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Margaret Sanger, "Birth Control: The Doctor's Duty," June 1937.

Source: " Clinical Medicine and Surgery, June 1937, pp. 242-44Library of Congress Microfilm 128:0591."

For other versions, see Library of Congress Microfilm, 128:623A, 128:623B, 128:575, 128:620, and the Margaret Sanger Microfilm, Smith College Collections, S71:940.

Birth Control: The Doctor's Duty

by Margaret Sanger, New York City

Hundreds of articles, thousands upon thousands of words, have been written about birth control since the term was coined in 1914. But the idea behind all the pros and cons is as simple as all truth. Birth control is the use of scientific knowledge to remove blind chance as the chief deciding factor in the birth of children and to control the birth rate by means that prevent conception. Scientific methods of birth control involve the use of chemical and mechanical methods of contraception.

The history of the concept of conscious control of conception goes back more than a hundred years, to the writings of Robert Malthus and James Mill, and man has attempted, from earliest antiquity, to save himself from the consequences of his own fertility. War, famine, pestilence, infanticide, abortion, and sexual customs dictating periods of enforced abstinence have, through the long centuries, acted as checks upon population and the birth rate.

A survey of the sociologic and moral roots of the birth control movement has no place in this article, for our concern is with today and tomorrow. We should remember, however, that her is no upstart, twentieth century idea, born of industrialism, modern unrest, and other factors, that it is sometimes the fashion to deplore. The human race has been conscious of this problem since earliest written history, and in all stages of civilization. The reason is not far to seek. The amount of the earth’s surface capable of supporting life is strictly limited. On the other hand, Nature, to insure survival, has equipped living creatures, mankind among them, with a disproportionate physiologic capacity to increase and multiply. The result, as Professor Henry Pratt Fairchild has pointed out in his article “Population and War,” is that “every species in existence periodically produces offspring at a rate which, if there were nothing to stop it, would overflow the earth is a very few generations.”

The hazards of survival in the vegetable and animal kingdoms maintain the balance. With man, the same checks held population increase and means of subsistence in equilibrium well into modern times. But the magnificent achievements of medical and other sciences have dramatically changed the picture--and no one would wish to set back the clock.

The young men and women who are entering the medical profession today take their place in a noble assemblage, join the ranks of those who have succored mankind, and it is because of this very fact that the problem of conscious control of the birth rate--birth control--is peculiarly their problem and their responsibility.

I can do no better than to go to the heart of the matter by quoting the challenging statement of the late J. Whitridge Williams, M.D., beloved and revered by physicians throughout the country.

“Where should we stand as medical men?” Dr. Williams wrote, in the Journal of the American Medical Association, nearly nine years ago (issue of Oct. 27, 1928). “I hold that it is just as much our duty to give contraceptive advice when medically indicated as it is to advocate the employment of any other prophylactic measure. . . If we feel that such advice is necessary, we must give directions as to how it can be made effective, for if we do one without the other we are failing in our duty as physicians and in great part are wasting our time.”

Is the young doctor sent out of medical school today (to say nothing of those graduated in past years) equipped to give effective advice on contraception? Unfortunately we cannot answer with a clear affirmative. For though the medical indications for conception are many and clear cut, a thorough grounding in contraceptive technic is not included in the curriculum of all medical schools.

In 1933, the National Committee on Maternal Health made a survey of 76 Grade A medical schools, inquiring into the teaching of contraception and sterilization. Thirty schools reported no contraceptive teaching, though some were planning for it and approved it in principle. The accompanying table shows the total number of schools teaching the subject, and the method of instruction. Lecture & Clinic Lecture only Clinic only Unspecified Total Contraception 12 11 2 3 28 Sterilization 16 9 4 2 31 Not teaching Contracept. but teaching sterilization -- -- -- -- 8 Not teaching either subject -- -- -- -- 20

The survey’s findings were summed up (in part) as follows: “Many of the Grade A medical schools are including both contraception and sterilization in their courses of instruction to students, but no school appears to have laid out a definite course in either subject as part of its curriculum. The subjects are taught by occasional lectures or clinical instruction or both, and usually in the senior year.”

No survey has been made since 1933, but it is safe to state that, though recent graduates may be better equipped in this field of preventive medicine than their older colleagues, they themselves still feel the inadequacy of their training. Physicians and students welcome the opportunity of observing technique at birth control organizations for not only lay, but technical data, and have been quick to see the value of the Journal of Contraception, a pioneering periodical for members of the medical and scientific professions.

There is, however, ample evidence of steady and increasing support of birth control and a recognition of its place in preventive medicine and public health. Organized medical groups, as well as individual physicians, have gone on record in support of the principles of birth control and the movement to wipe out legal restrictions, which latter was the major objective of the National Committee on Federal Legislation for Birth Control. Nearly one hundred medical bodies took such action, among them the American Gynecological Society; the American Neurological Association; the Section of Obstetrics, Gynecology and Abdominal Surgery of the American Medical Association; the Medical Women’s National Association; State Medical Associations of Florida, Maine, Michigan, and Connecticut; many County Medical Societies; and the New York and Cincinnati Academies of Medicine.

