Tag: countries

  • Maternal infections in health facilities

    Maternal infections in health facilities

    A clearer picture of the global impact 

    New research from the Global Maternal Sepsis Study (GLOSS), a major WHO/HRP initiative, shows that infection has a much larger impact on global maternal mortality and morbidity than previously thought.

    Logo of the Lancet Global HealthThe
    results from GLOSS, published in The Lancet Global Health, are the first to provide data on frequency of maternal infections and
    sepsis across the pregnancy and post-pregnancy period, in a large number of health facilities around the world. 

    Around 11 women per 1000 live births had an infection which resulted in or contributed to what is known as a severe maternal outcome – either they died or nearly died – during their hospitalization. 

    Urgent improvement is needed to manage this life-threatening risk faced by all pregnant and recently pregnant women, wherever they are in the world. 

    What is maternal sepsis and how does it lead to maternal death?

    Maternal sepsis is a life-threatening condition that arises when the body’s response to infection causes injury to its own tissues and organs during pregnancy, child-birth, post-abortion or the postpartum period.

    The latest global estimates place sepsis due to obstetric infections as the third most common cause of maternal mortality. However, this only includes infections as a direct result of pregnancy, such as endometritis or post-caesarean wound infections.

    Few
    previous studies include post-abortion infections. Neither do they address indirect infections such as respiratory and meningitis, which are aggravated by pregnancy but not directly caused by it.

    A better understanding of maternal infection

    GLOSS was a massive facility-based data collection effort led by WHO, accompanied by a ‘STOP SEPSIS!’ campaign to increase awareness among healthcare providers.

    The study gathered data on women who were admitted with suspected or confirmed infection during pregnancy or post-pregnancy over a one-week period in 2017. More than 2800 women participated in the study in 52 countries.

    GLOSS included healthcare facilities that care for women during pregnancy, childbirth or at the end of pregnancy, as well as facilities without maternity service but where women could be hospitalized during or after pregnancy, and data on infections
    which are not usually recorded as maternal sepsis, including post-abortion and indirect infections. 

    The result is a more complete understanding of the frequency and impact of maternal infections in health facilities. 

    GLOSS calls attention not only to the wider range of risks faced by pregnant women but also to the long period of time during which they are at risk. 

    Putting global numbers on maternal infection and sepsis

    Overall, around 70 pregnant or recently-pregnant women per 1000 live births were found to have a maternal infection needing hospital management. 

    Across the study, 11 women with either direct or indirect infection per 1000 live births developed a severe maternal outcome, but in low- and middle-income countries up to 15 women per 1000 births were affected.

    Infections were the underlying cause of most of the deaths recorded during the study, primarily post-abortion infection and indirect infections. Infections were also present in about a third of deaths attributed to other causes, such as postpartum
    haemorrhage.

    This suggests that the contribution of infection to global maternal mortality and morbidity may be larger than current reports of maternal sepsis mortality suggest.

    Preventing, identifying and treating maternal infection and sepsis

    Some of the most common maternal infections found in the study, such as urinary tract infections, post-caesarean and post-abortion infections, are largely preventable and treatable.

    GLOSS results suggest that current levels of monitoring and clinical care across health facilities are not enough to prevent, identify and treat levels of maternal infection effectively. 

    For instance, a complete set of vital signs was not reported for a third of the women in the study, on the day their infection was suspected or diagnosed. Delays in antimicrobial therapy were frequent.

    GLOSS also shows marked differences across countries, with the highest burden in low- and middle-income countries, compared with high-income countries.

    This may reflect the impact of broader health determinants in different country contexts. Challenges of overcrowding, limited access to water and sanitation and constraints to safe births by skilled birth attendants can reduce the ability of healthcare
    providers to manage the frequency and outcome of maternal infections.

    An opportunity to implement evidence-based practice

    GLOSS gives healthcare providers, policy-makers, and the public at large an opportunity: to mobilise around these data improve evidence-based practice, and save lives. 

    WHO has produced a number of resources which can support timely action to prevent, diagnose and treat maternal infection, as well as activities such as the upcoming SAVE LIVES: Clean Your Hands campaign
    on 5 May which celebrates the central role played by nurses and midwives in clean health care. 

    In addition, WHO will publish a global sepsis epidemiology report around the 73rd World Health Assembly (WHA) in May, as requested in the
    2017
    WHA Resolution on Improving the prevention, diagnosis and clinical managementof sepsis.

    Understanding why and how infection affects women is essential for equipping healthcare providers with life-saving knowledge and enabling health care systems to bring down global maternal mortality and morbidity.

    Related publications

    WHO recommendations for prevention and treatment of maternal peripartum infections

    WHO Clinical practice handbook for safe abortion

    Global guidelines on the prevention of surgical site infection

    WHO statement on maternal sepsis

    World Health Assembly resolution on Improving the prevention, diagnosis and clinical management of sepsis

    Health Topics

    Antimicrobial resistance

    Infection Prevention and Control

    Water Sanitation Hygiene

    Other links

    Global Maternal Sepsis Study

    SAVE LIVES: Clean Your Hands 5 May 2020

     

     

    Maternal infections in health facilities
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  • Global leaders unite to ensure everyone everywhere can access new vaccines, tests and treatments for COVID-19

    Global leaders unite to ensure everyone everywhere can access new vaccines, tests and treatments for COVID-19

    Heads of state and global health leaders today made an unprecedented commitment to work together to accelerate the development and production of new vaccines, tests and treatments for COVID-19 and assure equitable access worldwide.

    The COVID-19 pandemic has already affected more than 2.4 million people, killing over 160,000. It is taking a huge toll on families, societies, health systems and economies around the world, and for as long as this virus threatens any country, the entire world is at risk. 

    There is an urgent need, therefore, while following existing measures to keep people physically distanced and to test and track all contacts of people who test positive, for innovative COVID-19 vaccines, diagnostics and treatments.

    “We will only halt COVID-19 through solidarity,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Countries, health partners, manufacturers, and the private sector must act together and ensure that the fruits of science and research can benefit everybody.”

    Work has already started. Since January, WHO has been working with researchers from hundreds of institutions to develop and test vaccines, standardize assays and standardize regulatory approaches on innovative trial designs and define criteria to prioritize vaccine candidates.  The Organization has prequalified diagnostics that are being used all over the world, and more are in the pipeline. And it is coordinating a global trial to assess the safety and efficacy of four therapeutics against COVID-19.

    The challenge is to speed up and harmonize processes to ensure that once products are deemed safe and effective, they can be brought to the billions of people in the world who need them. Past experience, in the early days of HIV treatment, for example, and in the deployment of vaccines against the H1N1 outbreak in 2009, shows that even when tools are available, they have not been equally available to all.

    So today leaders came together at a virtual event, co-hosted by the World Health Organization, the President of France, the President of the European Commission, and the Bill & Melinda Gates Foundation. The event was joined by the UN Secretary General, the AU Commission Chairperson, the G20 President, heads of state of France, South Africa, Germany, Vietnam, Costa Rica, Italy, Rwanda, Norway, Spain, Malaysia and the UK (represented by the First Secretary of State).

    Health leaders from the Coalition for Epidemic Preparedness Innovations (CEPI), GAVI-the Vaccine Alliance, the Global Fund, UNITAID, the Wellcome Trust, the International Red Cross and Red Crescent Movement (IFRC), the International Federation of Pharmaceutical Manufacturers (IFPMA), the Developing Countries Vaccine Manufacturers’ Network (DCVMN), and the International Generic and Biosimilar Medicines Association (IGBA) committed to come together, guided by a common vision of a planet protected from human suffering and the devastating social and economic consequences of COVID-19, to launch this groundbreaking collaboration. They are joined by two Special Envoys:  Ngozi Okonjo-Iweala, Gavi Board Chair and Sir Andrew Witty, former CEO of GlaxoSmithKline.

    They pledged to work towards equitable global access based on an unprecedented level of partnership. They agreed to create a strong unified voice, to build on past experience and to be accountable to the world, to communities and to one another.

    “Our shared commitment is to ensure all people have access to all the tools to prevent, detect, treat and defeat COVID-19,” said Dr Tedros. “No country and no organization can do this alone. The Access to COVID-19 Tools Accelerator brings together the combined power of several organizations to work with speed and scale.”

    Health leaders called on the global community and political leaders to support this landmark collaboration and for donors to provide the necessary resources to accelerate achievement of its objectives, capitalizing on the opportunity provided by a forthcoming pledging initiative that starts on 4 May 2020. This initiative, spearheaded by the European Union, aims to mobilize the significant resources needed to accelerate the work towards protecting the world from COVID-19.

     

    Global leaders unite to ensure everyone everywhere can access new vaccines, tests and treatments for COVID-19
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  • INFOSAN Quarterly Summary, 2020 #1

    Food safety incidents

    During the first quarter of 2020, the INFOSAN Secretariat was involved in 38 food safety incidents involving 109 WHO Member States and 9 territories of WHO Member States. There were 25 incidents involving a biological hazard (Salmonella spp. [8], Listeria monocytogenes [5], Norovirus [3] Shiga-toxin producing Escherichia coli [2], Clostridium botulinum [2] Bacillus cereus [2], Cronobacter spp. [1], Shigella sonnei [1], unspecified biological hazard [1]), 6 involving an undeclared allergen (milk [3], peanut (1), egg [1], gluten [1]), 5 involving a physical hazard (undetermined foreign matter [2], glass [1], metal [1], plastic [1]), one involving a chemical/toxin hazard (histamine), and one linked to an unspecified hazard.

    The food categories that were most commonly involved in the 38 incidents during the first quarter of 2020 involved fish and other seafood (8), herbs and spices (4), legumes and pulses (4), milk and dairy products (3), nuts and oilseeds (3), snacks, desserts and other foods (3), cereals and cereal-based products (2), composite food (2), fruit and fruit products (2), meat and meat products (2), vegetables and vegetable products (2), products of special nutritional use (1), and food for infants and small children (1). One incident involved an unknown food source.

    During such international food safety incidents, the INFOSAN Secretariat relies on the swift action of national INFOSAN Emergency Contact Points to respond to requests for information. Rapid sharing of information through INFOSAN enables members to implement appropriate risk management measures to prevent illness in their respective countries.

    Geographic scope

    The outlined incidents involved Member States from all WHO regions: Europe (39), followed by the Americas (24), Africa (24), the Western Pacific (18), the Eastern Mediterranean (8) and South-East Asia (6).

