For most of history, childbirth was the same old story: women were frequently pregnant but often trying not to be, birth could be very dangerous, and abortion was attempted and achieved through various rudimentary methods. (Abortion was referenced in ancient Egypt, Greece, and Rome. It is age-old and evergreen.)1 Markedly, the whole continuum was female—a birthing woman was attended by a female midwife in a room full of female relatives and friends. (What’s the opposite of a sausage fest? It was that.)
And it stayed that way until reproduction became about control, capitalism, and fears that the number of white babies was being outpaced by immigrants, Catholics, and people of color. When slaveholders profited from Black children, that reproduction was encouraged. When there was no longer a white capitalist profit to it, there ensued a long trail of eugenics and forced sterilizations on people of color.
It’s not a pretty history.
In some ways, reproduction in America has been stripped back to basics, but we don’t find ourselves suddenly reliving a colonial life. We would argue it’s more perverse in some ways because the advances in medicine are available, but they’re being withheld. Like the Back to the Future timeline where Biff Tannen runs a dystopian Hill Valley, we’re going back to a place we never really were.
The current moment seems to have taken the worst components from America’s reproductive past while also withholding the medical advances that saved lives or that gave pregnant people any kind of control over their own bodies and futures. So how the hell did we get here?
Let’s back up to our beginnings. A married woman in colonial America (which spanned the seventeenth and eighteenth centuries) would spend most of her life childbearing and childrearing. Women were expected to be fruitful and multiply, and a lady with a bunch of kids would be admired for doing her job to populate a nascent America. White women typically married in their late teens or early twenties, nursed each child for a year or two before becoming pregnant again, and gave birth roughly every eighteen months to two years until menopause. They were likely welcoming grandchildren while still giving birth themselves. (Exhausting.)
Colonial women were playing a numbers game; most experienced five to ten pregnancies to end up with between three and eight surviving children because so many ended with miscarriage, stillbirth, and infant death.2 Nearly one in five children died in the first year of life.3 Yet the idea of grieving a miscarriage would have made no sense to them; they were worried about survival, for themselves and their children.
The experience of giving birth during this time was communal and exclusively female. It was also one of the only places where women had ultimate control (well, as much control as nature would allow), as historian Judith Walzer Leavitt wrote in Brought to Bed.4 Her friends, neighbors, mother, and sisters (if they could get away from their own duties and childcare—an unmarried sister was ideal) would create her “lying in” chamber where they’d all stay together during prelabor, labor, and a bit into the postpartum period to help with cooking, cleaning, and childcare. 5 The word gossip derives from the British “god sibs” or godparents. All these ladies descending onto the home for very frequent births? Godsibs. Gossips.
The follow-up to the lying-in period (the immediate postpartum weeks to months, depending on how rough the delivery) was followed by a “groaning” or “birthing” party, when the mother would cook a meal of appreciation for those who helped her.6 In Celebrating the Family, historian Elizabeth H. Pleck described this as “part of the cradle-to-grave system of emotional support among women.”7 The support part was great. How soon that grave could come calling was not.
Birth was often dangerous. Approximately one in thirty women could expect to die in childbirth or because of postpartum complications, and women were more likely to die in the prime of life than men.8 Cotton Mather warned in the early eighteenth century that conception meant “your Death has Entered into you.”9 (Rude.) Pregnant poet Anne Bradstreet, a resident of the Massachusetts Bay Colony, wrote a poem to her husband that read in part, “how soon, my Dear, death may my steps attend.”10 (Bradstreet died in 1672 at age sixty after bearing eight children, so she skirted the danger.) Thomas Jefferson’s first wife, Martha, died in childbirth, and his daughter Maria died after delivering her second child. Sam Adams’s first wife, Elizabeth, died soon after giving birth to a stillborn. Though some historians do not think childbirth deaths were as prevalent as feared, it’s fair to say that all colonists would have known someone who died from childbirth complications.11
Infants, children, and birthing women were often imperiled by the realities of colonial life, and pregnancies too close together could leave a woman weak, still suffering from injuries and infections from childbirth before the next round. Babies would often fail to thrive when born to physically exhausted women or if they were weaned too soon when their mothers became pregnant again.12 There is much evidence that women would have been very aware of the dangers of back-to-back pregnancies. In her letters, Abigail Adams lamented her daughter Nabby’s repeated pregnancies, called her sister Elizabeth “foolish” for starting “a second crop” of children at forty, and welcomed the news of a young relative’s miscarriage in 1800.13
Contraception was minimal. But colonial mothers consistently achieved two-year spacing between children through a combination of coitus interruptus (otherwise known as the pullout method) and breastfeeding, which is not reliable but can sometimes suppress ovulation. (Less so when rampant infant death would end lactation and start the cycle over sooner.) Prolonged breastfeeding was sometimes accompanied by abstinence, which was not always a popular option within the marriage. Alexander Hamilton grew impatient with his wife, Eliza, in 1802 and wrote, “I shall be glad to find that my dear little Philip is weaned if circumstances have rendered it prudent. It is of importance to me to rest quietly in your bosom.”14 (See the musical Hamilton for further evidence of that guy’s inability to say no to this.) There isn’t a lot of data on how often any of these methods were used, as a proper gentleman would be unlikely to note in his diary that he interrupted his coitus. And we don’t have a lot to go on from women in this era; not all could read or write, and their records were scarcer and similarly concerned with propriety.
