Birth Control: The Case for the State

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From Manteo, on the North Carolina coast, to Murphy, N. C., beyond the Smokies, is 618 miles by highway. Yet only three points on that long road are more than twenty miles from a state sponsored birth-control clinic. No spot in all the big state is more than fifty miles from such a centre. North Carolina, the first of the forty-eight states to promote birth control officially, is going at the job in earnest.

North Carolina is pioneering because it has a public-health officer who spent twenty-five years as a country doctor, practicing among North Carolina's poor. He knows why North Carolina has virtually the nation's worst record on all matters connected with births. Ignorance, poverty, insanitation, disease, poor hospital facilities, little if any prenatal care -- all these contribute to infant and maternal mortality rates that are truly appalling.

Of each thousand mothers, twice as many die in North Carolina as in Connecticut. The chances that a North Carolina baby will die in its first year are 66 in 1000, compared with Connecticut's infant mortality rate of 40 and the nation's 54. Some 20,000 North Carolina mothers each year are attended by midwives, most of them untrained and ignorant of asepsis. Abortions and infanticide are rife, especially among the large Negro population. If the nation bred at the North Carolina rate, we should have a crop of 700,000 more babies a year. That might be wholly desirable -- but not if the extra babies are born into indigent, dirty homes where they are not wanted and where their chances of survival are poor.

To improve conditions so that dirt, poverty, and disease will disappear is, of course, the ideal solution. But that, to put it mildly, will take time, involving long-term medical and economic campaigns on a dozen fronts. Birth control, in the meantime, offers immediate help. Its advocates point out that at least the family without much to eat ought to have the choice as to whether it wants to bring another high chair to the table. Birth control, they say, can help to stop the infant and maternal carnage and in the end build a healthier and perhaps even a larger population.

So, too, believed Dr. George M. Cooper, to whom the appalling statistics represent people he knows. Dr. Cooper is a native of the Tarheel State, and during a quarter century of country practice he listened, observed, and sympathized. He knew many a girl wife living in a two-room mountain shack with six children and a tuberculous husband. He had heard women tearfully beg, 'Isn't there something we can do?'

He had seen a Negro couple married seventeen years who had produced twenty children -- twelve of them to die in infancy. Good, hard-working people, desperately poor -- bewildered. 'I'm for any way that will keep me from having another child,' the mother pleaded. 'Any way so long as I can keep from losing that man I got.'

When he became director of preventive medicine of the State Board of Health, Dr. Cooper preached to fellow physicians and laymen alike that North Carolina could not climb far toward better health and happiness without birth control for the poor. But his hands were tied. Unlike most states, North Carolina had no law against spreading birth-control information, but there was always the federal law -- the old Cornstock law, dating from 1878, which frightened every physician in the country into complete silence with its untested but threatening provisions. It was not until the autumn of 1936 that the federal courts ruled the law could not prevent physicians from using contraceptives 'for the purpose of saving life or promoting the well-being of their patients.' That was the battle Margaret Sanger won. It freed the doctors, but it wasn't much immediate help to those who most needed help. There were no funds for birth-control clinics, and Dr. Cooper knew the futility of taking a contraceptive promotion program before a state legislature. The situation seemed hopeless as ever.

Thereupon Fate interposed a finger. Years before, Dr. Cooper had counseled a young woman who wanted to become a nurse, had suggested Roosevelt Hospital, New York, for her training, had kept in touch with her. In 1937 she was nurse in charge of an experimental program, giving birth-control information to the natives of the densely populated little island of Bocagrande, off the Florida Everglades. The work was being financed by Dr. Clarence J. Gamble, an heir of the Procter and Gamble soap fortune, who lived in Philadelphia. Homesick, Roberta Pratt kept talking about North Carolina, and eventually she got Dr. Gamble interested. One day she was able to send word to Dr. Cooper that the philanthropist was willing to provide the funds for a three months' program in the Tarheel State.

Dr. Cooper looked the gift horse straight in the mouth. He said he would accept a year's financing -- not three months -- if no strings were attached to the gift. There were long-distance telephone consultations. Dr. Gamble agreed, put a check for $929,250 in the mails for a starter, and on March 15, 1937, Dr. Cooper had the only state health department in the United States at work on birth control.

He realized that he was out on a limb. Although he had the backing of his chief and some important laymen, his program was launched without the formal endorsement of any North Carolina organization. He was warned the limb might break. It hasn't broken.

