Bulletin of the History of Medicine

On the Way to Family Planning

When the Ottoman Empire dissolved after a decade of wars in 1922, Republican Turkey inherited a population worn down with the physicians who were formerly the planners and practitioners of Ottoman era pronatalist policies. Like in late Ottoman practices, the Early Republican regime under the Republican People's Party (RPP) criminalized abortion in the Penal Law of 1926 and prohibited the use and circulation of birth control practices in the 1930 Law of General Hygiene.²¹ The government encouraged reproduction by allocating social aid allowances, tax exemptions, and education grants in the state-funded boarding schools for families [End Page 435] with more than five children.²² Turkish physicians also engaged with the eugenicist trends in the 1930s; and yet eugenicist conversation as a means of pronatalist policy arguably remained as a medical-intellectual conversation among urban-based high-ranking physicians.²³ Early Republican pronatalist policies yielded the desired results pertaining to population growth, in that population of Turkey increased from 13,648,270 in 1927 to 18,790,174 in 1945.²⁴

The single-party rule of RPP came to an end with the transition to the multiparty politics and the establishment of the Democrat Party (DP) in 1946. Under the leadership of Adnan Menderes, DP came to power in 1950 and implemented free-market policies, aggressive agricultural development, and diplomatic relations as a close U.S. ally through strategies to join NATO and other anti-Soviet regional alliances. Despite major political differences with the RPP, DP rule did not diverge from the former regime's pronatalist policies. Building a healthy population was a central theme and reflected escalating effects of the Cold War militarism. DP's pronatalist stance is best illustrated in the public health manuals, which were released as a Marshall Plan series for peasant families in 1951.²⁵ In The Care of Pregnant Women, for example, the author emphasized the significance of a healthy and large population, which was depicted as the child-soldiers, as a means of posing a serious threat to the nation's potential "enemies."²⁶ In other words, population growth was not considered to be an alarming matter yet in the early 1950s. On the contrary, the pronatalist policies advocated even a greater population growth and portrayed a strong nation as a healthy and happy family with multiple children.

What, then, drove a dramatic shift from a pronatalist policy encouraging population growth in 1951 to an antinatalist trend in the late 1950s depicting an increase as such as an alarming threat for national development? Turkey population increased from 20,947,188 in 1950 to 27,754,820 based on the 1960 census.²⁷ In addition to the increase, the census revealed a shift in Turkey's urban-rural divide: a ratio of 19 to 81 [End Page 436] percent urban-rural population in the 1950 census shifted to a ratio of 26 to 74 percent in 1960, signifying an accelerated pace of urbanization. A shared trend in population growth and urbanization was connected to the mechanization and commercialization of agriculture, construction of highway networks, and increased investment in public health. Although a small number of landowners and manufacturers profited from the rural economic growth, many dispossessed peasants migrated to urban centers for work and life opportunities. As Sinan Yıldırmaz discussed, the post–World War II era changed the way that peasants were viewed as a social class. The political formulation of the single party era desiring to keep the peasants in the rural in their "natural places" by way of village institutes that would cultivate self-sufficient work and life environment and prevent peasants moving to the urban areas was no longer an effective strategy. While peasants were viewed as an idealized component of the labor force and army as long as they engaged with agricultural production outside of the cities, the rapid domestic migration make the peasantry both visible and politicized.²⁸ In the mid-1950s, "population growth" became a social problem when the intensified domestic migration prompted an unprecedented and sudden encounter of urban and rural divides emphasizing class and cultural differences between the urban residents and newcomers along with a lived experience of housing crisis in urban areas.²⁹

Population growth was not simply viewed as a sociological issue. In the 1950s, physicians considered it as a public health matter. Among others, Nusret Fişek, a recent graduate of Harvard Medical School and the head of the Institute of Public Health, became one of the most significant advocates of family planning in rural Turkey.³⁰ According to Fişek, there had been a significant population growth, which occurred alongside high maternal-child mortality, suggesting additional evidence of underdevelopment by way of the state's failure to provide maternal health care. Based on large-scale research among 132,000 participants and 7,000 women from rural areas in the summer of 1958, Fişek concluded that birth, [End Page 437] death, and pregnancy were important social issues and that it was not only self-induced abortions and miscarriages that endangered the lives of mothers.³¹ Fişek claimed to find a high rate of infant mortality of 166 per 1,000 live births. Survey results linked access to elementary education to fertility tendencies and proposed overcoming the "population problem" through family planning and increasing elementary education among the rural population. Fişeks findings offered a critical analysis to impress and steer policy makers toward a new perspective for population planning. However, it would be interrupted by new political developments.

A military coup on May 27, 1960, ended DP rule. The midlevel officers who performed the coup rationalized the intervention with the increasing authoritarian rule of the government leading to the escalation of violence along with "unconstitutional" practices pursued by the government.³² The National Unity Committee (NUC) took over power as the temporary governing body until the declaration of the new constitution and transition to civil government in October 1961.³³ Debates regarding population planning took shape in the transitional post-coup political climate. Initially, the NUC launched the State Planning Organization (SPO) to draft the first five-year development plan, covering the period between 1963 and 1968.³⁴ A section dedicated to "Population Planning" was the first attempt at describing population growth as a problem in the agenda of the development plan.³⁵ Second, the NUC passed Law 224 of the Socialization of Health Services in January 1961. The new public health law aimed at enhancing the health care workforce and access to public health services free of charge, especially in rural areas, by offering competitive wages and limiting private practice for state-employed physicians.³⁶ A province included in the "socialized" health program, by default, received personnel and budget allocations for family planning programs.