    Recall in several countries of frozen spring roll sheets from Singapore due to the presence of an undeclared allergen

    In February 2020, the INFOSAN Secretariat was notified by the European Rapid Alert System for Food and Feed (RASFF) and INFOSAN colleagues in Australia of a recall in Australia and several European countries of frozen spring roll sheets due to the detection of an undeclared allergen (milk), imported from Singapore. In collaboration with RASFF, the INFOSAN Secretariat was informed that the implicated frozen spring roll sheets were distributed internationally to 46 Member States from four WHO regions and 4 territories in Europe and the Western Pacific. Moreover, through engagement with the INFOSAN Emergency Contact Point (ECP) in Singapore, the INFOSAN Secretariat also received details of further distribution of implicated products to additional WHO Member States from all WHO regions, taking the total number of Member States involved to 65. It was also reported that the products involved had been redistributed by some countries to Europe, the Americas and Africa. Consequently, several countries recalled the implicated products to relabel them and investigated the issue to identify illnesses related to the consumption of the implicated frozen spring roll sheets. No illnesses were reported to the INFOSAN Secretariat.

    This incident has highlighted undeclared allergens as an important category of hazards that can result in a largescale international response to implement risk management measures and prevent illness. In addition, it exemplified efficient communication among INFOSAN members and the Secretariat.

    Outbreak of Listeriosis in the United States of America linked to enoki mushrooms imported from the Republic of Korea

    In March 2020, the INFOSAN Secretariat was made aware by the United States (US) Centers for Disease Control and Prevention (CDC) of an outbreak of Listeriosis in the US linked to the consumption of enoki mushrooms, imported from the Republic of Korea. In total, 36 cases including 4 deaths have been reported in the US. Following investigations in Canada, carried out in collaboration with the US, the INFOSAN Secretariat was informed of 6 cases of Listeriosis between 2017 and 2019 in Canada potentially related by whole genome sequencing (WGS) to the ongoing outbreak in the USA. In addition, food isolates (from enoki mushrooms from the Republic of Korea) genetically associated with the cluster of cases have been collected in 2019 by authorities in Canada. The WGS information pertaining to the cases and food isolates were shared on the INFOSAN Community Website to assist the identification of cases in other countries.

    The INFOSAN Secretariat engaged the INFOSAN Emergency Contact Point (ECP) in the Republic of Korea to seek details on any further international distribution of the implicated enoki mushrooms. Investigations are ongoing. 

    News & activities

    Food Sector and the COVID-19 outbreak

    On 31 December 2019, WHO was alerted to several cases of pneumonia of unknown origin in the city of Wuhan, Hubei Province, China. The virus, a previously unknown coronavirus has been named SARS-CoV-2 and is the cause of the COVID-19 disease.

    The WHO Epidemic Information Network (EPI-WIN) aims to share information tailored to specific sectors, including food and agriculture. The INFOSAN Secretariat has recently developed a guidance document for food businesses with regards to COVID-19 and food safety which is now available online. The guidance has also been disseminated through EPI-WIN and presented during two webinars.

    Call for applicants: INFOSAN Train-the-Trainer Workshop

    In February, the INFOSAN Secretariat issued a call for applications for the INFOSAN Train-the-Trainer workshop. With the constant growth of the network, and the increased need for training that this entails, the INFOSAN Secretariat, in collaboration with the Canadian Food Inspection Agency (CFIA), has announced this workshop which aims to increase the human resources available to train INFOSAN members on a range of INFOSAN-related topics, online or in-person. As a result, it is expected that the understanding of the roles and responsibilities of INFOSAN members will be improved, resulting in greater participation that will enhance speed and efficiency during the response to food safety emergencies at the global level. The INFOSAN Secretariat, together with CFIA, look forward to hosting this important workshop later this year.

    Developing the new INFOSAN Community Website

    The INFOSAN Community Website (ICW) continues to be an effective tool for the network to disseminate information during food safety emergencies. Over the past year, through the INFOSAN member survey, the Secretariat has gained a better understanding of how members use the ICW and how it can be improved to enhance information sharing. The information collected, together with the experience of members of the Secretariat, has provided numerous innovative ideas to guide the development of the new ICW. The Secretariat is pleased to announce that the competitive process to select the vendor that will develop the new INFOSAN Community Website has concluded and the work on the creation of the new ICW has begun. 

    Voice of an active network member

    voice-5-2020

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    https://www.who.int/news-room/detail/23-04-2020-infosan-quarterly-summary-2020-1

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  • WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa

    WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa

    Severe disruptions to insecticide-treated net campaigns and in access to antimalarial medicines could lead to a doubling in the number of malaria deaths in sub-Saharan Africa this year compared to 2018, according to a new modelling analysis released by
    WHO and partners ahead of World Malaria Day (25 April).

    WHO urges countries to move fast and distribute malaria prevention and treatment tools at this stage of the COVID-19 outbreak in sub-Saharan Africa, and to do their utmost to safely maintain these essential malaria control services.

    The analysis considers nine scenarios for potential disruptions in access to core malaria control tools during the pandemic in 41 countries, and the resulting increases that may be seen in cases and deaths. 

    Under the worst-case scenario, in which all insecticide-treated net (ITN) campaigns are suspended and there is a 75% reduction in access to effective antimalarial medicines, the estimated tally of malaria deaths in sub-Saharan Africa in 2020 would reach
    769 000, twice the number of deaths reported in the region in 2018. This would represent a return to malaria mortality levels last seen 20 years ago.

    According to the World malaria report 2019, sub-Saharan Africa accounted for approximately 93% of all malaria cases and 94% of deaths in 2018. More than two-thirds of deaths were among children under the age of five.

    A window of opportunity

    To date, the number of reported cases of COVID-19 in sub-Saharan Africa has represented only a small proportion of the global total, though cases are increasing every week. This means that countries across the region have a critical window of opportunity
    to minimize disruptions in malaria prevention and treatment and save lives at this stage of the COVID-19 outbreak.

    Mass vector control campaigns should be accelerated, while ensuring that they are deployed in ways that protect health workers and communities against potential COVID-19 transmission. WHO and partners commend the leaders of Benin, the Democratic Republic of the Congo, Sierra Leone and Chad
    for initiating ITN campaigns during the pandemic. Other countries are adapting their net distribution strategies to ensure households receive the nets as quickly and safely as possible.

    Preventive therapies for pregnant women and children must be maintained. The provision of prompt diagnostic testing and effective antimalarial medicines are also essential to prevent a mild case of malaria from progressing to severe illness and death.

    WHO and partners have developed guidance to ensure that those suffering from malaria can safely receive the care they need within the package of essential health services to be delivered in COVID-19 settings. Tailoring malaria interventions in COVID-19 response includes guidance on the prevention of infection through vector control and chemoprevention, testing, treatment of cases, clinical services, supply chain and laboratory activities.

    Note to the editor

    The modelling analysis was conducted by WHO in close collaboration with partners, including PATH, the Malaria Atlas Project and the Bill & Melinda Gates Foundation. 

    The analysis is subject to uncertainties. It does not consider, for example, the effects of an interruption in indoor residual spraying or seasonal malaria chemoprevention (except in Burkina Faso); a suspension of these core malaria prevention tools would
    also lead to considerable loss of life.

    In addition, there is limited understanding of the spread of COVID-19, its epidemiology and interactions with malaria. The model will be updated as such data become available, and countries will be provided with relevant information to tailor their responses
    accordingly.

    WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa
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  • Hard fought gains in immunization coverage at risk without critical health services, warns WHO

    Hard fought gains in immunization coverage at risk without critical health services, warns WHO

    Shutting down immunization services in the COVID-19 pandemic risks triggering a resurgence of diseases that can be prevented with safe and effective vaccines, warns WHO in the lead-up to World Immunization Week (24-30 April). 

    When immunization services are disrupted, even for brief periods during emergencies, the risk of vaccine-preventable disease outbreaks, such as measles and polio, increase. Last year’s deadly measles outbreak in the Democratic Republic of the
    Congo, which took more than 6000 lives in a country already facing its largest Ebola outbreak, highlights the importance of maintaining essential health services, such as immunization in times of emergency. Further disease outbreaks will also overwhelm
    health systems already battling the impacts of COVID-19.

    “Disease outbreaks must not remain a threat when we have safe and effective vaccines to protect us,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “While the world strives to develop a new vaccine for COVID-19 at record speed,
    we must not risk losing the fight to protect everyone, everywhere against vaccine-preventable diseases. These diseases will come roaring back if we do not vaccinate.”

    WHO is working with partners all over the world to accelerate research and development of a safe and effective vaccine and ensure equitable access for the billions of people who will need it.

    But even with an expedited process, development of a vaccine for COVID-19 will take time. Precautionary measures are essential now to help keep us safe from disease, including diseases for which vaccines already protect children and adults.

    Too many people are still excluded from the benefits of vaccines

    Prior to the COVID-19 pandemic, the world had made immense progress in ensuring that children are vaccinated. In 2018, 86 percent of children under the age of five globally were vaccinated with three doses of diphtheria, tetanus and pertussis (DTP3) and
    one dose of the measles vaccine, up from 72 percent in 2000 and 20 percent in 1980. The number of children paralyzed by polio has been reduced by 99.9 percent worldwide. 

    Yet, global vaccination coverage is still far from the 95 per cent coverage needed to fully protect communities against outbreaks of this vaccine-preventable disease. 

    In 2018 nearly 20 million children worldwide – more than 1 in 10 – missed out on lifesaving vaccines, such as measles, diphtheria and tetanus. Roughly, 13 million of the children have never received any vaccines, putting them and their communities
    at risk of disease and death. The majority of these children live in countries with already fragile health systems, further limiting their access to essential health services when they fall sick.

    Measles continues to remain an ever-present threat, especially if vaccination rates drops. Current projections indicate that the number of reported measles cases for 2019 will be at least 800 000. In 2020 there are increasing concerns about another
    resurgence, especially if vaccination rates fall due to delay or suspension of scheduled immunization activities as a result of COVID-19. 

    Outbreaks of polio, diphtheria and yellow fever are also of high concern, especially in the countries least able to respond quickly and decisively to address an emerging outbreak, as seen in previous emergencies such as the polio outbreak in Syria in
    2013. 

    Maintaining immunization services during COVID-19

    As the response to COVID-19 continues, countries must act now protect immunization services, in order to further minimize disease outbreaks and loss of life. This includes, facilitating urgent catch up programmes in places where
    services have been disrupted, ensuring strong supply chains, disease surveillance and trained health workers. Caregivers should also make sure they continue to vaccinate their children in line with national policies.

    New WHO guidelines on immunization and COVID-19 recommend that governments temporarily pause preventive immunization
    campaigns where there is no active outbreak of a vaccine-preventable disease. But it urges countries prioritize the continuation of routine immunization of children in essential service delivery, as well as adult vaccinations such as influenza
    for groups most at risk. If immunization services must be suspended, urgent catch-up vaccinations should be rescheduled as soon as possible, prioritizing those most at risk.

    Hard fought gains in immunization coverage at risk without critical health services, warns WHO
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  • What matters to women in the postnatal period?

    What matters to women in the postnatal period?

