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The Strange History of Birth Control

In the 1920s it was illegal to advertise contraceptive diaphragms in the US or send them through the mail, and anyone who wrote about them risked imprisonment for indecency. The devices were entirely banned in some states, and in others doctors prescribed them only to women for whom pregnancy posed a clear health risk, if at all. Most couples relied on condoms, withdrawal, and douches, including the popular disinfectant Lysol, which was advertised in magazines along with “fountain syringes.”1

Margaret Sanger, the founder of the American Birth Control League, which became Planned Parenthood, and her allies eventually succeeded in making safe, reliable contraceptives— including condoms, diaphragms, intrauterine devices (IUDs), and hormonal pills and injections—accessible to millions of people throughout the world. But for years their campaign was opposed by two powerful forces. Eugenicists knew that white, middle-class women were more likely to use birth control than other ethnic groups or the poor. Making contraceptives more available would therefore only exacerbate what they saw as the problem: the swamping of the Nordic and Anglo-Saxon races by imbeciles, blacks, Asians, and eastern and southern Europeans. Meanwhile, the Catholic Church, bent on preserving its doctrine that procreation must be the primary purpose of sex, declared contraception sinful.

Two fascinating new books, Fatal Misconception: The Struggle to Control World Population by Matthew Connelly and Reproducing Inequities: Poverty and the Politics of Population in Haiti by M. Catherine Maternowska, show how this impasse was finally, if imperfectly, resolved. Today, family planning services are available throughout the US and even in remote parts of many developing countries. This is largely the result of an extensive, US-led effort during the 1960s, 1970s, and 1980s. Researchers invented cheap, easy-to-use contraceptives, and a global network of governmental and nongovernmental agencies, research centers, and think tanks developed the means to deliver them through specialized clinics, mobile vans, and door-to-door community distribution programs.

The family planning movement is one of the great success stories of public health. Birth control enables women to be more economically and socially independent, which may be crucial for sustainable development in general.2 It also enables them to lengthen the intervals between pregnancies, which improves child health and reduces the risk of fatal birth complications and abortion. However, the books under review remind us that at one time, these benefits were seen by many US family planning officials as secondary to the goal of reducing the absolute numbers of people in developing countries. The urgency of what came to be known as the “population control movement” contributed to a climate of coercion and led to a number of serious human rights abuses, especially in Asian countries. Family planning experts, in promoting the distribution of new contraceptives, sometimes failed to ensure their safety, and the staffs of local programs sometimes bullied people into using them, or even into being sterilized. Coercion was never a stated US family planning policy, but in their zeal to fight overpopulation, American policymakers, agency bureaucrats, and researchers often overlooked how local officials were interpreting their directives. They also did far too little to halt or at least distance themselves from the most abusive programs.3

When I mentioned to friends who work in the family planning field that I was reviewing these books, nearly all of them expressed anger at Connelly in particular, for “dredging up” this history and for failing to emphasize the positive aspects of the population movement. After all, these events occurred decades ago, and today funding for international family planning programs is severely threatened by religious conservatives in the US Congress, some of whom equate taking birth control pills with “murder.” These books only add “fuel to the furnace” in which the Christian right would like to incinerate family planning, one expert told me.

He had a point. Most family planning programs were not coercive and Connelly does dwell excessively on those that were and far too little on the benefits of contraceptives to individuals and even entire societies. But Connelly and Maternowska also have a point, which is not only about the unintended harm caused by well-intentioned but poorly run development programs. The mistakes those programs made— and not Connelly or Maternowska, who merely report them—provided fuel for the religious right, and these books, though painful to read, contain many valuable lessons for anyone who cares about making development programs work, both technically and politically.

These writers arrive at similar conclusions from different perspectives. Catherine Maternowska is a feminist anthropologist who spent several years observing the collapse of a particularly disastrous family planning program in Haiti. Connelly, a historian of the cold war, is an outsider to the partisan strife in the population field. His only declared source of bias is that he comes from a family of eight children. Both authors endorse the right of women everywhere to control their own fertility and support US funding for family planning services overseas. But they both argue strongly that programs narrowly focused on cutting fertility rates alone often fail, even on their own terms, when they overlook the many other priorities in poor people’s lives.

Until the late 1940s, world population growth was a concern mainly for eugenicist cranks. Demographers were aware that population was soaring—it had doubled in the previous three hundred years and they rightly predicted it would triple in the next sixty—but most maintained there wasn’t much you could, or should, do about it because population would stabilize on its own. Improved living standards, including better nutrition, health care, and education, led to the survival of more children. But at the same time, urbanization and wage employment, along with a growing culture of individualism, consumer aspirations, and secular patterns of thought, created a general desire for smaller families.

