Contraception/Chapter 14

Before indicating the ideal, or even describing the actual, birth control clinic in this country some further mention ought to be made of the pioneer Dutch clinics already noted in the historical section.

In Holland the first birth control clinic in the world was founded and carried on by Dr. Aletta Jacobs (see also p. 297 ante) and arising out of this grew a widely-extended service of clinics, staffed with specially trained nurses, in a large number of Dutch towns. In a recent letter to me, Dr. Rutgers of the Dutch League wrote: "In all large towns we have sub-divisions, as local centres for spreading knowledge. 7,000 members support us by their annual contributions. Moreover, we have educated many nurses to help women in the application of appliances, who give their consultation hours (at our clinics) where well-to-do people pay full, and poor people are helped for less, and even in some cases ​gratuitously." "Now when information is asked by post we send in suitable cases the practical leaflet giving a minute description of all methods of prevention. We send it cost free and post free to every sincere applicant giving his address and the names of himself and his wife (or herself and her husband); we send it as printed matter that cannot be opened by the way. Last year we spread 5,600 copies in Dutch, and many also in foreign languages."

The nurses at the various Dutch clinics not only advise individual women as to the best method to employ, but also supply them with a well-fitted pessary, and teach them how to adjust, remove, cleanse and care for it, and for this make only a nominal charge of about half a crown. They advise also against abortion and the use of drugs, and give general instruction in sexual hygiene.

It seems a very remarkable thing that clinics which have been so successful have not been universally adopted by all civilized countries.

The American attempt to imitate them in 1916 was at once stopped by the police, and when I visited New York in 1921 and spoke at an influential private meeting, although a sufficient sum was subscribed ​by American ladies that afternoon to open and support a clinic, a way devised to keep it technically within the law, and the management left in very influential hands, the actual clinic has not yet materialized (1922, Nov.).

People interested in control of conception in England have talked for years of the need for clinics, but no very definite attempt to found one was made till 1917. Then the offer by Mr. H. V. Roe, the aviation pioneer, of support for a birth control clinic, to be attached to St. Mary's Hospital, Manchester (already mentioned on pp. 314 and 324), was accompanied by a detailed statement of suggestions for the proposed foundation, among which the following is of sufficient interest to be put on record.

Dated 1917, the schedule was as follows:—

The proposed—

"Organization.

"Staff.—Male Doctor for male patients and Female Doctor for lady patients. Both should visit Holland gaining a few weeks' experience with Dr. J. Rutgers at the Hague and with Dr. Aletta Jacobs at Amsterdam.

​"Patients.—

1. "All women who have experienced serious shock or danger in childbirth.
2. "All parents who are obviously suffering from hereditary disease or defect or too debilitated.
3. "All married people whose economic conditions obviously preclude their doing justice to more children.
4. "All married men and women who ask for it.
5. "Midwives and nurses should also be instructed.

"Methods of Instruction.

"By printed pamphlets clearly describing the best contraceptive methods and precautions, and the cases in which birth control should be exercised.

"By demonstrating the use of Mensinga and other pessaries, douching, &c.

"Special information to those suffering from venereal or other hereditary or contagious diseases as to importance of avoiding conception and the precautions which may be taken to avoid communication to wife or husband.

"Special information in case of malformation.

​"Information concerning the obtaining of the best and most economical appliances.

"N.B.—A stock of pessaries, syringes &c., for free distribution to poorer patients and for purchase should be available."

The first Clinic actually to be founded in Britain however, was not attached to a hospital, but was opened as an independent institution, and this scheme therefore was modified to some extent. The actual British Birth Control Clinic is less a copy of the Dutch model and has more individuality of its own than might have been the case had not the physiological and constructive side of control of conception received special attention in England just about the time the Clinic was founded.

Although my husband and I were the founders of the first British birth control clinic, nevertheless I do not consider that more birth control clinics as independent institutions should be necessary. The obvious and proper places for the poorer classes to obtain contraceptive information are the Ante-natal Clinics and the Infant Welfare Centres, which they may be attending. All the necessary machinery for the distribution of contraceptive knowledge to the poor we have already in these centres and clinics. But it is lying idle for want of the national ​will to use it. Ante-natal and welfare centres are now provided in almost every district and subsidized by the Government, and they possess almost all the necessary equipment already. The few additions that they would need would be official encouragement, a breath of beauty and inspiration and the determination to have on the regular staff only such medical men (or preferably medical women) as are versed in contraceptive details and who possess so sympathetic a manner and attitude as to encourage the confidences of the timid inquirers who come and need help in the very intimate details which so often surround the problems of contraception and the marital relation.

