1 - In the Hands of Physicians

Summary

Chapter 1 explores the gradual introduction of family planning to Cuban women, highlighting the Revolution’s centralization of state authority as well as its rejection of medical plurality. The chapter argues that medical leadership implemented policies that ultimately increased state control over women’s labor and reproductive decisions. Early public health models failed to include access to abortion and helped fuel rumors that the government had criminalized the procedures. But revolutionary leadership never responded to these popular rumors and instead emphasized the benefits of hospital births and the ideological dangers of birth control; evidence suggests that poor Afro-Cuban women and rural women were specific targets of this effort to regulate reproduction. By 1965, following an unexpected baby boom, the Ministry of Public Health began to provide women with some contraceptive options. But reproductive autonomy was not the goal of these reforms, and Cuban women’s persistent reliance on unauthorized abortions to regulate reproduction reveals that state health programs were not meeting the needs of all its citizens. The chapter shows that it was only after 1971 that both contraceptives and abortions became more available to Cuban women, reflecting a shift to bring the ideology more in line with that advanced by the Soviets.

In the late 1980s, thirty years after the Revolution had come to power, Cuban obstetrician Celestino Álvarez Lajonchere recalled the government’s early efforts to improve maternal health. In an article for the International Journal of Gynecology & Obstetrics, he wrote that the revolutionary government’s goals were “to reduce home births and the dependence on traditional birth attendants (recogedoras).” To accomplish these goals, it established “a Statistical Department … to train staff located in the relevant areas of each hospital unit … to obtain on-going, comprehensive vital statistics.”¹ Lajonchere’s unembellished account of the implementation of maternal health programs belies the expansiveness of the projects to which he alluded. Indeed, the government’s creation of maternity homes (hogares maternos) for pregnant women and the placement of physicians in rural areas (campo) occurred in the context of broader public health reforms implemented by the Revolution. As for the collection of patient data, that too corresponded with larger efforts to count and categorize – through censuses and birth records – both the bodies and the behavior of Cuban citizens.

Targeted processes such as these highlight the Revolution’s centralization of medical and state authority as well as its rejection of medical plurality, including the expertise of midwives, Santería priests (santeros), and others. While the introduction of community-based primary care was unquestionably beneficial to the Cuban population as a whole – particularly for the many Cubans without adequate medical care prior to 1959 – this paternalistic approach to public health was not entirely positive. By prioritizing the community over the individual, the new approach allowed physicians to serve as the official arbiters of women’s reproductive health. As philosopher Michel Foucault has emphasized, medicalization is a political process that broadens medical discourse and surveillance over citizens’ bodies – particularly, in this case, over women’s bodies.² We see this exemplified in revolutionary Cuba, where government claims to women’s reproductive practices came in the form of physicians and other health professionals. Indeed, “from the collectivist perspective of the Cuban revolution,” write sociologist Lois Smith and historian Alfred Padula, “it was the rightful business of the community to monitor the activities of pregnant women.”³ In subsequent chapters, we see how restrictions on women’s labor autonomy assumed the form of state wedding ceremonies, reeducation centers for female prostitutes, and work camps for men living from women’s salaries.

The Revolution’s early emphasis on women’s collective well-being overlooked abortion access and left in place the 1936 Social Defense Code, which first made the procedures illegal; in this process, it neglected to account for Cuban women’s historical reliance on abortions to control reproduction. Throughout the 1960s, state public health experts sought to balance the Revolution’s resistance to abortion and contraceptives with the country’s skyrocketing birth rate and abortion-induced mortality rate. Indeed, the rate of births increased by 35 percent between 1958 and 1964, seemingly at a greater rate for black and mulata women than white women.⁴ The new government afforded medical assistance to rural Cubans a little more than one month after taking power; health care for mothers and children was a much-lauded component of the National Health System (Sistema Nacional de Salud) – established initially to oversee the provision of medical care to rural residents. Strikingly, these early public health models failed to include access to abortion, fueling rumors – as early as 1961 – that the new government had criminalized the procedures. Perhaps surprisingly, revolutionary leadership never responded to these popular rumors and chose instead to emphasize the benefits of hospital births and the ideological dangers of birth control. This chapter takes inspiration from the pioneering study of reproduction in post-Soviet Cuba by anthropologist Elise Andaya, who observes: “[Early] policy approaches to women’s reproductive freedom were thus frequently marked by confusion and contradiction.”⁵ By 1965, the MINSAP began to provide women with some medical options for controlling reproduction: adopting an alternative interpretation of the anti-abortion law and introducing a simple IUD (anillo) of Chilean origin. But the impact of these changes was limited, as the MINSAP made no public announcement about the improved availability of this technology, and confusion about accessibility continued through the late 1960s.

This chapter explores the gradual introduction of medicalized family planning to revolutionary Cuba. It begins by comparing the differing abortion services for women in rural and urban areas and continues by analyzing the class-dependent abortion experiences of Cuban women and US travelers in prerevolutionary Havana. It subsequently documents the Revolution’s early use of physicians as government representatives and reproductive health experts. While the MINSAP’s perspective on both abortions and contraceptives evolved throughout the 1960s, it retained its paternalistic approach to maternal and reproductive health and its disregard for non-biomedical health practices. This focus was initially on the campo, as revolutionary leadership sought to export the prosperity and practices of urban Cubans to rural campesinos. Yet amidst this health care reform, women’s continued reliance on unauthorized abortions to regulate reproduction reveals that – at least through 1971 – state health programs were not meeting the needs of all its citizens, particularly those the Revolution most claimed to support. Rather, medical leadership presumed to know what was best for women, foregoing or implementing policy that ultimately increased state control over women’s bodies and their reproductive decisions. Poor and working-class black and mulata women seem to have been specific targets of this regulation, as it appears that they were the recipients of the country’s first anillos. These women may have also faced extra pressure to abandon the use of abortions for reproductive control. Additionally, most maternity homes were located in the predominantly Afro-Cuban province of Oriente. Beginning in 1966, Fidel Castro argued that the only response needed to the baby boom of 1963–1964 was increased agricultural labor by adolescents and adults, whose labor would sustain the new generation of children. Indeed, Fidel’s argument for increased economic productivity was a direct response to, among other things, the country’s increase in population. Because of the persistence of this discourse, it was impossible for leadership to disassociate contraceptives from the ideology of capitalism. It was only after 1971, when Cuba became more economically dependent on the Soviet Union, that both contraceptives and abortions became more available, reflecting a shift to seemingly bring the discourse more in line with that of the Soviets.

Degrees of Abortion Access and the Influence of Male Physicians, 1938–1958

The Freedom and Danger of Prerevolutionary Abortions

From the late eighteenth century until 1979, most abortions performed in Cuba were illegal, yet tolerated. The Penal Code of 1870, instituted under Spanish colonial rule, classified abortions as criminal acts. Only abortions carried out under special circumstances were permitted, such as those necessary for the health of the woman.⁶ Following Cuban independence in 1898, most abortions remained illegal, and the republican state ratified their illegality in the 1936 Social Defense Code (Código de Defensa Social). But this Code also permitted abortions under very specific circumstances: when a pregnancy threatened the health of the woman, was provoked by rape, or would result in fetal impairment.⁷ Of course, with regard to the first condition, the law did not specify the exact criteria to be used in determining whether a pregnancy was hazardous to a woman’s health. This loophole meant that if two physicians agreed that a woman’s health was at risk, they could legally authorize an abortion.⁸

At least through 1958, doctors performing abortions operated largely without fear of punishment. According to sociologist Paula E. Hollerbach, people rarely accused physicians of abortion malpractice and the Ministry of Health and Social Welfare only investigated when they learned of the death of a patient. The Social Defense Code did indicate that in such cases, the abortion provider, patient, and anyone deemed an accomplice could all risk sentences of up to twelve years in jail, if convicted.⁹ Hollerbach notes that because so many individuals – including family members – could be held accountable for the abortion, citizens rarely filed charges. At the same time, the Ministry of Health and Social Welfare had no accepted criteria regarding the prosecution of abortions.¹⁰ Celestino Álvarez Lajonchere, who served as National Director of Obstetrics and Gynecology for the MINSAP, beginning in 1962, recalled that at the age of six (in 1923), “I already knew, living in a small Escambray town [in Las Villas province], that there was an abortion clinic in Cienfuegos … Those who performed them in clinics [also] performed them in their homes. It was private, not clandestine, because everyone knew, but it was not legal.”¹¹

In this context, abortions were available to a large part of the population, and these procedures were often carried out by physicians and midwives (recogedoras). Monika Krause, who later served as Cuba’s first sex educator in the 1970s, recalled that for many Cuban women, “abortions became a tradition.”¹² Indeed, when it came to regulating their reproduction, women relied almost exclusively on these procedures – prioritizing abortions over any other family planning method. Of course, rural residents did not have the same access to physicians as their urban counterparts. In the 1950s, the doctor-to-patient ratio in Havana was 1–227; while in rural Oriente province, it was only 1–2,423. Given these ratios, rural women were probably more likely to rely on female herbalists, healers, midwives, and religious practitioners than on doctors to assist them with terminating their pregnancies. In 1937, obstetrician José Chelala Aguilera insisted that these non-physician providers amounted to an unregulated abortion “industry” that was virtually ignored by the republican government.¹³ Lack of regulation allowed more practitioners to operate, thereby increasing the accessibility of abortions; but it also afforded patients little protection from disreputable or careless abortion providers. Separate abortion services emerged for people of different regions, paralleling class-differentiated abortion practices in nearby Puerto Rico, where midwives charged less and catered to the poor, while doctors performed abortions on the affluent, including foreign women, for a higher price.¹⁴

In Cuba, the differentiator was more geographic than class-based, as urban residents of all classes had relatively easy access to physician-induced abortions, including second-trimester procedures. Rural women, by contrast, relied on midwives. For example, when Mona Flores, who was interviewed by US anthropologist Oscar Lewis’s team of researchers, became pregnant in the late 1950s, she and her partner traveled to a local Havana cigar factory, where the physician on staff was known to perform abortions. He agreed to terminate her pregnancy and induced the abortion by injecting a shot of crude liver extract into Mona’s uterus.¹⁵ A type of instillation abortion, named because it involves introducing a solution into the uterus, this procedure would typically have been followed by one to two days of labor.¹⁶ In another example, Pilar López Gonázales, a former prostitute profiled by Oscar and Ruth Lewis, also became pregnant at this time and elected to terminate the pregnancy. Pilar stood in line with twenty other women at a Havana doctor’s office. The physician gave her a saline abortion, another type of instillation abortion, and Pilar aborted four days later. Pilar was alone when she expelled the fetus, and although she decided that abortion was “very wrong,” Pilar continued to use abortion as a form of birth control into the 1960s. Throughout 1958, as she performed prostitution, she became pregnant every two to three months. Each time this occurred, she went to the same doctors and terminated the pregnancy using this instillation method.¹⁷ While Pilar and others certainly benefited from easy access to abortions, the instillation abortions they received, particularly those induced by saline, were dangerous and could result in cardiovascular collapse, kidney failure, or swelling in the brain.¹⁸