The new public health law revealed the biopolitical as well as geopolitical implications of development plans and in that population had been a significant element of public health infrastructure. Instead of following [End Page 438] the initial plans to introduce the new public health law in urban areas in western Turkey, the NUC commenced the new public health practices in the rural eastern provinces, where the population was predominantly Kurdish. The militaristic wing of the post-1960 coup regime framed the "eastern question" as a problem of economic backwardness instead of a political matter pertaining to "Kurdish question" and mobilized resources in an effort for a national(ist) integration and, as discussed by Asena Günal, by winning the "loyalty" of the Kurdish citizens in return for "free health care."³⁷ This strategic choice was taken to highlight objectives linked to the establishment of a distinct planning as a "developmentalist" response to the political and social demands of the Kurdish population.³⁸ As Adalet demonstrated, modernization projects of the 1950s involved highways as a means of integrating eastern Turkey, "an open territory waiting to be acquired," through knowledge of its population and landscape.³⁹ Post-1960 coup reforms exhibited a continuity with the 1950s modernization projects modeled for Turkey by American theorists and Turkish bureaucrats. A pilot socialization program was first launched in 1963 in Muş, a predominantly Kurdish town, the population of which increased by 117 percent between 1945 and 1963 and reached 156,806 according to the 1960 census.⁴⁰ Other Kurdish-populated eastern provinces such as Ağrı, Bitlis, Hakkari, Kars, Van, Diyarbakır, Erzincan, Erzurum, Mardin, Siirt, Urfa, Adıyaman, Bingöl, Elazığ, Malatya, and Tunceli were included in the program gradually by 1967.⁴¹

Then, the members of the NUC government conceived population planning at the intersections of geopolitical and biopolitical matter and opted for framing it as part and parcel of public health policy in the rural east. Despite the presence of a vocal opposition of predominantly right-wing academics, politicians, and journalists, (military) members of the NUC encouraged Fişek, who became undersecretary of the Ministry of Health during the transitional rule, to draft a bill to replace the existing pronatalist law prohibiting birth control and the contraception use.⁴² In what follows, the NUC also "consulted" with the Directorate of Religious Affairs about the compatibility of birth control with Islam. The directorate issued [End Page 439] a fetva, an official religious statement, that explained the acceptability of contraception with conditions of the consent of women and in circumstances such as war and mobilization that would lead to the lack of proper conditions to raise a child.⁴³ In Turkey, which was ruled under a state of emergency as a pretext to war, the issuance of a fetva signaling the permissibility of contraception was a calculated step to quell growing opposition.⁴⁴ The results of the first elections, held in October 1961, revealed a divided political landscape in post-coup Turkey. RPP won the elections by a narrow margin of 36.7 percent to 34.7 percent for the Justice Party (JP), one of the newly founded political parties that inherited the DP's political and electoral legacy.⁴⁵ Turkey's political climate was dominated by aggressive competition between right- and left-wing parties spearheaded by JP and RPP. "Population growth" became an increasingly politicized phenomenon as a result of the ideological and political polarization between these political parties.

Upon transition to parliamentary politics after the 1961 elections under a RPP coalition government, population planning gained a transnational character when the Ministry of Health hosted two major global players in population planning: the PC and the Pathfinder Fund. The Cold War–era political climate played a significant role in dynamic shaping of the U.S.-Turkey collaborations. Population planning projects progressed in an environment of tense diplomatic relations marked by the rise of anti-American sentiments among the worker and youth movements as well as diplomatic confrontations over the "Cyprus issue" in the 1960s and 1970s.⁴⁶ In the escalating conditions of the global and local political climate, a group of high-ranking PC representatives conducted meetings with bureaucrats, scholars, officials, workers, and local residents in İstanbul, Ankara, Īzmir, Aydın, and Diyarbakır in April 1963.⁴⁷ Following PC members' visit, Mrs. and Mr. Charles Zukoski of the Pathfinder Fund spent the entire month of May and early June 1963 meeting with high-ranking bureaucrats and physicians in Ankara, Izmir, and Istanbul. They also developed close ties with nongovernmental actors such as the Turkish Family Planning Association (TFPA), a new organization founded by [End Page 440] a group of doctors, university professors, civil society workers, and philanthropists based in Ankara and Istanbul.⁴⁸ After the visit, the PC team presented a report suggesting implementation of an immediate family planning program, a network of programs and personnel training based on the local needs, a preliminary "trial" period for diverse methods of contraceptives and birth control through training and education sessions in pilot regions, and finally tests of methods such as IUDs and oral contraceptives. These recommendations, derived from prior PC projects in Korea, Pakistan, and India that emphasized cost-effectiveness as well as "social and cultural sensibilities of the users," constituted the backbone of PC operations in Turkey until they closed their Ankara office in 1971.⁴⁹

