Newsletter #15 (Spring 1997)
Foam Powder and Sponge: The Quest for Doctorless Birth Control
The late 1930s brought a series of major triumphs for Margaret Sanger and the American birth control movement. In 1936, a U.S. Circuit Court of Appeals decision in the US vs. One Package case, a test case instigated by Sanger in 1932 involving the illegal importation of diaphragms, essentially removed federal legal bans on contraception. The American Medical Association finally endorsed birth control at their annual meeting in 1937, the official medical sanction that Sanger had long sought. And a 1938 poll published in the Ladies Home Journal showed that 79% of American women believed in birth control, a statistic that Sanger hoped would finally convince state and federal governments to incorporate contraceptive services into public health programs. Surveying the status of birth control that year, Sanger wrote "Birth Control...is at last freed" ("The Status of Birth Control: 1938," New Republic, MSM S71:1020).
Yet Sanger's triumphs were muted by the failure of the birth control movement to reach a substantial number of poor and working class women, the very women that Sanger set out to reach when she instigated her crusade in 1914. As Sanger explained to Rockefeller Foundation representative Arthur Packard in 1937:
Our clinics today while doing great good in the areas in which they are located, are failing to reach the masses of women throughout the world that it has been my desire from the very start of the work to aid and assist. By the masses of women, I refer to those countless thousands who cannot afford the cheapest of present day contraceptives and who, even if they could, cannot reach a doctor or clinic for the necessary fitting (MS to Arthur Packard, July 4, 1937, MSM C6:552).
Sanger molded the American birth control movement around the idea of offering safe and effective contraception through medical professionals operating in clean and controlled environments; admitting the shortcomings of this strategy amounted to agreeing with many of her critics among feminists and human service providers that the clinic movement had largely abandoned the needs of the poor. While Sanger was among the most active proponents of "doctorless" birth control during the early years of her crusade – publishing directions for using inexpensive methods such as douches and suppositories in her 1914 manual Family Limitation – her support of doctor-controlled delivery of contraceptives led her to focus more attention on promoting the use of the diaphragm. However, she never wholly abandoned her interest in cheaper more accessible methods. And by the mid-1930s, with opposition to birth control more contained than ever before, Sanger allocated increased time and resources to developing and testing new contraceptives.
Sanger had favored the spring-form diaphragm ever since visiting clinics in Holland in 1915, where a prototype "Mensinga" diaphragm was successfully used by hundreds of women. The diaphragm and jelly contraceptive was the chief means of fertility control prescribed by Sanger's Birth Control Clinical Research Bureau and clinics across the country. But while the diaphragm was very effective when properly used, many women found it complicated and unpleasant. And for poor women it was especially burdensome since it required a doctor's visit for proper measuring and fitting, follow-up fittings, some degree of privacy to insert, as well as clean, hygienic conditions such as running water – something not found in many poorer American homes during the Depression.
Sanger sought an alternative and during the 1920s and 1930s, pursued scientific research on two new permanent forms of birth control: spermotoxins (substances that would immunize women against sperm), and hormonal research aimed at inhibiting ovulation. Both were highly experimental and unproven, and seemed unlikely to lead to practical forms of fertility control in Sanger's lifetime. She also investigated promising anecdotal evidence on several other contraceptive home remedies, including the "Fiji herb," a substance made from the bark of the Kakaula tree that reportedly caused sterility in both males and females; and salt-based spermicides that physician and Procter and Gamble heir, Clarence Gamble repeatedly tested in Asia. But local remedies of this nature failed to hold up under scientific investigation. Sanger held out hopes for a "pill" or shot that would preclude barrier methods and spermicidal solutions, but in the interim pursued and promoted alternate versions of barrier methods that would eliminate both the need for physicians and the discomfort associated with the diaphragm.
The most promising method-for-the-masses tested and promoted by Sanger during this period was the foam powder or jelly and sponge contraceptive. Although the sponge had been used as a contraceptive in many cultures throughout history, it was largely abandoned in the late 19th and early 20th centuries in favor of rubber diaphragms. But promising clinic tests conducted in Miami by a controversial physician and birth control researcher, Lydia Allen DeVilbiss, on a natural or rubber sponge and a new spermicidal powder won the attention of Sanger and her Birth Control Clinical Research Bureau, as well as the American Birth Control League (ABCL) and the National Committee on Maternal Health.