The types of abortions women obtained and the types of people who performed the procedures were dependent on social status and place of residence. As Lois M. Smith and Alfred Padula write, “Medical care was largely an urban phenomenon.”¹⁹ In the 1930s, for example, more than 50 percent of hospital beds and nearly half of doctors were located in Havana. Private clinics and physicians served the medical needs of the country’s affluent citizens, whereas mutual assistance societies provided medical care – paid for via prepaid health plans – to members of ethnic societies and labor unions. These two sectors overlapped somewhat, as in the 1920s, when private clinics began offering insurance plans to attract patients. But both these institutions, private clinics and mutual assistance societies, were almost exclusively restricted to Havana, as the latter existed in only a few provincial capitals.²⁰ People with limited resources relied on state hospitals and relief houses (casas de socorro) to provide free emergency care. For example, the Havana Casa de Beneficencia y Maternidad, in operation until 1963, served as both maternity hospital and orphanage. This tiered system of health care, however, meant little to people in the countryside (campesinos), who competed with Havana residents for physicians and hospitals beds.²¹

Because of the deficit of physicians, it seems that poor and rural women were more likely to rely on holistic methods to end unwanted pregnancies. Knowledge of abortifacients was passed down by word of mouth, from generation to generation, and it often originated with indigenous and enslaved women – those least likely to have institutional assistance. One example comes from the memoir of María de los Reyes Castillo Bueno – known as Reyita – who describes the abortion methods used by her grandmother, who had been a slave until the abolition of slavery in 1886. While not always successful, Grandma Tatica sought to end pregnancy by ingesting a decoction of herbs and roots.²² These same methods would continue to be employed by both rural and urban Cuban women into the twentieth century. In 1951, Pilar López’s Afro-Cuban mother sought to provoke a miscarriage by using non-medicinal methods. Pilar later related that her mother would do anything to end the pregnancy; she boiled cinnamon water, ingested senna leaves, and even inserted a stick of soap into her uterus. Pilar’s mother employed these methods multiple times and was often successful, but the complications that followed – including vomiting, hemorrhaging, and uncontrolled bleeding – made self-reliance a dangerous enterprise. The similarity between the stories of these two women illustrates the continued importance of oral traditions and herbal remedies to the reproductive autonomy of women of color in particular.²³

At the same time, citizens of all classes and backgrounds relied on religious healers to complement or substitute for biomedicine. Santeros, Spiritists, priests, and brujos all had a long history of popularity. As one interviewee told anthropologist Diana Espírito Santo, “[I]n crisis (‘cuando el zapato aprieta’), everyone believes, including an old atheist Marxist uncle … who pledged his devotion to the spirits and saints after his cancer was cured.” Comprised of many variants, espiritismo relied and still relies on mediums to channel the dead – who in turn oversee the safety of believers.²⁴ Santería, a syncretic religion based on West African beliefs and informed by Roman Catholicism, has long been practiced by the urban poor, particularly Afro-Cubans. Even Fidel was rumored to have sought guidance from orishas (deities) and padrinos (spiritual advisors) when confronted with physical and spiritual imbalances.²⁵ The influence of these spiritual practitioners frustrated physicians, who viewed them as threats to women’s health and to doctors’ own monopoly over medicine.

US Women in the “Abortion Capital of the Western Hemisphere”

Meanwhile, the restrictive abortion laws of the United States led US women with means to obtain abortions in Cuba. According to historian Leslie J. Reagan, McCarthy-era politicians associated abortion with communism and categorized it as political deviance. At the same time, some Cubans came to associate the same procedures with capitalism, revealing the link between ideological difference and sexual deviance. Throughout the 1940s and 1950s, many US states aggressively suppressed abortion, targeting both female patients and abortion providers. In prior decades, police officers and state prosecutors had pursued abortion providers only following the death of a patient. But by 1940, skilled and trusted abortion providers also faced charges, and the US government could force patients to testify against them. Hospital administrators also imposed greater limitations on therapeutic abortions, further constraining women’s ability to terminate their pregnancies. By the 1950s, obtaining an abortion in the United States was risky and potentially traumatic, and yet women demanded them in greater numbers.²⁶ Women’s growing social independence and the continued illegality of contraceptives in many states led more and more women to seek abortion, and the prevalence of police raids and public trials incentivized affluent – predominantly white – US women to terminate their pregnancies abroad.²⁷

US women who could afford to end their pregnancies abroad relied on US physicians or specialized travel agents to facilitate trips to Havana. For example, Michael Freiman, an obstetrician-gynecologist from Missouri, noted that he maintained a list of reputable Cuban abortion providers to whom he could refer his patients.²⁸ In 1958, a US doctor referred a Saks Fifth Avenue salesclerk named Julia to a Havana gynecologist for the procedure. Another US contact also provided Julia with transportation information, including the name of a local taxi driver.²⁹ Meanwhile, US entrepreneurs willing to risk jail time served as specialized travel experts for these travelers. They established contacts with Havana doctors and offered weekend “vacation” packages to women who wished to terminate their pregnancies. Many of these individuals were based in New York, Los Angeles, and Miami. For $1,200, they provided women with an all-inclusive package: first-class round-trip ticket to Cuba, hotel accommodations, and an abortion procedure at a private clinic. The customer could arrive in Havana on Friday afternoon, have an abortion on Saturday, and return to the United States on Sunday.³⁰ Given this infrastructure for foreign travelers, it is not surprising that mobster Meyer Lansky’s biographer referred to prerevolutionary Havana as the “abortion capital of the Western Hemisphere.”³¹

Since US tourism to Cuba surged following the US constitutional prohibition against alcohol in 1920, hedonism and imperialism seemed to merge in the culture and economy that arose to serve both. Because abortion services formed part of the larger business of Cuban tourism, increasing numbers of Cubans came to conflate abortions with prostitution, gambling, and illicit drug use.

Anecdotal evidence suggests that the conditions and types of abortions American women had in Cuba were safer than those experienced by poor and working-class Cuban women. US women remember paying between $250 and $600 for the procedure, a price that often gave them access to anesthesia, hygienic surgery conditions, and D&C (dilation and curettage) or D&E (dilation and evacuation) abortions – rather than the less-safe instillation abortions that poor working Cuban women appear to have typically received.³² The two former types of abortions were safer than the latter because they involved surgical removal of the uterine tissue and usually took less time and resulted in fewer complications than the instillation procedure. D&Cs also had a death-to-case rate half that of instillation abortions.³³ In addition to receiving the safer D&C and D&E procedures, the latter performed during the second trimester, American women seem to have typically received anesthesia – which was not true for poor working-class Cuban women.

According to Lajonchere, physicians rarely administered sodium pentothal before terminating a pregnancy. He recalled that Cuban doctors’ rationale was that, if the procedure were not uncomfortable, abortion rates would increase. Doctors wanted the “woman to be so terrified that she wouldn’t get pregnant again.”³⁴ While affluent Cuban women and foreigners could pay the modern-day equivalent of thousands of dollars for surgical procedures that included sedatives, poor working-class Cuban women paid little for what appears to have usually been instillation abortions. The loss of business from this latter clientele would have no great loss to physicians, who were less incentivized to provide these women with anesthesia.³⁵ This disparate treatment by Cuban medical professionals highlights how medical authorities privileged the money and influence of affluent women and used their power to impose on poor working women their personal beliefs regarding reproductive control.

Fertility Decline and Male Authorities’ Opposition to Women’s Reproductive Autonomy

As early as the 1930s, some Cuban physicians expressed worry about the prevalence of clandestine abortions. Most notably, Chelala asserted that outlawing abortions did little to stop them. He suggested instead that the health of the family would improve if the government legalized the procedures, prioritized birth control, and provided health services – specifically to poor women.³⁶ But not all physicians agreed with Chelala, and government officials ignored his requests. In 1957, Chelala declared, “We physicians have to fight to extend the reach of the Social Assistance Services in Cuba … Our leaders, in their blindness, have not paid any attention to it.”³⁷ Dr. Vicente Banet, professor of surgery at the University of Havana School of Medicine, disagreed, arguing that a pregnant woman with no financial support should still give birth, “because no matter her sufferings, they will never compare with the regret of having assassinated [her child].” Professor and physician Armando Ruíz Leiro also believed that abortions should never be allowed, even in the case of rape.³⁸ The resistance of these and other (male) physicians to providing safe access to abortions highlights their disconnect from the lives of the Cuban women who risked death to terminate unwanted pregnancies. At the same time, the belief – as expressed by Dr. José Ramírez-Olivella – that the “intransigence of the family” and the “indolent complacency of the State” pushed women toward abortions reveals that some in the medical community were in support of greater oversight from the republican government.³⁹

Other physicians promoted instead the Ogino-Knaus (rhythm) method of birth control. Their exclusive support for this system replicated the rhetoric of the Catholic Church. Indeed, Cuban archbishop Enrique Pérez Serantes approved of only one form of birth control: the rhythm method. Conceived of in the 1920s by Austrian Hermann Knaus and later by Japanese Kyusaku Ogino, the practice involves abstaining from intercourse in the period 12–16 days before menses. Cuban gynecologist (and Catholic) Luis Valdés Larralde reported that the sole birth control that he recommended to his patients was the Ogino-Knaus system, as it was “the most natural” and “healthiest for both partners.”⁴⁰ While Valdés Larralde did not doubt the effectiveness of this practice, Archbishop Pérez Serantes at least recognized that it was not always easy for women to predict ovulation; he lamented in 1964 that there did not exist a more morally acceptable system for preventing reproduction. He associated the use of contraceptive technology with lapsed or less-developed Catholic families, specifically those who were white and living in urban areas. This same urban demographic also had the easiest access to physician-assisted abortions.⁴¹

Despite the Archbishop’s concerns over their morality, medical contraceptives remained in (limited) use in Cuba until the second half of the 1960s and even later. Prior to this date, IUDs were rudimentary and occasionally injurious. Per Chelala, Cuban doctors opposed the use of these early, metallic instruments. Instead, women sometimes relied on alum or Coca-Cola douches, vaginal sponges, and, less frequently, cervical buttons – pills inserted into the cervical opening each time a woman wished to have intercourse with a man. Slightly more common were diaphragms and rubber condoms.⁴² While condoms were one of the (relatively) more popular forms of birth control, Chelala and others noted that men often refused to use them.⁴³ When Flora Santander married her husband Humberto in 1960, she accompanied him to a local pharmacy, where Humberto introduced her to the cervical pill. When I asked Flora about her decision to use this particular method, she quipped, “Men don’t like to use condoms.” Humberto was not alone in this, as Cuban men have traditionally opposed condom use. Féliz Ríos, for example, recalled that he did not use a condom (or any other form of protection) when having sex – even into the 1970s.⁴⁴ Indeed, male partners’ resistance to condoms and male physicians’ opposition to legal abortions created a climate in which women had few options beyond unregulated abortions with which to control reproduction.⁴⁵

