We were listening to Ann Patchett’s book of essays “These Precious Days” when “There are no children here” started. It is a remarkable essay in 23 parts, explaining why Patchett is not a mother.

            One of the micro-essays upset me a bit. Patchett met a woman who had always known that she didn’t want children. The new friend said that it took her two years to find a doctor who would do her tubal ligation.

            At age 37, Patchett decided she wanted a tubal ligation. She told her fiancé, a physician, and he told her “no”; she was doing well on birth control pills, and there is risk to surgery. She asked her gynecologist for a tubal and she also said “no”; the pill has benefits that help women. If Patchett had her tubes tied, there was a big chance that she’d go back on the pill in order to have milder periods.

            I disagree with what her fiancé and doctor advised. The failure rate of the pill is higher than that of a tubal ligation, and (despite its safety), the risk of blood clots from the pill increases rapidly as women age.

            I like what her friend said, referring to doctors who refused to do tubal ligations: “They think we don’t know our own mind when we decide to have an abortion, but we also don’t know our own mind when we decide to put ourselves in a position where we’ll never have to have an abortion.” Patchett wrote that the doctors who refused to do tubal ligations on request, considered women to be fools who couldn’t be trusted.

            Common parlance distinguishes between women who want a child but are infertile, and those who are “childfree” by choice. The latter group has always existed, but is becoming more common now. Some of these women are so focused on their work that they don’t have the time or energy to parent. Others feel that they would not be good mothers. In addition, there is a new group—women who are concerned that the future is to bleak to subject a child to climate chaos, as well as those who realize that adding to the population will worsen the future of the planet.

            There are women who did not have children—voluntarily or not—throughout history. Roman Catholic nuns take a vow of chastity. One well-known group were the Vestal Virgins, priestesses of the Roman goddess Vesta. They were chosen before puberty and could retire—and even marry—after 30 years. However, if one were caught breaking her vow of chastity, she would be executed.

            The latest figures I could find show that about one in 6 women in the USA never gave birth. Of course, that could be either for reason of infertility or voluntary childlessness.

In most societies women experience pressure to get married and then have children. Although pressure for marriage seems to have decreased, women are still expected to have babies. Pronatalism is causing humans to reproduce at an untenable rate, thus increasing overpopulation and environmental damage.

            There are many organizations for people who are considering being childfree, or have already made that decision. “The Notmom” ( is unique because it supports women whether they are childless “by choice or by chance”. One nonprofit provides funding for sterilizations for both men and women. ChildFree by Choice ( uses donations to help people of all genders avoid unplanned pregnancies.

            If you would like to know more about pronatalism, I suggest Nandita Bajaj’s article: Recently she was recognized as an expert in the field by coauthoring an article in the preeminent journal, Science Progress: “World scientists’ warning: The behavioural crisis driving ecological overshoot”.

            We live in an era where it is possible to have a loving, heterosexual relationship without fear of an unintended pregnancy. Now there are global as well as personal reasons to be childfree.

© Richard Grossman MD, 2024

Contraception Family Planning Population Reproductive Health

Sometimes it is Best to Hide Contraceptive Use

            55 years ago a young patient and I were standing in the sun just outside the clinic doorway when a butterfly alighted on my left ear. “Yes, I would like to try an IUD” the patient said, amazed and apparently encouraged by the butterfly.

            It was the summer between my 3rd and 4th years of medical school. My new wife and I were having a wonderful adventure at the Moravian Hospital in Puerto Cabezas, Nicaragua.  The patient I had been persuading to try an IUD was also newly married and wanted something to keep from conceiving right away. She didn’t think her husband would approve of using birth control, however.

            “If you had an IUD, he wouldn’t know about it unless you told him,” I had encouraged her. Apparently, the butterfly landing on my ear was the deciding factor, and I was able to insert a Lippes loop.

            Hiding contraceptive use is a common strategy in many countries where patriarchy rules. Men in patriarchal societies usually desire large families, and don’t want their partners to make decisions about childbearing. Research has found that covert use of contraception is common in some African countries, especially for wives of polygamous marriages. As many as a third of women in some places conceal their use of birth control! Although I am certain that some women in the USA use contraception without their partner’s knowledge, I have not been able to find a study of its prevalence in this country.

Some birth control methods are easier to hide than others. A pack of pills would be easy to conceal, but it would be a dead giveaway if found. DepoProvera® shots are effective for 3 months and are easy to keep secret. A wife could go into town to shop, as usual, but also stop at the health clinic for her birth control shot. Indeed, some women have stated that is one of the reasons they chose thei method. 

            There is a new form of DepoProvera® that is packaged so that a woman can give it to herself at home. It is small enough that the pre-filled injection unit would be easy to conceal. Large studies in African countries have found women like this formulation, but unfortunately Sayana®Press is not available yet in the USA. There are other LARCs (Long-Acting Reversible Contraception): Nexplanon®, good for 3 years, and several IUDs, which last up to 10 years, are all easily concealed.

            I do not recommend covert use of contraception. However, in some cases it is the only way that women can avoid unwanted pregnancies. Since the majority of family planning methods are female-controlled, the wife should—and can (by hiding her birth control)—have the last word about childbearing.

It only seems right that women should decide about family planning since birthing and most of the responsibilities for childcare rest on women’s shoulders. However, it is best if husbands and wives talk about whether to use contraception, and together choose the method that would be best. This is supported by a statement of friend, Dr. Stan Becker, who has studied reproductive health decisions among couples: “…reproductive health interventions that target couples are found to be more effective than those directed to only one sex.” 

           However, we don’t live in a perfect world—unfortunately, there are many couples where power and decision-making are not shared. Since family planning is recognized as potential driver of women’s autonomy and health, covert use of family planning can be seen as a symbol of agency for the women in these relationships.

© Richard Grossman MD, 2024