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Margaret Sanger (1879–1966). Woman and the New Race. 1920.


Why Not Birth-Control Clinics in America?

THE ABSURD cruelty of permitting thousands of women each year to go through abortions to prevent the aggravation of diseases for which they are under treatment assuredly cannot be much longer ignored by the medical profession. Responsibility for the inestimable damage done by the practice of permitting patients suffering from certain ailments to become pregnant, because of their ignorance of contraceptives, when the physician knows that if pregnancy goes to its full term it will hasten the disease and lead to the patient’s death, must in all fairness be laid at his door.

What these diseases are and what dangers are involved in pregnancy are known to every practitioner of standing. Specialists have not been negligent in pointing out the situation. Eager to enhance or protect their reputations in the profession, they continually call out to one another: “Don’t let the patient bear a child—don’t let pregnancy continue.”

The warning has been sounded most often, perhaps, in the cases of tubercular women. “In view of the fact that the tubercular process becomes exacerbated either during pregnancy or after childbirth, most authorities recommend that abortion be induced as a matter of routine in all tubercular women,” says Dr. J. Whitridge Williams, obstetrician-in-chief to the Johns Hopkins Hospital, in his treatise on Obstetrics. Dr. Thomas Watts Eden, obstetrician and gynecologist to Charing Cross Hospital and member of the staffs of other notable British hospitals, extends but does not complete the list in this paragraph on page 652 of his Practical Obstetrics: “Certain of the conditions enumerated form absolute indications for the induction of abortion. These are nephritis, uncompensated valvular lesions of the heart, advanced tuberculosis, insanity, irremediable malignant tumors, hydatidiform mole, uncontrollable uterine hemorrhage, and acute hydramnios.”

We know that abortion, when performed by skilled hands, under right conditions, brings almost no danger to the life of the patient, and we also know that particular diseases can be more easily combatted after such an abortion than during a pregnancy allowed to come to full term. But why not adopt the easier, safer, less repulsive course and prevent conception altogether? Why put these thousands of women who each year undergo such abortions to the pain they entail and in whatever danger attends them?

Why continue to send home women to whom pregnancy is a grave danger with the futile advice: “Now don’t get this way again!” They are sent back to husbands who have generations of passion and passion’s claim to outlet. They are sent back without being given information as to how to prevent the dangerous pregnancy and are expected, presumably, to depend for their safety upon the husband’s continence. The wife and husband are thrown together to bring about once more the same condition. Back comes the patient again in a few months to be aborted and told once more not to do it again.

Does any physician believe that the picture is overdrawn? I have known of many such cases. A recent one that came under my observation was that of a woman who suffered from a disease of the kidneys. Five times she was taken to a maternity hospital in an ambulance after falling in offices or in the street. One of the foremost gynecologists of America sent her out three times without giving her information as to the contraceptive means which would have prevented a repetition of this experience.

Why does this situation exist? We do not question the good intent nor the high purposes of these physicians. We know that they observe a high standard of ethics and that they are working for the uplift of the race. But here is a situation that is absurd—hideously absurd. What is the matter?

Several factors contribute to this state of affairs. First, the subject of contraception has been kept in the dark, even in medical colleges and in hospitals. Abortion has been openly discussed as a necessity under certain conditions, but the subject of contraception, as any physician will admit, has not yet been brought to the front. It has escaped specialized attention in the laboratories and the research departments. Thus there has been no professional stamp of approval by great bodies of experimenters. The result is that the average physician has felt that contraceptive methods are not yet established as certainties and has, for that reason, refused to direct their use.

Specialists are so busy with their own particular subjects and general practitioners are so taken up with their daily routine that they cannot give to the problem of contraception the attention it must have. Consultation rooms in charge of reputable physicians who have specialized in contraception, assisted by registered nurses—in a word, clinics designed for this specialty, would meet this crying need. Such clinics should deal with each woman individually, taking into account her particular disease, her temperament, her mentality and her condition, both physical and economic. Their sole function should be to prevent pregnancy. In accomplishing this purpose, a higher standard of hygiene is attained. Not only would a burden be removed from the physician who sends a woman to such a clinic, but there would be an improvement in the woman’s general condition which would in a number of ways reflect itself in benefit to her family.

All this for the diseased woman. But every argument that can be made for preventive medicine can be made for birth-control clinics for the use of the woman who has not yet lost her health. Sound and vigorous at the time of her marriage, she could remain so if given advice as to by what means she could space her children and limit their number. When she is not given such information, she is plunged blindly into married life and a few years is likely to find her with a large family, herself diseased and damaged, an unfit breeder of the unfit, and still ignorant!

What are the fruits of this woeful ignorance in which women have been kept? First, a tremendous infant mortality—hundreds of thousands of babies dying annually of diseases which flourish in poverty and neglect.

