Birth Control In Cambridge

EVEN public officials react with amusement or indifference to the "population problem" of Cambridge. The public is aware of the population problem as it exists in the streets of India; the bloated belly of a child is immediately called to mind. The ironic result of the mass media's concern with this issue is the creation of a sensationalism of suffering which renders the public unresponsive and insensitive to the less graphic conditions that exist in this city.

Energies and funds are desperately needed in the United States. Last year the National Institute of Health spent $800 million to save lives, what Roy Greep, director of the Center for Human Reproduction, calls "death control," and only one million on birth control. Last year alone, perhaps 5000-10,000 women suffered death or severe injury to their health as a consequence of illegal abortions. Of the 200,000 to 1,200,000 estimated illegal abortions performed in the United States each year, most women seeking them are married. Tragically, the state and national legislators are as insensitive to the need for liberalized abortion laws now as they were 30 years ago to the demand for legalized birth control.

But in Massachusetts it wasn't 30 years ago, or even ten; it was two years ago, August 8, 1966, that the state legislature approved a law which permitted qualified physicians to prescribe methods of contraception to married women. (As a result of a federal law passed this last session, funds will be cut off as of July 1, 1968 unless the state provides birth control information and service to both married and unmarried women.) Additionally, and almost humorously, the Massachusetts law prohibits the pharmacist from selling any item he knows is for contraceptive purposes; condoms, as everyone knows, are for sanitation and that is stated on the package. And spermicidal foam is a lubricant. It might be useful to investigate the possibilities of using the pill as flavoring in milk or tea.

There is no abortion law in Massachusetts. Public hearings on proposed abortion laws are currently being held. Discussion centers on whether abortion will be permitted only to have the mother's life or also when her health is endangered. Discussion of such bills is painful to watch. In Colorado, the medical profession was concerned that a liberalization would place the burden of life and death decisions in the hands of doctors, but the liberalization passed. On a lower plane, in Massachusetts, "the value of life" argument is coupled with the vindictive plea that liberalized abortion will encourage promiscuity.

I remember one old man who spoke after a sober and moving exposition of the terrible damage to maternal health caused by forcing a partially crippled woman to bear a full term pregnancy. The old man, who purported to be the leader of a "moral conservation society," asserted that a change in the law would somehow be an extension of the affront to society posed by the hippies "who feel they have a right to live together."

In the United States, population is a familial problem, not a national problem. This is not to discourage research and policy making at the national level, but to encourage consideration of the family as the unit of suffering in cases of "excess fertility" and the unit of persuasion crucial to the success of national population programs. Too often, family planning literature deals in descriptions (sensational statistics on pollution, living density, educational inadequacies) that are not significantly relevant to what may be called the "unit of persuasion," the family and the individual. People are rarely motivated to make important personal choices by abstract arguments. "A teeming population" and the possibility of toxic air and spoiled natural resources are less real than the mother's desire to remain a healthy and happy companion to her children, the closing of a nearby playground to erect an apartment building, or the prohibitive costs of higher education. In a recent poll published in Eugenics Quarterly, only two per cent of women practicing family limitation did so for "general social reasons." The pain of an unwanted child is personal. 30-33 per cent of all lower-income families and seven per cent of all college educated families experience that pain. One fifth of all deliveries in Cambridge City Hospital are to unmarried girls who feel that pain.

There are three sources of information in Cambridge for a woman seeking birth control information: private and public social service agencies, the hospitals, and private physicians.

The acting director of welfare for the City of Cambridge, who is responsible for 2,229 cases under Aid to Dependent Children, Old Age Assistance, Disability Assistance and General Relief, told me last fall that the welfare department, despite the intimate relationship between case and case worker, should not involve itself in matters of family planning or birth control. He justified, under the aegis of "privacy," the prohibition on social workers' discussion of birth control with clients. He could not enlarge up his philosophy of privacy, a philosophy not often associated with the welfare department. He intimated that even if a higher authority directed him to "get involved in birth control" he would refuse, "not as a Catholic," but as a public servant who felt birth control was "too personal."

The acting director stood over me nervously as I questioned one of his subordinates, the director of social workers for Aid to Dependent Children. This young woman, responsible for perhaps 1,500 families, would not state whether there was a policy on family planning or not. She was extremely defensive and would not even discuss whether her social workers, when asked, would refer the woman to her family doctor. I asked whether, in lieu of policy, a tacit prohibition arose; she would not answer.

The situation at Cambridge Welfare, particularly A.D.C., is a tragedy. The mute director of A.D.C. labored under the misconception that without official directive, and not being a physician, she could not discuss birth control. The welfare department has its own peculiar interpretation of the law which reads that the spirit of the law, though not the letter of the law, prohibits discussion of family planning. It was always legal and still is legal to discuss birth control and information verbally under the protection of free speech. The change of law in 1966 meant to the welfare department that medical bills from contraceptive consultation and prescription could be processed unless the woman was unmarried, divorced or widowed. The treatment of cases is not uniform; through interviewing I did in Census Tract 15, I found one woman whose enlightened social worker has initiated conversation with her on birth control and arranged for these bills to be processed even though the woman was unmarried. Two blocks away, there was a very young Negro girl with two illegitimate children who asserted her social worker would not give her the information and her doctor had balked at her request. I referred her to Planned Parerenthood for the appropriate service.