    The right to a positive maternity healthcare experience at every stage 

    Each pregnancy is unique and clinical needs can change across the pregnancy, childbirth and postnatal periods. One thing that never changes is the right to a positive experience at every stage. 

    Achieving the best possible physical, emotional, and psychological outcomes for every individual and newborn requires health systems to take a human rights-based approach: not only preventing maternal death and morbidity, but prioritising person-centred
    care and well-being.

    WHO is developing new guidelines for a positive experience of postnatal care, due to be published next year. To inform these guidelines and ensure that postnatal services can better meet the needs of women and their babies, WHO undertook a qualitative
    systematic review on what matters to women in the postnatal period.

    Joys and challenges in the postnatal period

    There is limited research about values and preferences in the postnatal period, defined by WHO as the first six weeks after childbirth. Studies have often focused on the results of specific postnatal interventions, rather than on the individuals who use
    them. 

    ‘What matters to women in the postnatal period: A meta-synthesis of qualitative studies,’ published in PLOS ONE, gives long-overdue respect to the authority of women’s own experiences. The authors review first-hand data from 15 countries
    and 36 studies published after the year 2000 relating to women’s beliefs, expectations and values at this significant time of life.  

    These studies affirm that a positive postnatal experience can result in joy, self-confidence and enhanced capacity to thrive as both a person and a parent.

    They are also vocal about the potential challenges of adjusting to a ‘new normal’ following childbirth, including changes in self-identity, relationships, and sexual behaviour.

    What is a positive postnatal experience? 

    A positive postnatal experience for a woman will be one that responds to her specific context and preferences. 

    It will provide the confidence, knowledge and skills women need in the weeks following childbirth, supporting them to adjust to any changes in their intimate relationships and build new family ones. Women will be better equipped to navigate physical and
    emotional challenges and to experience the dynamic achievement of personal growth. 

    This should be a shared responsibility, not a solitary one. Community has a critical role in enabling a positive postnatal experience, including partners, family and elders.

    It is crucial that healthcare providers meet each woman’s needs, as well as those of their babies. 

    Supporting choices and rights to improve postnatal health outcomes

    There are an estimated 303 000 maternal deaths annually, according to recent WHO figures. Most of these deaths occur postnatally. 

    The postnatal period is therefore a vital opportunity to improve both maternal and neonatal health and wellbeing: supporting healthy behaviors, providing life-skills education, facilitating breastfeeding, counselling women about family planning options,
    supporting good mental health, preventing and treating childbirth-related complications. 

    Health care systems that empower individuals by supporting their values, preferences and rights are fundamental to improving maternal and newborn health outcomes. 

    WHO’s guidance for positive maternity care

    WHO has recently released recommendations on antenatal care for a positive pregnancy experience, and on intrapartum care for a positive childbirth experience.

    These publications made important clinical updates, including an increase from four to eight recommended antenatal contacts, and a revision to the decision-making process for interventions to accelerate labour. 

    They also uphold every woman’s right to a positive maternity care experience: one where her pregnancy does not erase her competency, autonomy and right to participate in decision-making for her own care and the care of her newborn. 

    Women’s choices and rights to sexual and reproductive health care, including maternity care, should be respected at every stage of the continuum of maternal and newborn care. This is true across all income settings, as well as in humanitarian settings
    and during public health emergencies.

    When WHO’s postnatal guidelines are released next year, they will complete the maternity care series built around what matters to women.

    Rather than dividing care into three periods of antenatal, intrapartum and postnatal, these publications can be used to establish a model in which health systems support women, their baby and wider network physically, psychologically, socially and emotionally
    through this significant life event. 

    Other resources

     

    What matters to women in the postnatal period?
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  • Lifting restrictions ‘too quickly’ could lead to deadly resurgence of Covid-19: WHO

    Lifting restrictions ‘too quickly’ could lead to deadly resurgence of Covid-19: WHO

    Lifting restrictions ‘too quickly’ could lead to deadly resurgence of Covid-19: WHO 1

    GENEVA: World Health Organisation (WHO) Director-General Tedros Adhanom Ghebreyesus warned here on Friday that lifting restrictions “too quickly” could lead to a deadly resurgence of Covid-19, Xinhua news agency reported.

    Noting at a regular press briefing that “some countries are already planning the transition out of stay-at-home restrictions,“ the WHO chief warned that lifting restrictions too quickly could lead to a deadly resurgence.

    “The way down can be as dangerous as the way up if not managed properly,“ he said, underlining that the WHO is working with affected countries on strategies for gradually and safely easing restrictions.

    Some European countries are already considering relaxing their restriction measures as they see a slowing trend in the number of Covid-19 infections.

    Austria, for instance, aims to gradually ease the exit restrictions and reopen shops and businesses from mid-April. Switzerland also suggested “the first relaxations” by the end of April.

    The WHO chief stressed that decision of lifting restrictions should be made on the condition that transmission is controlled; that sufficient public health and medical services are available; that outbreak risks in special settings like long-term care facilities are minimised; that preventive measures are in place in workplaces, schools and other places where it’s essential for people to go; that importation risks can be managed; and that communities are fully aware and engaged in the transition.

    Globally, nearly 1.5 million confirmed cases of Covid-19 have now been reported to the WHO, as well as more than 92,000 deaths. — Bernama

    Lifting restrictions ‘too quickly’ could lead to deadly resurgence of Covid-19: WHO
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  • RACE SUICIDE

    RACE SUICIDE

    A favorite argument of certain opponents of scientific Birth Control is that such teachings and modes of conduct tend toward Race Suicide, and the consequent weakening and final destruction of the human race by means of “bleeding it white” by draining from it its normal supply of children. Those who hold this view argue that if Birth Control methods become popular, and sanctioned by the law and public opinion, then the race will eventually die out and disappear from the face of the earth. Some vary the argument by insisting that those nations favoring Birth Control would suffer decline and gradual extinction at the hands of other nations opposed to scientific methods of regulating the number and frequency of offspring. This is a serious charge against Birth Control, which if proved would probably serve to array all right-thinking persons against it.

    But the advocates of Birth Control seriously and positively controvert and deny the validity and truth of this argument. On the contrary they claim that scientific Birth Control would not only keep up the population of all countries, or any country, to a normal standard proportionate to its ability to sustain properly such population, but will also act to render that population stronger and better, physically, mentally and morally, and far more efficient in every way owing to improved quality of the stock. The first requisite is met by the reduction of the death rate to meet the decreasing birth-rate; and the second requisite is met by the improvement of the stock by proper rearing and training made possible by the decreased size of the average family. Birth control serves to eliminate the waste caused by excessive infant mortality, and to thus fully counterbalance the decreased birth rate.

    The advocates of Birth Control assert that the natural instinct of parenthood, the love of children, and the desire for offspring and the perpetuation of the family name and stock, are too firmly rooted and grounded in human nature to be seriously affected by such knowledge and practice on the part of the race. They point to the fact that in many families in which intelligent modes of Birth Control are favored, and in which the size of the family has been limited to a few children, the children are, as a rule, better cared for and provided for, better reared and better educated, than in the case of families in which children are brought into the world without thought or reason, and without the possibility of proper care and rearing. Birth Control, say its advocates, will not do away with children, but will merely regulate their number to rational limits, and at appropriate intervals between births. Moreover, it is claimed, that while the birth-rate in such families may be smaller, the death-rate is also smaller. And, at the last, it is the number of children that survive that counts with the race, not those who merely are born.

    The fact that many persons consult physicians for a cure for sterility, and go to great trouble and expense to further the bearing of children, and the fact many childless couples adopt children rather than to have a childless home, are evidence of the fact that there is no danger of the parental instinct dying out. It is the experience of physicians generally that the patients who desire information regarding scientific contraceptive methods are usually those who already have as many children as they can well take care of, and not those who wish to escape parenthood in toto.

    We are constantly reminded that the size of the average family is much smaller than it was a hundred years ago—but still the race is rapidly increasing, owing to the decreased death-rate resulting from a better knowledge of hygiene and medicine. Moreover, it is positively asserted that the “old time large family” frequently had one father but several mothers—the husband marrying several times in order to replace with a new life the old wife who had broken down and died from overwork and excessive childbearing.

    It is claimed that in Holland, in which Birth Control is recognized by law, and where it is legally sanctioned and even encouraged among those who are not able to support large families, statistics show that the population is increasing more rapidly than before, owing to the decreased mortality of infants and young children arising from the better care of those who are born.

    Dr. Robinson says on this point: “Here we have a whole country, Holland, in which the prevention of conception is legally sanctioned, in which the use of preventives is practically universal—and is this country dying out? On the contrary, it is increasing more rapidly than before, because we have this remarkable and gratifying phenomenon to bear in mind, that wherever the birth-rate goes down, the death rate goes down pari passu, or even to a still greater degree. This can be proven by statistics from almost every country in the world. For instance, in 1910 the birth-rate in Holland was 32, and the mortality 18; in 1912 the birth-rate fell to 28, but then the mortality rate fell still lower, namely to 12, so we see an actual gain in population, instead of a loss. And the physical constitution of the people has been improving * * *. And in New Zealand, where the sale of contraceptives is practically free, the birth rate is now 20, and the mortality rate is 10. Does that look like race suicide? On the contrary, there is a steady increase at the rate of ten per cent, while sickness and death of children, with their attendant economic and emotional waste, are reduced to a minimum.”

    Not only are the children of small families as a rule better cared for, from economic reasons easy to discern, but it is also a fact that the health of the mothers is far better, and consequently the health of the children when born is better than the average. One has but to look around him upon the families who boast of having had eight, ten, and twelve children born to them, to see what a frightful average percentage of deaths of infants and young children is present, and which brings down the number of the survivors.

    Dr. Alice Hamilton, in “The Bulletin of the American Academy of Medicine,” for May, 1910, reports that she has investigated the families of 1,600 wage workers, and found the following death rate per 1,000 birth among them, viz.:

    Families of 4 children and less 118 deaths per 1,000 births
    Families of 6 children 267 deaths per 1,000 births
    Families of 7 children 280 deaths per 1,000 births
    Families of 8 children 291 deaths per 1,000 births
    Families of 9 children or more 303 deaths per 1,000 births

    Dr. Hamilton sums up her investigation as follows:

    “Our study of the poorer working class shows that child mortality increases proportionately as the number of children increase, until we have a death rate in families of 8 children and over which is two and a half times as great as that in families of 4 children and over.”

    The facts above mentioned, and other facts of the same nature which will be disclosed in the progress of our consideration of the matter in the present book, have evidently been overlooked, deliberately or otherwise, by the fanatics in this country and in Europe who have been preaching to the people that a falling birth-rate means a decaying nation. Careful students of sociology now dismiss altogether the statement so often made that a falling birth-rate means “an old and decaying community.” The Germans for years have contemptuously been making this remark about France, but today they have been forced to recognize an unexpected vitality in the French, while, in fact, their own birth-rate has been falling more rapidly than that of France.

