A major controversy arose around third- and fourth-generation pills in late 2012 and early 2013, which led to the end of their reimbursement by the French national health insurance system in March 2013. What were the consequences of the controversy for the contraceptive model in France? Analysing the Fecond survey, carried out a few months later, the authors examine recent changes in contraceptive practices and the contribution of the media debate to these changes.
1 Third- and fourth-generation contraceptive pills were the subject of a media debate in France in December 2012 that focused on the risk of deep venous thrombosis associated with their use (Box 1), and in March 2013, the French national health insurance system stopped reimbursing these contraceptives. The Fecond survey (Box 2) offers an opportunity to study the impact of these events on contraceptive use and on the representations of the pill, through a comparison between the situation before their safety was brought into question (in 2010) and the situation a few months later. Trends that began before the media debate – notably the decline in pill use observed since the mid 2000s [1] – were reinforced, and new social inequalities in contraceptive use appeared. This controversy seems to have introduced more flexibility in a contraceptive model strongly centred on the pill, at a time when many women were already pointing up the constraints of daily pill-taking.
A new contraceptive landscape
2 No general decrease in the use of contraception was observed after the pill scare among women in need of contraception, i.e. who are neither sterile nor pregnant, who are engaging in heterosexual intercourse and do not want a child – only 3% were not using contraception in 2013, the same proportion as in 2010. The methods used to avoid pregnancy have changed, however. Nearly one in five women reported having changed methods since the 2012-2013 media debate on the pill. Use of the pill fell from 50% to 41% between 2010 and 2013, continuing the trend observed between the mid- 2000s and 2010 when use fell by 5 percentage points. In the space of a decade, oral contraceptive use in France decreased by 14 percentage points. The drop since2010,more marked than in previous years, seems to be related to the 2012-2013 controversy: it concerns almost exclusively types of pills that were targeted in the debate, the so-called third- and fourth-generation pills, which in 2013 accounted for 10% of the contraceptive methods used, versus 19% in 2010. Whereas 40% of the pills used in 2010 were third- and fourth-generation (45% second-generation and 15% progestin-only), this proportion fell to 25% in 2013 (59% for second-generation pills and 16% for progestin-only pills). However, the debate also seems to have prompted a disaffection for the pill in all its forms: very few women switched to second-generation pills in this period (22% in 2010 and 23% in 2013). Rather, women turned to other methods of contraception, notably intrauterine devices (IUD) (+1.9 percentage points), condoms (+3.2 points), and other methods such as the calendar method (fertility awareness method) and withdrawal (+3.4 points) (Figure 1). While the pill remains the most widely used contraceptive in France, contraceptive patterns have become more diverse (Figure 2).
Box 1. The media debate of 2012-2013 on third- and fourth-generation pills
The Ministry of Health decided to halt reimbursement of third-and fourth-generation pills beginning on 31 March 2013, and to withdraw the pill Diane-35, an anti-acne treatment with contraceptive properties, in May 2013, although it was returned to the market in January 2014 at the request of the European Medicines Agency.
Changes in contraceptive methods used in France between 2010 and 2013 by women’s age
15 13
109 9
6
5 444 4
53 33 33
22 2
10 11012 1 1 0
0
– 1 0 –01 –1 –2 0 –1 –1 0
– 5 – 4 – 4– 2
– 7
– 10 – 9
– 15
– 16
– 20
– 20 – 21
– 25
15-19 20-24 25-29 30-39 40-49 Overall
Age group (years)
Changes in contraceptive methods used in France between 2010 and 2013 by women’s age
* implant, patch, vaginal ring**Withdrawal, periodic abstinence, local method
Interpretation: the proportion of women aged 25-29 using a third- or fourth- generation pill fell by 21 points between 2010 and 2013 (28% in 2010 and 7% in 2013).
Coverage: Women aged 15-49 living in metropolitan France who are not sterile or pregnant, who have heterosexual sexual relations and do not want to have a child.
3 Although this reconfiguration of the contraceptive landscape has led to increased use of less effective contraceptive methods (calendar method, withdrawal), it is unlikely to have generated a significant rise in unplanned pregnancies in the population as a whole. An increase could occur in certain subgroups, however, as the changes observed since 2010 have been socially differentiated.
A recomposition of social inequalities
4 Between 2010 and 2013, use of the pill decreased among women of all ages, but the decline was particularly marked among women under 30 years of age (Figure 1). Among women aged 15-19, the 20 percentage-point drop in use of third- and fourth-generation pills was partly offset by increased use of second-generation pills (+13points). The shift was less marked among women aged 25-29, who switched to IUDs – a method seldom offered to them before the debate – and condoms.
5 Compared with the other categories, a higher proportion of women with no educational qualifications abandoned recent pill types in favour of the least effective methods (calendar, withdrawal), whereas those with a lower secondary education preferred condoms, and those with higher levels of education (four or more years of higher education) preferred IUDs.
6 Women in higher-level occupations, who were previously the main users of third- and fourth-generation pills, replaced the pill with IUDs, and, in some cases, with “natura” methods (calendar, withdrawal), no doubt through disaffection for hormone-based contraceptives of all kinds. At the other end of the social hierarchy, female manual workers, who were initially less inclined to use the newer generation pills, did not change their contraceptive practices. Women in intermediate occupations and female technicians switched from third and fourth-generation pills to second-generation contraceptives and condoms; female clerical workers opted to use condoms.
7 More broadly, while a portion of women without financial difficulties switched from newer pills toward older oral contraceptives, some of those in a difficult financial situation switched to “natural” methods. This is the case notably of women born in sub-Saharan Africa, who substantially reduced their pill use (–39%), turning to natural methods instead (26% in 2013 versus 5% in 2010).