While these early contacts with the PC and Pathfinder enabled the government to formulate the extent of the population planning programs, it took four years of media promotion, conferences, and voluntary organization efforts to negotiate the law with the JP-dominated opposition after the first draft of the Population Planning Law was submitted in 1961.⁵⁰ The opposition voiced by the JP persisted. Parliament minutes manifest the scale of politicization of the notions of population, body, and sexuality between the proponents and the opponents of the law during the multiple Parliament and senate meetings between February 1963 and April 1965.⁵¹ While the RPP government pleaded for population planning by arguing that the high maternal and infant mortality rate was the motivation for the law, JP members argued that Turkey was underpopulated given the vast quantity of uncultivated agricultural lands. Other JP members suggested that population growth was necessary given Turkey's geopolitics and Europe's reliance on guest workers from Turkey as a source of labor.⁵² Another JP view berated the international community for enforcing medical solutions rather than making socioeconomic investments to address issues like population growth.⁵³ Finally, some JP members contended that access to contraceptives would cause a moral crisis in society by promoting extramarital sexual intercourse and discouraging young women from getting married and reproducing.⁵⁴ On April 10, 1965, the law was [End Page 441] eventually passed. In July 1965, only three months after the promulgation of the law, the JP took over the government and Süleyman Demirel became the new prime minister. Despite their rigorous opposition during the parliamentary debates, it would be the JP-led government that would oversee the establishment of family planning programs.

Experimenting with Family Planning, Measuring Social Change

Turkish planners considered population growth a symptom of underdevelopment and a rural matter. In collaboration with American experts, Turkey crafted family planning programs framed around the discourse of social development by cultivating new notions about family, fertility, and birth control in rural areas and in the urban-based squatter neighborhoods that were social and cultural extensions of rural Turkey. As the debates about population planning continued in the early 1960s, Turkish and American family planners collaborated over small-scale experimental projects to formulate scientific, rational narratives on fertility trends, the demand for contraceptives, and social and cultural impulses about birth control. After the promulgation of the law in 1965, the government incorporated family planning into public health services undertaken by the Ministry of Health. A host of new actors including universities, professional medical associations, and nongovernmental organizations advocating for family planning were officially involved in outreach campaigns. In the absence of public health infrastructure in rural Turkey, a new phenomenon of mobile teams carried out the family planning campaigns, which were designed to serve rural and urban-dwelling low-income families. As weaved into the public health services, family planning took the form of an infrastructure for social development centering on the reformulation of "population" among the targeted rural and urban participants to impact local values and practices pertaining to family size, fertility, and gender dynamics.

In the aftermath of the Population Planning Law, Ankara became a pilot area where PC-sponsored family planning programs were launched in both urban and rural areas by the General Directorate of Family Planning (GDFP) and the Ministry of Health. Ankara Maternity Hospital (AMH), where "the women come from all over the city," started the initial experiments in June 1965 with the collaboration of GDFP and PC under the program titled "Family Planning for the Urban Disadvantaged," which was also known as the "Post-Partum Program."⁵⁵ Performing 30,000 [End Page 442] obstetric and gynecological visits and 11,000 deliveries per year, AMH became the model program also in introducing experiments on such new contraceptives technologies as IUD insertions and oral and injectable contraceptives.⁵⁶ To run the program, AMH needed to overcome technological and personnel shortages. Thus, PC initially contributed $15,000 for a two-year trial by investing in a vehicle for follow-up visits, salaries for three extra nurses, a sound system for on-site hospital announcements, and research materials.⁵⁷

In the first two years of PC-funded experimental family planning program at AMH, there had been 13,000 IUD insertions.⁵⁸ The injectable contraception experiment remained on a small scale, with sixty-one women participating, thirty-seven of whom discontinued because of side effects such as bleeding, pain, and depression.⁵⁹ As for the oral contraceptives, which were provided for free at the beginning, there were 3,500 women participated in the program for access to the medication on a monthly basis. However, when the family planning clinic ran out of pills and began using a prescription-based drug, only 18 percent of the women continued to use the pills. In addition to side effects such as decreased menstrual flow, psychological effects, and cancer concerns, women stopped taking the pills due to unaffordability and difficulty of access to the pills outside of the program.⁶⁰ By 1965, there were still no local pharmaceutical manufacturers producing tablets and contraceptives.

The AMH program expanded to include women in the emerging squatter neighborhoods through mobile medical team visits. Civil society and urban-based women's rights advocacy groups such as the Association of University Women (AUW) functioned as an extension of GDFP projects and joined the outreach campaigns on the outskirts of Ankara.⁶¹ Over the course of 1966 and 1967, AUW organized 174 meetings in and outside of Ankara, with an attendance of 15,424 women.⁶² As I will discuss in greater detail in the following sections, Serim Yurtören's (later Serim Timur) 1963 research, which included over a hundred questions for in-depth interviews with middle-class and low-income women based in Ankara, revealed that [End Page 443] women had long used both traditional and nonconventional birth control methods.⁶³ In other words, women's interests and voluntary participation in the hospital and mobile team activities were driven by their lived experiences and demands for access to reproductive health. The mobile teams of AUW and TFPA offered lectures and trainings to women of reproductive ages as well as their elder counterparts such as their mothers and mothers-in-law.⁶⁴ Their collective participation in mobile visits across generations was motivated by the culmination of painful and fatal reproductive experiences. Thus, contrary to the views that women were unaware of the implications of family planning, evidence suggests that they opted for an alliance with family planning agents to gain control over pregnancies and failed contraception methods.

A typical outreach program began with an education session to explain the various birth control methods, both traditional and pharmaceutical, to local women who gathered in the district elementary school.⁶⁵ Thereafter, a mobile medical team comprising a physician and nurses performed IUD insertions, following a basic medical examination in the vehicles or in the classrooms, which were converted into temporary clinics.⁶⁶ In Istanbul, for example, in addition to squatter neighborhoods, the government employed mobile teams for birth control trainings and IUD insertions in the factories for female factory workers exclusively.⁶⁷ Daily outreach campaigns carried out by mobile teams became increasingly important for the government in its efforts to establish a developmentalist infrastructure through family planning programs.