Colonial Americans would have understood pregnancy completely differently than we do now. There was no definitive test, no medical way to confirm a pregnancy—it all came down to a woman knowing her own body. She may suspect it when she was tired, had sore boobs, and missed a period or two, but there were many potential causes of irregular and late cycles in a time of rampant illness, not to mention a bone-weary life of constant childbearing, childrearing, and incessant chores. She wouldn’t know for sure that she was expecting until quickening, around sixteen to twenty weeks. Most American laws during this time were based on the English common law, which distinguished between being “with child” and “with quick child,” when it all became official. (A woman could be prosecuted for an abortion when she was “with quick child,” but such prosecutions were rare, even among the Puritans.15 And those guys would whip scofflaws who skipped church. They weren’t exactly known for being laid-back.16)
Lara Freidenfelds, a historian of health, reproduction, and parenting in America, wrote in her book The Myth of the Perfect Pregnancy that “women mostly tried not to be pregnant, at the same time that they wanted a family. They expected that their wanted children would result from pregnancies they had in fact tried to avoid.”17
Early miscarriage doesn’t look much different from a missed period, so a woman may never have known she was pregnant at all if she lost it before the fourth month. But if she had some pregnancy symptoms and maybe bled with some heavy cramps, she might call it a “mishap,” “miss,” or “abortion,” all of which were synonyms.18 Pregnancies lost further along resemble coagulated blood or lumps of tissue, and especially in an era before embryology or the stages of fetal development were understood, a fetus was reported to look “ill-formed and alien” when compared to a full-term infant.19 (Even now, plenty of people squint at a twelve-week ultrasound and acknowledge it looks more like a tadpole than the star of a diaper commercial.) Historian Barbara Duden noted that until the late eighteenth century, illustrations of the unborn showed a little man dancing in the womb or a full-term infant drawn smaller.20 Women at the time would have considered the passed tissue to be the beginning materials for the pregnancy that just didn’t properly “cook” into a baby.
Miscarriages only became worrisome if she had a lot of them and few or no children. They were not generally dangerous and often passed without much more fanfare than cramping and a heavy period. But very much like today, there was a possibility of hemorrhage or sepsis if she didn’t expel the materials of conception, and without modern antibiotics or procedures to help, she could sicken and die within weeks.21 A 1766 obituary in the South Carolina Gazette reads “of a miscarriage of twins, on the 10th instant, died here, and the 24th year of her age, one of the most pious and accomplished young women in these parts.”22
Stillbirths were much more common than they are today because there were so few safe options for intervening in prolonged labor. But it’s important to note that at this point, the woman’s life was always prioritized over any individual pregnancy, at least in part because a premature infant almost certainly would have died without the interventions we have today. Many old American cemeteries have gravestones marking a stillborn buried with his or her mother, both dead in childbirth.
The attitudes around all this were so different from what they are today. In a culture where pregnancy wasn’t real until quickening, “there was no obvious moral distinction between intervening before or after conception.”23 Abortion, miscarriage, stillbirth, and pregnancy were all part of the same continuum. Herbal remedies at the time were known to help with all sorts of “female” complaints. British herbalist Nicholas Culpeper’s book The English Physician, the first medical book published in the colonies (really just a list of folk remedies), included six to twelve herbs he believed would cause an abortion.24 Those best known would have been savin, rue, tansy, and pennyroyal. (Fun fact: the Nirvana song “Pennyroyal Tea” refers to this. In Kurt Cobain’s unused liner notes published in Journals, he wrote, “herbal abortive…it doesn’t work, you hippie.”)25 Tansy was also thought to help with fertility, a dual purpose that was “neither uncommon nor illogical in folk medicine.”26
These natural abortifacients, or substances that induce abortion, were far less efficient, predictable, reliable, or safe than medications we have today. The idea here was that if a woman wanted to get pregnant, try to bring on a period! And if she didn’t want to be pregnant, try to bring on a period! These herbal inducements were relatively easy to get, and they often worked. “But it wasn’t like, ‘I now need an abortion. I shall go harvest my herbs,’ and it would be just like taking misoprostol,” Freidenfelds told us, referring to a medication used in both miscarriage and abortion. “It was more like, ‘I’m late. I’m going to drink this tea to help my cycle come back.’ And it seemed to have worked sometimes to induce miscarriage.”27
It was so common and such a nonissue that in 1748, Benjamin Franklin added a recipe for an at-home abortion to an adapted British manual called The Instructor for the colonies, general instructions for how to do a little bit of everything, including math, writing letters, and caring for horse hooves. “Abortion was so ‘deeply rooted’ in colonial America that one of our nation’s most influential architects went out of his way to insert it into the most widely and enduringly read and reprinted math textbook of the colonial Americas—and he received so little pushback or outcry for the inclusion that historians have barely noticed it is there. Abortion was simply a part of life, as much as reading, writing, and arithmetic,”28 author Molly Farrell wrote on Slate. Abortion, she argued, is originalism.