The outlook of Cambridge Public Health and Cambridge Visiting Nurses is more progressive. Edna Skelley, the director of Public Health Nursing for Cambridge, outlined the tradition of service of the Public Health nurse. Once inside the home, regardless of initial service request (for example, rat bite or sickness), the Public Health nurse surveys the needs of the home, initiates discussion on these needs and does referral. Miss Skelley made it clear that although the majority of the caseworkers were Catholic, personal tastse and religious affiliations were subordinated to service. Since family planning is central to familial health, referrals to birth control and fertility service are made. Last year, the Health Department made 2,721 referrals altogether and visited 2,644 homes at least once. Cambridge Visiting Nurses reaches about 200 parental cases a year from Cambridge City Hospital and is referred prenatal cases from Boston Lying In's Clinic. The executive director made a strong statement in favor of a forthright approach to birth control. Even in cases not specifically prenatal (about 800), the visiting nurse will initiate discussion on contraceptive if appropriate. She mentioned the obstacle posed by some Catholic doctors who refuse to prescribe effective methods. She was the first of my many interviewees to concern herself with the problem.

Cambridge Visiting Nurses and the Department of Public Health are exceptions. The overwhelming attitude of social and public service in Cambrige, particularly welfare, is that the initiative belongs to the doctor in these matters coupled with the abiding faith that he will give service.

Of the five hospitals in Cambridge, Cambridge City alone offers a gynecological clinic, and only reluctantly did the trustees permit the dispensation of contraceptive materials through the hospital. Docotrs at Cambridge City do not initiate conversation with patients on family limitation; rather the client must start the discussion and present proof of marriage. Boston Lying-In and Boston City Hospital, recognizing the reluctance of many women to discuss birth control, are more aggressive. The latter provides a post-partum session on maternal (including contraception) and child care and the former offers contraceptive information routinely in the six weeks post-partum check-up.

The clinic's effectiveness is seriously circumscribed by the pre-conditions of its existence; proponents of birth control services had to sacrifice the right to advertise the service and make public use of its statistics. The backwardness of Cambridge City Hospital is disturbing since 50 per cent of all Cambridge deliveries take place there; furthermore, most welfare cases and low income families receive their prenatal care and have their deliveries through the clinic because of its convenience and low cost. The argumments for "conservatism" vis a vis family planning in Cambridge are not substantive. Having Catholics on the Board of Trustees (three out of five) should not retard progress if the example of Cardinal Cushing on the Board of the Boston City Hospital is followed. Cardinal Cushing preached ecumenicism of spirit and "private conscience" in approving the Boston City Hospital's liberal policy. Some, peripheral in power but not in the power of suggestion, attempted to make the hospital a tool of planned parenthood associaties. It is difficult to get a representative or quotable statement of the attitudes of the doctors associated With Cambridge City, though the atmosphere might be described as "cautious" grading into indifference. The political fate of the birth control issue of the projected East Cambridge Clinic (to meet the unsatisfied demand for medical attention) will be instructive to watch. One informed source said of the 25 potential associates, "They are universally frightened of the birth control issue." Whether this fear is one of patient reprisal in a heavily Catholic area or the prejudice of the physician is unclear.

In attempting to discern the validity of these two alternatives, I undertook to answer two questions: How do the people of Cambridge feel about birth control and family planning? What is the role of the physician in giving birth control information? For my inquiry I chose census tract 15, bounded by Western Ave., Putnam Ave. and Green Street. This area ranks slightly high (about the 66th percentile) in social disorder and inadequate living conditions. Students and professors are widely dispersed among lower and middle class families, 37 per cent non-white and 14 per cent foreign-born. The sample of 80 was selected randomly from 754 families. Interviews were done in person or on the phone after a letter was delivered explaining the study. I had very few refusals (which I count as negative responses) and there was no discernable difference between the attitudes expressed by those interviewed in person and those expressed over the phone.

"Do you have any objections to family planning or birth control?" was phrased negatively to see if "reprisal threat" is a realistic problem. Of the 70 responding, four were eliminated for "high suggestibility" or lack of comprehension (foreign speaking). Of 66 respondents, 62 had no objection, 2 had qualified objections ("If birth control is handled properly") and 2 had religious objections. The sample was 38 per cent Catholic, 42 per cent Protestant and 20 per cent other (7 Jewish, 4 unaffiliated, 1 Greek Orthodox and 1 Buddhist). Assuming the ten refusals to be negative, the ratio is still over five to one with no objections.

A corollary question was worded more strongly: "If a maternal and child health care clinic were opened in Cambridge, could it as a matter of policy initiate conversation about birth control with the women it served? Of 62 with no objections to birth control, all but five concurred on the second question. The qualifications imposed by these five were directed to "as a matter of policy," stating the doctor should treat each case individually; one woman suggested the service be available only to married women. The possibility of serving unmarried women may not have occurred to most respondents and if it had, more women would have favored separate policies for married and unmarried. The (3 to 1) results are highly encouraging and belie the myth of opposition among laymen to a liberal and forthright approach to birth control. In fact it seems that the professional policy-making middle class is acting neither in the spirit of the church as personified by Cardinal Cushing's ecumenicism, nor in accord with public opinon; rather it is upholding in the name of "prevailing sentiment" mythical standards that are dear to itself only and few others.

Since public policy has largely defaulted to the private physician, his attitude to contraception and to the