Childbirth and Maternity

1. From Cradle to Grave Childbirth and Maternity Lecture 14

2. Lecture themes The ‘medicalisation’ of childbirth? • Traditional childbirth – fear and ceremony (social childbirth) – lasts into 19th and 20thC? • Maternal morality • Midwives - roles, training, characteristics and practice, qualification • Lying-in hospitals to hospitalisation • Changes in the 19th and 20thC– GP practice, registration of midwives • Big 3 changes: hospitals, personnel and technology of childbirth

3. Fear! • Death in childbirth – of mothers and babies (high stillbirth rate, high infant mortality, high maternal death rate) • Childbirth could be lengthy and painful (impact of rickets, poor diet, instrumental births, childbirth fever, bad medical attendance) • While infant mortality began to fall around 1900, maternal mortality high until 1930s/1940s

4. Maternal mortality • 3 main causes: puerperal sepsis ([post-partum fever) (40%), toxaemia (20%), haemorrhage (20%) • Deaths from puerperal sepsis and septic abortion rose 1900-1934 • Middle-class women equally or more likely to die as poor women in childbirth – related to quality of obstetric care (meddlesome midwifery) (Irvine Loudon) • Maternal morality rate (MMR) 42 per 10,000 births in 1900, 1930 44,1940 26 and 1950 8.7 • How was fall explained? Sulphonomides – reduced infection, mid-1930s War – blood transfusion and obstetric flying squads, ergometrine 1942 reduced deaths from haemorrhage

5. Alice Gregory (ed.), The Midwife: Her Book (London 1923) • ‘I have twice seen the desolation of a working man’s home when the mother is suddenly taken from her young children, and I never want to see it again. She went up to her room in good health perhaps twelve hours before, and she will never come down again until her body is carried to the grave.’ • 1920-29 25,000 women died in Britain from childbirth-related causes

6. Poverty and pregnancy • Poor women’s pregnancies marked by money struggles and health problems. Many continued to work hard throughout pregnancy. • At the General Lying-in Hospital early 20thC patients were described as sickly and anaemic. One patient claimed she had been ‘half-starved’ and another had ‘not had good food during her pregnancy’ (see Ellen Ross, Love and Toil) • Women’s Co-operative Guild letters • Maud Pember Reeves declared at a 1912 conference on infancy and infant care that ‘motherhood is hanging over them like a curse’

7. Margaret Llewelyn Davies (ed.), Maternity. Letters from Working Women (London, 1915) • ‘Three months before the baby came, I was practically an invalid…. Of course, I had chloroform; indeed I had it with all my seven children, except two, as I have always such long and terrible labours… I am never able to get up under three weeks after confinement, as I always start to flood directly I make any movement… to me [childbirth] is a time of horror from beginning to end’

8. Who became midwives? • Ranged from neighbours who occasionally helped at childbirth, to women who delivered babies fairly regularly and those who worked ‘professionally’ as midwives • By turn of 20thC increasing split between ‘lady’ midwives and traditional midwives (bona fides) • Many ‘professional’ midwives scaled their fees according to what the patient could pay – often delivered for doctors • Many took on other roles – nursing and laying out the dead • Many also helped in the household • Mixture of abilities – some skilled and experienced, some not • Most worked in women’s homes

9. Training • 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 from early modern period). • Some midwives were trained by apprenticeship. • Or skills were 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 and book learning.

10. Attributes and Tasks • Ideal midwife kind, honest, gentle and not gossips. • Midwives were supposed to limit themselves to normal births and were not use medicines or instruments – to ‘wait on nature’. • They were not to be associated with birth control or abortion. • It was also important for them organise the birth and manage the lying-in. The social aspects of birth. Women’s sphere? • Some midwives acted as a court witness in cases of infanticide, rape and abortion – also task to persuade mothers of illegitimate children to name father. This role was important even in the 19thC.

