Citation
Women being delivered

Material Information

Title:
Women being delivered the rise of obstetric birth practices
Creator:
Nelson, Dana Michele
Place of Publication:
Denver, Colo.
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
235 leaves : ; 28 cm

Thesis/Dissertation Information

Degree:
Master's ( Master of Social Science)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Humanities and Social Sciences, CU Denver
Degree Disciplines:
Social Sciences
Committee Chair:
Everett, Jana
Committee Members:
Bookman, Myra
Tang, Michael

Subjects

Subjects / Keywords:
Obstetrics -- History -- United States ( lcsh )
Midwifery -- History -- United States ( lcsh )
Midwifery ( fast )
Obstetrics ( fast )
United States ( fast )
Genre:
History. ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )
History ( fast )

Notes

Bibliography:
Includes bibliographical references (leaves 219-235).
General Note:
Department of Humanities and Social Sciences
Statement of Responsibility:
by Dana Michele Nelson.

Record Information

Source Institution:
University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
45534671 ( OCLC )
ocm45534671
Classification:
LD1190.L65 2000m .N44 ( lcc )

Full Text
WOMEN BEING DELIVERED:
THE RISE OF OBSTETRIC BIRTH PRACTICES
by
Dana Michele Nelson
B.A., University of Oklahoma, 1991
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Social Science
2000


This thesis for the Master of Social Science
degree by
Dana Michele Nelson
has been approved
by


Nelson, Dana Michele (Master of Social Science)
Women Being Delivered: The Rise of Obstetric Birth Practices
Thesis directed by Associate Dean Jana Everett
ABSTRACT
Using research methods inspired by Michel Foucault, his definition of power
relations, his theory of the increasing bifurcation of society into normal and not
normal categories, and his concepts of discipline and docile bodies, this critique of the
rise of modem obstetrics exposes the multitude of power relations and arbitrary
circumstances that redefined birth from a normal and healthy life event into a perilous
medical crisis necessitating hospitalization and physician attendance.
For more than a millennia birth had been a female centered, home based, social
event. Laboring women surrounded themselves with women who had experienced
childbirth, at least one of whom displayed the skills necessary to be called midwife.
Birth was a normal, healthy event quite removed from illness, injury, and pathology.
Modem birth is a running series of surveillance, preemptive precautions, interventions,
and crisis management. Birth is described as a dangerous aberration from normal
and laboring women are shut away from most family and friends. Most modem births
take place in centralized, unfamiliar hospitals attended by surgically trained physicians
virtually inexperienced in the processes of uninterrupted labor and birth. Birth pain
went from being a manageable aspect of birth to being the focus of medical
intervention. This shift in birth practices and perception occurred during the 17th-19th
centuries, coinciding with the rise of scientific medicine as a whole. By the mid-
twentieth century midwives and a midwifery discourse were nearly extinct.
The events and circumstances that converged to precipitate such a dramatic
change are much more complicated than the simplistic, and partly false, notion of
scientific medicine making birth safer. Very few birth interventions improved the
safety of birth for most women. Instead, most birth interventions benefitted the
practices and convenience level of physicians and reinforced the societal view of
women. Scientific physicians, to distinguish themselves from midwives, focused on
pain elimination and the speeding of labor. Women, fashion, economics, geography,
sexism, science, prudery, professional specialization, male physicians, midwife
practices, and the unique circumstances of the particular historical moment all
m


contributed to the domination of midwifery by obstetrics.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signed
IV


ACKNOWLEDGMENT
This work would not have been possible without the support of the following people:
Stefani Barrows without whose babysitting I would have been unable to finish classes.
My parents, Barb and Jim Goodman, who have never failed me and taught me what
was truly important. My parents-in-law, Catharyn Baird and Robert Russell, who
never doubted my ability and provided days of childcare. My dear friends, the Lemon
Slushies, whose interest and patience were often tested by my vocal fascination with
this topic and my insistence they be the best informed potential parents. Lisa, Jami,
and Peggy who listened, understood, and helped me through the toughest days. My
thesis committee and program graduate assistants who assisted me when I could not
make it to campus myself. And finally, for my adored husband Thor, without whom I
would never have found my place, and for my boys, Andrew and Michael, whose
births, no matter the circumstances, were the best work of my life.
v


CONTENTS
CHAPTER
1. INTRODUCTION...............................................1
In the Spirit of Michel Foucault.....................4
Literature Review...................................13
Definition of Frequently Used Terms and Assumptions.20
2. PRE-MODERN EUROPEAN BIRTH PRACTICES AND
DISCOURSE...........................................26
13th Century to 1800................................26
Church Influence on Midwifery Practice........28
French Advances in Regulation and Education...44
Male Encroachment into Birthing Rooms.........51
Establishment of the Maternity Infirmary in Great
Britain..................................55
Foundation Laid...............................66
3. COLONIAL BIRTH ATTENDANTS AND DEBATE TO 1800..............71
Regulation, Medical Schools, and Birth Perception...72
Remarkable Diary of Martha Ballard..................83
4. CREATION OF THE OBSTETRICIAN EXPERT
IN AMERICA..........................................95
vi


Practice from 1801 to 1899...........................95
Medical Science.................................99
Professional Organizing and Regulatory Efforts.119
Alternative Movements and Irregular Education..128
A Womans Place in Medicine....................134
Conclusion.....................................146
5. conclusion:........................................154
APPENDIX
A. CHRONOLOGY OF EVENTS AFFECTING
CHILDBIRTH CARE.....................................167
B. TYPES OF MIDWIVES IN THE UNITED STATES.............218
BIBLIOGRAPHY..........................................................219
vu


TABLES
Table
1. Foucaults Science of Discipline Related to Obstetric Care...........9
2. Midwifery vs. Medical-Surgical Model of Care........................21
3. The Number of Female Physicians Practicing in the United States...136
4. Attractiveness of Nursing vs. Midwifery Careers
Late 19th Century.........................................144
5. Cesarean Deliveries in the United States...........................159
vm


CHAPTER 1
INTRODUCTION
Every human being on earth came into the world through the act of childbirth,
either vaginally or surgically by way of a cesarean section. But the experience of birth
has changed radically over time. The in-hospital, highly medicalized birth most of us
have experienced in the last 60 years is a radical departure from birth practices and
experiences throughout the vast majority of human history (Bogan, 1993; Boston
Womens Health Book Collective, 1998; Donnison, 1977; Kahn, 1995; Rooks, 1997,
Rothman, 1982; Wertz & Wertz, 1977).
From the earliest times of humanity, childbirth was a female-centered, home-
based, social event attended by female relatives, friends and midwives (Brown, 1995;
Donegan, 1978; Donnison, 1977; Ehrenreich & English, 1978; Kahn, 1995; Rooks,
1997; Trager, 1994; Ulrich, 1990; Wertz & Wertz, 1977). Women would surround
themselves with other women who had birthed their own children, women who were
learning what to expect during birth, and a woman, the midwife, who had special skills
and experience in helping laboring women to bring their children into the world
(Donegan, 1978; Donnison, 1977; Ehrenreich & English, 1978; Rooks, 1997; Ulrich,
1990; Wertz & Wertz, 1977). The laboring woman was active, ate, bathed, and
labored in many different positions, finding what was best for her. Birth was a
continuation of sex, pregnancy, and family. Female bodies were expected to
accommodate birth. Birth pain was an aspect, not the focus, of birth and provided an
indication of progress and health. The midwife and other women supplied non-
invasive methods of pain relief and support. The laboring mothers perception and
sensation were central to the occasion with her needs and feelings guiding her care and
1


support.
By the mid-twentieth century, women were expected to labor and birth in the
sterile, unfamiliar, and often uncomfortable environment of large hospitals. In 1950
over 88 percent of American women gave birth in hospitals (Suarez, 1993, p. 329;
Kahn, 1995, p. 304). By 1970 the percent of American women giving birth in
hospitals would rise to 99.4 (Rooks, 1997, p. 60). Instead of birth residing on a
continuum of life events, it was singled out as an abnormal, pathological medical crisis
requiring trained medical care and posing at all times a threat to mother and fetus.
Birth attendants would no longer be midwives and close members of a womans
community and family, but scientifically trained medical physicians who had been
educated to identify and treat pathology. Women hospitalized for birth would spend a
majority of their labor time alone. It wasnt until the late 1960's that fathers or close
family members or friends were finally allowed into labor and delivery rooms
(Boston Womens Health Book Collective, 1998; Rooks, 1997). The constant
support and attention of a midwife was replaced with occasional visits from a nurse,
resident or doctor, electronic monitoring devices, intravenous fluids and drugs, and
invasive precautionary procedures. Waiting for nature to take its course was
replaced by arbitrary schedules and limits that denied the individuality of each labor.
Massage, physical activity, vertical laboring positions, and herbal remedies to assist in
birth were supplanted by instruments, incisions, immobility, and, most drastically,
surgery in the form of cesarean section. The focus of social-based care upon the
laboring woman would be turned, in medical-surgical birth care, toward the attending
physician and his actions on the body of the mother. It would not be her actions that
birthed the child, but the careful management of her body by the physician who
delivered her child. Women could no longer have the direct experience of birthing
2


their children; everything would be mediated through the physician, the interventions,
and the institutional hospital setting.
How did this radically different medical-surgical approach to birth overtake a
centuries old midwife based model? How, in the course of a few centuries, did
midwives lose their standing as birth attendants? How and why did male birth
attendants supplant midwives in birthing rooms? Why, rather suddenly, did birth
become a dangerous medical event? An easy answer would be that the rise of science
and scientific medicine made birth attended by educated physicians safer. But the
claim that birth is made simply by scientific physician attendance has never been
proven true for the majority of pregnant women (Boston Womens Health Book
Collective, 1998; Kahn, 1995; Murphy & Fullerton, 1998; National Center for Health
Statistics, 1998; Rooks, 1997; Rothman, 1982; Suarez, 1993; Van Olphen-Fehr,
1998). Another possible answer is that the entrance of medical care into the market as
a commodity removed birth from the realm of women (Ehrenreich & English, 1978).
This too is only partially explanatory as the effective and cheaper care of midwives
should have garnered them more clients. Elements of economics, education, fashion,
sexism, professionalization, legal regulations, prudery, and science would all
participate in the attempted silencing of a midwifery discourse that had once been
unchallenged.
To better understand the current state of childbirth attendance and to inform a
serious critique of modem practices, we must look to the past. And, somewhat
surprisingly, it is not the history of midwifery that provides clues, but the historical rise
of obstetric discourse and practices that illuminate modernity. Inspired by the works
of Michel Foucault I have attempted to create a historical genealogy of obstetrics that
illustrates the complexity of issues that combined to form the circumstances of its rise,
and in turn, nearly destroy midwifery.
3


In the Spirit of Michel Foucault
The works of Michel Foucault, particularly Madness and Civilization and The
Birth of the Clinic, inspired my research and methods. My endeavor, using some
broadly simplified Foucauldian concepts, is to discern how we arrived at our modem
conception of birth by asking how and when pregnancy came to be defined as a
medical matter/crisis, and when a medical-surgical birth discourse came to nearly
silence a centuries old midwifery birth discourse.
Unlike Foucault, I do not claim to be on a great Nietzschean quest to become
what one is (Fillingham, 1993; Macey, 1995; Miller, 1993). I cant claim a desire to
challenge the formation of language (Macey, 1995; Miller, 1993). I have, as did
Foucault and many recent historians, allowed my own experiences and interests to
guide my choice of research subject. My experiences of pregnancy, labor, and birth
created the desire to expose the power relations and arbitrary twists and turns that
brought scientific obstetrics to the fore and forced a discourse and once noble
profession into the space of perpetual resistance and transgression.
Below are the broad theoretical assumptions I have taken from Foucaults
works. Many of the points, due to Foucaults notoriously difficult writing style, I have
summarized with the aid of Foucault scholars and biographers. Foucault never
worked from the belief that history neatly progresses toward some truth or better
existence. His works certainly do not create an organized system or theory of society
(Macey, 1995; Miller, 1993). In light of that, I have worked with only the theories
and findings I found applicable to my study of midwifery and obstetrics.
Miller (1993) has defined power in Foucaults work
...not as a fixed quantity of physical force, but rather as a stream of energy
flowing through every living organism and every human society, its formless
flux harnessed in various patterns of behavior, habits of introspection, and
systems of knowledge, in addition to different types of political, social, and
military organization ( p. 15).
4


The importance of this view of power is that it denies the possibility of power being a
limited commodity that can be exercised in isolation by a single
individual/group/institution against another (Fillingham, 1993; Gauntlett, 1998;
Macey, 1995; Miller, 1993; Pratt, 1986; Walker, 1994). In Foucaults philosophy
power is everywhere, and can be exercised in different amounts by anyone under
situational circumstances (Gauntlett, 1998). With power being pervasive, total victim-
hood and powerlessness is impossible. But power does have varied levels of influence
and situational boundaries for each individual/group/institution. Midwives could not
have completely thwarted the rise of the medical-surgical discourse due to their
exercise of power being limited to the small networks in which they operated. Instead,
the midwifery discourse and practitioners operated with a space of resistance. In
Foucaults work, every time a power relation is exercised, a space of resistance is
created (Foucault, 1977; Macey, 1995; Miller, 1993). It is in that space of resistance
that those wanting to be different must operate. The supporters of midwifery have
been forced into this space of resistance, never able to entirely escape being the
challengers and never able to instigate radical reformulation. What is then created is a
constant spiral of challenge through resistance and re-establishment of order (Miller,
1993).
Foucault has also stated that the work of any historian is at least partly a work
of fiction (Miller, 1993; Walker, 1994). I must agree in the context of this inquiry.
With few exceptions, the tale told here is not the experience of any one midwife,
mother, or doctor. I have selected the events, people, laws, regulations, movements,
and interventions that are representative of a shift in birth care toward scientific
obstetrics. As Gelbart (1998) has found, there is no such thing as a complete history,
someones story is always left out and there is always an exception to any rule or
generalization. I have certainly not conducted the exhaustive study of midwifery and
obstetrics and much of what I did find I could not include. This is not to say that the
5


claims I make on a more general scale are not supportable, they are merely one broad
version of the story.
Prior to the rise of capitalism, Foucault contended that there was a wide range
of normal human behaviors that included, for example, madness and certain
activities now considered criminal (Foucault, 1965; Foucault, 1973; Pratt, 1986). In
the 19th century, Foucault found society entered a time of bifurcation. New categories
to label and define people emerged. Foucault found everyone within society being
forced into a normaTor not normal category (Pratt, 1986). I contend that
pregnancy, birth, and female practitioners were pushed under the not normal label
while male doctors and non-pregnant bodies occupied a normal space. Anything
not normal, in Foucaults work, required surveillance as a means of force towards a
normal productive role in society (Foucault, 1977; Pratt, 1986). Those who could
define normal and not normal and perform surveillance upon those labeled not
normal gained the means to do so through their access to power relations influenced
by wealth, position, sex, age, education and a myriad other factors. (Miller, 1993;
Pratt, 1984). The growing institutional medicine community, and obstetricians in
particular, would be the group exercising their power to guide pregnant women and
institute disciplinary training, in the form of laws, regulations, norms, fashion, and out
right lies, upon midwives.
My historical examination of the midwifery birth discourse revealed a fairly
constant message. The traditions of midwifery nonintervention, trust in the
effectiveness of bodily processes, and female practitioners were present in every age
I reviewed. It was within professional scientific medicine, and obstetrics in particular,
where growth, change, challenge, and the exercise of power relationships were
dynamic. From early arguments seeking to break into birthing rooms, scientific
obstetrics would end up guiding birth discourse due to the convergence of multiple
discourses at a particular historical moment.
6