Contraceptive methods used in France in 2013 by women’s age
* implant, patch, vaginal ring**Withdrawal, periodic abstinence, local method
Coverage: Women aged 15-49 living in metropolitan France who are not sterile or pregnant, who have heterosexual sexual relations and do not want to have a child (i.e. 75% of all women aged 15-49).
A relaxing of the contraceptive norm
8 It is still too early to know whether health professionals are offering second-generation pills as a first contraceptive prescription, as recommended by the health authorities since early 2013. Note that the 2010 survey indicated that around one in two women had received a prescription for a third- or fourth-generation pill as their very first contraceptive pill.
9 But a sea-change has already occurred in IUD prescribing behaviour. French physicians, traditionally reluctant to propose IUDs to young or childless women, [2] seem to be adopting a new approach, partly due to demand from women themselves. Despite the recommendations issued by the French National Authority for Health (Haute Autorité de Santé) in 2004, the use of IUDs among young and childless women did not increase between 2000 and 2010. It did increase substantially between 2010 and 2013, however, with prevalence rising from 2% to 5% among women aged 20-24 and from 8% to 16% among women aged 25-29. In the latter group, this change occurred even among childless women (from 0.4% to 8%). Use of this method remains rare in these groups, but there has been an undeniable easing of the traditional contraceptive norm whereby use of different contraceptive methods is structured by age and number of children. This norm has not been totally overturned, however: no change has been observed in IUD use among women under 20, or among childless women aged 20-24. Perhaps health professionals, and possibly their female patients, remain reluctant to opt for IUDs because of the supposedly high risk of sexually transmitted infections at an age of greater sexual activity, and of the anticipated discomfort of IUD insertion for very young women. Yet the scientific literature shows that there is no contraindication to IUD insertion based on the woman’s age or parity [3].
A worsening image of the pill
10 The 2012-2013 debate around newer-generation pills and their related risks affected a population of users who had initiated sexual activity when the pill was already the linchpin of the French contraceptive model. But these younger cohorts are not so sensitive to the social and political significance of a contraceptive method that, for the first time in history, allowed women to control their own fertility. A look at the way the debate was received can shed some light on this partial disaffection for the pill.
11 The response to the debate was gendered and socially differentiated. In total, 77% of women and 56% of men said that they had heard about the media debate on contraceptive pills. This was true for a higher proportion of more educated individuals: 91% among the most highly educated women (more than four years of higher education) versus 63% of women with no educational qualifications (the corresponding figures for men were 76% and 42%). Members of more affluent social groups were more likely to have heard of the debate than those in the working class: 92% of women in higher-level occupations said they had heard about it, versus 67% of female manual workers (78% versus 45%, respectively, among men). This division may be related to the stability of the contraceptive practices of female manual workers mentioned above. The concerns expressed by different social groups also differed: the least educated women, fewer of whom use the newer generation pills, found that the information provided was clearer, but also more worrying than other women.
The Fecond survey was funded by INSERM, INED, the ANR and the DGS. The survey was conducted again in 2013 to analyse the impact of the media pill scare on contraceptive practices and representations. The questionnaire was administered to 4,453 women and 1,587 men. The second survey was funded by the Institut National de Prévention et d’Éducation pour la Santé (French National Institute for Prevention and Health Education (INPES).
The Fecond-2013 team consists of Nathalie Bajos and Caroline Moreau (principal investigators), Aline Bohet (coordinator), Géraldine Charrance, Stéphane Legleye, Mireille Le Guen, Henri Panjo, Nicolas Razafindratsima, and Mylène Rouzaud-Cornabas.
12 The debate also seems to have tarnished the social and symbolic image of the pill. In 2013, 37% of women “strongly agreed” with the idea that “the pill allows women to express their sexuality more fully”, versus 44% in 2010. The younger the women, the less likely they were to share this idea (from 32% among women aged 15-19 to 51% among women aged 45-49; 39% to 44% for men). Here too, there are differences between social groups: 34% of female manual workers, versus 47% of those in higher-level occupations, agreed with this idea (42% and 40% respectively among men). In contrast, the debate had no effect on negative representations of the pill: women were not more likely to cite its constraints or its supposed effects on the body in 2013 than in 2010 (around one in three women strongly agreed that the pill is burdensome, and one in four with the idea that it leads to weight gain).
13 The decline in pill use was more marked, however, among women who strongly agreed with the idea that the pill is burdensome (38% versus 6% among those who strongly disagreed with this assertion), as well as among those who believed that the pill causes weight gain. The media debate thus seems to have had a greater effect among women who used the pill but already had some reservations about doing so.
Towards a new contraceptive model?
14 The media and political events of 2012-2013 seem to have had a marked effect on the contraceptive landscape, although it is impossible to say whether this effect will last over time. The effects of the economic crisis on contraceptive practices, which were already noteworthy between 2000 and 2010 among women aged 20-24, now seem to have extended to the whole population. Today, the social groups facing the greatest insecurity have less effective contraceptive coverage, due to their lesser use of the pill and greater recourse to “natural” methods. Although second-generation pills are reimbursed by the French social security, as are IUDs and implants, and certain third-generation pills are now available in less costly generic forms, the increase in the cost of consulting a doctor may nevertheless pose a problem, notably for young women still covered by the parents’ health insurance scheme who want their contraceptive practice to remain confidential and do not want a medical consultation to appear on their parents’ health insurance records. Finally, it must be noted that condoms, one of the main methods of contraception at the start of sexual life, are still not reimbursed. The issue of free access to contraceptive methods – and hence of universal access to the most effective methods – is particularly relevant today.
15 Nonetheless, the survey findings show that this controversy had a considerable impact, especially by helping to reconsider a rigid, albeit not consensual, contraceptive model, leading to increasing diversity in contraceptive use patterns.