When discussing prerevolutionary abortion culture, Celestino Álvarez Lajonchere admitted to historian Elizabeth Fee, “There was no habit in the country of using contraceptives, and contraception did not even appear in the medical school curriculum.” He added, “The private physicians at that time didn’t give contraceptive services to their patients because they could charge much more doing abortions. They preferred that their patients get pregnant and then [they could] do the abortions rather than give [the women] contraceptives.”⁴⁶ One of Oscar and Ruth Lewis’ informants, Sara Rojas, confirmed that the men and women in her rural Oriente town likewise possessed little knowledge of contraception. Sara noted that while her husband knew about birth control, she was too embarrassed to ask him for details so that she too could learn. She reflected that he possibly purposely withheld this information from her, restricting information that would have allowed Sara more control over the regulation of her reproduction. Sara’s observation illustrates a way in which knowledge about contraception might be a powerful tool within a relationship and how men’s opposition to condoms, for example, could narrow women’s options for reproductive control. Because she did not know how to limit fertility, Sara continued to have “one pregnancy after another.”⁴⁷

Sara’s multiple births were not reflective of the national trend, as the Cuban birth rate was in decline from 1919 until 1959. This trend began in the years following the 1919 census, when nearly 50 children were born for every 1,000 people. By 1958, the number had decreased by 42 percent, to 27 per 1,000.⁴⁸ Women in their twenties experienced the largest reduction in fertility. This decline was not restricted to urban areas, where abortions and birth control devices were more available; rather, the predominantly rural provinces of Pinar del Río and Oriente also saw declining fertility throughout the first half of the twentieth century. Social scientists Sergio Díaz-Briquets and Lisandro Pérez suggest that some sort of family planning must have been practiced in rural areas, as the provincial birth rates “were well below what would be expected in the absence of deliberate birth control practice by couples.”⁴⁹ Indeed, the widespread availability of surgical abortions in urban areas, combined with the accessibility of recogedoras, healers, and holistic abortifacients – particularly in the campo – likely allowed Cuban women some control over the size of their families.

In addition to the use of natural abortifacients and surgical abortions, birth rates during the first half of the twentieth century likely decreased due to socio-political factors. As an example, the decrease may have simply been a return to “normal” subsequent to the surge in the crude birth rate, one that peaked in 1919, in the decades following the Cuban wars of independence.⁵⁰ It was only after 1943 that the crude birth rate dropped back to the number recorded in 1899: just over 32 births per 1,000 people.⁵¹ Historian Jorge Ibarra posits that the low crude birth rate responded to an increase in the standard of living generated from expanded sugar production (until the 1930s).⁵² Ibarra’s conclusion presumes an inverse relationship between the birth rate and the standard of living, whereby births decrease as the quality of life improves. Another possible reason for this early decline in the crude birth rate is the influx of male immigrants from Spain, China, and elsewhere in the Caribbean, which would have increased the number of people in Cuba, but not necessarily the number of births – skewing the crude birth rate and showing a decline.⁵³

While the Cuban census did not include racial information for the years 1953 and 1970, and information can only be inferred by examining prior and subsequent years, historian Alejandro de la Fuente suggests that the depressed birth rate, at least until 1953, was actually a white phenomenon. Between 1919 and 1931, he shows, the ratio of children born to black or mulata women aged 15–44 years old “remained more or less stationary” – even “increasing moderately during the post-Depression period, from 1931 to 1953.”⁵⁴ This is in contrast to the ratio of children born to Hispanic white women, which was in decline after 1919. Additionally, from the 1930s until the 1970s, blacks and mulatos seem to have had higher fertility rates than whites. At the same time, because Afro-Cuban children had higher mortality rates than white children, the ratio of children per woman decreased once surviving children were factored into the equation – although the ratio still remained highest among Afro-Cuban women.⁵⁵ This had changed by 1962, when de la Fuente observes that the mortality rate of blacks, mulatos, and whites began to equalize, even as higher fertility rates continued to prevail for black and mulata women.⁵⁶ We see in this analysis how – despite facing higher mortality rates – Afro-Cuban women successfully navigated structural limitations to reproducing families under republican governments. At the same time, if decreased mortality rates are an indication of improved quality of life, health inequalities appear to have decreased under the Revolution. But as we will see, access to health care did not necessarily correspond with increased agency for black and mulata women, who seem to have encountered more restrictions than white women to their reproductive autonomy after 1958.

Discursive Silence about Abortions, Ideological Opposition to Contraceptives, and Improved Maternal Health Care, 1959–1964

Replacing Midwives with Maternity Homes

One of the early projects initiated by the Revolution was the introduction of health services to the countryside, where pregnant women soon fell under the watchful eye of the state. Finding inspiration in the medical assistance previously provided by the M-26-7 to the peasants of the Sierra Maestra, the new government created in February 1959 the Department of Technical, Material and Cultural Assistance to Peasants (Departamento de Asistencia Técnica, Material y Cultural al Campesinado), which operated under the purview of the Rebel Army.⁵⁷ This was followed in January 1960 by the more formalized Rural Medical Service (Servicio Médico Social Rural), which assigned over 300 voluntary physicians to “the most densely populated places [in the countryside], with the most difficult means of communication and of the most importance for economic production.”⁵⁸ Rural health care continued to expand during these early years, coinciding with government efforts to increase control of the campo, reinforce the authority of biomedicine, and nationalize private hospitals and clinics. While the Revolution had nationalized many private hospitals, pharmaceutical companies, and health clinics by 1961, historian Jennifer Lambe observes that private care for those with funds was available “well into the 1960s.”⁵⁹

Francisco Rojas Ochoa served in the Rural Health Service, and he writes that “one of the first educational tasks” assumed by rural physicians was to “offer to collaborate with the empirical midwives known as recogedoras.” The process he describes was a cooperative one, with midwives receiving instructions from doctors about how to “improve their work: like gloves and sterilized, umbilical dressings.” Once the recogedoras were trained, Rojas Ochoa explains, the Rural Medical Service incorporated the women into its ranks.⁶⁰ This process was similar to the midwifery training programs implemented in the late nineteenth and early twentieth century in Jamaica, Guyana, and Barbados, where “reputable,” local women received instruction from white, British women in order to replace the ostensibly dangerous, “untrained” midwives.⁶¹ The decision to educate and welcome recogedoras into the new public health sector was a strategic one that may have limited conflict with these local experts.

But anthropologist Sheila Cosminsky, historian Nora E. Jaffary, and others have shown that replacing midwives with physicians is never an easy task, a reality alluded to by Lajonchere, who noted that when “persuasion” was not effective at “converting birth attendants into allies,” health officials paid “a young relative of the traditional birth attendant as support staff in the local hospital.”⁶² In other words, professionals sought to cultivate the allegiance of a midwife’s family member once it became clear that the midwife would not easily relinquish her medical authority. If the process of transitioning midwives into more “appropriate” labor was at all similar to the campaign to reeducate prostitutes, the recogedoras likely encountered a mixture of persuasion and coercion from the physicians and other revolutionary representatives. According to a 1965 “census of midwives” carried out in “the mountainous areas of the eastern provinces,” it is clear that efforts to “eradicate” midwives did not immediately succeed – as the census found 1,100 recogedoras (most over the age of 60) still working in the region.⁶³ While elderly midwives of the Sierra Maestra appear to have still overseen deliveries – at least through mid-decade – their advancing age and the expansion of biomedicine would have soon diminished even more of their numbers.

Another element of medical development in the campo were maternity homes (hogares maternos), which seem to have been the Revolution’s alternative to abortions, particularly for Afro-Cuban women. Originating in Camagüey in 1962, these hogares were located in close proximity to hospitals. The homes initially housed campesina women in the final months of their pregnancies to prevent them from, among other things, traversing long distances while in labor. The Ministry of Public Health calculated that in 1958, less than 20 percent of births had taken place in hospitals.⁶⁴ With maternity homes, the MINSAP aimed to obviate the need for midwives and at-home births, inculcating women in “proper” childcare and hygiene habits and increasing the number of hospital births.⁶⁵ Greater oversight of pregnant, rural women would also result in less infant and maternal mortality, physicians hoped.⁶⁶ Of course, more hospital births ensured better compliance with laws requiring the inscription of all births in the Civil Registry, a project further examined in Chapter 2.

Judging by the geographical placement of future maternity homes, it seems a key priority in the regulation of rural maternity was the regulation of the bodies of black and mulata women. While a pilot home was first established in Camagüey, the two subsequent hogares were located in Oriente province (in the cities of Santiago and what seems to be Baracoa). By 1967, seven more maternity homes existed. But at the end of the decade, only one of the institutions was in the city of Havana.⁶⁷ In 1989, the number of maternity homes had increased to 150, and 67 percent of institutions were in the former province of Oriente – suggesting that the predominantly black population of eastern Cuba experienced the most maternal health intervention during the first 30 years of Revolution, a trend that likely contributed to the slightly higher fertility increase among black and mulata women during the 1960s.⁶⁸ At the same time, increased attention to the maternal bodies of Afro-Cuban women likely facilitated the easier detection and screening of their abortions. This focused medical gaze would have also given health authorities increased opportunities to oppose the holistic and spiritual practices linked to Afro-Cuban belief systems and other biomedical alternatives.

A 1964 news article about the country’s first hogar materno in Camagüey illustrates contemporary perspectives about the benefits women received from these state homes. After a visit to Casa Bonita (Pretty House), the former residence of “one of those unmemorable senators” who had departed Cuba, Bohemia magazine described the twenty to twenty-five women in residence as “young, trusting, [and] in search of an expert who will help them in their natural role of giving birth to a new human being.” Portrayed by Bohemia as homogenous in background, knowledge, and interests, the women were expected to live together and – with the help of a midwife (comadrona) – “destroy superstitions and unconfessed fears” through education. Following a schedule that included courses on birthing techniques and infant bathing, as well as time dedicated to writing their families and reading, the residents inevitably went into labor. At that time, the midwife on call would send for an ambulance to transport the women to the hospital.⁶⁹ Bohemia described the pregnant women at Casa Bonita as nearly blank slates onto which scientific behaviors must be written and old prejudices erased. The midwife, too, had a new role and name. Bohemia referred to her by the less-colloquial name of comadrona and specified that she was to prepare the women for childbirth, relinquishing her control over the soon-to-be mothers once the contractions began. In this way, it seems that hogares maternos also served as institutions to place retrained recogedoras, positioning them as pre-birth assistants to the physicians who took their place.

Missing from this and other narratives of early maternity homes is information about patient consent and when – if at all – women experienced coercion to reside in maternity homes. If identified by health practitioners as high-risk or too geographically distant from a hospital and therefore ideal candidates for admission to maternity homes, could pregnant women refuse to leave their homes? Could they reject state representatives’ recommendations? It is likely that the women referred to hogares maternos faced at least some pressure from revolutionary representatives to comply with doctors’ recommendations. For example, Lois M. Smith and Alfred Padula note that in 1971, men resistant to their pregnant partners’ placements in maternity homes received visits from members of the Federation of Cuban Women and the neighborhood watch group (CDR), who sought to convince the men of the institutions’ importance.⁷⁰ Additionally, some maternity homes began to expand the criteria for admission in the 1970s, write José A. Gutiérrez Muñiz – one-time Minister of Public Health – and Gregorio Delgado García, physician and lead historian at the MINSAP. The authors emphasize that health factors became potential conditions for admission, including asthma, preeclampsia, depression, and a prior history of caesarean delivery. Other conditions for admission were social factors such as a residence perceived to be overcrowded with family members.⁷¹ In a public health system that prioritized community well-being over individual autonomy, physicians presumed they knew better than their patients. When instituted by a government that conflated social and political nonconformity, reproductive health decisions could rarely be made in isolation. Of course, regulating birth was more difficult for women in the perceived absence of birth control.