    Nor is it true that a falling birth-rate means a falling population. The French birth-rate has been steadily falling for a number of years, yet the French population has been steadily increasing all the time, though less rapidly than it would had not the death-rate been abnormally high. It is not the number of babies born that counts, but the net result in surviving children. An enormous number of babies are born in China; but an enormous number die while still babies. So that it is better to have a few babies of good quality than a large number of indifferent quality, for the falling birth-rate is more than compensated by the falling death-rate. In England, as the statistics show, while the birth-rate is steadily falling, the population has been steadily growing.

    Small families and a falling death-rate are not merely no evil—they are a positive good. They are a gain for humanity. They represent an evolutionary rise in Nature and a higher stage in civilization. We are here in the presence of a great fundamental principle of progress which has been working through life from the beginning.

    At the beginning of life on the earth, reproduction ran riot. Of one minute organism it is estimated that, if its reproduction were not checked by death or destruction, in thirty days it would form a mass a million times larger than the sun. The conger-eel lays fifteen million eggs, and if they all grew up, and reproduced themselves on the same scale, in two years the whole sea would become a wriggling mass of eels. As we approach the higher forms of life, reproduction gradually dies down. The animals nearest to man produce few offspring, but they surround them with parental care, until they are able to lead independent lives with a fair chance of surviving. The whole process may be regarded as a mechanism for slowly subordinating quantity to quality, and to promoting the evolution of life to even higher stages.

    This process, which is plain to see on the largest scale throughout living nature, may be more minutely studied, as it acts within a narrower range, in the human species. Here we statistically formulate it in the terms of birth-rate and death-rate; by the mutual relationship of the two courses of the birth-rate and death-rate we are able to estimate the evolutionary rank of a nation, and the degree in which it has succeeded in subordinating the primitive standard of quantity to the higher and later standard of quality.

    Especially in Europe we can investigate this relationship by the help of statistics which in some cases extend back for nearly a century. We can trace the various phases through which each nation passes, the effects of prosperity, the influence of education and sanitary improvement, the general complex development of civilization, in each case moving forward, though not regularly and steadily, to higher stages by means of a falling birth-rate, which is to some extent compensated by a falling death-rate, the two rates nearly always running parallel, so that a temporary rise in the birth-rate is usually accompanied by a rise in the death-rate, by a return, that is to say, towards the conditions which we find at the beginning of animal life, and a steady fall in the birth-rate is always accompanied by a fall in the death-rate.

    It is thus clear that the birth-rate combined with the death-rate constitutes a delicate instrument for the measurement of civilization, and that the record of their combined curves registers the upward or downward course of every nation. The curves, as we know, tend to be parallel, and when they are not parallel we are in the presence of a rare and abnormal state of things which is usually temporary or transitional.

    A study of the statistics of European countries furnishes us with evidence of the facts above stated. It is instructive to perceive how closely the birth-rate and the death-rate of the several European countries agree. It is perceived that the eight countries of Europe which register the highest birth-rate are the identical countries registering the highest death-rate. This is as might be expected, for a very high birth-rate seems fatally to involve a very high death-rate. The study of the following table may prove interesting—it certainly is instructive. In the following table the European countries having the highest birth-rate are stated in the order of rank according to size of such rate; and the countries having the heaviest death-rate are stated in the order of their rank in size of such rate:

    Highest European Birth-Rate.  Highest European Death-Rate.
    Russia. Russia.
    Roumania. Roumania.
    Bulgaria. Hungary.
    Serbia. Bulgaria.
    Hungary. Spain.
    Italy. Serbia.
    Austria. Austria.
    Spain. Italy.

    Moreover, Japan, with a rather high birth-rate, has the same death-rate as Spain; and Chile, with a still higher birth-rate, has a higher death rate than Russia. So, we see, that among human peoples we find the same laws prevailing as among animals, and the higher nations of the world differ from those which are less highly evolved precisely as the elephant differs from the herring, though within a narrower range, that is to say, by producing fewer offspring and taking better care of them.

    So, when we get to the root of the matter, the whole question of “Does Birth Control tend toward Race Suicide?” becomes clear, and we are able to answer, positively, “It certainly does not; on the contrary it tends toward Race Progress and Race Betterment.” We see that there is really no standing ground in any country for the panic-monger who bemoans the fall of the birth-rate, and storms against small families. The falling birth-rate is a world-wide phenomenon in all countries that are striving toward a higher civilization along lines which Nature laid down from the beginning. We cannot stop it if we would, and if we could we should be merely impeding civilization. It is a movement which rights itself and tends to reach a just balance.

    Instead of trying to raise the birth-rate by offering a bonus on babies as has been proposed in some quarters, it would be saner and better calculated for the betterment of the race to offer a bonus upon young men and women who attained maturity with a definite high standard of physical and mental development. As a writer on the subject has well said: “But we need not therefore fold our hands and do nothing. There is much still to be effected for the protection of motherhood and the better care of children. We cannot, and should not, attempt to increase the number of children born; there is still far more misery in having too many babies than in having too few; a bonus on babies would be a misfortune, alike for the parents and the State. But we may well work for the better quality of babies. There we should be on very safe ground. More knowledge is necessary so that all would-be parents may know how they may best become parents, and how they may, if necessary, best avoid it. Procreation by the unfit should be, if not prohibited by law, at all events so discouraged by public opinion that to attempt it would be considered disgraceful. Much greater public provision is necessary for the care of mothers during the months before, as well as in the period after, the child’s birth. Along such lines as these we may hope to increase the happiness of the people and the strength of the State. We need not worry about the falling birth-rate.”

    The more that one intelligently examines the argument against Birth Control based upon fear of Race Suicide, the more one becomes convinced that not only is there “nothing to it,” but that every fact brought to light in the inquiry reveals itself in the nature of proof of the desirability of Birth Control as a factor of Race Evolution, rather than evidence to the contrary. Therefore, the more inquiry and investigation that such argument brings forth, the stronger is the case disclosed for Birth Control, and the greater the amount of public opinion created in its favor.

    In all considerations of the general question of Race Suicide, one must take note of the general question of Eugenics or Human Breeding. This because the sound breeding of the race operates in a direction diametrically opposed to Race Suicide, while unsound breeding operates directly in favor thereof.

    When we consider the general subject of Eugenics we touch upon the highest ground, and are concerned with our best hopes for the future of the world. There can be no doubt that Birth Control, considered as a phase of Eugenics, is not only a precious but also an indispensable instrument in moulding the coming man to the measure of our developing ideals. Without Birth Control we are powerless in the face of the awful evils which flow from random and reckless reproduction. With it we possess a power so great that some persons have professed to see in it a menace to the propagation of the race, amusing themselves with the idea that if people possess the meansto prevent the conception of children they will never have children at all. It is not necessary to discuss such a grotesque notion seriously.

    The desire for children is far too deeply implanted in mankind and womankind alike ever to be rooted out. If there are today many parents whose lives are rendered wretched by large families and the miseries of excessive child-bearing, there are an equal number whose lives are wretched because they have no children at all, and who snatch eagerly at any straw which offers the smallest promise of relief to the craving. Certainly there are people who desire marriage, but—some for very sound and estimable reasons and other for reasons which may less well bear examination—do not desire children at all.

    For the class of married people who do not desire children at all, contraceptive methods, far from being a social evil, are a social blessing. For nothing is as certain as that it is an unmixed evil for a community to possess unwilling, undesirable parents. Birth Control would be an unmixed blessing if it merely enabled us to exclude such persons from the ranks of parenthood. We desire no parents who are not competent and willing parents. Only such parents are fit to father and to mother a future race worthy to rule the world.

    It is sometimes said that the control of conception, since it is frequently carried out immediately upon marriage, will tend to delay parenthood until an unduly late age. Birth Control has, however, no necessary result of this kind, and might even act in the reverse direction. A chief cause of delay in marriage is the prospect of the burden and expense of an unrestricted flow of children into the family; and it is said that in Great Britain, since 1911, with the extension of the use of contraceptives, there has been a slight but regular increase not only in the general marriage rate but also in the proposition of early marriage. The ability to control the number of children not only enables marriage to take place at an early age, but also makes it possible for the couple to have at least one child soon after marriage. The total number of children are thus spaced out, instead of following in rapid succession.

    It is only of late years that the eugenic importance of a considerable interval between births has been fully recognized, as regards not only the mother—this has long been recognized—but also the children. The very high mortality of large families has long been known, and their association with degenerate conditions and with criminality. However, of recent years, evidence has been obtained that families in which the children are separated from each other by intervals of more than two years are both mentally and physically superior to those in which the interval is shorter. Investigators have found that children born at only a short interval after the birth of a previous child are notably defective, even at the age of six, in a large percentage of cases; and when compared with children born at a longer interval, or with first children, they are, on the average, three inches shorter and three pounds lighter. These are facts of the most vital significance.

    Thus when we calmly survey, in however summary a manner, the great field of life affected by the establishment of voluntary human control over the production of the race, we can not see a cause for anything but hope. It is satisfactory that it should be so, for there can be no doubt that we are here facing a great and permanent fact in civilized life. With every rise in civilization, indeed with all evolutionary progress whatever, there is what seems to be an automatic fall in the birth-rate. That fall is always normally accompanied by a fall in the death-rate, so that a low birth-rate frequently means a high rate of natural increase, since most of the children born survive.

    Thus in the civilized world of today, notwithstanding the low birth-rate which prevails as compared with earlier times, the rate of increase in the population is still appalling—nearly half a million a year in Great Britain, over a million in Austro-Hungary, and three-quarters of a million in Germany. When we examine this excess of births in detail we find among them a large proportion of undesired and undesirable children. There are two alternative methods working to diminish this proportion: the method of regulating conception under the methods of scientific Birth Control, or the bungling substitutes for the same, on the one hand, and the method of preventing live births after conception by means of the abominable practice of abortion.

    There can be no doubt about the enormous extension of the practice of abortion in all civilized countries, even although some of the extravagant estimates of its frequency in countries, the United States for example, be discarded as unwarranted. The burden of bearing excessive children on the overworked and underfed mothers of the working classes becomes at last so intolerable that almost anything seems better than another child. As a woman in Yorkshire once said to an English investigator of this evil: “I’d rather swallow the druggist’s shop and the man in it, than have another kid.”

    A community which takes upon itself the responsibility of encouraging abortion lays itself open to severe criticism. And it must be admitted that just as all those who work for Birth Control are really diminishing the frequency of abortion, so every attempt to discourage Birth Control promotes abortion. We have to approach this problem calmly, in the light of Nature and reason. We have each of us to decide on which side to range ourselves. For it is a vital problem concerning which we cannot afford to be indifferent.