Black women today are at greater risk of experiencing stillbirths and miscarriages as well as dying from pregnancy and childbirth complications than any other American demographic. Overall, they receive poorer medical care, and their complaints are less likely to be believed. That didn’t arise out of thin air; it’s the result of deeply entrenched racism that dates back to the very founding of the nation.
The first enslaved people arrived in the colonies in 1619.29 In 1808, Congress ended America’s participation in the international slave trade but, of course, not slavery itself.30 Plantation owners could no longer kidnap slaves from abroad, so the slave population had to grow domestically. This, coupled with the expansion of cotton production, intensified the coercion and interference in enslaved women’s reproduction, and from 1807 to 1860, the number of enslaved people in the United States increased from just over one million to more than 3.9 million.31 Children born to enslaved women were slaves regardless of paternity, which legal theorist Dorothy Roberts describes in Killing the Black Body as one of slavery’s “most odious features: it forced its victims to perpetuate the very institution that subjugated them by bearing children who were born the property of their masters.”32 Thomas Jefferson, founding father and Virginia plantation owner, wrote that “a woman who brings a child every two years is more profitable than the best man of the farm.”33 It’s worth remembering that the man who authored the rhapsodic underpinnings of American freedom owned more than six hundred slaves in his lifetime, including Sally Hemings, whom he first impregnated when she was sixteen.34
Childbirth and pregnancy were so much worse for enslaved women, and the persistence of the variants on this racist history is horrifying. These women experienced pregnancy amid an environment of extreme fieldwork, poor nutrition, miscarriages, stillbirths, and infant deaths in addition to dangerous births and the risk of childbirth injury. Prenatal care would have come from Black “granny midwives”35 who offered comfort, advice, and herbal remedies. Some slaveholders might reduce a pregnant woman’s workload closer to her due date, but many worked a pregnant woman until the moment she went into labor and sent her back to the field the next day.36 Birth isn’t exactly something you can bounce back from in one day. Or maybe not even twenty depending on the labor. (You know that oft-repeated phrase “women used to give birth in a field” that is somehow supposed to be reassuring, like birth is no big deal? We couldn’t get confirmation if this phrase is rooted in American slavery or European peasantry, but regardless, giving birth in a field is demonstrably bad. This expression both minimizes the pain and physicality of childbirth and valorizes self-sacrificing for capitalism. Let’s stop perpetuating it.)
Pregnancy was unlikely to give her any reprieve from punishments, and some slaveholders devised a way to discipline a pregnant woman by digging a hole to accommodate her stomach while she lay on the ground to be beaten and whipped.37 Most academics working on women’s reproductive health today cite the rising importance of the fetus over the mother as a backlash to the women’s movement of the 1960s and 1970s and the post-Roe v. Wade antiabortion movement, but legal theorist Dorothy Roberts argues that whipping pregnant slaves while digging out space on the ground for her belly “is the most powerful image of maternal-fetal conflict I have ever come across in all my research on reproductive rights. It is the most striking metaphor I know for the evils of policies that seek to protect the fetus while disregarding the humanity of the mother.”38 Miscarriages and stillbirths were rampant. The infant mortality rate for enslaved babies in 1850 was twice that of whites, with fewer than two out of three Black children surviving to age ten, usually from malnutrition and disease.39 An enslaved women would not have been much troubled by miscarriage either, unless as with white women, she was unable to produce live children—though that had different implications for her life.