Government Opposition and Changing Access to Contraceptives

In the early 1960s, Cubans began to lament that both contraceptives and abortions were in short supply, an assertion that is difficult to confirm but which certainly reflected a change in accessibility – if not in amount, then in type. As Jennifer Lambe has persuasively argued in the case of broader conversations about medical shortage in these early years, “The notion that formerly available drugs were suddenly ‘gone’ was, in some cases, an accurate factual claim. Yet it was also necessarily an ideological assessment: a measure of revolutionary failure, perhaps of US intransigence.”⁷² Just as perceptions of pharmaceutical scarcity often reflected resistance to Soviet generic drugs, which replaced US brand-name medications, so too could they illustrate Cuba’s supposed medical underdevelopment.⁷³ In the case of contraceptives, allegations of shortage may also have responded to perceptions that it would be ideologically contradictory for countries opposed to neo-Malthusianism to have birth control and that imports from socialist countries were insufficient replacements for US brand-name contraceptives.

In November 1961, seven months after Prime Minister Fidel Castro formally announced the Revolution’s embrace of socialism, Cuban economists publically rejected neo-Malthusianism and the notion that their country was overpopulated. Neo-Malthusians, or followers of Englishman Thomas Robert Malthus and his 1798 “Essay on the Principle of Population,” accepted the argument that unchecked population growth was dangerous. While Malthus believed that “moral restraint” or sexual abstinence was the solution to overpopulation, neo-Malthusians later campaigned for the universal adoption of contraceptives.⁷⁴ Unsurprisingly, Cubans and their Soviet allies openly rejected neo-Malthusian thought, asserting that under socialism, population growth was not a problem. This was because, as written by Cuban economists in November 1961: “The problem is not population increase … but is basically a question of increasing production using modern techniques and of seeking a more rational distribution of what is produced.”⁷⁵ In other words, the authors avowed that more equal distribution of goods and improved technology would alleviate the social origins of disease – like food insecurity and homelessness – which neo-Malthusians instead viewed as symptoms of overpopulation.

The economists built on discourse articulated by the M-26-7 in its 1956 economic thesis, which labeled Malthus a “pessimist” whose views could be discredited through economic development informed by science and justice.⁷⁶ As described in the Introduction to this book, Minister of Justice Alfredo Yabur proclaimed in 1961: “While anti-contraceptive methods are usually employed in capitalist society, even to the point of criminality, motherhood is encouraged in socialist society.”⁷⁷ His statement classified birth control as a capitalist practice and implied that Cuba had a pro-natalist policy. In truth, the new Cuban government did not officially encourage population growth. But it did, along with the Soviets, distance itself from the population control movement, which invested hundreds of millions of dollars to decrease birth rates in East Asia, the Middle East, and Latin America – ostensibly seeking to combat “overpopulation.”⁷⁸ As we will see, rejecting birth control as a solution to the perceived problem of overpopulation did not entail a wholesale rejection of contraceptive methods. However, it did result in the various Cuban ministries, particularly the MINSAP, exerting control over contraceptive distribution and the education process.

The Ministry of Foreign Relations (MINREX) seems to have requested contraceptives from Cuba’s new Eastern bloc trading partners as early as 1961. But the arrival of birth control devices was not always assured, as they were cost-prohibitive to import and it seems other products sometimes arrived in their place. Nor were Cuban physicians always satisfied with the products, as they doubted the technologies’ safety and effectiveness. Carlos Franqui, one-time member of the guerrilla underground and first director of the newspaper Revolución, remembered: “A new supply of mothers was more or less guaranteed [in 1961] when a shipment of socialist condoms never arrived.”⁷⁹ Maurice Zeitlin, then a US graduate student in sociology, observed: “One reason for Cuba’s population boom is a Czech shipment of 10,000 automobile gaskets instead of the contraceptive diaphragms ordered by the Cubans.”⁸⁰ Asking other socialist countries to supply the island with contraceptives would have been a creative strategy employed by the MINREX to replace “absent” US products with pharmaceuticals from countries less tainted by neo-Malthusianism.

Chinese suppliers also delivered prophylactics to Cuba in 1961, but Cubans sometimes declared them ineffective. Franqui recalled that some people claimed Chinese condoms “were too small.”⁸¹ A resident of Oriente province later informed Cuban-American journalist José Yglesias, “Chinese condoms were known as butterflies because they have a short life. If you have not done it for a couple of days, you can shoot right through them!” Norberto Fuentes, formerly a part of Fidel’s inner circle, suggests that the nickname came from the packaging, as the Chinese rubbers were imported in cartons that looked like American matchboxes and adorned with the image of a multi-colored butterfly. Of course, since Cubans use the term “butterfly” (mariposa) as slang for “gay,” homophobia – in addition to racism – would have discouraged condom usage.⁸² As historians Michelle Chase and Jennifer Lambe have both observed, Cubans’ resistance to using both Chinese and Soviet imports was also a reflection of their long reliance on and close relationship with US brand-name products, an extant loyalty that may have prompted some to declare that there were no contraceptives to be found in Cuba.⁸³

Female sterilization was ostensibly available as a more permanent method of contraception, but it was not always permitted or recommended by physicians.⁸⁴ It seems that women had to be over 30 years of age and have had at least three children in order to qualify for surgical sterilization. Lajonchere and his colleagues thought, “a woman younger than 32 years of age should not [permanently] suppress fertility until she already has many children.”⁸⁵ Of course, some women became sterile after using the cundeamor root to terminate their pregnancies. For this reason, obstetrician Armando Peralta cautioned women against using it as an abortifacient. At the same time, it does not appear that sterilization for men was considered in the 1960s, which would have been consistent with contemporary beliefs that identified family planning as the responsibility of women (when chaperoned by the state).⁸⁶

Claims of Abortion Scarcity and Making Sense of Government Silence

Authorities’ public and vocal distrust of contraceptives contrasted with their silence on the matter of abortion, even as rumors circulated that the government had quietly criminalized the procedure. Indeed, anecdotal evidence suggests that abortions, which had long been tolerated, were suddenly criminalized. Some US women continued to terminate their pregnancies at private clinics in Havana through 1960 (i.e., after the prerevolutionary account given earlier), and their experiences mirrored those of many women who had traveled to Cuba before 1959. For example, a US woman named Ila recounted to writer David Reardon that she journeyed alone to Havana in 1960. After spending the night across the street from the Havana Hilton Hotel (now the Habana Libre), Ila was transported to a clinic where she consented via hand gestures to general anesthesia and received an abortion that she later described as “simple.”⁸⁷ But as early as 1961, Pilar López González recalled that abortions had become both risky and expensive in the capital city. Some physicians apparently refused to terminate a pregnancy unless the patient was escorted by someone the doctor personally knew. Pilar recounted that for an abortion, she was “accompanied by a man who knew the physician … or he wouldn’t have dared the risk.” At the same time, the abortion cost her 150 pesos, more than 7 times the amount it cost Cuban women in 1958.⁸⁸ By February 1963, it seems that authorities would also interrogate hospital patients for information about abortion providers. After giving birth in a Havana hospital, Monika Krause witnessed the police questioning an 18-year-old woman who had recently aborted a pregnancy with a choleric acid douche. The police demanded to know who had assisted her, but the woman refused to say. Krause noted that the woman’s reproductive organs had been so damaged by the acid that hospital physicians were forced to remove her uterus. Although the patient was lucky to survive, she declined to inform on her collaborators.⁸⁹ Perceptions that abortions were newly criminalized would surely explain why people would claim that the procedures were in short supply.

But why were governing elites and the media universally silent about abortions, even ignoring claims about the procedure’s recent criminalization? Per historian Lillian Guerra, rumors (bolas) were the basis of an “alternative news network” during these early years of Revolution, a form of contestation that challenged and introduced alternatives to the reality advanced by the state press. While Fidel and others sometimes publically rejected these challenges to the official narrative, officially responding to bolas was not always ideologically savvy, as it could confirm the existence of resistance and reveal the limits of state power.⁹⁰ Just as the revolutionary government refrained from recognizing medical scarcity, potentially because it could serve as proof of medical backwardness, the state also remained silent about the supposed shortage and criminality of abortions.⁹¹

Lajonchere was one of the few physicians willing to speak openly about abortion access during this period, and he later opined that it was impossible to legalize abortions during the first half of the 1960s (and even later) because “the ideology of the young Revolution condemned abortion,” as it was associated with the “criminal abortions of bourgeois society.”⁹² This perception of the procedures as bourgeois highlights leaders’ awareness that affluent Cubans and foreign (particularly US) women had depended on Havana physicians to perform procedures less accessible in the United States. But this conflation of abortion with affluence, privilege, and capitalism ignored the fact that women of all classes (and races) had relied and continued to rely on abortions to control reproduction; what distinguished these classes of women was the types of abortions they had. Even in the case of the (still illegal) physician-induced abortions, it is likely that poor and working-class urban residents were still more prone to receive unsafe instillation abortions, whereas affluent and foreign women may have continued to receive both anesthesia and D&Cs (or D&Es). Far more dangerous and lengthy were the instillation abortions, which seem to have continued well into the 1960s; and the continued practice of these procedures likely contributed to the increase in abortion-induced maternal mortality between 1962 and 1965 and again in 1969.⁹³

In addition to ideological perceptions of abortion as artifacts of socio-economic inequality, according to Lajonchere, the Cuban press adopted a “feigned moralist position” against abortion procedures, the Catholic Church opposed them, and some physicians refused to perform them on moral grounds, meaning legalization was not an option.⁹⁴ The suggestion that support from the Catholic Church may have influenced anti-abortion policy hints at the close relationship that initially existed between Catholicism and popular support for Fidel (fidelismo). Indeed, the Church and the Revolution were not always mutually exclusive. Throughout the anti-Batista movement, Cuban archbishop Enrique Pérez Serantes had backed Fidel and the M-26-7. Priests and Catholic intellectuals had also praised the new government and its apparent implementation of Christian social reform. While this relationship began to deteriorate at the end of 1959, the new government continued to mobilize Christian iconography.⁹⁵ As argued by historian Anita Casavantes Bradford, this early discourse of Catholic morality formed part of broader efforts to situate the state, rather than the Church, as Cuba’s moral arbiter.⁹⁶ At the same time, the use of Catholic symbols within an increasingly socialist Revolution exemplifies the underlying Christian ethos that motivated early conceptions of revolutionary morality.⁹⁷

In addition to perceptions of abortion’s criminality, claims of abortion scarcity were undoubtedly informed by the mass emigration of Cuban physicians. Between 1959 and 1963, an estimated 2,000–3,000 doctors departed the country, between one-third and one-half of all physicians. Although his estimate is likely exaggerated, Lajonchere believed that obstetricians and gynecologists accounted for 97 percent of these émigré doctors – who likely had homes in foreign locales such as Florida and much capital to lose under socialism.⁹⁸ These emigrants formed part of the hundreds of thousands of citizens who left the island in the early years of the Revolution, dissatisfied with the new government’s leftward turn. Until the 1970s, the country’s doctor-to-patient ratio remained lower than it had been in January 1959, despite efforts to educate a new generation of physicians and improve the health system by infusing resources.⁹⁹ Women living in Havana, in particular, may have experienced the medical exodus most acutely, as the capital city likely saw the sharpest decline in physicians during these early years.

