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Population Contraception in France: An Assessment After 30 Years of Liberalization (Population, 4, 1998) C.

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De Guibert-Lantoine C., Leridon Henri. Contraception in France: An Assessment After 30 Years of Liberalization (Population, 4, 1998). In: Population, an English selection, 11année, n°1, 1999. pp. 89-113.

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n°1, 1999. pp. 89-113. http://www.persee.fr/doc/pop_0032-4663_1999_hos_11_1_6981 Document généré le 17/10/2015

Résumé

Guibert-Lantoine (Catherine de), Leridon (Henri).- La contraception en France : un bilan après 30 ans de libéralisation La contraception a été légalisée en France par une loi adoptée fin 1967. La diffusion des méthodes contraceptives, notamment la progression de la pilule, s'est ensuite faite rapidement. La dernière enquête réalisée en 1994 (Ined/Insee) permet de faire le point sur les pratiques contraceptives. La contraception est généralisée à tous les âges : moins de 5 % de femmes prennent le risque d'une grossesse non désirée. On observe une forte progression, dans les générations successives, de la pratique contraceptive lors des premiers rapports sexuels. La contraception est aujourd'hui essentiellement féminine et médicale : la pilule s'est imposée, en particulier chez les plus jeunes ; le stérilet apparaît comme la méthode relais après la constitution de la famille; la stérilisation contraceptive n'occupe qu'une place modeste, réservée à la fin de la vie féconde ; les méthodes traditionnelles sont maintenant marginales ; l'usage du préservatif masculin est en progression, surtout chez les jeunes et les personnes seules, souvent utilisé en complément de la pilule, car il est un moyen de contraception autant que de prévention des maladies sexuellement transmissibles.

Abstract

Guibert-Lantoine (Catherine de), Leridon (Henri).- Contraception in France: An Assessment After 30 Years of Liberalization Contraception was legalized in France by a law adopted at the end of 1967. Contraceptive methods, in particular the pill, then spread rapidly. The most recent survey, conducted in 1994 (INED/INSEE), provides material to review the current state of contraceptive practices. Contraception is now practiced at all ages: less than 5% of women are exposed to the risk of an unwanted pregnancy. Contraceptive use in first sexual intercourse is observed to have increased greatly over successive generations. Contraception today is practiced mainly by women and takes a medical form: use of the pill has become widespread, particularly among young people; the IUD appears as the follow-on method once the family has been formed; traditional methods are now marginal; use of the condom is on the increase, particularly among young people and single people, for whom it is often used in conjunction with the pill, being both a means of contraception and a protection against sexually transmitted diseases.

Resumen

Guibert-Lantoine (Catherine de), Leridon (Henri).- La anticoncepción en Francia : balance a los 30 aňos de su liberalización Los anticonceptivos se legalizaron en Francia a partir de una ley aprobada a finales de 1967. La difusión de métodos anticonceptivos, y especialmente la expansion del uso de la píldora, fue rápida a partir de este momento. La ultima encuesta, realizada en 1994 (Ined/Insee) permite analizar las prácticas anticonceptivas. El uso de anticonceptivos se ha generalizado en todas las edades : menos del 5 % de las mujeres se arriesga a un embarazo no deseado. A través de generaciones sucesivas, se observa un fuerte aumento del uso de anticonceptivos en el momento de las primeras rela- ciones sexuales. Actualmente, la anticoncepción es esencialmente femenina y médica : la píldora se ha impuesto particularmente entre los más jóvenes ; el DIU aparece como método de relevo después de la constitución de la familia ; la esterilización es poco común, y su uso se limita al final de la vida fecunda ; el uso de métodos tradicionales es marginal ; la utilización del preservative masculino esta aumentando, especialmente entre los jóvenes y las personas solas, y a menudo se utiliza como complemento de la píldora ya que es tanto un método anti- conceptivo como una forma de protección contra las enfermedades de transmisión sexual.

ya que es tanto un método anti- conceptivo como una forma de protección contra las enfermedades

CONTRACEPTION IN FRANCE

An Assessment After 30 Years of Liberalization

Catherine de GUIBERT-LANTOINE* and Henri LERIDON*

Contraception was legalized in France by an Act passed in late 1967. A spate of bills were tabled, but it was that sponsored by Lucien Neuwirth, with the backing of the then President of the Republic (Charles de Gaulle) and Prime Minister (Georges Pompidou) which made it onto the statute book. After a stormy public debate and a rough passage through both

houses of parliament, the Act of December 28,

in tight check: no social security refunds, parental consent required for minors (under 21 years of age), doctors required to keep 'counterfoil books' and pharmacists 'log books' to keep track of contraceptive pill

prescriptions

to implement it effectively. The first such decree (on the manufacture,

import and sale of contraceptives,

which in the event were never distributed) was not enacted until February

3, 1969, and the subsequent ones in

coils), and April 24 (family planning and information centres). Finally, in December 1974, a new Act was added to the existing array just ahead of the vote initiated by Simone Veil on the Medical Termination of Pregnancy Act: the Act of December 4 allowed the cost of medical treatment and contraceptive drugs to be claimed back from social security, free prescriptions without parental consent for "minors wishing to preserve

in July

1972: March 7 (conditions for fitting

1967

still kept contraception

As with most statutes, a series of detailed regulations were required

and introducing the 'counterfoil books'

confidentiality" (the statutory age of majority having been lowered to 18

1974), and the opening of a "family planning or education centre" in every maternity and child welfare centre (for a more detailed background, see Leridon et al, 1987).

The existing legal set-up, therefore, dates only from late 1974. But in the real world, uptake of the new contraceptive methods (chiefly the

to start. By the time of the Neuwirth Act, a

pill)

significant proportion of Frenchwomen (4% of 15-49 year-olds) were on the pill, which was already available on prescription from some doctors

did not wait on

the law

* Institut National d'Études Démographiques. Translated by Glenn D. Robertson.

Population: An English Selection, 11, 1999, 89-114

90

С. de GUIBERT-LANTOINE, H. LERIDON

'to regulate periods' - the only grounds on which these hormonal drugs were granted marketing clearance. Between 1968 and 1972, the rate of

uptake increased, despite the lack of regulations. It will be seen below that pill use rose particularly sharply from 1970 to 1976. Latterly, it has

more or less levelled

virtually peaked; IUD use has declined somewhat, and the other methods barely feature at all - except for the condom, of which more later. The rise of AIDS in the 1980s has had no significant effect on contraceptive practices, apart from condom use.

Assessments being the order of the day, it may be relevant to consider how some of the expert forecasts made in the 1960s have panned out. In

1956, the INED published a group study on 'birth-control in France', which considered the prospective birthrate impact of the emergence and licensing of new contraceptive methods significantly more effective than those then

available (INED, 1956); bear in mind that the pill had been 'invented'

by

Gregory Pincus in 1951, and was first tested out -in Puerto Rico- only

in 1956, before being put on the United States market in 1961. The authors predicted two key results: a sharp decline in the number of unwanted births, and a scaling-down of the number of children wanted; the two combined could reduce fertility to below-replacement level (2.1 children). In 1966,

published another report on the same topic, at the request of

the High Consultative Committee on Population and the Family (INED, 1966). This time, such a sharp decline in replacement fertility was thought likely only if the overwhelming majority of couples used a 100% effective method; at 50% use, the decline was estimated at between 5 and 10%. However, between the 1935 birth cohort (which had most of its children between 1960 and 1970, at the end of the baby-boom, before the new contraceptives became available) and the 1950 birth cohort (post- Act children born between 1975 and 1985), completed fertility fell from 2.6 to 2.1: a relative decline of nearly 20% to the generation replacement level in the space of fifteen-odd years. By 1988, use of the most effective contraceptive methods (pill, IUD and sterilization) had spread to 57% of all 20-44 year-old women, i.e., close to 80% of women users at the survey date. The 1966 forecast, therefore, was ail-but borne out, even though the methods available were not yet 100% effective(1) -probably about 99% on average for the pill and IUD, allowing for the possibility of abortion in cases of failure. The two effects hypothesized in the 1956 article were borne out in broadly equal proportions: about half the fertility decline was attributable to the fall in the number of unwanted births, and half to a reduction in the number of wanted children (Leridon, 1985).

the INED

off: the increase

in pill

use

is now

slight and has

(1' Contraceptive method effectiveness is equal to the ones complement of the ratio of the monthly risk of conception when the method is used to the monthly risk when it is not, often expressed as a percentage. A 99%-effective method will give approximately 3 to 4 pregnancies per 100 woman-years.