Enslaved women were often separated from their children as they worked, if they were allowed to live with them at all. Frederick Douglass said, “I do not recollect of ever seeing my mother by the light of day.”40 His mother, Harriet, was sold when he was an infant, and she would walk twelve miles to see him after a full day’s labor, visit with him, then walk twelve miles back and work. She died when Douglass was seven. (Go ahead and stop to weep. We’ll wait.) Slaveholders would break up slave marriages if no children came about or, more likely, the childless woman was sold off to another plantation, but part of the trap was that she was less likely to be sold and separated from her loved ones by continuing to reproduce.41 Slave owners also used children as pawns to prevent enslaved women from running away. Because of this, “far fewer enslaved women than men escaped—only 19 percent of the runaways advertised in North Carolina from 1850 to 1860, for example, were women. The same pattern was common throughout the South.”42 Childbearing—separate from physical dangers—was emotionally fraught, to say the least.
They were also trying not to be pregnant, which would have included attempts to “bring on their menses” with cotton root, the preferred abortifacient for the enslaved because it was easy to get and could be chewed or brewed into a tea. As Marie Jenkins Schwartz poetically wrote in Birthing a Slave, “the fortunes of slaveholders rested on the portion of the plant that grew above ground, the destiny of women on the part below.”43 Slave owners and some white physicians may have suspected the use of herbs, but it’s hard to know how prevalent this was, especially against the backdrop of an environment so ill-suited to a healthy pregnancy.
At the same time, the culture around mothering and childbirth was evolving for white, middle- and upper-class native-born women who had the luxury of being able to change their attitudes. Enter the Victorian sensibility. The colonial era had been a mostly agrarian system where it was all hands on deck to keep the family economy going. But the Victorian era was marked by separate spheres—men started to work outside the home and were in the public sphere, while the ladies stayed home in the private sphere. This privacy extended toward pregnancy. Colonials referred to pregnancy as being “big with child,” “fruitful,” and sometimes even “lusty” because that fertility was her duty, her cache in society—something to be out and proud about. That attitude had reversed by the Victorian era, when pregnancy was called “confinement” because it was literally considered obscene for a woman to be seen in public with a pregnant belly. Why obscene? Because it was obvious evidence that she had sex at least once. Apparently, everyone would have dropped their monocles in Victorian streets by seeing a big belly go by in a petticoat. It sounds ridiculous now, but this confinement had very real consequences in keeping women isolated.
These Victorian mothers were the first to have children as their primary companions at home, and with fewer children to care for (and, for upper-class women, servants to take over household tasks), it all added up to smaller and more emotionally intense families.44 This kick-started the idea that mothers should devote their lives to their children. And though it started in the upper classes, it would eventually trickle down to the rest of American culture and change the family model forever, inventing our notion of childhood.45 (“Happy Birthday to You” was introduced in 1893, Halloween became gentler and more child-centric toward the end of the century, and Christmas transformed into a holiday where parents could buy presents without seeming to spoil their children.) That doesn’t sound so bad, right? But a side effect of these smaller families—the average number of children dropped from 7.04 in 1800 to 3.56 in 190046—contributed to white supremacist fears of losing ground to immigrants, people of color, and Catholics. That would lead to clamping down on reproductive rights later in the century.
All these societal and cultural shifts were happening against the backdrop of the changing medical profession. From 1600 to the mid-1850s, anyone who had healing skills was a “doctor.” It simply didn’t exist as an accredited profession. But “regular” doctors looked to professionalize the field. (This is what they called themselves, and we all know it’s never cool to give yourself a nickname. They did it to differentiate from the lay healers and midwives they deemed “irregulars,” or quacks, but “I’m regular” is a weird brag.) Regulars were usually middle- to upper-middle-class white men who had some stamp of training, though it wasn’t standardized and was from schools often characterized as “diploma mills.”47
These regulars started to turn an eye toward childbirth to expand their purview. Healing up until this point was a mostly female field, and childbirth was entirely female, whether it was through midwives, lay healers, or a mother at home attending to her family. Men weren’t part of the baby-delivering equation at all. So why the sudden interest? Money, of course. Barbara Ehrenreich and Deirdre English argue in For Her Own Good: Two Centuries of the Experts’ Advice to Women that medicine was becoming “a thing to be bought and sold.”48 Healing was female when it was a community enterprise, based on relationships; once healing became a commodity, it was male.49 Childbirth in the early part of the century was still taking place in the home, and it was what first brought the doctor into the family. Getting a foot in the door for the rest of the family’s medical needs “meant developing a working relationship with the birthing woman and her female friends and relatives who attended the delivery along with the physician.”50 That is to say, deliver her baby and have a family of patients for life. Doctors started to slowly shove midwives out of that position, starting with upper-class patients.
