Choice and Coercion

Birth Control, Sterilization, and Abortion in Public Health and Welfare

Johanna Schoen

• Publisher: The University of North Carolina Press
• Year: 2006
• Print ISBN: 9780807855850, 9780807829196
• eBook ISBN: 9780807876497
• Topic: Social Sciences
• Subtopic: Social Policy
• Index: Social Sciences

In August 2003, North Carolina became the first U.S. state to offer restitution to victims of state-ordered sterilizations carried out by its eugenics program between 1929 and 1975. The decision was prompted largely by a series of articles in the Winston-Salem Journal. These stories were inspired in part by the research of Johanna Schoen, who was granted unique access to summaries of 7,500 case histories and the papers of the North Carolina Eugenics Board.

In this book, Schoen situates the state’s reproductive politics in a national and global context. Widening her focus to include birth control, sterilization, and abortion policies across the nation, she demonstrates how each method for limiting unwanted pregnancies had the potential both to expand and to limit women’s reproductive choices. Such programs overwhelmingly targeted poor and nonwhite populations, yet they also extended a measure of reproductive control to poor women that was previously out of reach.

On an international level, the United States has influenced reproductive health policies by, for example, tying foreign aid to the recipients' compliance with U.S. notions about family planning. The availability of U.S.-funded family planning aid has proved to be a double-edged sword, offering unprecedented opportunities to poor women while subjecting foreign patients to medical experimentation that would be considered unacceptable at home.

Drawing on the voices of health and science professionals, civic benefactors, and American women themselves, Schoen’s study allows deeper understandings of the modern welfare state and the lives of women.

CHAPTER ONE
Teaching Birth Control on Tobacco Road and in Mill Village Alley

The History of Public Birth Control Services

In 1941, Josiah B. testified to his congregation, “The devil has been to my house and tempted me in my weakest spot.”¹ The devil—in the form of public health nurse Lena Hillard—was touring Watauga County in the western part of North Carolina to offer condoms to all women of childbearing age. Josiah, who was deeply torn between his moral objections to contraception and his wife’s desire to accept the nurse’s offer, sought spiritual help in his effort to solve this dilemma. He eventually acquiesced to his wife’s wishes.

Throughout the early 1940s, Lena Hillard offered condoms and a contraceptive foam powder to every resident of Watauga County. As part of a study of the reliability of foam powder and Trojan condoms, she distributed the contraceptives to her clients, gave instructions on their use, and kept careful records of the number of pregnancies among their users. Financed by philanthropist and birth control activist Clarence J. Gamble, this so-called condom project was only one of many programs to bring birth control to poor populations.

The notion that the state should provide birth control information to the poor dates back to the emergence of the birth control movement in the early twentieth century. Under the leadership of Margaret Sanger, the early birth control movement sought the repeal of the Com-stock Law of 1873, which prohibited the dissemination of birth control or information about birth control through the U.S. mail. Women, Sanger argued, needed access to birth control and the ability to control their own fertility. But the progress of the radical, broad-based birth control movement was hampered by a conservative medical profession that deemed birth control immoral, thought Margaret Sanger too radical, and feared any government involvement in medical matters. By the 1920s, Sanger had grown frustrated with the movement’s slow progress and had begun to work to forge a professional alliance with the medical establishment. Hoping to gain broader support, she began to emphasize eugenic and economic arguments, increasingly grounding her claims for the legalization of birth control on the ideal of racial progress and efficiency.²

The 1930s witnessed a struggle over the professionalization of the birth control movement, while the New Deal offered unprecedented opportunities for the delivery of contraceptives to the poor. Physicians replaced laywomen activists in the national birth control organizations and in local clinics. Hard economic times, rising popular demand for contraceptives, and a 1936 court decision removing all federal bans on the distribution of birth control contributed to physicians’ greater willingness to provide contraceptive information to their patients. At the same time, expanding welfare rolls increased state and federal governments’ interest in the distribution of birth control to the poor. Starting in the late 1930s, state public health programs and federal relief agencies became actively involved in the distribution of contraception.

With the removal of legal prohibitions of the dissemination of birth control, a patchwork of services emerged to address the contraceptive needs of poor women. Public, private, and nonprofit organizations participated in the establishment of a range of birth control services. Both federal and state governments began to provide family planning through public health clinics and traveling birth control nurses. Researchers supported by national birth control organizations and private philanthropies established contraceptive field trials. And some physicians provided poor women with birth control advice in their private offices.

Humanitarian, eugenic, and economic concerns converged in the complex set of factors that motivated health and welfare professionals’ involvement in the delivery of birth control. They were genuinely concerned with maternal and child health and hoped to improve women’s access to health and contraceptive services. At the same time, most health and welfare professionals shared the view that the poor possessed a number of undesirable qualities that they were likely to pass on to the next generation. They hoped that limiting the reproduction of the poor would provide a scientific solution to poverty and poor health and would improve the quality of the race. Birth control advocates also emphasized that the distribution of contraceptives among the poor would save taxpayers money by controlling state expenses for social services.

