A Social History of Maternity and Childbirth

Key Themes in Maternity Care

Tania McIntosh

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136344107
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

People are fascinated by stories of childbirth, and the sources to document maternity in Britain in the twentieth century are rich and varied. This book puts the history of maternity in England into its wider social context, highlighting areas of change and continuity, and charting the development of pregnancy and birth as it emerged from the shadows and became central to social debate.

A Social History of Maternity and Childbirth considers the significance of the regulation and training of midwives and doctors, exploring important aspects of maternity care including efforts to tackle maternal deaths, the move of birth from home to hospital, and the rise of consumer groups. Using oral histories and women's memoirs, as well as local health records and contemporary reports and papers, this book explores the experiences of women and families, and includes the voices of women, midwives and doctors. Key themes are discussed throughout, including:

• the work and status of the midwife
• the place of birth
• pain relief
• ante- and post- natal care
• women's pressure groups
• high-tech versus low-tech
• political pressures.

At a time when the midwifery profession, and the wider structure of maternity care, is a matter for popular and political debate, this book is a timely contribution. It will be an invaluable read for all those interested in maternity care in England.

1 Historiography and comparisons

DOI: 10.4324/9780203124222-1

Introduction

Writing about the history of maternity and midwives has always been driven by complex contemporary agendas. This is apparent in not only the English but the international context, and has impacted also on sociological explorations of this most fundamental of human experiences. The stories of maternity have been written by doctors, and more recently by midwives, with themselves as centre stage. Sociologists and statisticians have mined the history of birth in support of arguments about the meaning of profession, the subjection of women, or of the misuse of power and technology in the name of safety. This chapter will explore some of these issues and the impact that they have had on thinking and writing about the history of maternity. History writing should, as far as is humanly possible, put the story in the context of its time and not judge it by contemporary mores or paradigms. This is never easy as the writer is the product of their times and carries beliefs and prejudices so ingrained as to be invisible. However, it is possible to explore not only the stories that have been written, but to consider what purpose they served.

The first section of this chapter will concentrate on the historiography of maternity, birth and midwifery. Much of the work that has been published is reductionist in nature, and has focused on the positives or negatives of progress. The language used is that of ‘fights’, ‘battles’ and ‘campaigns’ won and lost, whether for the regulation of midwifery, the provision of analgesia in labour, or beliefs about the relative safety of one birthing environment over another. In the late twentieth century, as women began to tell their stories, similar language was used. The story of maternity is therefore a maelstrom of military language, often told in oppositional terms. This appears paradoxical when pregnancy and birth are quintessentially about nurture and development.

However, over the last 20 years a different strand in writing has developed, which looks at specific issues often using very detailed archive work. The outstanding example of this is Loudon’s book Death in Childbirth (1992) which explored the history of maternal mortality in twentieth-century Britain, and put it firmly in an international context. His work highlighted the multiplicity of factors at work in the maintenance of a relatively high level of maternal death rate, and in its final precipitous decline (in Western countries at least). This chapter will consider the ways in which this type of history has deepened and contextualised the stories told by great men and angry women, and how it carries its own ingrained truths and beliefs. Birth is publically mediated, but is also an intensely private and personal event. Historians have argued that the shift to hospital birth in particular exemplified the move of discourse around birth from the private domestic sphere to the institutional public one. Yet in all these debates the voice often lost is that of women who often did not leave written evidence of their beliefs and experiences. In order to capture these voices, this chapter will explore new approaches to what constitutes historical evidence and how it is gathered, in an effort to bring mothers back into the central drama of their own lives: pregnancy and birth.

The study of sociology has played a significant role in shaping the story of maternity. A large part of the writing on midwifery in particular is based around attempts to promote or destroy the concept of midwifery as a highly skilled occupation. Within this strand there has been much written about the relevance of the concept of profession to work such as midwifery, and whether it better conforms to subsets such as semi-profession, leaving the female midwife under the thumb of the obstetrician. All writing on midwifery history incorporates the idea of the profession and this has had a significant impact not only on attitudes to midwives and midwifery, but also the way maternity history is conceptualised.

Beyond issues of professional status, the way maternity is viewed by society has a huge impact not only on the way that the service has developed but also the kinds of stories which are told about it. Ideas of deference – women to men, everyone to the medical profession for example – have impacted on how and where birth is experienced. Waves of feminist thinking and action have also been central to readings of maternity. This might include women’s demands for pain relief, for hospital births and home helps, as well the influential work of women like Sheila Kitzinger and Ann Oakley in Britain who helped to drive the demands of women to wrest control of their maternities back from the paternalistic experts. Debates around birth have never taken place in the sterile atmosphere of medical discourse; birth is so central to the way a society sees itself that discussion is always broad and often heated. Similarly, the history of maternity cannot be viewed in isolation, but must be seen as part of the history of the way society sees itself.