Medical knowledge pure and simple is for these poor women not sufficient. They need deep personal understanding and help, not only instruction in the use of the method which will secure them freedom from conception, but also sex-lore which might make possible for them something like a normal sex life with their husbands, a happy state of affairs which is so incredibly difficult in the majority of poor homes to-day.

In the present transient stage of British society the one, first, birth control clinic as an independent institution was absolutely necessary. It may not be a permanent ​institution. But until many further reforms take place, both in society itself and in the details of our medical service, it is necessary that there should be not only this, but also many other centres in which experts in contraceptive measures are to be found by those who need their assistance, and who are not able to get adequate information in other ways. More especially for the really poor and very overburdened mother and the typical slum dweller who neither travels nor reads is the presence of a sympathetically staffed clinic, not too remote from her own dwelling, of great importance in guarding her own health and in the interests of the race. Unless experience in the clinic has brought first-hand knowledge of how some of the poorest women live it may not be realized how impossible it is for many a working mother to go any distance from home even for one day.

The patrons and staff of the Clinic have already been recorded (see Chapter XI, p. 324).

The simple equipment of this actual Birth Control Clinic^[1] (which has accomplished successfully a year and a half of work) may be described, as it may prove helpful to ​those desirous of having such a centre in a district too remote to make it possible for the promoters to visit the Clinic in London.

Two rooms are sufficient but three are desirable. The present clinic is worked with three small rooms and a fourth available for storage, filing and so on. The room space of any ordinary welfare centre should be adequate.

In order to make access to the existing clinic inconspicuous and easy, the ground floor and a small shop in an ordinary quiet thoroughfare in a poor district were secured, the shop window curtained off and the name, "The Mother's Clinic" painted on the shop front. The shop itself forms the outer reception room and its furnishing and decoration were specially chosen to have a psychological effect, namely that of health and sanity and as far as possible beauty. The accompanying photographs give an adequate indication of the Clinic which depends so much on its colour scheme for its attraction. The parents visiting this clinic are desired to feel that they come not to discuss disease, nor to be subjected to an operation but to discuss in an inspiring way in attractive surroundings one of the greatest and one of the most racially vital questions which arise. in their lives. The colour scheme is clear ​bright blue and white and the furniture that of an ordinary room with blue-toned pictures on the wall. The nurses wear a blue and white uniform: both are fully qualified midwives. The personality of the nurse-incharge is a very important factor in handling cases, particularly of women who are very unhappy and of an undermined temperament such as the weary workers of the slums. The Clinic is open daily and twice a week is open late in the evening so that the husbands, if they desire to do so, can come with their wives after work hours. No letter of introduction is necessary, and no fees are taken. Any mother or father who desires to do so can walk in at any time.

The procedure is as follows: After the case is talked over and general help and advice given, if definite instruction in the use of the cap or other preventive is found necessary, the nurse takes the inquirer to the inner room which is more severely furnished and provided with an examination couch, wash hand basin, disinfectants and a screen. Here, particularly if the cap (as is usual) is the method of control advocated, the nurse makes a simple digital examination (of course wearing rubber gloves and disinfecting adequately) to ascertain whether the uterus is in the normal position or ​whether there is serious prolapse, or any injury or malformation of the cervix. Where malformation or any difficulty or abnormality is detected an appointment is made with the visiting medical specialist who advises various methods according to the needs of each case In normal simple cases, after digital examination to verify the normality, the nurse can generally estimate the size of the cap advisable. A cap is then inserted and the woman shown the proper posture, squatting on her heels, and slightly bending forward. The cap is then removed and the woman told to insert it herself, to move about and then to allow the nurse to feel whether it has been placed properly and reliably. Few women require a second instruction, but the friendly atmosphere of the Clinic and the sympathy of the nurse encourage them to come again if any difficulty arises.