But why was this upper-middle-class Victorian woman so willing to jettison the female-centric birthing system that had existed for centuries in Western culture? Because she was really afraid of dying in childbirth, and those who could afford to were hunting for a safer, less painful birthing experience. The hope was that doctors could offer some relief (chloroform began to be used around 1847, though not widely) and use medical intervention to improve outcomes. But the regulars weren’t very good at it—just winging it as they learned—and the “frequent misuse of forceps” (large metal objects that resemble salad tongs and are used to help a baby out of the birth canal) and “variation in skill” of the doctor “did not, on the whole, increase women’s chances of survival.”51
This medical push into gynecology was nowhere more evident (and dangerous) than on Southern plantations. Enslaved women were mostly tended to by Black midwives who would deliver all babies—Black and white—in rural areas, and they were much less interventionist than the doctors who would be called in for a difficult delivery or prolonged labor. Regardless, the doctor would have been treated as the expert, despite the fact that most saw their first live births in the slave quarters, with the midwife dismissed as uneducated despite her vast practical experience.52 In fact, doctors were much more likely to do harm with their “heroic measures,” which in the beginning of the century would have included bloodletting and laxatives, moving as the century wore on to forceps and sticking their hands inside the womb, none of which tended to be lifesaving and often introduced fatal infection. When slaveholders called a physician, the slaveholder rather than the woman was the client, so it is unsurprising that enslaved women, seeing the invasive treatments and poor outcomes, remained devoted to their own midwives and came to dread the intervention of doctors.53 This is also part of the history that would make later generations afraid of medical care.
This inevitably brings us to J. Marion Sims, the so-called father of gynecology. (Sigh. This guy.) He supplemented his Montgomery, Alabama, practice by working as a plantation doctor, which was how he came to learn about vesicovaginal fistulas, a birth injury that tears an opening between the bladder and the vagina, leading to urinary (and possibly fecal) incontinence, which brings on frequent infections, discomfort, and an overwhelming smell that leads to social ostracism, all of which made subsequent children less likely. The condition isn’t fatal, but it is pretty miserable. Anarcha, a girl of only seventeen, had the first fistula Sims had ever seen. She had labored for three days in her first birth on the Westcott Plantation, which probably resulted in a stillbirth. (No records exist to say one way or the other.) She could no longer control urination or bowel function, and Sims decided to devote his life to finding a cure. He was not concerned about the enslaved women per se but the middle- and upper-class white women he hoped to treat once he mastered a fix.
By 1845, enslaved women Anarcha, Betsey, and Lucy were living and working at Sims’s Montgomery hospital among a group that included other enslaved people loaned to Sims and those he owned himself. According to the 1850 census, he claimed seventeen slaves, twelve of whom were female.54 He had them on a “rotational work and healing shift” where some recovered in the hospital while others worked on the farm, in his home, and in the hospital as his nursing assistants.55 Their duties would have included cleaning and dressing wounds, aiding in the techniques, and holding women down as they were operated on without anesthesia. They were given opium during recovery but not during the operations, which author and medical ethicist Harriet A. Washington says was probably more about controlling behavior than pain because addiction “weakened their will to resist repeated procedures.”56 (Just to recap, these enslaved women would split their time between backbreaking labor, raising Sims’s children, working as surgical assistants, and being unwilling, unanesthetized surgical patients. Oh, and until very recently, Sims was lauded for his medical contributions. There was a statue of the guy erected in Central Park, facing the New York Academy of Medicine, until 2018.) These surgeries would have been truly excruciating, and the stitches would become infected and reopen each time until he finally “perfected” the procedure.57 Sims notes that during one surgery where he yanked away a sponge that adhered to Lucy’s bladder, she nearly died, and her “agony was extreme.”58
Like other slaveholders, Sims subscribed to the commonly held racist belief that Black people don’t feel pain in the same way as white people. These dangerous falsehoods about a difference in pain thresholds persist and continue to cause harm. Anushay Hossain wrote in The Pain Gap that a 2016 University of Virginia study found that some doctors still believed that Black people have thicker skin and are less apt to feel pain.59 There’s a direct line from this era to today, when Black women are still less likely to be believed, their pain more often dismissed.
Sims’s white physician apprentices who held the women down quit within a year, because “they could bear neither the bone-chilling shrieks of the women nor the lack of progress any longer.”60 These guys left because they couldn’t handle watching the brutal surgeries; Anarcha, Betsey, and Lucy lacked the option to quit being the patients. Anarcha underwent a staggering thirty surgeries in just under four years—all without anesthesia. In June 1849, the silver suture technique finally repaired one of her fistulas. It is not known if Sims repaired the remaining tears61 or even if Anarcha ever found long-term relief. (The procedure Sims is so famous for didn’t really work, according to his associate Nathan Bozeman , who said that less than half of those Sims treated were cured.)62 Sims’s mission accomplished, the enslaved patients would have been returned to their masters, and there was a high likelihood that a subsequent pregnancy would have reopened the wound. Anarcha, Betsey, and Lucy did not have an opportunity to leave records of their own, and almost all of what is known about them comes from Sims’s self-aggrandizing autobiography, The Story of My Life. The historical record of the women mostly disappears after they left Sims’s hospital. But they were publicly recognized not that long ago with three towering statues, the Mothers of Gynecology Monument Park in Montgomery, erected in 2021. The J. Marion Sims statue that stood for nearly one hundred years, meanwhile, was removed from Central Park,63 and the plaque now bears the names of Anarcha, Betsey, and Lucy. (Two other Sims statues remain, in South Carolina and Alabama.)
