Kill or Cure

Childbirth, midwives and medical men c. 1700-1900

Aims

• To introduce ideas about maternity and social and medical models of childbirth.

• To set the context by looking at the experience of maternity before 1700.

• To explore changes in maternity care in the period 1700-1800 and the conflicts between midwives and men-midwives.

• To chart the regulation of midwifery.• To consider the risks of mortality in childbirth

and the rise of lying-in hospitals.

Part one

• Maternity care pre-1700

Traditional ideas of birth

• Traditionally pregnancy and childbirth were viewed as natural life events.

• Unless things went wrong, they did not need medical intervention.

• Pregnant women were not patients. • Feminists have accused the medical profession of taking over

childbirth: doctors wanted to control women and to take the credit for safely delivering their babies.

• Ann Oakley argues: “It is only by an ideological transformation of the ‘natural’ to the ‘cultural’ that doctors can legitimate reproduction as a medical speciality.”

• From what we know of maternity in the Middle Ages and the Renaissance, women figured prominently in the care of women during pregnancy and birth.

Middle Ages and Renaissance 1

Childbirth: Woodcut from Der Swangern Frawen und he bammen roszgarten, by Eucharius Rösslin, 1513. (Arons, 1994)

Birthing Chair: Woodcut from Der Swangern Frawen und he bammen roszgarten, by Eucharius Rösslin, 1513. (Arons, 1994)

Middle Ages and Renaissance 2• In England the midwife’s duties were incorporated into the

oath she swore under the licensing system operated through the Church under an Act of 1512.

• Midwives were forbidden from helping with contraception, abortion, child destruction or concealment of birth. They had to take weakly infants to the priest for baptism, or perform the ceremony themselves. If the mother died undelivered, the midwife had to cut the child out while it lived and christen it.

• As the 16th C progressed the Renaissance spirit of enquiry was applied by leading surgeons to the anatomy of childbirth. Eminent among these pioneers was Ambroise Paré.

• His fame encouraged male attendance in childbirth, first in ‘extraordinary’ cases and later in routine ones.

• There were new designations (‘Man-midwife’ in English, ‘accoucheur’ in French), for men who added midwifery to their practice.

• Church licensing, which had given the ‘sworn’ midwife her official standing, was gradually discontinued.

Ambroise Paré (1510-1590)

Part two

• Midwives and medical men 1700-1800

Sarah Stone • Practised in Taunton,

Somerset.• Extensive practice with

about 300 cases a year. • Apprenticed to her mother

for 6 years.• Attended lectures on

anatomy and watched dissections.

• She became a consultant and was called in by other midwives in difficult cases.

• Wrote A Compleat Practice of Midwifery (1737).

Rise of the man-midwife 1

• Fashion and forceps (Chamberlen forceps 1673) – science enters birthing room, though often ‘crude’ science, social kudos of employing accoucheur.

• Midwifery courses for male pupils – experience replaced by theoretical book learning.

• Lying-in hospitals – trained doctors and midwives.• Famous man-midwives e.g. William Smellie,

William Hunter.

Rise of the man-midwife 2• The reasons why men-midwives succeeded

in persuading the public of the value of their skill are still the subject of keen historical debate.

• Irvine Loudon argues it was due firstly, to a new spirit of medical enquiry, especially in the fields of anatomy and physiology. And secondly, the sudden rise of the surgeon-apothecary as the family doctor.

• The term ‘medicalisation’ has been used to denote the process by which childbirth was made subject to the power and authority of doctors. However Ornella Moscucci argues that the 18th C men-midwives’ onslaught on the female ceremony of childbirth must be read as an attempt to substitute women’s customs for new medical rites. Drawing of childbirth with use of

forceps by William Smellie.

• C18th = rise of lying-in hospitals – offered training to midwives and man-midwives.

• Run as charities – poor women had limited access to care, concerns about population. Many in London.

Lying-in hospitals

City of London Lying-in Hospital

Part three

• The regulation of midwifery

• Up until the late C19th there was no formal training or qualification in midwifery (in Britain, cf. the continent where midwifery training and schools were set up and midwives licensed by towns).

• Some midwives were trained by apprenticeship.

• More often skills was passed down from mother to daughter or other female relative.

• Most training was practical, hands on – honed by practice and experience.

• A few had more theoretical knowledge.

Training

Thomas Rowlandson, Midwife on her way to a labour, 1811.

Midwives and medical men• Before the 1902 Act there was no regulation,

and no definition of what a midwife should be. • Whilst it gave midwives independence and

women choice it meant women risked using dangerous, unskilled midwives as well safe and experienced ones.

• The disciplines of obstetrics and gynaecology did not have long established traditions either.

• At the beginning of the 18th C, the employment of medical men in the conduct of normal as well as abnormal labourers was rare.