When the PC and Turkish planners realized the efficiency of mobile medical teams, outreach campaigns gradually moved into rural Ankara. After being removed from his position as undersecretary when JP came to power, Nusret Fişek became the director of Hacettepe University's Institute of Population Studies. At this new academic home, Fişek championed the most significant experimental program in rural Ankara in 1966, with financial and technological support from the GDFP and PC. Etimesgut became the site of one of the longest-running family planning programs and a social laboratory for testing instructional and medical methods, the efficiency of mobile teams, and local responses to contraceptive methods. Traveling from Ankara with two vehicles provided by USAID, [End Page 444] educational and medical teams visited villages for two consecutive days to deliver physical examinations and information about contraception choices (Figure 2). After the completion of the education team's information sessions for the local authorities to "create a climate of acceptance and publicity," they met with women and men in the villages separately for lectures emphasizing "health and family economy" and the health risks of self-induced abortion.⁶⁸ The following day, medical teams set up temporary clinics for general physical examination and IUDs insertions for volunteering women. The Etimesgut mobile teams became the key model for the nationwide rural family planning programs in Turkey, especially in the eastern provinces, where family planning gained momentum in the late 1960s.

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Figure 2.

A hectic scene from Ergazi health center, where Dr. Ayşe Akın advised visitors about their birth control options. Courtesy of Rockefeller Archive Center, RAC/Population P20 Hecetteppe, Turkey-Family Planning, folder 321, Communication Office photographs.

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The perceived success and efficiency of the mobile medical teams were closely related with the lack of infrastructure including roads and public health facilities in rural Turkey, particularly in the eastern provinces. By the late 1960s, there were 27 million rural residents of 50,000 villages, around only 15,000 of which had road access. The rest of the rural population could be reached only "by jeep or donkey," illustrating the two extremes of developmentalist endeavors.⁶⁹ A growing economic and technological dependency on aid from the United States was combined with the desire to maximize the effectiveness of the mobile teams. In 1967, the government negotiated a loan agreement with USAID for the importation of a fleet of 1,400 vehicles and $300,000 to equip its rural family planning program.⁷⁰ In the absence of sufficient fixed health clinics, mobile teams became the backbone of family planning programs. To summarize the intensive work, in the course of 1968 a mobile team of four professionals visited rural areas by touring 227 villages with a population amounting to 160,500. They provided basic training to 7,000 women during these visits and returned to Ankara after 113 days on the road with a 10.7 percent acceptance rate—twice the national target of a 5 percent acceptance rate—and an overwhelming number of IUD insertions among rural women (Figure 3).⁷¹

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Figure 3.

Dr. Ayşe Akın, along with nurses and midwives, supervises the IUD insertions at Ergazi clinic. Courtesy of Rockefeller Archive Center, RAC/Population P20 Hecetteppe, Turkey–Family Planning, folder 321, Communication Office photographs.

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Rural family planning programs in Etimesgut and other areas around Ankara served as a model for the programs launched in the eastern provinces. In March 1967, PC received "A Family Planning Project for Erzurum Province," a joint proposal from the Ministry of Health and the newly established Medical School at Erzurum Ataturk University seeking support to launch a program.⁷² The proposal referred to Erzurum, which is located in the northeastern part of the country near the Russian border, as "the least developed and the poorest" region in Turkey. The province covered an area of 9,690 square miles and had a population of 628,856, with 106,301 people living in the Erzurum city center and the rest dispersed throughout thirteen towns and 1,067 villages.⁷³ Under the new public health law, Erzurum received state funding for the employment of medical personnel for basic health care and family planning activities. Four weeks after the physicians' appointment, there had already been 86 IUD insertions, and by March 1967 the total had increased to 468.⁷⁴ The proposal aimed to perform 6,300 IUD insertions per year by reducing population growth by half and reaching 31,500 insertions in five years through collaboration with the military, religious leaders, local radio stations, the malaria control administration, and potential partners such as the Health College and village midwifery school.

In contrast to rural Ankara, the political climate in the rural east highlighted political sensibilities and expectations of the local population from the state, for whom family planning was both a biopolitical and a geopolitical endeavor. The submission of the Erzurum proposal coincided with an increase in political opposition and dissent among the local, predominantly Kurdish, population against the growing socioeconomic and regional inequalities caused by the government's insufficient investments and distribution of welfare services. In the fall of 1967, a group of urban-based young Kurdish intellectuals, politicians, and university students, who were primarily affiliated with the growing Workers' Party of Turkey (TİP), organized a series of public campaigns, called the Eastern Meetings (Doğu Mitingleri), in various eastern provincial centers to voice the collective demands against the government's underinvestment in social welfare services in the eastern provinces.⁷⁵ There was a large socio-economic [End Page 447] disparity between the east and west of the country, which was most obvious in the distribution of medical personnel. In Istanbul, there were over 2,500 licensed physicians, whereas there was only one in Bingöl and none in Hakkari.⁷⁶ Protesters' demands for equal citizenship and equal access to health care, education, and economic development were quickly dismissed by the government and framed as Kurdish nationalist separatist activities. Nonetheless, key government officials and politicians, as well as the RPP-led opposition, rushed to the eastern provinces to hold local and counterpropaganda meetings.⁷⁷