Although all of the above issues are pertinent to the English story, which is the one which this book will be telling, it is important to put maternity into its international context. Just as in Britain, it is the ‘fight’ for midwifery which has formed the central tier of writing about maternity in countries such as

Canada, the USA, India and South Africa. This chapter will analyse the ways in which other countries tell their stories of maternity, and highlight the themes which other cultures see as central to the telling of birth.

This chapter will therefore place the history of maternity in twentieth-century England in a wider thematic and conceptual context.

Historiography of maternity

Much of the traditional writing on the history of maternity has come from the twin spectra of Whig history and what might be termed ‘great men’ (Versluysen 1980). The term ‘Whig history’ was coined in 1930s by historian Herbert Butterfield to describe the writing of history as that of the inexorable rise of enlightened progress; where every development leads to the sunlit perfection of today (Butterfield 1931). In a similar vein, there is the thesis that history is always written by the winners (Carr 1961), and this certainly appears to be true of a large proportion of the histories of maternity (Davies 1980: 11). The impression has always been given that maternity and care around childbirth particularly progressed and improved through the work of significant individuals. The story of the growing involvement of men in midwifery care during the seventeenth and eighteenth centuries is told as a series of names: Chamberlen, Smellie, Hunter (Radcliffe 1967). The Chamberlen family developed the midwifery forceps, and thereby transformed the safety of birth (Radcliffe 1947). The argument was that women previously left to die undelivered by midwives who just sat and watched, could now be saved by mechanical intervention. Smellie and Hunter not only lectured on midwifery, to both men and women, but also wrote about it, giving their philosophies and ideas a wider range and longer life span (Smellie 1752).

The medical profession has always been adept at celebrating those who came before them, and the stories of great men are often told by their successors. For an area such as midwifery this was particularly true as the nineteenth century saw the carving out of the specialised niche which would later call itself ‘obstetrics’ (Arney 1982; Drife 2002; Weisz 2005). It derived from ‘man-midwifery’, but saw itself as set apart in the sense that it was involved with delineating the normal as much as the pathological. That the speciality was a late developer and seen by more prestigious branches of medicine as lacking in complexity or taste, seems to have made obstetricians all the more determined to stake their claim. They were also wary of the charge of simply doing women’s work, and much of the hagiographic writing on great obstetricians was written in order to highlight their uniquely positive, and male, contribution to the story of maternity (Radcliffe 1947; Munro Kerr et al. 1954; Radcliffe 1967; Willocks and Barr 2004).

Obscure biographies written by now obscure men may at first appear irrelevant to the wider story of maternity, but the arguments they used and the issues they highlighted have made an impact beyond their numbers. Alongside the battles between doctors and midwives for the control of childbirth in twentieth-century England, was an equally significant one fought between general practitioners (GPs) and obstetricians. This story is seldom told however because GPs lost. In the nineteenth century locally based doctors, who worked outside the big hospitals and complex hierarchies of medicine, were building their practices as ‘family doctors’ (Loudon 1984). They attended births and visited ailing children, they dealt with fevers, accidents, injuries, and chronic conditions. At the end they helped to safeguard a good death and wrote the death certificate. As part of the community, the literature suggested that they were highly valued and the concept of the family doctor is still held dear by many in England today. However, as far as the increasingly specialised hospital-based medical profession was concerned, GPs were the jack of all trades and the masters of none. Their skill around childbirth was particularly mocked, and the need for specialist obstetricians constantly debated (Loudon 2008). This has had an impact on the way that maternity care is organised even now.

It was not just ‘great men’ whose lives and works have been celebrated in the stories of maternity; there have been great women too. Some of the most famous of these, such as Jane Sharpe and Louise Bourgeois who worked in England and France respectively in the early modern period, have been written about extensively by those who wish to put midwives back into childbirth (Hobby 1999). In an opposite twist to Whig history, these women are often held up as a model to follow and seen as shining lights for the cause of midwifery and women after whom things started to go wrong. More broadly, historians have argued that midwives in early modern England were highly regarded within their communities (Harley 1993; Allison personal communication). However, even for those midwives who were Church licensed and pillars of their community, there has lingered the suspicion that they were potentially engaged in superstition, witchcraft, abortion and infanticide (Forbes 1962; Forbes 1966; Harley 1990; King 1993). The debate between historians who characterise midwives of the time as eminently respectable and knowledgeable and those who believe that they trod the wilder shores of practice has been highly polarised and has sometimes been weakened by a lack of appreciation about social concepts of health and illness, which were very different in the early modern period (Porter 1997). Concepts such as ‘superstition’ are slippery and value-driven and need to be seen in the context of their time; it may be that in future a late twentieth-century belief in the ability of technology to reduce the risks of birth may come to be characterised as ‘superstition’. Nevertheless the power and influence of some midwives in the sixteenth and seventeenth centuries seems all the more remarkable in view of the decline in the status of midwifery which was perceived to follow (for one of the earliest readings of this in sociological terms, see Clark 1919: 242). However, after the supposed ‘dark ages’ of the eighteenth and nineteenth centuries in terms of midwifery, there has been a twentieth-century surge in ‘great’ women who have been involved in maternity. Some of these women, like Rosalind Paget who was a founder member of the Royal College of Midwives (RCM), were midwives (Hannam 1997). Many more however have been non-midwives, vocal in the late twentieth century for the way in which they have championed the cause of women; often the forgotten voice in maternity. Sheila Kitzinger, a redoubtable campaigner for women’s rights around birth and sexuality was described by The Guardian newspaper on the dust-jacket of one of her books, as ‘hav[ing] done for birth what Florence Nightingale did for nursing and Marie Stopes did for contraception’ (Kitzinger 2000). Similarly, the active birth campaigner Janet Balaskas is credited almost single-handedly with getting labouring women off beds and onto mats, bean bags and their feet (Kitzinger’s foreword in Balaskas 1991). These women are not midwives but, like the great doctors before them, are charged with having not only changed the history of maternity, but improved it.

