history of the midwifery profession in the United Kingdom

Chapter 2 A history of the midwifery profession in the United Kingdom

The office of midwife: a female domain

The office of midwife is a truly ancient calling. Sculptures of midwives attending birth date back at least 8000 years and the old Egyptian fertility goddess, Hat-hor, was frequently portrayed in this role. Midwives appear, too, in the Old Testament; the quick-witted Shiprah and Puah outmanoeuvre Pharaoh, and the birth of Tamar’s twins testifies to the midwife’s resourcefulness and skill.

Until early modern times, childbirth was considered a female province, of which women alone had special understanding. No word existed in any language to signify a male birth attendant, and when these appeared in the late 16th century, new terms had to be created. The Anglo-Saxon ‘midwife’, or ‘with-woman’, denotes the office of being with the labouring woman. Other titles like the old French ‘leveuse’ and the German ‘hebamme’ imply her function of receiving the child. The later French usage, ‘sage-femme’ (wise-woman), implies wider concerns and, indeed, midwives were commonly consulted on matters of fertility, female ailments, and care of the newborn.

Occasionally, when instruments were necessary to extract the child, a man might be called in. Traditionally, their use belonged to surgeons, who, with the increasing exclusion of women from medicine and surgery from the 1300s, were overwhelmingly men. Yet the surgeon’s scope was limited. Using hooks and knives, he might extract piecemeal an infant presumed dead or, hoping to save its life, swiftly perform a caesarean section on the newly dead mother. Hence a man’s advent into the birth chamber usually presaged the death of mother or child, or both. Where surgeons were not available, however, midwives themselves might undertake such operations. In wealthy households, a physician (a university-educated practitioner of internal medicine), whose midwifery knowledge came from classical writings rather than practical experience, might be called to prescribe medicines judged necessary for mother or child.

What manner of women were midwives?

Little is known about individual European midwives before the 16th century. As later, they would be married women or widows, generally of middle age or older. Most would have given birth, since until the late 1700s this experience, except for daughters following their mothers into the work, was usually considered essential. What formally educated midwives there were came generally from the artisan class or lower gentry. Such women invested time and money in several years’ apprenticeship to a senior midwife, and by the 17th century most would be literate. These midwives would mostly be found in towns, where there was sufficient prosperity to make their outlay worthwhile. Most would start by practising among the poor, possibly acquiring a more affluent clientèle as their reputation grew. Town midwives engaged by country nobility or gentry would arrive well beforehand, and stay several days or weeks afterwards, being recompensed accordingly. Attendance on royalty was the greatest prize. In 1469, Margaret Cobb, midwife to Edward IV’s queen, received in addition to her fee a life pension of £10 a year, as did Alice Massey, who attended Elizabeth of York in 1503. Mme Peronne, who in 1630 travelled from France to attend Charles I’s French queen, was paid £300, with £100 for her expenses.

These midwives, however, were in a minority. Inevitably the rest attended only the poor (the majority of the population), many living in rural, perhaps isolated, places. Such women would learn their midwifery through their own and their neighbours’ birthing experiences, undertaking the work by virtue of their seniority or the large number of children they had borne (McMath 1694; Siegemundin 1690, preface). Their work might entail travelling long distances on foot to outlying habitations, for a few pence or a small payment in kind. Many such women took up the work from necessity, eking out a poor living with sick nursing and laying out the dead, as did their successors until the early 20th century.

‘In the straw’

Generally, birth took place at home, poorer women typically delivering in the communal room, before the hearth, the floor covered with straw which would later be burnt. Usually the birth chamber was darkened, windows and doors sealed, with a fire kept burning for several days. These precautions were taken lest the woman took ‘cold’ (developed the possibly lethal ‘childbed fever’), and in more superstitious households for fear that malevolent spirits might gain entrance, harming mother or infant (Gélis 1996:97, Thomas 1973:728–732). Care was taken, too, that the afterbirth and its attachments (all credited with powerful magical properties) were disposed of safely, lest they be used in spells to harm the family. These beliefs were still current in remote parts of Europe in the early 20th century.