CONTRACEPTION IN FRANCE

9 1

The upheaval in French contraceptive practices thus had a discernible population impact within the space of the fifteen years from 1965 to 1980. On top of that, the two effects observed (fewer unwanted births and wanted children) are just two aspects of the same underlying trend: the aim to exert more control over one's fertility. This was what stood behind the passing of the Neuwirth Act, which expanded the ambit of personal

freedoms, particularly for women. To this extent, the Act is not 'responsible' for the subsequent fertility trend: it merely addressed a ground swell of demand, amply borne out by subsequent attitudinal behaviours: the new

Act was welcomed by 70%

consistently heads the list of things 'which most changed women's lives' in the past quarter- or half-century (cf Leridon et al., 1987). This article will now review contraceptive practices from the most recent survey findings (INED-INSEE, 1994) and the previous surveys of 1978 and 1988 (see Appendix). Other more recent data, not least the sales figures for contraceptive pills, suggest that the situation has changed little since 1994.

of the population in

1976,

and the pill

I. - Widespread, medically-provided contraception

Contraception is mainly medically provided to women today. A doctor must be consulted for the prescription or use of the pill or IUD (intra- uterine device). Non-medical, traditional methods - abstinence (periodic abstinence, basal body temperature method), withdrawal and vaginal

methods (diaphragm, creams, jellies, suppositories,

by the wayside. Only male condom use is rising, since it also addresses other concerns. Reversible contraceptive methods are still the order of the day in France - contraceptive sterilization is little used.

The behaviour of women users and their male partner if any will first be examined, followed by the practices of lone men. Table 1 shows

contraceptive practice for all women of reproductive age, from 20-49 years

of age

used at the survey date: where several methods are used at once, the primary method is determined by the method hierarchy given in Table 1 , which ranks those used mid-cycle (i.e. most effective) higher, and local/vaginal methods (especially condom use) lower (combinations of methods will be dealt with below). Table 2 shows the trend of practices since 1978 using the same method hierarchy; note that comparison between the 1978, 1988 and 1994 surveys is possible only for women aged 20-44.

1994 survey, according to the primary method

)-

have largely fallen

at

the

time

of the

92

Age at 1.1.1994

Year of birth

С. de GUIBERT-LANTOINE, H. LERIDON

Table 1 . - Primary contraceptive method used in 1994 for 100 women in each age group

20-24

25-29

30-34

35-39

40-44

45-49

1969-

1964-

1959-

1954-

1949-

1944-

1973

1968

1963

1958

1953

1948

68.8

67.9

67.3

69.7

64.7

45.5

58.6

50.3

41.0

31.2

20.3

14.5

2.9

7.7

15.0

27.3

25.5

17.6

2.3

2.1

3.6

3.5

7.8

5.6

4.0

5.3

4.7

5.3

3.7

4.0

0.3

0.1

0.7

0.2

1.2

1.1

0.7

2.4

2.2

1.8

5.1

2.2

0.0

0.0

0.1

0.4

1.1

0.6

0.6

0.5

1.6

5.2

7.0

11.9

0.6

0.5

1.6

5.2

6.9

10.7

0.0

0.0

0.0

0.0

0.1

1.2

30.6

31.7

31.1

25.1

28.3

42.6

0.0

0.0

0.0

1.4

5.9

10.1

0.4

0.7

2.5

3.0

6.1

16.6

3.6

11.4

7.1

3.0

0.2

0.0

2.9

8.5

7.6

3.2

1.1

0.0

21.3

7.6

8.6

10.0

9.0

10.5

1.7

3.4

1.9

1.1

0.7

0.0

0.8

0.1

3.4

3.5

5.4

5.3

100.0

100.0

100.0

100.0

100.0

100.0

2 088

2 125

2 170

2 139

2 140

1874

496

519

548

563

470

348

All

All

20-49

20-44

1944-

1949-

1973

1973

64.3

67.7

36.3

40.2

16.0

15.8

4.1

3.9

4.5

4.6

0.6

0.5

2.4

2.4

0.4

0.3

4.3

3.0

4.1

3.0

0.2

0.0

31.3

29.4

2.8

1.5

4.7

2.6

4.3

5.1

4.0

4.7

11.1

11.3

1.5

1.7

3.0

2.6

100.0

100.0

12 536

10 662

2 944

2 596

Proportion of women :

Currently using contraception inc. Pill IUD Periodic abstinence Condom Local female methods Withdrawal Other, not specified Sterilized (for contraception) Woman Partner (male) Not using any contraception inc. Sterilized3 Sterile Pregnant Seeking pregnancy No current partner

Want another child Do not want further children

All

Population(OOOs) Survey population

Source: INED, Enquête sur les situations familiale et l'emploi, (Family and Labour Survey), March 1994. Women aged 20 to 49. Read as: 58.6 % of women aged 20 to 24 were taking the pill at the survey date. In case of multiple responses, the primary method was determined according to the hierarchy:

sterilization followed by reversible methods in the table order. a : Sterilization on medical grounds (almost exclusively female sterilization). : Includes "don't knows".

Widespread female contraception from the start of reproductive life

More than two in three Frenchwomen aged 20-49 use contraception

- 68.6% if contraceptive sterilization is included. But this is not to say

that most

pregnancy: 7.5% could not have children -2.8% as a result of medical

at risk of unwanted

of the non-users at the survey date

were

CONTRACEPTION IN FRANCE

93

Table 2. -Primary contraceptive method in 1978, 1988, 1994 for 100 women aged 20-44

Survey Year

1978

1933-1957

1988 1994

Year of birth Proportion of women:

Currently using contraception inc. Pill IUD Periodic abstinence Condom Withdrawal Other methodsa

Sterilized (for contraception) Woman Partner (male) Not using any contraception inc. Sterilizedb Sterile Pregnant No partner

1943-1967

1949-1973

67.8

67.8

67.7

28.3

33.8

40.2

 

8.6

18.9

15.8

5.5

5.0

3.9

5.1

3.4

4.6

18.0

4.8

2.4

2.1

1.8

0.8

4.1

4.2

3.0

4.1

3.9

3.0

0.0

0.3

0.0

28.5

28.2

29.4

 

3.2

1.8

1.5

1.4

2.8

2.6

4.8

5.4

5.1

9.1

9.9

11.3

6.3

6.6

6.4

3.7

1.7

2.6

100.0

100.0

100.0

8

899

10 177

10 662

2

982

2 666

2 596

Want another child0 Do not want further children All Population (000s) Survey population

INED, Enquête mondiale de fécondité, 1978 (Leridon, 1987). INED, Enquête régulation des naissances, 1988 (Toulemon, 1991).