11. Celebration - traditional childbirth • Collective female culture (social rather than medical?) Midwife in charge – though the focus of their practices shifted to poor families in 18th/19thC • Organised by women – but this changed in many households in 19thC as male doctors took over • Period of lying in for 1 month after the birth • Ended with churching ceremony – marking the return of the mother to public life – still practised in East End in early 20thC

12. Lying-in Hospitals to Maternity Hospitals • 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. • Became dreaded sites of puerperal fever – feared by many. • 1848 Ignaz Semmelweis convinced infection was spread by contact by doctors moving from patient to patient. Introduced hand-washing and cleansing instructions. • Poor Law also provided maternity care – of sorts – to pauper women • By 1920s and 1930s private nursing homes increasingly popular with middle and upper classes. Poor women also keen to have birth in hospital, though conditions often bad.

13. Male obstetric practitioners • 3 groups involved • Man-midwife 18thC – increased in number (fashion and forceps) • Rise of GP, especially during 19thC – who took on more and more obstetric work • Rise of specialism of obstetrics (and gynaecology). New concerns about risks of childbirth (diseases of women). Though ostensibly worked with difficult cases also engaged themselves in normal obstetrics.

14. Training and Registration Doctors • 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 Midwives • 1862 King’s College Hospital introduces midwifery training for nurses, gradually training schemes introduced • Late 19th intense lobbying for registration and recognition of profession • 1902 Midwife Registration Act

15. Medicalisation of Childbirth? Why did male practice take hold? • Birth described as increasingly risky for mothers – made a medical matter with high levels of intervention – birth only ‘normal’ in retrospect • A new spirit of medical enquiry, especially in the fields of anatomy and physiology, emphasis on formal training – new forms of ‘expertise’ • New technologies – forceps 18thC, anaesthesia (chloroform) 19thC • The rise of the surgeon-apothecary as the family doctor • Marketplace competition – midwifery lucrative • From home to hospital • Changes in culture of childbirth

16. Campaigns for training midwives • Female Medical Society and Midwives Association campaigned for proper training programmes late 19thC • Midwives Act 1902 – certification became a requirement. Managed largely by doctors. Central Midwives Board established. Unqualified midwives – bona fides – given a few years to acquire a licence. • 1905 Select Committee established a register of midwives, with a central body to approve training schools and admit qualified candidates. • 1936 Midwives Act local councils charged with providing adequate, salaried domiciliary service. Relief for midwives but most women then had to pay the local authority for midwifery care. • 1948 NHS introduces free midwifery services

17. 1940s antenatal class

18. Rise of hospital births • Hospital has become synonymous with ‘safe’ birth – provided justification for move to hospital. • Yet little evidence to show hospital safer • 1900 most births at home with midwife • 1930s birth at home with midwife or GP standard • 1950s trend towards hospital set in. • 1960 33% of women in England and Wales gave birth at home – 13% 1970 and by 1992 1 % • 1970 Peel Report declared hospital the proper place to give birth – around same time women began to assert their right to a home delivery.

20. Technology and birth • Hospital associated with more interventions – increased use of analgesics and anaesthesia in 20thC • Pain relief also demanded by women. National Birthday Trust Fund set up in 1928 – aimed at ‘safer motherhood’ through better midwifery services and promoted anaesthesia in hospital and also pain relief at home. • After 1936 midwives allowed to use gas and air at home, but not chloroform.

21. Counter movements • Grantly Dick-Read, obstetrician and pioneer of natural childbirth – Childbirth without Fear (1942) • National Childbirth Trust – more natural approaches • Radical Midwives organisations • Sheila Kitzinger – advocated an active role for women in birth, breathing techniques • 1985 Wendy Savage Case

22. Grantly Dick-Read

23. Twentieth century 4 features that made ‘medicalisation’ of childbirth more apparent: • Male take over of childbirth – midwives lose autonomy. • Hospital deliveries increase – shift from home to hospital, especially after WWII. • Increasing intervention in childbirth – instruments and anaesthetics. • Fear of childbirth diminishes in the 1930s, as maternal mortality falls. 1948 free service • Consumption of childbirth / the good birth • Still problems – overstretched services and many women give birth in poverty; impact of immigration; many mothers over 40

24. Mother and child in maternity ward, 1962