It has been suggested, in pre-industrial society, there were three main hierarchies, that of men over women, Church over laity and landlord over peasant (Oakley 1976). The majority of midwives were women before the seventeenth century (Kirkham 1996) and so, on a gender basis alone, it could be anticipated that their status in society may have been limited. However, Hobby (1999), in introducing a manual written in 1671 by a practising midwife (Jane Sharp’s ‘The Midwives Book or the Whole Art of Midwifery Discovered’) creates a somewhat different impression. She identifies that the midwife may have been in a unique position as, at a time when a woman was “supposedly absorbed into her husband’s identity”, the midwife “could earn enough to make a comfortable living in a line of work still largely closed to men” (Hobby 1999:xi). Midwives may have had a status, which most women were denied, by virtue of their employment in an all-female sphere where men posed no threat to their authority. Wilson (1995:26) supports this and suggests that “power, then, was a defining feature of the midwife’s office” as she took charge in labour and stayed there until the birth was over, being paid in some way for her efforts. It cannot be expected that all midwives operated under the same conditions; Hobby (1999) points out that midwives in the 1600 and 1700’s were as varying as other medical practitioners of the time. Some will have provided care extending from the early antenatal period until well after the baby was born and received a handsome fee for the effort (Hobby 1999), whereas probably the majority would have had a more limited sphere and income. Regardless, at this point in history, midwives seem likely to have had autonomy in their practice and some status in society.
In respect of the second hierarchy (Church and laity), Hobby (1999:xi) points out that midwives “played a crucial role in the male-run church”… “participating in baptism and churching ceremonies”. However, in order for the Church to exert authority over midwifery, in 1512 in England, Parliament had placed the licensure of midwives under the control of the Church (Arney 1982). Hobby (1999) confirms that it was illegal to practice midwifery without a licence granted by the Bishop (sometimes at relatively great expense). Midwives had to produce either clients who would testify to their skills before they were licensed (Donnison 1977) or testimonials from other medical practitioners or church ministers (Hobby 1999). So midwives were controlled by the Church but also contributed to its work in a way that seems likely to have afforded them some status in pre-industrial communities.
The third hierarchy (landowners and peasants) is not likely to have been one that midwives challenged, as women were generally not landowners nor were midwives part of the gentry. Although property ownership would not have afforded the midwife status, Oakley (1976) claims that midwives were trusted parts of the community. In pre industrial European society, the female healer, including the midwife, was probably more trusted than her male counterpart. She was respected for her knowledge and ability to treat conditions, she was able to earn a living at a time when women were rarely in gainful employment outside of the home and she was an active participant in important ceremonies in the Church. Therefore, in Oakley’s analysis, it would seem likely that midwives did challenge the hierarchies of the time and have autonomy (which has rarely been the case since).
A fourth hierarchy that became more evident as the pre-industrial period progressed was that of medicine over midwifery. The increased interest in knowledge and scientific approaches, which became prevalent during the Renaissance period, had a significant impact on the status of midwives and midwifery. The next sections of this paper will explore the impact of the hierarchies of medicine over midwifery and men over women which altered the authority and autonomy of midwives through subsequent centuries.
Medicine in Childbirth
One key way to identify the increasing interest in childbirth by the medical community is in considering the publication of texts or manuals about the subject through history. Hobby (1999) describes the scenario in early modern Britain; childbirth was almost entirely in the hands of women but the midwifery writing was almost entirely produced by men. She points out that the British books of the time were largely exploited from translations from the Continent, which themselves were based on ancient authors (and not attributed to the sources as was the norm at the time), primarily from the writings of Aristotle, Hippocrates and Galen (Hobby 1999). These manuals focussed largely on the qualities of a ‘good’ midwife, similar to that described in the introduction to this paper and were mainly written by non-midwives. One notable exception is the book referred to earlier, Jane Sharp’s ‘The Midwives Book of the Whole Art of Midwifery Discovered’ which was written in 1671 by a midwife with thirty years experience of midwifery practice (Sharp 1671 in Hobby 1999). Sharp’s contemporaries (Culpeper, Sermon, Wolveridge) were medical men, often never having had any experience of childbirth. However their gender and status, by virtue of being doctors, established their authority in the field despite having little or no practical experience. Sharp did believe that women had considerable anatomical and medical knowledge but recognised that this was not learned at university but from “long and diligent practice” and was “communicated to others of our own sex” (Sharp 1671 in Hobby 1999:xxiii). This was largely unrecognised by her contemporaries of the day, who dismissed female midwives as largely ignorant.