INED,a LocalEnquêtefemale methods,sur les situationsor methodfamilialesnot specified.et l'emploi, March 1994.

c

On medical grounds only.

Now or later, includes "don't knows".

sterilization, 4.7% due to being sterile or past (at least presumptively) childbearing age; this relates mainly to women aged 45-49, more than one in four of whom consider themselves sterile. Also, among all women of reproductive age, 8.3% had other reasons not to use contraception: 4.3% were pregnant and 4.0% seeking pregnancy; this even includes 15 to 20% of young women aged 25-35. Finally, one woman in ten had no current partner or at least reported having "little or no sexual intercourse"; this was mostly young women, and almost exclusively women not in a partner

relationship (but that applies to only one third of lone women). That leaves

of

unwanted pregnancy - one in three of whom wanted more children: only

just 4.5% of women not in any of the above categories -i.e.,

at risk

94

С. de GUIBERT-LANTOINE, H. LERIDON

3% of these wanted no more children. Contraceptive protection can be said to be almost total, therefore, at an average 97%: it is maximum among young women and about 95% among the 40-plus group.

Who are these 4.5% presumptive risk-takers? Under 30, they mainly run the risk of earlier-than-planned childbearing. Above 30, they are mainly women who report being finished with childbearing: 3% of 30-39 year-olds and 5% of 40-49 year-olds; a significant number of these, however, are not at risk of pregnancy, either because they are not living with a partner, or because they are at the end of their reproductive life, have lower fertility and less frequent sexual intercourse. Contraception, then, can be said to be widely practised in France. This is not a new phenomenon - there was already a 68% contraceptive prevalence rate among women aged 20-44 in 1978 and 1988. It is among young people that contraceptive prevalence has increased most since the

up

when

fewer than 10% of women aged 20-44 were exposed to the risk of unwanted pregnancy; the proportion decreased slightly (8.3% in 1988) to level off at 9% in 1994. Of the 6% of non-contraceptors who still wanted children

(proportions observed in all three surveys), those not using contraception because they are trying for a child can be singled out in the 1994 survey:

1988

survey: 68.8%

of 20-24 year-olds were users in

1994,

i.e., 8%

1978,

on 1988.

The prevalence rate was already close to peak in

this

(under 30). These results confirm the controlled use of contraception at all ages, especially from the start of the reproductive period (see, below, steady increase in contraception at first intercourse).

is

the

case

with three quarters, and virtually all the young women

Women's conjugal status has an undoubted impact on their

contraceptive behaviour, but less so than their sexual relations (the role of conjugal status will be considered in more detail below, see Table 5). Women living in partner relationships, or their partner, more frequently use

not in partner

relationships. Among those women not living in partner relationships, taking the 51% of women users with the 36% who have no sexual partner,

and adding those who know themselves to be sterile, pregnant or seeking

pregnancy (7% in all),

unintended pregnancy (6%) than women who are living in partner relationships (5%). Also, 30% of women not living in partner relationships report that they have a stable loving relationship: contraception prevalence is high amongst this group - nearly 80%; of those not in a stable relationship (who may have occasional partners), 37% are protected by a contraceptive method.

This analysis bears out that contraception is widespread among women engaging in sexual intercourse at all ages and regardless of conjugal status. It will now be seen that further change has occurred in the methods used since the 1988 survey, towards increased médicalisation and hence greater effectiveness; there is still wide variability according to the woman's age, conjugal status and parity.

contraception (70%), but so do

over half of women who

are

we

find that they are

barely more at risk of

CONTRACEPTION IN FRANCE

95

More use of hormonal contraception

Since contraception was legalized in 1967, non-medical methods have

declined steadily in favour of the pill, and to a lesser extent, IUDs. Other than condom use, boosted by AIDS awareness campaigns, non-medical methods are being forsaken: withdrawal and periodic abstinence continue to wane in popularity: both are now the primary means of contraception for only 6.3% of women, against 9.8% in 1988 and 23.5% in 1978; vaginal methods - never very widespread - are now preferred only by fewer than 1% of women. By contrast, 52% of women aged from 20 to 49 - i.e., 76%

of users, including sterilization - now use

clear leader (36% of women), and its use increased still further between 1988 and 1994 to the detriment of IUDs, still the second most usual contraceptive method (16% of women). Contraceptive sterilization is not prevalent in France -just 4% of all women of reproductive age. Significantly, the morning-after pill is ail-but non-existent; only one survey respondent reported having used it, although, admittedly, it is not available on the market as such. Some doctors, however, prescribe an elevated dose of a readily available hormonal contraceptive as emergency contraception after unprotected sex. The salient feature of French contraception, then, is the high prevalence of medical contraception: the pill as birth spacing contraception and then as birth stopping contraception, and IUDs as contraception designed to prevent further childbearing. The 1994 survey also points up the growing use of condoms among young people and those not living with a partner, and the low prevalence of contraceptive sterilization, used only at the end of reproductive life. The decisive factors in the choice of pregnancy avoidance methods are the woman's age, number of children already born, and conjugal status. These will now be looked at in more detail.

the pill or

IUD. The

pill

is the

Medical methods Thirty six percent of 20-49-year-old women use the pill, i.e., 53% of contraception or sterilization users. Prevalence is highest among 20-24 year-olds: 59% of young women take

the pill, i.e., 85% of users; thereafter, it decreases progressively with rising age (Figure 1), but the pill is primary contraception for women up to nearly 40 years of age. As the preferred contraceptive method for three in every

four users

The pill has increased in prevalence at all ages in recent years, rising from 33.8% in 1988 to 40.2% in 1994 for all 20-44-year-olds. Figure 2a shows the age-specific rates in the successive birth cohorts: in the 5 years leading up to the last survey, the rate of increase was particularly marked among the youngest groups, rising from 50.9% to 58.6% among 20-24-year-olds, and from 41.4% to 50.3% among 25-29-year-olds.

A sharp rise during the 1970s has been followed by slower but steady growth. The levelling off in the sales figures curve after 1990 plotted in

under the age of 30,

it is the primary method of birth spacing.

96

С. de GUIBERT-LANTOINE, H. LERIDON

г КеУ:

I

[

i Contraceptive sterilization

1,1 Periodic abstinence + withdrawal + local methods

| Condoms

|IUD

I

Pill

20-24

I

25-29

I

30-34

I

35-39

I

40-44

I

45-49

Figure

1. - Primary method

in

1994 for 100 women

in each

age group

Figure 3 appears to conflict with the 1994 survey findings. The discrepancy may be due to an increase in the prescription of progesterone-only-pills for treatment of perimenopausal symptoms: because such treatments also

have contraceptive effects, respondents would in the nature of things report them in the survey, even though not all such products are licensed for marketing as contraceptives. If a third of the sales of this type of product are added to those of contraceptive pills proper, the number of pill users tallies with the survey estimate: 5.2 million users in 1994, against 4.0

million in 1988 (Toulemon and Leridon,

The pill thus continues to gain in popularity at both ends of the reproductive age range. Furthermore, the development of mini-pills extended the range of situations in which the pill could be prescribed and made

as a

result, the use of hormonal products continues to increase among the over- 35s, checking the prevalence of IUDs among these age groups. On average, the IUD is the second most popular contraceptive method, with an overall prevalence of 16%, i.e., 23% of users. But the age-specific trend is very different here, with a very pronounced peak (26%) between ages 35 and 45: the IUD tends to be used by women seeking to stop childbearing; although completely reversible, it can be described as a 'stopping contraceptive method'. This makes it the primary contraceptive technology for those around 40 years of age. On the whole, IUD prevalence has stopped

1995 b).

doctors less reluctant to prescribe the pill for more than ten years:

CONTRACEPTION IN FRANCE

97

15-19 20-24 N.B. There is a one-year variance between the birth cohorts observed in 1994
15-19
20-24
N.B. There is a one-year variance between the birth cohorts observed in 1994
(end point of each curve) and those given in the key to the chart.