    There is no desire here to exaggerate the importance of Birth Control. It is not a royal road to the millennium of the race; and like all other measures which the course of progress forces us to adopt, it has its disadvantages. But fairness and honest thought should admit freely that so far as is concerned the question of its being a factor toward Race Suicide, we must pronounce a verdict of “Not Guilty” upon Birth Control. On the contrary, the contrary course of teaching and practice, if carried to their full logical conclusion, would inevitably bring the race to such a stage of degeneracy, and retrogression to primitive type, that a fate far worse than suicide would befall the human race. For the race, as well as the individual, may commit “suicide” and an end to its career, not only by a will-not-to-live but also by a will-to-degenerate.

    The face of Birth Control is set toward the rising sun of Race Betterment, not toward the setting sun of Racial Decline. Its ideas are those of Race Life, not of Race Death. It bids the race not to perish, but rather to live on in greater strength, happiness, and efficiency. Birth Control is in full accord with the Racial Will-to-Live, and not opposed to it. All humanity, all civilization, all human progress, call upon us to take our stand upon this vital question of Birth Control. And, as a writer has well said, in doing so we shall each of us be contributing, however humbly, to that “one far-off event, to which the whole creation moves.”

    PRIVATE Sex Advice to Women By R. B. Armitage, M. D.

    For Young Wives and those who Expect to be Married.

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  • THE FETICH OF THE BIRTH-RATE

    THE FETICH OF THE BIRTH-RATE

    To the student of the progress of the human race the consideration of the state of public opinion regarding the Birth-rate of nations is of great interest. To the careful observer there is evident the gradual evolution of intelligent public opinion on this subject even in the comparatively short space of time in which the present generation has played its part on the great stage of human development.

    Public opinion on this subject during the period named may be said to have passed through three general stages. These stages are, of course, more clearly defined among the peoples of the most prosperous and intelligent countries, as for instance, in Western Europe and America, and particularly in England, France, and the United States. While the peoples of certain of these countries have passed through these stages somewhat more rapidly than have others, still it is perceived that each of these peoples have in the main followed the same general course.

    The first stage of this evolution of popular opinion may be said to have been begun about 1850, and to have ended about 1880. In this stage the ideal of a large and rapidly increasing birth-rate became a popular fetich before which all men and women were supposed to fall down and render worship. In this period public opinion manifested great satisfaction and joy in the evidences of a high and rapidly increasing birth-rate. It was held that this increasing birth-rate tended toward the success and glory of the particular nation, and incidentally to the race as a whole. The idea of Quantity was elevated to the throne of public favor, and the question of Quality was ignored or overlooked.

    This period was one of an unusual expansion of industry, and the rising birth-rate was regarded as a token that the world was destined to be exploited and eventually governed by the people of those nations who were able to demonstrate the greatest efficiency in industrial pursuits, and who at the same time were wise enough to increase their respective populations by an increasing birth-rate. The populace were excited by the idea of the dominance and prosperity of their own countrymen, while the leaders of industry were delighted with the idea of an increasing supply of laborers which would tend to keep down the rate of wages which otherwise would have reached proportions which would have interfered with competition with other countries. At the same time, the militarists were secretly delighted by the signs of an increasing supply of military material with which to build up gigantic armies.

    A writer on the state of public opinion on this subject during this period has well said: “It seemed to the more exuberant spirits that a vast British Empire, or a mighty Pan-German, might be expected to cover the whole world. France, with its low and falling birth-rate, was looked down at with a contempt as a decadent country inhabited with a degenerate population. No attempt to analyze the birth-rate, to ascertain what are really the biological, social, and economic accompaniments of a high birth-rate, made any impression on the popular mind. They were drowned in a general shout of exultation.”

    But this period of uncritical optimism was followed by a natural reaction. The pendulum stopped in its course, and soon began to swing in the opposite direction. Here, about 1880, the second stage may be said to have begun. Public opinion began to manifest a subtle change, and this mental attitude was accompanied by a physical manifestation in the form of a decreasing birth-rate. The rate of births began to fall rapidly, and has continued to fall steadily since that time.

    The writer above quoted from says of this second period: “In France the birth-rate fell slowly, in Italy more rapidly, and in England and Prussia still more rapidly. As, however, the fall began earliest in France, the birth-rate was lower there than in the other countries named. For the same reason it was lower in England than in Prussia, although England stands in this respect at almost exactly the same distance from Prussia today (1917) as thirty years ago, the fall having occurred at the same rate in both countries. It is quite possible that in the future it may become more rapid in Prussia than in England, for the birth-rate of Berlin is lower than the birth-rate of London, and urbanization is proceeding at a more rapid rate in Germany than in England.”

    It is not difficult to arrive at the psychological reason underlying this great change in public opinion, as manifested in this second stage. In the first place, the wonderful era of world-expansion was arrested, by natural causes well understood by students of sociology. The ambitious dreams of world-empires were rudely interrupted. Moreover, public opinion was being affected by a quiet education along the lines of sociology and economics.

    The working classes began to perceive, on the one hand, the tendency of overpopulation to hold down, or even decrease, the scale of wages. The evils of over-production, and of under-consumption were dimly perceived. And, on the other hand, the capitalists began to perceive that another factor was at work—one which they had failed to include in their optimistic calculations. Instead of the cheaper wage rate which they had expected by reason of the over-abundance of human material, they found that the growth of popular education in the democratic countries had caused the working classes to demand greater comforts of life, and to oppose the cheapening of human labor. And at the same time, the masses began to revolt against the idea of raising children to become “cannon fodder” for ambitious autocratic rulers. The masses began to protest against selling their labor and their lives so cheaply.

    These changed viewpoints of the working classes began to result in attempts on their part to form associations to resist the tendency on the part of capitalists to force down the scale of wages to fit the increased population. Trade unions flourished and became powerful, and the same impulse carried many into the ranks of socialism, and still beyond into the fold of anarchism and syndicalism. And, here note this significant fact, with these new perceptions and these new movements among the masses, the birth-rate began to fall rapidly.

    The writer above quoted from says of this period: “The pessimists were faced by horrors on both sides. On the one hand, they saw that the ever-increasing rate of human production which seemed to them the essential condition of national, social, even moral progress, had not only stopped but was steadily diminishing. On the other hand, they saw that, even so far as it was maintained, it involved, under modern conditions, nothing but social commotion and economic disturbance. There are still many pessimists of this class alive among us even today, alike in England and Germany, but a new generation is growing up, and this question is now entering another phase.”

    It would seem that the race is now well started in the third period, phase, or stage of this conception of the birth-rate. Even the Great War is not likely to seriouslyinterrupt its ultimate progress, though conditions in all civilized countries will unquestionably be disturbed by the unusual conditions now prevailing and caused by the great conflict. The spirit of this third stage seems to be that the Truth is to be found between the two extremes, viz.: (1) the extreme of passive optimism of the first stage; and (2) the extreme of passive pessimism of the second stage. It realizes that there is excellent ground for hope in better things; but it equally realizes that hope alone is vain, and will accomplish nothing unless it is accompanied with and directed by a clear intellectual vision manifested in individual and social action based on that clear intellectual vision.

    The writer above quoted from says of this developing period: “It is today beginning to be seen that the old notion of progress by means of reckless multiplication is vain. It can only be effected at a ruinous cost of death, disease, poverty, and misery. We see this in the past history of Western Europe, as we still see it in the history of Russia. Any progress effected along that line—if ‘progress’ it can be called—is now barred, for it is utterly opposed to those democratic conceptions which are ever gaining greater influence among us. Moreover, we are now better able to analyze demographic phenomena, and are no longer satisfied with any crude statements regarding the birth-rate. We realize that they need interpretation. They have to be considered in relation to the sex-constitution and the age-constitution of the population, and above all, they must be viewed in relation to the infant mortality rate.

    “The bad aspect of the French birth-rate is not so much its lowness as that it is accompanied by a high infantile mortality. The fact that the German birth-rate is higher than the English ceases to be a matter of satisfaction when it is realized that German infantile mortality is vastly greater than English. A high birth-rate is no sign of a high civilization. But we are beginning to feel that a high infantile death-rate is a sign of a very inferior civilization. A low birth-rate with a low infant death-rate not only produces the same increase in population as a high birth-rate with a high death-rate, which always accompanies it (for there are no examples of a high birth-rate with a low death-rate), but it produces it in a way which is far more worthy of our admiration in this matter than the way of Russia and China where opposite conditions prevail.”

    The evolutionary process which all students of sociology clearly perceive to have been underway in the matter of the attitude of public opinion toward the birth-rate, and which is now underway with increased impetus, is perceived to be a natural process. It is a natural process which has been underway from the beginning of the living world. For a long time it operated and manifested along unconscious and instinctive lines of activity, but now it has emerged into the light of human consciousness and manifests along the lines of conscious, voluntary, and deliberate human action.

    In its present state of evolutionary progress human thought along these lines has found expression in what is generally known as “Birth Control.” The process which has been working slowly through the ages, attaining every new forward step with waste and pain, is henceforth destined to be carried out voluntarily, in the light of human reason, foresight, and self-restraint. The rise of Birth Control may be said to correspond with the rise of social and sanitary science in the first half of the nineteenth century, and to be indeed an essential part of that movement.

    The new doctrine of Birth Control is now firmly established in all the most progressive and enlightened countries of Europe, notably in France and England; in Germany, where formerly the birth-rate was very high, Birth Control has developed with extraordinary rapidity during the present century. In Holland its principles and practice are freely taught by physicians and nurses to the mothers of the people, with the result that there is in Holland no longer any necessity for unwanted babies, and this small country possesses the proud privilege of the lowest death-rate in Europe.

    In the free and enlightened Democratic communities on the other side of the globe, in Australia and New Zealand, the same principles and practice are generally accepted, with the same beneficent results. On the other hand, in the more backward and ignorant countries of Europe, Birth Control is still little known, and death and disease flourish. This is the case in those eight European countries which come at the bottom of the list of the Birth Control scale, and in which the birth-rate is the highest and the death-rate the heaviest—the two rates maintaining such a constant correspondence as to lead to the inevitable conclusion that they are associated as cause and effect.

    But even in the more progressive countries Birth Control has not been established without a struggle, which has frequently ended in a hypocritical compromise, its principles being publicly ignored or denied and its practice privately accepted. For, at the great and vitally important point in human progress which Birth-Control represents, we see really the conflict of two moralities. The morality of the ancient world is here confronted by the morality of the new world.

    The old morality, knowing nothing of science and the process of Nature as worked out in the evolution of life, contented itself with assuming as a basis the early chapters of Genesis in which the children of Noah are represented as entering an empty earth which it is their business to populate diligently. So it came about that for this morality, still innocent of eugenics, recklessness was almost a virtue. Children were held to be given by God; if they died or were afflicted by congenital disease, it was the dispensation of God, and, whatever imprudence the parents might commit, the pathetic faith still ruled that “God will provide.”

