Restricting Choice
An editorial in this Journal in 1987 referred to 'The customer comes first' as a current political slogan and stressed the role of choice when "the commodity on offer is contraception". It was felt that there was a threat that "freedom of choice will be whittled away", as two government discussion documents had neglected to mention community services for family planning despite their widespread recognition as being essential for primary health care. Community services were perceived as providing value for money, as well as offering alternatives both to hospitals as service delivery points and to general practitioners (GPs) for service provision. It was felt that GPs tended to focus on oral contraception, to the exclusion of IUDs and barrier methods.
At that time, major challenges were being faced in the promotion of IUDs, both because of inadequate service provision and due to misconceptions regarding their indications, contraindications and effectiveness. Whereas IUD fitting by hospital gynaecologists would provide "a contraceptive service nearer to the Rolls-Royce than the rickshaw" for the great benefit of a few individual clients, it seemed more appropriate for service improvement to prioritise the training of community-based staff. IUDs had received poor publicity due to the erroneous attribution of adverse effects, such as pelvic infections, to the devices themselves as opposed to their surrounding clinical circumstances. With these incorrect views also prevailing in courts of justice in the USA, manufacturers could not afford the insurance premiums to enable them to defend themselves against litigation. All IUDs, except for the Progestasert®, had been withdrawn from the North American market. Transatlantic repercussions ensued with the withdrawal of the most popular IUD, the Copper 7, from the British market by its multinational pharmaceutical distributor. It was most unfortunate that commercial interests, and not clinical considerations, now limited choice in the selection of a contraceptive method. The USA was described as "a society devoted to the restriction of contraception" and with the important role of that country as an international donor for family planning, there were potential global implications as had previously been experienced with their ban on DMPA.