Family planning, a developmentalist project curated by a military junta in collaboration with global humanitarian aid, generated a political agenda in the east that was primarily motivated by the government's desire to combine public health infrastructure with a national welfare program and a securitization device of governance. On the government side, the Erzurum project exemplified the perfect environment for building a family planning infrastructure to meet the twin goals of public health service and population control. Nevertheless, the PC agreed to support the Erzurum proposal with substantial changes, insisting on a complete separation of family planning from maternal and child care services, and granted $25,000 for a two-year period beginning on January 1, 1968.⁷⁸ This revision begs further elaboration to highlight how priorities for the PC and the Turkish government almost conflicted with each other over the implications of family planning, especially in the rural context. For the PC, facilitating family planning programs simply meant population control through the execution of projects for maximum effectiveness in recruiting IUD and oral contraceptive users, monitoring their submission to the program, gathering information on continuation, obtaining statistical data through surveys and computation programs, and translating the data into an assessment measuring fertility trends on a global scale. Therefore, on the PC side, investments for local family planning projects required a standardized research and assessment plan to yield data that were not intended for health care.⁷⁹ Nonetheless, for Turkish authorities, family planning programs were substantially linked to health care infrastructure and, particularly in the eastern provinces, the construction of a national health program. [End Page 448]

Different from Ankara-based initiatives, there were significant climatic, social, and political circumstances that shaped family planning project attempts in Erzurum and in the entire eastern region. As PC representatives learned firsthand in early 1968 when they were stuck on the train for a week in the middle of a snowstorm in the east, harsh winter conditions and lack of highways and roads cut off the villages from the provincial centers for many months, depriving the rural population of access to food, health services, and communication.⁸⁰ The government considered foreign aid for rural development projects as a strategy to raise funds for competitive wages for health care personnel, especially for physicians, who avoided the area and therefore had to be convinced to work in the region. They also invested in visual materials and broadcasted many programs over local radio stations, which PC considered as a powerful medium in encouraging local families to join the programs.⁸¹ At the end of the second month, the Erzurum program was considered to be successful based on 2,000 IUD insertions, 1,700 of which were performed by mobile teams, and the distribution of 433 cycles of oral contraceptives into the third month of the project. John Frierson, Ankara officer for PC, described the Erzurum family planning program as "one of the best" based on the activities of the medical personnel as well as dynamic family planning propaganda.⁸²

Nonetheless, the local educational director in Erzurum depicted a more nuanced picture, revealing gendered, political, and religious dynamics shaping the program. As reported to the PC, local women tended to avoid IUD insertions by male physicians as well as conversations about birth control due to the implications of sexuality.⁸³ Local women were also concerned about the side effects of IUDs, such as bleeding and increased cancer rates. Communication was another problem. The lack of Kurdish translators among the mobile teams was a setback in addition to the discomfort among the Kurdish population toward family planning, which they considered to be a strategy of the government to eliminate the Kurdish population.⁸⁴ As discussed by Günal, in the formulation of the nationalization of the health services law in the 1960s, military authorities decisively excluded proposals for bilingual services.⁸⁵ As in other instances [End Page 449] in which the government refused to acknowledge the political and linguistic demands of local Kurdish populations, the PC did not engage with this account of linguistic barriers and fears of the Kurdish population about family planning as a means of ethnic extermination.⁸⁶ In the absence of personnel for trainings, the vehicle drivers, some of whom spoke Kurdish, volunteered for the educational work involving distribution of visual materials and posters as well as verbal translations while visiting Kurdish villages.⁸⁷ Finally, there were disagreements voiced by local religious authority (müftü) toward the family planning programs. A partial agreement was maintained only when the local education director provided translations of religious statements released in Egypt, Pakistan, Jordan, and Iran demonstrating the approvals of religious authorities in other Muslim countries. Yet the müftü, who was a state-appointed civil servant, was not convinced by the translations. Upon his request, the director contacted Al-Azhar University in Egypt to obtain the original Arabic version of the decision.⁸⁸

Only one year after the program's launch, in February 1969, Dr. Mithat Torunoğlu, the dean of the Medical School, suggested that PC discontinue the Erzurum program entirely.⁸⁹ For Torunoğlu, family planning programs were destined to fail, but not because of a lack of interest among the local population. On the contrary, despite significant demands from rural women, there was a major shortage of medical personnel, which dropped from forty-eight physicians to seventeen due to rotations, that caused program failures. Additionally, despite efforts to reduce the stigma associated with IUDs, local religious authorities persuaded women to cease using them. Nonetheless, Torunoğlu did not raise language barriers or Kurdish inhabitants' concerns about family planning in the report. Despite all the setbacks—voiced or implied—PC insisted on continuing the program and considered termination only as a "last resort" because the IUD insertion rates represented a success story.⁹⁰ [End Page 450]

IUD Alliances

By the late 1960s, Turkish planners, physicians, and global organizations' efforts and investments to promote family planning programs had resulted in an increase in IUD and birth control pill use among rural and urban squatter dwelling families in Turkey. However, focusing entirely on data acquired from local clinics, mobile team logs, and annual data analysis may conveniently lead to portraying the family planning programs as a standalone "achievement" on the part of the government and transnational players. On the other hand, rural and urban poor families entered into a negotiation and an alliance with the political and public health authorities about how to navigate new contraceptive technologies while protecting their subjective interests over their own bodies, fertility, and family size. Women played the most significant roles in these alliances and negotiations because their bodies were central to family planning narratives and practices. Knowledge about new contraceptive technologies provided women with new opportunities—other than self-induced abortion—to establish and secure a new form of authority over their own bodies and reproductive choices, which were otherwise dominated by the pronatalist state outside and their husbands at home. At the intersections of the negotiations and alliances, a plastic U-shaped tool took center stage as the Turkish government favored IUD technology as the primary choice of contraceptive method in family planning programs designed for rural and urban poor families.

