Rural Extension Work of the Kentucky Birth Control League, 1933–1942

“Completely Sold on Birth Control”: Rural Extension Work of the Kentucky Birth Control League, 1933–1942

By Courtney Kisat

In August 1939, after years of seeking birth control for her rural patients, community health nurse Lutrella Baker from the Line Fork Settlement in southeastern Kentucky wrote to Jean Tachau, president of the Kentucky Birth Control League (KBCL) in Louisville. “At last I have some grand news to report,” she exclaimed, “There is a new doctor at Pine Mountain Settlement School . . . [and] he is completely sold on birth control, especially as he sees conditions here.”1 Tachau and Baker went on to organize supplies for the clinic at Line Fork, a successful outcome of rural extension work from the KBCL. The birth control movement grew throughout the 1930s, and state affiliates of the American Birth Control League (ABCL) operated clinics that served thousands of women.2 The KBCL was the fifteenth state affiliate of the ABCL and like other state leagues, they success- fully established birth control clinics in urban areas such as Louisville and Lexington. But unlike other states, the Kentucky State Board of Health did not support birth control as a public health initiative, so county clinics offered no form of contraception. The KBCL filled that void with state extension work in rural counties. The initiative 1 Lutrella Baker to Jean Tachau, August 16, 1939, Box 1, Folder 12, Family Planning in Kentucky Collection, Kentucky Historical Society Collections, Frankfort, Ky., (hereinafter Family Planning in Kentucky Collection, KHS). 2 On the extent of the ABCL work with state leagues, see Catherine Moran Hajo, Birth Control on Main Street: Organizing Clinics in the United States, 1916–1939 (Urbana, Ill., 2010).

COURTNEY KISAT is an assistant professor of history and program coordinator of the Secondary Social Studies Education at Southeast Missouri State University.

REGISTER OF THE KENTUCKY HISTORICAL SOCIETY 303 VOL. 116, NOS. 3&4 (SUMMER/AUTUMN 2018) REGISTER OF THE KENTUCKY HISTORICAL SOCIETY came from Tachau, an experienced social worker who drew from her networking skills and experience to build collaborative committees in rural communities. Rural Kentucky women who received birth control access in the late 1930s and early 1940s benefitted from this collaboration. Central to the state extension work of KBCL was the creation of community committees, which included ministers, teach- ers, librarians, nurses, and women’s church groups. The KBCL was willing to recruit any person interested in establishing birth control services for the women of their county.3 Participants included a first- grade teacher in Edmonton, a USDA Home Demonstration Agent in Franklin, and a county health nurse in Daviess County, all of whom wrote the KBCL for information.4 Successful extension work was especially evident in Bell and Breathitt Counties, where the KBCL helped create community committees; in Madison County, where their efforts contributed to a strong local birth control initiative; and in Letcher County, site of the Line Fork Settlement. This study is a contribution to the growing literature of state-level birth control initiatives in the interwar period.5 It shows that despite the lack of support from the state, the KBCL impacted rural women in places where they were able to draw from social work methods to collaborate with people in those communities. Between 1880 and 1930, progressive women’s groups drove social, political, and economic changes in the Commonwealth. This included such initiatives as the Kentucky Equal Rights Association, founded by women in 1888, and the Kentucky Federation of Women’s Clubs in

3 Jean Tachau to Fairy Farley, November 1, 1936, Box 1, Folder 3, Family Planning in Kentucky Collection, KHS. 4 Summary County Folders, 1939–1944, Box 1, Folder 1, Family Planning in Kentucky Collection, KHS. 5 The history of reproductive politics has recently seen more contributions on state and local experiences in a departure from top-down studies of leaders of the movement. For examples of localized studies, see Tanya Hart, Health in the City: Race, Poverty, and the Negotiation of Women’s Health in New York City, 1915–1930 (New York, 2015); Rose Holz, “Nurse Gordon on the Trail: Those Early Days of the Birth Control Clinic Movement Reconsidered,” Women’s and Gender Studies Program Digital Commons, 2005, available online at https://digitalcommons. unl.edu/womenstudiespapers/3/ (accessed May 9, 2018); and Harold L. Smith, “‘All Good Things Start With the Women’: The Origin of the Texas Birth Control Movement, 1933–1945,” Southwestern Historical Quarterly 114 (Jan. 2011): 252–85. 304 COMPLETELY SOLD ON BIRTH CONTROL

Map of KBCL extension work. Counties in light gray represent places where birth control clinics were established. Those in dark gray represent places in correspondence with KBCL. Map by author, all rights reserved.

1894. Women’s clubs helped create the first county health department in Mason County in 1914, and by the late 1920s, health departments in every county of Kentucky. When Congress passed the Sheppard– Towner Act in 1922 to provide funding for health programs to benefit women and children, Kentucky legislators responded to women’s advocacy and approved a measure to create a Bureau of Maternal and Child Health. The birth control movement in Kentucky was not the first reform driven by women, but rather a link in a long chain of maternalist policies in state reforms.6 From their first meeting in 1933, the KBCL worked to “help mothers have healthier babies, check the practice of induced abortions, and establish clinics in all sections of the state.”7 They gained public support by promoting birth control 6 On the tradition of progressive reforms initiated by Kentucky women, see Dana M. Caldemeyer, “Yoked to Tradition: Kentucky Women and Their Histories, 1900–1945,”Register of the Kentucky Historical Society (hereinafter RKHS) 113 (Spring/Summer 2015): 453–75. 7 These goals were stated in a promotional pamphlet, “The Kentucky Birth Control League,” October 1, 1937–September 30, 1938, Box 1, Folder 11, Family Planning in Kentucky Collection, KHS. On Jean Tachau and the KBCL, see Judith Gay Meyers, “A Socio-Historical Analysis of the Kentucky Birth Control Movement 1933–1943,” (PhD dissertation, University of Kentucky, 2005); and Elizabeth Caskey, “Making Birth Control Acceptable: The Development of the Twentieth Century Birth Control Movement,” (MA thesis, University of Louisville, 2005). 305 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY to improve maternal and child health and as an economic measure for poor families. The KBCL was especially visible throughout the state, first in the cities of Louisville and Lexington, and gradually in over forty rural eastern Kentucky counties. Early professional social work methods were fundamental to women’s movements in the interwar period. Social workers had driven a professionalization movement that placed them in the emergency relief efforts of the New Deal. Developments in social work reflected growing knowledge of the importance of local invest- ment to a successful outreach project in rural areas and this was the case in the state extension work of the KBCL.8 Since 1917, KBCL president Jean Tachau had served in various social work capacities. She volunteered through the Red Cross Home Service and the Chil- dren’s Protective Association, served as chair of the Council of Social Agencies in Louisville, became president of the Children’s Agency in Louisville, and served on the boards of the Louisville and Jefferson County Children’s Home throughout the 1930s.9 Later, she recalled how her social work experience led to birth control advocacy. “We were involved in all kinds of family problems and in really the very lowest economic levels,” she said. “We saw the results of poverty and overpopulation. We saw the crowded conditions. We saw what it did to the children and their families.”10 Tachau’s social work training and instincts created a successful clinic-based movement in urban centers and led her to seek opportunities for collaboration to bring birth control to rural women. The KBCL did not stand apart from other state birth control leagues in their early work. In the summer of 1933, the KBCL established the first birth control clinic in the state at the Norton Memorial Infirmary in Louisville. Known thereafter as the “Norton Clinic,” it

8 Joan Marie Johnson, Funding Feminism: Monied Women, Philanthropy, and the Women’s Movement, 1870–1967 (Chapel Hill, N.C., 2017), 170. 9 Jean Brandeis Tachau, “An Interview of Mrs. Charles G. Tachau, Her Early Work with Planned Parenthood and Child Welfare in Louisville and Kentucky,” interview by Anne Dent on November 26, 1974, in Louisville, Kentucky, Nunn Oral History Center, University of Kentucky (hereinafter Nunn Center UK), 5. 10 Ibid., 8.

