Margaret Sanger promised it would be “a miracle tablet.” Hugh Hefner hailed it as “a powerful weapon.” A 30-year-old woman with six children called it “my ray of hope.” The pill is now so common—four out of five sexually active women have used it—that it’s easy to forget that oral contraception was once the stuff of fantasy.

In The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution, Jonathan Eig chronicles the decades-long effort to make that fantasy a reality. In his telling, this transformation is thanks to a unique alliance between feminists and scientists: the spotlight-seeking activist Margaret Sanger, the rebel researcher Goody Pincus, the single-minded heiress Katherine McCormick, and the photogenic family doctor John Rock. These four people provide a formula for what it takes to create scientific breakthroughs that are ahead of their time politically: an incredible amount of drive and little concern for traditional values, a willingness to flout powerful institutions and their rewards, a tremendous amount of money, and, eventually, a way to appeal to the mainstream. It’s no wonder that, despite lots of modern talk about disruption and innovation, truly world-changing breakthroughs are so rare.

America before the pill sounds like something out of Margaret Atwood. Contraception was illegal in most states from 1873 until after World War I, and not even recognized by the American Medical Association until 1937. Single women in 26 states were denied contraception until well into the 1960s. While some women were lucky enough to live in a state with more liberal birth-control laws or near a clinic that was willing to circumvent them, many were out of luck. Women used douches as a dangerous and ineffective morning-after contraceptive. Some tried the rhythm method, but even doctors’ knowledge of the reproductive system was still spotty, so that technique wasn’t very effective. Condoms were available, but married couples were reluctant to use them. Some clinics offered diaphragms, which were often poorly fitted and difficult to obtain. And these methods were only available to women with male partners who were interested in preventing pregnancy. Many men were not.

As early as 1914, Margaret Sanger, then a women’s health activist in New York, had a crazy idea: reliable birth control—ideally in pill form so women’s partners wouldn’t even have to know they were taking it. It wouldn’t just ensure that “woman” was not synonymous with “mother,” it would be the dawn of a new era of women’s pleasure and self-realization: sex without fear of pregnancy. Sanger knew that as long as men had the final say in when and how women became mothers, they would have the final say about all aspects of women’s lives.


This was a long-term goal, though. In the meantime, Sanger founded the Birth Control Federation, later called Planned Parenthood, to distribute condoms and diaphragms and lobby for the liberalization of contraception laws. She became a figurehead. She fretted that talking about “family planning” instead of “birth control” would dilute her movement, yet seemed to have few qualms about cozying up to racist, eugenicist “population control” advocates in the hopes of spreading the birth control message wider and farther. But in the post-war era, as contraception became more accepted but still remained politically taboo, Sanger grew sick of the incremental approach. She did not want to focus on improving the diaphragm. She did not want to distribute more condoms. She wanted a pill.

This was a tall order. The midcentury medical establishment was still figuring out how hormones worked—an oral contraceptive was a pipe dream. And Sanger couldn’t exactly roll up to a respected research institution and ask their most forward-thinking scientists to create one. Anti-contraception laws were still on the books in most states, and even though enforcement was lax, venerated institutions weren’t eager to push the bounds of legality. Sanger herself was a nationally known firebrand—not the type of person that tenured Ivy League medical researchers would have lunch with. Instead she sought out Pincus, “a scientist with a genius IQ and a dubious reputation” who had been fired from Harvard and recently established his own private research institution in Worcester, Massachusetts. Pincus was “interested in science and action, not long-term budgets or endowments,” Eig writes. He loved a challenge. And so when Sanger came to him in 1950 with her crazy idea for a pregnancy-preventing pill and asked if it was possible, he said he was willing to try.

Pincus’s research was enabled by the largess of Katherine McCormick, who had earned a biology degree at MIT and later inherited a fortune when her schizophrenic husband died not long into their marriage. She, like Sanger, saw controlling fertility as essential to women’s self-determination. In 1923, when contraception was still very much illegal in the United States, she smuggled diaphragms from Europe by buying them in bulk and having them sewn inside newly purchased clothing. When the paltry research budget Sanger was able to wrangle from Planned Parenthood proved insufficient, McCormick stepped in, funneling millions of dollars (in today’s money) toward Pincus’s research.

When rats and rabbits were injected with progesterone, Pincus discovered, their bodies thought they were pregnant, and so they stopped ovulating, making conception impossible. This was promising, but his results were still confined to lab animals. When it was time to test the effects of progesterone on human women, he hit a wall. And this is where John Rock came in. Rock, a practicing Catholic and researcher at Harvard, was one of the country’s foremost fertility experts. He came around to supporting birth control—despite his church’s staunch opposition—after years treating women for infertility. He realized that having too many children was just as much a burden as not being able to conceive any. He figured out that the hormones he was injecting into women to try to jump-start their reproductive systems had the short-term effect of stopping ovulation—which is what Pincus had found in his rats and rabbits. Rock agreed to work with Pincus to see if progesterone worked as a reliable contraceptive for women.