Figure 2a. -Pill use among women by age and birth cohort

i i 1 i i 09998 INED 50- B-IUD 40- - 30- -ГГ- /* 948-52
i
i
1
i
i
09998 INED
50- B-IUD
40- -
30-
-ГГ-
/* 948-52
J
,
1953-57K
20-
1958-62K
10- 1963-67—^g/--
0
i 1
1
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Age
N.B. There is a one-year variance between the birth cohorts observed in 1994
(end point of each curve) and those given in the key to the chart.

Figure 2b. -IUD use among women by age and birth cohort Sources: 1978 and 1988 surveys, and sales figures (Toulemon, Leridon, 1991); ESFE 1994 survey data

98 С. de GUIBERT-LANTOINE, H. LERIDON 40 1 1 1 1 1 1 1 1
98
С. de GUIBERT-LANTOINE, H. LERIDON
40
1
1
1
1
1
1
1
1
-Key:

1968

1970

1972

1974 1976

1978

1980 1982

1984

1986

1988

1990

1992 1994

Figure 3. - Pill and IUD use (among 100 women aged 15-49)

rising, and even declined from 18.9% to 15.8% among all 20-44 year-olds between 1988 and 1994, corresponding to a sharp fall in use between ages

25 and

14% of those born six years earlier, and 15% of those aged 30-34 against 25% (Figure 2b). At the same time, oral contraception prevalence added eight points, as we have seen. Use of IUDs is constrained by two factors. The (slight) risk of infection and possibly sterility make most doctors reluctant to prescribe it for young women and those with incomplete fertility; as a result, the current trend to defer age at childbirth has limited the proportion of women aged under 35 likely to use IUDs. For older women, the new hormonal products seem to offer the twin benefits of contraception and preventive treatment of the effects of the menopause, which IUDs cannot provide.

only 7.7% of women aged 25-29 use IUDs compared to

35.

So,

Note on social differentials

During the 1970s, medical methods (the pill and IUD) were more prevalent among women in the socio-economic groups most in touch with preventive health, e.g., better-educated, urban, non-manual workers. By 1988, practices had grown more consistent: pill use, in particular, was no longer connected with educational level, occupation or residence; IUD use, on the other hand, remained more prevalent amongst the most highly-educated women (see Toulemon and Leridon, 1992).

CONTRACEPTION IN FRANCE

99

Condoms Condoms are the contraception of choice for 4.5% of 20- 49-year-old women, slightly more than the 3.4% of 1988, following a downturn during the 1980s. But their position in this method hierarchy belies the reality, because they are often used in combination with another contraceptive method; in all, 7.8% of women aged 20 to 44 reported using them - a significantly higher proportion than the 5% of preceding surveys (see infra). In fact, condom prevalence has increased since 1988, especially among young people and those not living in partner relationships, as a provisional method, particularly for first intercourse (about half of which is with condoms today). Furthermore, condoms are as much a contraceptive method as a means of averting sexually transmitted diseases. Also, their use is assessed here based on women's replies, but must also be judged on those of men, who report significantly higher frequencies of use, as will be seen later (see also Toulemon and Leridon, 1995 a).

Contraceptive sterilization

permitting or prohibiting voluntary sterilization. The French General Medical Council allows it only "on very serious grounds", but what these are remains unclear. There is little legal precedent on the matter, but some insurers take the view that accidents connected with sterilization procedures are not part of the practitioner's or

hence not covered by their professional liability

insurance). This climate of uncertainty is obviously no great incitement to

anaesthetist's normal duties (and

France has no specific legislation

use sterilization as a method of birth control in France, unlike other

comparable countries. The distinction that can be made between sterilizations

(contraceptive) or 'on medical grounds' is

based solely on respondents' replies; contraceptive sterilization includes partially contraceptive sterilizations (carried out on both grounds), but not procedures carried out on purely medical grounds. Given the uncertainties surrounding the precise purpose of procedures, the analysis will embrace all sterilizations, specifying the reported purpose. 6.8% of women aged 20 to 49 in 1994 had been sterilized, including 4.1% (i.e., two thirds of them) for contraceptive purposes. The method is not prevalent among the under-40s, and even less so among the under-35s; it affects 7% of 40-44 year-olds and 11% of 45-49 year-olds. A slight but steady decline in female sterilization is discernible through the results of the three surveys. The proportion of surgically treated 20-49-year-old women declined from just under 10% in 1978 to 7.6% in 1988 and 6.8% in 1994. The corresponding proportions of purely contraceptive sterilizations decreased from 4.3% in 1988 to 4.1% in 1994. The decrease in such procedures is most marked among the under-40s, and is now almost nil before the age of 35. The decline in medical sterilizations was relatively more pronounced between 1978 and 1988; this form of major procedure - usually hysterectomy - now seems less prevalent than before.

'to avoid further childbearing'

1 00

С. de GUIBERT-LANTOINE, H. LERIDON

As a result, the relative share of surgical contraceptive procedures among all sterilizations has increased from 56% to 68%. Male sterilization is so uncommon as to be hardly discernible in the survey; only about 0.4% of women living in partner relationships reported having a sterilized partner in 1988, and even fewer in 1994 (11 and 5 survey respondents respectively). Using data from the three surveys, we can calculate the cohort trend in sterilization (Figures 4a and 4b)(2). The findings confirm a decline in sterilization at all ages, from the oldest to the most recent birth cohorts:

so, the proportion of women already sterilized at age 40 decreased from 16% for those born in 1939-1943 to 10% for those a decade their juniors. Note that the decrease in operations among the younger generations occurred between 1978 and 1988, with the proportion of women already

sterilized at age 35 seeming to level-off at the low level of nearly 5%. There is a comparable trend in purely contraceptive sterilizations: the proportions of women sterilized by the age of 40 declined quite sharply from 8.5% to

5%

in the 5 years between 1988-89 and 1994 (C. de Guibert-Lantoine,

1997).

Sterilization thus predominates among comparatively older,

ever-married mothers of large families:

(only 3.3% of them for contraceptive reasons), but 14.4% (12.6% contra- ceptively) of three-parity mothers, and 20% (14% contraceptively) of mothers with four or more children. Overall, average parity per sterilization contraceptor is almost double that of all women -2.8 compared to 1.5.

8.5% of two-parity mothers were sterilized

Contraception in France, therefore, is essentially female, hormonal - so, effective yet reversible - permanent and not coitus-related. Male contraceptive methods (condoms and withdrawal) which involve the woman almost as much as the man and are coitus-related, are often used in combination.

'Dual method' contraception

Contraceptive practices do not boil down to a choice of just one of the methods available: 7% of women, and 11% of men, contraceptors also use a back-up method. The proportions are higher still - 15% and 21% respectively - among respondents not living in partner relationships, and markedly lower among married women, where under 5% are dual method users.

(2) Figures 4a and 4b were plotted

from the

1988 and 1994 surveys, by comparing

results for the same birth cohorts and estimating mean values where divergences occurred;

some of the 1978 survey findings were factored in. The low numbers concerned mean that trends and orders of magnitude are what is essential.

CONTRACEPTION IN FRANCE

101

CONTRACEPTION IN FRANCE 101 Figure 4a. - Women already sterilized (all reasons), by age and birth

Figure 4a. - Women already sterilized (all reasons),

by age

and birth cohort

i

i

20 m

i

15 -

10 -

5 -

0

20

■i

1939-43^ _,.

