Thursday, March 20, 2014

THE EVOLUTION OF BIRTHING PRACTICES IN AMERICA BEFORE 1900

          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]



            1. William Leishman, M.D. A System of Midwifery (Glasgow, McMillan and Co., 1873), 515.
            2. Elizabeth Nihell, A treatise on the art of midwifery (London, A. Morney, 1760), 51.
            3. Walter W. Wertz and Dorothy C. Wertz, Lying-In (New Haven: Yale University Press, 1989), 44.
            4. Ibid. 47.
            5. Ibid. 112.
            7. Ibid. 198.
            6. Mrs. P. B. Saur, M.D., Maternity: A Book for Every Wife and Mother (Chicago, L.P. Miller and Company, 1888), 199 – 200.
            8. Wertz, Lying-In, 118.
            9. M. L. Holbrook, M.D., Parturition without Pain (New York, Wood and Holbrook, 1878), 45.
            10. Ibid., 46.
            11. Ibid., 48.
            12. Ibid., 53.
            13. Wertz, Lying-In, 120.
            14. Oliver W. Holmes, “Contagiousness of Puerperal Fever,” The Harvard Classics 38, no. 5 (2001): 1909 – 14, accessed July 28, 2013, http://www.bartleby.com/38/5/1.html
            15. Wertz, Lying-In, 122.
            16. Oliver W. Holmes, Puerperal Fever as a Private Pestilences (Boston: Ticknor and Fields, 1855), 60.
            17. Wertz, Lying-In, 121.
            18. Ibid., 125.
            19. Ibid., 126.
            20. Ann Dally, Women Under the Knife (Edison: Castle Books, 2001), 20.
            21. Ibid., 22.
            22. Ibid., 24.
            23. Ibid., 25.
            24. Ibid., 26.
            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.

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