Initially, Pincus and Rock sought out healthy American women for the hormone trials but didn’t tell them they were testing a possible contraceptive, or what the risks were. (At the time, there were no rules governing medical testing.) Nurses at the city hospital refused to participate. Inmates at a women’s prison refused. Rock and Pincus finally found a couple of takers—women who hoped their participation would contribute to fertility research—but due to side effects like nausea, dizziness, and breast tenderness, as well as a demanding schedule of invasive checkups, most of those women dropped out of the study. And so Pincus and Rock decided to take their trials to Puerto Rico, where contraception was entirely legal and abortion readily available (wealthy American women with unwanted pregnancies would fly there for a “San Juan weekend”), due in large part to concerns about overpopulation on the island. McCormick worried that Puerto Ricans couldn’t be trusted to follow the testing regimen, and Rock was concerned he wouldn’t find “ovulating intelligent” women there. But, the researchers assumed, women there would be more compliant test subjects.

Their racist paternalism had real consequences, arguably hindering the development of the pill. Women in Puerto Rico dropped out of the study, too, and so they started looking for women they could force to participate, both at home and in Puerto Rico. Women locked up at a Massachusetts mental asylum were signed up. Women enrolled in medical school in San Juan were told they had to take part in the medical test or face expulsion. Many dropped out rather than comply. Eig doesn’t shy away from relaying these details, which are certainly not part of the popular feminist history of the pill, but he stops short of pointing out the hypocrisy of treated women like lab animals in service of creating a pill to secure their reproductive freedom. Sanger and McCormick didn’t intervene—which is appalling but not surprising, given that rising concerns about the growth of “undesirable” populations lent their contraceptive quest some mainstream legitimacy.

It wasn’t until the researchers made the acquaintance of Edie Rice-Wray, an American expat doctor who worked with families in a San Juan slum, that they found access to a willing population of birth-control test subjects. Rice-Wray told them they were going about it all wrong. Turns out all they had to do was find women who were eager for birth control and tell them what the experimental drug was for—to stop them from getting pregnant—and the women clamored to sign up. When those women didn’t end up pregnant, the word spread, and they had even more willing test subjects.

With promising results in hand, the four crusaders began looking for a manufacturer. Pincus owned stock in Searle, and its executives cautiously agreed to mass-produce the pill. “The question wasn’t whether other companies had the capacity to make a similar drug,” Eig writes, “the question was whether other companies had the nerve.” And, even with the handsome Catholic doctor John Rock as a spokesperson, it certainly took nerve to be the first pharmaceutical company to push a pill that enabled women to have sex but not get pregnant.

Of course, Searle didn’t say that’s what it was doing. In 1957, the company applied for FDA approval to market the pill as a drug for irregular periods—knowing full well that doctors could then prescribe it for “off-label” use as a contraceptive. “Approval was based on the question of safety,” said associate FDA commissioner John L. Harvey on May 9, 1960, as he announced that the pill had been approved. “We had no choice as to the morality that might be involved.” It was a statement designed to placate Catholic and conservative citizens, but it was also a joke. If FDA approval did not imply some moral judgment, then Searle could have just submitted an application for the pill as a contraceptive rather than as a drug that would help with irregular periods. Not to mention the fact that, at nearly every step of the way, the development of the drug had been shaped by politics and the prevailing moral codes of the time—often at the expense of women’s safety.


Today the pill is so accepted that it’s as likely to be seen as an annoyance as a gift. Women who’ve never known a world without it complain about its well-documented side-effects, and about the fact that their male partners don’t have to set an alarm on their phone to remember to take a pill every day. They wonder if the long-promised male contraceptive is ever going to arrive. “Later generations would complain that the birth-control pill put the burden for contraception on women,” Eig writes, “but that’s not the way these women saw it. Sanger and McCormick were born in the nineteenth century. To them, an oral contraceptive wasn’t a burden for women. It was a tool. It was an opportunity.” Although drug companies have tweaked Rock and Pincus’s hormonal formula and created new delivery methods like rings and patches, the tool has remained fundamentally unchanged.

The opportunity remains, though, to think about scientific advancement as a long road to a major cultural change. Sanger and McCormick could have limited their efforts to more piecemeal efforts to expand women’s rights, just as reproductive-health advocates now fight against abortion restrictions, and for broader access to contraception. Instead they also played a long game behind the scenes, trusting that Pincus and Rock would deliver, and that when women (and men) had the pill, fighting would die down about whether women’s highest calling was motherhood. Women would settle the debate themselves by opting out of compulsory motherhood and choosing to take the pill in droves.

What Sanger once called a scientific miracle was actually a hard-won political victory. The Birth of the Pill is perhaps a misleading title, implying its creation was an inevitable result of a standard incubation period. Rather, it was a complicated, expensive, and often covert strategic effort—more akin to a cold war than a pregnancy. While Eig makes clear that the activists and researchers behind the pill made some dubious short-term ethical choices in service of their larger goal, he leaves it to the rest of us to weigh those choices against the eventual result. Even half a century later, it’s not clear: Would we have a birth-control pill—and all of the freedom that comes with it—if Sanger, McCormick, Pincus, and Rock had truly respected all women’s autonomy? I don’t think it’s possible to know. We can, however, recognize and honor the women whose rights were trampled in the service of creating birth-control options we still enjoy today. And, as we work toward our own feminist political and scientific breakthroughs, we can ask ourselves the question that the four birth control crusaders did not: How can we achieve our goals while protecting all women’s rights along the way?