"Margaret Sanger and 'a Glorious Chain of Clinics'," #9, Winter 1994/5

In Mary McCarthy's The Group, the character of Dottie Renfrew visits a New York City birth control clinic in 1934. The ensuing experience is both liberating and embarrassing. "Kay would hardly believe it but Dottie, all by herself, had visited a birth control bureau and received a doctor's name and sheaf of pamphlets that described a myriad of devices... and the virtues and drawbacks of each." (p. 56) The "Bureau" to which McCarthy referred was the Margaret Sanger Research Bureau which opened its doors in 1923.

Clinics like the Bureau were a critical element in Margaret Sanger's commitment to the birth control movement, for she was convinced they were the most viable method of disseminating contraceptive information. Deeply impressed by the network of birth control clinics each administered by trained medical personnel that she observed during a 1914-5 visit to the Netherlands, Sanger wanted to replicate the Dutch model in the United States: "Clinics –," she wrote "clinics in which women can be given direct and individual instruction in contraceptive methods, are the solution of the problem of getting the Birth Control message to those who most need it." Women, she insisted, "must be told by word of mouth and shown by demonstration what to do and how to do it. Otherwise much of our labor, so far as direct results go, is in vain. The answer is clinics." ("Clinics the Solution" July 1920, MSM S70:843).

Sanger "envisioned a glorious `chain' of clinics, thousands of them, in every center of America. I wanted to see specialists doing research work and gathering data to bring the subject up to other modern standards." (My Fight for Birth Control, 1931. p. 144) Sanger's first clinic, opened in Brownsville, Brooklyn in 1916, with Sanger and her sister serving as the medical staff, closely followed the Dutch model before it was shut down by police after less than two weeks in operation. Seven years later, Sanger opened the Birth Control Clinical Research Bureau (BCCRB), the first legal doctor-staffed birth control clinic in the United States.

The BCCRB and the other clinics it inspired offered women the same and often better contraceptive services as those obtained through private physicians. And not only did the clinics focus specifically on reproductive issues, they were reasonably priced to those who could afford them and free to those who could not. At a time when most women learned about reproduction and contraception through gossip and word of mouth, birth control clinics provided more than just gynecological examinations with contraceptive fittings; they served as a vehicle for educating women about their physiology and offered a forum for women to discuss their sexual and gynecological problems with other knowledgeable women. A few clinics even offered infertility counselling, and there is some evidence to suggest that clinic staff sometimes referred women to sympathetic doctors or hospitals for therapeutic abortions, although clinics could not perform legal abortions until the 1960s.

At the Clinical Research Bureau and similar birth control clinics, new patients were screened for eligibility; some clinics required that women be married (or in some cases engaged) and not pregnant at the time of the visit. Next, they were asked a number of background questions, varying from clinic to clinic in depth, but including factors such as age, age at marriage, medical history, (including number of pregnancies, abortions, or miscarriages), number of living children, and income level. Some clinics requested information concerning sexual practices and hereditary problems. The patient then met with a doctor, who evaluated the case history and, if appropriate, prescribed a contraceptive. If a diaphragm was recommended, patients were measured and given proper instruction in its use by a doctor or nurse. A follow-up visit was usually scheduled for the ensuing week and at regular intervals thereafter, both to check the measurements and to replenish expendable contraceptive supplies such as jellies.

With a large stake in the success of contraception, the clinic, unlike most physicians in private practice, conducted much more detailed follow-up work with their patients. Clinic staff measured the success rate, of course, but also paid close attention to the women who did not return to the clinic or who discontinued contraceptive use. Sanger's clinic had several social workers on staff who checked on women who missed refitting appointments, and kept careful records on success rates and specific reasons for complaint or failure.

The BCCRB served as the medical arm of the American Birth Control League (ABCL), founded in 1921, which focused on educational and legislative change. By 1926 the ABCL was flooded with hundreds of thousands of requests for help from women and couples, and responded by providing correspondents with the name and address of the nearest sympathetic doctor or clinic.

After establishing the BCCRB, the largest of the U.S. clinics, Sanger worked to help found other clinics which sprang up in cities across the nation; including Chicago (1924), Los Angeles (1925), San Antonio (1926), Detroit and Baltimore (1927), Cleveland, Newark, and Denver (1928), and Atlanta, Cincinnati, and Oakland (1929). Wherever she traveled across the US in the 1920s and 1930s, Sanger prodded her audiences to open clinics. Even if clinics were not immediately opened, many birth control leagues were formed in the wake of her visits. Most of these leagues were organized by middle class or well-to-do women, sometimes in cooperation with social workers, ministers, and physicians. They focused on lobbying for birth control legislation or promoting public education on reproductive issues. Those leagues willing to take the risks and responsibilities of hiring a physician opened dispensing clinics to offer medical services in addition to counseling and referrals.