Next, the rapid increase of the feebleminded, of criminal types and of the pathetic victims of toil in the child-labor factories. Another result is the familiar overcrowding of tenements, the forcing of the children into the street, the ensuing prostitution, alcoholism and almost universal physical and moral unfitness.

Those abhorrent conditions point to a blunder upon the part of those to whom we have entrusted the care of the health of the individual, the family and the race. The medical profession, neglecting the principle involved in preventive medicine, has permitted these conditions to come about. If they were unavoidable, we should have to bear with them, but they are not unavoidable, as shown by facts and figures from other countries where contraceptive information is available.

In Holland, for instance, where the information concerning contraceptives has been accessible to the people, through clinics and pamphlets, since 1881, the general death rate and the infant mortality rate have fallen until they are the lowest in Europe. Amsterdam and The Hague have the lowest infant mortality rates of any cities in the world.

It is good to know that the first of the birth-control clinics of Holland followed shortly after a thorough and enthusiastic discussion of the subject at an international medical congress in Amsterdam in 1878. The Dutch Neo-Malthusian League was founded in 1881. The first birth-control clinic in the world was opened in 1885 by Dr. Aletta Jacobs in Amsterdam. So great were the results obtained that there has been a remarkable increase in the wealth, stamina, stature and longevity of the people, as well as a gradual increase in the population.

These clinics must not be confused with the white enameled rooms which we associate with the term in America. They are ordinary offices with the necessary equipment, or rooms in the homes of the nurses, fitted out for the work. They are places for consultation and examination, opened by specially trained nurses who have been instructed by Dr. J. Rutgers, of The Hague, secretary of the Neo-Malthusian League, who has devoted his life to this work. There have been more than fifty nurses trained specially for this work by Dr. Rutgers. As a nurse completes her course of training, she establishes herself in a community and her place of consultation is called a clinic.

The general results of this service are best judged by tables included in the Annual Summary of Marriages, Births and Deaths in England, Wales, Etc., for 1912. (See table, below.)

In Amsterdam, the birth rate dropped from 37.1 for the period of 1881–85 to 24.7 for 1906 and 23.3 in 1912. During the same periods, the death rate fell from 25.1 to 13.1, and in 1912 to 11.2. Infant mortality for the same period fell from 203 for each thousand living births to 90, and in 1912 to 64. Illegitimate fertility also decreased. Results in other cities, as shown by the table at the end of this chapter, are exactly similar.

In the Australian Commonwealth, where birth control is taken as a matter of course, and information concerning contraceptives is available to the masses, the births were so well distributed in 1915 that while the birth rate was 27.3, there was a general death rate of only 10.7. New Zealand, which is also one of the typical birth-control countries, had a birth rate of 25.3 and a general death rate of only 9.1 for the same year. These figures are in marked and happy contrast with those for the birth registration of the United States, where the reports for 1916 show a birth rate of 24.8 but an infant death rate of 14.7. A similar comparison may be made with the German Empire in 1913, where there was a birth rate of 27.5 in 1913 and a mortality rate of 15. In these countries, birth-control information is not so generally within the reach of the masses and, consequently, the largest percentage of births come to that class least able to bring children to full maturity, as indicated in the mortality rates.

In conclusion, I am going to make a statement which may at first seem exaggerated, but which is, nevertheless, carefully considered. The effort toward racial progress that is being made to-day by the medical profession, by social workers, by the various charitable and philanthropic organizations and by state institutions for the physically and mentally unfit, is practically wasted. All these forces are in a very emphatic sense marking time. They will continue to mark time until the medical profession recognizes the fact that the ever increasing tide of the unfit is overwhelming all that these agencies are doing for society. They will continue to mark time until they get at the source of these destructive conditions and apply a fundamental remedy. That remedy is birth control.

Amsterdam [Malthusian (Birth Control) League started 1881;
Dr. Aletta Jacobs gave advice to poor women, 1885]:

Birth rate37.127.723.3 per 1,000 of population
Death rate25.113.111.2 per 1,000 of population
Deaths in first year
2039064 per thousand living births

The Hague [now headquarters of the Neo-Malthusian (Birth Control) League]:
Birth rate38.727.523.6 per 1,000 of population
Death rate23.313.210.9 per 1,000 of population
Deaths in first year
2149966 per thousand living births

These figures are the lowest in the whole list of death rates and infantile mortalities in the summary of births and deaths in cities in this report.

Birth rate37.432.029.0 per 1,000 of population
Death rate24.213.411.3 per 1,000 of population
Deaths in first year
20910579 per thousand living births

Fertility and Illegitimacy Rates:
Legitimate fertility6.4296.5252.7: Legitimate births per 1,000 married women aged 15 to 45.
Illegitimate fertility16.116.311.3: Illegitimate births per 1,000 unmarried women, aged 15 to 45.

The Hague:
Legitimate fertility346.5303.9255.0
Illegitimate fertility13.413.67.7

Legitimate fertility331.4312.0299.0
Illegitimate fertility17.416.513.1