''-^"^^*tí^-^""—'—

"

Г jr^^*^\ ^ 1959-63

 

25

30

35

/954-5S

i

^] 944.48

^^1949-53

i

40

09698 INED

-

45

Age

Figure 4b. -Women already sterilized for contraceptive reasons, by age and birth cohort

When these combinations are considered, the use of non-medical methods is thrown into stark relief: they are used, alone or in combination, by 16.4% of 20-49-year-old women, compared to having been the primary method for just 11.6%. The proportion of women using each method, alone or combined, in the survey month with a summary for those using at least

102

С. de GUIBERT-LANTOINE, H. LER1DON

one medical method (a) and those using at least one non-medical method

(b)

Condom prevalence (previously concealed by the method hierarchy) is discernibly higher especially among the younger age-groups, while dual use of traditional methods is especially prevalent among the older generations. So, 7.4% of 20-49-year-old women had used condoms in the survey month, compared with the 4.5% for whom it was the primary contraceptive. Prevalence is higher among the younger age-groups: 12.2% of 20-24-year- olds, rising to 16% among young women of this age not living in partner relationships; the likelihood is that this represents contraception for casual sexual relationships or at least temporary unions. Among traditional methods, abstinence and withdrawal are equally non- prevalent among women: 4% of 20-49-year-olds for each method. They are more prevalent among women aged 40-44, still fecund but mostly having completed their fertility: 15% use one or both methods, rising to 18.2% for married women. One in five women of this age, and nearly one in four married women, uses at least one non-medical contraceptive method, often in combination. 'Dual method' use can also be measured by calculating the frequency of combined use - i.e. within the same month - of two methods among 100 women users of a given contraceptive method. IUDs are seldom backed

Table 3. - Contraceptive methods used alone or as dual method in 1994 for 100 women in each age group

is shown in Table

3.

25-29

30-34

35-39

40-44

45-49

All

All

20-49

20-44

1964-

1959-

1954-

1949-

1944-

1944-

1949-

1968

1963

1958

1953

1948

1973

1973

67.9

67.3

69.6

64.9

45.5

64.4

67.7

58.0

56.0

58.6

45.8

32.1

52.4

56.0

50.3

41.0

31.2

20.3

14.5

36.3

40.2

7.7

15.2

27.3

25.5

17.6

16.1

15.8

13.4

12.5

12.1

20.3

14.6

14.6

14.6

2.1

3.7

3.5

7.8

5.6

4.1

3.9

8.7

6.2

6.2

4.8

4.8

7.4

7.8

0.4

0.3

0.3

3.3

1.6

1.1

1.0

3.3

3.3

3.3

7.2

4.3

3.8

3.7

2 125

2 170

2 139

2 140

1874

12 536

10 662

519

548

563

470

348

2 944

2 596

Age at 1.1.1994

20-24

1969-

1973

68.8

61.5

58.6

2.9

14.5

2.3

12.2

0.3

1.3

2 088

496

Year of birth

Proportion of women:

Using a reversible method

a. At least one medical method Pill IUD

b. At least one non-medical method Periodic abstinence Condom Local female methods Withdrawal Population (000s) Survey population

Source : INED, Enquête sur les situations familiales et l'emploi, March 1994. Women aged 20- 49. The sum of the proportions of different non-medical methods used "this month" (23. 1 % for ages 40-44) is greater than the proportion of women having used at least one non-medical method (20.3 %) because the different methods can be used in conjunction.

CONTRACEPTION IN FRANCE

103

up by another method

(6.0%), the most usual (four in five) backup to medical methods being the condom: 2.2% of women with an IUD and 4.9% of women taking the pill in the month preceding the survey used one in the same month. Non- medical methods are much more often backed-up by another method: 41.6% for condoms, 36.7% for withdrawal, 43.0% for abstinence, over 50% for vaginal methods. The most frequent combinations are condoms and the pill, abstinence and condoms, withdrawal and periodic abstinence. 'Dual method' contraception is most prevalent among and characteristic of lone contracepting women: nearly one in four was using condoms at the survey date, more than half (55%) in combination with medical contraception. In this context, condoms are used as much to protect against STD (especially AIDS) as pregnancy, especially when combined with efficient technology like the pill.

(in 2.7%

of cases),

the pill slightly more often

Methods known and previously used, medical advice

Measuring the generation- specific dissemination of contraceptive

1994 survey - "have

you previously used such a contraceptive method at least once?" and "have you previously discussed contraception with a doctor?" - reveals a mix of at least temporary individual practices. These results are shown in Table 4.

information and practice through two questions put in the

Table 4. - Contraceptive methods used at least once and medical advice sought for 100 women in each age group (1994 survey)

Age at 1.1.1994

20-24

25-29

30-34

35-39

40-44

45-49

1969-

1964-

1959-

1954-

1949-

1944-

1973

1968

1963

1958

1953

1948

Proportion of women having:

Sought medical advice

78.7

88.0

81.0

86.7

79.0

69.0

Sought advice or used a medical method

87.1

96.4

93.8

93.7

88.7

84.5

Using a medical method

83.0

93.6

90.7

90.9

83.8

80.6

Pill

82.7

93.3

88.6

86.3

77.3

72.5

IUD

4.5

13.4

27.7

46.9

48.9

42.1

Used a non-medical method

68.6

69.6

67.2

68.1

76.1

71.1

Periodic abstinence

12.1

15.1

20.9

14.9

27.9

26.4

Condom

58.3

52.7

41.5

41.9

44.4

36.8

Withdrawal

32.3

39.6

36.6

40.3

47.2

50.9

Used pill + condoms

52.6

50.7

39.1

38.1

37.8

29.9

Population (000s)

2 088

2 125

2 170

2 139

2 140

1 874

Survey population

496

519

548

563

470

348

All

20-49

1944-

1973

80.6

90.8

87.3

83.7

30.5

70.1

19.5

46.1

41.0

41.5

12 536

2 944

Source: INED, Enquête sur les situations familiales et l'emploi, March 1994. Women aged 20-49.

1 04

С. de GUIBERT-LANTOINE, H. LERIDON

Methods previously This question gives information both about con-

used at least once

a method, even if once only, necessarily betokens knowledge of it. It also supplements the findings presented above on the practice observed at the survey date for both primary and secondary methods:

the fact is that the contraceptive behaviour of non-users at the survey date, e.g., pregnant women (4.3%) and those seeking pregnancy (4.0%) -highest at ages 25-29 (11.4% and 8.5%, respectively) escaped notice; and yet it is precisely they who had most prior knowledge and practice, especially in medical methods: 93.3% of them had previously taken the pill.