Many of Foucaults findings in The Birth of the Clinic (1973) were echoed in
my examination of birth practices. With the rise of the medical specialist and a unique
exclusionary medical discourse, doctors could gamer greater access to power. During
the 17th-19th centuries the gaze of the doctor would become ever more intimate,
finally resulting in the doctor having total knowledge of the workings, inside and out,
of every body1 (Fillingham, 1993; Foucault, 1973;Macey, 1995; Miller, 1993). The
doctors perception became paramount with the patients perception and experience
unimportant, untrained, and unreliable (Muller, 1983). The objectification of the
patient by doctors, students, and eventually nurses is a hallmark of scientific medical
care (Walker, 1998). Every time a doctor succeeded in treating a patient, his access
to the exercise of power was increased over the patients he sees and the students
whom he trains. His word would be less and less susceptible to challenge due to his
past accomplishments.
In this inquiry I have also researched the preliminary question of how birth
came to be defined as a medical event in the first place. Utilizing similar methods and
the same view of power, I attempt to locate the transition of birth from a social life
event into a pathology prone medical crisis. I believe that the exercise of power and
arbitrary patterns Foucault found in the creation of the modem clinic were also at
work in altering the general perception of birth. Through most of the 17th-19th
centuries, there was no distinct advantage to the mother and fetus/baby in safety,
outcome, economic savings, or subjective experience in leaving the care of midwives 1
1 Dissections gained popularity during the 18th century, giving medical doctors knowledge of the
human body from the inside as well as out (Gelbart, 1998; Miller, 1993; Ulrich, 1990). Before any
questions were asked, symptoms described or exam conducted on an individual patient, the doctor
would all ready know that patient. With the invention of the x-ray, physicians could see inside a
living body and further increase their power over the patients perception and experience.
7


and resorting to mostly male scientific physicians2 (Scully, 1993). Matters exterior to
the actual care of pregnant women played influential roles in promoting a scientific
birth discourse. Fashion, economics, Victorian sex role ideals, industrialization, the
valorization of reason, and changing social networks all intersected to create a unique
historical period where childbirth could be redefined.
In order for modem obstetrics to become dominant, women would have to
accept the way in which they were created by the obstetric birth discourse. Scientific
obstetrics required women be transformed into docile bodies. The science of
discipline, as Foucault described in Discipline and. Punish (1977), is the means by
which the individual, both inside and out of the penal system, is engineered to accept
the role of docile body. Prisons and non-penal institutions such as schools, hospitals,
the military, factories, and asylums perform constant surveillance on each person to
assure that individual behavior is in line with what has been deemed appropriate.
Foucault found, in the context of the prison, that constant surveillance, while
pretending to be more humane and rehabilitative, controlled the bodies of prisoners as
effectively as physical punishment had in earlier eras (Fillingham, 1993; Foucault,
1977; Miller, 1993). The exercise of power in creating docile bodies can be as great
as that used to physically punish. Eventually the individual internalizes the surveillance
initially performed by the institution and behaves normally with no conscious
recognition of exterior surveillance (Fillingham, 1993, p. 125; Foucault, 1977; Miller,
1993; Pratt, 1986). This internalization effectively controls individual bodies without
resorting to physical restraint and punishment. Foucauldian discipline has the ability to
reward good or appropriate behavior early release from prison for following all the
rules determined by those who run the prison as well as punish those who breech the
2 Physicians held no advantage over midwives in their anatomical or medical knowledge and
treatment for most pregnant women. It would be in the later part of the 19th century that physicians
could offer what the midwives could not, total pain relief through pharmacology.
8


proscribed normal behavior pattern. Punishment comes in the form of additional
surveillance and tighter controls over behavior. Surveillance, to differing degrees, is
constant within society.
The science of discipline is applicable to scientific obstetric care in an
environment controlled by the physician. Laboring women are expected to be docile
bodies, having internalized the beliefs and rules of the scientific medical profession.
Having spent a good part of her pregnancy instilling in her that they alone are capable
of delivering her child to her, scientific obstetrics controls her labor. She is under the
constant surveillance of the hospital which controls her very location, her every
movement, and sits in constant judgement of whether or not her labor is normal.
These normalizing judgements are not simply medical determinations of danger for
mother or fetus, but include judgements of her manner of labor yelling, crying,
questioning physicians, and any other behavior uncomfortable for the hospital is
unacceptable. The hospitals judgements of her behavior can earn rewards, possibly in
the form of more emotional support from the staff or negotiation over the use of a
particular standard procedure, or punishments in the form of less support and more
interventions. The further outside the established normal definition a laboring
woman strays, the more disciplinary action she is subject to in order to bring her back
within the arbitrarily set limits of normal. The table 1 is a simple guide to the
elements of Foucaults science of discipline and its applicability to obstetric care.
Table 1. Foucaults Science of Discipline Related to Obstetric Care
Foucaults Categories Definition Applicability to Rise of Obstetrics
Spatialization Where you are is what you are. Maternity wards in hospitals with separate birthing rooms, exam rooms and recovery rooms.
Minute control of activity Schedules and clocks. Time limits for various stages of birth, expected course of events and intervention to keep on schedule.
9


Table 1. (Cont.)
Foucaults Categories Definition Applicability to Rise of Obstetrics
Repetitive exercises Standard procedures to create automatic responses with the ability to adapt as the individual successfully progresses toward normality. Standing orders by physicians to wash, shave, attach an electronic fetal monitor, etc. and dependent upon the progress of a womans labor when first examined by a physician to admitted to the hospital.
Detailed hierarchies Clear line of command. Doctors rule over residents, residents over nurses, and everyone rules over the patient.
Normalizing judgements Watching the subject of discipline for any sign of deviation from determined normal. Doctors decide when a labor has become prolonged or when a mother needs drugs or surgery. Women who refuse recommended care are labeled difficult and treated more harshly or ignored.
(Fillingham, 1993, p. 120; Foucault, 1977; Miller, 1993)
As with the exercise of any power relation, use of discipline creates a space of
resistance. Women have operated in the space of resistance to institutional obstetrics
by laboring in ways contrary to what they have been told are normal and by
choosing to follow an older model of midwifery care during their pregnancies and
births. Resisting the efforts to return her to normal behaviors can be very costly to
laboring women and bring down upon her more and more stringent surveillance and
disciplinary efforts.
In Foucaults works the importance of discipline for all of modem society, not
just within the prison, is that it keeps the Dionysian element of humanity, as
hypothesized by his most influential forefather Nietzsche, under careful wrap (Macey,
1995; Miller, 1993; Walker, 1994). The Dionysian element of man is that which
represents the entire chaotic realm of eternal motions and flux which form strives to
10


control, obscure, and deny3 (Walker, 1994, p. 4). This chaotic realm is where
Foucault locates madness, dark and tragic thoughts, and for him, the extremely erotic,
aspects of man. The Dionysian is timeless, unmediated, and offers direct experience
and insight. Foucault believes that the Apollonian drive that which organizes,
controls, is historically situated, and relies heavily upon reason has been so valorized
in the last centuries that the Dionysian has been virtually silenced4 (Miller, 1994;
Walker, 1994). Foucault, following Nietzsche, believed that the two forces should
develop in a kind of continuous spiral so as to achieve balance. This balance would
recognize the value of the subjective knowledge gained in Dionysian moments.
The attempt to access the Dionysian realm is what Foucault calls limit
experience. Through accessing the occluded Dionysian, Foucault hoped to free pre-
discursive experiences, those unmediated by Apollonian culture (Miller, 1993; Walker,
1994, p. 4). By freeing the unmediated experience, Foucault saw an avenue to
continually challenge the Reason upon which we have formed modem society. The
Dionysian frees man and the Apollonian imposes order and creates the subject
(Walker, 1994).
For Foucault, limit experiences included writing, alcohol and drug use, the
ravings of madness, and participation in S/M erotics. I contend that an
uninterrupted and unintervened birth experience is a limit experience. In the same way
that the Apollonian realm imposes order through surveillance and discipline on the
methods of accessing the Dionysian, the Apollonian imposes order on the modem birth
experience through the surveillance and discipline of modem obstetrics upon pregnant
3 Foucault never interrogated the difficulties, for feminists at least, of the use of man as a presumed
universal in philosophy. For my purposes in this inquiry I have given the benefit of the doubt and
viewed man to include woman.
4 The battle between Apollo and Dionysus is the culture vs. nature argument that has been put
forth by many philosophers of differing belief.
11


and laboring women. Foucault insisted that challenging the limits imposed by societal
order is dangerous in that it can bring the wrath of discipline upon the transgressor,
and he believed that forays into sadomasochistic practices challenged order by
confounding pleasure, pain, and death (Macey, 1995; Miller, 1993; Walker, 1994).
Birth outside of scientific medical surveillance is deeply personal, sexual, painful,
joyous, terrifying, and potentially life threatening (Clark et. al., 1997; Ehrenreich &
English, 1978; Gabbe et. al., 1996; Genevie & Margolies, 1987; Herzfeld, 1985; Kahn,
1995; Rooks, 1997; Rothman, 1982; Sullivan & Weitz, 1988; Van Olphen-Fehr, 1998;
Wertz & Wertz, 1977). Dionysian birth can be chaotic, refusing to be controlled and
yet susceptible to the beliefs and thoughts of the laboring mother; its interiority can be
empowering for women; it can expose new worlds absent from all description; it can
blur the subjectivity between mother and child, mother and woman, child and fetus.
As Kahn (1995) has commented, From the time I gave birth, the world appeared
altogether different to me, though I did not have the concepts for my altered
perception (p. 44). Dionysian birth is what has been denied women through the
surveillance and discipline of the scientific obstetrical discourse and practices.
Accepting Foucaults theory of power and resistance, the impossibility of a
complete and true history, subtle societal surveillance and discipline, the bifurcation
of society into normal and not normal categories, and the Dionysian realm as a
space of insight, I researched birth. I have made use of individual stories, legal and
regulatory efforts, the limited statistics available for the time, as well as textual items
ranging from works of fiction to newspaper and magazine commentaries. Through
these efforts I believe the shift in birth perception, and the factors that contributed to
it, and the differences between midwifery and medical-surgical birth care will be
exposed.
12


Review of Prominent Literature
An undertaking of this scope requires considerable amounts of reading and
research. Every pregnancy, labor, birth, and health care article, journal, study and
book I have read influenced my position and research direction. However, there are
certain texts that were exceptionally useful to my efforts. These texts are the most
frequently cited throughout this work. In order to better understand and support my
perspective, the perspective of these texts should be discussed.
Among the authors of these texts, there are certain shared perspectives. First,
all of the authors are pro-midwifery. Each believes that there are certain qualities of
midwifery that have been lost in modem obstetrics and that these unique qualities must
be recovered in order to better treat women. Second, all of the authors believe that
modem obstetrics does not treat the whole woman during labor and birth and
therefore is not as competent as it should be. Third, each of the authors presents a
historical analysis to support the common claims that birth has become over
medicalized and that the early rise of obstetrics had little to do with increased safety or
better birth outcomes. Fourth, the authors do not call for every women to be attended
by a midwife. Modem obstetric science has saved the lives of many women and
infants who would have otherwise died or been terribly injured. And lastly, each
author presents information, whether intentionally or not, from a feminist standpoint:
in the sense that it is feminist to advocate for women to be able to choose among all
possible attendant options for their birth care and that all women should be treated as
complex, fully functioning members of society. It is dangerous to assign all support of
midwifery discourse a feminist perspective. Many religious and socially conservative
women, who would never call themselves feminists, strongly believe in intervention
free birth and midwife attendance. However, that particular convergence of
conservativism and midwifery is not represented in the texts I have used in my
historical inquiry. The specific contribution of the five texts is described below.
13


Jean Donnison (1977), in Midwives and Medical Men: A History of Inter-
Professional Rivalries and Womens Rights, presents, from an equality feminist
standpoint, a detailed history of the medicalization and mystification of birth by male
practitioners in England from the medieval period to the early 20th century. Donnison
traces the path of male birth attendants from barber-surgeons, to man-midwives,
doctors, and finally obstetricians, and finds that each version of male birth attendant
hoarded knowledge, mystified birth, and used any means available to exclude women
from practice. Donnison sees economics, sexism, science, industrialization, and
fashion as all contributing to the shift in birth perception and attendance.
The focus upon practices in England, with comparisons to a more midwife-
friendly environment in France, serves to not only give an indication of where
American birth attendance tradition emanated, but provides a stark contrast to what
birth in America has become. Donnison finds that midwifery in England survived due
to a long collective memory, a commitment to shared care where midwives and
highly trained obstetricians work together providing more intense surveillance and
technologically complex treatment only to those women who need it, the regulatory
environment that allowed midwives to apply for incorporation throughout the 19th
century culminating in the Midwives Bill of 1902, and a unique form of nationalism
that encouraged the poor and middle class the traditional clients of midwives to
respond to growing German aggression by having more children who could then be
drafted into the army.
Donnisons attempt, in the conclusion, to explain the vastly different midwifery
situation in America as the result of a more powerful medical establishment is a
weakness. The questions of how and why American physicians became more powerful
than their English and French counterparts go unexamined by Donnison. The myriad
of other circumstances that contributed to the demise of midwifery in America,
different than in Europe, are not investigated.
14


Dorothy and Richard Wertz were inspired to write Lying-In: A History of
Childbirth in America (1977) by the dramatic difference in birth statistics maternal
and infant mortality, low birth weight, the number of cesarean sections, the high usage
rate of drugs and mechanical intervention, etc. between the United States and all
other developed countries. They asked how Americas peculiarly medicalized birth
rituals came to be (Wertz & Wertz, 1977, p. 234). In answering their query Wertz
and Wertz identified, in male medical students returning from European medical tours
around 1750, a unique combination of the English trend toward intervention and the
French pseudo-scientific investigation into the processes and bodily elements of birth
(p. 29). From this unique standpoint of new American doctors, Wertz and Wertz
conclude that birth in America was part and parcel of medical science to a degree that
was unmatched in Europe.
Wertz and Wertz put forth the argument that American dependence upon
physicians to attend birth is now culturally learned and extremely hard to change. The
very image of birth for most of America is threaded with medical vocabulary, medical
procedures, centralized hospital locations, physician attendants, and fear. Wertz and
Wertz propose that the choke hold scientific obstetrics holds over birth be loosened by
formulating a national system of health care, organized and subsidized by the
government, that includes the widest possible range of birth attendants and locations.
Their solution is the greatest weakness of their work. Wertz and Wertz do not
delve into any issues that might complicate instituting a national health care system or
the protests that would be powerfully voiced by scientific obstetrics whom the existing
system favors. They identify modem birth practices as culturally ingrained but have no
theory as to how those practices can be disengaged in favor of new ones.
In For Her Own Good: 150 Years of the Experts Advice to Women, Barbara
Ehrenreich and Deirdre English (1978) investigate the rise of male medical experts and
their remarkable influence over the lives of women through Marxist-influenced
15


feminist lenses that challenge the rise of the market economy and masculinist society.
They find the dismantling of the old order in favor of capitalism as the primary
catalyst of societal change in the last two centuries. The traditional work of women -
healing, midwifery, food production, weaving, sewing, etc. was swept into the
market. With the rise of the market economy, society was bifurcated into public vs.
private realms. Ehrenreich and English found the market to be male dominated, and
the private realm, now devoid of any clear work or tasks but overflowing with
expectations of altruism and selflessness to be the sole province of women.
Women, having lost their sense of productive duty as well as their wider social
networks, were isolated and at the mercy of their husbands, fathers, or other male
guardians. With no outside sources of knowledge, and a growing ambivalence about
exactly what they were supposed to be doing, women turned to the medical experts -
physicians, psychologists, child care experts, etc. to guide them. Ehrenreich and
English found that acceptance of the male medical expert was based upon a belief that
they would provide objective, science based advice. Ehrenreich and English found this
to be a faulty assumption on the part of women, who instead were fed ideology from
masculinist society that served to further female dependence and isolation. They trace
these early trends of female isolation, devaluation of community and caring, and the
valorization of the capitalistic market through much of the 20th century.
Ehrenreich and English see change possible only through what they term a
radical vision that feminism must adopt. As they summarized in their conclusion,
This is the vision that is implicit in feminism a society that is organized
around human needs: a society in which child raising is not dismissed as each
womans individual problem, but in which the nurturance and well-being of all
children is a transcendent public priority...a society in which healing is not a
commodity distributed according to the dictates of profit but is integral to the
network of community life...in which wisdom about daily life is not hoarded by
experts or doled out as a commodity but is drawn from the experience of all
people and freely shared among them (Wertz & Wertz, 1978; p. 324).
16


This vision of a united feminism as the way in which society could be reformed to
reject the dominant vales of the Market, has never come to fruition. In the two
decades since their work came out feminism, instead of adopting their vision, has
splintered into multiple factions with little in common as to problem identification,
goal, or method.
Robbie Pfeufer Kahn, in Bearing Meaning: The Language of Birth (1995)
conducts a critical analysis of medical-surgical birth discourse in the United States
making use of a postmodem-like multi-focal theoretical perspective influenced by
linguistics; French feminist concepts of bodily knowledge, language, and writing; work
by feminist women of color; Marxism; structuralism; and Freudianism. She pulls from
each perspective only those theories that work toward her desire to free the maternal
voice, experience, and body from all constraint.
Kahn sees birth as a remarkable act and metaphor for power. As evidence of
the power of birth, she notes the use of birth metaphors by men throughout history.
Kahn (1995) states, In sacking birth for metaphors, Western tradition acknowledges
that no descriptions of commensurate power can be derived from male experience (p.
4). Kahn finds that patriarchy the institution, not individual males has subsumed the
language and power of birth thus denying women the power to do so for themselves.
Kahn calls for the creation of a new language of birth, created by women, in
which the subjective knowledge gained through an embodied birth one not managed
by the male dominated medical establishment would be valorized. This new language
and discourse would directly challenge what has been deemed birth knowledge by the
medical-surgical discourse. Kahns new discourse would return to collective female
memory knowledge of birth practices and ancient reverence for birth. This discourse
would reclaim birth as a woman-centered, social event of significance to the entire
community.
This work, of all my sources, is by far the most critical of obstetric birth care.
17