DeVilbiss (1882-1964), an ardent eugenicist, expert on child hygiene, and director of the Mothers Health Clinic in Miami Florida, had held prominent public health positions in several states. Her concern with maternal mortality among the poor, along with her class and race-based conviction that many poor families – blacks in particular – were unable to effectively use sophisticated contraceptive devices such as diaphragms, led to her zealous exploration of simpler and cheaper means of fertility control. Working with chemists, veterinarians and pathologists, she created a recipe for a contraceptive powder with a base of sulphonated alcohol. The powder was used with a small sponge attached to a string. Unlike a diaphragm, the sponge did not need to cover the cervix; it simply served as a reservoir for the spermicidal powder (essentially a soap) which turned to foam upon insertion in the vagina. In theory, and to some degree in practice, the foam powder and sponge method did not require visits to a clinic but rather a single short home visit from a nurse and some brief words of instruction. Few sanitary conveniences were necessary to use the sponge, and it was said it could even be left in for several days without causing irritation. Best of all it cost pennies when mass produced.
DeVilbiss' preliminary report in 1935 on limited trial use of the foam powder and sponge seemed to show positive results: "...a gratifying percentage of success can be attained by careful instruction in the homes even among patients of limited intelligence," she declared, "and at a fraction of the cost of ordinary clinic methods" (DeVilbiss to MS, Nov. 20, 1935, MSM S10:659). However, her statistics raised concern among other researchers since 77 out of 271 subjects never reported back. Nevertheless, DeVilbiss claimed that only 9 women became pregnant out of 194 who had used foam power for a year; and 7 of the pregnant women admitted to non- or improper use (DeVilbiss to MS, Nov. 20, 1935, MSM S10:661).
When, in the fall of 1935, just prior to her departure for a tour of Asia, Sanger was apprised of DeVilbiss' success with foam powder she expressed interest and offered to "take the powder to India, or better still perhaps have the formula, if it could be so simplified that it could be prepared in India or the Orient ..." (MS to DeVilbiss, Sept. 19, 1935, MSM S10:372). Yet Sanger refused to wholeheartedly endorse DeVilbiss' work or promote her formula more energetically than other soaps and jellies undergoing tests in both the U.S. and England, even though DeVilbiss' foam powder showed the most promise in terms of effectiveness, ease of use, and expense.
A great distrust of DeVilbiss had fermented in Sanger ever since DeVilbiss accepted Sanger's invitation to head up her New York clinic in 1923, then bowed out at the last minute to protect her career. Ever mindful of her own reputation, Sanger was also infuriated by DeVilbiss' claim of pioneer status in the movement, and her frequent behind-the-back criticisms of Sanger, including the suggestion that Sanger was out of touch with the plight of poor women and tamed to passivity by political and fund-raising considerations. After DeVilbiss responded that she was glad that Sanger had finally seen the light on the need for more democratic birth control, Sanger replied in a courteous but defensive manner, typical of her letters to DeVilbiss:
I am rather amused at your statement that you are glad to know that I am coming to the same conclusion that you came to a number of years ago regarding the importance of a cheap contraceptive. I did not have to travel to Japan nor to China in 1922 to realize this for back in 1914 and during the years preceding that time during my work with the women of our slum districts, I saw that even the little cheap French pessary, which at that time sold for 50›, was too expensive and too complicated to be of general use to the masses (MS to DeVilbiss, Sept. 19, 1935, MSM S10:370).
Sanger, became more suspicious of DeVilbiss' motives on receiving reports from an aide who was in regular contact with DeVilbiss, informing Sanger of "Dr. Dee's" (as she was known) penchant for performing sterilizations on poor women. She "sterilizes women," wrote Hazel Zborowski, through the medium of introducing something into the uterus which sets up an inflammation with the result that a scar tissue is formed obstructing the passage. She claims this is a very simple operation requiring only a few moments in the office . . ." (Hazel Zborowski to MS, Aug. 6, 1935, MSM S10:271).
