Contraception/Chapter 3

AS will be seen in the chapters dealing with the history of the subject (p. 264), enlightened medical practitioners have for over a century spread information on contraceptive measures among their patients.

Yet in regular practice at present individual doctors still differ much in their willingness or otherwise to hand on to their patients what contraceptive knowledge they have. Cases such as the following are, unfortunately, still prevalent.

Case B. 200.—A very poor and delicate woman who has several children and nearly died with each childbirth. Doctor attending her told her she must have no more, and when asked how it was to be avoided replied "Find out." As her husband at times gives way to drink, she must have a means entirely within her own control.

Case 753.—Will tell her story in her own words. "I myself am an ex-nurse. I ​trained at —— Hospital fifteen years ago. I married my first husband, a dentist, on completion of my training. I had a very serious premature seven months' child the second year of my first married life. Then one year eight months after I had my little boy. He is now 10½ years. Then one year eight months after I had my little girl. She was a posthumous child born six months after my husband died. Fifteen months after the death of my first husband I married this second one, a school friend of the first, now 54 years. He had previously been married to his first wife twenty-three years and never at any time had they any children or even signs of any. I married him in 1913 and in spring 1916 I had a little daughter, and in November, 1918, another. It causes a lot of unpleasantness. My husband is a middle-aged man and a bad heart case and not at all strong (and by the way out of work two months now). I am in very bad health now, debility, tubercular and heart trouble. I have been under treatment the last six years. What right have we to bring children into the world? It takes me all I know to do the ordinary housework of a small house and keep the little ones clean. The boy and girl have had phthisis and it has taken me five years ​of great care and nursing to get them right and it is only a month ago I had them declared free from all signs. Now baby is under suspicion. I am so afraid of conception I cannot bear for my husband to even speak kindly to me, or even put his hand on my shoulder for fear he wants his rights. And it causes a lot of anger and misery. It is two months since I last allowed him intercourse, and many times it is much longer. I may say I am 37 years old last July and in each confinement I have been told I was not a fit or strong enough woman to have children." [And she was left ignorant.] "Do please help me if you can."

The following letter also is unfortunately not an account of a unique experience: ". . . a doctor whom, at my wife's request, I asked to provide the necessary article, charged me £1 1s. for ridiculing our request and advising us to scratch for however many children arrived, like the hen does for her chicks."

And one's heart is wrung by such cases as C. D. 1054, supplied to me by the medical practitioner who attended her end. She was married young to a man with syphilis and she had in all twenty-four miscarriages and then died of paralysis of the lower half of the body.

​Recently, however, several medical practitioners who might fairly be described as not particularly favourable to the idea of voluntary parenthood have published statements of a modified approval of contraception under certain conditions. Such, for instance, as the paper by Professor Louise McIlroy, M.D., who said^[1]: "The reasons for the exercise of birth control should be medical only, and should be considered from two points of view, viz., that of:

1. The Individual—as to possible danger of pregnancy.
2. The Community—as to the undesirability of the propagation of the unfit."

Whatever division of opinion there may still be about the advisability or otherwise of contraception in individual cases there appears to me to be no possible ground for refusal to tell a patient what means to pursue to prevent conception when that same patient has been told that her life is risked, or that serious consequences to the offspring are to be anticipated, were pregnancy to occur.

It is self-evident that all cases in which, were pregnancy to intervene, an evacuation of the uterus or an induced therapeutic ​abortion would be inevitable, are clearly and indisputably cases for instruction in contraceptive methods. It is surely also reasonable to conclude that all cases in which such evacuation or abortion are likely, are also cases for such contraceptive instruction.

Individual judgment may vary, as it depends largely on theological and other considerations in addition to the purely medical, so that an individual's attitude towards contraception and medical abortion may differ in accordance with the personal ratio of knowledge, temperament and judgment in estimating the amount of maternal danger involved.

The above, however, assumes that the woman herself, the potential mother, is to have little or no choice in the matter of her own pregnancy, and is to rely solely on her medical adviser to decide her fate in this respect. How much longer the public will be willing to take this attitude or submission is, of course, open to discussion.

Few impartial persons endowed with sympathy and humanitarian feelings would deny the right of the mother in such cases follow to have the best contraceptive knowledge available; or would deny that to permit further pregnancies would be little else than sheer cruelty.

​Case C. 221.—Woman very delicate, warned against pregnancy by more than one doctor. Fourteen times pregnant between 1900 and 1921. Nine children born alive of whom four died; five miscarriages. After the last miscarriage had been nine weeks in hospital.