Kahns critique is not limited to male birth attendants, she is equally critical of
midwifery and nurse-midwifery practitioners and programs that pretend to offer
female-centered care but actually rely upon a medical-surgical discourse that she sees
as prohibitive to free birth. Kahn takes to task American feminists that have been so
afraid of the mother knot which ties women to home and family that they have
largely ignored issues of pregnancy, birth, and motherhood. Issue that she believes
should be a foundation within any feminist critique of society. Kahns vision demands
that more and more women enter the space of resistance to the dominant obstetric
discourse in order to effect change.
Kahns suggestions to create a new birth discourse would be a good first step
toward returning birth to a collective female experience. She is convincing in her
tracing of the domination of birth-language by masculinist society as a way to provide
a powerful image within male experience. Her criticisms of mainstream American
feminism I found to be on point. The spiritual and empowering aspects of birth on
which Kahn focuses may be uncomfortable for feminists still concerned with escaping
the mother-knot, but she presents the issue as one of societal importance, affecting
every living being. The biggest weakness to her work is the lack of recognition she
gives the difficult task of molding the deeply theoretical work she has produced
around actual practice.
Judith Pence Rooks, in Midwifery & Childbirth in America (Rooks, 1997)
presents a history of midwifery in America and an extremely detailed analysis of the
current state of midwifery in all its forms. From a post-structuralist perspective,
Rooks, a midwife and officer in national midwifery organizations herself, attempts to
expose the forces and relations that are behind the silencing of midwifery in the United
States. Using both quantitative and qualitative data, she attacks the dominant obstetric
birth discourse in the United States for having falsely accused midwifery of being
dangerous and placing the health, safety, and subjective experience of birthing mothers
18


at risk. The failures of modem obstetrics are starkly visible in the statistics garnered
from hundreds of quantitative studies and demographic information Rooks presents.
Also included in the text are international comparisons between the United States
and Europe, Canada, Australia, New Zealand, and Japan to illustrate the ways in
which collaborative birth care has succeeded in populations similar to the United
States.
To remedy the sad state of birth care in America, she calls for the establishment
of a national health care system, collaborative practice between midwives and
physicians, an end to physician controlled malpractice insurance and hospital
privileges, and uniform regulation of various types of midwifery. She acknowledges
the difficulty of changing a medical system that is deeply ingrained in American culture
and powerfully defended by physicians and insurance companies.
Rooks work is the most convincing collection of data proving the safety of
midwifery that I found. He recommendations for the future are sweeping and would
face criticism, but she has compiled the statistics necessary to mount an effective
challenge. I believe her recommendations to be in the best interest of a healthy
American population. On the individual level Rooks demands a lot from women. She
expects each woman to become familiar with as much information as possible during
their reproductive life so as to be able to question and challenge the care they receive.
She would like to see more women go against the dominant practice of choosing an
obstetrician in favor of initiating care with a midwife. And I believe that any woman,
after having read Rooks work, would not only believe midwives to be better care-
givers but affirmatively seek one out for any future pregnancy and birth care.
The historical information, and analysis of it, provided by all of these texts was
remarkably similar feminist based, pro-midwifery, multi-focal. The same historical
information is repeated in this work with analysis influenced not only by their efforts,
but by the work of Foucault as well. In each text I have attempted to look beyond the
19


lens of the author to try and uncover what other discourses, power relations, or
perspectives might be present.
Definition of Frequently Used Terms and Assumptions
The history of childbirth attendance became considerably more complex
through the 19th century. This complexity makes consistency of terms and basic
assumptions difficult. I have attempted to be as clear as possible in the text as to
whom I am referring and from where the tradition, procedure, or argument emanated.
The subject of this investigation is childbirth discourse and how that discourse
has developed and changed in the last seven centuries. Discourse, according to Humm
(1995), is the relation between language and social reality (p. 66). I view discourse
as the conversations spoken and written about a particular subject. Historically
childbirth discourse was not very broad and women were the only participants. I
propose that this limited childbirth discourse, with the encroachment of men into birth
rooms, splintered into at least two new conversations that I have labeled the midwifery
birth discourse and the medical-surgical birth discourse.
It is within discourse that knowledge is determined. The participants within a
knowledge determining discourse possess a certain amount of power as they control
what will, and will not, be considered knowledge. Discourses, like individuals, have
differing access to the exercise of power and are never totally silenced by the dominant
discourse. Discourses challenging the dominant discourse must operate in the space of
resistance.
I also take to heart the social reality aspect of discourse in that I find practice
to follow conversation closely. Physicians participating in a medical-surgical birth
discourse are usually playing out the values and traits of that discourse upon the
bodies of pregnant women. Throughout this work I refer not only to a midwifery vs.
medical-surgical discourse, but also a midwifery vs. medical-surgical model of birth
20


care. These models of care, derived from their respective discourses, are detailed in
table 2.
Table 2. Midwifery vs. Medical-Surgical Model of Care
Midwife Medical-Surgical
Majority professionals are female, often with personal childbirth experience. Majority of the profession is male with no direct birth experience.
Female bodies as the norm of practice and research. Uses the male body as the norm for research and comparison.
Pregnancy a natural state, part of womans cyclical health. Pregnancy an aberration from normal.
Prenatal care involves dietary, emotional advice, preparation for birth, and screening tests. Prenatal care about screening for disease and pathology.
Holistic approach. Mind-body dualism intact.
Frequent conversations with mother about her feelings, sensations and experience of being pregnant. Explain to mother what her body and the fetus is doing.
Pregnancy and birth as a part of a life continuum. Pregnancy/birth broken down into discreet stages and developmental milestones.
Premiums on support, comfort, relaxation and emotion. Premium on time, efficiency, rationality and control.
Women labor and practitioners care for active moms and newborns. Practitioners deliver babies and move on.
Women bear the brunt of responsibility for care choices and outcomes. Practitioners bear the brunt of responsibility for care choices and outcomes.
Likelihood of interventions (surgery, drugs, instruments) very low. Likelihood of interventions very high.
Pregnancy defined by normality and health of pain as part of labor. Pregnancy defined by pain and pain management.
Woman is a multifaceted person with other relationships and circumstances that will affect her labor and motherhood. Woman seen only in role of patient.
Mother encouraged to labor in any way she finds comfortable. Women must labor in a position most convenient for attendant.
21


Table 2. (Cont.)
Midwife Medical-Surgical
Midwives trained to assist in uncomplicated births and watch for pathology. Doctors trained to handle pathology and complication.
Encourage and assist to establish breast feeding as soon as possible. Breast feeding education and assistance is the job of someone else.
Open to attending women at home, in birth centers and in hospitals. Located nearly exclusively in the hospital.
Relies upon a mutual participation relationship model. Works from an Active Passive relationship model.
Childbirth a personal experience. Childbirth as an industry.
Prepares women for a healthy experience that includes a certain amount of pain. Prepares women for interventions and not to overly question the use of interventions.
Careful explanation of risks involved in each option available to mother and support of her choice. Fear, guilt and shame used to force women into predetermined model of care.
Pain dealt with through education prior to labor and support and holistic methods during labor. Pain dealt with using drugs.
Activity, eating and drinking encouraged for mother. Immobility and fasting the rule.
Trust in the natural process of birth and belief that no two births are the same. Arbitrary time limits for each stage of labor Friedmans Curve.
Seeks shared care arrangements with physicians for emergency services and complicated pregnancy referrals. Not committed to shared care.
Limit number of clients so as to be able to give constant support and care to each woman. Deliver and treat as many women as possible, relying upon other staff.
Mother and fetus/infant are a unit, in harmony. Fetal subjectivity granted with objectives that are often in conflict with mother.
Climate of confidence. Climate of doubt.
Subjective knowledge valued. Knowledge subject to objective verification.
(Davis-Floyd, 1993; Donnison, 1977; Ehrenreich & English, 1977; Jones, 1991; Kahn, 1995; MANA, 1999; Muller, 1990; Nockels, 1995; Rothman, 1982; Suarez, 1993; Van Olphen-Fehr, 1998; Wertz &Wertz, 1977)
22


Discourse analysis is not a purely theoretical activity with no connection to
practical living. Physical practices are derived from the values and content of
discourse. In this work I have traced discourse and used examples of practical care to
exemplify the ways in which the values of each discourse have been acted out upon the
lives of women.
The terms obstetrician and obstetrics to identify formally educated, male
birth attendants and doctors and the medical specialty of birth were not used until
1828, therefore, I have not referred to male birth attendants as obstetricians until it
was chronologically appropriate (Trager, 1994, p. 228; Wertz & Wertz, 1977, p. 66).
In its place, I have relied upon the terms man-midwife, male-midwife, physician,
doctor, accoucheur, and surgeon. When the term midwife appears without any
other descriptive adjective, I am referring to a female birth attendant.
When referring to midwives I have relied upon the pronoun her not out of
the belief that males are incapable of performing as a midwife, but because the
overwhelming majority of practitioners following a midwifery model of care are
women. The reverse is true when referring to physicians and scientific medical
practitioners, which I refer to using the pronoun his.
Much of the early history of midwifery care, regulation, and education is
European-based. I have included this information, not only because it illustrates the
long tradition of midwife attended birth, but because much of American midwifery
practice and debate originated in England. The path of midwifery practice in Europe is
also important for this investigation as it provides a stark comparison to the near
extinction of midwifery that occurred in the United States. However, I do not wish to
imply that the primarily white, European tradition I describe here is the only midwifery
tradition in the United States. African, Native American, Hispanic, Asian, and Eastern
European communities in the United States have childbirth traditions that still make
very effective use of midwifery methods and beliefs. It is, in fact, these communities
23


that can claim a vital role in keeping midwifery alive in the United States.
My assumptions include the desire of every mother for the healthiest
pregnancy, birth, and child possible. I define healthiest not as the most pain-free,
shortest, or least pathological. My definition expects the physical survival of mother
and child, and also includes subjective factors such as maternal satisfaction, the ability
of the mother to labor in any way she chooses, the freedom from pressure to conform
to arbitrary rules, schedules and procedures, and the freedom to reject any
interventions regardless of the preference of the birth attendant. Along with these
assumptions, it is my expectation that birth attendants not place the laboring mother
and fetus/newbom in harms way by acting in any manner they know to be dangerous.
These standards are very high and based upon a modem concept of subjectivity and
health. For that reason, I have been hesitant to attack historical developments that
clearly have no manner of defense or justification. It is only when the harm of various
methods were known that I indict the actions of the attendants.
In the investigation that follows, I have attempted to show the convoluted way
in which medical obstetrics came into existence and overtook midwifery discourse and
practice. The physical functions of birth have been altered not out of physical
necessity but out of a paradigm of medicine that views birth in a totally different way
than has midwifery. My purposes are not to force modem obstetrics out of the birth
attendance picture, but to challenge the authority of its dominant discourse and reveal
the historical alternative to obstetric care. Pathological pregnancies and births that are
life threatening, though by far the minority of births, require a distinctly medical based
care. But modem obstetrics cannot hope to achieve the important social and less
interventionist quality of midwifery based attendance without challenge on the part of
those of us willing to be different.
The chapters that follow are organized chronologically. In chapter 2 the birth
practices and discourse of pre-modem Europe, influential on the populations that
24


would immigrate to Colonial America, are traced. Chapter 3 reviews the practices of
Colonial American birth attendants and outlines the American debate over who, female
midwife or male doctor, should attend birth. Covering a dynamic century in the
history of the United States, the information contained in chapter 4 not only shows the
path to dominance of the medical-surgical birth discourse, but also begins to illuminate
how the medical-surgical birth discourse filtered down to influence the physical
practices of birth. The conclusion steps briefly into actual birth practices in the 20th
century as they are examples of the dominant medical-surgical birth discourse well
established by the end of the 19th century.
25


CHAPTER 2
PRE-MODERN EUROPEAN BIRTH
DISCOURSE AND PRACTICES
A popular saying grants prostitution the title of oldest profession, but an
argument could be made for midwifery. Without the traditional cadre of women
helping bring most babies into the world, all other activities would not have been
possible. For centuries these women did not have formal education, professional
organizations or professional standing. They frequently went unpaid if the women
needing their assistance could not afford their services. Midwives were more often
than not skilled healers who were the primary health caretakers within their
community. Their services were one of the pillars of the agrarian and female
economies and societies that existed into the 19th century (Ulrich, 1990).
13th Century to 1800
Midwives were a common feature of early cultures. Their duties were so
average as to go virtually unnoticed by most. It was only those midwives who were
involved in some type of scandal that gained the attention of the recorders of history.
Despite many early references to individual Greek and Roman midwives, and
numerous Old Testament references, this inquiry begins in 13th century England1. As
Donnison (1977) has stated Until the thirteenth century practice in the whole field of
medicine appears to have been open to all, men and women, whether possessed of
education and training or not (p. 2). It is approximately 1250 when the barber- 1
1 See Appendix A for more ancient midwife references.
26


surgeon guilds of Great Britain put forth a show of professional organization and
power by limiting the practice of women (Rothman, 1982). Donnison (1977)
described the powers and duties of barber-surgeon guilds:
The guild laid down conditions for apprenticeships and admission to
membership and undertook the oversight of practice among its members. In
return for its part in guaranteeing standards of practice, the guilds members
were granted exclusive rights within the town and its environs, and the
privilege of prosecuting those engaging in this work without the guilds
license. Women were occasionally admitted to membership, either by
apprenticeship or patrimony, but their number does not seem to have been
large (Donnison, 1977, p. 2).
These barber-surgeons were not the friendly men giving clean shaves nor the highly
educated medical practitioners capable of deftly removing dangerous internal growths
or disease that we of the modem era envision. These guilds were made up of
butchers, barbers, tailors, farmers, dockmen and sundry other men, some more skilled
and educated than others, who were the last resort of medical care. They amputated
severely injured limbs, cut living fetus from dead mothers, and dismembered a dead or
impacted fetus from a living mother (Rothman, 1993).
As the guild created formal arrangements with governing bodies and influential
families to regulate its members and punish those usurping the activities granted the
guild, the use of instruments became a critical issue. As of 1250, only guild members
could use any instrument in the course of providing physical medical care (Donnison,
1977; Rothman, 1993). This regulation would restrict all midwives and limit the birth
exposure of barber-surgeons to only the most pathological. Midwives were prohibited
from using any type of instrument to aid in the process of birth2. They were then
forced into the position of determining when a labor had become dangerous abnormal
and calling for a barber-surgeon in time to save mother or fetus. The barber-surgeon
2 This would become an even greater issue limiting the practice of midwives when Peter Chamberlen
finally made his family invention of birth forceps widely available in 1733. The initial design of the
forceps, while not as effective as modem models, made saving the life of mother and fetus possible.
27


was only called for in extreme cases where a life was in the balance, and therefore he
never witnessed and had no knowledge of the processes of a healthy birth (Donnison,
1977, p. 2). His entire experience was of extreme pain, bleeding and death. This early
regulation laid part of the foundation for the great differences in how midwives and
surgeons perceived birth.
Church Influence on Midwifery Practice
Midwives, dating back to the Biblical era, served an important record keeping
function. Christianity, in the form of Catholicism swept across Europe, bringing to
bear a pervasive influence on all aspects of life as well as a general distrust of women
(Shlain, 1998). The male dominated leadership of the Catholic Church had neither
experience with nor control over the processes of pregnancy and birth. In exchange
for the lack of power the Church could exercise over pregnancy and labor, the Church
attempted to exercise control over all women by controlling who could serve as a
midwife and determining the surveillance midwives should perform on their
communities (Donnison, 1977; Ulrich, 1990). Midwives were charged with baptizing
infants likely to die before a priest could arrive; eliciting from single women the name
of the father of illegitimate children; preventing, reporting, and refusing to perform
abortions; disposing of afterbirth so as to prevent use by others; reporting the use of
contraceptives and irreligious conduct; assuring that the babies were not switched or
stolen for inheritance or lineage purposes; and assuring children were free from any
type of black magic or witchcraft (Donnison, 1977, p. 3-4; Rooks, 1997, p. 13;
Ulrich, 1990; Wertz & Wertz, 1977, p. 7).
The midwife became a mechanism of Foucauldian theorized surveillance. She
served to keep many within her community in line with Church teachings by her
mere presence and association with the Church. Regardless of whether or not she
actually did inform the Church of the goings-on of her neighbors, the knowledge that
28


