Science
tends to reflect the established attitudes and institutions of an age. The
shift from the traditional female to male dominated midwifery in the United
States occurred as a result of scientific advances coupled with the developing
ideology of the place of the woman in society. Traditional midwifery was an
empirical discipline, often built on the foundation of the lessons learned from
the observations of generations of women. The core of the midwife’s discipline
was to allow nature to take its course, which was an often a slow and painful
process. This core attitude would compete with the new, male-midwifery and the
growing presence of medical doctors, which offered a swift and painless birth
through the use of forceps and anesthesia; however, this promise was rarely
fulfilled. Medical intervention, at best, did little to help but also did
little harm and, at worst, caused life long consequences and sometimes death
for the mother and her child.
In the early part of the seventeenth
century two Hungarian born brothers were responsible for the invention of the
forceps. Both brothers were doctors and they went to great lengths to keep this
invention secret. The forceps were invented to free an infant that was impacted
in the birth canal without having to kill the infant during its removal. Prior
to his invention, if a child were stuck in the birth canal, the midwife would
call a barber/surgeon who would use a hook or a tie to remove the child. This
practice usually caused the death of the child and often the death of the
mother not long afterwards. The invention of the forceps remained secret for
close to a hundred years. However, by the middle of the eighteenth century,
forceps were widely known among English doctors. The forceps were far from a
perfect instrument, and would go through a number of modifications over the
centuries.[1]
William Smellie was a pioneer in the
teaching of obstetrics and midwifery. He was the first to develop a series of
rules for the safe use of the forceps. Largely self-taught, he never the less
returned to school after he had begun his medical practice to gain the
education he felt he lacked. Around 1742 he began a series of public courses,
teaching his theories on how to best use the forceps. Smellie was self taught
and had developed a system as to how and why forceps should be used to hasten
the birthing process. He designed a wooden and leather doll as a stand-in for the mother. The belly of the
doll would be filled with beer and a wax replica of an infant. Smellie was able
to use the doll to give his students practice in the processes of birth.
Smellie’s motivations and reasoning for
the use of the forceps were sound; however, many of the students who attended
his midwifery training courses saw his methods as an easy way to make a living;
they would use forceps to hurry the birthing process so they could take more
clients. Because they were able to make the birthing process faster, Smellie’s
students began to be preferred over traditional midwives, allowing them to charge
their clients more money.[2]
American doctors who had been trained in
Europe began to see the use of forceps in midwifery as a means to both making a
stable living and a key to bringing medicine to the fore in American society. Several
of these doctors designed American midwifery courses to train both male and
female midwives in European birthing sciences. Few women came to these courses,
but men flocked to them. Although cultural norms played a part in the absence
of women, these norms weren’t wholly responsible for their absence. In England
the government subsidized the programs, but in the United States the cost of
the programs was often too high for many women who would have otherwise
attended them.[3]
The use of forceps allowed for a faster
birth and a safer freeing of the infant when stuck in the birth canal, but when
they were used to reach the child deep in the womb, or were used roughly, they
could tear the vaginal wall, or cause other internal wounds. When not used
carefully, the forceps could also damage or even kill the infant. They were
also perfect instrument for the passage of disease from one woman to another.
Smellie’s courses attempted to teach the proper timing and use of forceps, but
his students were accused of making each of the above mistakes. However, they
speed of birth offered by the use their use often made doctors and
male-midwives a preferred option for a birthing attendant.
After 1810, the competition between
traditional midwives and the new, male dominated midwifery began to gradually
drive the traditional midwife out of business. Driven by this competition,
doctors began to opt for greater levels of intervention, hurrying the birthing
process along even more. The evolving culture of “true womanhood” also
contributed to the reduction of female midwives among the upper classes. It was
unacceptable to mix the genders, and it was believed that the female mind was
not suited for the education and training that was necessary to become a doctor
or educated midwife. This was an attitude for which doctors provided
“scientific” proof.[4]
Pain and complications in childbirth took
on a new character in the nineteenth century. The wearing of corsets from an
early age caused malformations of the ribcage and misplacement of the organs
causing greater degrees of pain and other complications. Doctors warned against
the wearing of corsets as a cause of complications in childbirth; however, upper
class women preferred the look of the corset to the look of the natural waist
and ignored these warnings.[5]
Strangely, various scientific manuals
claimed that pain was natural for the weaker female, but birth pain was
considered abnormal. It was believed that not all women suffered pain in
childbirth. Many doctors shared the view that pain in childbirth was unnatural,
and the idea that Native American women did not suffer in childbirth was often used
to defend this view. Dr. M. L. Holbrook reasoned that “parturition is likely to
be painless in proportion as the mother is physically perfect…”[6]
In this way the physical and moral health of the woman was considered a direct
cause of pain in childbirth. This was one more standard added to the ideal of
the perfect woman. If she would simply fulfill this feminine ideal, she would
not suffer pain in childbirth. Elizabeth Cady Stanton, one of the leaders of
the suffragist movement in America, gave a lecture in which she supported this
viewpoint:
We must educate our daughters to think that motherhood is
grand, and that God never cursed it… If you suffer, it is not because you are
cursed of God, but because you violate his laws… We know that among Indians the
squaws do not suffer in child-birth. They will step aside from the ranks, even
on the march, and return in a short time bearing with them the new-born child.