    But in the new morality it is realized that in these matters Divine action can only be made manifest in human action, that is to say through the operation of our own enlightened reason and resolved will. Prudence, foresight, self-restraint—virtues which old morality looked down upon with benevolent contempt—assume a position of first importance. In the eyes of the new morality the ideal woman is no longer the meek drudge condemned to endless and often ineffectual child-bearing, but the free and instructed woman, able to look before and after, trained in a sense of responsibility alike to herself and to the race, and determined to have no children but the best.

    Such were the two moralities which came into conflict during the nineteenth century. They are irreconcilable and each firmly rooted, one in ancient religion and tradition, the other in progressive science and reason. Nothing was possible in such a clash of opposing ideas but a feeble and confused compromise such as we find still prevailing in various countries of Old Europe. This is not a satisfactory solution, however inevitable, and is especially unsatisfactory by the consequent obscurantism which placed difficulties in the way of spreading a knowledge of the methods of Birth Control among the masses of the population. For the result has been that while the more enlightened and educated have exercised a control over the size of their families, the poorer and more ignorant—those who should have been offered every facility and encouragement to follow in the same path—have been left, through a conspiracy of silence, to carry on helplessly the bad customs of their forefathers. This social neglect has had the result that the superior family stocks have been tampered by the recklessness of the inferior stocks.

    In America, we find the two moralities in active conflict today. Until recently America has meekly accepted at the hand of Old Europe the traditional prescription. On the surface, the ancient morality had been complacently, almost unquestionably, accepted in America, even to the extent of tacitly permitting the existence of a vast extension of abortion, under the surface of society— a criminal practice which ever flourishes where Birth Control is neglected.

    But today, a new movement is perceptible in America. It would seem that, almost in a flash, America has awakened to the true significance of the issue. With that direct vision of hers, that swift practicality of action, and above all, that sense of the democratic nature of all social progress, we see her resolutely beginning to face this great problem. In her vigorous tongue she is demanding “What is all this secrecy about, anyway? Let us turn on the Light!” And the best authorities agree that America’s answer to the demand will be of the greatest importance, and of immense significance to the whole world.

    In concluding this portion of our discussion, I ask my readers to consider the following quotations from writers who have touched upon the question of the stimulation of the birth-rate by the State, for the purpose of military policy. These quotations speak for themselves, and need but little comment.

    The first authority, a German, whose name has escaped me for the moment, laments the falling birth-rate in his country, and urges his own nation to stimulate it by offering bounties; he says: “Woe to us if we follow the example of the wicked and degenerate people of other nations. Our nation needs men. We have to populate the earth, and to carry the blessings of our Kultur all over the world. In executing that high mission we cannot have too much human material in defending ourselves against the aggression of other nations who are jealous of us and our achievements and progress. Let us promote parentage by law; let us repress by law every influence which may encourage a falling birth-rate; otherwise there is nothing left us but speedy national disaster, complete and irremediable.”

    Havelock Ellis, an Englishman, says: “In Germany for years past it has been difficult to take up a serious periodical without finding some anxiously statistical article about the falling birth-rate, and some wild recommendations for its arrest. For it is the militaristic German who of all Europeans is most worried by this fall; indeed Germans often even refuse to recognize it. Thus today we find Professor Gruber declaring that if the population of the German Empire continues to grow at the rate of the first five years of the present century, it will have reached 250,000,000 at the end of the century. By such a vast increase in population, the Professor complacently concludes, ‘Germany will be rendered invulnerable.’ But Gruber’s estimate is entirely fallacious. German births have fallen, roughly speaking, about 1 per 1,000 of the population, every year since the beginning of the century, and it would be equally reasonable to estimate that if they continue to fall at the present rate (which we cannot, of course, anticipate) births will altogether have ceased in Germany before the end of the century. The German birth-rate reached its climax forty years ago (1871-1880) with 40.7 per 1,000; in 1906 it was 34 per 1,000; in 1909 it was 31 per 1,000; in 1912 it was 28 per 1,000; in an almost measurable period of time, in all probability before the end of the century, it will have reached the same low level as that of France, when there will be but little difference between the ‘invulnerability’ of France and of Germany, a consummation which, for the world’s sake, is far more devoutly to be wished than that anticipated by Gruber.”

    Writers of Teutonic sympathies have asserted that the aggressive attitude of Germany at the beginning of the Great War was to be legitimately explained and apologized for on the ground that the War was the inevitable expansive outcome of the abnormally high birth-rate of Germany in recent times. Dr. Dernburg, the German statesman, said not very long ago: “The expansion of the German nation has been so extraordinary during the past twenty-five years that the conditions existing before the war had become insupportable.” Another writer has said: “Of later years there has arisen a movement among German women for bringing abortion into honor and repute, so that it may be carried out openly and with the aid of the best physicians. This movement has been supported by lawyers and social reformers of high position.”

    Thus, it would seem that a birth-rate stimulated by unusual circumstances or by deliberate State encouragement, seemingly draws upon it the operation of natural laws which tend to increase its death-rate by War, as well as by an increased number of abortions, and an increased death-rate. It would seem as natural laws operate to bring down the population to normal by war if the other factors do not operate sufficiently rapidly and efficiently.

    Havelock Ellis makes the following interesting statement: “If we survey the belligerent nations in the war we may say that those who took the initiative in drawing it on, or at all events were most prepared to welcome it, were Germany, Austria, Serbia, and Russia—all nations with a high birth-rate, and in which the fall of the birth-rate has not yet had time to permeate. On the other hand, of the belligerent peoples of today, all indications point to the French as the people most intolerant, silently but deeply, of the war they are so ably and heroically waging. Yet the France of the present, with the lowest birth-rate, was a century ago the France of a birth-rate higher than that of Germany today, and at that time the most militarist and aggressive of nations, a perpetual menace to Europe.”

    Finally, let us quote Havelock Ellis once more; he says: “When we realize these facts we are also enabled to realize how futile, how misplaced and how mischievous it is to raise the cry of ‘Race Suicide.’ It is futile because no outcry can affect a world-wide movement of civilization. It is misplaced because the rise and fall of the population is not a matter of birth-rate alone, but of the birth-rate combined with the death-rate, and while we cannot expect to touch the former we can influence the latter. It is mischievous because by fighting against a tendency which is not only inevitable but altogether beneficial, we blind ourselves to the advance of civilization and risk the misdirection of our energies. How far this blindness may be carried we see in the false patriotism of those who in the decline of the birth-rate, fancy they see the ruin of their own particular country, oblivious of the fact that we are concerned with a phenomenon of world-wide extension. The whole tendency of civilization is to reduce the birth-rate. We may go further, and assert with the distinguished German economist, Roscher, that the chief cause of the superiority of a highly civilized state over lower stages of civilization is precisely a greater degree of forethought and self-control in marriage and child-bearing. Instead of talking about Race Suicide, we should do well to observe at what an appalling rate, even yet, the population is increasing; and we should note that it is everywhere the poorest and most primitive countries, and in every country (as in Germany) the poorest regions, which show the highest birth-rate.”

    The same authority says: “One last resort the would-be patriotic alarmist seeks when all others fail. He is good enough to admit that a general decline in the birth-rate might be beneficial. But, he points out, it affects social classes unequally. It is initiated, not by the degenerate and unfit, with whom we could well dispense, but by the very best classes in the community, the well-to-do and the educated. One is inclined to remark, at once, that a social change initiated by its best social class is scarcely likely to be pernicious. Where, it may be asked, if not among the most educated classes, is any process of amelioration to be initiated? We cannot make the world topsy-turvy to suit the convenience of topsy-turvy minds. All social movements tend to begin at the top and to permeate downwards. This has been the case with the decline of the birth-rate, but it is already well marked among the working classes, and has only failed to touch the lowest stratum of all, too weak-minded and too reckless to be amenable to ordinary social motives. The rational method of meeting this situation is not a propaganda in favor of procreation—a truly imbecile propaganda, since it is only carried out and only likely to be carried out, by the very class which we wish to sterilize—but rather by a wise policy of regulative eugenics. We have to create the motives, and it is not an impossible task, which will act even upon the weak-minded and reckless lowest social stratum.”

    PRIVATE Sex Advice to Women By R. B. Armitage, M. D.

    For Young Wives and those who Expect to be Married.

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  • WHAT BIRTH CONTROL IS, AND IS NOT

    WHAT BIRTH CONTROL IS, AND IS NOT

    The student of the progress of human affairs, or even the average person whose knowledge of the doings of mankind is derived from a hasty and casual reading of the daily newspapers and the popular magazines, cannot plead ignorance of the growing interest in the general subject which is embraced within the content of the term “Birth Control.”

    But while the general meaning of the term is at least vaguely grasped by the average member of the human crowd—the individual to whom we refer as “the man on the street”—we find a startling condition of mental confusion and often positive misconception concerning the essence and spirit of the general idea expressed by the term in question.

    While the fact is a reflection upon the average intelligence of the general public, it must be admitted that to the average person, or “the man on the street,” Birth Control means simply the teaching and practice of certain methods whereby men and women may indulge their sexual appetites, in or out of marriage, without incurring the liability or risk of conception and child-bearing. The average person does not stop to consider that such teachings and practices do not constitute “Birth Control” at all, but are, rather, merely the theory and practice of Birth Prevention, desirable only to those who seek sexual indulgences without being called upon to shoulder the responsibilities attached by Nature to the physical sexual union of men and women.

    The term “control” does not mean “prohibition,” or “prevention”; but, on the contrary, means “governing, regulating, or managing influence.” Birth Control, in the true meaning of the term, does not mean the prevention or prohibition of the birth of children, but rather the encouragement of the birth of children under the best possible conditions and the discouragement of the birth of children under improper or unfavorable conditions.

    Birth Control, in the true meaning of the term, does not mean theories and practices which would tend to reduce the population of the civilized countries of the world, but rather theories and practice which would inevitably result in the production of an adequate ratio of increase in the population of such countries, not only by reason of a normal birth-rate, but also by reason of a diminishing death-rate among infants—by the production of healthier children, accompanied by the raising of the standard of the average child born in such countries.

    Birth Control, in the true meaning of the term, therefore, is seen to consist not of the prohibition or prevention of human offspring, but rather of the governing, regulating, and managing of the production of human offspring, under the inspiration of the highest ideals and under the direction of the highest reason, for the purpose of the advancement and welfare of the race and that of the individuals composing the race. Instead of being an anti-social and anti-moral propaganda, Birth Control when rightly understood is perceived to be in accordance with the highest social aims and aspirations, and in accordance with the highest and purest morality of the race.