To hasten matters on in early labour the parturient would periodically be encouraged to walk, supported by two sturdy women, her strength sustained by warm broth or spicy drinks. The midwife, sharing the universal and time-honoured belief that the child provided the motive power for its birth, would follow ancient practice in greasing and stretching the woman’s genitalia and dilating the cervix to ‘help’ the infant emerge. Hence the ‘ideal’ midwife possessed, along with appropriate qualities of character, small hands with long tapering fingers (Temkin 1956).

The second stage of labour usually took place, as for millennia, with the woman in an upright or semi-upright position (Kuntner 1988). In rich households a birth chair might be used, but more commonly the parturient sat on a woman’s lap. Some women knelt or stood, leaning against a support; some adopted a half-sitting, half-lying posture, with a solid object to push their feet against during contractions, while others delivered on all fours (Blenkinsop 1863:8,10,73, Gélis 1996:21–36). As labour progressed, the woman would instinctively change position, ‘as shall seeme commodious and necessarye to the partie’, as the Byrth put it, urging the midwife to comfort her with refreshments and encourage her with ‘swete wurdes’ (see Fig. 2.1). Following delivery, the mother would be put to bed to ‘lie in’ – rich women for up to a month, the poor for days at most. The infant would be washed, then swaddled to ‘straighten’ its limbs, and if circumstances permitted, an all-woman celebration of this female life event would ensue.

The midwife, the church and the law

The midwife’s duties did not end with the birth, however. In pre-Reformation times, she carried heavy responsibilities for the salvation of the infant’s soul, being required to take weakly infants directly to the priest for baptism. If death seemed imminent, she should perform the ceremony herself, taking care on pain of severe punishment to use only the Church’s prescribed words. If the woman died undelivered, she was immediately to open the body, and if the infant were alive, to baptise it. Stillborn infants, in their unhallowed state unfit for Christian burial, she was to bury in unconsecrated ground, safely and secretly, where neither man nor beast would find them. Baptism would generally take place within a week of birth, and the midwife, infant in arms, headed the procession to the church, the mother remaining in seclusion until she had been ‘churched’. The midwife enjoyed an honoured place at post-christening celebrations and in prosperous households would be liberally tipped by family and friends (see Fig. 2.2). Later, after the lying-in period, she would accompany the mother to her ‘churching’ – originally a ‘purification’ ceremony, but under Protestantism merely one of maternal thanksgiving.

The midwife also had an important role in legal matters. Where a woman condemned to death pleaded pregnancy in the hope of postponing or mitigating punishment, a panel of midwives would be summoned to examine her, though some post-execution dissections demonstrated these examinations’ unreliability (Pechey 1696:55–56). Midwife panels were also called to examine unmarried women alleging rape, women accused of aborting themselves or of concealing the birth (and possible murder) of an unwanted infant, or determine the alleged prematurity of infants born within less than 9 months of marriage. Midwives attending an unmarried woman were also expected to make her name the father, lest he escape the Church’s punishment for fornication and his responsibility to the parish for the child’s upkeep.

Governing the midwife

In view of these religious and legal duties, the midwife’s character and religious orthodoxy were inevitably of concern to the Church. In 1481, Agnes Marshall of Emeswell, Yorkshire, was ‘presented’ at the Bishop’s Court, not because she lacked skill in midwifery, but because she used (pagan) ‘incantations’ to ‘help’ the labour. Midwives were suspect, too, because of their access to stillbirths, allegedly used in devil-worship. In 1415, a successful Parisian midwife, Perette, was turned in the pillory and banned from practice for supplying a tiny fetus used, unbeknownst to her, in sorcery. On account of her great skill, however, she was restored to practice by order of the King.