306 COMPLETELY SOLD ON BIRTH CONTROL operated under the direction of the hospital and only accepted patients with written referrals from a physician or social service agency. The Medical Council of the Norton Medical Infirmary emphasized that the clinic was to be operated “without additional cost to the Hospital and is in every way to conform to such rules and regulations as set forth by the Hospital,” a policy which excluded women of color.11 It did, however, reach hundreds of women in the Louisville area; by June 1935, 130 women were given “contraceptive advice” there.12 Throughout 1935 and 1936, the KBCL raised funds and established clinics in order to expand birth control access to more women. The Maternal Health Clinic at the Good Samaritan Hospital in Lexington opened in 1935, where licensed physicians provided birth control services to both African American and white women on alternating days. In 1936, the Adler Mothers Clinic opened in the parish house of the Church of Our Merciful Savior in Louisville to serve African American women.13 In 1937, the KBCL opened the Floyd Street Clinic in Louisville, accepting patients who applied directly rather than through referral. The Floyd Street Clinic served 130 mothers by 1939, 70 percent of whom were relief recipients.14 By 1939, the KBCL reported that nearly 3,000 women were seen at the Louisville clinics.15 These women fit the demographic target of the birth control movement: low-income, married women who wanted to prevent having more children. Most had already borne several children, and half qualified for free service because they were relief recipients.16 The

11 Note the “rules and regulations” of Norton meant that African American women were not seen at the clinic, since the hospital was restricted to white patients only. Declaration of Medical Council of Norton Medical Infirmary, May 1933, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 12 KBCL “First Clinic Report,” July 1933–July 1934, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 13 Undated news article, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 14 Undated news article, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 15 KBCL Annual Report, October, 1939, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 16 On the importance of relief status to obtain free services, see Linda Gordon, Pitied but Not Entitled: Single Mothers and the History of Welfare (New York, 1994) and Walter Trattner, From Poor Law to Welfare State: A History of Social Welfare in America, 6th ed. (New York, 1989).

307 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY clinics thrived as more women learned about them, but birth control advocates faced several challenges in promoting their work. One important challenge was reaching women of color. In 1935, Tachau presented at the Phillis Wheatley Home of Louisville, a shelter run by the National Association of Colored Women (NACW), about the activities of KBCL.17 She corresponded with black physicians who agreed to include birth control in their practice, including John M. Hammons of Louisville. According to KBCL records, Hammons advised twenty women in “birth control matters” between 1934 and 1935.18 In 1937, Tachau worked with the Mountain Maternal Health League (MMHL) to open a clinic in Richmond to serve black women. In this, the KBCL mirrored national initiatives such as the Harlem Clinic, opened by the Birth Control Clinical Research Bu- reau (BCCRB) in 1930, and the Division of Negro Services (DNS) of the Birth Control Federation of America (BCFA) in 1939. Where the Harlem clinic was situated to serve urban women, the DNS sent nurses on home visits to hundreds of rural women in South Carolina between 1940 and 1942.19 Raising funds was another constant worry for birth control leaders. The KBCL required dues for members and boasted names of top physicians and community leaders in Louisville.20 They raised funds through solicitation, touting the common supports for birth

17 “Invitation to Select Group of Colored Persons,” May 6, 1935, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 18 “Kentucky Birth Control League, Financial Report, October 1934 to October 1935,” Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 19 The subject of race in rural birth control work, while outside the scope of this essay, is an important issue deserving of further study. On the Negro Project, see Peter Engelman, A History of the Birth Control Movement in America (Santa Barbara, Calif., 2011), 175–77; on the DNS project, see Carole McCann, Birth Control Politics in the United States, 1916–1945 (Ithaca, N.Y., 1994), 160–73. Several historians have exposed the paternalistic and discriminatory nature of birth control clinics targeting black women, including Jamie Hart, “‘Who Should Have Children’? Discussions of Birth Control among African-American Intellectuals, 1920–1939,” The Journal of Negro History 79 (Winter 1994): 71–84; Jessie Rodrique, “The Black Community and the Birth Control Movement,” in Darlene Clark Hine, et al., eds., We Specialize in the Wholly Impossible: A Reader in Black Women’s History (Brooklyn, N.Y., 1995), 505–20; and Johanna Schoen, Choice and Coercion: Birth Control, Sterilization, and Abortion in Public Health (Chapel Hill, N.C., 2005), 44–52. 20 KBCL Annual Report, October 1935, Family Planning in Kentucky Collection, KHS. 308 COMPLETELY SOLD ON BIRTH CONTROL control, that it helped the poorest members of the Commonwealth, as a measure for maternal and infant health, and to relieve tax payers the burden of supplying relief.21 The KBCL encouraged county committees to solicit donations as well. In fact, the relatively high cost of birth control was a barrier to inclusion in public health programs.22 Public acceptance of birth control was another major challenge. The conservative view held that birth control would increase promis- cuity, violate religious and moral codes, and even destroy the family as an American institution. Advocates of birth control pointed to high maternal and infant death rates and, especially after the onset of the Great Depression, promoted birth control as an economic measure for poor families. Polling revealed a wide range of opinion on the matter, but by 1936, two-thirds of Americans polled supported some form of birth control.23 Newspaper coverage helped raise awareness of birth control, especially in states with wide newspaper readership. More than two hundred newspapers circulated in Kentucky by 1930, including the Louisville Courier-Journal, which became one of the KBCL’s staunchest supporters. Between 1937 and 1942, the Courier- Journal increasingly covered KBCL activity and printed editorials from people on both sides of issue. The paper publicly endorsed birth control in 1941.24 Nationally, the birth control movement had been in headlines since 1914, following the actions of its leader Margaret Sanger, a public health nurse who worked with poor women in New York. After the 1918 New York Court of Appeals ruled that licensed physicians could provide birth control, Sanger focused even more on tying birth control to public health. She formed the American Birth Control

21 “To Aid Solicitors,” June 1940, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 22 James Reed, The Birth Control Movement and American Society: From Private Vice to Public Virtue, (Princeton, N.J., 2014), xviii. 23 Peter C. Engelman, A History of the Birth Control Movement in America, 172. 24 On KBCL coverage in the Courier-Journal, see Elizabeth Caskey, “Making Birth Control Acceptable,” 57–59. On the way mass media helped gain public acceptance for birth control, see Manon Parry, Broadcasting Birth Control: Mass Media and Family Planning (New Brunswick, N.J., 2013). 309 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY

League (ABCL) in 1921 and the Birth Control Clinical Research Bureau (BCCRB) in 1923 to open clinics in impoverished inner-city neighborhoods. In 1928, Sanger resigned from the ABCL and worked to overturn legal restrictions on birth control, forming the National Committee on Federal Legislation for Birth Control. In 1936, the U.S. Second Circuit Court of Appeals overturned legal restrictions of birth control in U.S. vs. One Package Japanese Pessaries.25 The court decided that federal prohibitions on birth control originating from the Comstock Law were unconstitutional and gave doctors the “sole judge of propriety” in deciding whether to prescribe it.26 This decision led the American Medical Association (AMA) to endorse contraception if prescribed by licensed medical physicians, which cemented what historian James Reed has called a “medical monopoly on birth control” and achieved a major goal of the overall movement, securing acknowledgement from the medical community that equal access to birth control was necessary.27 However, the AMA discouraged any activism that departed from the clinical model, warning that “lay activities . . . may serve to hinder rather than to promote sound progress by antagonizing physicians and local health authorities.”28 Lay women in dozens of states chose to ignore this advice and promoted birth control anyway. The services sought by working-class and urban women varied at these clinics. Some, like the Norton Clinic, were included in hospi- tals where women had access to a number of health services. Others, such as the Adler Mothers’ Clinic inside of a church, provided only

25 United States v. One Package of Japanese Pessaries, 86 F.2d 737 (2d Cir. 1936). 26 Engleman, A History of the Birth Control Movement in America, 169. On Margaret Sanger and the national movement, also see Simone Caron, Who Chooses?: American Reproductive History Since 1830 (Gainesville, Fla., 2010); Ellen Chesler, Woman of Valor: Margaret Sanger and the Birth Control Movement in America (New York, 2007); Rose Holtz, The Birth Control Clinic in a Marketplace World (Suffolk, U.K., 2014); and Carole R. McCann, Birth Control Politics in the United States, 1916–1945 (Ithaca, N.Y., 1994). 27 James Reed, From Private Vice to Public Virtue: The Birth Control Movement and American Society since 1830 (Princeton, N.J., 2014), 101. 28 “Statement Approved by the Executive Committee of the National Medical Council on Birth Control,” October 28, 1937, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS.