If Sanger did not express overt disapproval of the large number of sterilizations DeVilbiss performed, her controversial techniques, or the racist management of her Miami clinic where services were segregated and based upon an assumption that black women were not intelligent enough to properly use a diaphragm, she also did not condone them. Sanger frequently ignored the racial motivations of eugenicists such as DeVilbiss, if she thought their support and research would benefit her movement. She maintained a working relationship with DeVilbiss and contributed money to support the foam powder trials even after the ABCL had rejected DeVilbiss' research methods earlier in 1935. At the same time Sanger told others that DeVilbiss was undependable, quarrelsome, impatient with standard scientific trials, and incapable of keeping adequate records. But the potential of the foam powder and sponge outweighed, in Sanger's mind, any liabilities that DeVilbiss' politics or clinical techniques posed.
Foam powder trials were conducted in 1936 and 1937 by DeVilbiss in Miami and at the Birth Control Clinical Research Bureau in New York under Sanger's watchful eye. Although the case studies were small, the results suggested that the method, if used properly, was nearly as reliable as the diaphragm and jelly combination. Both studies, however, showed a relatively high refusal rate. In the Bureau study, for instance, more than a third of the women never used the method after it was prescribed to them, or discontinued its use after a short period, complaining of irritation, messiness, husband's objections due to "physical awareness," and a lack of confidence (The Journal of Contraception, 3:1, [Jan. 1938], 3-6).
Another field test in the South ran into different problems. In 1937, North Carolina, the first state to incorporate birth control into a public health program, started county contraceptive programs for the indigent (segregated). Clarence Gamble donated money to the North Carolina effort largely to test foam powder on a large group of poor women. But only a very small percentage of eligible women (under 10%) actually benefitted from the program. Local public health officials were slow to recruit patients, and local doctors who could have helped sell the program avoided affiliation since the foam powder method precluded their services, and, according to historian James Reed, partly because they thought any effort to help the poor and uneducated, especially blacks, was futile (James Reed, The Birth Control Movement and American Society: From Public Vice to Private Virtue, pp. 252-256). Consequently, the North Carolina study was inconclusive as to the effectiveness of foam powder.
After the completion of additional studies on foam powder in Florida, Tennessee and Virginia, both Gamble and Sanger remained optimistic that the foam powder and sponge would eventually succeed with poor women living in rural areas more effectively than other methods. "The Foam Powder Method seems an answer to a prayer...,'' Sanger wrote in a fundraising letter during the summer of 1937 (MS to Arthur Packard, July 4, 1937, MSM C6:552). However, constant tinkering with the various contraceptive formulas used in the field tests, and the introduction of a lactic acid jelly spermicide in some of the trials produced inconclusive results. More troubling was DeVilbiss' feud with chemist Philip Stoughton, the New York researcher responsible for producing the primary foam powder product with the widest circulation. DeVilbiss and Stoughton both claimed rights to the original formula and accused each other of pursuing commercial gain. Early in 1937, on the advice of attorney, DeVilbiss refused to supply any more formula to Sanger's Birth Control Clinical Research Bureau or any other testing facility, or to share recipes for old or new foam powders and jellies because Stoughton "might take the notion to claim these as his property also" (DeVilbiss to MS, Apr. 29, 1937, LCM, 6:461).
Sanger refused to get drawn into such skirmishes, telling another chemist; "...having started this series of tests and interest in research, I refuse to stop because of personal animosities toward the manufacturer or chemist" (MS to Carl Scheffel, January 21, 1937, MSM S12:456). But as more difficulties with the method surfaced, including instances of disintegrating sponges, clumping problems in the foam powder cans due to humidity, certain ingredients losing potency over time, and continued incidences of irritation, Sanger, Gamble and others lost some of their enthusiasm. Moreover, Sanger's long experience with prescribing diaphragms had convinced her that some percentage of women would simply avoid all barrier methods. In 1935, even before significant trials had been completed on the foam powder and sponge, she wrote to DeVilbiss: "...while it would seem that the insertion of a sponge or the insertion of a suppository or jelly is simple enough, they all involve a certain amount of trouble and will keep a certain number of women from using them" (MS to DeVilbiss, Sept. 19, 1935, MSM S10:370).
