Contraception: Freedom from Fear

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roads into remote parts of Winston and Walker counties. "Most of the women there," says Dr. Bolding, "don't have the 250 bus fare to get to a stationary clinic, and some don't have the motivation. We're taking this service to the people who need it—to the women with twelve children who don't want any more." Most of these women choose lUDs; some get a supply of pills sufficient to last them until the van's next visit.

Memory in Plastic. The pills might never have had such an impact and acceptance if research on lUDs had been pursued more vigorously. The lUD's underlying principle traces back to an old practice of Arab cameleers: putting a round, smooth stone in the womb of a female camel at the start of a long trade journey, to avoid the economic loss of having the animal get pregnant. In the 1920s, Berlin Gynecologist Ernst Grafenberg transmuted the Arabs' camel stone into a ring of surgical silk or silver, gentle enough for the human womb. But this was in pre-antibiotic days; many women developed severe infections. Except in a few foreign medical centers, the 1UD was neglected. When the pill was proving itself, several inventive Americans took up the lUDea and devised vastly improved models. Most of them are now made of plastic with a built-in "memory," so that the device can be straightened for easy insertion but will resume its desired shape in the womb.

From Dr. Jack Lippes' labs in Buffalo came a series of doubleS designs, now known as the Lippes loop, which has probably the widest acceptance both in the U.S. (150,000 users) and overseas (up to 4,000,000). Manhattan's Dr. Lazar C. Margulies devised a spiral; Brooklyn's Dr. Charles Birnberg, a bow; Kentucky's Dr. Ralph Robinson, a twin-spiral "safety coil"; and Brooklyn's Dr. Gregory Majzlin, a wire formation that looks like a bunch of paper clips. How the lUDs work is uncertain. Dr. Margulies believes that it is by speeding the ovum through the Fallopian tubes too fast for it to be fertilized, because of intensified muscle contractions.

lUDs must be inserted by a physician or highly trained nurse-technician. A non-expert can easily push one through the wall of the uterus, and the U.S. armed forces have decided not to use them, for lack of doctors skilled in this procedure. There are other drawbacks. It is difficult to fit an IUD for a woman who has never had a child, because the cervical orifice is too small. Even with women who have had children, anywhere from 10% to 15% expel the device by uterine contractions—in many cases without knowing that they have done so until they become pregnant. The IUD "failure" (meaning pregnancy) rate in the first year of use is about 3%, dropping to 2% thereafter.

"With its higher failure rate," says Dr. Alan Guttmacher, president of Planned Parenthood-World Population, "the IUD may not be good enough for your wife, but it may still be good enough for a public-health program in a developing country." And it is in just such places that the IUD is mainly being used—Taiwan, Ceylon, India and Mexico.

Elite Planning. Even in areas where poverty and population pressure are greatest, the pill is beginning to crowd the IUD. Dr. Rice-Wray, now in Mexico City, pooh-poohs the idea that poor, illiterate women cannot learn to take pills

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