    Much of the opposition toward the general movement of Birth Control which has been manifested by many well-meaning, though misinformed, persons, has arisen by reason of the erroneous conception and understanding of the term itself, and of misleading information concerning the true nature of the best teachings on the subject. This prejudice has been heightened by certain zealous but ill-balanced advocates of the general movement who have overemphasized the incidental feature of the limitation of offspring under certain conditions, and who have appealed to the attention and interest merely of those who wished to escape the responsibilities of parenthood. This has caused much sorrow and distress to the many persons who have the highest ideals and results in view, and who deplore this unbalanced propaganda under the name, and apparently under the cloak of the general movement. Such persons have felt inclined to cry aloud “Good Lord, deliver us from our so-called friends!”

    One of the most distressing features of the popular prejudice against Birth Control, arising from a total misconception of the subject, has been the widely spread and popularly accepted notion that Birth Control is practically analogous to abortion—or, at the best, but a more refined and less repulsive and less dangerous form of abortion. In view of the fact that one of the important results sought to be obtained by a scientific knowledge of Birth Control actually is the prevention and avoidance of the crime of abortion which has wrought such terrible havoc among the women of civilized countries, it is most distressing and discouraging to the conscientious and high-minded advocates of Birth Control to have it said and believed that their teachings encourage and justify abortion.

    A reference to any standard dictionary or textbook will reveal the fact that “Abortion” means: “the premature expulsion of the human embryo or foetus; miscarriage voluntarily induced or produced,” etc. It is seen at a glance that the essence and meaning of abortion consists in the destruction of the human embryo which has resulted from conception. The embryo human child must already exist in its elemental form, before it can be destroyed by abortion. Therefore, if no such embryo form exists, it cannot be destroyed, and therefore there can be no abortion in such a case. And, it may positively be stated, no true advocate of Birth Control can possibly justify, much less advocate, the destruction of the human embryo or foetus, which act constitutes abortion. The difference between true Birth Control teachings and methods, and that of the advocates of abortion, is as great as the difference between the two poles. Instead of the two being identical or similar, they are diametrically opposed one to the other—they are logical “opposites,” each the antithesis of the other.

    Even in those forms or phases of the Birth Control propaganda in which the use of “contraceptives,” or “preventatives” is considered justified in certain cases—and these forms and phases are far from being the most important, as all students of the subject know—even in these exceptional forms and phases of the general subject the idea of abortion is combatted, and never justified or encouraged. A “contraceptive” agency merely tends to prevent or obviate undesirable conception; it never acts to destroy the result of previous and accomplished conception. A “contraceptive” merely prevents the union of the male and female elements of reproduction, and consequently the process from which evolves the foetus or embryo. A leading medical authority has said regarding this distinction: “In inducing abortion, one destroys something already formed—a foetus or an embryo, a fertilized ovum, a potential human being. In prevention, however, one merely prevents chemically or mechanically the spermatozoa from coming in contact with the ovum. There is no greater sin or crime in this than there is in simple abstinence, in refraining from sexual intercourse.”

    What then must we say when we consider the higher and more advanced forms and phases of Birth Control, those phases and forms which may be said to be mental or emotional “contraceptives,” rather than physical? Surely these cannot be considered as identical with or similar to abortion. And when we consider those phases and forms of Birth Control which are concerned with Pre-Natal Culture—the culture of the child before its birth—can one, even though he be intensely prejudiced against Birth Control, assert that there is to be found here anything which in any way whatsoever can be considered as relating to the theory or practice of abortion? And what must we say of the still higher phases in which the teachings are concerned with the mental and physical preparation of the parents prior to the conception of the child, to the end that the child may have the best possible physiological and psychological basis for its future well-being? Is not this the very antithesis and opposite of all that concerns abortion or abortive methods?

    The trouble about all great movements designed for the benefit of the human race is that at the beginning there is attracted to the movement, by reason of its novelty and “newness,” certain elements which seize upon certain incidental features of the general idea, make them their own while excluding or ignoring the more important things, and then exploit these incidental features in a sensational way, thereby attracting public attention and gaining much undesirable notoriety, and as a consequence bringing discredit and disfavor, prejudice and misunderstanding, to the general movement.

    Birth Control has passed through this apparently inevitable experience, and has suffered greatly thereby. But the Light is being thrown on the Dark Places, and the more intelligent portion of the public is beginning to realize that there is another side to the shield of Birth Control. And, as a consequence, much of the original prejudice is disappearing, and a new understanding of the subject is arising in the minds of many of the best individuals of the race. It is the purpose of this book to help to dispel the ignorance and misconception concerning this great subject of Birth Control, and to aid in presenting the higher and nobler aspects of the general movement to the attention of those who are concerned with the advance and progress of the race as a whole, and of the individual members thereof.

    The student of the subject of Birth Control will fall into grievous error if he begins his consideration of the subject under the impression that the questions concerned therein are new to the world of living things. If the process of Birth Control were something which had suddenly sprung into existence in the consciousness of man, without having an antecedent activity in the history of the race, and of living creatures in general, we might well hesitate to go further in the matter without the most serious and prolonged consideration of the entire principle by the careful thought of the wisest of the race. But while such consideration is advisable, as in the case of any and all important problems presenting themselves for solution and judgment, it is found that those so considering the subject have a sound and firm foundation upon which to base their thought and to test their conclusions.

    As many thoughtful students of the subject have pointed out to us, the question of Birth Control has been with the race practically since the beginning of human history; and it has its correspondences in the instinctive actions of the lower forms of life. The chief difference is that we are now seeking to deal with these problems consciously, voluntarily, and deliberately, whereas in the past the race has dealt with them more or less unconsciously, by methods of trial and error, through perpetual experiment which has often proved costly but which has all the more clearly brought out the real course of natural processes.

    We cannot hope to solve problems so ancient and so deeply rooted as these by merely the rational methods of yesterday and today. To be of value our rational methods must be the revelation in deliberate consciousness of unconscious methods which go far back into the remote past. Our deliberate methods will not be sound except in so far as they are a continuation of those methods which, in the slow evolution of life, have been found sound and progressive on the plane of instinct. This is particularly true in the case of those among us who desire their own line of conduct in the matter to be so closely in accord with natural law, or the law of creation, that to question it would be impious.

    It may be accepted without an extended argument or presentation of evidence that at the outset the prime object of Nature seems to have been that of Reproduction. There is evident, without doubt, an effort on the part of Nature to secure economy of method in the attainment of ever greater perfection in the process of reproduction, but we cannot deny that the primary motive seems to be that of reproduction pure and simple. The tendency toward reproduction is indeed so fundamental in Nature that it is impressed with the greatest emphasis upon every living thing. And, as careful thinkers have told us “the course of evolution seems to have been more of an effort to slow down reproduction than to furnish it with new facilities.”

    Reproduction appears in the history of life even before sex manifests itself. The lower forms of animal and plant life oftener produce themselves without the aid of sex, and some authorities have argued that the presence of sex differentiation serves rather to check active propagation rather than to increase it. If quantity, without regard to quality or variation, be the object of Nature, then that purpose would have been better served by withholding sex-differentiation than by evolving it. As Professor Coulter, a leading American botanist, has well said: “The impression one gains of sexuality is that it represents reproduction under peculiar difficulties.”

    To those who find it difficult to assimilate this somewhat startling idea, we now present a brief statement of the infinitely greater facility toward reproduction manifested by living creatures lacking in sex-differentiation as compared with those possessing it. It is seen that bacteria among primitive plants, and protozoa among primitive animals, are patterns of very rapid and prolific reproduction, though sex begins to appear in a rudimentary form in very lowly forms of life. A single infusorian becomes in a week the ancestor of millions, that is to say, of far more individuals than could proceed under the most favorable conditions from a pair of elephants in five centuries; and Huxley has calculated that the progeny of a single parthenogenetic aphis, under favorable circumstances, would in a few months outweigh the whole population of China. It must be noted, however, that this proviso “under favorable circumstances” reveals the weak point of Nature’s early method of reproduction by enormously rapid multiplication. Creatures so easily produced are easily destroyed; and Nature, apparently in consequence, wastes no time in imparting to them the qualities needed for a high form of life and living.

    And, even after sex differentiation had attained a considerable degree of development, Nature seemed slow to abandon her original plan of rapid multiplication of individuals. Among insects so far advanced as the white ants, the queen lays eggs at the enormous rate of 80,000 a day during her period of active life. Higher in the scale, we find the female herring laying 70,000 eggs at one period of delivery. But in both of these cases we find the manifestation of that apparently invariable rule of Nature, viz., that a high birth-rate is accompanied by a heavy death-rate, whether that high death-rate be caused by natural enemies, wars, or disease.

    At a certain stage of the evolutionary process, Nature seems to have awakened to a realization of the fact that it was better, from every point of view, to produce a fewsuperior beings rather than a vast number of inferior ones. Here, at last, Nature discloses a heretofore hidden aim, namely, the production of quality rather than quantity; and once she has started on this new path, she has pursued it with even greater eagerness than that of reproduction pure and simple. And here we pause to note a principle laid down by the students of Evolution, viz., that advancing evolution is accompanied by declining fertility.

    This new stage of Nature’s processes is marked by a constant and invariable manifestation of diminished number of offspring, accompanied by an increased amount of time and care in the creation and breeding of each of the young creatures. Accompanying this, we find that the reproductive life of the creature is shortened, and confined to more or less special periods; these periods beginning much later, and ending much earlier, and even during their continuance tending to operate in cycles of activity. Here, we see, Nature, grown wiser by experience, herself began to exercise her power in the direction of Birth Control—the use of preventive checks on reproduction.

    A writer has said along these lines: “As reproduction slackened, evolution was greatly accelerated. A highly important and essential aspect of this greater individuation is a higher survival value. The more complex and better equipped creature can meet and subdue difficulties and dangers to which the more lowly organized creature that came before—produced wholesale in a way which Nature seems to look back on as cheap and nasty—succumbed helplessly without an effort. The idea of economy began to assert itself in the world. It became clear in the course of evolution that it is better to produce really good and highly efficient organisms, at whatever cost, than to be content with cheap production on a wholesale scale. They allowed greater developmental progress to be made, and they lasted better. Even before man began it was proved in the animal world that the death-rate falls as the birth-rate falls.”

    Let us compare the lowly herring with the highly evolved elephant. The herring multiplies with enormous rapidity and on a vast scale, and it possesses a very small brain, and is almost totally unequipped to grapple with the special difficulties of its life, to which it succumbs on a wholesale scale. A single elephant is carried for about two years in its mother’s womb, and is carefully guarded by her for many years after birth; it possesses a large brain, and its muscular system is as remarkable for its delicacy as for its power, and is guided by the most sensitive perceptions. It is fully equipped for all the dangers of life, save for those which have been introduced by the subtle ingenuity of modern man. Though a single pair of elephants produces so few offspring, yet their high cost is justified, for each of them has a reasonable chance of surviving to old age. This contrast, from the point of view of reproduction, of the herring and the elephant, well illustrates the principle of evolution previously referred to. It brings clearly into view the difference between Nature’s earlier and her later methods—the ever increasing preference for quality over quantity. Unless we grasp this underlying principle of Nature in its wider aspects we may fail to perceive its operations in the case of man, which latter we may now consider.