II

When the North Carolina plan was launched there were only three birth-control clinics in the state. By the end of 1938 the state had created 56, and North Carolina, with less than 3 per cent of the national population, had 13 per cent of the nation's birth-control clinics. It now has a total of 692; only New York has more. They are situated in 58 of the state's 100 counties and, since patients are permitted to jump county lines, provide a state-wide coverage. The 58 counties participating had 50,565 births in 1937 -- a figure which is topped by only 18 entire states.

And this coverage was attained quietly and without ballyhoo. When the program was nearly a year old, there was a bare announcement that it had been endorsed by the Federation of Women's Clubs and the powerful Conference for Social Service. That is the only official public mention of contraception the state has made.

In furtherance of this policy, Dr. Cooper has never tried to force birth control upon any county. Dr. Gamble's funds -- he has extended his financing to 1940 were used to buy contraceptive supplies and to provide a consultant nurse, Miss Pratt. The state made these supplies and services available to any county health officer who wished to set up a contraceptive clinic as a part of his existing county health unit.

County health officers were asked to get the opinions of local physicians individually rather than at meetings, which might lead to unmanageable debates Particular caution was used to prevent public controversy. When opposition developed in one county Dr. Cooper called off all activities there, reasoning that it was better to lose a county than to risk losing the whole state. He was like a general employing a deep elastic defense and refusing to let the enemy come to grips with him. His program was in operation for eight months before he even broadcast a general letter telling county health officers he had a program. By that time he and his assistants, Dr. Roy Norton and Miss Pratt, had clinics going in most of the strategic counties.

The prestige of these clinics was adroitly used to persuade other counties to follow the leaders. On one occasion a health officer didn't think his county needed contraception. He was asked to check his vital statistics. When he discovered that the Negroes were accounting for 85 per cent of the births he quickly changed his mind.

But statistics were sometimes useless. One county, with notably horrible maternal and infant mortality records, has no clinic to-day for the reason that the question was put to its county medical society the day it was meeting for a fish fry. The atmosphere was wrong; opposition cropped out which the health officer couldn't handle; once aroused, it solidified.

But time is on Dr. Cooper's side, and he can afford a delaying action. In one county he ran into a health officer of ancient vintage who condemned birth control as a sin. The issue could have been forced and probably won, but Dr. Cooper bided his time. In eighteen months the county had a new health officer and Dr. Cooper had an extra clinic spotted on his map without having risked his whole war on a minor skirmish.

County autonomy extends to other matters. Each health officer is free to run his clinic as he wishes, to use the simple technique which the state advises for the poor or to lean more heavily upon surer but more expensive individual examinations. In some counties the nurses carry information into the homes, while in others they bring the mothers to the county health office. Some clinics have secured appropriations for materials from the county commissioners; others depend upon donations from individuals and organizations such as the women's club. In Winston Salem, where young socialites have assumed financial responsibility, a pamphlet giving dates for clinics goes out with every birth certificate. Some of the counties try to make their funds go further by getting patients to pay anything they can -- even as little as ten cents. In one county where there is a homestead project, the contraceptive clinic actually has the financial support of the Federal Government. Thus, directly and indirectly, federal, state, county, city, and private funds are all working together.

At the end of the second year of state contraception the clinics had provided instruction and materials for 2000 women. The present year may see this figure doubled. Of course, that is only scratching the surface of the need; North Carolina has more than three quarters of a million persons receiving financial support from governmental agencies. The nurse in charge of one staff told me her centre alone would have 1200 clients if funds were available. But Dr. Cooper's idea has been to build firmly and then expand. Before the state program was launched, the clinics in North Carolina had only 64 patients. The 2000 women -- by now closer to 2500 -- are people who cannot pay for medical care, a fact certified in each case by a welfare officer or a private physician. And to each one of these 9,500 women a pregnancy would be actually, or nearly, a tragedy.

Already the state has files of letters and case histories which constitute a social Magna Charta. Most of the letters are written in pencil on the kind of rough, ruled paper sold in country stores. Some are from women seeking information. Some are from women who have had the service and want to put their thanks on paper -- naïve but honest letters. One closes, 'Come out to see us and I will give you some melons. We have some real nice ones.'

But let's run across the state's three sections and glance at a few typical beneficiaries of state birth control: Negro tenant farmers in the flat, piny coastal plains, textile and tobacco workers in the rolling industrial Piedmont, and then the mountaineers themselves. In a cotton county, fifty Negro women appeared at the clinic the morning it was opened. One woman of thirty nine, married nineteen years, had ten children; her husband didn't make enough to support the family, so she took in laundry.