she could do so would influence behavior. While still in the era of physical punishment
as a means of control, the midwife already occupied a space of Foucauldian discipline,
both as one in a position of power over her patients and as one in the position to be
disciplined by the Church in the form of prohibition of her practice.
In 1280 at the Council of Boulogne the Church issued a mandate that the
mouth of a dead woman must be kept open so as to allow the fetus to continue to
survive while all attempts were made to save it (Rothman, 1993, p. 55; Trager, 1994,
p. 75). No attempts to save the mothers life by sacrificing a fetus were allowed by the
Church. This mandate was directed at midwives as well as surgeons, and carried harsh
penalties, including hanging and burning at the stake, to be incurred by midwives
should they even attempt to spare the mother by sacrificing the fetus
Thirteenth century surgeons apparently followed the mandate, performing
cesarean sections only on dead women. Following their successful campaign to
prohibit instrument usage in Great Britain, surgeons could, by decree or statute, claim
the exclusive right in nearly all of Western Europe. Municipalities in Germany in
particular created dire penalties, including public execution, for non-surgeons using
instruments on laboring women or the sick (Donnison, 1977, p. 5). Despite the fact
that most labors never required the attendance of a surgeon, the methods of surgical
removal of a fetus were becoming more widespread. In 1305 a French physician,
Bernard of Gordon, recorded extremely general instructions as to where an incision
should be made on a, presumably dead, woman to most easily extract the fetus3
3 The record left by Bernard is the first written instruction for a cesarean section to be verified as to
its author and date, although there had for centuries been emergency surgical deliveries. The most
popular myth, perpetuated by historian Pliny the Elder, surrounding cesarean birth is that the
procedure was named after the Great Roman leader Julius Caesar who was said to have been
delivered from above or surgically. This is truly a myth in that Caesars mother outlived him
which would not have been possible in 100 B.C., the year of his birth (Trager, 1994, p. 75). The
labeling of surgical delivery as a cesarean section has been attributed to a French surgeon, Francois
Rousset, who in 1581 referred to the procedure as an operation cesarienne (Kahn, 1995, p. 185;
Rothman, 1993, p. 54).
29


(Rothman, 1993, p. 55). The combination of the spread of instructions to surgeons on
how to remove a fetus from a dead mother and the increasing limitations and penalties
for midwives who attempted to use instruments served to increase the perception of
childbirth as a crisis.
The availability of more manuals, instructions, regulations, and tales combined
with the new regulations on instrument usage to create a new surgical childbirth
discourse. What was once a virtual non-event had come to the attention of a new
group of people, the barber-surgeons; and due to their exclusive right to use
instruments and their total lack of education or training in uncomplicated birth, the
only births most barber-surgeons saw were the most traumatic. As the barber-
surgeons organized themselves and sought to expand their practices their tales of
horrific birth were the only ones being widely spread. Midwives were in no position to
expand their discourse as they were unorganized and did not foresee the male barber-
surgeons wanting to take over attendance at all births.
Religious bodies would further impose their agenda on the actual practices of
midwives as demonstrated vividly in two instances: First, the persecution of primarily
women and girls, across Europe, specifically in Germany, as witches and minions of
evil; and second, the system of regulation and registration of midwives set up by
religious authorities in Great Britain. These two instances of interaction between
midwives and the powerful religious bodies that influenced much of society played a
role in determining the future of midwifery in Europe, and eventually in the United
States as well.
Witch Hunts. The witch hunts were a terrifying period of persecution, false
accusations, torture, execution, and in some villages in Germany, the near extinction of
the female population. It has been estimated that in Western Europe between 1450
and 1750 more than 60,000 people were executed under the accusation they were
witches (Rooks, 1997, p. 13). Approximately 80 percent of those executed, 48,000
30


people, were women and half of those, or 24,000, could be classified as midwives
(Rooks, 1997, p. 13). Pope Innocent VIII, in 1484, issued a papal bull against
witchcraft and initiated harsh penalties for those found guilty (Trager, 1994, p. 98).
For a number of reasons, the search for witches was particularly intense in Germany
where the Catholic Church faced great philosophical challenges (Donnison, 1977;
Trager, 1994). Women with any type of herbal or healing knowledge not widely
known and the confidence to share their skills outside of immediate family circles
placed themselves at great risk of accusation and eventual punishment.
Anyone with a grudge of any type against a midwife could accuse the woman
of witchcraft and concoct any proof they saw necessary, a practice shamefully
employed by some physicians (Trager, 1994, p. 98). Siting the papal bull and Exodus
22:18, Thou shalt not suffer a witch {sorceress) to live (International Bible Society,
1984), fledgling physicians reported the activities of midwives to Church authorities;
midwives whose crime may have been caring for a potential patient of physician or
healing better than the physician (Trager, 1994, p. 98).
The publication of the witch-hunting manual, Malleus maleficarum (The
Witchs Hammer), in 1489 further added to the witch hunt hysteria4. Inquisitors and
authors Heinrich Kramer and Jacob Sprenger painted an unflattering picture of all
women: sexually insatiable and willing to stoop to involvements with devils, so adept
4 Malleus maleficarum would be used for centuries to justify witch hunts as well as serving as a
judgement manual to determine guilt. In 1554 inquisition officer Paramo boasted to his supervisors
that at least 30,000 witches had been burned in the last 150 years (Trager, 1994, p. 118). In 1589
more than 130 witches were burned in a single day in the German village of Quedlenburg (Trager,
1994, p. 127). In 1634 Urbain Grandier, curate of the Huguenot St.-Pierre-du-March in Loudon,
France was accused of witchcraft for his remarkable ability to seduce virgins, insulting Cardinal
Richelieu and bewitching convent nuns into fits of blasphemous hysteria. Despite his vehement
protests of innocense and no actual evidence, Grandiers legs were crushed and he was burned alive
(Trager, 1994, pg. 140). In 1692 the infamous Salem (Mass.) witch trials took place in which 19
women were hanged and another pressed to death based on the testimony of a small group of girls
who had been entertained, and clearly heavily influenced, by a female slaves tales of voodoo from the
West Indies. One of the girls, Anne Putnam, confessed in 1706 that the accusations were all a
delusion of Satan (Trager, 1994, p. 163).
31


at hiding their evil arts they could easily fool their fellow women, and so weak as to
resort to witchcraft to vindicate themselves from detection (Trager, 1994,p. 99). The
book created women as simple minded and easy targets for the forces of evil who
preyed upon their natural weaknesses.
The sexual component of witchcraft described throughout Malleus
Maleficarum associated midwives closely with the prevailing view of witches.
Midwives knowledge of conception, and perhaps more importantly contraception,
placed them in the forefront of sexual activity. Their knowledge of sexual function
was frequently used against them when someone they had attended, or even dealt with
casually, suffered from any sexual disfunction or disease (Trager, 1994, p. 99). The
prevailing wisdom seemed to be that if midwives had the knowledge to prevent
conception, terminate pregnancies, and ease the discomfort or symptoms of sexual
disease and childbirth, then they surely knew how to cause them all as well. The
accusers went on to believe only a witch would want to cause illness. It was a no-win
situation for many healers and midwives.
Municipal and Ecclesiastical Licensing. One way in which municipal and
ecclesiastical authorities sought to control the seeming epidemic of witch-midwives,
beyond the obvious route of executions, was to establish systems of regulation and
registration. Tracking midwives kept governmental bodies and religious authorities in
a position to determine acceptable midwife behavior and hold a position of disciplinary
power over those midwives who should step out of the acceptable definitions. The
first municipal system was established in Regensburg, Germany. The city chose to
focus upon establishing the qualifications and character of the midwife. Every midwife
had to prove her technical skills, learned from often lengthy apprenticeships and
attested to by senior midwives who had supervised them, and provide witnesses to her
high moral character (Donnison, 1977, p. 5; Rooks, 1997, p. 12). Every woman, to
satisfy the Church leadership, had to swear an oath to practice no magical rights,
32


provide no abortions or contraceptive counseling, and follow the rules of conduct as
determined and enforced by religious authorities5 (Donnison, 1977, p. 5-6; Rooks,
1997, p. 12). In exchange for assuming the responsibility of meeting the new
regulations, midwives were to be granted municipally funded retirements6 (Donnison,
1977, p. 6). The registration and regulation of midwives served to quell some of the
witch hunt hysteria as well as recognize midwives as a necessary health care element
of society, but registration also placed midwifery under the purview of authorities that
hadnt previously participated in a childbirth discourse.
A more organized system of regulation was established in Great Britain. An
Act of Parliament in 1512 called for nationwide formal regulation of medicine,
surgery, and midwives (Donnison, 1977, p. 5). This initial inclusion of midwifery in
the same regulatory category with medicine and surgery has been one of the greatest
areas of challenge to the licensing and regulation system in Great Britain and later the
United States. Midwives protested being lumped together with practitioners who
treated ill and injured people when pregnancy and birth were, in their view, conditions
of health. Responsibility for implementing the act fell upon ecclesiastical authorities.
Their efforts came to fruition in the form of the Episcopal Licensing System.
As founded, the Episcopal system required each person, male or female,
seeking a license to practice medicine, surgery, or midwifery to appear before the local
Bishops Court and submit to an examination (Donnison, 1977, p. 5). Those
previously licensed to practice as graduates of traditional universities were exempt
5 The French midwife Perrette was turned in the pillory and banned from future practice for
unwittingly providing a placenta that was consequently used in a magical right. The prohibition
against magical rights seems to include not only direct participation, but facilitation in any manor
(Donnison, 1977, p. 4).
6 Midwives who had attended the wives or mistresses of nobility were often recognized with pensions
or large renumeration for helping birth babies and keeping mothers alive. Margaret Cobb, midwife to
the Court of Edward IV was granted a pension of £10 a year for life in 1469, as was Alice Massy who
attended Elizabeth of York in 1503 (Donnison, 1977, p. 8).
33


from examination before the Bishop7. The midwifery examination focused on religious
knowledge and ethics, and the societal functions of midwives. The examination, as
originally created, in no way determined a midwifes knowledge or skills in attending
laboring women (Donnison, 1977, p. 7). The design of the system served as a
reasonably efficient means of social control in terms of reducing the dangers of
midwives practicing witchcraft, but had no hope of improving or even certifying the
overall skills of birth attendants (Donnison, 1977, p. 7). The initial act had no
specifications for the type of knowledge a midwife should possess nor did it make any
provisions to provide public support of her education or practice. In addition, there
existed no regulations prohibiting a surgeon or physician with no education or
experience with female anatomy from attending births.
In the absence of a public program of midwife education and training,
midwives were expected to utilize privately printed instruction manuals and long
apprenticeships. However, reliance on reading texts to educate midwives assumes
access to the limited number of texts and widespread literacy. Such was not the case,
especially outside large cities where a majority of the population lived (Donnison,
1977, p. 7). The absence of educational requirements for all midwives and the reliance
upon independently published texts assured that illiterate midwives would wallow in
ignorance and endanger the lives of laboring women. Those lucky enough to
apprentice with literate midwives and be able to themselves read the texts would
benefit most.
Early Midwifery Texts in Great Britain. The inability of a majority of
midwives to acquire and read the instructional books does not mean the better class
of midwives didnt have texts to choose from (Donnison, 1977, p. 7). Written by both
7
Virtually eveiy exemption granted by the Bishops Court was to men, as few women could attend
university.
34


physicians and midwives, these texts sought to improve birth care by midwives,
physicians, and surgeons. Rosslins The Byrth ofMcmkynd was translated into English
in 1545 (Donnison, 1977, p. 7; Rooks, 1997, p. 13; Trager, 1994, p. 115). The birth
manual described specific ways in which midwives should assist laboring women as
well as what their conduct should be. The midwife shall,
...sit before the labouring woman and shall diligently observe and wait, how
much and after what means the child stireth itself. Also shall with hands
anoynted with the oyle of those white lilies, rule and direct everything as shalle
seme best. Also the midwife must instruct and comfort the party, not only
refreshing her with good meat and drink, but also with sweet words, giving her
hope of a good speedie deliverance, encouraging and enstomaching her to
patience and tolerance, bidding her to hold her breath as much as she may, also
stroking gently wit her hands her belly above the navel for that helps to depress
the birth downward (As appearing in Trager, 1994, p. 115).
Notations of the herbal teas and oils to be used in assisting labor as well as the
massage and hands-on techniques encouraged in the text are still useful in many
holistic practices today. However, the manual also contains practices and advice that
were challenged and abandoned within a few short years of publication.
In the century and a half to follow, birth manuals would proliferate in England8.
English physician Nicholas Culpepper, in 1653, published Directory for Midwives
written to improve the techniques of birth attendants, presumably both female
midwives and male physicians, attending normal births. (Wertz & Wertz, 1977, p. 16).
Also published in 1653, William Harveys Anatomical Exercitations Concerning the
Generations of Living Creatures, sought to prove much of the advice in Byrth of
Mankynd as not only erroneous but patently dangerous (Donnison, 1977, p. 7). Dr.
William Sermon outlined what he believed to be the most desirable qualities of a
8 Many texts will also be published out of Paris during this time. These texts, to be discussed in the
following section, would prove to be the standard by which advancement in childbirth attendance
would be measured. The tradition of English midwifery would come to rely on the information
contained in the French texts, and therefore, much of the American tradition would also be influenced
indirectly and often centuries later.
35


midwife in his 1671 book Ladies Companion, or, The English Midwife-, between
young and old, healthy, neat in dress, clean, small hands, cheerful, mild and gentle,
sober, chaste, patient, and discreet (Donnison, 1977, p. 16). Dr. Sermon fell into line
with many of his colleagues in viewing a good midwife not in terms of her skills, but
by her personality and willingness to call a surgeon in a difficult labor (Donnison,
1977).
Jane Sharp, a well known London midwife, published Midwives Book by Mrs.
Jane Sharp of London, Practitioner in the Art of Midwifery above Thirty Years in
1671 (Donegan, 1978; Donnison, 1977, p. 15; Rooks, 1997, p. 16; Trager, 1994, p.
15). Mrs. Sharp not only put forth practice instructions for fellow midwives, but
picked up a new debate, the practice of midwifery by male physicians and surgeons in
cases where there were no indication of complications. The barber-surgeons had
gained access to birth rooms through instrument regulation and were becoming more
vocal about the horrific scenes and dangers they had seen (Donegan, 1978; Donnison
1977). They spread their stories, making birth seem remarkably dangerous and their
presence at births, just in case, a good idea. Sharp attacked their descriptions of
birth and the substandard quality of care offered by men, citing the nearly universal
lack of training in female anatomy by medical programs and the use of false
pretensions to impress women and cover their own mistakes (Donnison, 1977, p. 15;
Rooks, 1997, p. 16; Trager, 1994, p. 155). She encouraged women to further their
practical knowledge in order to stem the flow of man-midwives into the homes of
pregnant women (Donnison, 1977). She justified her view by citing that midwifery
was womens work in the Bible and ancient midwives were honored and rewarded by
God (Donnison, 1977, p. 17). Mrs. Sharp feared for the future of childbirth
attendance. She foresaw fewer educational opportunities for women to improve their
skills and a shift toward inferior male attendance. Mrs. Sharp questioned the morals
and education of male attendants, believing they did not have the best interests of
36


