GIVING BIRTH
A woman giving birth would be surrounded by women, a practice that continued until late in the nineteenth century. The early modern English birth room has been described as a ‘gossip’s parlour, busy with bustling women’.42 We know that across much of Europe women typically gave birth at home, aided by a local midwife or wise-woman.
Women probably assumed any position that was comfortable: standing or squatting or kneeling with the aid of others. Few would have been attended by a doctor; a physician was the dubious privilege of the aristocracy at the start if the century. The Duchess of Devonshire described the somewhat chaotic scene at the birth of her daughter in 1783:I was laid on a couch in the middle of the room. My mother and Dennis supported me. Canis was at the door, and the Duchess of Portland sometimes bending over me and screaming with me, and sometimes running to the end of the room and to him. I thought the pain I suffered was so great from being unusual to me, but I find since I had a very hard time. Towards the end, some symptoms made me think the child was dead. I said so, and Dr Denman only said there was no reason to think so but we must submit to providence.43
By the middle of the nineteenth century, general practitioners were more likely to be present at the birth in smaller non-manufacturing towns and amongst the more affluent classes in the towns and suburbs, whereas midwife deliveries predominated in working-class areas of large towns, in villages and remote parts of the country. Prior to the appointment of a doctor to serve the northerly Shetland islands of Yell and Fetlar in the 1890s, it was said that ‘mothers reared families numbering ten to fourteen children, all assisted by local “skilful” women.’ According to the testimony of one such ‘wife’ aged 87, ‘I never had a doctor. The wife who came to me from Unst used to bring a [bible] and a razor with her.
The razor she placed under my pillow for luck, and she used to read a chapter out of the testament now and then to keep up my spirits.’44 By the 1880s in England and Wales it has been estimated that midwives and general practitioners each undertook around half of all deliveries.45 Amongst the respondents to the Women’s Co-operative Guild survey a high proportion had consulted doctors during pregnancy; indeed, doctors were preferred to midwives in some cases. One woman, who was unable to afford a doctor, commented that, ‘Had the midwife called in the doctor, as she should have done, I might have been saved a lot, for my back has never been right since.'46However, much of northern Europe was arguably a safer place than Britain to have a baby for most of the century because of the reliance on home deliveries by trained midwives. Owing to the absence of a system of training and licensing in Britain, male surgeons or apothecaries were able to claim childbirth as one of their areas of expertise. By contrast, much of the rest of Europe had, early on, established a trained midwifery service, a development which almost certainly benefited mothers. Maternal mortality rates were lower where trained midwives were the norm. Death in childbed was the commonest cause of death amongst women of childbearing age as a result of complications during a difficult labour or infection leading to puerperal fever brought on by intervention in the birth or poor post-natal care. In the Netherlands, France, Norway, Sweden and Denmark for instance, training and the regulation of the midwifery service was seen as important in order to marginalise untrained midwives who, it was alleged, were often responsible for carrying infections that caused puerperal fever.47 In Sweden, the decision to create a well-trained autonomous midwifery service at the beginning of the century, and the authorisation of their use of instruments such as forceps in 1829, effectively did away with unlicensed midwives or help-women (hjalpkvinnof), despite rural attachment to traditional birth attendants.48 In rural Russia, where peasant women were attended only by a povitukha, equivalent to the wisewoman of western Europe, infant and maternal deaths were high.
In 1900, Russia still had the highest infant mortality rate in Europe: 275 newborn babies died out of every 1000 compared with figures of 160 in France, 140 in England and only 80 in Norway.49 The solution, according to reformers, was to create a corps of trained rural midwives, and by 1905 more the 10,000 were practising although the majority preferred to work in urban centres and the povitukha remained the choice of most peasant women.50 Wherever a city, a county, a region or a nation, had developed a system of maternal care which was firmly based on a body of trained, licensed, regulated and respected midwives', argues Loudon, ‘the standard of maternal care was at its highest and maternal mortality was at its lowest.'51 Hospital births were still the exception. In Germany fewer than one per cent of all births occurred in hospital in the 1870s. At this time home birth was still safer for mother and child owing to the high likelihood of contracting an infection in an institution.52Figure 4.1 Midwives and maternal mortality, 1860-1914
Note: This graph comprises the mean of available maternal mortality statistics in each decade. ‘Countries without trained midwives' includes England and Wales (1867-1914) and Scotland (1867-1914). ‘Countries which introduced trained midwives' includes the Netherlands (1878, 1883, 1888, 1893, 1898, 1903, 1905-14), Sweden (1867, 1872, 1877, 1882, 1887, 1892, 1902, 1907, 1911-14) and Denmark (1895, 1905, 1914).
Source: Figures calculated from data in I. Loudon, Death in Childbirth (Oxford, 1992), appendix 6.
Figure 4.1 illustrates the connection between maternal mortality rates and the existence of a trained and licensed midwifery service. In the Netherlands, for example, which achieved a notably low rate of maternal deaths in childbirth, particularly after the introduction of antisepsis in the 1880s, a long history of midwifery training dating back to the seventeenth century was enhanced by a regulatory system established in the first two decades of the nineteenth century.
Midwives either followed an apprenticeship leading to official accreditation, or they attended a school for midwifery training. By 1900 the maternal mortality rate in the Netherlands was 24 deaths per 10,000 births whilst in England and Wales the rate was double that at 48 deaths.53 The Dutch midwives were clearly dealing relatively successfully with sepsis (bacterial infection) and puerperal fever, whilst their general practitioner counterparts in England and Wales were shockingly cavalier in their use of forceps and anaesthesia without due attention to antiseptic techniques.54 Similarly, in Denmark, following a scare which blamed midwives for carrying infections that caused puerperal fever, instructions were issued on cleanliness and hygiene, and midwives quickly learned antiseptic techniques, with the result that deaths from puerperal fever declined significantly.55 The type of birth attendant was a key determinant of maternal mortality, more so than the social class of the mother.56 The lesson of this story is that some training was better than none at a time when advances in medical understanding promised safer births.Table 4.2 Infant mortality rates per 1000 live births in selected European countries, 1850-1910
a Selected states only
Source-. Compiled from data in B.R. Mitchell, European Historical Statistics, 1750—1970 (London, 1975), pp.137—41.
Infant deaths, on the other hand, were rising for much of the nineteenth century as Table 4.2 illustrates. In England and Wales a peak was reached in 1846 when 164 infant deaths per 1000 live births were recorded. In rural Russia, mortality rates were almost double those in industrial western Europe, with 290 deaths per 1000 births in one province around the turn of the century, explained by the poor physical condition of the mothers, low literacy rates and the difficulties mothers had in combining child care with work, particularly in the summer.57 More mothers were surviving childbirth by the end of the century, but the fate of babies was still uncertain. Yet, in contrast with the maternal mortality rate which was seen to be in the hands of the midwives or medical practitioners, the responsibility for the high infant mortality rate was roundly placed on the shoulders of mothers. Middle-class philanthropists, government inspectors and medical men united in their condemnation of the infant-care methods of poor women, conveniently ignoring the often appalling housing conditions of urban and rural workingclass families characterised by overcrowding, poor sanitation and the pervasiveness of disease. Infant deaths, it was believed, could be prevented if ‘ignorant’ poor mothers breast-fed their babies and were taught baby care. This was an area of mothering where the state was to play a significant role.