During World War II, legislators sharply curtailed spending for health and social services, rolling back many of the programs that had expanded during the New Deal. Maternal and child health improved, and health professionals, resenting government involvement in matters of medicine as an unwanted intrusion into the profession, lost interest in public health birth control programs. Public welfare officials stepped into this gap. Concerned with swelling Aid to Dependent Children (ADC) rolls, they began to look to birth control as a means to limit poverty. In the 1960s, population control rhetoric and the development of a new generation of contraceptives increased both funding for family planning programs and the possibility of abuse. While some programs advocated women’s right to reproductive control, others sought to control poor women’s reproduction.

Clinics existed on a continuum between two extremes. On one end were clinics whose officials saw contraceptives as an integral part of public health services that, if offered along with prenatal and postnatal care and increased supervision of the state’s midwives, would improve the health of mothers and infants. Spacing children, officials at these clinics held, was essential to women’s health and contributed to the birth of healthier babies. By the 1960s, officials of some clinics even expressed the belief that women had a right to reproductive control. On the other end of the continuum were clinics that offered only contraceptives. Supporters of these clinics held that general health care services would divert funds needed more urgently for birth control work. Since they deemed it most important to reach as many women as possible, the officials at these clinics stressed quantity over quality by providing only basic services to a larger number of women. In the 1930s and 1940s, such clinics offered simple contraceptives in order to reach as many women as possible. These contraceptives did not require a physician for fitting and thus could be distributed by visiting nurses or through the mail and used safely by a woman with minimal sanitary facilities. By the 1960s, these clinics moved to the use of contraceptives such as the IUD that required little client cooperation; control over the insertion and removal of these forms of birth control lay with physicians rather than their patients.

Most of the women who took advantage of state-supported birth control programs lacked access to the most basic health services. The quality of their experiences with birth control programs depended in part on the extent to which officials integrated contraceptive advice into broader health and social services. Neither minority nor poor white clients of the birth control programs necessarily experienced the contraceptive offers as a form of state control. Nor did they usually see eye to eye with the largely white, middle-class professionals who ran the services. Instead, they had their own agendas, often unanticipated by public health and public welfare officials. These women welcomed the services, participated in them, and helped shape the contraceptive programs. Black health and social work professionals demanded better health and contraceptive services for African American women and occasionally even adopted eugenic rhetoric. They repeatedly challenged public health officials and influential whites to increase their outreach in black communities.

This chapter captures the diversity of delivery systems so typical of the American welfare state by analyzing several birth control programs around the country. It examines North Carolina’s public health birth control program and the efforts of the Farm Security Administration (FSA) to offer family planning as part of the New Deal. It follows Florida physician Lydia DeVilbiss, who during the height of the Great Depression distributed contraceptives from her private office. And it explores the “Negro Project” of the Birth Control Federation of America (BCFA) and the efforts of pediatrician Joe Beasley to bring family planning to Louisiana’s poor population.³

The proliferation of a variety of birth control services such as those described in this chapter marked the development of a welfare state that drew on the government, private, and nonprofit sectors.⁴ The geographic inequalities so familiar to us in today’s welfare programs have their origin in such services: the lack of a coherent delivery system resulted in a patchwork of services of uneven quality. This chapter’s focus on a variety of programs also allows for a fuller understanding of client experiences. Although, for instance, the archival sources in North Carolina offer little material on the politics of race in public health birth control programs, the records of the BCFA Negro Project tell the story. And while the records of the Negro Project are silent on questions of client reception, the sources of the FSA speak volumes.

Infant and Maternal Health in the Early Twentieth Century

High rates of infant and maternal mortality alerted health professionals in the early twentieth century to the need to improve infant and maternal health. In 1915, around 10 percent of all infants in the U.S. birth registration area—but 20 percent of infants of color—died before they were one year old. Approximately six white and ten nonwhite women died for every thousand live births between 1900 and 1930.⁵ Mortality rates were exacerbated by the general ill health of poor women. Many suffered from hookworm and other intestinal parasites, malnutrition, and malaria. Health conditions for African Americans were particularly dire. In the mid- to late 1930s, about 35 to 40 percent of adult black males in the South were either “fairly sick or just about to be” in any given year. It is safe to assume that black women were in no better health. Indeed, poor women who survived childbirth often suffered from long-lasting and debilitating injuries that resulted from frequent pregnancies, deliveries, and abortions without sufficient medical care.⁶

