Why Isn't Our Birth Control Better?

By Philip Elmer-DeWitt.

A portrait in American fecundity: every day hundreds of young women, their bodies roundly pregnant, descend on the University of Southern California Women's Hospital. They overflow the available chairs and sprawl awkwardly on the floor. They come for prenatal checkups, gynecological care and, finally, to deliver their young. Last year more than 18,000 babies were born in this building, roughly 1 out of every 200 babies born in the U.S. "Sometimes they are lined up in the hallways and stacked up for C-sections like planes at LAX, six or seven deep," says obstetrician-gynecologist David Grimes.

But this busiest of U.S. obstetrics units also symbolizes an American failure: the extent to which the birth control revolution has not fulfilled its promise in the country where it began. Three decades after the Pill was introduced in the U.S., a shocking number of the 58 million American women of childbearing age still find it difficult to control their own reproduction, especially compared with women in other countries. Teenage pregnancy in the U.S. is more than double that of European countries, and the nation's abortion rate -- 1.6 million a year -- is one of the highest in the developed world. All told, more than half of all American pregnancies -- 3.4 million out of 6 million each year -- are accidents, the result of misusing contraceptives, using unreliable contraceptives or using no contraceptives at all.

The sorry state of birth control in America is underscored in a report prepared by the Population Crisis Committee, a nonprofit research group based in Washington. The committee found not only that Americans have fewer contraceptive options than their counterparts in most developed countries, but also that contraceptive devices are more expensive and more difficult to obtain in the U.S. than in some parts of the Third World.

While scientists around the globe are making rapid progress deciphering the dance of hormones that makes pregnancy possible -- work that raises new strategies for blocking conception -- the major American pharmaceutical companies have all but abandoned the field. Of the nine doing research in contraceptives 20 years ago, only one (Ortho Pharmaceutical) is still active. The others have been scared off by the fear of costly lawsuits like the one that drove the maker of the Dalkon Shield, an intrauterine device, into bankruptcy, and by public controversy such as that surrounding RU-486, the French "abortion pill."

Most of the world's governments encourage family planning and even subsidize the use of birth control devices. The U.S. stands out as the only major industrialized country that is moving in the opposite direction. Over the past decade, Washington has halted federal research on new reproductive technologies and declined to approve some of the most promising new methods of birth control.

There have been some improvements in U.S. contraceptive options, but they have been incremental rather than revolutionary. Manufacturers of the Pill have developed low-dose versions that avoid most of the side effects associated with earlier varieties. IUDs have improved greatly in the past decade and are now about as safe and effective as the Pill. And owing largely to the fear of AIDS, the condom, which dates back to the age of the Pharaohs, has come out from behind the pharmacists' counters and is now prominently displayed at stores across the U.S. in various colors, shapes and sizes.

Even the Food and Drug Administration-sanctioned Norplant -- the long- lasting hormone implant hailed as the first new contraceptive device approved for use in the U.S. in three decades -- is really a repackaging of the same chemical used in the Pill. Norplant is housed in matchstick-size tubes and inserted under the skin of a woman's arm. Its main advantage is that it does not depend on someone's remembering to take it every day. But it can cause irregular bleeding, and its cost (up to $1,000) puts it out of the price range of many who need it.

In Europe sexually active couples can choose from a wide selection of contraceptive approaches that includes more than two dozen different kinds of pills, monthly and bimonthly contraceptive injections, and an IUD that boosts its effectiveness with the slow release of hormones. The big news this summer is Britain's decision to become the second country -- after France -- to approve the sale of RU-486, the controversial postcoital contraceptive.

Carl Djerassi, the Stanford chemist who helped develop the original Pill in the early 1950s, calls RU-486 "the single most important new development in contraception of the past two decades." Reason: it gives women, for the first time, a relatively safe way to avoid pregnancy after they have had unprotected intercourse -- thus fully removing the decision to exercise birth control from the decision to have sex. Basically, RU-486 is a menses inducer. Used in conjunction with a prostaglandin, it brings on a woman's period whether or not she is pregnant. Although there has been one death associated with its use ; (triggered by an allergic reaction to the prostaglandin), it is considered fairly safe. Several states, including conservative New Hampshire, are lining up to become test sites to speed its adoption in the U.S.

That is not likely to happen soon. Right-to-life groups have made opposition to the "French death pill" a rallying cry and have vowed to boycott not just it but all products made by any drug company that dares distribute it in the U.S. They argue that the notion of postcoital birth control is just abortion by another name; in addition, they are not enamored of the idea of separating sex from its consequences. "The problem is not that contraceptives are not available; the problem is that many people are not behaving responsibly," says Allan Carlson, president of the traditionalist Rockford Institute.

That attitude, which has come to dominate federal policy, indicates that the real dispute in America is not so much about abortion or contraception as it is about sex and values. American culture is a strange blend of prurience and prudery that tends to lead to the worst of both worlds: movies and magazines that exploit sex and teach kids that it's glamorous and free of consequences, combined with a skittish denial of the facts of life that makes it hard to teach those kids how not to get pregnant.

"Many American women are grossly misinformed," says U.S.C.'s Grimes. For instance, 31% of American women in a 1985 Gallup poll indicated their belief that birth control pills cause cancer, when in fact the evidence shows that for nonsmokers the Pill actually reduces the risk of ovarian and endometrial cancer. Europeans are much better at putting sex -- and birth control -- in its place. Despite their Roman Catholic heritage, the French schools conscientiously provide sex education during which birth control and abortion are frankly discussed.

It would be a mistake, however, to blame the paucity of new contraceptive devices in the U.S. just on puritanical attitudes and conservatism. One group that would have been expected to be contraception's natural constituency, feminists, has been more vocal in pointing out the dangers of various devices than in promoting their use. The positive result was the development of the new low-dose pills. The negative effect was that thousands of women abandoned the Pill altogether.

The National Academy of Sciences last year called for an infusion of federal dollars into contraceptive research, better sex-education programs and protection from liability suits for manufacturers who want to get back into the birth control business. But under the current Administration such actions are unlikely. Meanwhile, sexually active Americans are often left with an inadequate range of options: make the best of the contraceptives they have, choose to be sterilized, or turn to abortion when all else fails. With the last option under increasing legal challenge, the choices at the turn of the century are likely to be narrower than they are today.

With reporting by Ann Blackman/Washington, Tom Curry/Chicago and Edwin M. Reingold/Los Angeles