laboring women at heart9.
The criticisms of Jane Sharp would finally inteiject the midwives perspective in
the childbirth discourse that had been created and dominated by male barber-surgeons
and physicians. Her fears for the future of midwifery and the safety of pregnant
women would be echoed by some and denied by other male physicians. In The
Female Physician (1724), John Maubray of London placed himself in the crux of the
half century old argument between midwives and male physicians over the practice of
midwifery. Maubray in no way supported the practice of female midwives, seeing
childbirth as a dangerous medical condition that required attendance by a surgeon
(Donnison, 1977, p. 22; Trager, 1994, p. 174)). However, in agreement with Mrs.
Sharp, he was critical of male physician reliance upon instruments in a growing
number of cases (Donnison, 1977, p. 22; Trager, 1994, p. 174). Maubray had landed
upon a conundrum: How could male student physicians be taught all of the manual,
non-surgical techniques developed over centuries by midwives without granting
midwives status as experts in childbirth and female anatomy?
This desire to improve the manual skills of male physicians while also
eradicating midwives may have been difficult for some physicians wishing to increase
their practice but posed no quandary for many others. In 1736 John Douglas
vehemently opposed man-midwifery in favor of bettering the education of practicing
and future midwives (Donegan, 1978, p. 32; Donnison, 1977, p. 24). His book, Short
Account of the State of Midwifery in London, Westminster, supported
physician/surgeon involvement in labor only when birth became complicated and he
saw no reason for surgeons to attend all births (Donnison, 1977). Douglas refused to
believe that women were incapable of comprehending and practicing in difficult cases,
Frequently, in deference to a womans presumed modesty and frailty, a man-midwife often worked
blind. An examination took place with the patient fully clothed with both doctor and patient averting
their gaze. Through touch only, and often with no concrete concept of female anatomy, it is easy to
see how rampant misdiagnosis and/or undiagnosed conditions could occur (Donnison, 1977, p. 11)
37


as was contended by many, choosing instead to focus on the fact there had been
accomplished women of every era who had been give the opportunity of study and
that French-educated female midwives were quite skilled in using instruments and
attending complicated labors without reliance upon male surgeons (Donnison, 1977, p.
24). Douglas believed that thick-headed physicians posed as great a threat to future
generations of Britons as untrained, experience-educated, illiterate midwives did.
While Douglas education solution seems logical, there were many practical
reasons that made improving midwife education across the board nearly impossible.
First, most women of the time could not hope to acquire even a basic education let
alone the knowledge of foreign languages and Latin necessary to participate in
university medical programs (Donnison, 1977, p. 18). Second, most women became
midwives only after they had bourne their own families and participated in some type
of apprenticeship that could last for many years (Donnison, 1977). This custom
meant that midwives were generally older than the male practitioners, somewhat past
their most eflBcient learning years, and saddled with significant domestic
responsibilities (Donnison, 1977, p. 18). Their familial obligations created a lack of
time to devote to better education in current methods or delving into theoretical
endeavors to improve future practice. Despite most male surgeons basing their
research and knowledge into pregnancy and childbirth on the observations and
experience of midwives, the women were given little credit or reward and continued to
loose prestige and respect (Donnison, 1977, p. 10-11). And third, when educational
opportunities were available to women they were far inferior to those offered to men,
as demonstrated by a widely used Thomas Dawkes text The Midwife Rightly
Instructed (1736). Dawkes recognized the place of midwives in the attendance of
uncomplicated labors and included all the information he believed necessary to deliver
a normal, healthy mother and fetus (Donnison, 1977, p. 24). However, he refused to
included any instruction to midwives should a complication arise other than to call a
38


surgeon when the labor deviated from his description of normal (Donnison, 1977). It
is clear that even among medical men of the time there was widespread disagreement
over the role, if any, midwives should serve in childbirth.
In an effort to stem the tide of male efforts to educate, regulate, or defame
them, midwives themselves continued to produce texts, though far fewer in number
and less influential upon the bodies that would decide their future. These women
sought to educate as well as defend their profession from the onslaught of surgeons.
In 1737 Sarah Stone, a Taunton midwife with 35 years experience, in her text
Complete Practice of Midwifery, supported education programs specifically for female
midwives so they could competently handle many of the complications of childbirth
including hemorrhage and delayed expulsion of the placenta (Donegan, 1978, p. 31;
Donnison, 1977, p. 23). These complications of childbirth most often did not require
surgical intervention, but could only be dealt with by a better understanding of
anatomy and herbal remedies. However, that type of information was excluded by
most surgeon authored texts in favor of just calling the surgeon to the scene. Mrs.
Stone warned that if women didnt improve their skills, pregnant women would call
for surgeons in the first place, as was becoming the fashion among the ladies of Bristol
(Donnison, 1977).
One of the most detailed texts by a midwife was A Treatise on the Art of
Midwifery appearing in 1785 by Elizabeth Nihell (Donegan, 1978; Donnison, 1977, p.
32; Trager, 1994, p. 187). The foreign trained Nihell focused on the proper and
scientifically valid treatment of laboring women based upon her superior education at
the Hotel-Dieu in Paris10. She also used a good portion of her 400 page book to
attack and refute much of the practice of surgeons who relied upon damaging
instruments, specifically forceps, to speed deliveries for their own purposes, charge
10 The French system of midwife education and regulation will be discussed in the following section,
including the impressive educational record of the Hotel-Dieu.
39


higher fees, and give the appearance of doing something a midwife could not11
(Donnison, 1977, p. 32). Elizabeth Nihell would spend her career as an outspoken
advocate for female midwives while attacking and exposing male practitioners as
nothing more than hastily trained barbers, tailors, and butchers attempting to earn
more money (Donnison, 1977).
Nihell publically condemned the fee disparity between male and female
attendance at uncomplicated labors (Donnison, 1977, p. 35). It seemed that men of
learning who entered midwifery
were automatically accorded
higher status regardless of skill or
experience. Nihell played upon
midwifery as a traditional female
occupation that was being stolen.
The very name itself conjured up
the image of a woman attending
her fellow women. Her argument,
however perceptive of the coming
situation, was sabotaged by a
combination of events.
Industrialization, urbanization, and
population growth all lead to an increasing middle class where women moved away
from productive public and agrarian life to the seclusion of leisure entertaining in their
carefully decorated parlors (Donnison, 1977, p. 21). Thoughts of female occupations
were increasingly being pushed aside, to the detriment of the poor and widowed
working and middle-class women who would be searching for a means of support 11
Elizabeth Nihell vs. William Smellie
Elizabeth Nihell was an outspoken opponent
of the views of William Smellie, a well-known
Scottish man-midwife and instructor. Smellie, in his
1752 Treatise on Midwifery created, what he believed,
to be a clear account of the mechanisms of labor.
Smellie was portrayed in the midwife-friendly
London media as wearing a dress and bonnet to
fool his female patients into allowing him access to
their bedrooms and under their skirts. His procedures
were extremely interventionist, relying upon forceps
in nearly eveiy birth. Nihell frequently accused
Smellie of endangering women by his refusal to show
patience for the natural rhythm of labor and for, in his
teachings, attempting to contort every labor to a time-
line of his making.
(Donegan, 1978; Trager, 1994, p. 186)
11 While the design of forceps wouldnt become legally public until 1733, the Chamberlen family had
shared the design with male practitioners for decades.
40


(Donnison, 1977). Nihell was perhaps one of the accomplished women of her era who
could clearly foresee where the current debate would leave midwives, and the women
they served, in future centuries.
Challenges to the Ecclesiastical Licensing System. The loose system of
midwife regulation established in 1512 and placed under the control of Episcopal
authorities suffered flaws and challenges nearly from its founding. As previously
noted, the Episcopal system did not focus upon determining or assuring the skills of
midwives. As more men entered the field of midwifery this became problematic for
women who were assumed to be less qualified regardless of education or experience.
Male practitioners were withholding support for the system as it did not distinguish
them from their female counterparts in anyway. Episcopal licenses would loose what
little prestige they carried as the influence of the Church declined and holders of the
license began to challenge and attack one another (Donnison, 1977, p. 22).
As other professions gained respect and secular regulatory bodies recognized
by ruling authorities, specifically the Royal College of Physicians, midwives sought to
have their profession recognized. In 1616 a proposal was put before James I to grant
a charter for the incorporation of midwives into an independent society (Donnison,
1977, p. 13-14). The proposal sought to establish standards of practice and to
develop a system to restrict and punish those practicing midwifery without the
approval of the society, in a manner similar to the privileges granted the barber-
surgeons guilds in the 13th century (Donnison, 1977). This proposal was destined for
failure when it became publically known that the force behind the measure was Peter
Chamberlen, a man-midwife of some renown and of the family that invented, and, for
over a century, kept a proprietary interest in, birth forceps. As Chamberlen designed
the proposal, he would be granted the powerful position of Governor with the power
to grant licenses, determine standards of practice, teach applicants, and serve as the
attending practitioner on complicated cases (Donnison, 1977). The Royal College of
41


Physicians, to whom the Kings advisors referred the request for analysis, opposed the
charter based on their own refusal to grant midwifery, as practiced by either men or
women, professional status as well as their belief that their own practices may be hurt
by Chamberlens control over who may serve as an emergency surgeon/physician12
(Donegan, 1978, p. 26-27; Donnison, 1977).
The Chamberlen family would not be put off in their attempts to design a
system of midwife regulation directly involving them. In 1634, Peter Chamberlen, the
nephew of Peter the Elder who had applied to the King in 1616, again proposed a
secular society to Charles I (Donegan, 1978, p. 26-27; Donnison, 1977, p. 14). Again
the matter was referred to the College of Physicians whose position had not changed.
However, there were two other groups opposing the measure this time. A large group
of female midwives, in a letter of opposition to the Lord Bishops Court who oversaw
the current system, refused to be governed by a man-midwife who not only had a
pecuniary interest in regulating others, but had no expertise in normal labor and birth
(Donegan, 1978, p. 26-27; Donnison, 1977, p. 14-15). Chamberlen had a great
interest in keeping female midwives ignorant in the ways of emergency intervention,
not to mention what the female midwives saw as his inability to educate new
practitioners about uncomplicated labor and birth. The midwives insisted that then-
work was contrary to that of Chamberlen. They did not use instruments, nor had
they any desire to do so (Donegan, 1978, p. 27). Chamberlen, they contended, in his
limited experience would seek to use instruments in every case.
Chamberlens proposal to add anatomy education to midwifery practice also
met with resistance from the women:
12
The Royal College of Physicians had long refused to admit male midwives to their ranks. Surgery,
despite the modem conception as one of the more difficult specialties of medicine, was viewed as
nothing more that butchery upon the dead and dying. The College certainly wasnt about to confer
professional status on women practitioners when it had been refusing the men for decades.
42


Anatomical demonstrations and lectures were of little value to the midwife,
they maintained, unless the subject of the dissection were pregnant or post
partum women. The English law that made felons available for anatomical
dissections exempted gravid women. Thus, reasoned the midwives, any
possible anatomical demonstration Chamberlen could present would be
irrelevant to their purposes (Donegan, 1978, p. 27).
Chamberlen appeared to be attempting to turn the average midwife into a medical
doctor, which very few actually wanted or needed to be. The viewpoints of the
midwives and medical birth attendants were radically different. They were arguing
from oppositional paradigms. The differences between practicing medicine and
practicing midwifery were beginning to surface in debates over educational standards
and regulatory authority.
The 1634 proposal also raised the ire of the Episcopal authorities. The female
midwives complaint to the Bishops Court brought to their attention the ferocious
manner in which Chamberlen attacked the existing system. Chamberlen was
unforgiving towards the Episcopal authorities and set a tone that blamed them for the
malpractice and ignorance that existed in midwifery. His charges, while carrying some
truth, could not be blamed entirely upon the Episcopal authorities themselves, as they
were living up to the letter of their mandate. In their own defense, and siding with the
female midwives, the Lord Bishops Court opposed the measure.
The Chamberlen proposal was soundly defeated, again. But this time
Chamberlen would have to suffer greater indignity. Due to the female midwives letter
to the Bishops Court, Chamberlen was ordered to apply for a midwifery license from
the Episcopal authorities, the very same people and system he had so ruthlessly
attacked in his proposal (Donegan, 1978, p. 27; Donnison, 1977, p. 15).
The defeat of the Chamberlen measures and the new group consciousness
among female midwives encouraged the women to put forth their own proposals.
Midwife Elizabeth Cellier, in 1684, proposed a self-governing midwife corporation
that would set standards for practice and education, as well as assure the continued
43


existence of midwifery within England (Donnison, 1977, p. 19). The Royal College of
Physicians opposed this proposal as well. Despite including prohibitions against the
use of instruments and mandating punishments for those practicing without approval
from the corporation, the College of Physicians denounced the measure for failing to
specify midwives as subordinate to
physicians (Donnison, 1977, p. 19).
Midwives would not see the need to
subordinate themselves to physicians when
in their view they were practicing totally
different arts that only occasionally
overlapped. The Cellier proposal had
strong support from King James, but royal
intrigue would intervene and force the king
into exile before the measure could be
debated (Donnison, 1977, p. 19). The
succession of proposals to regulate
midwives in Great Britain would not result
in the formation of a secular body to regulate midwifery practice until 1902.
Midwives Unified
In addition to banding together to
oppose the Chamberlen regulatory plans,
midwives would find a unified voice to
protest the Civil War before Parliament. In
1643 the Midwives' Just Petition called
for a speedy end to the war so that the men
could return home to their wives and bring
forth the next generation of Britons. The
Midwives' Just Complaint appeared in
1646 London. With the end of the Civil
War no where in sight, the midwives
informed Parliament that the only work for
them was doing bloody clean-up of dead
and dying men whose children they should
instead be bringing into the world.
(Trager, 1994, p. 144)
French Advances in Regulation and Education
The most progressive system of midwife education and regulation was
developed in France. While the fervor of the witch hunts affected the French, they
dealt with the issue rather differently than the English or Germans. Midwifery was
regarded as a unique practice that may include aspects of medicine and surgery. The
assumption in Paris was that far more births were uncomplicated than not and that
pregnancy and birth was a normal occurrence.
Procedures for licensure and regulation of midwives was established in Paris by
44


statute in 1560 (Rooks, 1994, p. 14). The initial regulatory body was completely
secular and sought to certify the skills as well as character of every midwife. Every
potential midwife appeared before a board made up of two senior midwives, one
physician, and two surgeons to take the standardized exam13 (Rooks, 1997, p. 14).
Midwives who passed the exam and provided character references would then receive
state certification to practice.
Paris rapidly became the center of medical study and advancement. The
ascendancy of the French to the
position of standard bearer in
pregnancy and birth care was
influenced by two developments:
First, the remarkable educational
tradition of the Hotel-Dieu in
Paris, and second, the prolific
publication of well respected
physicians and midwives.
The Hotel-Dieu was
originally founded as a school
specifically for midwives who
professed the Catholic faith
(Trager, 1994). Over time, as the
possible complications of childbirth became better understood, aspects of anatomy and
surgery were added to the curriculum.
By the 17th century the Hotel-Dieu was a public hospital specializing in
French Midwife Practice
The French would lead the way in regulation
and education of midwives through much of the 19th
century. The post-revolution government sought to
increase the population and in 1803 embarked upon a
midwife education project on a national level.
Midwives were to be divided into two classes; the
first, for midwives with more experience and
education, could practice anywhere in the country and
attend complicated births; the second could practice
in their local area under the in-direct supervision of a
first class midwife or a qualified physician. The
government subsidized the education of local women
at the Paris Matemite, the successor to the Hotel-
Dieu, where programs could last as little as 6 months.
No less than 80 women participated in the first
classes at the institute, more than all the women
participating in all midwife training programs in
England and Germany combined.
(Donnison, 1977, p. 41)
13
It is important to note the involvement of midwives on the examination board from its inception.
No other national system would recognize the expertise of practicing midwives for centuries. There is
no indication that midwifery in France was subservient to other specialties.
45


educating new physicians, surgeons and midwives with the most up to date birthing
techniques in combination with the tried and true methods of the past (Donegan, 1978,
p. 19; Donnison, 1977, p. 18; Trager, 1994). The hospital, supported by French
royalty, ran numerous programs that not only educated students, but treated the
indigent and supported ongoing scientific research14. The efforts of French birth
research focused primarily on discerning the laws of a natural process as opposed to
developing techniques to speed it as appeared to be the efforts of English medicine
(Wertz & Wertz, 1977, p. 33). The Hotel-Dieu achieved its preeminent status by
making use of the best practitioners, male or female, as instructors and care givers, as
well as having the royal support to mediate the influential, and often superstitious,
forces within the Catholic Church (Donegan, 1978; Donnison, 1977). Approximately
1400 to 1600 women gave birth at the Hotel Dieu each year (Gelbart, 1998, p. 52).
These remarkably high numbers allowed the midwifery program to graduate midwives
in as little as three months while assuring that the women has experienced the full
variety of birth circumstances and complications.
Medical and health care givers in 17th century France produced influential texts
documenting their own practices as well as new methods for treatment. These texts,
and the scientific experimentation and observation on which they were based,
contributed to the overall improvement of medical care during the century throughout
Europe. This is not to say that the scientific method as we now know it was up and
14 The poor have always, and continue to be, treated in public hospitals as teaching material for
future physicians. The debate over using the poor can be summarized as education for physicians
and treatment for those that wouldnt otherwise have it vs. the inhumanity of subjecting people to
often unnecessary and/or interventionist treatments for the sake of a timetable that demands
physicians learn a certain number of procedures and how to diagnose in a limited amount of time.
There are great implications in this debate for pregnant women. The implication of historical
physician education in public hospitals for the indigent is that the newly minted doctors were
accustomed to only treating poor women who statistically have more pregnancy and birth
complications. The physicians may have never experienced a healthy, unmedicated birth that
required nothing of them other than to wait for the baby. The move of birth into the hospital was
influenced by the need to train doctors quickly in as many birth situations as possible.
46


running in France, but the observational efforts of French medical men and midwives
far outpaced their Continental counterparts.
Frenchman Ambroise Pare (1510-1590), surgeon to King Henri III, was a
forefather of the study of anatomy (Donnison, 1977, p. 10; Trager, 1994, p. 127).
Pare studied female anatomy and developed an interest in the functions of pregnancy
and childbirth. Beside his anatomical breakthroughs, he is noted for re-introducing
podalic version, a method of manually repositioning a fetus in the case of
malpresentation and/or delivering a fetus feet first (Donegan, 1978, p. 41; Donnison,
1977, p. 10). Midwives would contend that the art of in-utero manipulation had never
been lost to them, but it would be the claims of Pare, due to his more scientific
foundation and his study of anatomy. His work was picked up by many male
surgeons, often as their only exposure to female anatomy.
By far the most influential midwife of 17th century France was Louyse
Bourgeois. At the age of 25 Bourgeois surgeon husband died, leaving her to solely
care for an extended family and children (Donnison, 1977, p. 8; Rooks, 1997, p. 14;
Trager; 1994,p. 131). Taking advantage of the medical information she had gleaned
during her marriage as well as the support of some of the more notable of her
husbands patients, she entered the Hotel-Dieu as a student15. She would be one of the
first and most prolific graduates of the school.
Her success as a midwife is well recorded as are her opinions on the state of
her profession. In 1601, she attended to Queen Marie de Medici during the birth of
her first child before an audience of 200 witnesses (Rooks, 1997; Trager, 1994, p.
131). She would attend the births of all six of Queen Marie de Medicis children and
be appointed the official court midwife.
15 Sponsorship by nobility or rich members of fashionable society was required for admission to the
Hotel until 1631 when married or widowed women, with children of their own, were admitted based
upon aptitude and character (Donnison, 1977, p. 18).
47