The inaccessibility of medical care even in cases of serious disease contributed to high infant and maternal mortality rates. Poor roads often made even a distance of ten miles an insurmountable obstacle to medical care, and medical and nursing care was usually unattainable for women living outside of towns. In 1932, the Committee on the Costs of Medical Care issued a report entitled Medical Care for the American People that demonstrated that medical resources, while plentiful enough, were not distributed according to need, but rather according to patients’ ability to pay for services. For instance, while New York, a relatively wealthy and urbanized state, boasted 1 physician for every 621 individuals, in extremely poor rural counties the physician-to-population ratio sometimes exceeded 1 to 20,000, and some areas had no practicing physicians at all. Furthermore, although southern state boards of health were responsible for serving black as well as white residents, they usually reserved services for whites. Until the late 1930s, poor southern blacks rarely received medical attention for any of their ailments, and many died without having once seen a physician.⁷ As late as 1941, sociologists Arthur Raper and Ira Reid estimated that half of the South’s people were unable to pay for medical care, leading one commentator to describe the South as “a belt of sickness, misery, and unnecessary death.”⁸

Patients who had access to medical care often encountered doctors and nurses who lacked basic skills. Early-twentieth-century reports indicated the poor quality of American medical education in general and of education in obstetrics in particular. Without adequate teaching facilities, most schools trained students of obstetrics on mannequins. A 1912 survey found that in over half of the schools in the sample, students saw three or fewer cases of childbirth. As a result, more childbearing women died from improper obstetrical operations than from infections caused by midwives.⁹ One critical physician accused his colleagues of frequently hastening labor, needlessly intervening in delivery, and disregarding the need for sterility. Careless physicians, he warned, not only contributed to maternal and infant mortality but also hurt the reputation of the entire medical profession.¹⁰ No wonder, then, that many women showed little respect for physicians.¹¹

Physicians concerned with improving their professional reputations and winning patients who normally used midwives as clients placed the brunt of the blame for high mortality on the presumed ignorance of black midwives and their poor black and white clients. “The disease that tops the list with us,” one physician lamented, “is ignorance, complicated by poverty.” He characterized most childbearing women unfavorably: “Their homes and labor beds are unbelievably unsterile. There are no screens and usually no lights. In other words, these pregnant women make little or no preparation for their delivery—by engaging a doctor, keeping their bodies in health, or preparing their delivery rooms.”¹²

In the early twentieth century, health professionals began to single out lower infant mortality rates as an index of regional achievement and pride.¹³ State boards of health adopted a variety of measures to improve infant and maternal health. Together with officials from the U.S. Children’s Bureau, North Carolina’s health officers and physicians developed a series of responses ranging from the establishment of infant and maternal health centers to the regulation of midwives. The state’s interest in maternal and infant health grew out of state health officer Watson Smith Rankin’s outreach efforts to improve the health of North Carolina’s citizens. In 1920, the North Carolina State Board of Health began a systematic effort to instruct pregnant women and mothers throughout the state about the value of professional medical services. The Bureau of Maternity and Infancy sent out monthly letters to all expectant women reminding them of the role physicians should play in pregnancy and delivery.

Despite their attempts to convince mothers of the need for medical care, physicians recognized that many rural women, particularly in the South, would continue to hire midwives for their deliveries. In the 1930s, approximately one-third of the deliveries in North Carolina, for instance, were attended by midwives—69 percent of births among African American women and 12 percent of white births. So prevalent were midwives’ services that in 1933 there were nearly twice as many midwives as physicians in the state. Midwives’ reputation was inevitably linked to the fact that most of them were black women serving the black community. “Many of these women are ignorant and dirty,” the director of the North Carolina Bureau of Maternity and Infancy, Dr. George H. Cooper, charged in a private letter.¹⁴ In a public speech, he argued, “They represent the lowest class of midwives, and also their work [is] among the lowest and most sordid class of our population.”¹⁵

Since they could not abolish midwifery, health officials hoped to train midwives and to exclude those whose skills they found unsatisfactory by instituting licensing requirements. With the 1921 passage of the Sheppard-Towner Act, which provided grants to states to meet the health needs of expectant mothers and newborns, the North Carolina State Board of Health began to organize maternal and infant health clinics for poor women. Nurses conducted classes on prenatal care and infant hygiene, made home visits to pregnant women and women with infants, and i...

Table of contents

• Cover Page
• Choice & Coercion
• Copyright Page
• Dedication
• Contents
• Illustrations and Figures
• Acknowledgments
• Abbreviations
• INTRODUCTION A Great Thing for Poor Folks
• CHAPTER ONE Teaching Birth Control on Tobacco Road and in Mill Village Alley
• CHAPTER TWO Nothing Is Removed Except the Possibility of Parenthood
• CHAPTER THREE I Knew That It Was a Serious Crime
• CHAPTER FOUR Taking Foam Powder and Jellies to the Natives
• EPILOGUE From the Footnotes to the Headlines
• Notes
• Bibliography
• Index
• Series