Probably the first system of compulsory midwife licensing in Europe was instituted in the city of Regensberg in Bavaria in 1452, a system gradually emulated in other European cities. Applicants for a licence were commonly examined by a panel of physicians, who, innocent of practical midwifery, based their examination on classical texts. Generally, midwives were required to send for a physician or surgeon in difficult cases, and in Strasbourg, midwives were prohibited from using hooks or sharp instruments on pain of corporal punishment. Many cities appointed midwives to serve the poor, supplementing their remuneration with payment in kind and providing financial aid in old age or disability (Gélis 1988:25, Wiesener 1993:78–84).

In England, the first arrangements for formal control of midwives were made under the 1512 Act for regulating physicians and surgeons. The Act’s aim was to limit unskilled practice and prevent the use of ‘sorcery’ and ‘witchcraft’ in medicine. It therefore provided for Church Courts to license practitioners able to produce testimony to their skill and religious orthodoxy, and to prosecute the rest. A midwife applying for a licence would normally bring to the Court a reference from the local parson, together with ‘six honest matrons’ she had delivered, to testify to her competence. There was, however, no formal examination on this point as existed under Continental schemes.

Successful applicants swore a long and detailed oath, promising ‘faithfully and diligently’ to help childbearing women, to serve ‘as well poor as rich’, not to charge more than the family could afford, nor divulge private matters. They swore not to use ‘sorcery’ to shorten labour; to use only prescribed words when christening infants; and to bury as directed all stillborn children. They undertook not to procure abortion nor connive at child destruction, false attribution of paternity or substitution of infants. Neither were they to allow any woman to be delivered secretly, and always, if possible, see that lights were available and ‘two or three honest women’ present, a requirement clearly aimed at preventing the speedy suffocation of an unwanted child.

Advent of the man-midwife

Around the mid-16th century came other changes laden with import for midwives, as surgeons, inspired by the new Renaissance spirit of enquiry, turned their attention to the anatomy of childbirth. Outstanding in this field was the French barber-surgeon Ambroise Paré (1510–1590), notable for his description in his 1549 Briefve Collection of the use of podalic version in malpresentation cases. The success of men like Paré was to encourage the extension of male attendance from ‘extraordinary’ to routine cases. This development gradually spread throughout Europe, being recognized around 1600 in Britain with the new term ‘man-midwife’, and in France that of ‘accoucheur’.

The centrality of anatomical knowledge to good midwifery was well understood by leading practitioners, men and women. The London midwife Jane Sharp began her 1671 ‘Midwives Book’ by deploring ‘the many Miseries’ women endured at the hands of midwives who practised ‘without any skill in Anatomy…merely for Lucres sake’. Her contemporary, the Derbyshire man-midwife Willughby, concurred, finding that many country midwives could not manage malpresentations, however also condemning inexperienced young surgeons and ill-prepared apothecaries, whose ‘fatal bunglings’ deserved the branding-iron or the hangman’s noose.

Maternal mortality

Given the general lack of statistics, the extent of contemporary maternal mortality (calculated as death at or within the month after the birth) is impossible to discover. However, in his 1662 study of the London Bills of Mortality, John Graunt estimated maternal mortality in London at about 15 per 1000 births. Those dying from the ‘hardness’ of their labour, as distinct from other causes, he put at less than 1 in 200 (5 per 1000). Significantly, along with other authorities, Graunt believed that poor hard-working countrywomen did best in childbirth. The celebrated Dr Harvey went further. Challenging the general practice of dilating the parturient’s vulva and os uteri, he argued that women delivering unattended fared best, since Nature, escaping the midwife’s interventions, was allowed unhindered to take her course. His friend Willughby confessed himself converted to this view, condemning interference in all but abnormal cases, as always harmful

Interestingly, Willughby also links such interference with the woman ‘taking cold’ (Blenkinsop 1863:6), a likely reference to ‘puerperal’ fever, not so named, but recognized under ‘fevers’ and ‘agues’ occurring after childbearing. Following ancient humoral theory, the condition was ascribed to a bodily ‘humours’ imbalance (Jonas 1540: xxxiii, Sharp 1671:243–250) and was probably then, as later, the chief single cause of maternal death. Not until the late 18th century was it publicly proposed that this deadly malady might be carried to the woman on the attendants’ clothing or unwashed hands (Gordon 1795:98–99), a view not completely accepted, even in medical circles, until the 1940s.