    It is, of course, impossible to speak positively regarding the birth-rate and death-rate of the pre-historic primitive races of mankind, for there is not data upon which to base such a report. But reasoning upon the basis of conditions existing among the primitive tribes of the present time we are justified in holding that in the early stages of the evolution of the race there was manifested a high birth-rate and a correspondingly high death-rate. Upon the basis of conditions now existing among savage tribes it would appear that primitive man has a higher birth-rate than the average of mankind today, and likewise a higher death-rate. The rapidly increasing number of children born to the tribe was counteracted by deaths among children caused by neglect, poverty, and disease. In some cases the population was prevented from becoming larger than the means of subsistence justified by the practice of infanticide.

    As to the condition of the race in the early stages of “modern” civilization, we have modern Russia as a surviving instance of this stage. In modern Russia we find, side by side with the progress in neighboring nations, conditions which a few centuries ago existed all over Europe. Here we have an enormous birth-rate, and a terrible death-rate caused by ignorance, superstition, insanitation, filth, bad food, impure water, plagues, famines, and other accompaniments of overcrowding and misery. We find a mortality among young children which sometimes destroys more than half of the children born before they have attained the age of five years. As high as is the Russian birth-rate, it is a matter of record that at times the death-rate has actually exceeded it. And among the survivors there is found a startlingly large percentage of chronic and incurable diseases, with a large number of cases of blindness and other defects.

    Similar results follow in China, where the birth-rate is exceptionally high, and the death-rate correspondingly large; and where there is a large percentage of inferior physical development and pathological defects, the evil conditions which produce death also tending to produce deterioration in the survivors. In both of these countries we have an example of the result of unrestricted reproduction, and unrestricted destruction—as among herrings, so among men. And yet this condition of unrestricted reproduction is the logical goal of certain persons who, inspired by the best possible intentions, in their ignorance and criminal rashness would dare to arrest that fall in the birth-rate which is now beginning to spread its influence in every civilized land.

    In Western Europe before the nineteenth century the population increased very slowly. The enormous birth-rate was nearly equalled by the exceedingly heavy death-rate caused by plagues, pestilences, and famine, and by the frequent wars large and small. The mortality among young children was particularly heavy. Writers have pointed out that the old family records show frequently two or three children of the same Christian name, the first child having died and its name given to a successor.

    During the last quarter of the eighteenth century, when machinery was introduced and a new industrial era opened, the birth-rate rose rapidly. Factories springing up gave increased support to many, and as children were employed as “hands” in the mills at an early age, the richest family was the one with most children. The population began to increase rapidly. But soon disease, misery, and poverty arose from filth and insanitation, immorality and crime, overcrowding and child-labor, drink and lack of sane courses of conduct.

    In time, however, progress set in, and social reformers began the great movement for the betterment of the environment, sanitation, shorter hours of labor, and restriction of child-labor, factory regulation, etc. And when the environment is bettered, the death-rate drops, and the birth-rate accompanies it on its downward progress. As Leroy-Beaulieu says: “The first degree of prosperity in a rude population with few needs tends toward prolificness of reproduction; a later degree of prosperity, accompanied by all the feelings and ideas stimulated by the reduction of such prolificness.”

    The law of the reduction of reproduction in response to the improvement of environment is a natural law, arising from fixed biological principles. This is because when we improve the environment we improve the individual situated in that environment; and the improvement of the individual has always resulted in a check upon reproduction. We must remember, however, that this change is not the result of conscious or voluntary action; instead it is the result of unconscious activities and instinctive urge. As Sir Shirley Murphy has said: “Birth Control is a natural process, and though in civilized men, endowed with high intelligence, it necessarily works in some measure voluntarily and deliberately, it is probable that it also works, as in the evolution of the lower animals, to some extent automatically.”

    Science shows us that even among the most primitive micro-organisms; when placed under unfavorable conditions as to food and environment, they tend to pass into a reproductive phase and by sporulation or otherwise begin to produce new individuals rapidly. This, of course, because of the fact that their death-rate is increased, and an increased birth-rate must be manifested in order to maintain a balance. If the environment be improved, the death-rate decreases, and this is followed by a fall in the birth-rate, according to the constant laws of Nature manifesting in such cases.

    The same law is seen to be manifested in the case of Man. Improve his environment, and his death-rate drops, which is accompanied by a falling birth-rate. Here, once more we see the application of the scientific axiom “Improve the environment and reproduction is checked.” As Leroy-Beaulieu has said: “The tendency of civilization is to reduce the birth-rate.” And as Professor Benjamin Moore has said: “Decreased reproduction is the simple biological reply to good economic conditions.” And as Havelock Ellis has said: “Those who desire a higher birth-rate are desiring, whether they know it or not, the increase of poverty, ignorance, and wretchedness.”

    Among men, Birth Control has now evolved from the unconscious and instinctive phase, and is now unfolding and manifesting on the plane of conscious and voluntary activity. The influence of deliberate intention and conscious design is now one of the important factors in the process. Here at this point we reach a totally new aspect of reproduction. In the past stages of evolution the original impetus toward reproduction has been checked and directed by Nature, working along instinctive and unconscious lines; and the result has been an extreme diminution of the number of off-spring; a prolongation of the time devoted to the breeding and care of each new member of the family, in harmony with its greatly prolonged life; a spacing out of the intervals between the offspring; and, as a result, a vastly greater development of each individual, and an ever better equipment for the task of living. All this was slowly attained automatically, without any conscious volition on the part of the individuals, even when they were human beings, who were the agents.

    Now, however, we are confronted with a change which we may regard as, in some respects, the most momentous sudden advance in the whole history of reproduction, namely, the process of reproductive progress now become conscious and deliberately volitional. Birth control, no longer automatic, is now being directed by human mind and will precisely to the attainment of ends which Nature has been struggling after for millions of years; and, being consciously and deliberately directed, it is now enabled to avoid many of the pitfalls into which the unconscious method fell.

    Havelock Ellis says: “The control and limitation of reproductive activity by conscious and volitional effort is an attempt by open-eyed intelligence and foresight to attain those ends which Nature through untold generations has been painfully yet tirelessly struggling for. The deliberate co-operation of Man in the natural task of Birth Control represents an identification of the human will with what we may, if we choose, regard as the divinely appointed law of the world. We can well believe that the great pioneers, who, a century ago, acted in the spirit of this faith may have echoed the thought of Kepler when, on discovering his great planetary law, he exclaimed in rapture: ‘O God! I think Thy thoughts after Thee!’”

    The following brief general history of the modern Birth Control movement is quoted from Havelock Ellis, and will be of interest to students of the subject: “The pioneers of modern Birth Control were English. Among them Malthus occupies the first place. That distinguished man, in his great and influential work, ‘The Principles of Population,’ in 1798, emphasized the immense importance of foresight and self-control in procreation, and the profound significance of birth limitation for human welfare. Malthus, however, relied on ascetic self-restraint, a method which could only appeal to the few; he had nothing to say for the regulation of conception in intercourse. That was suggested twenty years later, very cautiously by James Mill, the father of John Stuart Mill, in the ‘Encyclopaedia Britannica.’ Four years afterwards, Mill’s friend, the Radical reformer, Francis Place, advocated this method more clearly. Finally, in 1831, Robert Dale Owen, the son of the great Robert Owen, published his ‘Moral Physiology,’ in which he set forth the ways of preventing conception; while a little later the Drysdale brothers, ardent and unwearying philanthropists, devoted their energies to a propaganda which has been spreading ever since and has now conquered the whole civilized world.

    “It was not, however, in England but in France, so often at the head of an advance in civilization, that Birth Control first firmly became established, and that the extravagantly high birth rate of earlier times began to fall; this happened in the first half of the nineteenth century, whether or not it was mainly due to voluntary control. In England the movement came later, and the steady decline in the English birth-rate, which is still proceeding, began in 1877. In the previous year there had been a famous prosecution of Bradlaugh and Mrs. Besant for disseminating pamphlets describing the methods of preventing conception; the charge was described by the Lord Chief Justice, who tried the case, as one of the most ill-advised and injudicious ever made in a court of justice. But it served an undesigned end by giving enormous publicity to the subject and advertising the methods it sought to suppress. There can be no doubt, however, that even apart from this trial the movement would have proceeded on the same lines. The times were ripe, the great industrial expansion had passed its first feverish phase, social conditions were improving, education was spreading. The inevitable character of the movement is indicated by the fact that at the very same time it began to be manifested all over Europe, indeed in every civilized country of the world.

    “At the present time the birth-rate (as well as usually the death-rate) is falling in every country of the world sufficiently civilized to possess statistics of its own vital movement. The fall varies in rapidity. It has been considerable in the more progressive countries; it has lingered in the more backward countries. If we examine the latest statistics for Europe, we find that every country, without exception, with a progressive and educated population, and a fairly high state of social well-being, presents a birth-rate below 30 per 1,000. We also find that every country in Europe in which the mass of the people are primitive, ignorant, or in a socially unsatisfactory condition (even although the governing classes may be progressive or ambitious) shows a birth-rate of above 30 per 1,000. France, Great Britain, Belgium, Holland, the Scandinavian countries, and Switzerland are in the first group. Russia, Austro-Hungary, Italy, Spain, and the Balkan countries are in the second group. The German Empire was formerly in the second group, but now comes within the first group, and has carried on the movement so energetically that the birth-rate of Berlin is already below that of London, and that at the present rate of decline the birth-rate of the German Empire will before long sink to that of France. Outside Europe, in the United States just as much as in Australia and New Zealand, the same progressive movement is proceeding with equal activity.”

    The same authority sums up the present attitude of the advocates of scientific and rational Birth Control, as follows: “The wide survey of the question of birth limitation has settled the question of the desirability of the adoption of preventing conception, and finally settled those who would waste out time with their fears that it is not right to control conception. We know now on whose side are the laws of God and Nature. We realize that in exercising control over the entrance gate of life we are not fully performing, consciously and deliberately, a great human duty, but carrying on rationally a beneficial process which has, more blindly and wastefully, been carried on since the beginning of the world. There are still a few persons ignorant enough or foolish enough to fight against the advance of civilization in this matter; we can well afford to leave them severely alone, knowing that in a few years all of them will have passed away. It is not our business to defend the control of birth, but simply discuss how we may most wisely exercise that control.”

    PRIVATE Sex Advice to Women By R. B. Armitage, M. D.

    For Young Wives and those who Expect to be Married.

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