Which of the following was true of contraception in nineteenth-century europe?

2.5 Contraception

Contraception is arguably the main factor modifying fertility in contemporary societies. There have been exceptions in eastern Europe where for some periods of time the practice of induced abortion was extremely high and thus more important in inhibiting fertility. In a few developing countries the use of contraception is still low, but practically everywhere it has been growing. During the second half of the twentieth century the unprecedented increase in the use of contraceptives and the availability of new modern more effective contraceptives have led to the perception that a ‘contraceptive revolution’ has taken place (see Westoff and Ryder 1977).

The effectiveness of contraception is measured as the percentage reduction in fecundability. For instance, a contraceptive with a 95 percent effectiveness used by women with a 0.2 fecundability will yield a 0.01 monthly probability of conception. Actual contraceptive effectiveness of a method depends primarily on the extent to which it is used as prescribed. Improper use results in contraceptive failure. The effectiveness of modern methods, such as oral contraceptives and intrauterine devices, is more than 95 percent in developed countries and that of conventional methods, such as the condom, diaphragm, or spermicides, about 90 percent. Depending on the knowledge and motivation of the average user, those levels tend to be lower in developing countries. In a number of countries female and/or male sterilization is popular and is 100 percent effective. The mix of methods used differs very much from one country to another.

A. Oral Contraceptives for Older Women

If contraception is required, the healthy, nonsmoking perimenopausal older woman should seriously consider the use of oral contraception. The anovulatory woman cannot be guaranteed that spontaneous ovulation and pregnancy will not occur. The use of a low-dose oral contraceptive will at the same time provide contraception and prophylaxis against irregular, heavy anovulatory bleeding and the risk of endometrial hyperplasia and neoplasia.

A traditional postmenopausal hormone regimen is often utilized to treat a woman with the kind of irregular cycles usually experienced in the perimenopausal years. This addition of exogenous estrogen without a contraceptive dose of progestin when a woman is not amenorrheic or experiencing menopausal symptoms is inappropriate and even risky (exposing the endometrium to excessively high levels of estrogen). And most importantly, a postmenopausal hormonal regimen does not inhibit ovulation and provide contraception [12]. The appropriate response is to regulate anovulatory cycles with monthly progestational treatment along with an appropriate contraceptive method or to utilize low-dose oral contraception. An oral contraceptive that contains 20 μg estrogen (the lowest available dose) provides effective contraception, improves menstrual cycle regularity, diminishes bleeding, and relieves menopausal symptoms [13].

Hormonal Treatment for Emergency Contraception and Abortion

Emergency contraception involves hormonal treatment designed to inhibit or delay ovulation, inhibit corpus luteum function, and disrupt the function of the oviducts and uterus. Candidates for emergency contraception include women who have been sexually assaulted or who experienced a failure of a barrier method (e.g., ruptured condom). The currently preferred medication is levonorgestrel (Plan B), which is a synthetic progestin-only pill. The efficacy of the pill is inversely correlated with the time it is taken after intercourse. The exact mechanism of action is not known. Treatment has no effect if implantation has occurred.

Medical (hormonal) termination of pregnancy (abortion) can be achieved until up to 49 days of gestation by administration of mifepristone (RU-486). Mifepristone is a progesterone receptor antagonist (i.e., an antiprogestin), which induces collapse of the pregnant endometrium. Mifepristone is followed 48 hours later by ingestion or vaginal insertion of a synthetic prostaglandin E (e.g., misoprostol), which induces myometrial contractions.

Conclusion

A range of methods exists that allow couples to regulate their fertility. While permanent sterilization is available for both men and women, there are only a few reversible methods for use by men, namely condoms and withdrawal, and both are among the less effective methods of contraception. For women, a range of reversible methods allows a choice between barriers, intrauterine contraceptives, and hormonal methods, with or without estrogen, and deliverable by a variety of routes (oral, injectable, etc.).

All methods are very safe for healthy women and a robust classification of medical eligibility helps providers choose suitable methods for women with preexisting medical conditions.

Method choice is influenced by a long list of factors but is vital to successful use of contraception. While methods vary in their effectiveness, and while those that rely little or not at all on compliance are the most effective, correct, consistent, and continued use is most likely when people use the method they find most acceptable.

