Thirty-five years ago this month, the introduction of the birth-control pill promised unprecedented sexual freedom and personal choice for American women.
The pill became a catalyst for both the sexual revolution and the women's liberation movement. It promised to end unwanted, unplanned pregnancy and give women ultimate control over the decision to bear children.
But 35 years after the Food and Drug Administration approved the world's first oral contraceptive, the issue of birth control remains complex and resistant to simple solutions.
Teen pregnancy rates are staggering, and unplanned pregnancies abound. And the ever-troubled relationship between America's family-planning efforts and conservative views of sexuality grows worse.
"What our data shows is that it remains hard not to get pregnant, because biology is very powerful," said Sarah S. Brown, who was senior director of a recent study by the National Academy of Sciences' Institute of Medicine. "You can't glean from this study that the pill is a panacea, but it remains one of the most effective, safe methods around."
An estimated 10 million American women under 45 take the pill, and when used correctly, it's 99 percent effective in preventing pregnancy. But some poor women lack easy access to the pill. Many other women shun it, fearing negative side effects. Even among pill users, the percentage of those who can't or won't use it correctly is rising.
Despite these paradoxes, few dispute the pill's indelible imprint on America's consciousness.
"More than any other factor, it was responsible for the entry of women into the social and economic scene of this country," said Pamela Maraldo, president of Planned Parenthood Federation of America Inc. in New York. "It brought the hope of full participation in the marketplace and in social settings, for women to come and go as they pleased without the intrusion of unplanned pregnancy and childbirth."
For millions of female baby boomers, the decision to delay motherhood and pursue careers changed the face of the American workplace. Women weren't merely choosing when to get married and have children but were debating if they even wanted to start families, given the expanding options they enjoyed.
Among those options was the freedom to explore their sexuality, without having a baby as a byproduct. Though many women reveled in that freedom, other sectors of society saw the pill as contributing to a sharp decline in morality.
"There's no question that the pill has been a contributor to the breakdown of sexual ethics in society," said the Rev. Robert M. Friday, vice president for student life at Catholic University in Washington. Rev. Friday, who teaches moral theology, said contraceptives such as the pill allow people to trivialize sexuality. Birth control biologically frees up people to engage in sex at a whim but doesn't engage them any further.
The pill was the first high-tech form of birth control. It contains synthetically produced hormones similar to the ones that regulate the menstrual cycle, and prevents ovaries from releasing eggs into the uterus where they might be fertilized.
The rules are clear for those who want to avoid pregnancy: If you're sexually active, you should take the pill every day at the same time. If you skip a few days, or a few weeks, the risk of pregnancy rises.
But the evidence shows that many women either aren't using contraceptives properly or are dealing with consequences of contraceptive failure.
The Institute of Medicine study directed by Dr. Brown revealed that women using reversible contraception, such as the pill, the condom and the diaphragm, experience half of all unintended pregnancies.
Between 1982 and 1988, the rate of women reporting pregnancies after pill usage increased from 6.2 percent to 8.3 percent. By 1993, half of the 1.5 million abortions performed in America were for women whose contraceptive method failed.
Studies show that sexually active American teen-age girls report using the pill more often than other forms of contraception, but they are the most likely to skip days of taking it.
Not every woman can take the pill. Smokers over age 35 or women with high blood pressure or heart problems are advised against it.
But the American College of Obstetricians and Gynecologists thinks that if more women knew about potential health benefits of pill usage, they would give it another look.
"Research shows that the pill protects women against certain cancers," said Dr. William C. Andrews, president of the American College of Obstetricians and Gynecologists. "It is far safer today than it was in the early 1960s, when it had nearly four times the amount of estrogen and nearly 10 times the amount of progestin as it does now."
Those high levels of hormones caused blood clots in the lungs of some women, Dr. Andrews said. Today, that risk is negligible.
Pill usage lowers a woman's risk of ovarian cancer by 40 percent, Dr. Andrews said, and cuts her risk of endometrial cancer in half. Furthermore, the pill helps prevent conditions like pelvic inflammatory disease and ectopic pregnancy.
But researchers are aware that in today's tense sexual atmosphere, any contraception that doesn't also help prevent sexually transmitted disease may border on irrelevancy.
"As awkward as it may sound, today it makes sense to use two forms of contraception," the Institute of Medicine's Dr. Brown said. "Women should insist on condom use as well as the birth-control method of their choice."