The overwhelming majority of women of reproductive age (87.3%)

traceptive knowledge and practice, in that use of

have previously used a medical contraceptive method, and 83.7% have

decreasing

slightly among the older birth cohorts, from 93.3% to 72.5% for ages 45-49 years at the survey date. IUDs had been used by 30.5% of women, chiefly the over-35s. The use of a contraceptive method at least once is not equally meaningful for medical methods and local methods in terms of duration and constraint; there are, for example, few grounds of comparison between an IUD fitted and normally worn for a period of years, and the transient use of a condom. The fact remains that 7 women in 10 have used local methods during their contraceptive life, often ad hoc: 46.1% used condoms and 41.0% withdrawal. Prevalence is higher for condoms among the younger age-groups (58.3%), and for withdrawal (50.9%) among the older age- groups; significantly, however, nearly a third of young women had already used withdrawal, and more than a third of the older age-groups had also used condoms at least once in their life. While the survey shows a highly age-specific differentiation between 'current' methods, it is also true that respondents of all ages across the board have at one time or another, even transiently, used different methods. Contraceptive information and practice is already widely disseminated among the youngest women, a small proportion of whom can be assumed not yet to have had or considered sexual intercourse. In 1994, the proportion of 20-24-year-old women who had already taken the pill (82.7%) was close to that of women who already had coitus, but their contraception experience was not limited to that method: 68.6% used a non-medical method, mainly condoms. Other methods are known to the younger age- groups - 32.2% of 20-24-year-olds had used withdrawal and 12.2% periodic abstinence- but not routinely; in the survey month, only 1.3% of 20-24- year-old women used withdrawal and 2.3% periodic abstinence.

taken the pill. Prevalence

of pill

use

is

highest at ages 25-29,

Medical advice

tion; non-coitus-related contraceptive methods imply forethought, which entails consulting a doctor to prescribe the pill or fit an IUD. In fact, 78.7% of women aged 20-24 and 88.0% of women aged 25-29 report already having seen a doctor about contraception. If women

Medical follow-up is now an essential of

CONTRACEPTION IN FRANCE

105

who have previously used the pill or an IUD but did not report "having seen a doctor" (i.e., who may have gone to a family planning clinic) are included, those proportions rise to 87.1% and 96.4%, respectively. Women born in the mid-1950s, whose sexual life commenced post-Neuwirth Act, were more likely to seek medical advice, while those who were older at the survey date - ages 45-49, born in 1944-48 - were less likely: only 69.0% had sought medical advice, and approximately 15% had neither sought medical advice nor used medical contraception. By comparison, only 63% of the 1940 cohort had seen a doctor about contraception (Leridon and Toulemon, 1990). In three of four cases, doctors prescribed the pill at the first consultation; from the turn of the 1980s, doctors also began prescribing condoms:

77% of women were prescribed the pill on first consultation between 1990- 94, of whom 12% said their doctor had also advised condoms.

II. - Men's and women's replies compared

The 1994 survey questionnaire was also put in broadly the same terms

to a representative sample of men aged 20-49. This was because the survey

was chiefly concerned with family patterns and backgrounds, where the two sexes' life paths were not necessarily identical. These enabled us to compare men's and women' replies on contraceptive practices. In some cases, similar replies could be expected: methods reported by people living in partner relationships should be identical for men and women (at least, taking only couples where both members fall within the scope of the survey). In other cases, especially people living alone, replies can differ very widely.

The wording of questions is crucial in this context. A seemingly

straightforward question like "Are you currently using contraception, and

if so, what type?"

actually contains three key ambiguities:

— the base period is not specified: does "currently" mean this month,

or usually (even if no method has recently been used because the woman

is pregnant, for example)?

— it is not clear whether the "you" is the interviewee (man or woman)

alone, or the couple of which s/he may be part; if the former, a man whose wife uses the pill should reply "none" (because he is not personally using any), whereas in the latter, he should reply "the pill" (because 'the couple'

uses the pill);

— for many respondents, the term "contraception" excludes all

which may result in

a significant under-reporting of the prevalence of traditional methods.

For these reasons, the INED questionnaires on these topics contain

a battery of questions designed to dispel the main ambiguities. Bear in

'natural' methods and refers only to the pill and IUDs,

mind that, throughout the preceding section, the methods reported were

106

С. de GUIBERT-LANTOINE, H. LERIDON

those used in the survey month, by the respondent or partner if applicable. For those living in partner relationships, comparing replies will act as a cross-check: any discrepancy between the partners' replies will be

attributable to misinformation (some men may be unaware that their partner uses

the

living in partner relationships, by contrast, the variances will be indicative

or a misunderstanding of the questions. For those not

pill or

IUD)

of different behaviours (men cannot use the pill or IUD), or interpretation problems (will a woman relying on condom use by her casual partners report what she may regard as a male method?).

People in marital and Men's and women's replies (for the

consensual partner relationships

conjugal status in Table 5. People living in marital and consensual partner relationships were first distinguished from those not living in partner relationships.

Table 5. - Primary contraceptive method used in 1994, by conjugal status

A/ All women aged 20-49 In partner

primary method) are compared by

All

Not in partner relationship

relation

- Use contraception:

inc: pill IUD condom other

- Surgically sterilized (M or F)

- Use no contraception

inc: not wanting further children

- All

 

A 11

Stable

Not in

 

loving rel.

loving rel.

64.3

70.0

50.9

78.6

37.3

36.3

36.1

36.9

57.8

26.6

16.0

20.0

6.5

8.7

5.7

4.5

4.6

4.4

5.6

4.2

11.4

9.3

3.1

6.5

0.8

4.3

5.1

2.4

1.8

2.8

31.3

24.9

46.7

19.6

59.9

3.0

3.1

2.9

2.2

2.9

100.0

100.0

100.0

100.0

100.0

В/

All men aged 20-4Ç ) In partner

All

relation

Not in partner relationship

 

Д 11

Stable

Not in

loving rel.

loving rel.

62.5

70.6

46.6

86.8

30.6

33.6

37.6

25.6

65.2

9.6

13.5

19.7

1.0

2.6

0.0

8.4

4.2

17.0

13.5

19.0

7.0

9.1

3.0

5.5

2.0

3.4

5.0

0.0

0.0

0.0

34.1

24.4

53.4

13.2

69.4

3.9

4.5

2.9

2.2

3.3

100.0

100.0

100.0

100.0

100.0

- Use contraception:

inc: pill IUD condom other

- Surgically sterilized (M or F)

- Use no contraception

inc: not wanting further children

- All

Source: INED, Enquête sur les situations familiales et l'emploi, March 1994.

CONTRACEPTION IN FRANCE

107

Significantly more women in partner relationships than lone women used IUDs (nearly three times more) and traditional methods (other than pill, IUD and condom); by contrast, the women's replies revealed no

significant difference between the two groups for the pill and condoms. The age difference is certainly contributory, but not the only factor in the observed variances: being younger than the others, lone women should use the pill more than those living in partner relationships, which is not the case. The fact is that lone women use less contraception all told, but when

they do,

The replies of men in partner relationships are remarkably akin to those given by women living in partner relationships, even for condoms:

mutual information is clearly good and it can be concluded that contraception is definitely 'a joint concern'. The convergence also bears out the reliability of our data, since the two samples are independent (only one interviewee was selected per household).

they

tend to use

the pill more often.

sexual in-

in partner relationships tercourse with more or less regular partners. Some also self-reported at the survey date

relationship" which, for these purposes, puts

as being in a "stable loving

them in a similar category to "living in a partner relationship". Others may have one or more regular partners, whom they know and may well trust for contraception. Yet others engage only in casual sex, which presumably suggests that they make their own contraceptive protection arrangements. A final category had had no coitus in the recent or more distant past, and so needed no contraception. The category studied here is a very mixed one, therefore: the only distinguishable sub-group is those in "stable loving relationships", other than which we have no information on respondents' sexual activity.

