If abortion "came out" in the 1860s and 1870s, it was the doing not of the women who practiced it so much as of the medical authorities who exposed and indicted it. Falling birthrates and rising abortion in the United States—and the greater sexual autonomy of middle-class women they seemed to denote—generated a two-sided political response: a propaganda campaign systematically attacking abortion and birth control use among middle-class "native" women; and a program of "negative eugenics" to limit the propagation of the poor, the foreign-bom, and the "unfit." The first of these responses was led by the newly consolidated medical profession, whose ideological and lobbying efforts forged the national abortion policy that would prevail for the next century. The physicians’ campaign was double-edged, representing both a gender and a class and ethnic conflict. It was aimed first at the redomestication of married WASP women, who made up the physicians’ primary clientele. At the same time, it was aimed at the defense of the WASP establishment against rising immigration and proletarianization, a goal that would be taken on more directly by early-twentieth-century eugenicists.
Just as the Yankee woman was duty-bound to "propagate the race" and defend "the home," the immigrant, poor, or black woman, regarded as a carrier of disease and a breeder of "bad stock," was admonished to avoid reproducing.35 Thus misogyny and sexual control clearly interact with population control; pronatalism geared toward the upper classes and antinatalism geared toward the lower classes presuppose that for women to control fertility is a dangerous and subversive thing. But there is also an underlying tension. It would take over forty years before upper — class fears of lower-class sexuality would be reconciled with their fears of lower-class fertility, to allow the provision of state-sponsored birth control services for the poor. In what follows we look at the role of the medical profession, the eugenics movement, and birth control radicals, including feminists, in forging a national fertility policy. The record shows that if the relationship between these groups has at times been one of ideological and political conflict, it has also been one of mutual influence and accommodation.
Prior to the mid-twentieth century, if there was a state policy on population and fertility, it was created not directly by the state apparatus but by emerging elites who sought control over the dispensing of private reproductive health care and the state’s backing to legitimate that control. In its first stage it was a policy created through the pressure of the "regular" medical profession, particularly its ob-gyn specialists. The American Medical Association, more than any other group, led the campaign in the post-Civil War years to criminalize abortion, until then regarded by most Americans as "morally neutral" prior to "quickening" (the stage of pregnancy when fetal movements are noticed):
From the Louisville convention of 1859 through the rest of the nineteenth century, the steadily growing AMA would remain steadfastly and officially committed to outlawing the practice of abortion in the United States, both inside and outside that organization, and the vigorous efforts of America’s regular physicians would prove in the long run to be the single most important factor in altering the legal policies toward abortion in this country.36
The 1859 convention was the first of many occasions on which the AMA took a stand favoring the "general suppression" of abortion. Until that time abortion had in most states been legal, or at worst a misdemeanor, if performed before quickening. Not only did the AMA oppose the doctrine of quickening on biomedical grounds; it also called for the nonparticipation of physicians in abortion practices and asserted the "moral" view that the fetus was a "living being" at all stages of gestation, a being with civil rights.37 For the next two decades, AMA leaders such as the singleminded Horatio Storer engaged in a concerted campaign of propagandizing and lobbying among state medical societies, state legislatures, professional journals, and the popular press, using their growing influence to secure the criminalization of abortion at any point in a pregnancy.38 The criminal statutes that resulted and lasted in most states until 1973 prohibited abortion unless necessary to save a pregnant woman’s life.
Before examining the reasons behind the medical profession’s initiative, two points deserve emphasis. The first and most striking is that the doctors’ crusade was overwhelmingly a moral crusade; health or health — related matters—for example, the high mortality and morbidity rates associated with abortion—were never the principal issue. The sharpest evidence that concern for women’s health had little to do with the "regular" physicians’ attack on abortion is the fact that the attack came "at the very time abortion might theoretically have become an obviously safer procedure than it had been earlier in the century. . .
By 1890 the vast majority of American physicians had been taught the great advantage of antiseptic techniques, and antiseptic techniques might have rendered abortion—which had always been simple surgery in any event—safer, in all likelihood, than childbirth.39
Indeed, many physicians acknowledged that abortion was relatively safe and that only its illegality and practice under unhygienic conditions made it dangerous.
The second point is that the churches, even the Catholic church, remained lukewarm toward the issue. Unlike doctors, leaders of organized religion never played a central role in the late-nineteenth-century delegitimation of abortion in this country, despite medical leaders’ efforts to recruit them. An 1871 AMA report on abortion shows the peculiar "moral leadership" exerted by the medical profession, appealing to "the clergy of all denominations" to heed "the perverted views of morality entertained by a large class of females—aye, and men also, on this important question."40 Clearly, the AMA saw itself as shepherding the clergy on this issue, not the other way around.