In October 1962, at the beginning of the Cuban Missile Crisis and preceding the opening of the new “Victoria de Girón” Institute of Basic and Preclinical Sciences in Havana, Fidel delivered a speech in which he condemned the doctors who emigrated, accusing them of having committed a “crime against the people (pueblo), against the sick, against the unhappy, against those who suffer.” He criticized these same physicians for their willingness to travel to Miami, but not to the Sierra Maestra mountains of Cuba to practice medicine, and essentially ignore the material needs of rural citizens. While Fidel celebrated the young Cubans enrolled in medical school – who were all mandated in 1960 to spend one year post-graduation working in the campo – the absence of the departed physicians would have been keenly felt by the patients who had long relied on these professionals to terminate pregnancies.¹⁰⁰

Increased Birth, Infant Mortality, and Maternal Mortality Rates

Beginning in 1959, the birth rate increased dramatically, eventually peaking in 1963 and 1964 and reaching a high not seen since 1919. More specifically, between 1958 and 1964, the birth rate grew by 33 percent, from 27 to 36 children born for every 1000 people.¹⁰¹ This baby boom occurred across all racial groups and was known to some as “Generation Fidel.” Krause described the demographic explosion as “incredible,” recalling that “there were teenagers giving birth, their mothers giving birth, and their grandmothers giving birth – from thirteen, fourteen, to forty-five years old.” She added that because birth control was limited in supply, women could not prevent their pregnancies: “There were no options!”¹⁰² “A lot of mothers who didn’t want to have children [in fact gave birth to] babies,” admitted Lajonchere.¹⁰³ As Krause observed, many of these women were teenagers. Indeed, the 15-to-19-year-old cohort experienced the greatest increase in fertility, jumping more than 50 percent.¹⁰⁴ Franqui claimed to have witnessed “lines of pregnant mulatas, dancing and chanting: ‘Fidel, Fidel, watch me swell. Here you see the Revolution; now please give a smart solution.’”¹⁰⁵ The surge in births impacted rural and urban women alike, but it was sharpest in the provinces of Havana, Las Villas, and Matanzas. These provinces likely experienced greater increases because they originally had lower fertility rates than the other provinces. At the same time, women in Oriente province continued to have the highest birth rates in the country – a potential continuation of the increased fertility rates amongst Afro-Cubans that occurred after 1931.¹⁰⁶

Some contemporaries claimed that women became pregnant in order to qualify for more goods through the ration system. In March 1962, the Cuban government had sought to mediate an economic crisis by institutionalizing rationing, reflecting “a new revolutionary creed of austerity and sacrifice.”¹⁰⁷ Economist Carmelo Mesa-Lago writes that at this time, each Cuban qualified for six pounds of rice, two pounds of lard, and one and a half pound of beans each month – in addition to other items.¹⁰⁸ Because the state allocated additional foods to children, rationing ostensibly alleviated the stress of additional children and indirectly promoted big families, or so argued political scientist Aaron Segal. Alfredo Barrera Lordi agreed, informing Oscar and Ruth Lewis, “Rationing is easier for people who have children. Every married couple has heaps of children; the more the merrier. That’s the only way of beating the food shortages.”¹⁰⁹ Of course, rationed goods were not available free of charge – they were simply at a lower price than non-rationed or black-market goods. Even rationed products were not inevitably present on store shelves, and the above statements ignore the fact that eligibility did not equal accessibility.

Thanks to new, commercial relationships with socialist countries such as Bulgaria and East Germany, these nations promised to the Cuban people goods weighing tens of thousands of tons, and the pledged items reveal how much access to consumer products had changed – particularly in urban areas – by early 1962. As Michelle Chase describes, the government-decreed reduction in rents (beginning with the first Urban Reform Law of March 1959) and increase in salaries had initially contributed to greater consumption of food and other commodities – products of which there was a finite amount. Likewise, cheap credit and the redistribution of land to tenant farmers had made the sale of produce less of an economic necessity for these farmers, and urban residents found vegetables and fruits to be in short supply. US trade restrictions on Cuba, which had begun in 1960, had left the country unable to sell its sugar or purchase food staples – including lard and rice.¹¹⁰ Entering into trade agreements with socialist countries, thus, was an economic strategy that ensured Cuba trading partners. Reported in March 1962, the same month as the announcement of rationing, a list of promised imports from Bulgaria and East Germany appeared in the Gaceta Oficial – the country’s legal gazette – and included basic food items such as beans, butter, and onions; alcohol in the form of champagne and brandy; technical apparatuses, including dental chairs and X-ray machines; and even more medicine and medical supplies. The lists also included a smaller number of domestic and child-rearing products, such as mops, washing machines, clothes irons, and pacifiers.¹¹¹ The wide array of requested items, including Cuban food staples, illustrates the diversity of demands for goods from medical professionals to housewives and mothers. At the same time, it is clear that the products from Europe did not mean a return to the Revolution’s earlier promise of prosperity for all, as rationing was formally implemented the same month as the Gaceta Oficial announced the promised goods. Thus, we should not surmise that greater access to rationed, consumer goods was a motivating factor for citizens growing their families during the first half of the 1960s. At the same time, however, people’s belief that their material needs would be met by the new state may have alleviated concerns about health and welfare and thus incentivized families to reproduce without the fears they had before 1959.

Specialists from the period explained the increased birth rate through the lens of the jubilation and hope that (for some) proceeded the revolutionary victory. Demographer and historian Juan Pérez de la Riva wrote in 1969 that the birth rate increased partly due to an “atmosphere of euphoria and unlimited confidence in the immediate future.” He added that the migration of rural workers to cities, decrease in the average marriage age, and “almost total disappearance of family planning” also explained the demographic explosion.¹¹² Lajonchere opined, “We were in a revolutionary war and had been at war for many years, and in that period marriages and births were way down. It was natural that there was a large increase in births after the triumph of the revolution.”¹¹³ So too does Alejandro de la Fuente assert that the surge in births “reflects the optimism and confidence generated by the revolution in the population, and this suggests that confidence in a better future was felt with particular intensity by blacks and mulatos.”¹¹⁴

While it is impossible to determine with any certainty why the birth rate surged in Cuba before peaking in 1963–1964, the baby boom certainly reflected a transformation in women’s – particularly Afro-Cuban women’s – experiences with reproduction. Improved economic conditions for the rural and urban poor following the conclusion of the civil war against Fulgencio Batista likely prompted individuals to expand their families as an expression of hope for the future. Perceived lack of access to contraceptives and increased state regulation of abortions seems to have also provoked an unknown number of unwanted pregnancies. Following the emigration of thousands of physicians, urban residents of all races and classes had to find alternatives methods for regulating reproduction. But it is black and mulata women who seem to have encountered the most changes in their reproductive autonomy. After 1958, these two groups had higher fertility rates than white women, as well as declining mortality rates by 1962. We see this reflected, for example, in the population of Oriente, which swelled by 27 percent between 1958 and 1967.¹¹⁵ And while this demographic certainly benefited from the early health reforms – including maternity homes – afforded by the National Health System, state oversight of reproduction appears to have unequally focused on the maternal bodies of poor working-class mulata and black women, subordinating their agency to the will of the Revolution’s health professionals.

Despite increased surveillance of women’s maternal bodies, the rates of infant and maternal mortality suggest that terminating a pregnancy, carrying a pregnancy to term, giving birth, and raising an infant were dangerous enterprises between 1960 and 1971 – particularly at the turn of the decade (1968–1970). As described below, this surge in mortality rates in the late 1960s likely stemmed from increased attention to production, at the expense of health. Intent to abort is impossible to ascertain with this data, but the data certainly exemplifies the limited scope of maternal and infant health care during this decade – potentially due to the National Health System’s nascency and women’s limited reproductive autonomy. Between 1958 and 1962, the reported infant mortality rate increased by 25 percent, to 41.7 deaths for every 1,000 infants. In 1962, this rate was the highest in the province of Havana, a likely consequence of the emigration of the city’s physicians and the limited reach of the new health system. However, it is significant that the infant mortality rate did not go below 36.4 (per 1000 infants) at all during the 1960s. The rate of infant deaths surged again in 1968–1970, before steadily declining throughout the 1970s.¹¹⁶ The resurgence in infant mortality can be partially attributed to the yet-unstudied health crisis that emerged in response to the Revolutionary Offensive – which eliminated nearly all private economic activity – and mobilization for the 10-million-ton sugar harvest of 1969–1970. Both of these resulted in the economy’s rapid contraction, decreased productivity in all sectors, and enormous physical stress.¹¹⁷

Perhaps a better suggestion of self-induced abortions, the maternal mortality rate also seems to have followed a similar pattern as the infant mortality rate. Indeed, abortion-induced deaths appear to have constituted a significant portion of the maternal mortality rate, at least until 1971. Social scientists Paula E. Hollerbach and Sergio Díaz-Briquets agree that covert abortions provoked one-third of maternal deaths in Cuba between the years 1962 and 1965, a period bracketed by the implementation of rationing and the physicians’ increased authority to perform legal abortions. Abortions “performed secretly by unqualified individuals or in private facilities without adequate means,” assert researchers Carmen Luisa Aguila Acebal and Antonio Neyra Reyes, “resulted in so many deaths that provoked abortions were the primary cause of maternal mortality during these early years.”¹¹⁸ Dr. Orlando Rigol Ricardo, a one-time student of Lajonchere, recalled accompanying the obstetrician to Oriente province in the fall of 1964 to investigate the causes of maternal mortality in the region. The men attributed maternal deaths to two primary factors: childbirth in the home, in which 50 percent of Oriente women reportedly engaged, and abortions that turned septic.¹¹⁹ Physicians sometimes saved the lives of these latter patients by removing their uteruses, much like what happened to the woman described by Krause earlier in this chapter. Some patients suffered long-term complications, such a pelvic inflammatory disease and infertility.¹²⁰ For 1968, after abortions were somewhat more available, Hollerbach and Díaz-Briquets calculate a maternal mortality rate of 83 maternal deaths per 1,000 births (including abortions). Twelve years later, after the legalization of abortion in 1979, this rate had decreased by 37 percent.¹²¹

Abortion-induced, maternal mortality – like infant mortality – appears to have increased again in 1969, before decreasing throughout the 1970s. Indeed, data indicate that clandestine abortions accounted for 30 percent of maternal deaths in 1969, decreasing to 17 percent in 1971.¹²² This suggests that clandestine abortion procedures also increased at the turn of the decade, another health-related outcome of the 10-million-ton harvest, potentially decreased access to health care, and the 1968 Revolutionary Offensive. A suggestive link between the Offensive and self-induced abortion is found in the case of an unnamed woman from San Antonio de los Baños who allegedly sought to terminate her pregnancy with the help of Emérida Guerra Perdomo and Marta Alonso Almeida on March 14, 1968 – the very day after Fidel’s announcement of the Revolutionary Offensive. The Cuban Supreme Court later overruled a local criminal court’s decision and found the women innocent, arguing that there was not sufficient proof that an abortion had occurred.¹²³ Paralleling the Supreme Court’s seeming leniency in this abortion case, the apparent rapid descent in the abortion-induced, maternal mortality rate from 1969 to 1971 suggests that physicians were more willing to perform legal abortions by 1971. At the same time, contraceptives seem to have been available in greater quantities by 1971, and women were perhaps more willing to carry their pregnancies to term due to the return of material incentives and Cuba’s improved economy. Indeed, support for this latter hypothesis is found in the brief uptick in the crude birth rate in 1971.