310 COMPLETELY SOLD ON BIRTH CONTROL very basic services. More common in rural areas were birth control clinics held in private practices on certain days with one or two supporting physicians.29 Building clinics was part of the national agenda for birth control movement, and reformers wanted poor women to come to them. The KBCL, like other state leagues, suggested a fee of one dollar which was waived for relief recipients and others who could not afford it. An initial clinic visit consisted of a pelvic exam, fitting for a diaphragm, and instructions for use. The diaphragm was the most popular and effective method of contraception in the 1930s, but was available only from a physician, leaving women without access to a doctor to find another method. The diaphragm was also relatively expensive at four to six dollars each.30 Condoms were obtainable without a doctor’s prescription but were also cost prohibitive at about fifty cents for a package of three.31 Pharmaceutical companies continued to experiment, and developed a contraceptive method using a spermicidal powder and sponge in the early 1930s. It did not require a clinic visit and had been used by low-income women since 1935.32 The new research and products excited Tachau and her col- leagues. She recalled, “it became very necessary to involve the medical profession and research, biological research, in order to have means for the mothers and fathers of the country to practice birth control. ‘Scientific birth control’ was one of the terms used and which seems such an obvious thought today.”33 Birth control clinics contributed data to scientific studies. National leaders recognized the needs of rural mothers. In 1919,

29 On the range of services available at birth control clinics, see Johanna Schoen, Choice & Coercion: Birth Control, Sterilization, and Abortion in Public Health and Welfare (Chapel Hill, N.C., 2005), 23–25. 30 Andrea Tone, Devices and Desires: A History of Contraceptives in America (New York, 2004), 154–55. 31 Schoen, Choice and Coercion, 101. 32 On the sponge method pioneered in Florida directed by Dr. Lydia DeVilbiss, see Esther Katz, et.al, eds., The Selected Papers of Margaret Sanger, vol. 2 (Urbana, Ill., 2006), 347. Andrea Tone has provided a detailed analysis of various methods of contraception available to poor women. Andrea Tone, Devices and Desires, 2004. 33 Ibid., 10. 311 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY

Sanger worried that birth control clinics would not address the needs of every woman. She encouraged strategies to “. . . reach women on homesteads, on farms, in mining districts and millions of women in outlying rural districts where medical help is unavailable.”34 A popular argument for birth control which emphasized the wellbeing of mothers and babies applied naturally to rural mothers. In 1921, sociology professor E.C. Lindeman wrote, “if Birth Control is to be one of the means of providing children with a better birth, a better childhood environment, and better parents, its mission will need to extend to rural areas where most of the children are brought into existence.”35 A 1929 study emphasized the correlation between high birth rates and rural occupations such as farming and mining, concluding that birth control was a solution to rural poverty.36 Even the powerful AMA recognized the need in 1937, calling for “further investigation and extension of the distribution of simplified techniques to women in rural areas who cannot attend the clinical centers.”37 Nearly every argument for birth control—population control, maternal and infant health, as an anti-poverty measure— seemed to apply doubly to rural women as the Great Depression wore on. Birth control reformers, like other New Deal-era reformers, seized the opportunity provided by the Great Depression to advocate contraception for poor families. A speaker at the spring 1938 KBCL meeting reminded members that, “birth control, while not a cure-all, could prevent much of this tax on public funds.”38 Throughout the 1930s, the KBCL promotional material increasingly emphasized the links between relief families and high birth rates. Tachau and her ally

34 Jean H. Baker, Margaret Sanger: A Life of Passion (New York, 2011), 248. 35 E. C. Lindeman, “Birth Control and Rural Social Progress,” Birth Control Review, (November 1921): 70. 36 W. F. Ogburn and Clark Tibbitts, “Birth Rates and Social Classes,” Social Forces 8 (September 1929): 1–10. 37 “Statement Approved by the Executive Committee of the National Medical Council on Birth Control,” October 28, 1937, Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. Emphasis in original. 38 “Birth Control Called Lever to Lift Relief Tax Burden,” Louisville Courier-Journal, April 27, 1938.

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Edna McKinnon, a veteran birth control reformer sent by the BCCRB to help the KBCL expand, secured spots on two FM radio channels in the spring of 1939. Their scripted conversations were meant to appeal to listeners on humanitarian grounds, but the underlying mes- sage was that, “unwanted children in overcrowded homes [become] a further drain upon the taxpayer.”39 As was the case in other state leagues, Tachau used the arguments and terminology she felt would help her make the best case for birth control in Kentucky.40 The study of KBCL rural extension work is especially significant in the context of state demographics, as nearly three-in-four Kentuckians living in an area defined as rural in 1920 and 1930.41 Rural people lacked comprehensive medical care as Kentucky faced a shortage of health professionals, as noted by historian John Ellis.42 To address this need, reformers throughout the early twentieth century made forays into rural counties, especially in the southeastern Appalachian region. Reformers founded the Hindman Settlement School in Knott County in 1902 and the Pine Mountain Settlement School in Harlan County in 1913, for example.43 Rural sociologists, including John and Olive Campbell, sponsored by the Russell Sage Foundation, had a special interest in working with rural families in Appalachia. In 1925, Mary Breckinridge formed the Frontier Nursing Service to deliver health care to rural people in Leslie County.44 Each group increased access

39 “KBCL Scrapbook, 1933–1941,” Box 2, Folder 1, Family Planning in Kentucky Collection, KHS. 40 On the characteristics of lay women who ran state leagues, see Hajo, Birth Control on Main Street, 96–97. 41 Census Data with Socioeconomics, Table 1: Urban and Rural Population, 1900–1990, (U.S. Census Bureau, 1995). 42 Between 1909 and 1940, the state lost nearly one thousand licensed physicians while the state population increased by almost 700,000. John H. Ellis, Medicine in Kentucky (Lexington, Ky., 2009), 56. 43 On the folk revival of the 1930s headquartered at Hindman Settlement School see Jane Becker, Selling Tradition: Appalachia and the Construction of an American Folk, 1930–1940 (Chapel Hill, N.C., 1998). On the culture clash between out-of-state reformers and native Kentuckians, see David E. Whisnant, All That is Native and Fine: The Politics of Culture in an American Region (Chapel Hill, N.C., 1983). 44 On the Frontier Nursing Service, see Mary Breckinridge, Wide Neighborhoods: A Story of the Frontier Nursing Service (Lexington, Ky., 1981) and Melanie Beals Goan, Mary Breckinridge:

313 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY to education, health care, and social work in southeastern Kentucky. Throughout this period, reports about rural Americans often reflected cultural misunderstandings and reinforced negative perceptions of rural people. The field of rural sociology grew in the 1920s and informed New Deal programs beginning in 1933. In Kentucky, several New Deal programs were initiated which increased contact between rural people and government agencies.45 For instance, the Works Progress Administration (WPA) program sent packhorse librarians to rural areas, and the Federal Writers Project (FWP) sent collectors of folklore into rural Kentucky counties. Federally funded studies on rural poverty often painted a negative picture of rural Americans, depicting them as uneducated, illiterate, and unhealthy. A 1935 report from FWP author Virginia Landfear reflected her negative perceptions of rural people. She wrote that “Until the past decade, the life in much of the mountain region of Ky. has been isolated and primitive. Along with feuds, illicit stills, emotional religion and genuine hospitality which are characteristics of the pinched life in the mountain fastnesses [sic], folk superstitions have survived with great tenacity.”46 Others saw these same characteristics as unique challenges. H.W. Hopkirk, a social worker from New York examined an orphanage in rural Kentucky in 1933 and complained, “In part it is the individualism of mountain folk which is holding back the development of adequate social service.”47 Reformers who understood the cultural divide stood the best chance at gaining the trust of their target populations. Despite popular misconceptions, rural families reproduced at comparable rates to urban Americans, as shown by data collected by relief officials in 1936. A survey of rural relief recipients in southern states, including three Kentucky counties, showed an average of

The Frontier Nursing Service and Rural Health in Appalachia (Chapel Hill, N.C., 2008). 45 On the New Deal in Kentucky, see George T. Blakey, Hard Times and New Deal in Kentucky: 1929–1939 (Lexington, Ky., 1986). 46 Virgnia M. Landfear, “Folklore,” typed manuscript, 1935, WPA in Kentucky, 1937–1939 Collection, Kentucky Department for Library and Archives, Frankfort, Ky. 47 H. W. Hopkirk, “Dependent Children in the Southern Mountains,” Mountain Life and Work 9 (Oct. 1933), 25–28.

