Celebrating the 50th anniversary of the NP role coincides with the 50th anniversary of the U.S. Supreme Court decision of Griswold v. Connecticut. This ruling overturned a Connecticut law making it a crime for any person to use any drug or article to prevent contraception. The court held that the law violated the right of marital privacy.1 Seven years later in 1972, the court ruled in Eisenstadt v. Baird that unmarried persons also had the right to access contraception.2
Two generations later, how many NPs recall these landmark decisions? And how many NPs know how the oral contraceptive, a drug that revolutionized women's healthcare and lives, was developed?
Two excellent books chronicle the work of four activists whose tireless efforts resulted in this modern miracle. The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution by Jonathan Eig, published in 2014, details the decades long work of Margaret Sanger, Katharine McCormick, Gregory Pincus, and John Rock.3The Pill: A Biography of the Drug that Changed the World, written by Bernard Asbell and published in 1995, covers much of the same content and also examines the sociopolitical consequences of a medication that neither prevents nor cures an illness.4
The context for the development of the pill is carefully portrayed in these books through the voices of women whose lives were controlled by their fertility. Multiple pregnancies and births with little spacing contributed to poor maternal and child health. In many large families, children starved; mothers died in childbirth or from botched abortions. While Sanger wanted women to be able to control fertility and enjoy sex, she was pragmatic enough to understand the mores of the day. She focused on the need for "birth control," eventually replaced by the term "family planning".
Improving women's lives
A founder of Planned Parenthood Federation of America, Sanger was an unabashed advocate, sometimes to the point of alienating her own supporters. She was fueled by passion to improve the lives of women and their families. An interesting tidbit in Eig's book is Connecticut businessman Prescott S. Bush, a father and grandfather to Presidents Bush, served as treasurer for Planned Parenthood's initial national fundraising campaign in 1947.
McCormick's personal fortune supported Pincus' research and development, an unprecedented $2 million private pharmaceutical venture. A 1904 graduate of the Massachusetts Institute of Technology, McCormick was an active member and vice president of the National American Woman Suffrage Association and also served as vice president of the League of Women Voters. She and Sanger began a long-term collaboration in 1921 by planning the first American Birth Control Conference.3 The two sought out and promoted Pincus, a Cornell University undergraduate with a graduate degree from Harvard where he had a brief career prior to joining the Worcester Foundation for Experimental Biology.
Pincus was a visionary who believed in the possibility of an oral contraceptive. An unconventional scientist, Pincus spent a decade testing different methods to achieve oral contraception with the least possible adverse reactions. He collaborated with John Rock, a highly-respected obstetrician and gynecologist from Boston. Puerto Rico was selected for clinical trials for many reasons, including having no laws against contraception, a network of birth control clinics, and many clinicians educated in the United States. A devout Catholic, Rock used science to educate people on the benefits of birth control and tried unsuccessfully to persuade the Catholic Church that the oral contraceptive should be endorsed rather than banned.3
Pincus and Rock contended with the competition of other scientists and pharmaceutical companies also attempting to produce a contraceptive pill. They succeeded first with assistance from the pharmaceutical company Searle. Enovid was approved by the FDA in 1957 for menstrual disorders and infertility. Three years later, the FDA approved Enovid for birth control.3
Contraceptive usage
Where are we today? In the United States alone, nearly 10 million women used oral contraceptives in 2012.5 Worldwide, it is estimated that more than 100 million women use oral contraceptives with rates varying by country, age, and education.6 California and Oregon have passed laws authorizing pharmacists to dispense hormonal contraception without a prescription following a health screening. California has no age restriction, while Oregon's law applies to women 18 or older.7
Nonetheless, access to contraception is not universal. According to the Center for Reproductive Rights, half of the six million pregnancies in the United States each year are unintended, and funding for Title X low-cost family planning services is 61% lower in constant dollars than in 1980.8 There have been over 100 court cases filed to challenge the Affordable Care Act requirement for health plans to provide contraception without a co-payment. While the cases are primarily initiated by religious groups, the U.S. Supreme Court ruled on a for-profit employer suit in the 2014 case Burwell v. Hobby Lobby Stores Inc. The court decided a closely-held corporation can refuse to comply with the federal law based on the owners' religious beliefs.9
The health benefits of contraception are well documented. A woman's ability to delay, plan, and space children leads to earlier and more sustained prenatal care and a higher likelihood of breastfeeding; improved birth outcomes; reduced maternal and infant morbidity and mortality; and increased likelihood the father will be engaged in the pregnancy and birth. There are also socioeconomic benefits for the family.10
I encourage you to read either or both of these books to learn about the challenging scientific and social endeavor to create the oral contraceptive. As we celebrate the 50th anniversaries of the birth of the NP program and the overturn of a law preventing access to contraception, consider emulating nurses such as Margaret Sanger. Fearless, tireless, and passionate, she was a human with flaws who never let them stand in the way of improving the lives of women and their families. As NPs, we owe the same to our patients today. Honor the past by keeping the spirits of Sanger, McCormick, Pincus, and Rock alive through advocacy.
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