Resisting Neo-Malthusianism, Adopting the IUD, and Facilitating Physician Control over Women’s Bodies, 1965–1968

Promoting the Zipper Ring while Opposing Population Control

It is difficult to establish a causal link between the increased birth rate, the high maternal mortality rate, and the MINSAP’s modified treatment of abortions and contraceptives, but changes introduced by the MINSAP in 1965 seemed to have been in response to these demographic changes.¹²⁴ Not only did the MINSAP introduce a low-cost, locally produced IUD to women in 1965, so too did it approve an alternative interpretation of the Social Defense Code – allowing doctors the freedom to determine when an abortion was permissible. The new IUD, known as the Zipper ring or the anillo de nilón, had its origins in Chile (Figure 1.1). As historian Jadwiga Pieper Mooney has written, Chilean physician Jaime Zipper began experimenting with a simple IUD made of nylon thread in the form of a ring while working at the Barros Luco Hospital in Santiago in 1959. He based his design on an IUD developed in 1929 by the German physician Ernst Graefenberg. Zipper’s research was unsupervised and unauthorized; even his low-income patients, whom Zipper categorized as lacking in “culture,” were unaware that they were participants in a new study. But lack of informed consent laws meant Zipper could only face reprisal for not informing his colleagues and superiors about the experiment.¹²⁵

Figure 1.1 Illustration of the Zipper ring intrauterine device by Mary Allegra Paul, for the author.

Lajonchere had learned about the Zipper Ring on a trip to Chile in the early 1960s. As Director of Obstetrics and Gynecology for the Ministry of Public Health, Lajonchere sought an IUD option that was neither manufactured nor patented in the United States (due to the embargo).¹²⁶ In principle, the partial US trade embargo of 1960 – which was reinforced by the near-total embargo of 1962 – exempted food and drugs.¹²⁷ But early on, Cubans reported medical shortages and difficulties importing medicine from the United States. A 1964 US measure that mandated “special licenses” for the sale of drugs and food to Cuba would have further incentivized Lajonchere to find contraceptives elsewhere.¹²⁸ The anillo met Lajonchere’s qualifications, as it could be manufactured in Cuba for a very low price. Even Zipper and his colleagues celebrated the cost-effectiveness of the IUD when they wrote, “This device can be made by anybody [who is] interested, at an insignificant cost. This was a decisive factor, at least in Chile, in the spread of its use without the need for setting up distribution networks … We believe this to be true anywhere in Latin America.”¹²⁹ The anillo may have also appealed to revolutionary leadership, as it restricted the technology of the United States from penetrating the bodies of Cuban women.

In 1964, physicians fitted the first Zipper rings for “low-income women” who lived amidst “unfavorable social conditions” in Havana’s shantytowns (solares), a likely indication that the patients were black and mulata. According to gynecologist Orlando Rigol Ricardo, social workers identified these indigent women as most in need of fertility regulation and referred them to the Calixto García General Hospital in Havana. For the pilot study, Lajonchere worked alongside Aida Santamaría, sister of M-26-7 martyr Abel Santamaría and director of the Department of Social Services of the Metropolitan Administration of Havana. As medical resident at the University of Havana School of Medicine, Rigol Ricardo observed and wrote about this anillo testing for his medical school thesis, later accompanying Lajonchere to the newly inaugurated University of Santiago medical school to lecture on contraceptives.¹³⁰ Rigol Ricardo wrote that Lajonchere sought permission from the MINSAP prior to making anillos available to the women of southeastern Cuba. The Ministry responded by stating that since “the Revolutionary Government [has] not made a decision regarding birth control or family planning, [you] should act according to your knowledge and understanding.” Of course, the claim that the government had not formalized an opinion about birth control ignored the degree to which it had invested time and money in so many other aspects of maternal health care, to the exclusion of women’s reproductive control. Rigol Ricardo and Lajonchere subsequently began IUD insertions in Manzanillo, followed by Santiago, Guantánamo, Bayamo, and other Oriente cities.¹³¹ Rigol Ricardo’s description of how the women of southeastern Cuba and Havana solares, locations with high concentrations of Afro-Cubans, served as the initial recipients of these IUDs illustrates the degree to which women of color may have been the targets of government control over women’s reproduction. Indeed, the fertility increase among black and mulata women during the early 1960s – which was greater than that experienced by white women – suggests that Afro-Cuban women had greater access than in previous years to maternal health care. But if such care were imposed upon Afro-Cuban women, rather than simply made available, it would mean that blacks and mulatas continued to face restrictions to their reproductive autonomy.

Doctors, nurses, and assistants easily constructed these Zipper rings using fishing line from the Cuban Fishing Institute, and the demand seems to have sometimes been greater than the supply. Dahlia Gómez, a resident of Pinar del Río, recalled to Elise Andaya that she and her friends sought to mitigate this problem by meeting at the home of an FMC representative to make anillos by hand. “It wasn’t so easy for most women to get one of them,” Dahlia stated. She added, “We were lucky, because we made them, but I knew lots of women who were dying to get their hands on one of those rings.”¹³² Dr. Zipper also recognized that anillo insertions were limited, reporting to the World Health Organization (WHO) that Cuban physicians inserted 8,000 IUDs in 1966 and another 8,000 in 1967.¹³³ By 1971, his number had increased, when Dr. Chelala wrote that Havana health practitioners alone averaged 4,700 insertions each month.¹³⁴

In a country where abortions and holistic remedies had long been the primary methods to control fertility, contraceptive use was slow to gain in popularity – both with physicians and with patients. Each group had to become accustomed to the idea of biomedical birth control. Adoption of the anillo was further slowed by the reticence of physicians to speak about contraceptives, sometimes due to the doctors’ own ignorance. Per Lajonchere, family planning was only incorporated into the medical school curriculum in 1962, when he assumed the position as head of Obstetrics and Gynecology.¹³⁵ Eulalia Fontanés, one of Oscar and Ruth Lewis’ interviewees, noted that she obtained a Zipper ring in 1965, following the birth of her fourth child. Eulalia said she was one of the first Cuban women to have the anillo, and she served as a test subject for the Soviet physician who was teaching Cuban gynecologists how to fit the IUD. Eulalia recalled, “I was embarrassed while the ring was being inserted because a lot of doctors walked in and out of the room. The doctor explained to each of them how to insert it.”¹³⁶ But when Canadian sociologist Barent Landstreet visited Cuba just three years later in 1968, he observed that the Zipper ring was “one of the most popular methods of birth control.” Of course, the shortage of doctors meant that women could wait up to a month for their IUD insertion.¹³⁷

While some people were glad to have the anillo as a birth control option, not everyone was convinced of its success. The obstetricians with whom Landstreet spoke in 1968 stated they were “reasonably content with the ring,” although they admitted that it was not as effective as the Lippes loop, a plastic IUD with an open, serpentine design. Since the loop contained barium, so as to be detected in an X-ray, Cubans were unable to create their own version. According to Landstreet, Cuban manufacturers attempted to manufacture the Lippes loop in 1968, but they lacked the equipment to embed the barium.¹³⁸ Zipper himself recognized the potential for physical pain with the anillo, noting that it sometimes exacerbated chronic pelvic inflammations. He also wrote that the “high incidence of primary expulsions with this IUD – 17% in the first year – discouraged many investigators from using it.”¹³⁹ Indeed, Teresa Noble recalled to me that a physician mistakenly inserted two anillos at once, and both fell out.¹⁴⁰ Deborah Tuñas also had an anillo failure, from which she became pregnant with her second daughter. But it was not merely the anillo’s success that was sometimes questionable, so too was patient aftercare, as illustrated by Deborah, who was surprisingly nonplussed when she told me that an anillo inserted in 1979 still remained in her uterus at the time of our interview in December 2011.¹⁴¹

Beginning in 1966, Cuba’s new emphasis on the accumulation of capital for the country, rather than increased consumption by citizens, incentivized Fidel to proclaim his opposition to contraceptives as the solution to population growth. In Havana, at the September meeting of school monitors, Fidel formally announced the beginning of escuelas al campo (rural schools), where students between the ages of 12 and 18 could study and perform agricultural labor for 45 days each year. In 1967, more than 80 percent of Cuban teenagers would attend an escuela al campo.¹⁴² Fidel anticipated that the schools would resolve the problem of classroom scarcity and provide youth with the technical skills found lacking in so many extant administrators. Through this education, no student would become “an anchor, a tax, a deadweight, a burden; in other words, an enemy to all his fellow men.” He would instead gain the technical know-how to provide Cubans with nourishment, “regardless of whether the family consists of one, two, or twenty individuals.” Fidel added, “No one [who is] aware of what man can do with the aid of technology and science is going to set about limiting the number of human beings on earth. Much less in a country like ours, with a soil capable of feeding a much larger population.”¹⁴³ With the baby-boom population in nursery school and therefore unable to work, Fidel proposed that their only-slightly-older compatriots mix work and school in order to benefit the Cuban economy and feed the population.

From Abortos to Interrupciones: Increasing the Authority of Physicians and Reinterpreting the Social Defense Code

Just as opposition to the ideology of population control allowed some space for contraceptives, so too did it permit limited numbers of legal abortions. This change, combined with greater access to contraceptives, likely contributed to the declining birth rate between 1964 and 1970.¹⁴⁴ Scholars and contemporaries contend that in 1965, the MINSAP responded to public health concerns by allowing for a more “flexible interpretation” of the Social Defense Code, specifically the section that permitted abortions to avoid harm to the mother’s “health.”¹⁴⁵ Lajonchere explained that after the MINSAP expressed concern about the high rate of maternal mortality attributed to abortions, officials queried of him whether a new abortion law was necessary. Lajonchere recommended instead a new interpretation of the law and the MINSAP’s adoption of the World Health Organization’s definition of health: “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” While there was no change to the Social Defense Code and most abortions remained illegal, the MINSAP agreed to allow physicians to determine when the woman’s health (under the new definition of health) was at risk. Per Lajonchere, this was also at this time that the MINSAP stopped referring to abortions as abortos and instead began to call them interrupciones (interruptions), seeking to “eliminate the emotional baggage that generally encumbers abortion.”¹⁴⁶ This reinterpretation resulted in increasing numbers of doctor-approved, hospital abortions and much confusion, as access to abortion services appears to have depended to a large extent on the attitude of each individual doctor.