Historically, the position of physicians with regard to abortion has been ridden with contradiction. On the one hand, the profession has never disguised its contempt for the practice; to this day, abortion is considered by many doctors as the boundary dividing professionals from charlatans and quacks.41 On the other hand, for all its disdain, the profession has never been successful in wiping out abortion (as opposed to quashing its legality and respectability) and has been constantly preoccupied with how to bring the practice under medical control. In mid-nineteenth-century America, before the medical profession had secured a monopoly over health care, including fertility-related care, controlling abortion required enlisting the powers of the state. By the same token, the ideological and legal campaign against abortion helped the profession to establish its monopolistic control over health care. During this period, "regular" physicians (those who had received formal training and commanded capital-intensive techniques) sought the systematic regulation of lay competitors, using the instrumentalities of the state (e. g., legislation to impose stricter training, credentialing and licensing requirements, and penalties for their violation). "Doctors as a group" came to discredit the popular health movement and midwives by defining their activities as "unladylike" while defining their own as technically superior—the "best" care. "Doctors worried that, if midwives were allowed to deliver the upper classes, women would turn to them for treatment of other illnesses and male doctors would lose half their clientele. . . . Doctors had to eliminate midwives in order to protect the gateway to their whole practice."42 Widespread abortion and family limitation clearly threatened the newfound status (to say nothing of potential profits) of male physicians as "at — tenders" of birth. The moral and legal attack on abortion therefore became an essential part of an exclusionary process that used discrediting tactics. Midwives were expelled from large-scale medical/obstetric practice through their delegitimation as incompetents ("quacks"), as "females," and as purveyors of wickedness.
On one level, then, the leadership of regular physicians in the anti — abortion campaign clearly reflects the economic position of the medical profession in the mid-nineteenth century, its push to monopolize the market in health and childbirth, a particularly female market. It is more than an analogy to characterize this process as a stage in the capitalization and consolidation of medical practice in which regular physicians attempted to drive petty craftswomen and tradesmen from the market. In this pursuit the use of state laws to regulate, rationalize, and delegitimate traditional practices assisted in centralizing the autonomy of the professions and the bureaucratization of "social welfare" functions in the state.
But the growth of the medical profession was distinct from that of, say, the steel industry or textile manufacture in that its "product" was a certain kind of woman, a certain kind of female behavior and consciousness. In fact, social and ideological control over reproduction were inseparable. The economic interests of physicians cannot explain either the moralistic rhetoric or the misogyny of the antiabortion campaign. By 1860 the male "regulars" had more or less secured their dominance over American medical practice, at least to the extent that formal medical training was seen as a prerequisite to reliable care.43 What remained was to establish an ideological hegemony that would give them an exclusive authority over their principal clientele—upper — and middle — class married women. Historians portray physicians more than any other group as the social agents who, through their popular writings as much as their medical treatises, propagated the Victorian ideology of ‘True womanhood/’44 Through its moralizing function as well as its claim to scientific knowledge, the profession attempted to establish its elite credentials.
Nowhere was the moralizing tendency of regular physicians more striking than in their relentless campaign against contraception and abortion. Medical school curricula and teachers were silent on these subjects; an address by the president of the American Gynecological Society in 1890 implied that "physicians should have nothing to do with the nasty business/’45 Both contraception and abortion were associated by a male, upper-middle-class, WASP medical profession with obscenity, lewdness, sex, and, worst of all, rebellious women. Physicians condemned the abortion practices of married women as "self-indulgence in the most disgusting forms," abandonment of maternal and child-care duties to "selfish and personal ends."46 Their "medical" views of abortion and contraception cannot easily be separated from the conservative sexual values of their class, particularly the view that "female chastity is necessary to protect the family and its descent; that female chastity must be enforced with severe social and legal sanctions, among which fear of pregnancy functioned effectively and naturally."47
Physicians’ active participation in shaping the ideology of female chastity and maternalism and giving it concrete political form (the antiabortion campaign) was motivated, then, not only by economic interest but by class and culture. It was part of a conservative reaction, in the postbellum period, against women’s rights activists—who were well organized and outspoken—and more generally against middle-class women’s perceived rejection of their "traditional role." One side of this cultural reaction was sexual; the other side, inextricably tied to the first, had to do with class and race. Medical tracts opposing abortion stressed not only women’s "self-indulgence" but abortion’s prevalence among the "wrong" women (white/middle-class Protestant married women), while immigrant and Catholic birthrates climbed. "Respectable" women—that is, the appointed clientele of the "regulars"—would find themselves out — bred by "the ignorant, the low lived and the alien."48 Along with this pronatalist class message, the practice of physicians itself communicated, and embodied, a strong class and race division. Regular physicians scorned and dissociated themselves from anything connected to popular health, "female doctors," midwifery, and abortionists precisely because these practices administered to the reproductive needs of immigrants and the poor.