• By the end of the 18th C, many women of all social classes engaged a medical practitioner rather and virtually all surgeon-apothecaries were also ‘men-midwives’’.

• This development was deeply resented by the midwives.

• 1840s midwifery added to the medical curriculum

• 1850s diplomas awarded by medical schools.• Licence in Midwifery (LM) acquired by many

general practitioners – midwifery ‘a foothold’ of general practice.

• 1862 King’s College Hospital introduces midwifery training for nurses.

• Female Medical Society and Midwives Association campaigned for proper training programmes.

• 1902 Midwife Registration Act – certification became a requirement. Managed largely by doctors.

• 1905 Select Committee established a register of midwives, with a central body to approve training schools and admit qualified candidates.

Regulation and registration

Part four

• Maternity and mortality

Death in childbirth• Death in childbirth – of

mothers and babies.• Childbirth could be lengthy

and painful (impact of rickets, instrumental birth, childbirth fever).

• Maternal mortality from 1850-1900 c. 5 per 1000 births.

• Women made preparations for death while pregnant.

MMR per 1000 live births

Estimates of maternal mortality rates (MMR) from records of 13 English parishes in 50 year periods

Puerperal fever

Ignaz Semmelweis, 1818-1865.

• Ignaz Semmelweis (Vienna Maternity Hospital) thought puerperal fever was carried on the hands of medical students who did postmortem dissections.

• He showed that by washing hands with carbolic soap before attending women in labour cases could be greatly reduced.

• In 1858 he published The Aetiology of Childbed Fever.• He was attacked widely by the establishment of

obstetricians in Europe, who could not believe they were responsible for the enormous number of deaths.

• Louis Pasteur showed in 1879 that the streptococcus could be cultured from most cases of puerperal fever. This led to the search for antiseptics, chemicals which would kill bacteria.

• Joseph Lister introduced a carbolic spray into the operating room to keep the atmosphere above the wound free of bacteria. Antisepsis was joined by asepsis, the keeping of bacteria away from open wounds.

Bleeding• Antepartum haemorrhage may

be due to placenta praevia or to separation or abruption of the normally sited placenta.

• Postpartum haemorrhage can follow trauma at delivery, or more usually, because the uterus does not contract down after delivery.

• Treatment of excessive postpartum bleeding was attempted with vaginal packing, or with cold or hot vaginal douches, but the first effective treatment was with ergot, which caused uterine muscles to contract.

Edward Rigby (1747-1821)

John Braxton Hicks (1823-1897)

Lawson Tait (1845-1899)

Toxaemia• It was probably John Lever, a lecturer in obstetrics

at Guy’s Hospital, who first recognized the link between protinuria and fits.

• Its treatment was by sedation with drugs currently available, leading to the technique devised by Vasili Stroganoff in 1898 of controlling fitting by the use of sub-cutaneous morphia and chloroform.

• Magnesium sulphate was first used in America in the 1920s and soon spread there to both treat and prevent fitting, but was not picked up in Britain until some 60 years after its widespread use in the USA.

• The real management of eclampsia and pre-eclampsia followed its diagnosis and early treatment with hospitalization and bed rest in the 1920s.

John Lever (1811-1859)

Vasili Stroganoff (1857-1938)

Abortion

A 19th C advertisement for Beecham’s Pills.

“For females of all ages these Pills are Invaluable, as a few a doses of them carry off all humours, and bring about all that is required. No female should be without them. There is no medicine to be found to equal BEECHAM'S PILLS for removing any obstruction or Irregularity of the system. If taken according to the directions given with each box, they will soon restore females of all ages to sound and robust health.”

• Abortion seems to have become more organized than previously in the mid-19th C.

• It is likely that illegal abortion was common by the end of the 19th century.

• The most obvious sign of more widespread abortion was the appearance of a large number of thinly veiled abortion advertisements.

“For females of all ages these Pills are Invaluable, as a few a doses of them carry off all humours, and bring about all that is required. No female should be without them. There is no medicine to be found to equal BEECHAM'S PILLS for removing any obstruction or Irregularity of the system. If taken according to the directions given with each box, they will soon restore females of all ages to sound and robust health.”

A nineteenth century advertisement for Beecham’s Pills.

Conclusions

• The practice and development of maternal care has centred on the questions: is there such a thing as a normal pregnancy and labour; where should the ‘normal woman’ give birth; who should look after her; how much medical intervention should occur; and should attention focus on the mother or child.

• Implicit in discussions about maternal care is whether pregnancy and childbirth should be medical questions at all.

• The medicalisation thesis criticises doctors and downplays medical accomplishments, arguing the medicalisation of childbirth was part of the medical profession’s method of controlling and exerting power over the population.

• But, in the words of Ann Oakley, “There was no golden age in which women gave birth both safely and effortlessly.”