Individual physicians, in their writings, in testimony at hearings on birth control bills, and in their generous service in birth control centers and on medical advisory boards of birth control organizations, have shown a keen awareness of the urgency of the birth control problem. Dr. Prentiss J. Willson, of Washington, D.C., chairman of the National Medical Committee on State and Federal Birth Control Legislation, gave testimony before a sub-committee of the U.S. Senate Judiciary Committee in 1934, which would, I think, be echoed by every thoughtful physician. As such it merits detailed quotations:

“The list of medical indications for contraception is a rather formidable one. Among chronic diseases there are heart and kidney disease, tuberculosis, syphilis, diabetes, chronic or potential chorea, several types of anemia, and exophthalmic goiter. There is a whole list of disease conditions of the female organs, which, because of the risk of abortion or extra-uterine pregnancy, indicate contraception. Nervous and mental disorders, such as epilepsy, paralysis, feeblemindedness, multiple sclerosis, and various types of psychoses and neuroses furnish additional and well-recognized indications, according to the consensus of medical opinion. . . I venture the opinion that the question of control of conception is doubtless one of the major problems affecting the married women of America. My experience teaches me that, in the absence of sane and safe methods of contraception, under the stress of the present economic situation, married couples are going to resort to some method of birth control. Many of these are harmful, either in a physical sense, because of damage done to the delicate tissues of the generative tract, or through the production of neurotic states, many of which I have had occasion to see, due to this cause. Here lies the crux of the whole argument in favor of placing birth control in the hands of the medical profession of this country.”

Birth control is indicated in still another field--one which makes it (or rather should make it) a routine part of postnatal care. It is needed for child spacing. Medical authority holds that a period of at least two years (possibly three), should elapse between the birth of children, so that the mother can adequately recover from the drain of pregnancy and childbirth and give care, including nursing if possible, to the newborn child. In advocating a three-year interval I have often put it thus graphically for lay audiences: One year for nursing and infant care; one year for the woman to be herself, an individual; and one year to plan for, conceive and carry the new child.

The U.S. Children’s Bureau, in its studies on “Causal Factors in Infant Mortality,” showed the definite relation between child spacing and infant mortality. Children born one year apart die at the rate of 146.7 per thousand--a rate which is reduced to 98.6 when the interval between births is two years, and drops to 86.5 for the three-year interval. The mother, the older children, and the infant all suffer when children come too close together. From this point of view alone, birth control is indicated for every married woman of childbearing age.

I have made mention several times of legal restrictions. In 1873, Congress, at the instigation of Anthony Comstock, passed laws classing “prevention of conception” with obscenity, and forbidding the importation of contraceptive information or materials or their transportation within the country by mail or common carrier. America has paid dearly for this blunder, for it has clouded and confused an issue which should have rested on medical findings; it has tied the hands of physicians, retarded research, and doomed countless women to ill health and death. The birth control movement, particularly during the past seven years, has been largely focused upon securing legislation to exempt the physician from these restrictions, so that, as Dr. Williams stated, “he might carry out his duty as a physician.”

The gradual build-up of public support, the better understanding of the real meaning of birth control and its constructive possibilities, have borne fruit, due in large part to efforts attendant upon securing the passage of a birth control bill; but the Courts, instead of the Congress, have clarified the law and handed down to the American physician his bill of rights in the field of contraception.

In a test case on the importation of contraceptive materials, sent to Dr. Hannah M. Stone from Japan for research purposes, the U.S. Circuit Court of Appeals for the Second Circuit ruled that the intention of the Comstock statue "was not to prevent the importation, sale or carriage by mail of things which might intelligently be employed by conscientious and competent physicians for the purpose of saving life or promoting the well-being of their patients." This decision marks a milestone in the birth control movement, and (I venture to say) in the history of preventive medicine. Contraceptive advice may now be given by physicians in their public as well as their private practice. Every hospital and dispensary, every Public Health Agency, every welfare organization may, and should, now include birth control in its services.

The century-long groping for sane control of births is over. The legal obstructions have been surmounted. Science has given us reliable and harmless methods of contraception, and research is developing even better and simpler methods. Freed from the taint of being classed with obscenity, birth control can now be used by the wise physician to promote a well-rounded married life for his patients. The necessity for child spacing, for family planning in accordance with health and income, all point toward the place of birth control as a necessary part of medical practice.

Whether the physician is a “family doctor” or a “specialist,” he will be faced with the necessity (if he is to carry out the highest dictates of his calling) of advising his patients on this most fundamental issue.

“The three great strides of medicine are towards the control of pain in labor and operation, the control of infection in obstetrics and surgery, and the control of communicable diseases,” said Dr. Robert L. Dickinson some years ago, addressing the New York Academy of Medicine. “These three advances, made in the face of opposition and indifference on the part of the organized profession, are now its common pride and glory. A fourth control, the control of conception, needed to safeguard life, health, and happiness, though now suspect and maligned, will take its place of honor with these others. Courage and wisdom were required to restrain the forces of disease and death. A greater courage and a higher wisdom are called for within our profession to undertake a guiding part in the control of life.”

I know that the doctors of America, and particularly those young and eager newcomers who this year enter the profession, will rise to the challenge of this greater courage and higher wisdom.

17 West 16th St.

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