The fastest route to lower birthrates was therefore through development and modernization, and the best way for governments to reduce population growth was by investing in human welfare, especially in health care, education, and the reduction of poverty. Promoting birth control and opening clinics would certainly help those mainly white, middle-class women who were already trying to practice family planning by whatever folk methods (withdrawal, Lysol, etc.) were available. But the overall birthrate was held to be determined by social conditions and the spread of ideas, religious beliefs, and attitudes concerning the value of having children, women’s role in the family, and so on. Already, birthrates were plummeting in many Western countries, with or without Margaret Sanger’s clinics. It seemed likely that they would soon begin to fall in the rest of the world, too, as it developed and modernized.4

Then, sometime around 1950, the demographers changed their minds. Their articles and reports increasingly referred to rising world population as a “Frankenstein” monster, as demographer Kingsley Davis put it, threatening economic chaos, ecological disaster, and wars over food. Suddenly population control was the leading edge of development, not the other way around, and the fate of the planet seemed to hinge upon the rapid expansion of family planning programs, especially in Asia.5 In 1966, President Lyndon Johnson declared that five dollars spent on population control was worth one hundred dollars spent on economic and social development. He was particularly concerned about the situation in India, where reporters and academics, including Paul Ehrlich, author of the 1968 best-seller The Population Bomb,6 were dispatching accounts of squalid, teeming slums, mass starvation, and imminent political collapse.

According to these observers, India’s population was soaring because colonialism had trapped it in a “low mortality high fertility” phase of development. The British had installed public health reforms and improved nutrition in the subcontinent, but in seeking to preserve markets for their own manufactured goods, they had discouraged industrialization. Thus the changes in norms and values and the consequent shift to be expected in an industrial society toward individualism and small nuclear families had not occurred. India’s “rigid caste system” and “other-worldly religion” made it especially resistant to modernization, according to Kingsley Davis.

While famine loomed, Johnson used food aid to pressure the Indian government to meet its family planning targets. When Johnson’s adviser Joseph Califano suggested increasing relief in advance of a visit by Indira Gandhi to the US, Johnson replied, according to Califano, “Are you out of your fucking mind? I’m not going to piss away foreign aid in nations where they refuse to deal with their own population problems.”

By the early 1970s, Bangladesh was spending one third of its entire health budget on family planning and India was spending 60 percent. These programs brought services to many people who wanted them, but sometimes did so while ignoring other needs, like the safety of those services, as well as other health care, food education, dignity, and humane treatment.

Connelly shows that between the 1960s and 1980s, millions of people in India and other Asian countries were sterilized or had IUDs, as well as other contraceptives, inserted in unhygienic conditions. Numerous cases of uterine perforation, excessive bleeding, infections, and even death were reported, but these programs made little effort to treat these conditions, or even determine their frequency, so we don’t know precisely how common they were. However, Connelly’s account gives us some idea.

One way to increase the use of contraceptives was to promote devices that required as little decision-making and technical skill as possible on the part of the user. In the 1960s, researchers came up with new IUDs and hormonal methods of contraception such as Depo-Provera and Norplant that could prevent conception for months or years; but not all of them were safe. Some of the early IUDs posed significant risks of infection, sterility, and death. During the 1960s, the US Population Council, a private organization supported by foundations and the US government, sent large shipments of unsterile IUDs to India, with too few inserters. The council officials involved must have known how difficult it is to sterilize equipment in rural India, and that contaminated inserters would undoubtedly be reused. When American patients sued A.H. Robbins Corporation in the 1970s because its defective “Dalkon Shield” IUD heightened the risk of infection and uterine perforation, USAID quietly bought up thousands of the devices at a discount for distribution overseas. As Connelly shows, they were inserted into nearly half a million women in forty-two developing countries before they were finally recalled in 1975.

As side effects made IUDs and long-acting hormonal contraceptives increasingly unpopular, locally run and US-supported family planning programs kept up their quotas by urging men and women to be sterilized. During India’s “State of Emergency” in the 1970s, sterilization was made a condition for receiving land allocations and water for irrigation, as well as electricity, rickshaw licenses, and medical care. Connelly quotes a Swedish diplomat touring a joint Swedish/World Bank population program at the time who admitted, “Obviously the stories…on how young and unmarried men are more or less dragged to the sterilization premises are true in far too many cases.” Indian officials recruited many men and women for sterilization programs by paying them nearly three times the annual wage of the average Indian at the time. Especially in the poorest areas where food was scarce, large numbers of people volunteered for sterilization, including a sizable number of women in their fifties and men in their seventies and eighties.

  1. 1

    Ellen Chesler, Woman of Valor: Margaret Sanger and the Birth Control Movement in America (Simon and Schuster, 1993).

  2. 2

    UN Population Fund, “Population and Poverty: Achieving Equity, Equality and Sustainability,” 2003.

  3. 3

    Thanks to Professor Susan Watkins of UCLA for discussions on this point.

  4. 4

    Regine K. Stix and Frank W. Notestein, Controlled Fertility: An Evaluation of Clinic Service (Williams and Wilkins, 1940).

  5. 5

    See Simon Szreter, “The Idea of Demographic Transition and the Study of Fertility Change: A Critical Intellectual History,” in Health and Wealth: Studies in History and Policy (University of Rochester Press, 2007); Denis Hodgson, “Demography as Social Science and Policy,” Population and Development Review, No. 9 (1983), pp. 1–34.

  6. 6

    Ballantine.

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