Midwives under threat

When urging midwives to study anatomy, Jane Sharp had recognized that women’s exclusion from the universities and ‘schools of learning’, where this was taught, disadvantaged them compared with men. Girls were barred, too, from grammar schools, which taught Latin, knowledge of which was the mark of an educated person and which was still used for many medical texts. Leading male practitioners therefore enjoyed higher social status than midwives, however successful. Although in 1762 Mrs Draper delivered the future George IV, with Dr Hunter and the surgeon Caesar Hawkins waiting elsewhere, Hunter’s diary makes their relative ranking clear (Stark 1908). Moreover, the distinction of great 18th-century practitioners like Manningham, Ould, Hunter and Smellie was to reflect credit on every man-midwife, deserved or not.

However, it was probably the general introduction in the 1720s of the midwifery forceps that precipitated the rapid acceleration of the existing trend. The forceps enabled the delivery of live infants where previously child or mother might have been lost, and the shortening of tedious labour. Since custom discouraged use of instruments by midwives, this development further enhanced the position of men and many surgeon-apothecaries, taking up midwifery, became general practitioners in fact if not yet in name. Some men-midwives, too, saw childbirth as a mechanical process and themselves, with their right to use instruments, as better suited to preside over it. Indeed, for many, the educated male practitioner represented the new enlightened age, while midwives, whose ranks included many ignorant, illiterate and superstitious women, appeared relics of a benighted past.

Keenly aware of the threat to their livelihood, midwives fought back, supported in books and pamphlets by both medical and lay sympathizers. For reasons of modesty, these argued, many women would not send for a man, nor would their husbands allow it. Many could not afford men’s fees, and male assistance, especially in the country, was commonly unavailable. Men-midwives, it was contended, resorted to unnecessary use of instruments in order to save their time and increase their fees, and were thus responsible for increased maternal and infant mortality. Furthermore, they exaggerated the dangers of childbirth, frightening women into believing that extraordinary measures, and therefore male attendance, were more necessary than they actually were. Also, by insisting on being called to every ‘trifling’ difficulty, men were reducing midwives to ‘mere nurses’, while taking every opportunity to denigrate their competence and blame them, however unjustly, for any mishap, even if caused by themselves.

Lying-in hospitals and ‘out-door’ charities

One champion of the midwives’ cause was the London surgeon John Douglas. Writing in 1736 to rebut men-midwives’ claims that difficult births were beyond female capacities, he instanced the career of Mme du Tetre, lately Head Midwife at the great Paris hospital the Hôtel-Dieu. Douglas maintained that if English midwives had the same opportunities as Frenchwomen (the Hôtel-Dieu had trained midwives since 1631), they could reach equally high standards. British counterparts of such hospitals had been abolished in Henry VIII’s dissolution of the monasteries, and Douglas, seeing lying-in hospitals as essential to improved midwife instruction, demanded their establishment in all the principal English cities. The first such permanent foundation, however, was the Dublin ‘Rotunda’, established in 1745. Two lying-in wards were created in the Middlesex Hospital in 1747, and four (tiny) lying-in hospitals opened in London shortly afterwards. Similar institutions appeared in major provincial cities as the century progressed.

These hospitals, like others founded at the time, were charitable institutions, funded by the subscriptions of the wealthy for the benefit of the poor (in this case ‘respectable’ poor married women), and run by voluntary lay boards. Hospitals were a mixed blessing for the women attended there. Outbreaks of puerperal fever, a regular feature until the adoption of antiseptic practice in the late 19th century (and occurring sporadically even in the 1930s), boosted death rates and necessitated closure for weeks on end. Safer and cheaper were ‘out-door’ charities, such as the Royal Maternity Charity, London (founded 1757). These provided poor women with midwife attendance at home, with designated medical assistance as necessary, and probably trained far more midwives than the tiny hospitals. There was, however, no move in England from government, central or local, on this vital matter of midwife instruction. By this time, Bishops’ licensing – which although no great guarantee of skill, and never properly enforced, had given the licensed midwife some status – was generally defunct.