On balance, slightly fewer men than women not living in partner relationships were self-reported users; the more marked difference lay in the distribution of methods: the pill and IUD significantly less than the condom. What is interesting, however, is that the archetypically male method - the condom - still trails the field: the pill still tops the list of methods reported by lone men. These results can be further clarified by distinguishing within the group of those "not in partner relationships" those (m/f) who were

in a "stable loving relationship" at the survey date. It can be assumed

that most of these loving relationships involve coitus, and that the description of them as both "loving" and "stable" suggests that they are the primary, if not the sole, focus of the respondents' sexual life. To take the women's replies first, the very high prevalence of pill use and lower prevalence of IUDs in this group is unsurprising inasmuch as they are mainly young women; but pill use rises to 70% among 20-29-year-olds (significantly more than among those of the same age in partner relationships),

People not living

These people may obviously have

reportedly

1 08

С. de GUIBERT-LANTOINE, H. LERIDON

which is indicative of specific behaviour: all told, contraception is more prevalent among these women than those in partner relationships, probably

because pregnancy is not an option in this phase of their life. It is relevant

same "loving relationship" situation report a somewhat

higher contraceptive practice still, but also rely overwhelmingly on their partner's hormonal contraception.

Final finding: men and, even more, women who are neither living in partner relationships nor claiming to be in a stable loving relationship, reported significant. contraceptive use of about half that of those in partner relationships. The pill was still most reported by women (27%, rising to 38% at ages 20-29), while for the first time, condom use was most frequent for men (19%), i.e., two-thirds of reported use. Again, this must be caveated by the lack of information on sexual activity among this last - probably fairly mixed - group of respondents.

that men in the

All

told,

it

can

be concluded that men's

and women's replies are

highly self-consistent where that is to be expected (living in partner relationships), and that otherwise they show that, consensually or otherwise, men rely largely on their long- or short-term partners' contraception. That, moreover, is probably as the latter wish it, confidence in condom effectiveness not being sufficient for women to rely on it alone.

III. - Methods at first intercourse

After being questioned on their current method, respondents were asked a series of retrospective questions, beginning as follows:

— "Let's go back a little

how old

— "Did either you or your partner use contraception or take precautions when you first had sexual intercourse?

Let's start with the first time you had sex:

were you at the time?"

1. Yes, starting before, you were already on the pill

2. Yes, starting then

3. Starting just after (the following month)
4.

— {If yes): "What method(s) did you use?" (You can give two answers)

No"

A word first about ages at first intercourse. Men are traditionally

younger than women, but the gap halved between the 1944-48 birth cohorts and the 1969-73 birth cohorts. However, the reduction in age was less

marked for men than for women: the

median age fell from 19.5 to 18.4 years

for women and 18.5 to 17.9 years for men (Toulemon and de Guibert-Lan-

toine, 1996). It should also be noted that most of the trend was

1953), and that the median

accomplished in the earlier birth cohorts (1944 to ages now seem to have levelled off.

CONTRACEPTION IN FRANCE

109

To take women's replies first, Table 6-A shows a sharp rise in contraception at first intercourse through the successive birth cohorts: 72% of

the 1944-48 birth cohorts used no contraception at first coitus against 32% of the 1969-73 birth cohorts. The rise was initially due to the increase in pill use from 11 to 44%, and -more recently- to condoms, reported by 6% of women in the older birth cohorts against 27% of the 1969-73 birth

cohorts (and even nearly

said that, in this table, dual pill and condom use could be reported: under 1% of women aged 30-plus, but 5% of the youngest women (ages 20-24) did

so. Table 6-B shows the men's replies. The first thing to say is that they do not tally exactly with the women's replies due to the differing ages at first intercourse, and the widely varying previous sexual experience of the first partners; the women, for example, had their first intercourse with an appreciably older partner (at mean age 19 with a 22-year-old, generally experienced, partner: see Bozon, 1993). Condom use is more often reported by the men, the proportion rising to 38% for the 1969-73 birth cohorts (and 48% of those born in 1973 only). Overall, the men more frequently report not having used any contraception at first intercourse (generally + 10%): some may have been unaware of their partner's behaviour, as is suggested by the markedly lower reporting rate for the pill (-10 percentage points in the oldest birth cohorts to -25 in the most recent).

Method used at first intercourse

39%

of those

born in

1973

only).

It has

to

be

Table 6. - Contraceptive method used at first intercourse by age at survey date by 100 people in each age group (Column totals may exceed 100 where combined methods are used)

A/ WOMEN

Age at 1.1.1994 Year of birth

- No contraception

- Pill

- Condom

- Other methods

inc: Pill + Condom

Age at 1.1.1994 Year of birth

45-49

40-44

35-39

30-34

25-29

20-24

All

1944-48

1949-53

1954-58

1959-63

1964-68

1969-73

1944-73

71.6

68.7

59.1

56.9

41.2

32.0

54.2

11.0

14.1

29.5

34.7

43.8

44.4

30.6

6.3

7.6

6.3

3.8

9.4

26.7

10.0

14.3

10.8

5.6

5.2

7.9

1.8

7.2

0.0

0.5

0.0

0.3

1.6

4.6

1.2

 

B/ MEN

45-49

40-44

35-39

30-34

25-29

20-24

All

1944-48

1949-53

1954-58

1959-63

1964-68

1969-73

1944-73

- No contraception

- Pill

78.8

1.7

77.9

5.0

68.0

15.6

72.6

15.4

60.9

18.5

42.4

19.6

65.5

13.8

- Condom

8.0

9.9

11.4

8.5

17.0

38.0

16.2

- Other methods

15.5

9.3

7.0

4.6

6.0

4.5

7.0

inc: Pill + Condom

0.5

0.7

0.5

0.7

0.8

3.1

1.1

110

С. de GUIBERT-LANTOINE, H. LERIDON

The earlier the first coitus -especially in the under- 16s- the less

frequently protected it was. So, 56% of 20-24-year-old women whose first intercourse occurred at age 14 or 15 reported no contraception, against

only 23% (under half) whose first coitus was at ages

argued that the earlier first intercourse occurs, the less likelihood there is

of it being planned and prepared for, but these findings also suggest that the younger age-groups are not well-enough informed about the risks and available methods of prevention at the time of the event. The pill in

particular is notable for its absence

apparent from the women's replies), while condoms are more frequently used in later intercourse, after age 18. While first intercourse may be 'unplanned' and unprepared, it cannot go unremarked that even including contraception started immediately after produces only a slight increase in the rates of use at first intercourse: less than 1% for condoms, approximately 5% for the pill, according to the women's replies across all birth cohorts.

among the younger age-groups (this is

18-19; it could be

Conclusion

Trends in contraceptive practices in France could have been heavily

influenced by three key facts: the misgivings voiced in some countries

about the side

users; the possibility that 'competition' from abortion may have led to some laxity in contraceptive use; and finally, the sudden development of the AIDS epidemic. In fact, none of these have had a deep-reaching effect on contraceptive behaviour.

Since its introduction into France, the pill has become the norm

among the youngest women, and take-up has grown steadily in that group. Among older women, the new hormonal products seem to offer the twin benefits of contraception and preventive treatment of perimenopausal problems: growth of these has offset a decline in the use of strictly

thus

traversed the forecasts that increasing user apathy might send the method into an early decline, and the ground swell of concern which led women in some countries (the United States, Great Britain) to shun it has not emerged in France. The IUD is increasingly seen as the preferred 'follow-on method' for women of 30- or 35-plus, and once the family has been formed. Here too, the absence of controversy - like that in the United States which led to ruinous lawsuits against doctors and manufacturers and the withdrawal of all intra-uterine devices from the market - has allowed this method to become established, in all likelihood curbing an increased use of sterilization.

contraceptive pills. The general trend in hormonal contraception

effects of the pill

and IUDs,

or a measure of apathy by

has

There were fears that the passing of liberal abortion laws would see a turning away from contraception. Our findings clearly show that modern

CONTRACEPTION IN FRANCE

111

methods have continued to gain ground steadily across all social groups (see Toulemon and Leridon, 1992), leaving only a very small part of the population at risk of unwanted pregnancy. It is clear that termination of pregnancy (IVG) has largely supplanted the old illegal practices, and helped reduce the number of unwanted pregnancies and births. But it still remains the final resort after contraception failure, or unprotected intercourse; some of these abortions could doubtless be avoided by better public information about the different methods available and, especially, exactly how to use them.