Case C. 866.—Age 40, looks older, sight very bad. Hates and loathes the sight of her husband who gives her no peace. Has been seventeen times pregnant between the years 1903 and 1922. Pregnancies as follows: the first three children lived, then followed one who. died a few months after birth, two who died at birth, one bad miscarriage. Of the remaining ten pregnancies only four lived, and three were born at eight months, two of these lived a few hours and one lived ten months. From the total seventeen pregnancies, only seven living children resulted.

Case C. 456.—Very fertile, had four children in five years: husband says he "has only to look at her and she is pregnant." Had used withdrawal and douching, both of which failed. At the first pregnancy instruments were used and the perineum torn, at the second chloroform and instruments, and the third was a twilight sleep case and the child (♀) lived ​only a month. She is taking salts every morning and quinine every night, and said she would just as soon kill herself as have more children.

Case C. 1156.—Deaf. Has had eleven pregnancies, one child only, the eldest, living. Ten of the pregnancies terminated at the seventh month and though the children were born alive none lived more than a few months and some lived only a few days.

Case C. 1167.—Fifteen times pregnant since 1900. Eight living children three who died as imbeciles in the second year, and three miscarriages.

Case 466.—Seven times pregnant, the first child born at 5½ months, the second at seven months which only lived 3½ hours. Acknowledges two abortions, one brought on by salts and the other by "French capsules."

Case C. 366.—Has been in hospital for months at a time, has been told by her doctor that pregnancy may be fatal, has bronze patches all over her body, fainted several times during the birth of the last child. Pregnant eight times, the first child born dead and the sixth at six months. The last child born with twisted legs and now has very bad rickets.

​Case C. 627.—Married in 1919. In 1920 bore one child which lived only seven days. In the same year conceived again, had an operation for appendicitis and a miscarriage. In 1921 had a child which lived seven hours and in 1922 a child which lived three hours. The death certificates of the children show that all died after hæmorrhage from nose, mouth or anus.

The last case must surely make the medical profession blush.

The above are merely samples of the hundreds of cases that have come to me for the help of contraceptive knowledge.

A telling case, illustrative also of those for whom contraceptive knowledge is absolutely indicated was given from her own practice by Dr. Jane Hawthorne at the first Queen's Hall Meeting^[2] "In twelve years the woman was the mother of nine children, and of these only two were alive" . . . "Her first-born did not walk until it was 5 years old, and during that time three more children were born to her, so that in five years she had four little children to care for. The second child is very ​delicate and needs constant care, but being one of nine it is impossible to give it the little luxuries and skilled attention which might make it a healthy child. The third child was born deaf and dumb and died at 2½ years. The fourth child was paralysed and died at eighteen months. Then twins were born and those lived one hour. The next child was born at six months and died. The seventh was born with meningitis and lived eighteen months. The eighth child is very delicate, but that one still lives."

Education of all sorts is being forced on the people in Government schools: it cannot be long before they will learn that such sufferings as these quoted above are not inevitable. Let one of the mothers state her case in her own words. "What I would like to know is how I can save having any more children as I think that I have done my duty to my country having had 13 children, 9 boys and 4 girls. I have 6 boys alive now and I little girl who will be 3 years old in May. I burried a dear little baby girl 3 weeks ago who died from the strain of whooping cough the reason I rite this his I cannot look after the little ones like I would like to as I am getting very stout and cannot bend to bath them and it do jest kill me to carry them in ​the shawl. I have always got one in my arms and another clinging to my apron and it is such a lot of work to wash and clean for us all and it is such a lot you have got to pay for some one to do a days washing or a bit of scrubbing if I was only thin I would not grumble and as my husband and myself is not so very old I am afraid we should have more children yet I was only 39 on the 19th of February just gone by and the husband is 40 in July coming, we have been married 20 years come next Thursday I was 19 when I married so you can see by the family I have had that I have not had much time for pleasure and it is telling on me now I suffer very bad with varrecross vaines in my legs and my ankles gives out and I just drops doun."

That woman is obviously not very well educated: if she were, would she not have used her education to assist herself in her search for knowledge to save herself some of this misery?

Assuming, however, that the medical practitioner is to decide whether or not his or her patient shall be given contraceptive information, what are the cases in which it is clearly indicated?

Dr. Killick Millard, a medical officer of distinction, summed up the general position ​at the Queen's Hall meeting when he said:^[3] "There are very many people in our midst who on account of some constitutional taint (it may be tuberculosis, epilepsy or venereal disease) are unlikely to give birth to normal or healthy children. There are thousands of people turned out every year from the tuberculosis sanatoriums, venereal disease clinics, &c., temporarily patched up but with the taint still in the blood, although the outer manifestations have been removed," who ought no longer to go on "adding to their families with the terrible risk of transmitting that taint to the next generation."