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4.8 children per family, a bit higher than 4.0 dependents among non-relief rural families.48 However, populations in rural counties of Kentucky grew during the Great Depression, as people who had left rural areas years earlier returned, unemployed and destitute, to their hometowns. For example, the population of Knox County grew by seven hundred families in 1933 alone, illustrating the influx of families seeking relief by venturing home.49 To compound matters, dwindling tax revenues failed to fund almshouses and county poor farms. Mary Breckinridge worried in 1930 that, “a free and hospitable people are sharing their corn-meal with returning neighbors and kin; they are sheltering them in their one and two-room cabins; but when winter comes, the picture will be one of starvation if work cannot be found for this surplus population.”50 The ecological catastrophes of the Great Depression compounded these factors, which began in Kentucky with a serious drought in 1930 and 1931. While the conditions of the Depression were helpful to the national birth control movement—Margaret Sanger coined the term “relief babies” to appeal to taxpayers— the obvious answers to chronic poverty meant structural change the American economic system, a level of reform rarely promoted within women’s movements.51 Birth control reformers advocated for partnership with the medical community, however, as evidenced by the importance of the AMA endorsement, but they were not always able to convince state boards of health. In Kentucky, the State Board of Health supported rural public health measures like trachoma eradication in 1915 and 1916. It supported a robust rural public nurse program begun by the American Red Cross in which public health nurses staffed outposts and visited mountain

48 Thomas McCormick, “Rural Families on Relief,” Rural Sociology 1 (Dec. 1936): 30–40. Demographer Frank Notestein warned social workers of inflating numbers to increase public support. Frank W. Notestein, “The Fertility of Populations Supported by Public Relief,” The Millbank Quarterly 14 (March 1936): 37–49. 49 Earl Mayhew, “The Agricultural Situation in Southeastern Kentucky,” Mountain Life and Work 10 (April 1933), 20–24. 50 Mary Breckinridge, “The Corn-Bread Line,”The Survey (August 15, 1930), 422–23. 51 Margaret Sanger, “Human Conservation and Birth Control,” March 3, 1938, Margaret Sanger Papers, Sophia Smith Collection, Margaret Sanger Microfilm S71:0977, Smith College, Northampton, Mass. 315 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY families in their homes throughout the 1910s.52 But the conservative state board blocked family planning services, citing the Bureau of Maternal Health as a satisfactory solution to all matters involving pregnancy and childbirth. Seven southern states, including North Carolina, South Carolina, Alabama, Florida, Mississippi, Georgia, and Virginia responded by adding family planning to public health services between 1937 and 1942.53 The lack of endorsement wore on Tachau—she complained to a friend, “It is indeed discouraging . . . we are trying every means we know to persuade our Health Depart- ment to include birth control; some day we will succeed.”54 Not to be deterred, however, she invested countless hours into expanding birth control access in Kentucky. The rural social work network to which Tachau connected in 1936 began much earlier, especially in the southeastern Appalachian region of the state. Rural nurses, educators, and social workers published reports of their work in journals including Mountain Life and Work, a monthly journal about rural social work, established at Berea Col- lege in 1925. Topics included relief funds, case management, health concerns, and education in rural Appalachia. The interdisciplinary nature of the publication helped link health issues to relief funds. For example, in April 1933, a case manager reported that 10 percent of farm families in Knox County suffered from pellagra, a disease caused by malnourishment, and 98 percent of children presented

52 On the trachoma project, see Sandra Lee Barney, Authorized to Heal: Gender, Class, and the Transformation of Medicine in Appalachia, 1880–1930 (Chapel Hill, N.C., 2000), 92–93 and “Campaign to Prevent Blindness II,” The American Journal of Nursing 16 (April 1916): 641. On the development of the American Red Cross rural nursing program, see Sandra B. Lewenson, “Town and County Nursing: Community Participation and Nurse Recruitment,” in John C. Kirchgessner and Arlene W. Keeling, eds. Nursing in Rural America: Perspectives from the Early 20th Century (New York, 2015), 1–20. On public health nursing, see Karen Buhler-Wilkerson, False Dawn: The Rise and Decline of Public Health Nursing, 1900–1930 (New York, 1989). 53 On birth control in public health programs, see Johanna Schoen, Choice & Coercion, and Edward Larson, Sex, Race, and Science: Eugenics in the Deep South (Baltimore, 1995). 54 Jean Tachau to Dr. E. S. Dunham, January 8, 1940, Box 1, Folder 8, Family Planning in Kentucky Collection, KHS. The State Board of Health did not endorse birth control in public health clinics until 1962. 316 COMPLETELY SOLD ON BIRTH CONTROL

“The Cabin,” a rural health clinic in Gilley, Kentucky. Part of Pine Mountain Settlement School, Marian Kingman Album, 1928–1932, 16. Pine Mountain Settlement School Collections. dental problems.55 The rational solution to address poverty in Knox County was for relief workers to distribute healthy food and nutri- tional education to relieve the burden of poor health. These reports galvanized reformers, including Reverend Robert and Doctor Ida Stapleton, who moved to the Line Fork Settlement in Letcher County the late 1920s.56 Stapleton supported the birth control extension work of the KBCL because of the poor socioeco- nomic conditions in the region. Her letters described the poverty her patients faced and how they struggled for basic supplies. In one instance she found a laboring mother alone, “all hunched up on a feather tick–the sheet a mere rag.”57 Another letter thanked a friend

55 Earl Mayhew, “The Agricultural Situation in Southeastern Kentucky,” Mountain Life and Work 10 (April 1933), 23. 56 Ida Stapleton and her husband Robert were veterans of relief and missionary work overseas. They moved to Pine Mountain in 1926 and directed the settlement school and clinic for eleven years. Pine Mountain Settlement School Collection, KHS. 57 Ida Stapleton to “My dear friends,” October 24, 1926, Folder 1, Pine Mountain Settlement School Collection, KHS.

317 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY for sending old sheets and linens for diapers and pads, “as no mother ever has enough even for three days cleanliness.”58 Like her urban counterparts, Stapleton linked poverty to a need for birth control. Reformers saw a fundamental problem in the practice of untrained lay midwives, or “granny women,” attending home births.59 To gain a sense of the extent of this practice, Mary Breckenridge conducted a survey of three Kentucky counties in 1923. She found that the rural women usually gave birth attended by a neighbor, friend, or granny woman.60 Oral histories from rural Kentuckians confirm the frequency of unattended births. For example, Effie Humble of Wayne County in southern Kentucky remembered that her mother, who had no medical training, served as a midwife for her neighbors. “We was poor, but there’s still people poorer than you,” Humble said. “She [mother] would give them baths and take care of the little baby.”61 Granny women resisted the intrusion of trained health professionals, recalled FNS physician Jean Tolk. “Some of them couldn’t even read and write but they were midwives . . . . It was their intention to help out their friends and neighbors, primarily because there was no one else around.”62 In some cases, distance and topography presented an obstacle for any midwife to reach a birthing woman in time. In that situation, the unfortunate mother would “have a kid by herself at home [because] there’d be nobody close.”63 As noted by historian Melanie Beals Goan, the main impetus of Mary Breckinridge and

58 Ida Stapleton to Mrs. Adams, January 20, 1931, Folder 1, Pine Mountain Settlement School Collection, KHS. 59 A White House Conference on maternal and infant health in 1933 specifically linked “poor aseptic practices” to maternal death rates. On increased government intervention in maternal and infant health from 1900 to 1930, see Richard and Dorothy Wertz, Lying-in: A History of Childbirth in America (New Haven, Conn., 1989), 202–10. 60 Anne Z. Cockerham, “Mary Breckinridge and the Frontier Nursing Service: Saddlebags and Swinging Bridges,” in John C. Kirchgessner and Arlene W. Keeling, eds. Nursing in Rural America (New York, 2015), 83–100. 61 Effie Humble, interviewed by Tom Gatewood, July 14, 1982, Rural Health Care Oral History Project, Kentucky Oral History Commission, KHS. 62 Jean Tolk, interviewed by Dale Deaton, November 1, 1978, 1979OH078 FNS034, Frontier Nursing Service Oral History Project, Nunn Center UK. 63 John F. Caldwell, interview by Dale Dearon, July 6, 1978, 1978OH142 FNS002, Frontier Nursing Service Project Collection, Nunn Center UK.