Doctors had pushed their way into the birth experiences of enslaved women without their permission and upper-class white women with their consent. Immigrant women still preferred midwives from their own country who knew their customs, but even that was about to change. Unprecedented immigration into cities in the latter half of the nineteenth century during the Industrial Revolution often left the poorest and most isolated women with no choice but to give birth in charity hospitals. They lacked a social network of female friends or relatives, not to mention money to pay a midwife, so there were no other options.
Sims moved to New York after publishing his paper on fistula repair and enjoying a stint as the toast of Europe. In 1855, he helped found the Woman’s Hospital of the State of New York, a charity hospital where doctors were rough with the immigrant and working-class women and women of color who were its main clientele. The doctors were much more likely to insert their (likely unwashed) hands or metal instruments into the womb, and Sims continued to experiment—this time on poor Irish women who left Ireland in droves during the Great Famine, who were also subjected to the same nonsensical and harmful ideas about higher pain tolerance.64
These charity hospitals provided care, yes, but it’s impossible to ignore the fact that they were also about access to bodies for practice—living and dead. More bodies meant more time for doctors to use their skills. In a time when medical schools were proliferating and there were laws restricting the study of human cadavers, bodies for dissection were poor, Black, or enslaved and donated (a requirement of a charity hospital) or stolen from (usually Black) graveyards. This access to bodies is also why all early gynecologists were Southern: Kentucky-based Ephraim McDowell, father of the ovariotomy, and Louisiana-based Francois Marie Prevost, father of the C-section, also operated on enslaved women.65 (Julius Caesar was not, in fact, born by cesarean, because his mother, Aurelia, lived to advise her grown son, and no woman could survive a C-section in ancient Rome. Julius was shot out of a standard vagina.66)
This lack of access to medical specimens is what fueled the “medicalization of miscarriage.”67 Until this point, miscarriages usually occurred at home, but the proliferation of charity hospitals meant they were happening more often in a medical setting. “The fetus served as a handy stand-in for the cadaver,”68 historian Shannon Withycombe wrote in Lost, her book about nineteenth-century miscarriage. Access to human tissue intersected with the budding field of embryology. Doctors and scientists were finally understanding the basics of mammalian reproduction, that sperm and egg met to start development. (A baby had previously been thought to be just one of many possibilities of a pregnancy—what they thought were misfires between “seed” and “blood,” sometimes called “fleshy morsels” and “useless beings.”69) Fetal tissue began to be displayed in jars around doctor’s offices, museums, and labs across the country. Male doctors were trying to establish the medical profession in part by engaging with science in a way they felt midwives and “irregular” doctors were not. “They could say, midwives know nothing about science, but I do, and I even have this physical specimen in my office to prove it,” Withycombe told us.70 Most people would not have considered the products of miscarriage to be a child, and the fetal remains would have been collected from hospitals.
Meanwhile, women would still be relying on “misses” to keep their families smaller. Withycombe studied the personal letters and diaries of women of this era, which did not reveal any trace of the guilt or shame associated with modern miscarriage. Instead, her subjects expressed a variety of emotions—relief, grief, frustration, and even happiness. Interestingly, at a time when women were told their sole duty in life was to have children, “when that enterprise failed in the form of miscarriage, no one blamed the woman, least of all herself.”71 Those, she wrote, are twentieth-century notions.