All will agree that contraception, either permanently employed, or at any rate used over a period or two or more years, seems indicated in all multiparæ in whose histories the following are found:—

1. Active syphilis.
2. Congenital blindness.
3. Virulent tuberculosis.
4. Acute heart diseases of various types (see paragraph, p. 35, Note).
5. Kidney diseases of various types.
6. Epilepsy.
7. Leprosy.
​
8. Diabetes.
9. Marked "feeble-mindedness." [For such cases sterilization is to be preferred as they are likely to be too careless to use contraceptives effectively.]

As revealed by former pregnancies, marked tendencies to:—

10. Puerperal insanity.
11. Severe albuminuria.
12. Serious eclampsia.
13. Toxæmias (various).
14. Spinal and pelvic deformations (where Cæsarean section is objected to or not available).
15. Cæsarean section within two years.

[Note re (d).—"Heart disease is, of course, of many grades, and it sometimes arises in circumstances in which it is obviously wise not to prohibit normal coitus, but where child-bearing may be most inadvisable then contraceptives are necessary. As Dr. Blacker said^[4]: "The bad effect produced on the heart by pregnancy is, on the whole, not sufficiently marked to justify you in advising a patient strongly that she should not marry. It is true that, if she marries it will be better for her not ​to have children, and it is true that if she does have a child she should not suckle, but it is not right that a woman with heart disease should be forbidden to marry. Yet unless contraceptives are used she runs the risk of repeated pregnancies.]

While considering indications for contraception from the medical point of view it is not out of place to note the reasons guiding married women who have spontaneously adopted it. Data on such a point are, of course, difficult to get, but a very interesting paper has recently been published on the results of a questionnaire in America.^[5] Out of the first thousand replies received from normal married women 734 expressed approval of voluntary parenthood and only 78 expressed disapproval of preventive means.

Other conditions in many homes certainly point to the advisability of contraception. The following are additional and among the commonest reasons for the use of contraceptives.

16. The persistent drunkenness of one or other of the potential parents.

The medical world is now too well ​acquainted with facts for it to be necessary to point out the inferiority likely to result in the offspring of persons consistently alcoholic, and therefore the racial value of prevention in such families.

17. In homes where permanent povety or inferior wage-earning exists and where there are already as many children as the parents can bring up decently, contraception is obviously indicated rather than the saddling of the community with children of a very doubtful racial value.

To this even Lady Barrett, M.D., and the Archbishop of Canterbury^[6] assent by inference in the little book on "Conception Control," which concludes: "There are many women of the poorer classes in whom child-bearing is sometimes the last straw in circumstances all of which tend to destroy health and vitality." Although Lady Barrett advises the "safe period" as the best method for the public to use, she ignores its utter unreliability (see p. 85 of this vol.), of which she gives no warning.

18. In homes which at other times may be comfortable, during periods of extended ​unemployment it is disastrous both to the mother and the child conceived for a woman to become pregnant. "Doles" such as are granted to her do not free her mind from anxiety and misery which react unfavourably on the stamina of the child and tend to breed unemployables to swell the ranks of the unemployed twenty years hence.
19. On the part of women who as a result of very bad times at childbirth or through marital unhappiness so dread the matrimonial advances of their husbands as to suffer nervously from coitus, and still more those who even go so far as to refuse all coitus. Such cases are more frequent than is at present realized, and are the source not only of discomfort and distress to the husband and of physical detriment to the woman, but tend to social instability, divorce, the fostering of prostitution, and other evils.

In such cases as these instruction is not only required in the details of contraceptive methods but also advice on the whole art of marriage. Such knowledge as is given in "Married Love," supplemented by personal details adapted to the individual case have frequently, to my knowledge, resulted in the re-establishment of harmony in the home. Where children exist the ​advantage of this to the community is still more obvious.

Incidentally in connection with such cases as this the most difficult and obstinate to deal with successfully is the type of woman who either instinctively, or through early training or by contact with others, has acquired the view that all sex union after the procreation of the desired number of children has been accomplished, is wrong. Such views are often extremely difficult to eradicate and require both great tact and patience on the part of the husband and consultant, but where the woman is normally constituted the effort is well worth while both on behalf of her health and that of her husband and family. Dr. Robie's books give at first hand many cases of this sort (see p. 99).