Finally, the AIDS epidemic prompted vigorous campaigning for

condom use at the turn of the 1990s. One fear

lead some young people to turn away from the pill: judging from the situation at first intercourse, condom use initially seemed to be a back-up method used with the pill; more recently, it may have led to some decline in pill use, and the situation should be kept under close review. The specific roles of the pill and condom are better known among older women and men, and condom use - more prevalent among those most at risk of AIDS - does not seem to be curbing the use of other more effective contraceptive methods.

was that this approach might

APPENDIX on the surveys

The Enquête sur les situations familiales et l'emploi (Family and Labour Survey) (ESFE) was conducted by INED and INSEE in March 1994. It was supported by the National Family Allowances Fund and the Department of Health in the Ministry for Social Security, Health and Urban Development. Approximately 5,000 interviews (1,926 men and 2,944 women) were conducted by INSEE after the Annual Labour Force Survey. The sample is representative of all men and women aged from 20 to 49, and children under 18 years of age. 'Non-standard' situations were over-represented in the sample by an unequal probability of selection procedure. The results for women are comparable with those of two similar surveys carried out in France: the 1978 Enquête mondiale de fécondité (World Fertility Survey) among 2,982 women aged from 20 to 44; and the 1988 Enquête sur la régulation des naissances (Family Planning Survey) of 2,666 women aged from 18 to 49.

BIBLIOGRAPHY

Bozon M., 1993, «L'entrée dans la sexualité adulte : le premier rapport et ses suites», Population, 48(5), p. 1317-1332 and in English in: Sexuality and the Social Sciences, M. Bozon and H. Leridon (eds.), Dartmouth Publishers, 1996. Guibert-Lantoine C. de, 1997, «Le choix de la stérilisation, comme méthode contraceptive, dans les pays développés : l'exemple de la France et du Canada», communication au Congrès de l'UIESP, Pékin, octobre 1997. Ined, 1956, «La limitation des naissances en France», Population, 11(2), p. 209-234. Ined, 1966, «Rapport à Monsieur le ministre des Affaires sociales sur la régulation des naissances en France», Population, 21(4), p. 645-690.

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Leridon H., 1985, «La baisse de la fécondité depuis 1965 : moins d'enfants désirés et moins de grossesses non désirées», Population, 40(3), p. 507-526. Leridon H., Charbit Y., Collomb P., Sardon J.-R, Toulemon L., 1987, La seconde révolution contraceptive. La régulation des naissances en France de 1950 à 1985, Travaux et Documents de l'Ined, Cahier 117, Puf, Paris, 380 p. Toulemon L., 1990, « La contraception médicale est devenue une partique courante », Données sociales, Insee, p. 289-292. Toulemon L., Guibert-Lantoine С de, 1996, «Enquêtes sur la fécondité et la famille dans lesn° 56.pays de l'Europe. Résultats de l'enquête française», Dossiers et Recherches, Ined,

Toulemon L., Leridon H., 1991, «Vingt années de contraception en France, 1968-1988», Population, 46(4), p. 777-812. Toulemon L., Leridon H., 1992, «Twenty years of contraception in France: 1968-88 », Population: An English Selection, p. 1-33. Toulemon L., Leridon H., 1992, «Maîtrise de la fécondité et appartenance sociale :

contraception, grossesses accidentelles et avortements », Population, 47(1), p. 1-46. Toulemon L., Leridon H, 1995a, «La diffusion des préservatifs : contraception et prévention», Population et Sociétés, n° 301, mai 1995. Toulemon L., Leridon H, 1995b, «Les pratiques contraceptives en France», La Revue du Praticien, 45, p. 2395-2400. Toulemon L., Leridon H, 1998, «Contraceptive practices and trends in France», Family Planning Perspectives, 30(3), p. 114-120.

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Guibert-Lantoine (Catherine de), Leridon (Henri).- Contraception in France: An Assessment After 30 Years of Liberalization

Contraception was legalized in France by a law adopted at the end of 1967. Contraceptive methods, in particular the pill, then spread rapidly. The most recent survey, conducted in 1994 (INED/INSEE), provides material to review the current state of contraceptive

practices. Contraception is now practiced at all ages: less than 5% of women are exposed to the risk of an unwanted pregnancy. Contraceptive use in first sexual intercourse is observed to have increased greatly over successive generations. Contraception today is practiced mainly by women and takes a medical form: use of the pill has become widespread, particularly among young people; the IUD appears as the follow-on method once the family has been formed; traditional methods are now marginal; use of the condom is on the increase, particularly among young people and single people, for whom it is often used in conjunction with the pill, being both a means of contraception and a protection against sexually transmitted diseases.

Guibert-Lantoine (Catherine de), Leridon (Henri).- La contraception en France : un bilan après 30 ans de libéralisation La contraception a été légalisée en France par une loi adoptée fin 1967. La diffusion des méthodes contraceptives, notamment la progression de la pilule, s'est ensuite faite rapidement. La dernière enquête réalisée en 1994 (Ined/Insee) permet de faire le point sur les pratiques contraceptives. La contraception est généralisée à tous les âges : moins de 5 % de femmes prennent le risque d'une grossesse non désirée. On observe une forte progression, dans les générations successives, de la pratique contraceptive lors des premiers rapports sexuels. La contraception est aujourd'hui essentiellement féminine et médicale : la pilule s'est imposée, en particulier chez les plus jeunes ; le stérilet apparaît comme la méthode relais après la constitution de la famille; la stérilisation contraceptive n'occupe qu'une place modeste, réservée à la fin de la vie féconde ; les méthodes traditionnelles sont maintenant marginales ; l'usage du préservatif masculin est en progression, surtout chez les jeunes et les personnes seules, souvent utilisé en complément de la pilule, car il est un moyen de contraception autant que de prévention des maladies sexuellement transmissibles.

Guibert-Lantoine (Catherine de), Leridon (Henri).- La anticoncepción en Francia :

balance a los 30 aňos de su liberalización

Los anticonceptivos se legalizaron en Francia a partir de una ley aprobada a finales de 1967. La difusión de métodos anticonceptivos, y especialmente la expansion del uso de la píldora, fue rápida a partir de este momento. La ultima encuesta, realizada en 1994 (Ined/Insee) permite analizar las prácticas anticonceptivas. El uso de anticonceptivos se ha generalizado en todas las edades : menos del 5 % de las mujeres se arriesga a un embarazo no deseado. A través de generaciones sucesivas, se observa un fuerte aumento del uso de anticonceptivos en el momento de las primeras rela- ciones sexuales. Actualmente, la anticoncepción es esencialmente femenina y médica : la píldora se ha impuesto particularmente entre los más jóvenes ; el DIU aparece como método de relevo después de la constitución de la familia ; la esterilización es poco común, y su uso se limita al final de la vida fecunda ; el uso de métodos tradicionales es marginal ; la utilización del preservative masculino esta aumentando, especialmente entre los jóvenes y las personas solas, y a menudo se utiliza como complemento de la píldora ya que es tanto un método anti- conceptivo como una forma de protección contra las enfermedades de transmisión sexual.

Catherine de Guibert-Lantoine, Institut national d'études démographiques, 133 boulevard Da- vout, 75980 PARIS Cedex 20, tél. 01 56 06 21 28, fax 01 56 06 21 99, e-mail lantoine@ined.fr