In Our Control (19 page)

In this chapter I examine similarities and differences between alternative hormonal contraceptive methods and the Pill. I also address the question of why the new developments in contraception have been almost exclusively hormonal, essentially a simple repackaging and remarketing of the same oral contraceptive drug. If the original Pill constituted a true fertility
control innovation, why have the past fifty years brought simply “me too” drugs, and what has happened to prospects for truly new methods?

False Starts and Uncertain Futures: Norplant and Long-Lasting Contraceptive Implants

Ironically, it is the failure of one method—the Dalkon Shield IUD—that has seriously hampered the development of new ones. When infection, infertility, and other health problems caused by the Shield led thousands of women to participate in legal actions against the device’s manufacturer, liability insurance for contraceptives shot to astronomical heights. Many drug companies decided they had had enough and got out of the birth control business altogether, with many more simply curtailing involvement to marketing existing drugs. It simply didn’t make economic sense to spend time and valuable research and development dollars chasing new methods.

The birth control pill changed American medicine. It showed that it was possible to successfully market a preventative pill to a healthy person, potentially for decades of continuous use. This caused seismic changes in the pharmaceutical industry, and today, disease-free midlife patients are often counseled to consider long-term drugs for cholesterol, mood, pain, and menopause management and as interventions in bone and sexual health. Drug companies have realized they don’t have to stick with contraception: there are untold horizons for preventative medicine and plenty of new drugs—for men as well as women—to pursue.

Financially speaking, it has been hard to improve on the profitable Pill. A drug that doesn’t need to be taken monthly would almost certainly represent a less lucrative option for manufacturers, so there has been no real incentive for contraceptive innovation.

Population control groups and some sexual health organizations have been on the opposite side of the issue. International groups interested in contraception have been highly motivated to find methods that require less stringent patient adherence and less repeat involvement in fertility control. Some argue that women with limited access to health care are less likely to stick with a method that requires repeatedly procuring pills each
month (or even every couple months). Others suspicious of long-acting methods that take some measure of reproductive control out of women’s hands have pointed out that these devices have been disproportionately and sometimes coercively pushed on poor women in developing nations and low-income women in the United States.

The idea of a long-acting contraceptive implant has been a serious possibility since the 1960s, and over ten hormonal compounds have been tested over the years as possible candidates. The idea is simple: hormones are placed in flexible and nonbiodegradable tubes and inserted under the skin, where they gradually release enough of the compounds to prevent pregnancy. All of the implants to hit the American market so far have been progestin-only methods.

Given the cost of insurance required to be in the birth control business, the only entities that can afford to be players in research and development are drugmakers and large organizations, and the former are simply not very interested in doing so.

But large nonprofit groups, such as the Population Council, have both the resources and the interest in making new methods. Norplant, the first of all the alternative distribution methods to be approved in the United States, was developed by the Population Council and first used for contraception around the world in the 1980s in part with the help of $15 million dollars in American and foreign aid.
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The international introduction of Norplant was not always a pretty story: Indonesia, one of the first countries to adopt the device, promoted and even forced its use in many ways, including withholding paychecks from women who didn’t agree to insertion and requiring Norplant use as a condition of certain types of employment.
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A program in Peru in the 1980s administered by the United States Agency for International Development (USAID) offered only Norplant and sterilization to the patients it serviced. In Bangladesh a massive program targeted poor women with the device. In all cases, the emphasis was on making sure that women had the device put in and little attention was given to how they would get it out if they changed their minds about it. This meant both that doctors weren’t adequately trained in removal and that women often lacked the resources to access the doctors. Nonetheless, declining birth rates in test populations led to the view that Norplant was a successful and promising method of birth control.

The Population Council wanted to market the device to American women, but they lacked the funds, so they eventually partnered with Wyeth Ayerst, one of the few pharmaceutical companies left standing in the field of contraceptive development by the end of the 1980s. Norplant
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was made of six 2.4 mm silicone tubes, each containing 36 mg of levonorgestrel, a progestin. A doctor implanting the device would make a 3 to 5 mm incision in a patient’s upper forearm and insert the tubes in a “fan-like pattern.”
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By 1990, it hit the American market. The option enjoyed a very short honeymoon before the problems that continue to plague it today came to be understood by American women.

The first problem Norplant encountered wasn’t really its fault. By 1992, enormous controversy and media attention were swirling around the terrible problems suffered by women with silicone breast implants. Historian Andrea Tone notes, “When silicone gel breast implants began to be taken off the market in 1992, Norplant fell under suspicion because its rods were made of silicone (although not silicone gel).”
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The result was that implantation of new Norplant devices, which was as high as eight hundred per day in 1990, plummeted to less than sixty by 1995.

Other safety problems more substantively tied to the Norplant device began to rear their heads. Many women had unpredictable bleeding and scarring at the insertion site. There were other side effects, including weight gain, arm pain, and mood changes, but bleeding remained the most upsetting for many patients. If women had bleeding problems (and other symptoms) on oral contraceptives, they could simply stop taking the drug. But Norplant was less forgiving: once a woman had the device implanted, it was expensive and painful to take out.