Since this was a change to abortion practice – rather than law – it was possible for policy makers and physicians to avoid making a statement to the public. The initial absence of information in state newspapers was clearly purposeful, a decision made by officials to withhold information from the media, which revolutionary leadership had overseen since 1960. This decision fostered much misunderstanding amongst patients, obstetricians, and visiting researchers. While the number of ostensibly legal interrupciones performed in hospitals seems to have increased at this time, Paula Hollerbach claims that availability was universal. She writes, “Since 1965 … requests for abortions up to 10 weeks of gestation have been performed for single women 18 and older, and for all married women, solely at the woman’s request.” But in a conversation with Barent Landstreet, one Cuban stated that the majority of legal abortions seemed to have been performed on married women who already had several children.¹⁴⁷ Furthermore, hospital directors had different interpretations of the law, and abortion access varied from hospital to hospital. For example, Nicolás Salazar Fernández told Oscar and Ruth Lewis’ research team that in the mid-1960s he had engaged in a debate with his partner, Emelina, over the accessibility of legal interrupciones. She had claimed that getting pregnant was not a problem, because “if I do, I’ll just go to a doctor and have an abortion.” Nicolás had disagreed, declaring that “getting a [legal] abortion isn’t nearly as easy as you think. Suppose that doctor says no?”¹⁴⁸ This confusion over the country’s abortion policy alludes to official ambiguity surrounding the procedures and a willingness to entrust physicians with interpreting the law on their own terms.

In the late 1960s, it appears that some doctors were willing to perform legal interrupciones if the anillo failed. While this was certainly not the law, it was prevalent enough for individuals and the even state media to believe it was government policy. In July 1967, the Granma Weekly Review – the English-language edition of the Cuban Communist Party’s newspaper Granma – reported: “In the event a woman using contraceptives becomes pregnant, an abortion is … permitted,” revealing the extent to which even government publications conflated policy with law.¹⁴⁹ Eulalia Fontanés agreed, asserting in 1969, “If you get pregnant with the ring in place, you can have an abortion.” She added, “Some women use that as an excuse because it’s a crime to have an abortion unless a woman tells a doctor that she lost her ring.” But it was not always true that a woman could get an abortion following IUD failure.¹⁵⁰ At the same time, women’s insistence that the state was to blame if her contraception failed derived from the government’s own logic that it was the responsible patron of women’s bodies and sexual destinies.

Because the MINSAP made no effort to impose a uniform abortion policy, physicians gained increased power over the bodies of female patients. This was illustrated in the case of Ilona Sorel, who attempted to terminate her pregnancy in 1967. A friend gave her numerous – potentially saline – injections, but instead of having a miscarriage, Ilona merely developed an infection. When she begged for help at the Mayarí hospital in Oriente province, Director Padrón stated, “It is not our job to give her an abortion.” In a later conversation with Cuban-American novelist and journalist José Yglesias, the director amended his statement and said he could only perform an interrupcion if he had the permission of Ilona’s husband.¹⁵¹ When interviewed in 1966 by Chilean diplomat and writer Luis Enrique Délano, Dr. Cruz Álvarez proclaimed “We’re not prudes (gazmoños), but we currently only perform abortions when necessary for physical reasons. For economic reasons, it’s still not possible to deal with the issue of legal abortions.”¹⁵² The new interpretation of the abortion law permitted Cuban physicians to terminate pregnancies or refuse interrupciones, depending on how they applied the new definition of health to the 1936 law.¹⁵³

Since the accessibility of abortion depended to a large extent on the willingness of the physician or hospital director, unknown numbers of women still resorted to illegal abortions. Pilar López Gonázales recalled that she paid $200 to a physician to terminate her pregnancy in 1966. Since the “penalties for practicing abortions were harsh. I went to his house alone to be less conspicuous,” she noted. “I was given no anesthesia, and the pain was horrible,” Pilar added, “It was brutal. Afterward I felt very ill but said nothing because I didn’t want to arouse any suspicions at home.”¹⁵⁴

But not all interrupciones were voluntary, and some abortion providers were seemingly willing to terminate a pregnancy without the consent of the patient. In a self-published memoir, Mirnia Linares writes that in 1966 – shortly before an anticipated move from Cuba to New Jersey – she was pleasantly surprised to find herself pregnant (by her husband). Mirnia’s family attempted to convince her that traveling to the United States with an infant would be difficult. But when their entreaties proved unsuccessful, family members paid a physician to anesthetize Mirnia during a routine examination and terminate the pregnancy while she was unconscious.¹⁵⁵ Mirnia’s experience speaks to the desperation of families fleeing the island as well as the persistence of unregulated interrupciones and women’s vulnerability in these situations.

Of course, non-hospital and non-physician-assisted abortions were criminal acts, even after the 1965 change in legal interpretation.¹⁵⁶ For example, Dr. Padrón claimed in 1967 that when hospital doctors examined a patient whom they believed was recovering from an abortion, they were required to report her to the authorities. He added, however, that the police were only interested in prosecuting the abortion provider, not the woman who ended her pregnancy. “They come and question the woman,” noted Padrón, “only to find out if there is someone who makes an illegal profession of giving abortions.”¹⁵⁷ Eulalia disagreed, asserting that friends and family members could also be imprisoned for helping a woman terminate her pregnancy. A hospital physician in at the Calixto García hospital in Havana had interviewed Eulalia in 1966, suspicious that her sister’s miscarriage had been provoked. But Eulalia had refused to provide any information about her sister or the boyfriend who had transported her to the abortion provider.¹⁵⁸ Regardless of whether or not patients faced punitive action alongside abortion providers, these anecdotes highlight that women were inevitably impacted by the criminalization of abortion and by state efforts to oversee women’s reproductive practices.

It is evident, however, that patients, family members, and even doctors sometimes protected the confidentiality of individuals involved in the clandestine abortion. While physicians were required to report evidence of potentially clandestine abortions to the police, some did not. Dr. Padrón admitted that physicians at his hospital were “rather relaxed about it,” and did not always contact the authorities.¹⁵⁹ It is unclear how prevalent this attitude was among Cuban doctors, but historian Raúl Necochea López writes that this was a pattern in early twentieth-century Peru. Despite their professed opposition to abortion, Peruvian physicians rarely charged women with the crime of abortion. Necochea López attributes this to the “desire to protect their careers, the sympathy they felt for some women, and the ease with which they could be tricked or denied information.”¹⁶⁰ Something similar also appears to have occurred in Cuba, where the actions of physicians often differed from those prescribed by law.

But rather than reinterpreting the Social Defense Code, why not create a new law? Such a change would have afforded physicians and patients information about what exactly determined a threat a woman’s health, thereby clarifying when abortions were legally permitted. However, in addition to the continued discursive link between capitalism and birth, the MINSAP may have also feared an increased demand for abortions that the extant number of physicians could not meet. The Ministry could have also opposed returning to an era when women nearly exclusively relied on abortions to control their reproduction. Support for this latter theory is found in the words of physician and the MINSAP historian Gregorio Delgado García, who admitted: “This emergency solution [reinterpretation of the Code], for a population still insufficiently prepared to appropriately use prophylactic methods, will be gradually supplemented by the use of anticontraceptive methods, which will set the grounds for fair, rational, and scientific family planning.”¹⁶¹ Delgado García suggested that physicians worried what women would do without “proper” knowledge about birth control; he also demonstrated a paternalistic attitude toward women’s reproductive health, insinuating that physicians knew better than patients. Thus, in the absence of pro-natalist discourse, the quiet introduction of a new “policy” on abortions could serve a similar purpose – allowing physicians to dictate when and how many abortions to legally perform and under what circumstances.

The Cuban Ministry of Health and the Planned Parenthood Federation of America

By the mid-1960s, Soviet physicians had begun to challenge the belief that capitalists inevitably supported birth control and that Marxists did not, but Cuban experts were more reticent to adopt this new ideology. During the second half of the 1960s, argues Barent Landstreet, Soviet demographers admitted that population problems existed but attributed them to socio-economic circumstances rather than excessive reproduction. The Soviets’ proposed solution to overpopulation was socialism combined with birth control.¹⁶² Despite their ties to the Soviets, though, Cuban leadership did not agree that increased birth rates were a problem. It chose to make contraceptives available but in limited quantities and only when requested by patients. Fidel, in particular, continued to articulate discourse that condemned contraceptives as tools of imperialism. But events surrounding the official visit of Dr. Alan Guttmacher, President of the Planned Parenthood Federation of America, to Cuba in February 1966 also highlighted what a delicate balance it was for the government to distribute birth control and assert that inequality and underdevelopment were the results of capitalism, not overpopulation.

By inviting Guttmacher to lecture at the XI Cuban Medical Conference in Havana, the MINSAP hoped to both improve its access to medical contraceptives and situate itself as an actor in the international debate on population control. The introduction took place at that 1965 World Population Conference in Belgrade, Yugoslavia, which Dr. Lajonchere and two colleagues attended alongside 800 other population experts and demographers from 90 countries. In attendance was Guttmacher, whom Lajonchere (on behalf of the MINSAP) invited to speak at the following year’s medical conference.¹⁶³ Part of the MINSAP’s motive for asking Guttmacher to the conference was to establish a relationship with the International Planned Parenthood Federation (IPPF) in order to purchase birth control devices. In a letter to Sir Colville Deverell, Secretary General of the IPPF, Lajonchere wrote: “Our Foreign Commerce Agencies are interested in acquiring the contraceptive elements that are in [sic] sale in those countries with which we have not [sic] commercial relations. We should like to know if the Federation has any available way to enable us … [with] this difficulty.”¹⁶⁴ But the MINSAP also sandwiched Guttmacher’s presentation between a panel on the importance of individual choice and contraceptives and a speech by Fidel, who discussed the myth of overpopulation. The quietly expressed desire for medical contraceptives did not necessarily contradict the belief that such technology was unnecessary for the world’s population, but it does partially suggest why birth control would not become more widely available to Cubans until later in the 1970s.

The 1966 Cuban Medical Conference not only highlighted the balancing act performed by Cubans on the issue of birth control, but it also revealed the extent to which women were excluded from conversations surrounding this issue.¹⁶⁵ The panel consisting exclusively of male, white-appearing, Cuban physicians – including Lajonchere – argued that each family should decide for itself the number of children to have and which method of birth control to use, if at all. “The best method is that which the couple most prefers,” the panelists affirmed. They advocated the use of contraceptives to control the spacing of childbirth and added that the ideal number of children for Cuban families was two to three.¹⁶⁶ By endorsing birth control to space out births, the physicians sidestepped debates about the use of contraceptives to stem population growth, a policy endorsed by Guttmacher. The Cuban panelists’ polite resistance to the politics subsequently advanced by Guttmacher were not without foundation. Contrary to his belief (expressed a year earlier in a personal letter) that “the IUD’s are not as effective as the pill in preventing conception,” Guttmacher recommended to the Cuban audience that women use IUDs to prevent pregnancy, cautioning them against taking oral contraceptives.¹⁶⁷ But his was not the last word on this issue.

