1 On December 19th 1967, in response to a large demonstration by the French Family Planning Movement, the deputy Lucien Neuwirth persuaded the National Assembly to pass a law authorizing the sale and use of “anti-conceptional” methods in France. With the legalization of contraception, contraceptive practices in the French population gradually changed and the pill became the country’s most popular method of birth control. But France’s pill-centred model – which came in for criticism with the recent pill scare – is far from universal; contraceptive methods and their prevalence vary considerably from one country to another.

Contraceptive practices differ across the world

2 In some countries – for example, Burkina Faso, Iraq and Mozambique – less than 50% of women of childbearing age in a union use contraception, as opposed to 83% in France. While some do not need contraception because they are pregnant, seeking to become pregnant, or sterile, other women have little or no access to birth control.

3 Among women who use contraception (Figure 1) the world’s most widespread method is sterilization, performed more often on the bodies of women than on men ones’.

4 In Mexico, among women of childbearing age in a union who use contraception, 54% are either sterilized themselves or have a sterilized male partner; the corresponding figure for the United States in 2006 was 43%; for Brazil in 2013, 32% [1]. In 2006, 39% of women in China and 20% of women in Spain were using sterilization; in Turkey in 2008, the figure was 11%. In France, sterilization for contraceptive purposes, regulated under a law that was passed only in 2001, is a marginal contraceptive method because of the pronatalist national context: in 2010, only 5% of women in a union there had been sterilized.

5 Long-term contraceptive methods rank second after sterilization: they do not involve taking a pill every day or manipulating a device before each intercourse. In China (48%), the Palestinian territories (46%), and Ukraine (38%), the intrauterine device or IUD is the most frequently used long-term method. Women in Burkina Faso who use contraception more often turn to implants (45%).

6 Birth control pills are the third most widespread method in the world. Large proportions of women of childbearing age in a union were using the pill in Algeria in 2012 (75%), France in 2010 (50%), Brazil in 2013 (43%) and Iraq in 2006 (29%), but use is much lower in Mexico (4%) and China (1%).

Figure 1

Contraceptive usage in selected countries across the world

Contraceptive usage in selected countries across the world

Population: Women aged 15 or over in a cohabitating union and using a method of contraception. The countries were selected to show diversity of contraceptive models while ensuring data comparability (women’s conjugal status; age; sum of contraceptive methods = 100%).

7 The last method is hormonal injections [2]. While seldom used in France, their place in the world’s contraceptive landscape is considerable: 45% of women of childbearing age in union in Kenya used them in 2015, 44% in Mozambique in 2011, and 24% in Peru in 2014.

8 The case of Spain is an exception to the widespread understanding that women are in charge of contraception: so-called male methods (male sterilization, condoms and withdrawal) account for 53% of contraceptive use in that country, as opposed to 15% in France and 37% in the US. The diversity of contraceptive methods across the world can only be accounted for by analysing the historical and social contexts in which contraceptive use spreads. How did the pill became the most widespread method of contraception in France?

From contraception within the couple to medicalized contraception managed by women

9 Practices for controlling fertility have existed for many centuries. We find references to techniques such as pessaries and supposedly spermicidal products for limiting the number of births in Ancient Greek and Roman writings, most of the time in medical texts. Those methods were not widely used, however, as only the most privileged social groups expressed the desire to reduce their numbers of offspring.

10 During the eighteenth century, reproductive behaviours radically changed in France. A considerable share of the many couples seeking to control their family size began using the withdrawal method – this was the “first contraceptive revolution” [2]. The result was that French birth rates began falling sharply, contrary to the situation in neighbouring countries where fertility remained high for another century. French political authorities, population experts, doctors and some writers of the time expressed concern about the phenomenon. The country’s defeat to Prussia in 1871, followed by the massive loss of life during World War I, gave weight to pro-birth discourses calling for the “repopulation” of France. The fear of “French depopulation” reached its peak on July 31th 1920, when National Assembly passed a law prohibiting pro-contraception propaganda and the sale of anti-conceptional devices.

11 Despite this prohibition, many contraceptive techniques circulated in France after 1920. Couples continued to use withdrawal, the most widely used method in France up until the 1970s. Condoms, appreciated for prophylactic reasons, were never taken off the market. Several barrier methods (for example the diaphragm) and hormonal preparations were prescribed “therapeutically” for women whose lives would be threatened if they became pregnant. The birth control pill developed in the United States of America in the 1950s arrived on European markets in 1961 and was at first prescribed to regulate women’s menstrual cycles. Later in the 1960s, physicians in favour of birth control introduced the IUD in France; the same physicians also participated in French Family Planning Movement demonstrations demanding the legalization of birth control.