Sanger's American Birth Control League and the BCCRB provided instructions for every aspect of setting up a clinic, including suggestions for a name, recommendations for facilities, staffing, and equipment, advice on financial and legal matters, and a list of "medical indications" for which contraception could be legally prescribed. Those clinics which met Sanger's standards were officially affiliated with the BCCRB, an imprimatur of quality. By 1930, some of the services that birth control clinics provided included: infertility and sterility treatments, sterilization, sex education, and marriage counseling (Robinson, Seventy Birth Control Clinics, 1930, pp. 158-162)

For most local clinics, funding was an ongoing problem. Most depended on private support to stay in business, as public funds were unavailable. Some of the more prominent clinics, such as Sanger's BCCRB and the Los Angeles Mother's Clinic were fortunate. "Los Angeles... raised all its funds specially and privately, its doctors donating their time, but now it has received two bequests: $30,000 from Dr. [Henry] Brainerd, and $150,000 from Clara Baldwin Stocker." (Robinson, p. 112) However, most struggled to break even on their services. In Illinois, the local league and clinic brought in only "$6,644 in contributions and dues in 1926, and $4,165.73 from the sale of supplies and fees from patients able to pay." (Robinson, p. 112) As a result, many local clinics depended on voluntary contributions of time and/or money to survive, factors which limited their multiplication and expansion.

Aside from financial difficulties, the clinic movement also faced religious and political opposition. The Chicago clinic was, for example, refused a license "on the grounds that the purpose of the clinic was `against public policy, tends to corrupt morals, and is unlawful.'" ("Report of the Illinois Birth Control League" in International Aspects of Birth Control, 1925, p. 155) Represented by Harold Ickes, later a member of Franklin D. Roosevelt's administration, the Illinois Birth Control League fought the decision. While the Illinois League was denied the right to open a free clinic, it was able to proceed with the Chicago clinic if it charged small fees. The Chicago clinic was fortunate. In Massachusetts, for example, laws prohibited the opening of any sort of clinic, and Catholic pressure was responsible for the cancellation of clinic plans around the country.

Nevertheless, from the late 1920s until the end of the 1930s, the number of birth control clinics continued to grow to approximately 320 by 1937. However for Sanger this was not enough. "I look forward to seeing, not twice that number, but ten times that number at the close of this year..." she wrote "We must also reach and help thousands of women who are unfamiliar with or isolated from clinics, by sending nurses into their homes to teach them. ("A New Day Dawns for Birth Control," July 1937, MSM S64:748) Furthermore, Sanger envisioned the incorporation of birth control education and services into public health programs throughout the country, in effect, reducing the reliance on the small, doctor-staffed clinics she created and allowing for a broader range of health workers and facilities to dispense contraception. However, opposition to birth control remained intense and government funding scarce.

Today there are close to a thousand clinics affiliated with the Planned Parenthood Federation of America across the nation and additional thousands of unaffiliated and commercial clinics. (Insider, January, 1994, p. 2). Like those of the earlier generation, these modern clinics provide a wide variety of medical, counseling, and referral services. While the emphasis may have shifted to counseling on problems relating to AIDS prevention and teenage pregnancy, for the most part the mission of today's clinics remains the same: to provide women with a full complement of preventative health care services.

Sanger wanted birth control to be "understood by the public at large. It must be removed from the realm of propaganda and argument, and accepted as a way of life." ("A New Day Dawns for Birth Control, July 1937, MSM S64:748) Today's birth control is in many respects, part of our way of life. Though their use is still debated and sometimes questioned, contraceptives are available in many supermarkets, most drug stores and even many schools. Indeed our own government, instead of prohibiting the distribution of birth control to women, may soon make it mandatory for welfare mothers. Yet birth control has not become a part of the public health system to the degree Sanger hoped. Most birth control clinics continue to be privately operated, but are reliant on government funding for large portions of their budgets. Unfortunately the nature and level of government support has shifted with changing political agendas. In post-election 1994, it is likely that women's clinics will have to renew their fight to continue to offer women affordable, reliable, effective services for all their health care needs.