In addition, in 1938 Sanger sent out supplies of foam powder and sponges to small clinics and doctors throughout the country and most reported mixed results. Several responses indicated that a number of patients did not fully understand how to use the method or had overriding health complications, such as gonorrhea, that interfered with proper use. One clinic administrator in Washington, D.C. sent Sanger a report based on a fairly small number of users, listing numerous failures and complaints, such as "soreness, gas, dizziness and burning" associated with prolonged use of the foam powder (Agnes McNutt to MS, June 24, 1938, MSM S15:349).
By the early 1940s, Sanger had turned her attention to trying to establish educational programs aimed at training African-American field workers to organize clinics in segregated regions of the South. The foam powder and sponge method continued to be studied but not with the urgency or grand expectations of the earlier trials. "Doctorless" birth control lost some of its attraction once field workers noted the need for gynecological care in many poorer communities. Getting women into a clinic for contraceptive services helped control other health problems. Eventually Clarence Gamble and many state health officials in the South joined Sanger in abandoning DeVilbiss and her dubious clinical trials, all of them citing their inability to work with her.
In the 1950s as her work focused on international programs, Sanger again encouraged use and examination of foam powder and jellies abroad, particularly in India where it met with considerable success. (MS to DeVilbiss, Mar. 20, 1952, MSM S36:956). While a few major manufacturers were producing spermicidal foams, including DuPont and Johnson & Johnson, the cost was substantially higher than the foam powder products developed by DeVilbiss and Stoughton. Sanger restarted her correspondence with DeVilbiss after more than 15 years in order to obtain DeVilbiss' foam powder formula to send to India. "...it seems to me," Sanger wrote in 1952, "that the greatest contribution that anyone could make to the peace of the world today is to offer a formula to the head of a nation as a means to peace" (MS to DeVilbiss, Apr. 15, 1952, MSM S37:119). DeVilbiss, flattered that Sanger had approached her again, complied with Sanger's wishes and sent her the formula and copyright.
Reports from field representatives working under the auspices of the International Planned Parenthood Federation throughout the 1950s show evidence of successful use of the foam powder and sponge in Asia, Africa, the Caribbean and Mexico. In Canada, birth control organizer Alfred Tyrer developed his own "rubber-tissue sponge" that proved popular in Canadian clinics. The sponge paired with a jelly or foam found a niche in the product offerings of birth control clinics around the world, but the method never became the ultimate means of fertility control for the poor that Sanger had envisioned. By the 1950s Sanger was concentrating on supporting research to ready the anovulant pill for market, the next great "answer to a prayer" in her quest for more democratic birth control.
It is clear from the statistical and anecdotal evidence collected on the foam powder trials that it was counterproductive (not to mention immoral and unethical) to promote and circulate a single birth control method based solely on race and class. Condoms were generally inexpensive yet seldom offered in conjunction with other barrier methods. And field tests in 1936 on a jelly spermicide used without diaphragm and sponge, along with the foam powder trials in 1936-1938, reported frequent requests for other contraceptives besides the one being tested (James Reed, The Birth Control Movement and American Society, p. 251). While the failure rate for women using the foam powder and sponge was relatively low, all of the clinical trials exhibited a high number of non-use cases, suggesting that many women were simply put off by this particular method. Research conducted by Sanger at her Negro Clinic in Harlem in the early 1930s, and other clinic studies carried out by researchers within and apart from the birth control movement, concluded that poor and minority women could and would successfully use a variety of contraceptives as often as middle class white women.
The medical profession recently announced that a large dosage of certain birth control pills taken (under a doctor's direction) up to 72 hours after intercourse usually prevents pregnancy. This long-delayed disclosure represents another instance of the medical community's reluctance to offer all women, and especially poor women, a wide array of choices for fear of misuse. The fact that many women with access to the range of contraceptive choices available have utilized "morning after" pills for years makes the long period of official silence all the more unpalatable. We can gain from Sanger's mistakes today by recognizing that the imposition of limitations on all women's birth control choices tends to confound the democratizing effect of any one method. The push to offer RU486 and the "morning after pill," though far from "doctorless," demonstrates that those who carry on Sanger's legacy are learning they must increase choice at all costs in order to reach the largest number of women and men.