the feminist and socialist caucuses of the American Public Health Association (APHA) have fought strenuously against the unethical "dumping" of a product considered unsafe for North American women on millions of women in the Third World. (Manufacturers and suppliers get around the illegality of exporting a product banned for domestic sale by producing it through their foreign subsidiaries in Europe and Canada.) As with high-dosage oral contraceptives in the past, these women are essentially being used as guinea pigs, and the goals of population control, as usual, are being put before women’s health.19 Feminist opposition has confronted a solid wall of Depo-Provera supporters, who would like not only to expand its international sale but to lift the ban in the United States. The "pro-Depo" alliance consists of the Upjohn Company and its industrial allies; the International Planned Parenthood Federation (IPPF), which "is one of the largest international suppliers of Depo," and its research arm, the International Fertility Research Program (IFRP) in North Carolina; the U. S. Agency for International Development (AID), from whom IPPF gets most of its funds; and a substantial number of physicians and population researchers who have controlling voices in the APHA, the American College of Obstetricians and Gynecologists (ACOG), and the Population Association of America (PAA). These interests have parried criticisms of Depo-Provera by discrediting the animal studies as inconclusive, failing to conduct thorough clinical studies where evidence of the relation to cancer in women was available to them,20 and arguing that the "benefits" of avoiding pregnancy in countries where fertility rates and maternal mortality are extremely high outweigh any long-range health risks the women may incur.
The principle that a drug may be used indiscriminately on human beings until clinical trials prove it harmful is the opposite of that on which the FDA is supposedly founded: that no drug may be commercially sold until clinical trials have proven it safe. Applying the perverted principle to millions of Third World women sets up an imperialist double standard; it says, in effect, the risk of cancer matters less for these women than it does for North American women. Particular national and local conditions and levels of development do make a difference; in some countries, a poor woman’s risk of dying in childbirth may be much higher than any risk of cancer she incurs from Depo-Provera, which may in fact diminish her maternal mortality risks. But the internationalization of reproductive rights struggles through the Depo-Provera issue can only strengthen women’s position in the long run, since it applies to all women, whatever their economic or national identity, the standard that women’s health cannot be traded off for "efficacy." To be saved from death in childbirth only to die from cervical or endometrial cancer is hardly an unmixed blessing of advanced technology; raising the issue forcefully puts manufacturers on notice that, as with oral contraceptive pills in the United States, they will be continually monitored by a politically conscious public concerned about health and safety standards.
Indeed, the seriousness with which the Depo-Provera alignment has had to meet its feminist critics, and its failure thus far to lift the ban in the United States, shows that the concentration of interests controlling the contraceptive market is not all-powerful. It has to accommodate the self-perceived needs and organized demands of women through a subtle process of negotiation and struggle. When we try to analyze why medical professionals and population experts favor one fertility control method over another at a given time, the reasons often have as much to do with strategies for securing control, political legitimacy, and the absence of vocal resistance to a method as with technological sophistication and profits. In this process, women have made real gains. The producers and purveyors of birth control commodities have had to contend with a new political consciousness, within this country and increasingly in the Third World as well, about not only the need for birth control but also its hazards. This consciousness has arisen since the late 1960s as the result of a growing consumer and feminist health movement on the one hand and the awareness in Third World communities of the threat of population control on the other.
Today women in all groups seek control over pregnancy, bolstered by a popular ethos that sees that control as a fundamental right. But they seek control that is compatible with their health and safety as well as their personal and ethnic autonomy. The »choice" between effectiveness and safety no longer seems reasonable or tolerable because that "choice," given the possibility of safe, early abortion, is unnecessary. What is clear is that it is not only the anticipated risks of mortality and morbidity associated with the pill that more and more women find unacceptable; it is also, and perhaps more often, the day-to-day experience of unpleasant side effects. At the same time, the health hazards of the pill may be viewed by a growing number of black, Native American, Puerto Rican, and Mexican-American women on a continuum with involuntary sterilization, toxic environments, and other conditions that diminish not only their reproductive capacity but also the length of their lives.