Use of contraception allows couples (and individuals) to choose whether, and when, to have children and contributes enormously to sexual and reproductive health. In a recent article, Cleland et al. (2006) described family planning as being:

unique among medical interventions in the breadth of its potential benefits: reduction of poverty, and maternal and child mortality; empowerment of women by lightening the burden of excessive childbearing; and enhancement of environmental sustainability by stabilising the population of the planet (Cleland et al., 2006: 1810).

3.3 Empirical determinants of gender identity norms

Assuming that the gender identity model is relevant to women’s labor market outcomes, one is left with the question of what drives gender identity. Under an identity model, the changes in women’s labor market outcomes over the last decades could only have occurred in conjunction with deep societal changes in the strength and meaning of the male and female social categories.

Innovations in contraception, and the introduction of the Pill in particular, may have contributed to altering women’s identity in the 1960s and 1970s. As Goldin and Katz (2002) show, the introduction of the Pill led to both an increase in women’s investment in schooling and an increase in the age at first marriage. This, Goldin (2006) argues, meant that women’s adult identities were less influenced by traditional gender roles (as these identities were now more likely to be formed before marriage) and more influenced by career considerations.36 Also, as we just discussed, Fortin (2009) singles out the AIDS crisis as an exogenous shock that may have undone some of the “liberating” effects of the Pill and contributed to a return to more conservative gender identity norms in the 1990s.

Other papers have discussed the influence of nurture in the formation of gender identities. Many believe that gender role attitudes are largely determined early in childhood, and several papers have documented something akin to an intergenerational transmission of gender identity norms. In an early paper, Vella (1994) establishes a relationship between a young female’s attitudes towards working women and her background characteristics, including her religious affiliation, and the educational background and labor market behavior of her parents.37

Fernandez et al. (2004) provide a related explanation for why men may differ in how traditional their views are with respect to whether women belong at home or in the office. They argue that a significant factor in the steady increase in women’s involvement in the labor force has been the growing number of men growing up in families with working mothers. These men may have developed less stereotypical gender role attitudes, with weaker association between their masculinity and them being the only or main breadwinner in their household. In particular, they show that men whose mothers worked are more likely to have working wives. The paper follows Acemoglu et al. (2004) and uses variation in the male draft across US states as an exogenous source of variation in mothers’ labor force participation. This finding suggests a virtuous cycle: with more of these “new” men around, women should rationally invest more in labor market skills work and thereby expose their sons to this less traditional family structure.38

Farre and Vella (2007) directly test for the intergenerational transmission of gender role attitudes. Using the NLSY1979, they find that a woman’s view regarding the role of females in the labor market and family affects her children’s views towards working women. Farre and Vella (2007) also show the impact of those attitudes in labor market participation: mothers with less traditional views about the role of women are more likely to have working daughters and (reminiscent of Fernandez et al. (2004)) more likely to have working daughters-in-law.

A broader take on the importance of intergenerational transmission for gender role attitudes is to demonstrate the relevance of one’s cultural background in shaping identities, attitudes and behavior. In a recent paper, Fernandez and Fogli (2009) study the labor force participation and fertility choices of second-generation American women.39 They use past values of female labor force participation and fertility rate in these women’s country of ancestry as cultural proxies. The underlying logic for isolating cultural effects this way is that while these women live in the economic and formal institutional environments of the US, conditions in the country of origin might have been transmitted to them by their parents. Controlling for individual and spousal socio-economic backgrounds, they find that American women whose ancestry is from higher labor force participation countries work more; similarly, American women whose ancestry is from higher fertility countries have more children. Interestingly, spousal culture appears to also matter in explaining these women’s labor force participation.

The schooling environment, which was earlier singled out as a driver of gender differences in preferences, has also been linked to gender identity. Specifically, adolescent girls in a coed environment could see their traditional female identity reinforced as they are trying to be attractive to the surrounding boys and are competing with other girls to get boys’ attention. Studies by Maccoby (1990, 1998) suggest that the pressure might be greater on girls to develop stereotypical gender identities when they are surrounded by boys, than they are on boys when they are surrounded by girls. Also, Lee and Marks (1990) discuss how girls that attend single-sex schools were less likely to hold stereotypical views of gender roles even after they no longer attended these schools.