What an absurdity, then, to suppose that only enlightened Christian women are
cursed… I am the mother of seven children. My girlhood was spent mostly in the
open air. I early imbibed the idea that a
girl is just as good as a boy, and I carried it out. I would walk five
miles before breakfast, or ride ten on horseback. After I was married, I wore
my clothing sensibly… I never compressed my body out of its natural shape. When
my first four children were born, I suffered very little. I then made up my
mind that it was totally unnecessary for me to suffer at all… The night before
the birth of the child I walked three miles. The child was born without a particle of pain…[7]
Despite these beliefs, pain in childbirth
remained a persistent and common issue. In an effort to relieve the unnatural
suffering of women, some doctors began to use anesthesia in childbirth. Dr.
Walter Channing of Boston first used anesthesia as an aid to childbirth in
1848. He encouraged other doctors in its use, but it was a confusing topic with
contradictory claims and methods. There was confusion as to what chemical to
use. Some doctors preferred chloroform, others like ether. Each doctor seemed
to have his own methodology for the use of whatever chemical he preferred. Most
American doctors found the whole thing too confusing to make any sense out of.
If they used it at all, most American doctors used anesthesia only once the
baby crowned, rather than when it would have been most effective.[8]
The second half of the nineteenth century
saw the development of several non-medical treatments for pain in childbirth. Mostly
preventative in nature, these treatments were designed to ease childbirth
through their conscientious use throughout pregnancy. The sitz-bath was one
such treatment. The sitz-bath prescription was to be individual; it was
considered “quackish” to prescribe the same treatment to everyone.[9]
The bath could be hot or cold, it could be a sponge bath or immersion, and the
timing of the bath was to be determined by the doctor and the individual
together. The frequency of the bath was important because it was believed that
bathing too often could do harm. These baths were in addition to the normal
bathing for cleanliness and were designed to “strengthening the nerves.”[10]
Vigorous rubbing of the abdomen and limbs was usually included as long as the
body was not preoccupied with digestion.[11]
Another method of ensuring a painless
birth was the “fruit diet,” which was used alone or along with the use of the
sitz-bath. The fruit diet was comprised of eating primarily acidic fruits with
light grains and fish. The goal of the diet was to ensure that the bones of the
child were soft and “all in gristle;” that they remained as close as possible
to the original “gelatinous pulp” of the fetus [12]
Preventative measures and anesthesia may have aided in the relief of birth pain
for those who could afford them, but such methods did little to prevent or
relieve the common complications of birth such as puerperal fever or vaginal
fistula.
Puerperal fever is a bacterial infection
contracted during childbirth. Reaching epidemic proportions several times in
Europe, American women, who gave birth at home, were not typically in danger on
a large scale until the nineteenth century when women increasingly gave birth
in the hospital. Most of the time, the infectious bacteria are passed to the
individual from other patients or autopsy matter via the doctor or the
equipment. It was quite easy to infect large numbers of women in maternity
wards and hospitals in this way. Some forms of this infection were so virulent
that it could pass on the clothing of anyone exposed. The symptoms were
abdominal inflammation, blood poisoning, and eventual death.[13]
Oliver Wendell Holmes was the first to
suggest that doctors were at least partially responsible for the spread of the
infection.[14]
The backlash to his claims was quick and sometimes abusive. In 1854, Dr.
Charles Meigs published a scathing rebuttal of Holmes’ paper claiming that,
because doctors were gentleman, their hands were clean. Any attempt to
insinuate that doctors could be the “medium of transmission” was to imply that
doctors were “both dirty and culpable.”[15]
Dr. Holmes published a response in 1855
where he made clear the evidence and his reasoning. This work is cogent in its
arguments. One portion, in particular, is worth quoting at length:
Dr.
