Reproductive Health in the 20th Century – «The Right to Choose»

Ensuring access for all people to their preferred contraceptive methods advances several human rights including the right to life and liberty, freedom of opinion and expression and the right to work and education, as well as bringing significant health and other benefits, according to the WHO. This position is reflected by emphasis in the United Nations Sustainable Development Goals (SDG) , which calls on countries in resolution 3.7 “by 2030, to ensure universal access to sexual and reproductive health-care services, including for family planning information and education, and the integration of reproductive health into national strategies and programs».

But how did we get here?  The story of family planning is nearly as old as the story of humans but in a little over 100 years, we have written the most decisive chapter to date. A key figure in this chapter is a visionary woman by the name of Margaret Sanger.

Historical Background

In some parts of the world, choosing the number spacing of one’s children may now be taken for granted by women and men.

This choice is made possible by the cooperation of a variety of elements, including access to information regarding contraception, availability of suitable contraceptive methods, and provision of contraceptive and other family planning services to women seeking them. While this ability to choose is accepted as standard by some women in the year 2020, this landscape differs greatly from that which faced women of only a few generations ago.

References exist to use of contraceptives in historical texts produced by Greek and Roman scholars. A variety of methods, ranging from the possibly reasonable (eg. use of acidic substances as spermicides) to the downright superstitious (jumping backwards seven times following sex) have been employed by our ancestors to control the number and timing of their offspring. By the turn of the 20^th century, safe, scientific methods of contraception including abortion were described and even practiced sporadically on both sides of the Atlantic. Until very recently however, contraceptives and information surrounding contraceptive use were legally forbidden in many parts of the world. In the United States in 1873, federal ‘Comstock Laws’ outlawed the supply or distribution of any material considered ‘obscene’, which included information on contraception.

What sparked the change?

The modern birth control movement in the Unites States is often attributed to Margaret Sanger, although a variety of other independent thinkers, scientists and activists played their role in the development of public (although often outlawed) discourse, possibly none more so than Dutch clergyman Maltheus. His 1803 essay on fertility and population has come to be seen as a decisive intellectual fulcrum separating acceptance of results of human fertility from the active pursuit of scientific understanding and practice.

Sanger was a public health nurse in New York in the early 1900s, and shook the sensibilities of the day when she published her pamphlet ‘Family Limitation’ in 1914, describing various contraceptive methods. She was arrested for publishing the ‘obscene’ pamphlet, although charges were dropped in the wake of significant public support for her cause. Sanger made significant ground in recruiting medical professionals to the cause of fertility control and contraception and went on to set up the first ‘Birth Control’ clinic in USA in 1916. Many years later, Sanger would be involved in mobilizing funds for research into oral contraception and would see the first oral contraceptive become commercially available in the Unites States, framing quite a remarkable lifetime’s work.

Current status and ongoing challenges

Today, a variety of highly effective contraceptive methods are available to women in many parts of the world. In the United States and in many countries in Europe and Latin America, as well as east and southeast Asian countries, contraceptive use was over 70% in 2019. Widespread use of contraception has been noted in countries including Thailand, Egypt, Colombia and Iran.

Nevertheless, in many countries around the world, contraceptive uptake is slow. This is particularly the case in low-income countries in sub-Saharan Africa, central America and south Asia where weak government programs and limited access to services have hindered the adoption of modern methods of contraception. The United Nations Department of Economic and Social Affairs estimates that, as of 2019, there are 190 million women of reproductive age with an unmet need for family planning. This number highlights the disparity that still exists between the reproductive intentions of women and their use of contraceptives.

Challenges continue to exist with regard to funding of government programs, particularly in some low-income countries. This is partially related to the ongoing policy debate in the United States on funding of global family planning initiatives. The Mexico City Policy (known as the ‘global gag rule’), first introduced by Reagan, places restrictions on overseas family planning programs by NGOs in receipt of US federal funds. The fact that this executive order has been rescinded by every subsequent Democratic US president, only to be reintroduced by each Republican president, shows the of the volatility of the ongoing debate around family planning and contraception.

Under Trump’s reintroduction of the gag order in 2017, the rule is broader, and applies to all global health assistance furnished by all departments or agencies. As many NGOs in receipt of US funding aim to integrate family planning services with other health services such as HIV/AIDS services and other maternal and child issues, the global gag rule has had significantly detrimental consequences on access to family planning and other health services for many women. Research indicates that when women do not have access to family planning services, the number of unwanted pregnancies increases, as does the incidence of unsafe abortions.

Despite ongoing challenges with regard to access to reproductive healthcare, especially among certain populations, great progress has been made in the past 100 years. While we are some way from achieving the goals described in the SDGs of universal access to reproductive healthcare, the work of visionaries like Margaret Sanger has allowed an unprecedented rate of development of the »freedom to choose’’, which helps women, helps children and helps us all.