The popularity of IUDs was directly related to views depicting and structuring body politics, fertility, and sexuality of targeted women based on class and ethnic differences. Despite the dubiousness of IUDs under legal scrutiny in the United States, they quickly became the key tool in Turkey with free donations from the PC as a "technological fix" to population growth and fertility control among rural and urban poor women.⁹¹ In clinics and during the mobile team visits, a regular family planning training provided instruction on both traditional contraception methods, such as withdrawal and douche, and new technologies with pharmaceutical features, such as diaphragms, vaginal gels, condoms, IUDs, and finally pills.⁹² Nevertheless, the GDFP officially presented IUDs as the preferable method during outreach campaigns owing to prospects of less expensive technological solution, eliminating the burden of frequent medical visits [End Page 451] for refills and ensuring a successful outcome.⁹³ Following the passage of the legislation, the Ministry of Health quickly incorporated IUDs into family planning programs and provided a three-week IUD insertion training in Ankara to physicians from all across the country. For motivation and better productivity, the ministry even compensated licensed physicians ten liras of incentive payments for every IUD insertion, even though often female nurses and village midwives performed the insertions.⁹⁴

In the years after 1965, Turkey imported hundreds of thousands of IUDs through donations based on collaborative agreements with international aid organizations. PC provided 50,000 IUDs and 2,500 inserters in 1966 and approved another order of 50,000 IUDs and 2,500 inserters for the next delivery.⁹⁵ In February 1966, PC negotiated patent agreements for "non-exclusive, royalty free rights and licenses" for Turkey's Lippes Loop and Margulies brands of IUDs.⁹⁶ Considering Turkey as a new pharmaceutical market for IUD use, PC in collaboration with the Ministry of Health conducted research among Turkish plastic manufacturers for potential local IUD producers to contract production of 350,000 IUDs per year with the preblended polyethylene-barium raw material and the hydraulic injection machine provided by the United States.⁹⁷ While such mass production in local scale did not materialize immediately due to low profitability for the local manufacturers, there had been 203,698 IUDs inserted nationwide through the family planning programs by April 1970 based on annual data of 33,056 in 1966, 43,655 in 1967, and 58,669 in 1968, and 57,452 in 1969.⁹⁸

The GDFP's eagerness to popularize IUDs over other pharmaceutical contraceptives was closely linked with Turkish planners' portrayal of rural and urban squatter-dwelling women as an underdeveloped social class shaped by illiteracy and poverty and rural in character; however, they were physically robust, strong, and enduring. The GDFP, like their American counterparts, invested the most in IUDs because they did not consider [End Page 452] rural and urban low-income poor women to be appropriate consumers of birth control pills since they viewed the pill as a technology of self-discipline and the targeted women were not seen as capable of managing twenty-eight-day pill cycles as well as their educated upper- and middle-class counterparts.⁹⁹ This viewpoint was most openly expressed by local physicians during the summer 1968 field trip of John Frierson of PC and Turgut Metiner of GDFP to the eastern provinces including Ağrı, Van, Diyarbakır, and Mardin. One such physician in Diyarbakir advocated for the use of IUDs and questioned the usage of pills among rural women, claiming that "they would not take them regularly and would then get pregnant and bring family planning into disrepute."¹⁰⁰ In other words, rural women were thought to be unfit to comply with the use of pills; and to counteract the doubts and reluctance about contraceptive technologies, IUDs provided physicians with a better scientific ground of reliable outcomes in preventing pregnancies than pills to convince and recruit women for family planning programs. Physicians, on the other hand, did not consider the common side effects of IUDs to be potential problems for rural women. A 1969 report noted the low rates of side effect complaints and argued that the rural women in Turkey "live on a high protein diet and tend to be very hardy and robust. They are therefore less likely to suffer from anemia that their sisters might be in countries where the diet is more vegetarian."¹⁰¹ The use of IUDs as a contraceptive technology contributed to the perpetuation of a stereotype of rural and urban poor women who were physically well-built and robust and only fit for a "quick fix" to manage their fertility.

IUDs met the desires of family planners and social scientists for easy and efficient methods of experimenting, surveying, measuring, and ultimately manipulating fertility trends, especially in rural areas.¹⁰² Physicians, nurses, and village midwives as well as population researchers contributed to conduct "knowledge, attitude, and practices (KAP)" surveys to track nationwide contraception use, whether traditional or pharmaceutical. To judge the "success" in family planning programs, the GDFP and PC depended heavily on IUD insertion counts, which were documented via insertion coupons, village visit logs, and monthly and annual questionnaires.¹⁰³ [End Page 453] Through punch card and computation technology, IUD insertion counts were used to generate statistical knowledge about social trends in fertility, values attributed to motherhood, and sexuality. IUD insertion counts were used to formulate production and prediction of sociological trends about gendered and social attitudes and practices as quantifiable and statistical data to measure progress.