The point of view indicated in the first chapter of this book is one on which great stress should be laid, when dealing with such cases. The reasons for sexual intercourse should be explained, and the woman told that the complete act of coitus has a mutual physiological value apart from its procreative power, and the seminal fluid of the man has accessory qualities apart from its procreative capacity, and that the man is not being merely "selfish" and "self-indul​gent" when he is having union with his wife. In such cases an understanding of the importance of the coital act, together with instruction in the use of the necessary contraceptives, generally restore normal life and health to the woman.

Many cases exist, particularly in poor families, where the use of contraceptives (and, therefore, presumably instruction in their proper use) is indicated by reason of the puny and unsatisfactory condition of the existing children, although an absolute indication, such as specific disease, may not be present. Toward these congenital "C3's" the position of the medical adviser will be different according to his temperament and sense of responsibility. One may take it, I think, as a general rule that if a couple have produced more than two unsatisfactory children, the chances of the later children being satisfactory are too remote to justify the responsible medical adviser, whose first duty is to the State as a whole, in leaving the couple in such ignorance that they may continue to reproduce involuntarily. It may appear to the parents themselves right to bring into the world still another, a desired child, which they are able to support; but they should be instructed and the responsibility for it only ​taken on voluntarily. Few indeed are the women who would bear more than three unsound children willingly! And without doubt ignorant, coerced and unwilling motherhood is detrimental to the child even if its ill effects are not evident in early infancy. The difficulty in this type of case is very frequently due to the carelessness of one or both of the couple who may be haphazard, or too mentally deficient, carefully to follow out instructions given. Such cases, of course, raise the important question of permanent sterilization, notes on which will be found on p. 53.

The use of contraceptives in order to space the desired births of normal people is generally indicated, even on the part of the healthiest woman.

The idea that lactation is a sure contraceptive is, of course, most unreliable and misleading; and although it is less common for a woman to become pregnant when nursing, it is by no means impossible, and she may become pregnant without menstruation intervening. An illustration is given of a case personally known to me for years:—

​Case 251.—A lady in very comfortable circumstances, finely built and exceptionally strong and healthy, exceptionally intelligent and with an intelligent and devoted husband. After the birth of her first child she was told by both doctor and nurse that she could have unions while she was nursing with perfect safety from risk of conceiving. She nursed the infant and became pregnant within a month again. Second child born ten months after the first, it was weakly and died in early infancy. Husband furious with misleading medical advice, ascertained and took contraceptive measures, spaced the next child after three years' interval, next child very healthy and successful and wife regained her strength.

Modern gynæcology is quite clear on the principle that at least two,^[7] preferably three, and in some cases even five years should intervene between successive preg​nancies in the interests both of the mother and the child. Whenever the doctor informs the potential parents that this should be so, the further duty devolves upon him of informing them about the methods best suited to their individual circumstances of achieving this end.

The foregoing paragraph applies with even greater stringency to all cases of Cæsarean section. After Cæsarean section any pregnancy intervening in less than two years is a potential disaster, and should on no account be permitted to take place. That doctor is surely inhuman who, after performing Cæsarean section, fails to give reliable instruction, or to satisfy himself that the couple are sufficiently acquainted with contraceptive methods to ensure his patient's safety for two years.

Whether or not a young couple who as yet have had no children should use contraceptives is a question about which there is greater latitude for individual opinion. Among such couples circumstances of course vary very greatly. There are sometimes the personal requirements of travel where the pregnant wife would have to face conditions likely to be injurious to herself or to her child which would fully justify the imparting of such information to ​a bride. In circumstances, however, where the couple are rationally intelligent and in good health the matter of their immediate parenthood seems a subject for their own decision rather than one to be settled by their medical adviser.

Most of the opponents of contraception consider it only as a negative measure destined to prevent births and forget its most valuable positive side. In the interests of the offspring, quite apart from considerations of the mother, the use of contraceptives to space births is of great value in reducing infant mortality.

Recent work has demonstrated quite clearly the life-preserving effect of spacing the births of children at suitable intervals. Dr. Weinberg found that the chance of death in the first year alone was so much less as to be almost halved if a two or three-year interval was secured as compared with infants who came as rapidly as with one year's interval or less. These results were obtained from 1,045 cases, all from really poor parents of the same class, and are strikingly shown in text fig. 1, p. 45, taken from a compilation of great value ​giving a number of other charts illustrating similar facts.^[8]

Death-rates of very Poor Children in the First Year, Showing the Value of SPACING Births.

Text Fig. 1.—a, with 0-1 year's interval, between births; b, with 1-2 years' interval between births; c, with 2 and over years' interval between births. Percentages reckoned on 1,045 cases, after Dr. Weinberg.

In my opinion, after a first birth a contraceptive should always be used for not less than one year, however much a second child is desired, and similarly after every successive birth (see also p. 220).