Margaret Sanger, "Why Not Birth Control Clinics in America?," Mar 1919.

Source: " American Medicine, Mar. 1919, pp. 164-167."

This article was reprinted in the May 1919 Birth Control Review under the same title. (Margaret Sanger Microfilm, Smith College Collections S70:821.)



New York City.

The absurd cruelty of permitting thousands of women each year to go thru 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 each other: "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 a paragraph on page 652 of his Practical Obstetrics. "Certain of the conditions enumerated form absolute indications for the induction to abortions," he says. "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 combated 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. Back comes the patient again in a few months to be aborted and told 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? One does not question the intent or the high purposes of these physicians, or that they are working for the improvement 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 only recently been brought to the front.

It has been permitted to lie latent; 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. Its sole function should be to prevent pregnancy. In the accomplishment of this, a higher standard of hygiene is attained. The result would be not only the removal of a burden from the physician who sends her to the clinic, but an improvement in the woman's general condition that would reflect itself in a number of ways to the benefit of 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 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, 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 them 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.

These abhorrent conditions point to a blunder upon the part of those to whom we entrust 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 would 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, thru 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 thoro and enthusiastic discussion of the subject at an international medical congress in Amsterdam in 1878. The first birth control clinic in the world was opened in 1881 by Dr. Aletta Jacobs in Amsterdam. So great were the results obtained that there has been a gradual increase in the number of clinics, until today there are fifty-two in operation in that country of some 6,000,000 people. Physicians have found that nurses trained for this work by specialists are highly competent to take care of it and it is the almost invariable rule that Birth Control clinics are conducted by such nurses. Dr. J. Rutgers of The Hague, secretary of the Neo-Malthusian League, is the specialist who trains and instructs the nurses. The general results of the work are best judged by tables, appended to this article, taken from The Annual Summary of Marriages, Births and Deaths in England, Wales, etc., for 1912*

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 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.) 1881-85 1906-10 1912 Birth Rate 37.1 24.7 23.3 per 1,000 of population Death Rate 25.1 13.1 11.2 per 1,000 of population Infantile Mortality: Deaths in first year 203 90 64 per thousand living births

The Hague (now headquarters of the Neo-Malthusian {Birth Control} League) 1881-1885 1906-10 1912 Birth Rate 38.7 27.5 23.6 per 1,000 of population Death Rate 23.3 13.2 10.9 per 1,000 of population Infantile Mortality: Deaths in first year 214 99 66 per thousand living births

Rotterdam. 1881-85 1906-10 1912 Birth Rate-- 37.4 32.0 29.0 per 1,000 of population Death Rate 24.2 13.4 11.3 per 1,000 of population Infantile Mortality: Deaths in first year 209 105 79 per thousand living births

Fertility and Illegitimacy Rates: 1880-2 1890-2 1900-2 Legitimate fertility 306.4 296.5 252.7} Legitimate birth per 1,000 married women aged 15 to 45 Illegitimate fertility 16.1 16.3 11.3 }Illegitimate birth per 1,000 unmarried women, aged 15 to 45 The Hague. 1880-2 1890-2 1900-2 Legitimate fertility 346.5 303.9 255.0 Illegitimate fertility 13.4 13.6 7.7 Rotterdam. 1880-2 1890-2 1900-2 Legitimate fertility 331.4 312.0 299.0 Illegitimate fertility 17.4 16.5 13.1

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