In addition to quantitative sociological measures of women's progress based on IUD insertion, family planning surveys produced a gendered narrative in which eager, collaborative, and yet ignorant rural and urban low-income women were depicted against conservative men, who were viewed as obstacles to family planning programs and thus to social development. In one case reported in the Foundation Quarterly Report, a village headman from Gümüşhane, a small town in central northeastern Turkey, refused the mobile family planning team entry into the village and redirected them to a neighboring village, claiming that "in [their] village, [they] have no such problem," alluding to family planning as problem-driven matter. Local women, however, gathered to protest the headman and forced him to reinvite the mobile team back to the village, according to the story. "The headman," as narrated in the Report, "caught up with the Health Ministry team in a nearby town and begged them to return: 'You've got to save me from these women!' He cried. 'They are after me with sticks and pitchforks.'"¹⁰⁴ Despite the fact that the article was written for a particular audience, namely friends, supporters, and donors of the Rockefeller Foundation, for whom an archetype of illiterate, ignorant women and oppressive conservative men was a common Middle Eastern stereotype, the moral of the story suggests that despite the village headman's rejection, the village women demanded meeting with the mobile team for their own collective and individual reasons, which may have included the opportunities of medical consultation and health examination without the hassle of going to the center or simply because they were curious to know about family planning at large. In other words, despite the government's involvement and the opposition of the local men, rural women decidedly formed an alliance with the family planning teams to negotiate their authority over family, reproduction, and health. [End Page 454]

The lack of first-person accounts from rural women prevents us from uncovering the motivations behind their demands to meet the mobile team. Family planning surveys often collected systematic data using quantitative and universalizing approaches, but they failed to reflect social factors that encouraged women to use family planning. On the other hand, despite its limitations, print media coverage and scholarly research shed light on urban squatter dwellers' experiences and their rationale for adopting contraceptive technologies. One such study, "Fertility and Related Attitudes among Two Social Classes in Ankara, Turkey," by Serim Yurtören (Timur), demonstrates that women were actively exploring and experimenting various contraceptive alternatives long before birth control was made legal.¹⁰⁵ In the summer of 1963, Timur headed to Yenimahalle, a middle-class neighborhood, and Altındağ, an emerging squatter community, both of which were just a few miles away from Parliament, to interview fifty women. One hundred nineteen questions were used in Timur's interview to capture significant details about the decisions women from different social classes made regarding fertility and contraception as well as familial and social factors shaping those decisions at the intersections of reproduction and sexuality (Figure 4).

Timur's interviews challenge the stereotype of women's ignorance about birth control methods by demonstrating that women from both socioeconomic classes "wholeheartedly" supported the idea of birth control, even though it was illegal in Turkey at the time.¹⁰⁶ The research also revealed that in fact many women already practiced withdrawal, douche, and pessary.¹⁰⁷ Condoms were also known and accessible; however, they were a less popular method due to their cost as well as men's unwillingness to use them with the excuse of condoms' alleged interference with their sexual pleasure.¹⁰⁸ The participating women believed condoms to be safer, especially for spacing. However, Timur argued that "male authoritarianism" failed women in convincing their husbands to use condoms because "it is always the husband who decided what method to use and when to start."¹⁰⁹ Thus, monitoring fertility and managing birth control methods drew women's bodies into the focus of family planners as the condoms were dropped from the Ministry of Health's choice of contraceptive investment because, as the director of GDFP simply stated to a [End Page 455]

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Figure 4.

A fifth-year medical school student conducting a survey in Ankara's Gülveren neighborhood and conversing with a twenty-year-old mother of five who recently migrated from eastern provinces. Courtesy of Rockefeller Archive Center, RAC/Population P20 Hecetteppe, Turkey–Family Planning, folder 321, Communication Office photographs.

PC representative, "Turkish men won't use it!," noting the fact that the government never attempted to promote their use.¹¹⁰

Despite the widespread belief among women that reproductive capacity was what qualified womanhood and motherhood as acceptable social status in the family and society, women from both classes increasingly explored various contraceptive methods and also shared their personal experiences with each other as they pursued new methods when others failed. The unpredictability of both withdrawal and douche methods [End Page 456] contributed to failures in these endeavors. Due to shortcomings of the squatter dwellings, they eventually stopped using birth control methods like douche. For example, 40 percent of Altındağ interviewees lived in single rooms, whereas 48 percent lived in two-room homes, frequently with the extended family.¹¹¹ These homes shared an outside toilet with two or three neighbors and had no interior bathrooms or kitchens, meaning there was no running water available inside. Therefore, even though squatter-dwelling women tried traditional methods like douche and failed to avoid pregnancy, they turned to self-induced abortions. Despite the life risks, they employed foreign objects as well as pharmaceutical injections to induce vaginal bleeding in the absence of menstruation to stop their pregnancies.¹¹² As a result, when a family planning mobile team emerged in their neighborhood, promoting a new contraceptive technology in the form of a small plastic or coiled spiral or pills, many women seeking to control their pregnancies participated.