The correspondence and secretarial work of this Clinic are done partly in the outer reception room and partly in the third room. The correspondence and demands for help from a distance would be almost non-existent were such clinics available in every district. At present this one Birth Control Clinic serves not only London but Great Britain, and even Greater Britain, and also ​to some extent even foreign countries in all parts of the world, so that the correspondence is unduly heavy in this pioneer Clinic. Individual inquirers by post are answered so far as possible, but in a general way all that can be done in regard to inquiries from a distance is to send them a copy of the simple pamphlet entitled "A Letter to Working Mothers" with any supplementary advice and help which may seem necessary, and to instruct them where to obtain the appliances from reliable firms rather than to submit themselves to the extortion and dishonourable dealings of too many of the so-called "rubber shops" and doubtful retail chemists.

As was indicated in the preceding pages this Clinic handles birth control from its broadest and truest aspect, namely that of "CONTROL" which implies the use only of methods which leave later conception potentially available, and also implies the positive side, namely, the inducement of conception where couples are childless and desire children and are themselves healthy. This positive side of the Clinic's work, of course, requires a much wider knowledge than is necessary for the use of the simple contraceptive measures, and it is interesting that even in the short time that this aspect ​has been accentuated, a considerable number of persons desiring children have used the Clinic with benefit. Unfortunately, however, far too many who come are childless due to long cured venereal disease or some other fundamental sterilizing influence which makes it impossible to render assistance. Yet it is surprising how many also come whose childlessness is due to lack of sex knowledge and who can therefore be rendered fertile by simple methods which they themselves are able to carry out. It may appear incredible but I have had one or two cases even of perfectly intelligent normal people who did not know how coital penetration was effected and who had been married some years. In many cases, however, some elementary lack of adjustment in the coital act is at fault and can be put right by very simple and direct instruction. In a book on contraception, however, as distinct from Constructive Birth Control, a discussion of this aspect of the Birth Control Clinic is out of place.

After careful consideration it was decided that, desirable though it would be to have the fullest and most elaborate details recorded about each patient who used the Clinic, yet it is humanly impossible to ascertain all the facts a scientist might wish for without ​thwarting the object of the Clinic and frightening away the people who most need help and whose whole temperament and outlook are disposed to make them shrink from and fear any kind of categorical inquiry.

In designing the case sheets therefore it was endeavoured to draw the mean between a standard of impossible though desirable detail, and the minimum of those factors which might prove useful in any future consideration of the case. The case sheets have spaces for the Number, Name, Address, Husband's name, Age at Marriage, Husband's Age at Marriage, Date of Marriage, and twelve columns for the births already existing, with spaces for the Date of each Birth or Miscarriage, a note whether still living or dead, and the Duration of Pregnancy. Also further notes on the Mother's history, Father's history and details about the children, if these are volunteered. It should be remarked that quite often the twelve columns are not sufficient for the pregnancies when abortions and miscarriages are taken into account, as, of course, they should be in every consideration of woman as mother.

It should be noted that from the point of view of economy and convenience of filing, the sheets were made the same size ​as an ordinary quarto sheet of typewriting paper. They are so arranged as to be folded backwards in half and filed with the folded edge uppermost, which gives each the necessary stability to form a convenient file on the card index system, and also makes it possible for the nurse to withdraw the record from the file on a second visit from the patient and consult it without the patient perceiving the nurse's more intimate comments on the case which are folded on the inner side.

As it is possible that those who practise among the wealthy classes may have forgotten their student training in the slums, and still feel that birth control information is not required, the following few sample letters from among our many hundreds are selected as typical of the misery and anguish, to say nothing of the national wastage involved when working women are left unaware of methods to control their conceptions; other cases have been given on pp. 29 and 368.