Dasgupta and Asgari (2004) study gender stereotypes (as measured by performance on a gender-stereotype Implicit Association Test), among college-age women both before and after their first year at either a coeducational or a women’s college. While the two groups of women do not differ in their level of gender stereotyping at college entry, differences start emerging one year later: students in the women’s college display no gender stereotyping, while the female students at the coeducational college show higher levels of gender stereotyping than in the previous year. Interestingly, Dasgupta and Asgari (2004) argue that their finding is mediated through female students’ exposure to female professors: being exposed to more women in counter-stereotypical positions appears to undermine the automatic stereotypical associations women hold about themselves.40

3.2 Fertility Control

Access to adequate contraception and to abortion is important to women's physical and psychological well being. Where abortions are legal, around 2 percent of women aged between 15 and 44 have an abortion in any year. The worldwide annual death rate from illegal abortions has been estimated at 100000, while the death rate from legal abortions is 0.05 per 10 000, 25 times lower than the rate for childbirth. Provision of safe abortions and adequate contraception would have a major impact on the well being of women and children in developing countries.

Women may need support in deciding whether to choose abortion, but the majority experience no significant psychological distress. Psychological distress following abortion is considerably lower than that associated with childbirth. Distress is highest during decision making before the abortion, and the most common postabortion reaction is a sense of relief.

Women who cope best with abortion are characterized by optimism, high self-esteem, and a sense of personal control. Social, cultural, and partner support, and confidence in the decision, assist in coping, while women with a history of psychiatric disorder are likely to react negatively (Adler et al. 1992).

3 Behavioral Models and Empirical Analyses

Standard models for the use of contraception suggest that the prevalence of abortion should be affected by the perceived costs and benefits of children (and their determinants), the broadly defined cost of abortion (i.e., monetary costs, time costs, and psychic costs), and the broadly defined cost of other methods of fertility control.

Beyond these insights from the general theory of fertility control, theoretical approaches to abortion focus on the temporal position of abortion between conception and birth. This approach suggests two paths to abortion. First, especially in places where contraceptives are difficult to obtain, some women do not contracept, planning that if they become pregnant, they will abort. Second, some women do contracept but plan (sometimes only implicitly) to abort if they experience a contraceptive failure. The limited survey evidence suggests that both paths are important. In the US, slightly more than half of women having abortions report that they were contracepting at the time of conception; the rest were not using any method.

Abortions following contraceptive failure appear to result from two different phenomena. First, the standard modern life-course—early initiation and high prevalence of sexual activity and a desired family size of about two—implies that many women must contracept for over 200 months. Thus, even given consistent use of contraceptive methods with low failure rates (e.g., the oral contraceptive), a sizeable fraction of all women will experience an unintended pregnancy during their lifetime; many of them will choose abortion. Second, among those nominally contracepting (i.e., using any method at some time in the previous month), some subpopulations have high pregnancy rates. Such rates appear to be due to a combination of selection of a method with a high use failure rate (for example, the condom, chosen partially because it protects against sexually transmitted diseases) and inconsistent and ineffective usage of the method (e.g., not taking every pill every day). These two phenomena lead both to abortions and to high rates of voluntary sterilization.

Social psychological considerations also appear to be important. Some women choose not to contracept because of ambivalence about their sexuality (e.g., they deny that they are sexually active, or that they plan sex). Other women choose not to contracept (or not to contracept effectively) because they underestimate the probability of conception (e.g., they underestimate their own fecundity or they overestimate the effectiveness of their method as used) or highly discount the future. For these women, abortion is a second chance that allows them to remedy the effects of their earlier denial or incorrect perceptions.

Finally, some women choose abortion rather than contraception because they learn something because of the pregnancy. Particularly in parts of Asia, it appears that abortion is used as a tool for sex selection and yields an imbalanced sex ratio. Similarly, some women become pregnant in order to learn the true intentions of a partner, and abort if the revealed intentions are unfavorable. Some empirical studies find an increase in nonmarital births with lower costs of abortion, which is consistent with this motive for abortion. These ideas have been extended to models of equilibrium in the labor market, where they imply that the availability of abortion lowers women's bargaining position in the marriage market and reduces the marriage rate. (Men need no longer promise marriage in order to get sex and need no longer marry a woman if she becomes pregnant; Akerloff et al. 1996.)

Statistical analyses of the determinants of abortion and the effects of abortion regulation have been hampered by the difficulty of measuring abortion rates. Early work considered country-level time-series for contraception, abortion, and fertility. More recent work has applied difference-of-difference methods to time-series of cross-sections data to explore the effect of specific public policies and abortion access on abortion and fertility (e.g., Joyce and Kaestner 1996, Klerman 1999, Levine et al. 1999).