Several hours later, Fidel took the stage at the Charlie Chaplin Theater in Havana. Fidel publicly recognized Latin America’s high fertility rates and lamented the high number of childhood deaths in the region. But rather than agreeing with Guttmacher and the World Health Organization (WHO), which opined that overpopulation was one of the reasons for poverty and infant mortality, Fidel pronounced that the world’s children were “killed by poverty, and what is poverty but the consequence of exploitation.” By exploitation, he meant imperialism that frustrated economic growth and revolution.¹⁶⁸ While Cuban authorities theoretically allowed more space for individual autonomy in family planning, the reality was that abortions and birth control were not yet available in the quantities desired by Cuban women.

Throughout the second half of the decade, Cuban physicians continued to communicate with the International Planned Parenthood Federation, but they appear to have established no formal affiliation with the organization. In 1966, Cuban gynecologists participated in an IPPF-sponsored training program in Santiago, Chile. The following year, they attended the Eighth International IPPF Conference in the same city.¹⁶⁹ While in Santiago, Lajonchere did not hesitate to voice his disagreement with the conference’s orientation. He accused conference organizers of replacing the “Malthus principle” of eliminating overpopulation through warfare with the “pill principle,” which ostensibly did the same with oral contraceptives.¹⁷⁰ Contacts made in Chile ultimately resulted in a May 1967 training seminar in Havana on family planning and public health. Some of these exchanges were funded by the IPPF; and in 1968, an informant told Barent Landstreet that “if demography and family planning had been tools of the bourgeoisie before, they could now be used against [the bourgeoisie].”¹⁷¹ But this was not the position advocated by the MINSAP or Fidel himself. Indeed, increased contact and training with the population control movement did not alter the Cuban government’s official opposition to neo-Malthusian ideology.

In March 1968, two years after Fidel spoke at the 1966 Cuban Medical Conference, he stood on the broad steps of the University of Havana to announce the Revolutionary Offensive and underscore the importance of labor to compensate for the country’s population increase. Through the Revolutionary Offensive, he emphasized moral incentives over material incentives and ordered confiscated the country’s nearly 56,000 remaining private businesses. Launched with the intention of combating selfishness and recommitting to communism, the Revolutionary Offensive nationalized dry cleaners, hardware stores, corner groceries, boarding houses, hat shops, and other small businesses identified as belonging to the “petty bourgeoisie.” More than half of these businesses had begun operations after 1961, with the state serving as the primary customer. But by 1968, the government had come to view the material accumulation of small entrepreneurs as a threat to the country’s overall economic development.¹⁷² Fidel argued that one of the reasons that production had to increase was because the Cuban population, despite significant emigration, had grown an average of 2.3 percent per year for the previous 5 years and children under the age of 15 now accounted for 40 percent of the population – assessments that both appear to be accurate.¹⁷³ He added, “Let no one be frightened, for we are not promoting planning or [birth] control.” Instead, Fidel avowed that economic development would occur at the hands of the “active population,” as “only with work can we win the battle of underdevelopment.”¹⁷⁴ The Granma Weekly Review expanded upon Fidel’s comments two months later, on the ninth anniversary of the first Agrarian Reform, and it argued that the much-needed economic development in Cuba and the rest of Latin America was only possible through socialism and agrarian reform. “In order to keep up with the huge population increase and overcome backwardness of all kinds,” it wrote, “there is only one road: to combat underdevelopment beginning with a revolution in agriculture and within the framework of a revolution moving toward socialism. Not to follow this road is to invite self-destruction.”¹⁷⁵

New Perspectives on Family Planning, 1970–1979

The failure of the 1969–1970 sugar harvest to reach the targeted 10-million-ton goal, however, necessitated a closer economic and political relationship with the Soviet Union – as revolutionary leadership was forced to confront its inability to transform the economy through collectivization and moral incentives. This change seems to have incentivized Cuban leadership to adopt a more Soviet-style perspective on family planning. In a 1971–1972 survey, over 90 percent of Havana women between the ages of 20 and 45 had heard of the IUD, although they had not necessarily used it.¹⁷⁶ This growing consciousness likely stemmed from the increased general availability of birth control, which continued to grow throughout the 1970s. At the 1974 Bucharest World Population Conference, the United Nations Fund for Population Activities (UNFPA) promised the Cuban government nearly $4 million to expand maternal and child health care and purchase contraceptives. This pledge came on the heels of an official statement by the MINSAP: “We agree with the resolution of the World Health Assembly which states that ‘each family should have the opportunity of obtaining information and advice on problems connected with family planning, including fertility and sterility’ … Our practice in this connection is based on freedom for the women or the family to decide upon pregnancy … without any outside influence or inducement.”¹⁷⁷ At the same time, deaths due to illegal abortions appear to have slowly declined throughout the 1970s, coinciding with an increase in the rate of legal, hospital abortions, as physicians were ever more willing to perform these procedures. Birth rates likewise decreased during this period.¹⁷⁸

The government’s official opposition to neo-Malthusianism had disappeared by 1977, when Fidel publicly voiced concern for Cuban population growth. On May 17, at the Fifth Congress of the National Association of Small Farmers (ANAP), Fidel admitted:

We can’t grow horizontally, because there’s no room; we must grow vertically. That is, the only way to increase our output of agricultural produce and foodstuffs is to boost productivity per hectare … Of course, as the country develops, we will be a more cultured people, and the birth rate will logically decline. We can harbor the hope.¹⁷⁹

With this comment, Fidel expressed worry about the amount of food and resources required by the large generation of Cubans born after 1959. He also replicated neo-Malthusian discourse by associating high birth rates with less progressive populations.¹⁸⁰ Thus, it is no surprise that between 1977 and 1979, the government accepted $630,500 from the IPPF to support family planning services.¹⁸¹ In 1979, Cuba also introduced a new Penal Code, which replaced the 1936 Social Defense Code and legalized abortions, a seemingly inevitable decision considering how physicians had been increasingly willing to interpret the Social Defense Code to women’s benefit by performing more and more legal abortions. Of course, the new law mandated that all abortions be performed at state institutions by trained doctors. People who performed an unsanctioned abortion could be interned for anywhere from three months to twelve years, and individuals who assisted the crime likewise faced the possibility of up to three years in prison.¹⁸²

Conclusion: Medical Paternalism and the Regulation of Pregnancy

From the perspective of revolutionary authorities and health professionals, it was the responsibility of the state to protect and oversee the health of pregnant women. This approach afforded maternal care to Cubans who had never before seen a physician or received medication. However, the bodies of women also came under increased scrutiny by male health officials who claimed to know better than the the patients themselves how best to regulate their reproduction and carry pregnancies to term. This attention was particularly salient in the case of poor working Afro-Cuban women, who appear to have been the focus of early maternal health interventions, including maternity homes and the Zipper IUD. Yet women’s persistent use of illegal abortions to control fertility underscores how – throughout the 1960s – health reforms did not always satisfy the demands of patients and instead expected that women relinquish to the state control of their reproductive health practices.

Beginning in 1961, women started to report on the difficulty of accessing abortions and the scarcity of contraceptives. These assertions are difficult to verify, as the government never publically confirmed that it began to enforce the republican anti-abortion law. Likewise, claims of limited birth control supplies could reflect the absence of these technologies, or simply changes in how to access them. But while revolutionary representatives were silent on the matter of abortos, they condemned birth control as a tool of capitalism beginning in 1961. The government seems to have imported some contraceptives in these early years, yet it placed greater emphasis on regulating maternal health, specifically in rural areas. Seeking to replace local midwifery and spiritual and holistic health practices with biomedicine, the National Health System began creating maternity homes in 1964, the majority of which were ultimately located in Oriente province. Increased attention to maternal health in this predominantly Afro-Cuban region was consistent with the Revolution’s early focus on the maternal bodies of black and mulata women. The surge in Cuba’s birth rate that began in 1959 and peaked in 1963–1964 occurred across races and classes, but data suggest that it was greater in black and mulato communities – a potential consequence of Afro-Cubans’ hope for the changes introduced by the Revolution, the continuation of a pre-1959 trend that suggests higher fertility rates amongst black and mulata women, and government efforts to encourage hospital births and prevent abortions amongst Afro-Cuban women.

Over the second half of the 1960s, perspectives on family planning continued to evolve; but at least with regard to contraceptives, revolutionary leadership remained ideologically opposed. Seemingly in response to the surge in birth rate and the apparent increase in infant and maternal mortality rates that accompanied it, the MINSAP authorized in 1965 a more flexible interpretation of the Social Defense Code, which permitted abortions when they threatened a woman’s health. Reinterpreting an old law, rather than creating a new one, allowed the MINSAP to continue its silence about the questionable legality of the procedures and endowed physicians with greater power over women’s bodies, as they decided when women’s health was threatened. At mid-decade, anillos of Chilean origin slowly became available, but they were not always accessible to women who wanted them. The introduction of IUDs in the context of a Revolution that was ideologically resistant to contraceptives as a solution to economic difficulties required that Cuban physicians carefully balance these seemingly inconsistent actions. Throughout the 1960s, for example, conversations about family planning had to be initiated by the patient. Dr. Guttmacher’s presence at the 1966 Cuban Medical Conference highlighted this tension, likewise revealing women’s exclusion from discussions about contraceptives.

Fidel, recognizing that the children of the baby boom would require state resources as they aged, began to proclaim in 1966 that the capital for these resources would be found in increased agricultural labor by Cuba’s adults and adolescents. In his March 1968 announcement of the Revolutionary Offensive, Fidel argued that the population increase was one of the reasons he was demanding increased economic productivity in service to the state. Coinciding with a new emphasis on the accumulation of capital, the sugar harvest of 1969–1970 shrank the economy to the size of the sugar industry and proved detrimental to Cubans’ health. Indeed, the once-declining maternal and infant mortality rates seem to have briefly surged at the turn of the decade.

Official resistance to neo-Malthusianism continued at least until 1971, after which abortions and birth control appear to have become more available to women. Cuba’s new dependence on the Soviet Union after 1971 would explain the Revolution’s softening response to family planning, one more in line with that adopted by the Soviet Union in 1965. But since the MINSAP continued to dictate best practices for pregnant women, only legalizing abortions in 1979 after physicians had already been performing the procedures in increased numbers – and in the same year that Cuba ratified the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) – it would appear that the legalization of abortion occurred in response to urging from the global medical establishment, which identified reproductive autonomy as a key indicator of women’s equality.¹⁸³ At the same time, the MINSAP’s eventual adoption of legal, physician-assisted, hospital abortions and medical birth control allowed little space for midwives, healers, or the individual health preferences of average citizens in this process. As we will see in Chapter 2, state programs in support of legal matrimony were likewise institutionalized, homogenized, and antipathetic to local practices that transgressed the elite-informed model.