It is difficult to know how many midwives would have been able to access any of these writings as literacy in working class women, from which the majority of practising midwives emanated (Heagerty 1997), may have been limited. Wilson (1995) claims that the majority of midwives could in fact read in the 1600s in Britain (but that writing was a much less commonly held skill generally in society). Opportunities to acquire these medical or midwifery writings, however, may have made it difficult for midwives to use them to inform their practice. Traditionally, practising midwives’ knowledge would have been communicated verbally and experientially, through being apprenticed for long periods, in order to learn their trade (Evenden 1993). This knowledge has been attributed less status than that of the written word; the erosion of the authority of midwives in childbirth was starting as medical men took command of the authoritative knowledge of the day.
The first textbooks written by the French (who were fairly prolific writers in that period) for midwives and about midwifery were largely inaccessible to females, as women were not able to participate in formal education at the time (Arney 1982). It was largely men, who were training to be doctors, who would be influenced by these writings and would form an understanding of childbirth that was not based on practical knowledge. Medical men had significant control over the writings about childbirth and would shape the development and spreading of midwifery knowledge from a limited experiential base. “They were medical practitioners acquainted with medical books” (Hobby 1999:xviii); midwifery was being presented formally by individuals who may never have seen labour or birth to fit the academic convention at the time.
As the ecclesiastically sanctioned control of midwifery was taking place in England, developments in Europe were leading to an increased interest by doctors in childbirth. Public hospitals appeared in the sixteenth century in France leading to an increase in the percentage of births that took place outside of the home and affording the opportunity for doctors to become more actively involved in what had been primarily a domestic affair previously. Donnison (1977) suggests that other important developments were also taking place in France that would have far-reaching consequences for the future of both childbirth and midwifery.
The spirit of enquiry which the Renaissance had brought to other branches of medicine was now being directed to the processes of childbirth, as part of the new scientific study of anatomy.
This scientific interest and investigation began to strip away the perception of birth as natural, applying a rational approach that undermined the symbolic basis of traditional midwifery (Arney 1982). Progress, in relation to an increased understanding of anatomy which could inform care for childbearing women, did not come about as a result of the work of midwives however, as women generally did not have access to the new academic or anatomical studies (Donnison 1977), as discussed earlier. The “outstanding scientific achievement of the Renaissance was the rise of anatomy as the subject basic to the practice of medicine, surgery and midwifery” (Rhodes 1995:16). The knowledge that became formalised during that period led to birth being reframed, largely without midwifery input.
Science as Authority
The word ‘science’ is rooted in the Latin ‘scientia’ meaning knowledge. In its pure sense therefore, science does not assume the nature of reality, only that it is knowable.
The making ‘knowable’ of the ‘reality’ of childbirth escalated from the early 1500’s. The well known drawing by Leonardo do Vinci of the ‘fetus in utero’ was followed by Vesalius’ book on anatomy in 1543 which depicted human organs as a result of dissection and recording by artists (Rhodes 1995). Fallopio, a student of Vesalius, identified and defined many female anatomical features in his ‘Observations on Anatomy’ published in Venice in 1561; these included the Fallopian tubes, ovaries, uterus, vagina, clitoris and hymen (Rhodes 1995). An understanding of the effect of the size and shape of the pelvis on labour was first described by Aranzi in 1564. Pare described the technique of turning the fetus in the uterus (internal podalic version) to assist poor progress in labour in the mid 1500s, using the knowledge of anatomy to intervene in the birth process (Rhodes 1995).