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Frontier Nursing Service was to train nurse-midwives to practice in rural areas.64 The oral histories of rural women demonstrate that Kentuckians valued self-reliance, expected to work hard, and looked for comfort in church and family. 65 Despite a persistent agrarian myth touting large families, rural mothers did not always want large families. Ida Crowley, who raised fourteen children in the 1930s and 1940s in Whitley County, told an interviewer she would have “stole me some” birth control pills if she had the chance.66 Children did create more work, remembered Natel Meadors, mother to twelve children born in the 1940s. Meadors remembered that she had to haul water to a home with no electricity. She recalled, “we had rag diapers and the floor was their playpen.” Her mountain toughness persevered though; when her interviewer asked if life had been rough, Meadors replied, “No, not too bad.”67 But physician Louise Hutchins at Berea, who connected hundreds of women to contraception in southeastern Kentucky, reported that rural women wanted contraception. She said, “We met with no resistance. Only on the rarest occasion did we find a woman who said it was the Lord’s will to continue giving birth.”68 More than anything, social norms and religious traditions dictated that rural women become wives and mothers. Rhoda Britain, the oldest of twelve children and mother to several more, said of being a mother, “I felt the responsibility to do it and I enjoyed it. I don’t think I ever got too discouraged at any time, but you know it felt like

64 Melanie Beals Goan, Mary Breckinridge, 2. 65 Barbara Ellen Smith, “Beyond the Mountains: The Paradox of Women’s Place in Appalachian History,” NWSA Journal 11 (Fall, 1999): 1–17. Feminist historians have demonstrated how oral histories help us hear from women who would otherwise remain silent to the historical record. See Rebecca Sharpless, Fertile Ground, Narrow Choices: Women on Texas Cotton Farms, 1900–1940 (Chapel Hill, N.C., 1999). 66 Ida Croley, interviewed by Joie Carroll (n.d.), unpublished interview, 1988OH06.13, Patterns in Parenting Oral History Project, 1986–1987, KHS. 67 Natel Meadors, interview by June Meyers, (n.d.), unpublished interview, 1988OH06.23, Patterns in Parenting Oral History Project, 1986–1987, KHS. 68 Louise Hutchins, “A Better Life for Mountain Mothers,” Mountain Life & Work 34 (1958), 16–18.

319 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY our duty to do what we thought was best.”69 Cultural expectations of rural girls held that they would marry and become mothers. Those who sought birth control wanted to exercise some control over their bodies and fertility. Tachau and KBCL sought to find the rural women who wanted birth control by working through citizen committees, called “Ma- ternal Health Committees” for marketing purposes.70 A successful extension program required investments of time and patience to build trust. Reformers who saw public health initiatives as a way to address rural poverty were most successful when they remained mindful of cultural differences. Cultural traditions were important to rural people, a nurse from Frontier Nursing Service recalled. “We soon learned not to refuse anything they offered us to eat, as they were very sensitive to any seeming lack of appreciation of their offering to share what little they had.”71 Another FNS nurse-midwife commented, “I have always found the [rural] people to be kind, and generous, and most of them hard-working . . . they really were self-supporting.”72 While the outside world perceived rural Appalachian people to be isolated and backward, reformers who lived among them grew to appreciate these characteristics. Rural people perceived reformers differently depending on their motives and personalities. Reformers were certainly not a monolithic group; major differences separated urban reformers like Tachau from women who settled and lived among rural people.73 Members of

69 Rhoda Brittain, interviewed by Beverly Woliver, May 15, 1987, unpublished interview, 1988OH06.5, Patterns in Parenting Oral History Project, 1986–1987, KHS. 70 Harold Smith has explored the way the Texas Birth Control League promoted birth control as a maternal health issue, calling clinics “Maternal Health” rather than “Birth Control” clinics, to gain public support. Harold L. Smith, “All Good Things Start with the Women,” 266. 71 Anne Z. Cockerham, “Mary Breckinridge and the Frontier Nursing Service,” 97. 72 Betty Lester, interview, July 15, 1970, 2008OH677 FNS 211, Frontier Nursing Service Oral History Project, Nunn Center UK. 73 David Whisnant considered ways that settlement house reformers in Appalachia manipulated the local culture to achieve their goals. Whisnant, All That is Native and Fine, 1989, Ch. 1. Urban reformers like Tachau never intended to form cultural connections to other groups of women, while settlement house reformers relied on these connections as the basis for their reforms. 320 COMPLETELY SOLD ON BIRTH CONTROL the KBCL from Louisville and Lexington were relatively wealthy, and they resembled the urban reformers who populated progressive causes through the nation. Progressive reformers of the early twentieth century met challenges in rural southern communities, where “traditionalists” resisted their goals and methods.74 Social workers wrote about the importance of observing customs to avoid negative interactions, especially on issues involving children.75 Social worker Florence Adams at Berea noted in 1934 that “parents are quick to resent any infringement of parental authority, and friendship between parent and worker must be preserved.”76 Reformers meant well, but their advice could be perceived as condescending to the people tar- geted by their reforms, an issue which has been widely explored in social welfare history.77 Health reformers sometimes faced resistance from rural people who relied upon their own traditional folk medicines or trusted the methods of neighbors and friends over the clinic. For example, in October 1939, Ida Stapleton at Pine Mountain wrote about a rural woman who “brought their baby to the [Line Fork] Cabin and the doctor gave advice as to feeding and ordered cod-liver oil. At a later visit the baby was still very puny and did not seem to gain. On enquiry I found that they had never given the oil. A neighbor had advised against it.”78 Stapleton convinced the mother to use the remedy she prescribed and reported a thriving baby a few months later. Martha Canada, mother of eleven from Whitley County, only

74 William A. Link, The Paradox of Southern Progressivism, 1880–1930(Chapel Hill, N.C., 1997). 75 For a contemporary look at rural social work practice, see Josephine Strode, “Rural Social Workers Do Everything,” Survey Mid-Monthly 74 (Oct. 1938): 309. 76 Florence S. Adams, “New Trends in Family–Child Welfare Work with Mountaineers,” Mountain Life and Work 10 (July 1934), 8–12. 77 On the importance of interactions between reformers and local women, see Mimi Abramovitz, Regulating the Lives of Women: Social Welfare Policy from Colonial Times to the Present (Boston, 1988); John Erhenreich, The Altruistic Imagination: A History of Social Work and Social Policy in the United States (Ithaca, N.Y., 1985); and Susan Stein-Roggenbuck, Negotiating Relief: The Development of Social Welfare Programs in Depression-Era Michigan, 1930–1940 (Columbus, Ohio, 2008). 78 Ida Stapleton to unknown, October 1939, Pine Mountain Settlement School Collection, KHS.