Her admonitions to the midwives that followed her are still incorporated into
the modem midwifery model of care: Serve the poor as well as rich, birth is a healthy
process not usually needing interference, laboring women should not be put in any
situation that would inhibit them, each pregnancy is a unique experience for the mother
as well as midwife, physical position should not be limited, and respect must be shown
for the power and mystery of birth (Donnison, 1977; Rooks, 1997, p. 14; Trager,
1994).
Bourgeois model of birth attendance allows the mother to delve into her own
limit experience. Bougeois advocated not inhibiting the mothers in any way during
labor and birth until such time as the mother needed assistance or pathology presented.
Bourgeois appears to have found a position between too much care and too little. Her
presence was initially one of re-assurance as opposed to action. She understood the
uniqueness of every birth and every mother. Perhaps, her own birth experiences had
provided her with Dionysian moments of revelation and experience and she therefore
provided a space for the women she attended to experience birth in their own way.
In 1608 Bourgeois published Divers Observations of Sterility, Miscarriage,
Fertility, Childbirth and Illnesses of Women and Newborn Infants. The treatise
included detailed and accurate explanations of female anatomy and function complete
with diagrams. Relying upon her experience, by 1608 she had attended over 2000
births, Bourgeois instructed readers how to handle most complications as well as
advising when to call for a surgeon. While Bourgeois was an accomplished midwife
and viewed birth in terms of health, she also had attended births that presented serious
medical pathology that extended beyond her knowledge of pregnancy and birth care.
She was very definite in her attack on male-midwives. In her experience, she found
male birth attendants suffered from a general lack of knowledge of female anatomy
and had no experience of normal childbirth (Donnison, 1977, p. 15; Trager, 1994, p.
133).
48


Her attacks on male midwifery would continue in her 1617 publication
Instructions to My Daughter. Bourgeois felt that men should neither be present
during birth nor attempt, in the absence of dire complications, to treat laboring women
(Donnison, 1977, p. 11, 20; Rooks, 1997, p. 14; Trager, 1994, p. 135). Based upon
her observations, men failed miserably in supporting laboring women and only served
to inhibit them (Donnison, 1977, p. 11, 20; Rooks, 1997, p. 14; Trager, 1994, p. 135).
She presented instruction on everything from untangling the umbilical cord to the type
and degree of emotional support women might need (Donnison, 1977; Rooks, 1997;
Trager, 1994). Bourgeois seems to have been able to tread the thin divide between the
practice of midwifery as a healthy art and falling into a medical crisis model. She
viewed pregnancy and birth, including a good number of complications that could be
dealt with non-surgically, as normal physiological processes that were nonetheless
unique for every woman.
Louyse Bourgeois was not afraid to also point out the shortcomings of
midwives nor insist they continually improve their own education and skills. She
believed the medical exploration occurring in France could add to the knowledge base
of midwives without changing the character of the practice. In 1626, ten years before
her death, she exposed the many incompetent mid wives of Paris who had hauled out
the uterus while attempting to force the release of the placenta (Trager, 1994, p. 138).
Uterine detachment results in massive hemorrhage and almost always maternal death.
Bourgeois taught that there was no need for this tragedy when there were numerous
techniques to expel the placenta safely.
The climate of Paris during the 17th century was conducive to the advancement
of medical knowledge as well as the consistent regulation of midwives. The
institutions and secular regulation established in Paris reflected, for nearly the entire
century, a balance between the Catholic Church and the healthcare experimenters, and
the midwives and academic medical men. As is inevitable with most balances
49


dependent upon human participation, a shift of power and influence would come.
Even in France, medical doctors and surgeons would begin to re-define birth as a
medical crisis and assume a share of the birth attendance.
Madame du Coudray
Midwife to France
Angelique Marguerite Boursier du Coudray taught over 10,000 midwives and physicians
in France during her 30 year midwifery career. Historian Nina Rattner Gelbart credits her with
directly contributing to the dramatic upswing in French population figures after 1760. Madame
du Coudray was an ambitious woman who made and cultivated relationships with influential
physicians, priests and government officials.
1739 Madame!du Coudray began practicing in Paris at the age of 25. She serves her
wealthy neighbors and tlje poor one day a week at health clinics in local churches. The 200 Paris
midwives each attend approximately 100 births per year.
1745 The College of Surgeons suddenly refused to allow women in to lectures on
anatomy and surgery, Madame du Coudray and 40 other Parisian midwives presented the Faculty
of Medicine of the University of Paris with a petition urging the medical doctors to provide
midwives with instruction. They secured not only instruction, but the doctors began to refer
women to the care of competent midwives.
1751 The climate in Paris was becoming unfriendly towards midwives. Madame du
Coudray was lured away from Paris to teach rural women and physicians to improve the mortality
rates. i
1755- Midwives were denied the use of forceps. Du Coudray created a training
machine she felt would better train birth attendants so that forceps use would be unnecessary.
The life size mannequin was texturally the same as skin and muscle as well as anatomically
correct. With her machine she could teach illiterate women midwifery and provide experience
without endangering pregnant women. Du Coudray used her machine ton teach both midwives
and male physicians.
1759 Louis XV commissions her to travel throughout France and teach her course. She
secures approval to publish a midwifery text book that works in conjunction with her machine.
She has the text and a version of her machine delivered to many location throughout France for
her use in her courses as well as reference materials.
Madame du Coudray was a master midwife. She served her clients with remarkable skill
and dedication. But her legacy to the French would be her efforts to provide the best education
possible to the most women and physicians. She was a skilled diplomat for the midwifery cause.
She dealt with surgeons and government officials as an equal and made her own struggle a matter
of State importance. She never sought fame or fortune for her students and while she could have
become a matron of a very large training program, she instead focused on improving care.
(Gelbart, 1998.)
50


I
Male Encroachment Into Birthing Rooms
Despite the impressive work and efforts of Louyse Bourgeois and the vocal
supporters of midwifery throughout Europe, men would appear at greater and greater
numbers of normal births in the next century. In 1663 King Louis XIV of France
employed the court physician Julien Clement to deliver the child of his mistress Louise
i
j
de la Valiere16 (Trager, 1994, p. 151). This arrangement was primarily for secrecy
purposes, as the King did not wish for the entire court to be waiting outside his
mistresses quarters17. Apparently pleased with Clements service, the King again used
him to attend dauphine Anne-Victoire in 1682 (Donnison, 1977, p. 20; Trager, 1994;
p. 158). This very public use of a male birth attendant precipitated a subtle shift by
royalty and courtiers. It became a statement of fashion to have an educated male
midwife, called accoucheurs in France, attend your birth (Donegan, 1978; Donnison,
1977; Trager, 1994). Clements attendance on Anne-Victoire would mark the
beginnings of the shift of the fashion conscious nobility and upper class to male birth
attendants while the middle class and poor would depend upon midwives for over a
century. The elite male physicians of Western Europe would quickly see the benefits
of following their French colleagues in to the birthing business.
Male physicians and surgeons may have begun attacking the skills and
16 Julien Clement was one of the physicians with whom the Chamberlens of London had shared their
design for birth forceps.
17 The gossiping midwife is a recurrent theme in actual instructional texts as well as literature. Jane
Sharp, Dr. William Sermon, Louyse Bourgeois, Sarah Stone, Dr. Frank Nicholls and Margaret
Stephen all take care to instruct midwives to protect their reputations by holding their mouths tight
against spreading gossip, turn a deaf ear towards gossip around them, refuse celebratory drinks,
always appear clean and well dressed, constantly improve their education and skills, become certified
or licensed if possible, andlexhibit their competency and good character at all times (Donegan, 1978;
Donnison, 1977; Rooks, 1997; Trager, 1994). The Apostle Paul condemned women who travel from
house to house, the manner to describing a midwife without actually using the term, spreading gossip
(Ulrich, 1990, p. 46). Charles Dickens in Martin Chuzzlewit, Samuel Richardson in Pamela, and
Sarah Josepha Hale in Northwood all make use of the sterotyped gossiping midwife who was not
unknown to a liberal libation during anothers labor (Ulrich, 1990, 47-48).
51


character of midwives early in the 16th century, but until they could provide services
midwives could not, or at least convince more women of their superiority, men would
continue to be the exception in birth rooms. The two events that cracked the door for
male physicians in Western Europe were public release of the design of birth forceps
and, the upper echelons of society women emulating nobility by admitting males to
attend them.
As Donnison (1977) stated, From the 1720's onward, more and more men
were coming into the field. Moreover they were no longer only called in to attend
abnormal labors, but were beginning to be engaged for routine cases. In consequence
they were now in direct competition with the midwives (p. 21). The number of
midwives in England was actually declining while the overall population continued to
grow. Birth attendants of all types were needed to accommodate English women. By
1720 Chamberlens forceps were in wide use throughout England (Donegan, 1978;
Donnison, 1977; Rooks, 1997; Trager, 1994; Wertz & Wertz, 1977, p. 34). Forceps,
forbidden English midyives due to the instrument restrictions of the barber-surgeon
guilds, were touted by male practitioners as a saving grace to laboring women. Male-
midwives insisted forceps usage could save the lives of both mother and fetus in
complicated labors and, perhaps the more influential claim in terms of gaining a
foothold on healthy birth, forceps were said to be capable of shortening all labors
(Donegan, 1978; Donnison, 1977; Rooks, 1997; Trager, 1994; Wertz & Wertz, 1977,
p. 35). These claims were dubious at best. Forceps use certainly did improve infant
and maternal mortality rates in complicated labors, but there were also widespread
catastrophic injuries to; mother and fetus from early application and misuse of the
instrument (Rothman, 1982; Wertz & Wertz, 1977). With few exceptions, instruction
in female anatomy to male physicians was still virtually non-existent. Male medical
students were taught by male surgeons and doctors who had themselves only attended
complicated births. Hauling out a fetus before it has descended fully into the birth
52


canal in an effort to shorten the length of labor is extremely invasive, often injuring the
mother and possibly resulting in fetal decapitation (Donnison, 1977). Male midwives
did not have the knowledge of female anatomy and birth processes that female
midwives did, gained through long apprenticeships and experience, and therefore were
totally unfamiliar with normal anatomy and uncomplicated births (Donegan, 1978;
Donnison, 1977; Rooks, 1997). Their lack of anatomical knowledge and desire to do
something was more harmful to women than the patient waiting of the midwife who
trusted in nature and provided emotional support and non-invasive methods.
By the 1760's, the politer part of the world had already begun to put
themselves in the hands of men (Donnison, 1977, p. 22). The most successful
members of the artisan and tradesman classes were falling into step behind the upper
crust, eager to show neighbors and relatives that they could afford fashionable care
(Donnison, 1977, p. 22). Donnison (1977) found that,
Men-midwives, it was said, anxious to establish their own importance in the
eyes of the public, took every opportunity of helping Fashion do its work. To
this day they exaggerate the dangers of childbirth and frighten women into
believing that extraordinary measures, and therefore male attendance, were
more generally necessary than they actually were. At the same time they made
the most of every occasion to denigrate the understanding and competence of
midwives, and to blame them, however unjustly, for anything that went wrong
(p. 28-9).
The male birth attendants were continually exercising any power relations available to
re-define birth in terms that not only frightened women, but impugned the reputation
of midwives. Through their professional guilds and wider social networks the medical
birth discourse was gaining momentum, participation, and prestige.
As with most occupations and services, the underlying assumption that males
were supporting families and had better education lead to an increasing disparity in the
fees paid to male vs. female practitioners for attending essentially the same healthy
births (Donegan, 1978; Donnison, 1977; Ulrich, 1990). The position of male birth
53


attendants appears to have been that having a surgeon immediately available in the
unlikely event something should go wrong was worth the extra expense. And more
women were buying into the propaganda put forth by the men. However, there were
hidden expenses to having a surgeon instead of a midwife attend labors. Most
surgeons of the era had no training in uncomplicated births and simply having the
ability to intervene with instruments was enough for many to do so unnecessarily as
justification for their higher fees (Donegan, 1978; Donnison, 1977). Fewer friends and
family would accompany a male birth attendant, providing less oversight of his actions
and gaining no knowledge or experience with labor and birth. Many experienced
midwives recounted with horror the damage done and death caused at the hands of
raw graduates of barber-surgeon programs (Donnison, 1977, p. 31-2). Then,
according to midwife Elizabeth Nihell, the male practitioner, adding insult to injury,
was so adept at concealing his errors with a cloud of hard words and scientific jargon,
that the injured patient herself was convinced that she could not thank him enough for
the mischief he had done (Donnison, 1977, p. 33). Donnison (1977) stated that As
the century wore on, so the decline of the midwife continued a cumulative process
accelerated by the interested propaganda of a section of the medical profession, and in
particular, of younger men anxious to capture ... midwifery which gave the entree to
general practice (p. 37).
The prejudice against midwives that had been put forth by those male
practitioners hoping to gain access to a new patient base was now being picked up and
spread widely by varied groups in society. What was once a female only event had,
with increased attendance by male physicians and male-midwives, become a topic of
debate and discussion for the whole of the community. Men in all walks of life were
inteijecting themselves into what had traditionally been a decision made only by
pregnant women. Journalists, clerics, male physicians, politicians and aristocrats were
all participating in a childbirth discourse that only a century before hadnt existed for
54


them.
As more women paid greater and greater sums for the services of male
attendants, midwives were increasingly assigned to serving only the working and poor
women. With fees already lower than those of men and now a growing client base of
those often unable to pay at all, midwifery found it nearly impossible to attract new,
qualified, and dedicated female recruits. (Donnison, 1977, p. 33). The illiteracy rate
and proportion of dangerous complications and injuries to laboring women among
practicing midwives increased as the health of their patients worsened and their
knowledge declined. What was once an inflammatory charge by a few usurpers to the
office of midwifery became a self-fulfilling prophecy by the 19* century. The proud
tradition of midwifery that Elizabeth Nihell, Sarah Stone and others had fought to
defend was succumbing to the outrageous claims of physicians (Donegan, 1978;
Donnison, 1977).
Establishment of the Maternity Infirmary in Great Britain
Man-midwives, accoucheurs, surgeons, apothecaries, and physicians all
recognized the stability and growth potential of beginning a medical practice by
attending births. But even as the men managed to overcome their critics and attend
more and more births, their own reputation and educational credentials had to be
addressed. If their claims of superiority and their desire to perform disciplinary
surveillance over dangerous midwives were to succeed, male birth attendants had to
justify their right to do so.
Male birth attendants held little respect from established medical professionals.
Midwifery had always been womens work, and rather messy, time consuming and
loud work at that. Much too undignified for the Gentleman Doctor of the early-18th
century. Such was the disdain others held for midwifery that when the barber-surgeon
guilds were dissolved and replaced by the national Company of Surgeons, midwifery,
55