These examples of developments through that period identify an emerging priority for knowledge of the human body. The exposure of the ‘inner’ workings of the female body, which would have been poorly understood previously, led to a new understanding of ‘reality’. The reality for those early anatomists was considered to be ‘science’ or, by their definition, truth.
The scientific paradigm was born in the sixteenth and seventeenth centuries when Newtonian physics and Cartesian reality replaced the softer and more organic logic of a world view based on religion and an Aristotelian respect for nature. A desire to predict and control events gradually replaced a less intrusive quest for meaning and significance. This displacement of one paradigm by the other has been associated with a drive towards complex technologies, rather than ecological solutions to human needs.
This move from religious and ‘softer, more organic’ explanations of the body, and therefore birth, set a scene for science as the eminent source of knowledge. Science can be defined as “observation, identification, description, experimentation, investigation and theoretical explanation of natural phenomena” (Marriner-Tomey 1989:3). Shiva (1996) points out that the rise of the ‘science of nature’ which took place between the fifteenth and seventeenth centuries in Europe, was a revolution led by males of western origin and which set in place a gendered hierarchy for modes of thinking. She continues by suggesting that science is projected as being objective or a universal, value-free system of knowledge that has displaced virtually all other beliefs and knowledge. The movement that started some five centuries ago has been an effective means of making science the authoritative knowledge in the western world. As midwives were largely excluded from building that knowledge base, unlike doctors who were educated and involved in the investigative and experimental scientific methods, they did not either impact on the knowledge development or maintain an equivalent status to that of doctors.
Science and Medicine
It is worthy of recognition, however, that knowledge and truth change all the time. In Hobby’s descriptions of the pre-industrial writings on childbirth, she points out that there were many beliefs at that time which we now find somewhat amusing, assuming that we now know the ‘real’ truth (Hobby 1999). These include the thought that conception only took place if each partner had an orgasm during intercourse, that labour pains were caused by the baby’s struggling to be born rather than by uterine contraction, and that the womb and breasts were attached by special vessels which allowed the postnatal blood to travel from the womb to the breasts where it was transformed into milk. New ‘scientific’ breakthroughs are now daily occurrences, for example genetic sequencing or cloning, yet it is impossible to know if scientists of the future will consider the knowledge we currently believe to be true as amusing, in the light of findings we cannot even consider at this point in history. Science is thought of as ‘true’ and ‘real’, but it is bound by contemporary understandings and capabilities, and these change all of the time.
There appears to be an implicit belief, from the writings in these early times to the current notion of evidence based practice that medicine is science-in-action. As science became increasingly revered as truth, medicine sought to find ‘scientific’ answers to the challenges posed by childbirth. The impact of this will be further explored later.
Men in Midwifery
As scientific interest in birth increased, so did the part that men played in the process. “In England, the existence of this new order of practitioners had been recognised by the early 1600s with the addition of the word ‘Man-Midwife’ to the English language” (Donnison 1977:23). The development of the obstetric forceps by Chamberlen, from as early as 1634 (Rhodes 1995), gave male midwives (or accoucheurs as they preferred to be known) a more positive role than that of their predecessors, the barber surgeon (Towler & Bramall 1986). “No technology will gain widespread acceptance and be the basis for reform of culture unless it is introduced into an ideologically social field” (Arney 1982:27). The forceps, then, became a symbol of socially accepted change; men were increasingly accepted as having a part to play at birth. Hobby (1999:xii) identifies that the Chamberlens’ “secret midwifery forceps are seen as a proper scientific intervention into birth” and that they kept the design of these secret in order to protect both their profits and their control.