321 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY used folk remedies, including slippery elm bark for whooping cough. She said, “I didn’t take them to the doctors cause I couldn’t afford it . . . I doctored them myself with my mother’s teaching and what I learned from her.”79 In places where no clinics or nurses were available, people had no recourse but to use folk medicine. Even when clinics such as FNS were established, health professionals found that rural people were not all ready to embrace modern methods of health care. To encourage the extension work of state leagues, Sanger’s BCCRB sent field workers to build rapport in rural areas. Field worker Edna Rankin McKinnon arrived in Louisville in 1938 to help the KBCL organize support. McKinnon, a veteran birth control reformer with rural outreach experience in other states, dedicated her career to the belief that “every single child born on this earth should be wanted and cherished. Birth control and peace are the answers we must give to death control by war and pollution.”80 During her stay in Ken- tucky, she visited with community leaders, approaching them with “explanations of what birth control could mean to the fulfillment and happiness of an individual family and to the economy of a specific city or county.”81 She was well prepared, driving a black Ford filled educational materials about birth control and samples provided by the BCCRB. Field workers like McKinnon and her successors laid the groundwork for birth control extension outreach by arousing public interest with a combination of statistics, testimony from mothers, and data tailored for relevance to each group.82 The education component of the outreach strategy was important to its success. The KBCL sent field workers to “convert and

79 Martha Canada interviewed by Joie Carroll (n.d.), unpublished interview, 1988OH06.23, Patterns in Parenting Oral History Project, 1986–1987, KHS. 80 Edna Rankin McKinnon, sister of Jeanette Rankin, the first woman elected to Congress, was a lifelong devotee to the birth control movement. See Wilma Dykeman, Too Many People, Too Little Love: Edna Rankin McKinnon: Pioneer for Birth Control (New York, 1974), 276. 81 Dykeman, Too Many People, 54. On field workers of the BCCRB between 1936 and 1938, see Hajo, Birth Control on Main Street, 16–21. On the merger of BCCRB with the Birth Control Federation of America in 1939, see Engleman, A History of the Birth Control Movement in America, 171–72. 82 Elizabeth Cosby, Family Planning in Kentucky: A History, Box 1, Folder 1, Family Planning in Kentucky Collection, KHS, 8.

322 COMPLETELY SOLD ON BIRTH CONTROL strengthen” support in the counties.83 They stepped carefully, always promoting birth control as a measure for health and well-being of mothers and their existing children. Tachau wrote to a community leader in Harrodsburg that the KBCL could “give any kind of talk you want. The movie (a talking slide film) presents every possible argument for birth control but offers no information as to any method except that it should be taught by a competent physician.”84 By 1939, the KBCL was able to offer polished presentations, visits from field workers, referrals to local physicians who supported birth control, and free or discounted supplies. One remaining obstacle was the method of contraception offered to rural women. This problem had gained the attention of contraceptive manufacturers and scientists.85 A spermicidal foam powder, which did not require a clinic visit, seemed like the answer. Tachau negotiated with pharmaceutical companies to receive discounted supplies in exchange for data supplied by physicians. In a June 1938 letter, Tachau outlined the extension program to a rural physician:

Realizing that the clinic plan, as functioning in cities, where the doctor makes a pelvic examination and fits the patient with diaphragm and jelly method, is not practical for rural mothers, we are trying to visit doctors in towns all over Kentucky, and asking for their individual cooperation for their own poor patients, or for those referred to them by nurse or social workers or friend. We ask the doctor to prescribe a simple and inexpensive contraceptive, such as jelly and sponge or foam powder and sponge, and we agree to give a year’s supply free so that the mothers may get in the habit of using a reliable method . . . . We ask that the doctors keep a set of simple record cards (like enclosed) and let us know when

83 Jean Tachau to B. T. Hume, February 28, 1940, Harrodsburg, Ky., Box 1, Folder 8, Family Planning in Kentucky Collection, KHS. 84 Ibid. 85 On the development of new contraceptive methods in the 1930s, see Engleman, A History of the Birth Control Movement in America, 174–77; on the development of spermicidal foam powder, see Teresa Ortiz-Gomez, Gendered Drugs and Medicine: Historical and Socio- Cultural Perspectives (New York, 2016), 96–98.

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he needs more supplies.86

According to KBCL records, Tachau sent similar letters to over seventy rural physicians by October 1938. The state extension work of KBCL was successful in at least three ways. The first was to develop Maternal Health Committees, like the KBCL formed in Breathitt County in southeastern Kentucky. In December 1938, Tachau wrote to Methodist minister John H. Lewis and offered to send a field worker to speak to a women’s group. The following week, the field representative, Louise Bowser, presented to Lewis and ten citizens at the Presbyterian Church in Jackson. Bowser reported that the group “recognized the need for birth control” for poor women and planned to discuss it with physicians and community leaders.87 Tachau charged the Breathitt County Maternal Health Committee with finding a physician who supported the work and would prescribe birth control in his or her own office. In January 1939, Lewis reported that physician Philip Brest was willing to serve in that capacity. Brest wrote the KBCL in February 1939 to report the opening of a “clinic for the indigent,” and asked for supplies until the committee could raise funds to purchase their own. The KBCL complied and sent free supplies to the new clinic. Tachau continued to correspond with Lewis to provide materials, personnel, and other forms of support. The experiment in Breathitt County was halted in 1941, when Dr. Brest left to serve in the Army.88 A second example of KBCL extension work was in Bell County in southern Kentucky. Beginning in 1936, Tachau worked with Fairy Farley, a public health worker in Pineville, to develop a plan for a Ma- ternal Health Committee affiliated with the League. Tachau wrote that once committee members were selected, they should “plan to have one or more physicians agree to see patients when sent by another doctor,

86 Jean Tachau to Dr. Porter, June 29, 1938, Box 1, Folder 4, Family Planning in Kentucky Collection, KHS. 87 Breathitt County, Marion County, Summary County Folders, 1938–1944, Box 1, Folders 4 and 8, Family Planning in Kentucky, KHS. 88 Ibid.

324 COMPLETELY SOLD ON BIRTH CONTROL nurse, a social worker or an interested friend.”89 Tachau supplied the names of two Bell County physicians she believed to be willing to serve on this committee and suggested they “work quietly but try to interest enough people to raise a little money and educate citizens to understand the purposes of Birth Control.”90 From there, the citizen committee helped expand birth control access. When a KBCL field worker conducted a follow up visit to Bell County in 1940, she found a thriving movement with eleven participating physicians.91 Birth control extension work took a different form in Madison County, where the KBCL contributed to an established local movement. In 1936, a group of women from Berea College heard a Council of Southern Mountain Workers (CSMW) conference presentation about rural outreach work in West Virginia, where “a nurse was going from home to home telling women how to space their children.”92 States that included birth control in public health programs similar to Kentucky utilized the visiting nurse model in rural areas.93 Inspired by the visiting nurse approach, the Berea women formed Mountain Maternal Health League (MMHL) in 1936. Rural birth control work in the Berea region differed from other state projects. The West Virginia project was driven by concerns of population control and, as explained by historian James Reid, was “insensitive to feminist issues or even . . . rights of human subjects in social experiments.”94 The work of Dr. Louise Hutchins and the MMHL differed from the West Virginia project, Reid asserted, because Hutchins “wanted to liberate women from male tyranny as well as bad health and unwanted pregnancies.” Their motives differed, but the MMHL borrowed methods from other rural projects, namely the “door-to-door distribution of

89 Fairy Farley to Jean Tachau, October 30, 1936, Box 1, Folder 3, Family Planning in Kentucky Collection, KHS. 90 Ibid. 91 Summary County Folders, 1936–42, Box 1, Folder 3, Family Planning in Kentucky Collection, KHS. 92 Hutchins, “A Better Life for Mountain Mothers,” 17 (quotation). For a history of the MMHL, see Jenny M. Holly, “The Mountain Maternal Health League and the Changing Politics of Birth Control in Kentucky, 1936–1944,” (MA thesis, Indiana University, 2017). 93 Hajo, Birth Control on Main Street, 167. 94 Ibid.