12 On December 19th 1967, the National Assembly adopted Lucien Neuwirth’s law legalizing contraception [3]. In the 1970s, “modern” methods – that is, medical methods that are highly effective if properly used– were gradually adopted throughout the French population; this was the “second contraceptive revolution” [2]. Because the pill enabled women to manage their fertility effectively and on their own, it became a symbol of female emancipation and sexual liberation. The French contraceptive landscape began to change (Figure 2) [4]. While older women continued to use withdrawal, the younger generations turned massively to the pill and the IUD, both of which required a medical prescription. Contraceptive choices were no longer confined to the private sphere of intimate relationships; they could now be discussed in the physician’s office. The relationship between a woman and her gynaecologist now became more important in matters of contraception than her relationship with sexual partners. In the 1980s, the pill and the IUD became France’s most widely used birth control methods. Oral contraception soon pulled ahead, however, in response to French physicians’ reluctance to prescribe IUDs to women who had never had a child.

13 The HIV epidemic in the 1980s complexified the French contraceptive model, already centred on the pill, by legitimazing male use of condoms as a mean of preventing sexually transmitted diseases (STDs). In this context, condoms enjoyed renewed popularity as a method of contraception. Condoms were most frequently used in early sexual life and are often combined with oral contraception for dual protection against pregnancy and infection.

14 In the 2000s, the patch, ring and implant arrived on the French contraception market, diversifying the hormonal methods available to women. Designed as alternatives to the daily constraint of taking the pill, those methods none the less accounted for no more than 5% of contraception use in France in 2010.

15 In the fifty years since the legalization of contraception in France, the types of methods used have radically changed. By legalizing access to “anti-conceptional” methods, the Neuwirth law paved the way for the diffusion of the pill and IUD and for the medicalization of contraception. From “traditional” contraception practiced privately within the couple, the French shifted to a model of medical contraception managed by women themselves. Once illegal and illegitimate, the use of contraceptive methods now follows a set of implicit rules: condom during sexual debut, the pill in a stable relationship, and the IUD once the desired number of children has been reached – this is the French “contraceptive norm” [4] [5]. Given that this norm prompts women to use a certain contraceptive method for each age and relationship status, it can be said to prevent them from choosing their preferred type of contraception. It also reinforces the notion that contraception is primarily –not to say entirely – women’s responsibility.

Figure 2

Methods of contraception used in France, 1968 to 2013

Methods of contraception used in France, 1968 to 2013

* implant, patch, vaginal ring
** periodic abstinence, local methods, other, don’t know
*** respondent or her partner
Population: Women aged 18-44 living in metropolitan France, using or not using a contraceptive method, not sterilized or pregnant, sexually active and not wishing to conceive.

The “pill scare”: calling the French contraceptive norm into question?

16 In 2012, after the media covered a lawsuit brought by a young stroke victim who blamed the new generation oral contraception for her condition, France experienced a “pill scare”. From 2010 to 2013, birth control pill use fell by 18% [3]. The trend seemed a lasting one, as use of oral contraception continued to fall (by almost 9%) from 2013 to 2016, though it is still the most widely used method in France [5]. Decline in pill use seems to vary by social category: privileged women have switched to the IUD while the less privileged tend to turn to condoms or withdrawal. The pill scare amounts less to a health crisis than to a change in the social image of oral contraception over the generations [3]: young women are less likely than their elders to think of the pill as liberating. While, on average, women are not more likely now than before to think of it as a constraint, those who did find it so were the first to stop using it. The controversy around birth control pills seems to have galvanized reluctant pill users to change methods. It may therefore have facilitated a new kind of relationship between women and health care professionals, in which the emphasis is now on informing women patients and taking their preferences into account.

17 Last, the pill scare has provided an opportunity to probe the question of men’s responsibility regarding contraception. Not only does the French contraceptive norm limit women’s choice of method, but according to that norm, the mental and material burden of managing the couple’s fertility falls primarily on the woman. Should women alone have to bear contraceptive responsibility and the undesirable side effects associated with some methods? Though men too have benefited from improved fertility control, it is as if they had no role to play, and there are few specifically male birth control methods [6]. Meanwhile, men who show interest in using these methods are perceived as suspect [7] given how fully contraception has come to be considered a woman’s affair in France – a radical change in only fifty years’ time. While access to contraception and, at a later date, abortion, enabled women in France to assert their right to control their own bodies and freed them from an exclusively maternal role, the country may now be moving toward a new stage, involving more egalitarian sharing of contraceptive responsibility. As France celebrates the fiftieth anniversary of the Neuwirth law, which opened the way for the massive spread of contraceptive use, French men and women seem increasingly ready to call into question the medicalization and feminization that accompanied that change.