despite the frequent use of surgical procedures by male birth attendants, was
specifically excluded as a specialty (Donnison, 1977, p. 42).
In their efforts to gain more patients, male attendants realized something had to
be done to improve their respectability among the medical establishment and broader
society. Attacking midwives had won them a small clientele. The next obvious
solution was to increase their practice and reputation through better education and
more clinical experience. To provide more clinical experience for male attendants,
more pregnant women were needed as teaching subjects. The only source of women
left unmolested by male attendance were the working and poor women still served
primarily by midwives. However, men seeking respectability could not be traveling
throughout the poorest neighborhoods of London forced to spend their time with
numerous bustling women attending the home and needs of a single laboring woman.
The indigent would have to be lead to a centralized location where many woman could
be attended at the same time by many students (Donegan, 1978; Donnison, 1977;
Rooks, 1997; Rothman, 1982; Trager, 1994). Such was the concept behind the
maternity infirmary in Great Britain.
The lying-in hospital or ward became a favorite cause of the burgeoning and
cash-rich upper and middle-class. Sir Richard Manningham founded a charitable
infirmary for poor married women in 173918 (Donegan, 1978,p. 63; Donnison, 1977,
p. 25). The ward occupied two sections of St. James Infirmary in fashionable
Westminster, not far from Manninghams home (Donegan, 1978; Donnison, 1977).
The infirmary was one of the first to provide midwifery and medical students, both
men and women, with clinical experience. Manningham was dedicated to allowing
18
Women bearing illegitimate children were too unrespectable even for charity hospitals. Propriety
was observed at all costs and the donating members of society could not be seen in any way
supporting out of wedlock births. In later centuries poor women and unmarried women would be the
only patients available to charity and public hospitals. These women would be subjected to
unnecessary procedures, crowds watching them deliver and premature interventions.
56


women the opportunity to study, however their program within the infirmary was very
different then that for men. The women only paid half the tuition of men and were
excluded from instrumental and difficult labors (Donegan, 1978, p. 63). The primary
goal of teaching women in nearly all the hospital based midwifery programs was so
they could return to rural and extremely poor areas to treat the women who could not
afford a male attendant or were unable to travel to a hospital (Donnison, 1977). The
practice of excluding women from learning how to treat complications and then
sending them out to serve pregnant woman who are the farthest from emergency
assistance is questionable at best and approaches unethical. This practice endangered
the lives of rural women and their children simple to satisfy the needs of male birth
attendants to exclusively possess specialized knowledge and set themselves apart from
midwives. There appears to have been little intent for female midwives to continue
practice in an infirmary setting. Manningham hoped to emulate the Hotel-Dieu in
Paris and eventually earn government support19. His wishes for the establishment of a
national lying-in hospital would not be realized for over a century, but other maternity
infirmaries would be founded across England and Ireland (Donnison, 1977).
Dublins Lying-In Hospital, later to become the Rotunda Hospital, was
founded in 1745 (Donnison, 1977, p. 25; Trager, 1994, p. 183). The Rotunda served
unwed mothers, unusual for the time, as well as making use of some important Irish
developments in midwifery. In 1738, Mary Dunally, an illiterate midwife in rural
Ireland performed the first recorded cesarean section in the British Isles where both
infant and mother miraculously survived (Donnison, 1977, p. 49). Dr. Fielding Ould
of Dublin added another surgical milestone to birth practices when he, in 1742,
19 The midwifery program at the Hotel-Dieu, by this time, included education in most complications
of birth at least to the level of competency to keep mother and fetus/infant alive until emergency help
arrived (Gelbart, 1998).
57


described an episiotomy to assist in the delivery of the fetal head20 (Trager, 1994, p.
181). Dr. Ould, in 1748, would also be among the first physicians to prescribe pain
killing opiates to women in difficult labors, but vocally opposed attempting cesarean
sections (Trager, 1994, p. 184). The Rotunda provided care for a segment of the
population frequently forced to go without birth assistance.
Between 1739 and 1790 numerous lying-in hospitals, complete with midwifery
education programs, would open; The British Lying-in Hospital (1750), Queen
Charlottes Hospital (1752), Royal Maternity Hospital (1757), The General Lying-in
Hospital (1765), Westminster New Lying-in Hospital (1765), and St. Marys Hospital
School or Nursery of Young Midwives (1790) (Donegan, 1978, p. 73; Donnison,
1977, p. 40; Trager, 1994, p. 190). Admittance of female students depended upon the
views of the founder or senior faculty members of the hospital. The British and City
of London hospitals only accepted female students who were at least 25 years of age,
widowed or married, and of good character21 (Donnison, 1977,p. 27). Most of the
women seeking admittance were of the tradesman class, the wives or widows of
shoemakers, masons, butchers, etc. Tuition for the average program, including travel
to London, was around £30 for the minimum stay of four months22 (Donnison, 1977,
p. 27). The lying-in hospital had succeeded in drawing in the poorest of pregnant
women to be treated by student midwives and physicians. This task hadnt proved that
difficult, for as many would note, what other choice did the poorest women of London
2Q
An episiotomy is a surgical incision of the perineum, the space between the vaginal and anal
openings. Ostensibly performed to provide more space for the fetal head to pass. This surgical
intervention, still used in many births today, is today a subject of debate and controversy.
21 Shortly after the turn of the century the British Lying-in Hospital would break with tradition and
begin to admit single women to its midwifery program in recognition of the fact that middle class
girls with decent education were often thrown into circumstances that required an occupation for
survival (Donnison, 1977, p. 51)
22 With the centralized lying-in hospital providing teaching lectures along with constantly available
clinical experience, the length of the average institutional midwifery program was decreasing.
58


have?
The establishment of the maternity ward fits birth attendance into the
Foucauldian model of discipline as described by Fillingham (1993) and Miller (1993).
The women laboring in an infirmary setting are physically set apart in their own ward
which defines their existence within the infirmary, all of their activities are strictly
controlled by the staff of the hospital, they are subjected to standard procedures
regardless of their individual circumstances, there are hierarchies in place and in which
they have very little access to the exercise of power, and they are subjected to exterior
judgements of their subjective birth experience.
Male-midwives would experience a marked improvement in their public
reputation during the first 40 years of English maternity infirmary growth. The senior
lecturers, or the Gentlemen of the Faculty, frequently held licenses and/or diplomas
from the Apothecaries Society and the Surgeons Company (Donnison, 1977). These
men had gone through an entire program of medical training and apprenticeship in
order to get their licenses and diplomas from the recognized bodies. They chose to
focus on the newly minted, but not officially recognized birth science. They were
medical practitioners, most holding a view of childbirth very different than that of
experienced female midwives. They had private practices and frequently donated their
services as lecturers at the infirmary (Donnison, 1977, p. 26). These men were the
senior attending physicians at the hospital and oversaw treatment by the students.
Some became quite well known, William Smellie, Colin MacKenzie, and William
Hunter to name a few, and the male-midwives who could rightfully claim to have been
their students shared in their accomplishments and reputation (Donegan, 1978).
Having discovered the convenience of attending women in a central location,
many male-midwives and physicians viewed the next obvious step to be expanding the
number of women laboring in the hospital. Women of the tradesman class would be
the next target for hospital birth. Westminster New Lying-in Hospital specifically
59


catered to the women of the tradesmen or working class (Trager, 1994, p. 190).
These women could have afforded competent female midwife attendance in their
homes, but chose a hospital birth for two primary reasons. First, the services of the
Gentlemen of the Faculty would have otherwise been out of reach for the working
class family. But at the charity hospital, there would always be a senior attending
physician supervising the students. Working class women could emulate the upper
class women who had been paying large fees for the services of the same men available
to working class women at the infirmary. The loss of home-birth among the working
class served to further the re-definition of birth by the medical-surgical birth discourse.
The second reason working class women began to birth in hospitals was the
greater availability of drugs and instruments. By centuries end opiates were being
administered, often virtually untested as to their dangers, to greater numbers of
laboring women. Many of the herbal remedies midwives had used for generations
were being deciphered by medical scientists and reconstituted in much more powerful
dosages (Donegan, 1978; Donnison, 1977; Wertz & Wertz, 1977). Primary among
these was ergot, a fungus that grows on rye and other stored grains (Trager, 1994, p.
194). When administered to women with prolonged or slowed labors, ergot causes
extremely powerful and unremitting cervical contractions23 (Trager, 1994, p. 194, 224;
Wertz & Wertz, 1977, p. 66). Hospital physicians and man-midwives also had greater
access to forceps and surgical instruments to free a fetus and mother from one another
when a death occurred during or prior to birth. These interventions were touted as a
boon to laboring women but required women of moderate means to place themselves
in a hospital setting.
23 There was no antidote for ergot which can cause serious damage to fetus and mother. If the fetus is
not fully engaged in the birth canal, the use of ergot can cause the uterus to mold around the fetal
body and literally crush it and/or rupture the uterus most likely killing the mother. Until the early
20th century, when ergot is successfully distilled and its effects can be better controlled by physicians,
its use is challenged and even discouraged except in cases of extreme maternal hemorrhage or as an
abortifacient (Trager, 1994, p. 194, 223; Wertz & Wertz, 1977).
60


Childbirth was transformed by the move to the infirmary into an event more
resembling an illness requiring treatment or heroic measures. The mere association of
birth with a hospital setting conjures images of a medical condition and crisis. The
redefinition of birth by male physicians and participants in the surgical childbirth
discourse was gaining momentum and faced little challenge from a shrinking midwifery
community and quiet midwifery discourse.
Ironically, midwifery in Great Britain may have been saved by the move to
infirmaries. The female students of infirmary based programs were clearly subordinate
to male students and physicians, and their programs were less complete, but the
infirmary programs would be the only way to receive midwifery education at a time
when the accomplished midwives of previous generations were retiring and dying
(Donnison, 1977, p. 27, 34). The infirmary programs were completed faster than
traditional apprenticeship based education which was dependent upon the number of
local women bearing children over the course of a few years. And while the national
system of regulation, such as it was, did not require a formal education, a certificate or
diploma from one of the infirmary programs did carry a certain amount of prestige.
The overall medical-surgical discourse had been successful in spreading the message
that medical education was necessary in order to treat and heal. Even as male birth
attendants accrued more female patients, the reality of the situation at the time was
that there were not nearly enough male-midwives or doctors to handle the childbirth
attendance for the upper and middle classes let alone the clients the male attendants
didnt want poor, rural women. Midwives were a necessary evil in the world of men
that would liked to have seen their elimination.
The transition to infirmary birth for poor and working class women and the
male attendance at a growing number of births across all classes did not silence the
critics of man-midwifery during the late 18th century. Everyone from accomplished
midwives to journalists and supportive male physicians continued to speak out against
61


man-midwives. Their arguments can be grouped into three general criticisms: skills,
medicalization, and morals.
Well known London journalist Philip Thicknesse would join with physicians
and midwives to challenge and expose man-midwifery as fashion. In his publication
Man-Midwifery Analysed Thicknesse attributed the rise in male attendance not to a
demonstrable improvement in skills or knowledge, but to a slavish desire on womens
part to follow fashion (Donnison, 1977). Thicknesse cited incidences of injury,
mutilation and death caused by hasty and improper use of instruments by novice male
attendants. He made use of the opinions of experienced midwives to show that many
of the injured women and fetus could have been spared, thereby granting birth expert
status to midwives and publicizing their continued practice availability to the classes
that were leaving their care the fastest.
Also speaking out was Dr. Frank Nicholls, author of A Petition of the Unborn
Babes (1751), member of the College of Physicians, and physician to King George III.
Dr. Nicholls, like Thichnesse, exposed many of the safety claims of man-midwives as
so much bunk (Donnison, 1977, p. 32). He chastised those male physicians, surgeons,
and man-midwives that denigrated female midwives across the board while themselves
frightening women into engaging male attendants with questionable skills (Donnison,
1977, p. 32). Nicholls joined with Margaret Stephan and many other midwives in
calling for a national examination of all practitioners, male and female, in order to
insure the competence of every birth attendant (Donnison, 1977, p. 36).
Man-midwifery was charged with overly medicalizing birth, turning it from a
physiological-social event into a medical crisis. Midwives Elizabeth Nihell, Margaret
Stephen and others, echoing portions of the criticism by Dr. Nicholls, cited the
overuse of forceps and the move to houses of illness and disease, away from friends
and family, as detrimental to healthy birth (Donegan, 1978; Donnison, 1977; Rooks,
1994; Ulrich, 1990). Just because pain, blood, and the possibility of pathology were
62


inherent in birth, did not mean it was a dangerous physical event requiring medical
care. Nor was birth an inherently abnormal state simply because of blood and pain.
As proof of their argument, the critics of medicalized birth cited the healthy births of
women in rural and poor areas attended by midwives who never used forceps
(Donnison, 1977; Wertz & Wertz, 1977). Medicalized, infirmary birth was too far
removed from the historical view of birth as a social event, at which a number of
women would gather with the midwife to attend to all of the needs of a laboring
woman. Cleaning, cooking, babysitting, stitching, whatever needed to be done would
be handled by the new mothers women so that a she could focus upon the work of
birth (Donegan, 1978; Ulrich 1990. As Wertz and Wertz (1977) found:
The event of birth presented an important, perhaps the primary, occasion for
female solidarity. Women could help in practical ways at birth, but they
attended also, it may be supposed, because they sought to hearten the
expectant woman, to share their own knowledge and experiences of birth, and
to prepare themselves for their own future deliveries. The laboring woman
must have gained confidence from being surrounded by women who had
themselves suffered and survived, often to old age. The potential medical
value of the psychological support these female friends offered should not be
undervalued; the presence of women provided particular reassurance during a
womans first birth, helping her to relax and thus ease her pain (p. 5).
As men entered the labor room, they found the hustle and bustle of so many women
not only distracting, but often annoying and threatening to their authority (Donegan,
1978; Ulrich, 1990; Wertz & Wertz, 1977). The fact that what may have been
distracting him could also have been providing the same service to the benefit of the
laboring woman was never analyzed. The practice of calling ones women when
labor began declined in similar proportion to the rise in male birth attendance. The
tradition of midwife attended home-birth recognized the health, normalcy, and social
aspect of birth, while the new type of birth attendance focused more on pathology,
pain control, and hasty intervention (Rooks, 1994). The trust in the processes and
timing of birth that was a foundation of midwifery was being thrown out, without
63


significant cause, in favor of medical means of speed and pain control.
Perhaps the most interesting critique of man-midwifery was the argument that
it represented a threat to the moral fiber of society. The late 18th century was a time of
increasingly limited opportunity and assumed limited capacity for women.
Industrialization and efficiency advances in agrarian science had created a much larger
middle class and more women at leisure (Donegan, 1978). Staying home and keeping
proper appearances was the duty of all middle class women. In the few years before
Victoria would ascend the English throne, the public role of women was being
diminished greatly while tales of female frailty and challenged intelligence grew.
Woman had to conform to constraints placed upon nearly every aspect of her
behavior, from whom she could admit to her home to what type of correspondence she
could answer and where she could travel alone. The access to power relations for
woman was being diminished as she was forced to withdraw from more and more
societal interactions. Ironically, it was during this era of rampaging prudishness that
men made their way into the most intimate of female company.
Critics of man-midwifery noted the discrepancy between societal expectations
for women and what was actually occurring. If a married woman could be put at
moral risk by admitting a single man to her parlor, critics said, imagine her danger in
the presence of a man-midwife expected to view her most intimate of bodily parts and
functions (Donegan, 1978; Donnison, 1977). Not only did the man-midwife want to
expose women, but through dismissal of her women he sought to practice
unchaperoned or observed. And worse yet the critics charged, many of these man
midwives were of a lower class than their patients and nearly all were lecherous, for
why else would they want to treat women in this way (Donegan, 1978; Donnison,
1977, p. 50). The critics, including Francis Foster, author of Thoughts for the Times
but Chiefly on the Profligacy of our Women (1779), put forth the belief that once a
woman had admitted one man to such familiarities others would surely follow and
64