’Towards a complete new system of midwifery’

By the mid-18th century, male practitioners, disdaining the familiar ‘man-midwife’, began to adopt the French term ‘accoucheur’, as conveying greater status. Their approaches to delivery varied, however. Some still dilated the cervix and the labia vulvae, practices continuing among the more ignorant at the century’s close (Clarke 1793:21). Some extracted the placenta immediately after delivery by introducing the hand into the uterus, while others roundly condemned this (Smellie 1752–64:238–239). The general trend, however, was towards less intervention. This development stemmed from the new realization that it was not exertions by the child but uterine muscular action that provided the necessary expulsive force (ibid. 202). Significantly, Smellie (since regarded as the ‘father of British obstetrics’) concluded from his vast experience that, out of 1000 parturients, 990 would be safely delivered ‘without any other than common assistance’ (ibid. 195–196).

Though ambulation in the first stage was still encouraged, women’s freedom to choose their delivery position was gradually being curtailed. Earlier authorities, male and female, had encouraged women to adopt the position most comfortable to them as facilitating the best outcome for mother and infant. Smellie underlined the advantages of upright positions in furthering labour, partly through gravity, and partly through the ‘equalisation of the uterine force’, recommending them for ‘tedious labours’ (ibid. 202). Yet, along with other authorities, Smellie generally advised delivery in bed (half-sitting, half-lying) for fear that otherwise the woman might take ‘cold’, and hence develop ‘childbed fever’ (ibid. 204). Others, like Dr John Burton of York, favoured the ‘dorsal’ and ‘left lateral’ positions as ‘easiest for the Patient and most convenient for the Operator’ (Burton 1751:106–107). Indeed, sitting by the edge of the bed, his hand concealed under the sheet, was less tiring and less undignified for men hoping for recognition of their art as part of medicine proper, than was crouching at the woman’s knees on the midwife’s low stool (see Fig. 2.3).

Recumbent delivery positions gradually became the norm for ‘civilised’ practice. Although delivery out of bed was to continue in rural areas into the 20th century, it was generally considered low class, if not inhumane. Significantly, the parturient’s transfer to bed, together with her increasing designation as a ‘patient’ (a word originally used only of the sick), indicated her transition from an active to a passive role in this important life-event, and, implicitly, the growing medicalization of childbirth itself.

The decline of the midwife

By the early decades of the 19th century the midwife’s situation had deteriorated still further. Growing prudery, largely the result of the Evangelical movement, had rendered reference to childbirth, and even the word ‘midwife’, taboo in polite society. Together with the male capture of the wealthier private practice and the growing reluctance of the middle classes to allow their women to work, this prudery meant that fewer educated women were entering midwifery, leaving many who wanted skilled assistance in childbirth forced to send for a man. Midwife supporters argued that midwives’ instruction (where it existed) had not kept pace with men’s and increasingly calls arose for the better education of female practitioners to the highest professional standards, in midwifery and women’s diseases. The medical response was predictable. Women were unfitted by nature for ‘scientific mechanical employment’ (which midwifery was), and could never use obstetrical instruments with ‘advantage or precision’, even if presumptuous enough to try. Such remarks, together with allegations that midwives were generally abortionists, prompted one midwife supporter to remark that ‘the greatest slanders against the moral and intellectual characters of women have been uttered by practitioners of man-midwifery’.