325 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY contraceptive jelly.”95 Reid interviewed Hutchins in 1975, and she recalled how she visited women “in a state sponsored public health van dispensing contraceptive services in areas where there were for- merly no medical services at all.”96 The MMHL supplied the jelly and syringe at low or no cost.97 The early work of MMHL was funded by Clarence Gamble, a biomedical researcher and heir to the Proctor and Gamble fortune. Gamble, an ardent eugenicist who feared rapid propagation of the working class, dedicated substantial resources to the development of a low-cost and accessible birth control method for poor rural women.98 Gamble approached the MMHL in 1936, proposing financial support to provide birth control supplies, a car, and a nurse’s salary. The MMHL hired nurse Lena Gilliam to visit nearly five hundred women in their homes in Madison, Rockcastle, and Jackson Coun- ties, collect case histories, distribute tubes of a contraceptive jelly and syringe, and conduct follow up visits.99 The women Gilliam visited had, on average, conceived a child about once every twenty-eight months and had between four and five living children. Lena Gilliam left the MMHL in 1938 and her sister Sylvia, also a trained nurse, took her place.100 When the study concluded in 1942, Gamble’s team announced that the jelly was about 85% effective.101 In 1938, Gamble began to reduce funding, and concluded his study in 1943. The Gamble project happened without KBCL involvement because Gamble refused to partner with KBCL in the birth control

95 Reid, The Birth Control Movement and American Society, xviii. 96 Ibid., xix. 97 Holly, “The Mountain Maternal Health League and the Changing Politics of Birth Control in Kentucky, 1936–1944,” 34. 98 On the motives and biases of Clarence Gamble, see Schoen, Choice and Coercion, 33–35; and Reid, From Private Vice to Public Virtue, 225–57. 99 Johanna Schoen has shown that in a similar research project in North Carolina, partnering with Gamble meant a loss of autonomy over the methods of contraceptive methods. Contraceptives used in the Gamble study were distributed at his command, even when it became clear that some products were not viable options. Schoen, Choice and Coercion, 33–35. 100 Lena Gilliam, “A Contraceptive Service for Mountain Women,” Journal of Contraception 3 (March 1938): 57–58. 101 Data from the study was published in Gilbert W. Beebe and Murray A. Geisler, “Control of Conception in a Selected Rural Sample,” Human Biology 14 (February 1942): 1–20. 326 COMPLETELY SOLD ON BIRTH CONTROL project.102 However, Tachau found other ways to network with birth control advocates at Berea. She found a kindred spirit in Dr. Louise Hutchins, who arrived at Berea in 1939. In 1940, Hutchins and Tachau collaborated to send Sylvia Gilliam on follow-up visits to over five hundred women in Harlan, Lancaster, and Adair Counties.103 She found about three-quarters of them still using the methods provided by the KBCL and MMHL.104When Gamble began to withdraw funding, under Hutchins’ direction the MMHL continued to supply the seven hundred women in the study with refills of spermicidal jelly.105 But by 1943, Hutchins realized their funds were “too slim to send a nurse out” and she established a clinic at Berea to supplement the visiting nurse program, recruiting FNS nurse-midwives to provide maternal health care. Thus, the extension work of KBCL was limited in Madison County, but still provided an important source supplies and support. A third successful model of KBCL birth control extension work in could be found in Harlan and Letcher Counties in southern Kentucky near the Cumberland Gap. Efforts in health and education outreach had been underway there since 1914, when educators founded the Pine Mountain Settlement School (PMSS).106 In 1918, Katherine Pettit led an expansion movement to nearby Gilley, site of the Line Fork Settlement. The “Health House” of the Line Fork Settlement was a “little three-room cabin, covered with rough slabs . . . with home-made furniture.” The clinic boasted a “home-made operating table” and the “first bath-tub on Line Fork,” but most importantly, a dedicated space for nurses to provide health care to rural residents of Harlan and Letcher Counties.107 Community health nurse Lutrella Baker arrived at Line Fork in 1935, enthusiastic to begin a birth

102 Holly, “The Mountain Maternal Health League and the Changing Politics of Birth Control in Kentucky, 1936–1944,” 10. 103 Hutchins, “A Better Life for Mountain Mothers,” 17. 104 Ibid. 105 Hutchins, “Better Health for Mountain Mothers,” 18. 106 David Whisnant, All That is Native and Fine. 107 “Pine Mountain Settlement School,” Harlan County, Ky., 1919, 3.

327 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY control clinic.108 She corresponded with KBCL for birth control supplies and expressed interest in a visiting nurse program in 1938, when she wrote to the MMHL for help solving the “baffling, over- whelming problem of . . . babies, babies, babies.”109 Surely aware of the problems with the foam powder and jelly-and-syringe methods, Baker was thrilled in 1939 to finally have a doctor “completely sold on birth control” at Line Fork, one who would “fit the diaphragms and educate the women as the need arises.”110 In the eyes of Baker, this was the best outcome. The networking efforts of the birth control coalition in Kentucky were gendered in that they were efforts led by middle and upper- class women to help poor women. Their work conforms to a pattern of female philanthropy identified by Joan Marie Johnson.111 The importance of women on citizen committees must be underscored. Reverend Lewis in Breathitt County told Tachau in 1939 that “this work should be carried on by the women of the community.”112 In addition to gender, class was an important component in rural reform efforts like birth control extension. Nurse Lena Gilliam was a proud native of rural Kentucky, and although she had travelled widely and trained in New York City, she was selected to work with rural women because she “knew exactly how to approach the women and was absolutely convinced of the need for work.”113 This was important because, as one county health nurse told Tachau, “native mountain

108 Dana Allen Johnson, “‘A Cage of Ovulating Females’ : Mary Breckinridge and the Politics of Contraception in Rural Appalachia,” (MA thesis, Marshall Digital Scholar, 2010), 73. 109 Holly, “The Mountain Maternal Health League and the Changing Politics of Birth Control in Kentucky, 1936–1944,” 37. 110 Lutrella Baker to Jean Tachau, August 16, 1939, Box 1, Folder 12, Family Planning in Kentucky Collection, KHS. 111 Joan Marie Johnson described the way society women contributed funds and legitimacy to the birth control movement in Funding Feminism. Other scholarship that emphasizes the feminist nature of reform in Kentucky includes Caldemeyer, “Yoked to Tradition.” On the way women led the birth control movement in Texas see Smith, “All Good Things Start with the Women.” 112 Dr. Porter to Jean Tachau, June 29, 1938, Box 1, Folder 4, Family Planning in Kentucky Collection, KHS. Cathy Hajo highlighted the ways local clinics were almost exclusively run by women. Hajo, Birth Control on Main Street. 113 Louise Hutchins, “A Better Life for Mountain Mothers,” 17.

328 COMPLETELY SOLD ON BIRTH CONTROL

Lutrella Baker of Line Fork Cabin. Lutrella Baker Album, Line Fork Settlement, 1937–1941. Pine Mountain Settlement School Collections.

329 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY women . . . resent the intrusion of outsiders.”114 The responses of physicians involved in KBCL extension work varied. A doctor from Metcalf County, for example, reported that after giving out one hundred boxes of spermicidal powder to indigent mothers, about half of his patients refused to use it again because of irritation. “We need a contraceptive that requires no exam or fitting, but foam powder is not it,” the doctor wrote.115 Other rural doctors refused to participate in the birth control outreach efforts at all; one small town physician told a KBCL representative that his female patients were “too lazy” and “ignorant” to use birth control correctly.116 Women wrote to KBCL of their negative experiences with doctors when they asked about birth control. One wrote of an interaction with an unsympathetic physician, “I have asked my doctor for help but he only laughs and says there is no way except to make my husband let me alone.”117 Lila Clifton of Johnson County decided to ask her family physician how to prevent another pregnancy. The doctor advised the use of condoms; after giving birth to three more children, Clifton asked for a diaphragm. She was fitted for one and instructed on how to use it, but two years later became pregnant again. Her sister-in-law was fitted for a diaphragm for the same doctor, but became pregnant with twins while using it, and another baby a year after the twins.118 Clearly there was a flaw in the fitting or explanations of these diaphragms. Some physicians saw sterilization as most suitable for the rural poor, although Kentucky did not have a sterilization law. In Bell County, a KBCL representative noted that “doctors in Pineville are firm believers in sterilizing the men,” with

114 Stella R. Miller to Jean Tachau, November 6, 1940, Box 1, Folder 3, Family Planning in Kentucky Collection, KHS. Emphasis in original. 115 Edmonton, Metcalfe County Report, July 9, 1940, Box 1, Folder 8, Family Planning in Kentucky Collection, KHS. 116 Cosby, “Family Planning in Kentucky,” Box 1, Folder 1, Family Planning in Kentucky Collection, KHS, 10. 117 Cosby, “Family Planning in Kentucky,” 12. 118 Lila Clifton, interviewed by Glenna Graves, November 5, 1988, Family and Gender in the Coal Community Oral History Project, Nunn Center, UK.