Contraceptive use became much more commonplace in the nineteenth century. Literacy rates skyrocketed to up to 90 percent by 1850 among American-born white people, and advances in printing and transportation meant there was a proliferation of reading material available, including health manuals.72 The upshot? People could read about sex and contraceptives without having to rely on family and friends to give them the scoop. (A scoop that was harder to obtain for women, particularly at a time of such relentless decorum. Your dowager aunt was unlikely to hand you a diaphragm.) Also, advertisements for contraception and abortion-inducing services were widely published in newspapers, magazines, and mail-order catalogs, often under “female complaint” and “feminine hygiene,” among many other euphemisms. There was a veritable smorgasbord of devices to try—diaphragms, condoms, douches, and abortifacients among them—which although available through doctors and pharmacists primarily became a mail-order business to allow for anonymity.73 None of these methods would be considered reliable by today’s standards, but even a rate of 50 percent was significant at the time.74 These, combined with traditional abortifacients, miscarriages, and traditional child spacing would, taken together, keep the number of pregnancies down. “It doesn’t have to be super reliable to change from having a family of seven kids to a family of four,” historian Freidenfelds told us.75
There was also a lot of easily accessible, legal abortion. (Most people still believed that pregnancy wasn’t official until quickening, so intervening before then wasn’t an issue.) If other methods failed, women could always turn to an instrument abortion, a D&C surgical procedure. And it was widely used, with an estimated one out of every five to six pregnancies being willfully terminated by the 1850s.76 (In the United States in 2020, one in five pregnancies ended in abortion, according to the Guttmacher Institute.77 Even though the nation’s population is now almost fourteen times larger—23.1 million in 1850 to 330 million in 2020—the average rate did not change.) By the mid-nineteenth century, abortion was a business.78 Middle- and upper-class women would have been able to get surgical abortions at home through their family doctor,79 with whom they already had a relationship (and whose livelihood depended on doing what they asked). Women in major cities would have been able to find abortion practitioners through word of mouth or ads in pamphlets and newspapers.80 Immigrant and working-class women were more likely to go to midwives, who charged about half as much as doctors for both birth and abortion.81 In addition to perennial reasons for not starting a family—personal finances, relationship status, etc.—it was certainly part of the calculation that pregnancy and childbirth could be more dangerous than having an abortion given the high maternal mortality at the time.
This permissiveness didn’t last long. Starting in 1857, just nine years after its founding, the American Medical Association moved to prohibit abortion with a campaign led by Dr. Horatio R. Storer, who was against both abortion and contraceptives with near equal zeal. Doctors were by far the most vocal antiabortion activists in the nineteenth century, and historians ascribe different motivations. Some say it was to consolidate professional power and push out competitors, mostly homeopaths and midwives, who had helped women with both childbirth and abortions for centuries. But there’s no question that Storer and many other activists against abortion and contraception were also anti-feminist. (Storer blamed newfangled ideas about women’s rights for the increase in abortions and equated a childless marriage to legalized prostitution.82) It’s also likely that restricting contraception and abortion was about limiting “the means by which women could avoid childbearing and domesticity.”83 An opinion of the American Medical Association’s Committee on Criminal Abortion in 1871 read, “she overlooks the duties imposed upon her by the marriage contract.”84 (Pretty unambiguous.)
In Susan Faludi’s groundbreaking feminist work Backlash: The Undeclared War against American Women, she argued that the antiabortion campaign was a backlash to the first women’s convention in Seneca Falls a decade earlier in 1848. The convention brought together women who were fighting for suffrage, temperance, abolition, and “voluntary motherhood”—they wanted the right to occasionally refuse sex with their husbands. “Perhaps it is inevitable that even the most modest efforts by women to control their fertility spark a firestorm of opposition,” Faludi wrote. “All of women’s aspirations—whether for education, work, or any form of self-determination—ultimately rest on their ability to decide whether and when to bear children.”85
Critics were also concerned that births among white, nonimmigrant women were demonstrably declining at a time when immigration was exploding. In other words, one of the major objections was about who was having abortions more than the abortion issue itself. Nativist white men didn’t want to lose political, economic, and cultural power to European and Catholic immigrants, let alone people with brown skin. Storer asked white Protestant women of the expanding western territories, “Shall [these regions] be filled by our own children or by those of aliens? This is a question our women must answer; upon their loins depends the future destiny of the nation.”86 (Any mention of the word “loins”—in particular what depends on them—doesn’t portend anything good for women.)