No. C.C. 10. "After reading Lloyd's News^[2] to-day, I felt I must sit down and ask your help. I cannot get down to you, or I would like to. Birth Control I cannot understand. I am the mother of ten, nine born alive, one premature through the ​raids. My eldest 24 in August. My baby 1 year 9 months. We are poked up in three rooms because we cannot afford more rent than 11s. 6d. I own the eldest is living away as barman but is home rest times. Do you think it decent for me to have more babies ? Yet I have nearly poisoned myself with drugs to keep them away. Again the unpleasantness between my George and I are awful, for I fear I will drive him to other women in my fear of having kiddies. So after reading about the Mothers' Clinic I had to write to you. We cannot keep those we have got as they should be kept. I have tried hard all my married life. George earns £3 a week, one girl 19 gives me 15s., the other 16 is doing two days a week, then there is Harry, Sonnie, Bubbles and baby. Can you imagine my struggle? If you would write references to the truth of this write to Mrs. —— [full address given], she will tell you, but of course she don't know I am writing as she is very good and says I ought to be proud of the gift of babies, but I am so tired of them, all these years babies, babies. So please tell fine if I can help having them."

No. C.C. 23.—"I trust you will excuse the liberty I am taking in writing to you, ​but I must say it was with the greatest pleasure I read about you in the article in Lloyd's Sunday News, but my one regret is that this has not been brought forward sooner or it may have saved me months of misery, but I really ought to explain my position. I am a railway signalman with only a small wage. I have been married between eight and nine years and I am now left with five little children, the last one proving too much for my poor wife's strength, and now the poor woman is in —— Asylum, but happily is recovering nicely from her mental breakdown. She has now been there a matter of ten months, and I must leave you to imagine my awful misery and sometimes the thought that it is my fault; it is very hard when one has tried their best. I understand that there is now a likelihood of her returning within the next few weeks, and the doctor informs me that there must be no more family (and God knows I do not want any more for I have more now than my wage will keep properly), or he would not say what the consequence would be, but yet he never offers any advice, so seeing your letter and the article I decided to write to you. If I have taken too much liberty in doing so I trust you will excuse me and this I am sure ​you would if you had only seen how my little children have missed their mother this last ten months you would then understand. May God bless your work and may it prosper for the sake of the poor."

About six months after the Constructive Birth Control Clinic was opened, the Malthusian League opened a Welfare Centre at Walworth where birth control information is given on demand in addition to the usual Welfare Work. The Centre is in charge of Mr. Norman Haire, M.B., who uses chiefly the Dutch cap. The objections to this for normal people have already been noted (p. 162). The Centre, however, attracts the very poor and neglected types of women and it may be that an unduly high proportion of these are injured so as to be unable to wear the cervical cap.

There are many demands for other Clinics and Centres in poor districts. Once a Birth Control Clinic is established in every district, as it should be, and once the cases where the women themselves are intelligent enough and only too eager to use methods of contraception have been dealt with and supplied with knowledge and appliances, there will remain the urgent racial problem of dealing with those who ​from every national point of view ought not to produce the unhealthy and degenerate infants which they are now producing and who therefore should be sterilized. Whether future developments will associate a sterilizing Department with the ordinary Birth Control Clinic is, in my opinion, doubtful. The best procedure seems to me to hand on the sterilization cases to the ordinary Surgical Departments of the Hospitals prepared to receive them in their surgical wards. For this, of course, public opinion must also press, as the average surgeon is still afraid to be known to take on sterilization cases.

Meanwhile the foundation of pure contraception among the poor has been laid, and there has been for a year and a half a Birth Control Clinic in active work in England, which has given help not only to over fifteen hundred women personally, and to thousands by correspondence, but also to a large number of nurses, health visitors, welfare workers and medical doctors, who have spread and handed on knowledge gained there. This Clinic was founded to inform those who so badly needed its help, and to crystallize and advance public opinion, and is for that very reason debarred from experiment in new contraceptive ​measures or from testing the results of novel researches. The poor women who come so trustfully for help must be given information which is at any rate as reliable as anything available at present. A group of better class and perhaps more intelligent women to whom an unexpected pregnancy is less of a disaster could perform very useful social service by placing themselves in communication with the Clinic in order to test new methods which might be devised.

The practice of contraception is in many ways the connecting link between health and disease. When used by the normal individual as a health measure its essential value and purpose is to keep that individual healthy and out of the hands of the doctor, yet it often shows the need for medical attention which has been overlooked.

The prime object of the medical profession being the health of the community, a full knowledge of contraception should be one of the doctor's most useful adjuncts. When used by diseased persons contraception becomes the great preventive measure to arrest the spread of disease and degeneracy throughout the nation.