A cotton farm tenant's wife of twenty five, married at sixteen, had six children in seven years, four boys and two girls, all delivered by midwives in a small, unscreened shack. Water supply, questionable; sanitary facilities, none. After her fifth pregnancy this woman asked, 'Isn't there something you can do?' and the county nurse -- this was before state contraception -- had to admit there wasn't. A few months later the nurse found the woman in tears -- she was pregnant again. But her sixth child came at about the time the county set up a birth-control clinic. That was in the fall of 1937, and there have been no more children; this slender little Negro woman is now bright and cheerful; when she gets to town she usually drops by to tell the nurse how well her children are doing.

The Negroes in the industrialized Piedmont towns are also being helped. Here are my notes on one case: husband forty, wife thirty-eight. Husband has cardiac and kidney trouble -- unable to work, though he has tried to get jobs. Moved to city from tenant farm. Wife -- one of ten children -- has had thirteen, four of them born since family became charity case. In 1938, trying futilely to get on relief; that year had tenth child. In 1936, receiving fuel, groceries, and clothing from local charity; that year had eleventh child. Wife had factory work at six to seven dollars a week, but was laid off just before New Year, 1937; that year received food orders, did piecework at home along with children, and had twelfth child. Continued to receive cash, shoes for children, and then had thirteenth child, a seven-months baby who died after one month. Early in 1938 became Case No. -- at the newly opened contraceptive clinic.

But most of the Piedmont cases are whites who came to the mills from the red-clay farms. Here, in one cottonmill centre, is a mother, forty-one years old, married twenty-four years, who has had eleven children; when she came to the clinic her husband had lost his job and she was unable to get work.

A few houses away is a woman who in sixteen years of married life has had ten children; her husband was on WPA when a welfare officer sent her to the clinic. Incidentally, there are no statistics to show what percentage of patients are on relief, but I rarely turned over three cards without seeing one marked WPA.

In the mountains, state contraception seems to reach dramatic heights. The nurses start on their rounds at eight thirty each morning, pushing back into the hills and hollows and up the forks of the creeks to cabins where human life has never been given a particularly high valuation. But the women are now eager for birth-control information. A nurse went to a schoolhouse to give instructions on making a sickbed; she found fifteen mountain women there in bonnets and faded calico dresses -- all wanting to know about birth control. Saturday is the big day for these people to come to town, and on Saturday the mountain clinics do a thriving business.

Frequently a nurse visiting a sick child will notice the mother motioning toward a corner of the room. The nurse knows then that the mother has been listening to a neighbor and wants to get information first-hand.

I saw a sick husband and an overworked wife huddled with their five little children in two filthy rooms with but two beds; and a twenty-nine-year-old mother, married twelve years, with nine children, who was obviously in such physical and mental condition that another pregnancy would endanger not only her life but that of her children.

See these people, and you are forcefully impressed with the need for more money, more clinics, more nurses, and more health officers. The state Maternal Health League is now organizing citizens' committees in each county to give contraceptive clinics additional moral and financial support. These pressure groups will work on county commissioners for appropriations, and eventually they may try to get something in the state budget.

Iv

The by-products of the North Carolina program are as significant as the program itself. Two of the largest manufacturing plants in the state have set up birth-control clinics for their employees. One of the plants has placed printed slips in payroll envelopes telling employees that the firm's physicians and nurses may be consulted. All this has been done quietly, to prevent the possibility of a boycott, but as word seeps out over the state other mills may follow suit.

The state contraceptive program has also had its effect on private physicians, many of whom were formerly asking, 'Is it legal?' To-day they have no fear of being caught on a technicality. The druggists tell me that more and more women are bringing in prescriptions from their family doctor. The older doctors are brushing up on modern knowledge.

At Duke University, Dr. Bayard Carter is carrying on fundamental research with contraceptive cases which were not available until the state made a clinic possible in that county. Dr. Carter may one day emerge with data as significant medically as the program is socially.

South Carolina, after watching its sister state for two years, recently launched a parallel program. Georgia, spurred by resolutions of both its State Medical Society and its Conference of Social Work, is about to make a decision. Arizona has shown lively interest, but has not yet moved into action. It looked for a time as if Tennessee would be first to follow North Carolina's lead, but politics has stalled progress there. Inquiries pour in from all quarters, and the first birth-control paper ever read at a meeting of the American Public Health Association described the North Carolina plan. Other national organizations are asking for similar presentations, and sending observers to make reports.

Important as are the results of the program to North Carolina itself, the greatest importance of its pioneering may well be the example it has set for others to follow.

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