And this, maybe, is the most American lesson: abortion “has always been a contest not only over women’s reproduction, but also over the reproduction of political power—because in a (putatively) representative democracy, power is a function of population.” The latter-day assault on abortion is similar: “the wider move to reclaim the ‘commanding place’ in society for a small minority of patriarchal white men.”87
Restrictions started to proliferate. When abortion had been readily accessible, between 1821 and 1841, there were laws in ten states that outlawed abortion, but not until after quickening, which was consistent with earlier regulations.88 These early laws were really more about protecting women from poisonous abortifacients rather than instrument abortions, because “quack” medicines had unlisted and unregulated ingredients.89 (This was the era of snake oil, after all.) But between 1860 and 1880, quickening was eliminated as an underpinning of legality, and abortion became prohibited at any point in pregnancy. This was a complete departure from how abortion had been regulated since the first Puritan settlements. “Almost all states got rid of quickening and changed it to say ‘from the moment of conception,’” Withycombe told us. “It lost its legal power as well as something that marks a definitive pregnancy.”90
It’s hard to overstate how different this would have been from any previous understanding of pregnancy. Doctors had started to insist that conception made the baby “real,” not quickening. Many of these doctors were also religious and talked about “ensoulment” as conception rather than quickening, Freidenfelds noted.91 “They insist there is no scientific difference between conception and birth that quickening would signify. It’s just the woman’s experience, and that doesn’t count,” Freidenfelds told us.92 As body historian Barbara Duden wrote, “without her own witness, no woman was definitely pregnant. For at least two thousand years, the annunciation of quickening took place in her own secret parts.”93 That secret was no longer of any consequence. Doctors, irritated that women continued to believe in quickening, took pains to dismiss it as meaningless folk medicine in lecture circuits, in journals, and to their patients.94
By 1900, every state had passed a law forbidding the use of drugs or instruments to procure abortion at any stage of pregnancy unless it was to save the woman’s life. Whether she qualified as being in mortal peril was determined, of course, by a doctor. (And now, in many states, by a doctor in consultation with a lawyer to avoid punishments for making the wrong call.) As historian James C. Mohr wrote, in a span of about twenty years, the United States shifted from a country with no abortion laws to one that almost entirely prohibited it.95
Why was this so successful, so swiftly? In large part because the nineteenth century, particularly the latter half of the century, had produced the fastest, most dramatic changes to American life that had taken place up to that point. The nation went from agrarian to industrial; the Civil War literally tore the country in two; slaves had been freed, and the Jim Crow backlash moved to contain that newfound freedom; the railroad pushed settlement farther into the United States but also pulled families apart as it became easier to move; nearly twelve million immigrants arrived between 1870 and 1900, the largest influx to date; medicine was establishing itself as a “science” that could (possibly) keep death and illness at bay; and women had obtained a slight modicum of reproductive freedom and were trying for more—including temperance and suffrage. Immigration and industrialization weren’t going to be reversed, but those in charge were rattled and doing their best to halt changes that threatened their dominance. One way to do that was to assert their sole control over women’s reproduction, which included limiting abortion unless they deemed it necessary. Now that upper-class Anglo doctor was in charge of who could end a pregnancy. He commodified doctoring, pushed out the competition, outlawed most abortion, and then made himself the decider on who was worthy of one. A momentous half century for a guy worried he was being crowded out by immigrant masses and ladies with pesky rights.
By the late nineteenth century, the American Medical Association started categorizing pregnancy and childbirth as medical conditions to be managed and controlled by doctors.96 Philosopher Iris Marion Young wrote, “once women’s reproductive processes came within the domain of medicine, they were defined as diseases… Being female itself was symptomatic of disease.”97 Similarly, by the 1880s, doctors began describing miscarriages as “serious and risky,” a change from natural miss to pathology.98 Rather than waiting for miscarriages to pass, doctors started “clearing out the uterus” by using a finger, metal instruments, and sometimes spoons, which by 1899 were commodified in medical instrument catalogs as curettes.
Which demon was left to slay? Contraception. How we view pregnancy loss today has a lot to do with contraception—the ability many of us have to choose not to be pregnant. The man who went after this with messianic zeal was postal inspector and anti-vice crusader Anthony Comstock, who was lampooned in his day as a “mutton-chopped buffoon.”99 (Buffoonery is still a ticket to rule in postmillennial America. Mutton chops optional.) His dislikes included pornography, urbanism, abortion, masturbation, gambling, prostitution, and “anything that created impure thoughts in otherwise innocent minds.”100 (Wouldn’t want to ruin a promising young man’s future, after all.) His backers included the richest and most powerful families in New York City, who encouraged his dogged efforts in lobbying Congress to pass anti-obscenity legislation. The Comstock Act passed in 1873, a sweeping law that included abortion and birth control, making it illegal to send contraceptives—or information about them—by mail.101 (Sound familiar? We’re still here. Various lawsuits that invoke the Comstock laws threaten access to abortion medication mifepristone by mail.)102 Some states went beyond the federal regulations, punishing both the recipient and the senders with prison and steep fines.103
The Comstock laws were mitigated by some court decisions in the 1930s but not overturned until a series of Supreme Court decisions in the 1960s and ’70s. After couples finally had access to semi-reliable contraception, it disappeared again for nearly one hundred years.
The rhythms of reproduction that had marked birth for centuries were upended by the late nineteenth century. Women lost their authority as both the pregnant person and the one attending a delivery, and a new era of restriction overseen by the ruling class was instated and would remain mostly unchanged until the 1960s. As we’ll see in the next chapter, these changes influenced not just care but also the notions of motherhood that have implications today.