330 COMPLETELY SOLD ON BIRTH CONTROL over 130 sterilizations completed by two physicians in 1939.119 This reflected a national initiative to enforce sterilizations of any deemed “socially inadequate.”120 Despite her efforts, Tachau did meet resistance in some counties. Field workers sent notes to warn of obstacles, such as in Marion County in Central Kentucky, where KBCL was cautioned to “tiptoe” around the “large Catholic” population.121 In other places, the work of KBCL clashed with previously established health care initiatives. For example, the FNS had operated in Leslie County since 1925. Its director, Mary Breckinridge, was a strong and effective leader, but one who disliked collaboration or infringement upon her autonomy. After all, it had taken FNS time to build a rapport with the rural people of Leslie County, and by 1937 they had treated over 3,000 maternity cases.122 In October 1939, Mary Breckinridge wrote to congratulate the KBCL on “Plan Your Family,” an “extremely well done leaflet” that emphasized “making things better for the baby rather than on having less babies.”123 In October of 1940, a KBCL field worker visited the FNS center in Leslie County. She was taken on a tour and the FNS nurse “was enthusiastic about their Birth Control work. She said that last year they fit 70 diaphragms and so far this year they have fit about 30 with splendid results.”124 It is unclear what led the KBCL

119 Middlesboro (Bell County) Report, June 6, 1940, Box 1, Folder 3, Family Planning in Kentucky Collection, KHS. 120 A 1934 statute was introduced for eugenic sterilization in Kentucky but failed. George T. Skinner, “Sterilization Statue for Kentucky,” 23 Ky. L.J. On social class and rural physicians, see Sandra Lee Barney, Authorized to Heal. On sterilization of the poor, see Paul A. Lombardo, Three Generations, No Imbeciles: Eugenics, the Supreme Court, and Buck v. Bell (Baltimore, 2008) and Karen A. Keely, “Poverty, Sterilization, and Eugenics in Erskine Caldwell’s Tobacco Road,” Journal of American Studies 36 (2002): 23–42. 121 Marion County, Summary County Folders, 1938–1944, Box 1, Folder 8, Family Planning in Kentucky Collection, KHS. 122 Goan, The Frontier Nursing Service and Rural Health in Appalachia, 171. 123 Mary Breckinridge to KBCL, October 21, 1939, Box 1, Folder 8, Family Planning in Kentucky Collection, KHS. 124 Field Report, Wooten (Leslie County), October 10, 1940, Box 1, Folder 8, Family Planning in Kentucky Collection, KHS (quotation). See also Goan, Mary Breckinridge, 165 and 171. According to their reports, the FNS had lost only two women in childbirth out of 3,000 cases. The national average was 5.9 maternal deaths per 1,000 births. 331 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY to create a leaflet in 1940 asserting itself as “the only organization equipped to provide ‘Mrs. H. P.,’ a letter writer and rural mother of seven from Leslie County, with the means by which she may avoid another pregnancy.”125 A terse exchange a few years later showed that the two groups no longer enjoyed the camaraderie of earlier times. In September 1944, FNS assistant director Dorothy Buck wrote Tachau that the clinic could not comply with her request for records, as they were shorthanded after several doctors, nurses, and staff had joined the armed services. She wrote, “I think you understand that we haven’t a separate clinic for birth control, but that the teaching is given at our Monday clinic for women where gynecological work, prenatal and postpartum work is also handled. The personal records of thousands of women would have to be gone over in order to get exact information for your purposes.”126 Tachau replied with a polite explanation of the record collecting needs of the newly established Planned Parenthood Federation of America (PPFA).127 The birth control coalition in Kentucky began to unravel as cooperating nurses and physicians left the Commonwealth to serve in the military. World War II affected Kentucky like the rest of the country; unemployment went down, income went up, and people moved to cities for wartime jobs. Between 1940 and 1942, 19 percent of Kentucky’s rural population left, accounting in some places for 40 percent of men aged fifteen through thirty-four.128 It also became safer to bear children in the U.S.; the maternal mortality rate fell 32

125 “To Aid Solicitors,” June 1940, Folder 1, Box 2, Family Planning in Kentucky Collection, KHS. 126 Dorothy Buck to Jean Tachau, Septmber 13, 1944, Folder 8, Box 1, Family Planning in Kentucky Collection, KHS. 127 Historians including Linda Gordon and Peter Engleman have discussed the changing nature of the birth control movement after PPFA was formed in 1942; Sanger’s vision of voluntary motherhood, women’s reproductive rights, and sexual autonomy faded as the PPFA instead promoted birth control as a family planning measure meant to increase children’s wellbeing. This had a negative effect on rural extension efforts, as the PPFA doubled down on urban clinics staffed by licensed physicians. Peter Engelman, A History of Birth Control in America, 178–79; Linda Gordon, The Moral Property of Women: A History of Birth Control Politics in America (Urbana, Ill., 2002), 242–46. 128 Goan, Mary Breckinridge, 178–79. 332 COMPLETELY SOLD ON BIRTH CONTROL percent between 1934 and 1939.129 On a more sinister note, funding for birth control work dried up during World War II, a trend which Engleman blames on leaders whose “eugenic motivations narrowed the vision of the organizers, who tended to focus on reducing the birth rate among indigent populations—a good percentage of whom were considered ‘unfit’—instead of quality of life issues.”130 In 1942, the ABCL and its state affiliates became the Planned Parenthood Federation of America, a group still in operation today. As time went on, the important figures in the Kentucky birth control movement moved on to other projects. Jean Tachau worked with the new statewide Division of Child Welfare established in the early 1940s to focus on changing state policy.131 Edna Rankin McKin- non went on to serve as executive director of PPFA in Chicago from 1947–1957, and Gamble worked with PPFA until 1957 when he founded Pathfinder Fund to study contraception in underdeveloped countries. Sylvia Gilliam left to manage a rural birth control project in Michigan, and Louise Hutchins served as medical director and board president at Berea College for nearly fifty years.132 Kentucky continued to be a site for experimentation however; a nurse from FNS recalled early testing of the birth control pill beginning in 1958 as part of a field test.133 The birth control pill, still the most popular method of contraception today, became available in 1965. It was also in the early 1960s when the federal government began to encourage state public health programs to include family planning services. The Kentucky State Board of Health finally endorsed birth control in public health clinics in 1962. The Family Planning Services and

129 The Public Health Service Act of 1975 included family planning programs. On increased clinics in the states, see McCann, Birth Control Politics in the United States, 1916– 1945; Edwin F. Daily, “Maternal Mortality, 1939,” Division of Maternal and Child Health, Children’s Bureau, U.S. Department of Labor, Washington, D.C. (August 1941), 352–54. On the conservative nature of the medical profession in general, see Reid, The Birth Control Movement and American Society. 130 Engelman, A History of Birth Control in America, 177. 131 Dent, “An Interview with Mrs. Charles G. Tachau,” 12 132 Hutchins, A Better Life for Mountain Mothers, 18. 133 William Linwood Montell, Tales from Kentucky Nurses (Lexington, Ky., 2005), 236. 333 REGISTER OF THE KENTUCKY HISTORICAL SOCIETY

Population Research Act of 1970 and the Public Health Act of 1975 both continued the shift of birth control from a privately-funded, women’s reform movement to a public health measure supported by public funds.134 In conclusion, this study demonstrated the way one state birth control league drew upon social work methods to establish networks in rural communities despite the lack of state support. The extension work of KBCL was powered by collaboration with people in rural communities, but as birth control is a preventative measure, it is not possible to know how many pregnancies were prevented. We know from oral histories that rural women who did not live in the area canvassed by the KBCL or MMHL, or who lived in those places after the work ceased, did not have knowledge of birth control access. The KBCL was not the first women’s group to initiate a reform movement in Kentucky, but their collaborative work with established groups and individuals in rural counties provides an example of how networking grounded in social work was the key to a successful extension movement.

134 On birth control history after 1950, see Donald T. Critchlow, Intended Consequences: Birth Control, Abortion, and the Federal Government in Modern America (Oxford, 2001). 334