One strand of history writing in midwifery and maternity which has been particularly powerful is that of what might be termed conflict writing, whereby those with an axe to grind put down another group in a contemporary dispute under the aegis of historical writing. This writing has often been highly polemical. The trend started with doctors, anxious to carve out a respectable and lucrative corner of midwifery practice. James Aveling, a nineteenth-century doctor with ambition (he founded the Jessop Hospital for Women in Sheffield and the Chelsea Hospital for Women in London) was one of the earliest chroniclers of the history of midwifery (Aveling 1872). He had many irons in the fire, not least his scheme for the training and regulation of midwives as subordinates to doctors. He described midwives as dangerous and ignorant in their practice, and as responsible for high rates of maternal death. However, while many contemporaries used similar rhetoric as a reason to argue that midwifery should be outlawed, Aveling suggested that they could be rehabilitated under suitable medical supervision. His historical writing was therefore designed to support him in arguing his political point. All historical writing needs to be seen, as far as possible, in the context of the time in which it was written; it is never unbiased and never without a wider agenda. Maternity, wrapped as it is in social meaning, its rituals reflecting the concerns of society around it is particularly susceptible to contemporary readings. In the late nineteenth and early twentieth century the image of the dirty, ignorant, gin-swilling midwife, developed by writers such as Aveling, was shorthand for everything that was wrong in maternity care. Sarah Gamp, Dickens’ portrayal of a nurse-midwife in Martin Chuzzlewit, as happy at a laying out as a lying in, was frequently pressed into service as an awful warning to those who would not accept progress (Bullough 1917; Summers 1989).

Conflict writing has remained a powerful tradition in histories of English maternity, but has increasingly been written by women from a feminist perspective. One of the most notable proponents of this style of writing has been Donnison, who wrote a powerful and detailed account focusing on the battle for the legal foundation of midwifery and whose book is still the touch-stone for those referencing the history of the maternity services (Donnison 1988). It put the story of registration and its aftermath in the social context of the battle between midwives and doctors for ‘the control of childbirth’ as it was described in the subtitle. This perspective was partly influenced by the time in which Donnison wrote; the 1970s and 1980s saw the development of a rhetoric of birth based on feminism, the language of disempowerment, and the demand for re-empowerment. In representing this ‘struggle’ as a linear one between two occupational groups scrapping for professional hegemony, Donnison marginalised the role of women as service users in shaping their own reproductive destinies and this is an omission that has been perpetuated by other histories (Oakley 1984; Towler and Bramall 1986). Donnison’s work has continued to exert a powerful influence over the way that the story of maternity has been told. But the sense of maternity as a battleground has been evinced in other areas. Heagerty (1996) wrote of the conflict between elite educated midwives and untrained midwives. In her reading, trained midwives, represented by Paget and the College of Midwives, sought to marginalise the work of midwives who continued to give care in the traditions of pre-registration times. Heagerty described statutory supervision of midwives in particular as a powerful tool of social control, used not only by doctors against midwives, but by midwives to discredit their rivals. Midwifery writers such as Kirkham (1996) have drawn on this reading to inform their own work on contemporary supervision, although Hannam (1997) argued that Heagerty’s reading was too simplistic and that early midwifery leaders had considerable sympathy with, if not always a thorough understanding of, the plight ...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Contents
• List of tables
• Preface
• Acknowledgements
• List of abbreviations
• Introduction
• 1 Historiography and comparisons
• 2 1902–14
• 3 1915–39
• 4 1940–60
• 5 1961–80
• 6 1981–2002
• Conclusion
• Appendix 1 Main government legislation relevant to maternity care
• Appendix 2 National reports relevant to maternity care
• Bibliography
• Index