Summer, now a thirty-something waitress in Salt Lake City, UT, was in her early twenties when she had Norplant put in. At the time she was an on-again, off-again student at the University of Utah and was waiting tables part time to put herself through school. She’d been in a relationship for several years that had ended when she had a reluctant abortion after becoming pregnant while on the Pill. Hoping never to be in a situation like that again, Summer decided to try Norplant. Two years later, she was desperate to get the device out of her arm. It had caused lots of problems, the worst of which was shooting pains in her arm that made carrying trays and accomplishing the other tasks required for her work
difficult. More pressingly, she was married to another man and ready to start a family. Unfortunately, she lacked the financial resources to remove the Norplant tubes. “I ended up taking twice the shifts, letting other things go,” Summer told me. “I was just desperate to save the money for removal.”
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Many women found themselves in similar situations, particularly low-income women and those in developing nations. In the summer of 2001, I met a young doctor from Nepal at a conference related to the massive United Nations Beijing + 5 gathering. She shared her story with me. Trained by an international population control group, she inserted hundreds of Norplant devices. She was undertrained to do so, and the providers of the implants never suggested that there could be side effects. When her patients started experiencing problems, she was equally ill equipped for removal, and some patients had scarring. Others were simply unable to make the long journey back to the clinic. As she told the story to me and a small group of women’s health activists, tears came to her eyes. “No one told me there would be problems like that—I would never have used it, and I certainly wouldn’t have put it into so many women.”

Other international health workers and their patients found it to be a useful method. Abigail Fee, a young Harvard student, was living and conducting research among the Ewe women of Ho, Ghana, in West Africa. She became accustomed to women who came to the clinic where she was working bemoaning the fact that they could no longer get Norplant. Social stigma made it difficult for many women to get contraceptives and therefore necessary that women conceal their use. A long-term method was, in this context, ideal, and they were willing to put up with the side effects.

These two examples illustrate the difficulty of assessing risks and benefits in the diverse contexts in which women (and their doctors) make contraceptive decisions. None of this is simple, and calling a drug “bad” or “good” is too easy. Different birth control options are good for certain people, bad for others, and mixed for the majority of women. What is less debatable, in the case of Norplant, is that doctors and health care providers should have been better informed about its potential risks and problems.

Another problem for Norplant was the perception that it was a shiny new engine of social control waiting and ready to coercively manage the fertility of low-income and nonwhite women. These concerns were well founded: the initial terms of the Norplant debate in America focused on its usefulness for curtailing births in poor communities. Indeed, within two days of the drug’s approval, the
Philadelphia Inquirer
ran an editorial entitled “Poverty and Norplant: Can Contraception Reduce the Underclass?”
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In making its argument for creating “incentive” programs that would bribe women to have the device inserted in exchange for benefits or food, the article singled out women of color and “black poverty”
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as problems that the new birth control might be able to curtail. While activists decried the blatant racism and classism of these arguments, state legislatures scrambled to put together bills proposing just such tactics. In all, thirteen states created two dozen bills that some activists argued would have used Norplant “for social engineering purposes, making the use of Norplant a condition of receiving welfare payments or enticing women on welfare to use Norplant through financial incentives.”
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Due in no small part to the constant efforts of African American women’s health activists, none of these proposals was put in to place, although many less obvious means of pressuring poor women to have the device inserted did happen.

An official program to use the drug coercively did enter into public practice: female prisoners convicted of sexual crimes were offered a choice between Norplant and prison, and forced to undergo insertion as a condition of release.
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While such practices were gradually made illegal, both proposed and enacted plans for eugenic uses of Norplant served to highlight that a painful national history of forced sterilization of poor, disabled, and minority women was not as far in the past as many believed.

Sheldon Segal of the Population Council was quick to react to accusations of racism by insisting that none of these uses of Norplant were proposed or designed by its maker; he also insisted that the buck for such abuses stopped with the lawmakers and judges who saw such unsavory potential in the six little tubes: “It was developed to improve reproductive freedom, not to restrict it,”
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he wrote in the
New York Times
. Others noted that the way in which Norplant was developed—with a focus on limiting pregnancy, as opposed to making more complicated forms of reproductive autonomy the goal—undermined this claim. Author and
law professor Dorothy Roberts became one of the most outspoken voices in favor of examining racial and class contexts of Norplant. In chronicling the launch of the contraceptive, Roberts notes, “What appeared to be an expensive contraceptive marketed to affluent women through private physicians soon became the focus of government programs for poor women. Lawmakers across the country have proposed and implemented schemes not only to make Norplant available to women on welfare but to pressure them to use the device as well.”
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These programs included offering free insertion—but not removal—of the device to low-income women and to teenagers predominantly in schools with low-income and nonwhite students. There were also reports of doctors pressuring patients to try the insert. Such “provider coercion” remained largely anecdotal,
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but it further tarnished an already singed image, bringing Norplant closer to recall.

Many public health researchers pointed out that while concern about forced uses of the device “might well have served to reduce the magnitude of the problem by creating an atmosphere of vigilance,”
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it also branded a potentially useful contraceptive. Researchers from Columbia University’s Mailman School of Public Health conducted a study of two thousand low-income women, many of whom were using Norplant as their primary contraceptive. After conducting a series of interviews, they found that only three claimed to have been unduly pressured by physicians to undergo insertion.
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While it is important to mention that this trial received some financial support from Wyeth Ayerst, the maker of the device, Jadelle, also called Norplant II, it is also worth recognizing a crucial point it makes: just because a poor woman chooses a long-acting contraceptive doesn’t mean she was forced to do so. In fact, many studies indicate that women from diverse social and economic backgrounds were excited by the prospect of a new birth control option.