Thus, sexual conservatism, professional elitism and aggrandizement, and class and race bias entwined to determine the unique role of medical professionals in formulating a state policy criminalizing abortion in the nineteenth century. At the same time, the antiabortion campaign was a significant part of the historical process that produced a capitalist system of medical care in the United States, one that sharply divided along lines of class, race, and gender. Other non-Catholic countries developed policies that combined opposition to abortion with promotion of racist eugenics— for example, Germany and England. But the absence in the United States of either a strong centralized church or a national "public hygiene" implementation system meant that a policy to contain the fertility of the poor and foreign-born and to promote racial and sexual "purity" appeared as an emanation of "science." Privatism both legitimated and obscured the policy. Well into the mid-twentieth century, the medical profession, which both influenced and reflected the policy of the state, rejected any form of fertility control other than abstinence or "eugenic" sterilization.
Given this staunch and nearly universal opposition of the AMA and its adherents, how did a medical paradigm of abortion develop? A look at the reasoning of the handful of medical supporters of birth control in the late nineteenth century gives some clues as to how the medical arguments would evolve. A few argued that "preventive measures" should be supported by physicians as an antidote to abortion. Other medical practitioners, voicing a restrained support of birth control, revealed a concern that was primarily eugenic—the idea that "regulation of reproduction would be one effective remedy. . . [for] poverty, pauperism, prostitution, drunkenness, crime, imbecility, insanity, infanticide, etc."49 Increasingly during the twentieth century, physicians would come to endorse eugenics and population control, and for some this might also sustain a conditional support of abortion, although they continued to prefer sterilization as a "solution."
The most telling sign that physicians might eventually alter their hostile position on birth control and abortion emanated less from moral or even eugenic concerns than from issues of professional control. Those few physicians, such as Robert Latou Dickinson, who became active campaigners among their colleagues for a more liberal view toward birth control were concerned that birth control practices, which were clearly not going to disappear, at least be brought under medical control and exercised according to medical standards.50 Contributions to medical journals show that, as early as the 1880s, regular medical practitioners felt themselves under pressure from patients to supply birth control information. The inference that these doctors were beginning to draw was that if they were to avoid losing patients—to lay practitioners or abortionists or to fatal risks—it would be better to "keep the matter in our own hands":
The demand upon the practitioner to prevent conception is an unquestionable fact. Under these circumstances, it is the duty of the profession to define more clearly what conditions justify and what do not justify interference, and then to settle upon some safe, efficient measures to meet the demand.51
What is being articulated here is the impulse toward defining a medical paradigm of birth control, later to be extended to abortion. Another contributor to the same journal spells out the terms of this paradigm more precisely:
I would always advise [contraceptive measures] where puerperal or uraemic convulsions accompanied pregnancy; where vomiting was severe during pregnancy; where any pelvic deformity existed, or any uterine or ovarian growth was present; where excessive hemorrhage accompanied labor; where the perineum or other parts had been lacerated much during labor; where any hernia of the intestines was present; and where any heart, kidney or lung mischief was present—in fact, in all cases in which the medical attendant was of the opinion that evil results would follow conception; but never merely for social or economic reasons*2
Here, then, is the origin of (1) the distinction between "medical" and "socioeconomic" indications, or "therapeutic" versus "elective" procedures, and (2) the idea that the medical attendant alone (meaning a certified physician) is qualified to judge when "evil results [will] follow conception." This application of the "medical model" to birth control occurs within the context of a general shift among American medical practitioners from a moralistic to a positivistic mode of discourse. But the concept of "medical necessity" also reflects a conflict between medical professionals and their patients as well as midwives and lay practitioners. It represents a narrow accommodation by some medical practitioners to the popular demand for birth control, an accommodation that absorbed the feminist idea of women controlling their pregnancies into the framework of medical control over disease.