Among other new contraceptives, IUDs provided a limited but novel opportunity for rural and urban squatter women to negotiate their reproductive choices with both their husbands, who held the authority over contraception methods, and the government, which sought to fulfill a multifaceted biopolitical agenda that included population control and maternal and child care. There was resistance, too. Some doubts about the safety of IUDs regarding cancer and infertility risks appeared in newspaper articles, and this information spread among women by word of mouth.¹¹³ In the mid-1970s, however, the socialist feminist press leveled a harsher criticism at the Turkish government's family planning programs. Appealing to emerging urban working-class women along with rural (working) women, Women's Voice, the official magazine of the Progressive Women's Association, centered feminist discourses and demands along the lines of women's labor both in the workplace as factory, domestic, and agricultural workers and at home as homemakers and mothers. Feminist authors frequently criticized government social policies, or the lack thereof, by highlighting employers' and the state's inadequate provision (and violation) of working women's rights to health care, child care, and lactation rooms. They did this by construing "motherhood" as a discursive ground for political and social rights demands.¹¹⁴ Women's Voice's portrayal of "motherhood" as labor, women's right to reproduction, and the responsibility [End Page 457] of society at large to honor women's multifaceted labor shaped the feminist narrative regarding family planning programs. Hence, Women's Voice advocated for a family planning discourse through a vocabulary of social policy and justice demands by employing reproduction and motherhood as manifestations of labor at home and at work:

Instead of social and moral assistance, the leaders of our social order give us advice of not to reproduce, and if we do, not to leave [children] unattended. This social order, which forces us to work with low wages and in hunger, also give us—other than advice—birth control pills and devices. Hence, in Turkey, birth control and family planning are defined by this useless advice and the pills. This is the definition, and they embellish it with fancy words. In reality, we are not against birth control pills, devices, and acquiring birth control information. On the contrary, we believe that these tools and information enable women to freely reproduce and become mothers without jeopardizing their health.¹¹⁵

Weekly themes covered in the "Maternal-Child Health Care" column manifested motherhood as a discursive and practical domain of feminist activism with remarkable statements such as "the right to become a mother with access to work, child care, and without risking one's life" in the late 1970s.¹¹⁶ Family planning, according to the authors of Women's Voice, was just a supplement to social policy encompassing access to health care and reproductive rights for urban and rural working women.

Conclusion

Family planning continued to be a realm of collaboration and political contestation among global, national, and local players in Turkey in the 1970s even after the PC closed their Ankara office to relocate in Tehran. The PC was dissatisfied with the lack of accomplishments because of the JP-led government's reluctance to invest owing to concerns about opposition in Parliament.¹¹⁷ Collaborations between GDFP and PC were revitalized only after the launch of the Taylor-Berelson method, which led to substantive revisions to incorporate maternal and child health care into family planning.¹¹⁸ In the 1970s, family planning became a crucial international [End Page 458] aid and interdependence mechanism between the West and the Global South, promising significant flows of loan. By the early 1970s, the Turkish government secured funds up to $7 million for vehicles and contraceptives for rural family planning from the Ford Foundation, Swedish International Aid Agency, as well as USAID.¹¹⁹ Between 1973 and 1977, the United Nations Population Fund (UNPFA) became a key investor, with a loan agreement for $10 million between 1973 and 1977 for "family planning services progressively available as a part of maternal and childcare."¹²⁰

In the social and political climate of the Cold War, family planning in Turkey developed at the nexus of biopolitical objectives and geopolitical concerns customized for a select population in rural and growing urban squatters of the working-class families. As they became a nationwide phenomenon in the 1970s, family planning programs integrated state, civil society, and global aid enterprises for a social development goal embodied in women's bodies by using IUD insertion as the key family planning tool. Between 1970 and 1973, the GDFP envisioned 300,000 women to use IUDs to meet the national acceptance rate of 5 percent, with mobile teams performing 80 percent of IUD insertions.¹²¹ IUDs and pills were supplied by the PC, Pathfinder Fund, and alike and were delivered to rural and urban squatter-dwelling women with mobile teams navigating rough terrain with USAID jeeps. Among many other collaborating civil society institutions, TFPA organized 1,306 group educations in addition to 3,893 IUD insertions reaching approximately 13,500 women and men between 1963 and 1969.¹²² By 1976, TFPA had established twenty-nine branches throughout Turkey from east to west. Only in Istanbul did thirteen TFPA-volunteering physicians provide free maternal-child health care on a weekly basis by appointment.¹²³ In other words, despite the unrealistic goals in the light of the limited resources, family planning combined with public health agenda to build an infrastructure upon a collaboration between global, national, and local actors and tailored for social development and an imagined governable population. [End Page 459]

Women's choice and participation had been central to all planning efforts. To circle back to the opening image of this article, after all, women looked toward the new contraception technologies with both optimism and skepticism. Turkish family planners created a new sociomedical narrative about bodies and moralities of rural and urban squatter-dwelling women based on their choices and "alleged" (in)ability to use new contraceptive technologies. According to surveys and case studies conducted in "social laboratories" in rural and urban areas, family planning programs encouraged the use of traditional and new contraceptive methods among women, who had already been exploring available options to prevent unwanted pregnancies prior to the legalization of contraception.¹²⁴ Contraception technologies could potentially provide new avenues for women to acquire control over their bodies and reproduction. Despite the availability and practicality of condom use, qualified as "male contraception method," family planning authorities on global and national levels aggressively opted for IUDs, birth control pills, and vaginal gels, seeking to exert direct control over women's bodies. In other words, birth control was invented on the bodies of women. In the 1970s, research revealed that abortion was commonly used "to correct a contraceptive failure, rather than as a primary means of control."¹²⁵ Indeed, the increase in the number of abortions, primarily among urban-dwelling women, whether self-induced or performed illegally with excessive fees by private practice physicians, became a major public issue in the late 1970s.¹²⁶ Women's resort to self-induced abortions over state-sponsored IUDs and other popularized birth control devices demonstrated what everyone already knew: women's bodies remained the domain of political contestation, and they relied on their bodies as the only bare ground for empowerment even if the cost was fatal and until the alliances paid off. [End Page 460]

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