Simpson attended the dissection of two… cases, and freely handled the diseased
parts. His next four cases of midwifery were affected with puerperal fever, and
it was the first time he had seen it in practice. As Dr. Simpson is a gentleman (Dr. Meigs, as above,) and as
‘a gentleman’s hands are clean,’ (Dr. Meigs’s Sixth Letter,) it follows that a
gentleman with clean hands may carry the disease.[16]
In Vienna a doctor named Ignaz Philipp
Semmelweis was able to statistically show that puerperal fever is contagious
and to prove certain measures that were effective in its prevention. He was
able to show that women who never reached the hospital or gave birth on the
hospital steps did not contract the fever. He also noted that a colleague died
with the same symptoms of the fever after having performed an autopsy. He
concluded that the cause was decomposing flesh, and he instituted a practice of
sterile procedures that reduced the death rate from 459 in 1846, to 88 in 1848.[17]
Dr. Holmes also suggested a rigorous
series of sterile procedures, but these were only partially effective since no
one understood the cause of the fever, until Louis Pasteur discovered that
streptococci bacteria were the primary cause. He was also able to show that the
risk of contracting the fever was much greater in women who had been wounded
during childbirth.[18]
Since many doctors did not understand
Pasteur’s work, they were still reluctant to believe that they were carriers of
a virulent disease. Many of these same doctors, however, followed the advice of
Holmes and others like him and attempted to prevent puerperal fever. Unfortunately,
the aseptic methods used were often inadequate and the performance of these
methods lax. Prior to 1885 the statistics of morbidity are unreliable since
causes of death were not accurately recorded. Yet it is clear that the fever
was still present and repeatedly reached epidemic proportions. It wasn’t until
the 1940s, when penicillin became available, that there was a curb in the
deaths cause by the fever.[19]
One of the most unfortunate results of the
dangerous and ignorant childbirth practices of the nineteenth century was
fistula. Fistula is an abnormal opening between two organs or between one organ
and outside the body. Caused by impacted birth or the misuse of childbirth
tools, fistula was most often a tear between the vagina and the bladder, the
vagina and rectum, and sometimes both.[20]
Most often fistula is caused by the
misuse of instruments, but it can be caused by a prolonged impaction where the
child’s head is lodged against the soft tissues of the mother’s body. This prolonged
impaction causes the blood supply to cease resulting in the death of the
tissue. After a few days, the dead tissue falls off and an opening between
organs is created. This condition is most likely to occur in women who have
suffered from Vitamin D deficiency, which means people who are poorly fed and
not often in the sunlight. In the nineteenth century, fistula was common among
the poor. Having a condition that causes continual leakage from the bladder
and/or the rectum into the vaginal canal often caused extreme social
consequences.[21]
Several doctors worked with varying degrees of effort and success. All
experiments were surgical and performed without anesthesia.[22]
When the cost is so high, such as social isolation due to the constant stench and
mess, people are willing to do almost anything.
In 1845, Dr. Marion Simms was called to
help a seventeen-year-old slave-girl who had been in labor for three days. He
used forceps to quickly deliver the baby, but he knew it was likely that the
mother would develop fistula. Three days later he was proven correct. She
developed holes in her vagina leading to both her bladder and her rectum. Over
the next several weeks he was called to help more women with similar
conditions. This experience had a lasting effect on Dr. Simms.[23]
While attending to an elderly patient
with a different condition, Dr. Simms had a revelation as to how he might be able to
operate on a fistula and actually cure it. He had to place the women in the
“all fours” position in order to work on her, and he saw that the vagina filled
with air in this position. He realized that he would be able to operate on both
forms of vaginal fistula with the patient in this position. He was able to recruit
several slave women who had the condition and were willing to go through
virtually anything to be cured. It took over four years and dozens of
operations, all without anesthesia, but eventually he made it work. Dr. Simms
went on to have a lucrative career that included many firsts in the field of
medicine.[24]
This discussion of advances and setbacks
in childbirth practices prior to the twentieth century are representative of
the evolution of the birthing practices in America during this time period. The
years leading up to the twentieth century saw many innovations in the birthing
practices of the United States. The evolution of these practices is intimately
tied to the development of medicine as a respectable science. From traditional
forms of midwifery through the sometimes arrogant and misunderstood advances in
the field, by the twentieth century, the entire world had changed, and the
practice of birthing science with it. As abhorrent as some of these practices
may seem, they still managed to move us forward in knowledge and understanding
of the complexities involved in the process of childbirth.[25]
25. For more information on
childbirth injuries in the world today, including Obstetric fistula, here is a
documentary and website. Both cover the problem of childbirth injuries in
Ethiopia. The social stigma, and emotional pain of these women give insight
into what women in the United States suffered prior to the twentieth century.
The documentary can be found here: A Walk to Beautiful. The website can be
found here: website.