This use of the word ‘scientific’ equates it to technological development. Although some of the developments of the day would have been based on the increased knowledge of anatomy, this in itself did not make them ‘scientific’. Using Marriner-Tomey’s definition above, science is explanation rather than intervention. However, under the name of science, many of the developments taking place in and around childbirth were interventions intended to expedite birth to the benefit of mother and baby. Male midwives or accoucheurs were those using this technology; they would have been seen as the ‘rescuers’ when the attempts of the midwife were unsuccessful in supporting normal birth, in cases of complication.
The midwives’ role, which would rarely have been questioned before the 17th and 18th centuries, now started to be both challenged and influenced by medical men. Bourdillon (1988) identifies that, by the mid eighteenth century, accoucheurs were the most highly paid practitioners employed by the upper classes. Therefore the male midwives had moved into the influential sphere of society and were seen as more prestigious than their female counterparts. The working classes continued to be served by the lay midwife or local handywoman (Kirkham 1996). These lay midwives practised in their local communities with little or no communication between them and, therefore, were not organised in any way to challenge the increasing control over birth which the medical men were exerting. These women did not receive any formal educational preparation for their work but, as discussed earlier, were apprenticed, often for lengthy periods (Marland 1993), into learning the skills necessary to support women through the birth process. But the value of this learning was becoming less recognised as important and considered by some as inferior to the new ‘scientific’ knowledge.
The Dickensian image of the gin-swilling, unkempt ‘Sairey Gamp’ type midwife devalued any knowledge base on which practice was established. It gave the impression that these women were unscientific and therefore unsafe, despite there now being available evidence of ‘unofficial’ systems of training from at least the seventeenth century in London (Evenden 1993). Even though this training existed, it would not have been based on a formal understanding of human anatomy / physiology or the potential value of ‘scientific’ intervention. The midwives who cared for women giving birth could have been considered as ill prepared or even dangerous by those in the developing scientific community despite the fact that, both historically and internationally, birth was normally successfully accomplished under these conditions.
The early 19th century saw significant change; no longer was just birth of interest to accoucheurs but pregnancy began to be framed as a pathological possibility and, as such, not safe in the hands of midwives. In Britain, there were moves to try to organise lay midwives through regulation; the Obstetrical Society (an organisation of male practitioners) from 1826 tried to make a case for this with some success (Arney 1982). But possibly the most significant development was in mid century, when the Royal Colleges in Britain established examinations for male practitioners in midwifery. Donnison (1977) claims that this put the final seal on the exclusion of women from controlling midwifery as women were unable to attend university and, therefore, take these exams.
Towler & Bramall (1986) point out that Elizabeth Nihell had tried to attack the male midwife in her ‘Treatise on the Art of Midwifery’ as early as 1760, claiming that they used forceps unnecessarily. Nihell decried the pay differential between male and female midwives and appealed to midwives to maintain the ‘naturalness’ of birth. However the lack of organisation and education of lay midwives would have made this plea one which few midwives heard. Donnison (1977:177) points out that the poor and sometimes illiterate working class midwife was not “the stuff of which a successful pressure group is made”.
A number of groups tried to take control of the organisation and education of midwifery in Britain through the nineteenth century; for example, Florence Nightingale set up a training school and the Female Medical Society organised a Ladies’ Medical College. Both of these allowed midwives the opportunity to be formally trained in a way largely inaccessible to them previously. The Matron’s Aid or Trained Midwives’ Registration Society (to become known as the Midwives’ Institute) was formed as a key player in the move to gaining recognition for midwifery as a respectable means of employment (Arney 1982). This group was to be instrumental in both the survival of midwifery as an occupational group and its ultimate control by medical men.
The Midwives’ Institute was a group of middle- and upper class nurses and trained midwives who sought to provide respectable employment for middle-class women (Heagerty 1997). It was instrumental in bringing about the Midwives Act of 1902, which made the training of midwives compulsory to stop the perpetuation of the attendance at birth by lay (and largely working-class) women. The social standing of this group was crucial to the outcome of their energies. They aligned themselves to the prestigious medical community and had little in common with either the midwives or women from the working-class and were, therefore, unlikely to take into account the needs and desires of these groups.
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