This animosity towards midwives arose partly from men-midwives’ generally low status within the medical profession. Their specialty was not officially recognized as part of medicine and no official qualification existed in England to distinguish men with midwifery training from those with none. Hence men seeking such qualifications were forced to go to Scotland or the Continent. For decades leading accoucheurs had requested the English chartered medical corporations to establish such a qualification, but had been repeatedly rebuffed. Many leading medical figures viewed attendance on childbirth as ‘women’s work’, and below the dignity of professional men. In 1827 Sir Anthony Carlisle (later President of the Royal College of Surgeons) denounced man-midwifery as a ‘dishonorable vocation’, whose practitioners from financial motives sought to turn a natural process into a ‘surgical operation’. It was 1852 before the College established its Midwifery Licence and 1888 before such qualification was required for admission to the Medical Register kept by the General Medical Council, the doctors’ regulatory body established in 1859. Thenceforth midwifery was formally recognized in the UK as part of medicine.

The end of the midwife?

The midwife’s image had not been helped by Charles Dickens’ caricature in Martin Chuzzlewit (1844) of the unsavoury ‘Mrs Gamp’, a poor widow who, like so many over the centuries, earned her living by practising midwifery, sick and ‘monthly’ nursing, and laying out the dead. A blowsy, tippling, unscrupulous character, Mrs Gamp soon became the stereotypical midwife (see Fig. 2.4). But although along with Farr some medical men advocated the replacement of such midwives by respectable, trained women, certain accoucheurs, seeking a male monopoly of midwifery (achieved in North America by the 1950s), were pressing for the midwife’s total abolition. ‘All midwives are a mistake’, Tyler Smith told his students at the Hunterian Medical School in 1847, ‘and it should be the aim of every obstetric practitioner to discourage their employment’. Furthermore, because of its origin, the word ‘midwifery’ should no longer be used to describe male attendance on childbirth, being replaced by the new construct ‘obstetrics’. Here Smith well understood that a term of Latin origin, even if derived actually from the Latin for ‘midwife’ (‘obstetrix’), had a snob value which would further elevate men above their female competitors. This substitution of ‘obstetrics’ for ‘midwifery’ in male practice was, however, not fully achieved until after World War II.

The Royal Maternity Charity and maternal mortality

Directly in Smith’s line of fire was the 98-year-old Royal Maternity Charity. The Charity’s employment of midwives, however well instructed, Smith contended, was ‘degrading’ to ‘obstetrics’ and harmful to its clients, who instead should be attended by ‘educated’ practitioners. Yet the Charity’s statistics, published annually by the eminent medical men supervising its work, repeatedly disproved these allegations. Serving only poor women, many undernourished and living in unhealthy conditions, the Charity (and similar foundations) consistently demonstrated death rates of less than half the Registrar-General’s current rates for England and Wales.

A further onslaught on such charities came in 1870 from the obstetrician Matthews Duncan in his Mortality of Childbed. Dismissing the charities’ results as an impossibility since ‘educated accoucheurs’, in [affluent] private practice, lost five times as many women, Duncan postulated an ‘irreducible minimum’ of at least 8 per 1000, an admission, in fact, suggesting that the rich might indeed fare worse in childbirth than the poor.

Despite this obvious inference, the anti-midwife faction had an answer. The cause of higher mortality among wealthier women lay not with their medical attendants but with their own ‘artificial ‘ way of life, which disabled them for parturition. Increased (medical) vigilance was therefore necessary in attending them, not less. The degree to which childbirth among the prosperous was progressively viewed as pathology was evident in Chavasse’s 1842 Advice to a wife. While declaring childbirth a natural event, Chavasse required the ‘pregnant female’ to rest for 2 to 3 hours daily, while the post-parturient was to keep to a meagre diet, lying flat on her back for 10 to 14 days lest she should faint, haemorrhage, or suffer a prolapsed womb.

This invalidization of pregnancy and childbirth naturally implied more medical attention and higher fees, catching women in a double bind. Not only were they regarded as physically, intellectually and morally incapable of undertaking the ancient female duty of attendance on childbirth, but were also increasingly seen as requiring male assistance to give birth at all.

Jun 18, 2016 | Posted by in MIDWIFERY | Comments Off on history of the midwifery profession in the United Kingdom

Full access? Get Clinical Tree

Get Clinical Tree app for offline access