Rational-choice analyses using dynamic programming methods suggest that raising the cost of abortion should be expected to increase both contraceptive use (and other methods for fertility control such as decreasing coital frequency and delaying marriage) and realized fertility. While abortions are often common even when abortion is illegal, legalization of abortion in Europe and the US sharply increased abortion rates and decreased fertility. In addition, public funding of abortions in the US through Medicaid appears to raise abortion rates and lower fertility rates for blacks. Given poor measurement of contraceptive prevalence, it has been difficult to estimate the effect of changes in the cost of abortion on the prevalence of contraception. In principle, the effect could be detected as the difference between the change in the number of abortions and the number of births. The clearest case appears to be Romania's banning of abortion after a period when it was legal. The number of births increased much less than the previous number of abortions (even after accounting for illegal abortions) and there were reports sharp decreases in coital frequency. Similar effects appear to have been present when abortion became legal in other countries of Eastern Europe, especially when experience with contraceptives was of short duration (Frejka 1983).

Similarly, decreasing the cost of contraception should be expected to increase contraceptive prevalence. This should prevent unintended pregnancies, some of which would have been terminated by abortion; thus lowering both the abortion rate and the fertility rate (see Rahman et al. in press for evidence from Bangladesh). Such substitution has been used to explain the simultaneous increase in contraceptive prevalence, decrease in abortion, and decrease in fertility in Russia in the early 1990s, in Hungary in the late 1960s and early 1970s, in Japan in the 1960s; and in Kazakhstan in the 1990s with the introduction of a USAID contraceptive distribution program. Similarly, the (broadly defined) low costs for contraception, easily available without stigma, appear to explain high rates of sexual activity, high rates of contraception, but low rates of abortion and low fertility in Western Europe.

2.2 Behavioral Methods of Contraception

This section reviews methods of preventing contraception which do not require the use of any type of physical or chemical substance, but which rather rely on the modification of sexual and reproductive behavior. In this category fall some of the oldest effective methods known. Reduced coital frequency, even if practiced without regard to the timing of sexual intercourse during the menstrual cycle, will affect the monthly probability of conception to an extent which is roughly proportional to the percentage decline in coital frequency (Trussell 1979). Clearly, sexual abstinence, or continence—that is, refraining from vaginal intercourse—reduces fertility. David and Sanderson (1986) argue that sexual restraint of these kinds were important factors in bringing about the nineteenth-century decline in fertility in the United States.

Fertility awareness methods of periodic abstinence, by which the fertile days during the cycle are correctly identified and avoided, will be more effective than a simple overall reduction in coital frequency. Various types of methods are in use today (e.g., Calendar Rhythm Method, Basal Body Temperature method, Cervical Mucus charting), but historically, these are fairly new developments. It was not until the early 1930s that the timing of ovulation within the menstrual cycle was correctly identified and a chart was worked out for use by women desiring to identify the days it was ‘safe’ to have sexual intercourse. Typical-use failure rates of periodic abstinence hover around 25 percent. Prior to the second quarter of the twentieth century, attempts at periodic abstinence, based on incorrect beliefs about the timing of the fertile period, while often discussed, were generally ineffective.

Prolonged and intensive lactation have the effect of delaying the return of ovulation after a live birth. There is evidence that certain preliterate societies, as well as the ancient Egyptians, were aware of the fertility-inhibiting function of breastfeeding, and practiced prolonged lactation for the purpose of increasing the spacing between births. Such practices were common in the currently developed nations in the 1900s, and they are still in use there among various religious groups. In addition, throughout history, it has often been believed that semen would spoil the milk of lactating women. Customs of post-partum abstinence during lactation, more common in polygynous societies, enhance the fertility-inhibiting effect of breastfeeding, whether or not they are practiced for the purpose of fertility control (see Fertility Control: Prevalence and Consequences of Breastfeeding).

Modifications of sexual practices, such as oral sex, anal sex and coitus reservatus—vaginal penetration without ejaculation—may have been used for the purposes of preventing conception. Probably the ancient Peruvians, Greeks, and Hebrews, among others, performed such practices. However, the behavioral modification invoked most universally, both in terms of time and space, and most certainly for the purposes of fertility control, is coitus interruptus, or withdrawal, whereby male ejaculation occurs outside the vaginal cavity, following vaginal penetration.

Which of the following was most responsible for the steady population growth in eighteenth century Europe?

Which of the following best describes Charles Darwin's theory of evolution?

Why did seventeenth century Protestants and Catholics condemn Dutch scholar Hugo Grotius's conception of natural law?