the fiber of English society would be forever weakened24 (Donegan, 1978, p. 20;
Donnison, 1977, p. 29-30). In sensationalist pamphlets, the critics made thinly veiled
charges of unwanted seduction and cited unnecessary and incompetent instrument use
as evidence of unprincipled adventurous attitudes that endangered women (Donnison,
1977, p. 50). In their defense, man-midwives relied upon the unproven argument that
midwives were dangerous, were prohibited from treating any complication of birth,
and were incapable of the mental capacity to handle the medical education necessary
to attend birth (Donegan, 1978; Donnison, 1977).
A vicious circle ensued; women of moderate means were removed from the
public arena to entertain politely in their parlors, they rarely ventured into public
matters or advanced education and therefore all they knew were the latest games and
gossip. Confronted with women who knew nothing of the world, society in general
could only assume the claims of inferior ability and mental capacity were substantive.
The well-educated, publically involved woman became the exception, an aberration,
something less than wholly feminine. With female midwives labeled as incapable of
safely attending birthing mothers, man-midwives would be the only choice.
The move to the infirmary setting was established, although as something less
than fashionable, by the 19th century. Low cost or free care, mechanical intervention,
and more widespread experimentation with pain relief drew women of the poor and
working class to the hospital where they were in no position to control their care or
experience of birth. They placed themselves under the disciplinary surveillance of the
hospital who would make virtually all decisions for them and dictate their experience.
Due to male disinterest in attending the poor and rural patients in their own homes and
the necessity of teaching women simple midwifery, midwifery education for females
may have been saved. However, infirmary based midwifery education was very
24 Francis Foster cited the rise in the divorce rate as evidence of the collapse of female virtue in
England: there were three recorded divorces in 1779 (Donegan, 1978, p. 20).
65


different than the apprenticeship based learning of earlier years. Infirmary midwives
had a much more medical view of birth and had never been exposed to birth
complications. Infirmary trained midwives would be forced to call for assistance from
male physicians at any sign of abnormality. The difficulty with a medical view of birth
that relies on one set description of the processes and schedules of birth is that it
denies every laboring woman a unique birth process. What may be a prolonged labor
under the catch-all schedule determined by the medical establishment may be a very
normal birth for the individual woman and pose no danger whatsoever to her or her
child. Infirmary trained midwives would have much less experience with the varied
rhythms of uninterrupted birth and increasingly call upon physicians to assist at the
first detour from the prescribed path. Overall the number of births classified as
complicated and requiring interventions increased (Donegan, 1978; Donnison, 1977).
As physicians were called to more and more abnormal births, the medical-surgical
birth discourse gained momentum in re-defining birth as a dangerous medical condition
removed from healthy living. In the same way that Foucault found physicians to have
greater access to power relations after every successful treatment of a patient, male
birth attendants gained a stronger voice in defining birth as the number of births
requiring their assistance grew (Foucault, 1973; Muller, 1983).
Foundation Laid
The foundations of the modem argument for and against female and male
childbirth attendance were set by the end of the 18th century. Men had forced their
way into a very limited number of births beginning in the 13 th century by placing
limitations on instrument usage by female midwives. This initial foray by male
surgeons into childbirth drew some criticism in that no knowledge of anatomy or
childbirth functions was necessary, and even though either mother or fetus were dead
by the time a surgeon was called, the surviving member was frequently horribly injured
66


by the efforts of the surgeon. A new discourse of medical-surgical childbirth was
created where the participants defined birth in medical terms of pathology, pain, and
danger. The new birth discourse would spread rapidly, as the male participants could
access wider societal discourses such as politics, journalism, education, and finance.
Their more public role in society, by virtue of their sex, would increase the broadcast
of the new, medical-surgical view of birth. Women were being limited in their public
roles and activities to a greater extent than ever before and the trend would only
continue into the 19th century. Most midwives themselves operated in a small
community and did not view their art in terms of an organized profession. Midwives
were not in a position to exercise the type or degree of power relations the medical-
surgical birth proponents could and therefore their range of influence was limited.
The next significant advance made by the male birth attendants was the
creation, spread, and finally public release of the design of birth forceps in the early
18th century. Forceps allowed male midwives to not only attend complicated births
where both participants survived, but led to claims of speedier labors and safer births
for all women. Male-midwives began competing directly with female midwives for
normal births having all ready subsumed complicated births. Female midwives and
their supporters relied upon the lack of knowledge critique, and added the charge of
unnecessary instrumental intervention and disbelief of the safety claims of male
attendants.
Female midwives also had to contend with societal fashion that wasnt kind to
their practice or presence. Emulation of the French court and the wealthy citizens of
the Continent who had begun to employ male childbirth attendance as a status symbol
grew25. The actual quality of care appears to have been less a consideration than the
25 It is interesting to note that the highest echelons of the English court had not yet succumbed to
fashion, preferring to make use of female midwives. However, the court relied upon the services of
French and German midwives who had benefitted from government supported education and
licensure programs in addition to regulations that were far less restrictive in the use of instruments
67


assumption that higher fees garnered if not more competent care, at least access to
instruments and drugs for pain. Fashion is difficult to combat until the claims can be
disproved decisively or another convention claims preeminence. The female midwives,
mostly from the middle or lower-class themselves, could hardly determine fashion, but
they did attempt to point out the hypocrisy of the claims of male attendants,
themselves with questionable skills, education, and reputation.
Toward the end of the century female midwives also had to contend with a
move of birth from the home to the charitable infirmary among urban poor and
working class women. While the loss of these women as clients was troublesome to
the home-based female midwives, at least the early infirmaries continued to accept
women as students in their midwifery education programs. And despite being based in
an infirmary, the female students continued to learn that birth could be a healthy. The
division of women in to programs that did not included education into birth
complications served to increase the gap of knowledge between male and female birth
attendants. Men were seeing mostly complicated labors and births requiring
intervention and therefore came to view birth is those limited terms. Women from the
infirmary programs were helpless in the face of complications. The charges of male-
midwifery proponents that female midwives were less educated and skilled would be
true, but only because they were not given the opportunities to improve their skills and
knowledge.
The infirmary midwife education and birth programs also placed women,
midwives and those laboring, under the disciplinary surveillance of physicians and the
institutional hospital. The nearly entirely male hospital board, founders and operators
determined what was acceptable behavior for women and closely watched to make
sure that the women within the institution followed the program. Midwives and
and drugs (Donnison, 1977, p. 53)
68


laboring women were spatially segregated to keep track of who they were and what
they should be doing, all treatments and stages of labor were carefully monitored,
standard procedures such as washing, shaving and notifying the supervising physician
were followed, the midwife and patient were below the male resident and physician on
totem pole of power relations, and every action of the midwife and laboring woman
was placed under scrutiny to determine when and if she were straying from the
normal path or treatment or progress. Any deviation form the prescribed path
would result in having the midwife removed from caring for the laboring women, and
the laboring woman would be subjected to interventions to pull her abnormal labor
back onto the arbitrary schedules set by the institution.
The ascendancy of the male medical practitioner was underway. With more
and more males entering medicine and the science of childbirth developing away
from the midwife attended home-birth, the informally trained female midwife was
sinking into the annals of history. For every traditional midwife, physician or journalist
that attempted to expand the midwifery discourse and challenge medicalizing birth,
there were many more participants within the medical-surgical birth discourse that
responded to further limit midwifery. The government officials to whom the English
midwives appealed for independent incorporation, which would have allowed them to
determine educational requirements, skills testing, and punishments for practicing
without a license, relied upon the advice of male surgeons and medical practitioners
who had no concept of normal labor or birth and a pecuniary interest n keeping
midwives out of birth rooms. Unlike the French system, where midwives served on
the board governing licensure and testing, English midwives had no representation that
could have served to delineate the difference between medical conditions and birth.
Given the fact that even a totally uncomplicated birth involves blood and pain, it is not
surprising that the surgeons and medical doctors accepted the re-definition of birth by
male birth attendants as a dangerous condition. The midwives had no one to turn to
69


for assistance in keeping the traditions of birth from re-definition. And even among
their own ranks, perceptions were changing. New midwives would come from
institutional programs and have a reliance upon male surgeons and physicians built into
their education and practice. New midwives, due to the very structure of institutional
programs, would begin to view birth as full of potential pathology.
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CHAPTER 3
COLONIAL BIRTH ATTENDANTS AND
DEBATE TO 1800
The history of midwifery in England bears a direct influence on the state of
midwifery in Colonial America. Colonial midwives practiced in a system similar to
that which dominated in England prior to the male midwife debate in the mid-18th
century. There was little regulation of midwives as too their character and none as to
their skills. As Wertz and Wertz (1977) point out:
Since the colonial midwives came initially from England, English traditions
prevailed in the colonies. Before....the colonial period English society did not
consider midwives to be part of the medical establishment or professions but
saw them as performing a special social and quasi-religious function. That is,
midwives did not formally train for their work, did not organize a guild to
license midwives, and did not transmit skills by formal apprenticeships. Rather,
midwives succeeded one another by selecting themselves, or being selected by
other women, to attend births. The fund of knowledge about birth practices
was widely shared among women who had given birth themselves and aided
others to do so. A midwife had to satisfy the expectations of such groups of
women. Many midwives probably came from networks of women who had
aided one another in birth and were distinguished by such intangibles as manual
dexterity, sensitivity, and luck. Many may have been older women, themselves
past the childbearing age, who were available for the sometimes time
consuming work and possessed of certain admired moral qualities as well as
physical abilities (p. 6).
The American midwives, like their English colleagues, did not view childbirth as a
medical crisis. Most births were uncomplicated. When they encountered a serious
complication they called for help. They were knowledgeable members of a
community, not professionals. They served many roles in keeping the community
healthy and frequently worked in concert with the more formally educated
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Gentlemen physicians.
The same issues pro-midwifery supporters in England protested could be found
creeping up in Colonial American. The perception of birth, the professionalization of
medicine, fashion, the explosion of medical schools, and the increase in the number of
male doctors would combine to challenge female midwives and their definition of
birth. The survival of midwifery in America would face challenges much greater than
in England. In America there were fewer supporters, more competition, fewer
education opportunities, and no way to unite for defense. Larger numbers of men
would begin midwifery practice throughout the colonial period. Midwives would be
able to change their situation only subtly. Fewer and fewer women would be
interested in apprenticing and more women would begin to ask to have the surgeon
called should their labor be long or hard. Professional medicine would become a more
constant aspect of the lives of midwives and all women.
Regulation. Medical Schools, and Birth Perception
Initial regulation of midwives in America was not designed to improve care,
but to control practicing midwives by outlining the services they could provide. The
first recorded midwife regulation in colonial America appeared on the books of New
York City. In 1716 the City Council passed an ordinance requiring midwives to take
out licenses and swear an oath to serve all who asked, conceal no information about
birth events or parentage from civil or religious authorities, not to coerce fees for
service, and provide no abortifacients (Donnison, 1977, p. 22; Trager, 1994, p. 172;
Wertz & Wertz, 1977, p. 7). The ordinance resembled the English Episcopal system
in that there was no required educational standard, no examination of skills, little
means of enforcement for not registering, and virtually no punishment mechanism to
handle complaints against those midwives who were licensed. The additional difficulty
the New York measure faced, especially in later decades, was getting even a small
72


percentage of non-English speaking midwives to take out a license.
The absence of official regulatory and oversight procedures did not mean any
woman could practice midwifery. Wertz and Wertz (1977) uncovered an unofficial
mechanism to weed out incompetent female midwives.
In many American colonies,... the civil and religious authorities were closer at
hand and more watch full. They were deeply concerned with increase as a
sign of Gods favor and as a prospect for prosperity; it seems unlikely these
authorities would tolerate any midwife who consistently failed their
expectations. Some colonies... treated midwives as servants of the State, giving
them privileges in return for their carrying out certain acts for the moral order
(p. 12).
Population growth was essential for the survival of America and was, for some, a
comforting sign of Gods devotion. The midwife played a vital role in the survival of
the new colonies and was expected to be competent and knowledgeable.
Colonial midwives had great success in helping women perform what many
saw as a heroic devotion to childbearing (Ulrich, 1994; Wertz & Wertz, 1977).
American midwives appear to have been more skillful and less damaging than English
mid wives of the same period, and this may have been because American women were
healthier than English women (Wertz & Wertz, 1977, p. 18). Healthier mothers
usually have less complicated births, a situation that may account for the better
survival rates for colonial midwives (Rooks, 1997). Wertz and Wertz (1977), in
reviewing demographic data of New England births during the colonial period, found
the claims of catastrophic rates of maternal death to be vastly overestimated (p. 19).
Not to say that childbirth did not pose dangers or that colonial women didnt fear the
associated pain. But the historical information indicates that childbirth in the colonies
was by far a safer endeavor than in England.
What may have influenced the unjustified overestimation of maternal death is
the spread of the tales of truly pathological labors and births despite the limited actual
instance of catastrophe (Wertz & Wertz, 1977). The few horrific birth tales traveled
73


far, refusing to fade away and frequently overshadowing thousands of healthy, normal
births. That being the case, one of the most important tasks of the colonial midwife,
and other attending women, was to reinforce a laboring womans confidence that all
was normal, that she was healthy, and that all of the mothers in the room had
obviously survived birth (Ulrich, 1990; Wertz & Wertz, 1977).
With the success of childbirth attendance by colonial midwives and the virtual
lack of prestige for the few doctors that were practicing at the time, how did man-
midwifery make significant inroads to childbirth attendance in colonial America?
Education, the availability for some and restriction of it for others, and birth
perception, by practitioners and women, played significant roles.
The sons of wealthy colonial Americans began to return home from European
medical tours around 17501 (Wertz & Wertz, 1977, p. 29). With them came the
instrumental intervention model developed in England and the French definition of
birth as a scientifically decipherable process (Wertz & Wertz, 1977, p. 37). The
French were describing birth as a natural process that followed its own laws, as a
machine with shapes and movements of its own (Wertz & Wertz, 1977, p. 33). The
female body was studied and diagramed as mechanistic and therefore predictable
outside of malfunction. Machines are often repaired and maintained with tools,
therefore the English and French male practitioner efforts to not only attend but
improve childbirth melded together well in the education of colonial male midwives
and doctors. While colonial midwives did not yet have to contend with surgeon or
physician guilds and legal restrictions on instruments, their tradition was
noninterventionist and the cost of instrument use, both financial to acquire them and 1
1 Midwifeiy had become part of the basic curriculum for medical education at the University of
Edinburgh and University of Glasgow. By 1740 the faculties of both universities had established a
system of examination and licensure for midwives in the surrounding areas (Donnison, 1977, p. 22).
Despite the refusal of many medical guilds to recognize midwifeiy as a medical specialty, medical
schools throughout England and France began to teach it to nearly all tuition paying students.
74


physically for the laboring woman and fetus, was prohibitive (Wertz & Wertz, 1977, p.
39). Diverging from the centuries old English and French tradition that began
admitting males only to complicated births and only recently had suffered male
attendants at uncomplicated births, the new colonial male practitioners were
competing with female midwives for all births from the moment they established
practices in America (Wertz & Wertz, 1977, p. 39).
As in England, colonial man-midwives had to deal with the reality of their
numbers being too few to attend all births. Midwives were necessary, they could not
be eliminated entirely until there were enough physicians to assume all their duties.
Until that time, the ideal system would be shared care in which women having
normal pregnancies and labors would be attended by midwives and women with
complications of pregnancy or labor would be attended by surgeons/physicians.
Through the end of the 18th century, colonial physicians spoke of the necessity of
implementing a shared care arrangement for pregnant women between trained
physicians and trained midwives. The physicians insistence upon determining the
course of and requiring formal education for all midwives would be the biggest
roadblock to establishing shared care in America. Wertz and Wertz (1977) found
that,
The plans of doctors for a shared enterprise with women never developed in
America. Doctors were unable to attract women for training, perhaps because
women were uninterested in studying what they thought they all ready knew
and, moreover, studying it under the tutelage of men. The restraints of
traditional modesty and the tradition of female sufficiency for the management
of birth were apparently stronger than the appeal of a rationalized system for a
more scientific and presumably, safer midwifery system (p. 45-46).
Many physicians would not work with women, who despite having considerable
experience, had no formal medical training. One cannot help notice the irony in that
stance; if midwives, working in collaboration with or even under the supervision of
male practitioners, were to attend only uncomplicated births, the informal experiential
75


and apprentice based system all ready in place had been proven safe, efficient, and
effective. The vast majority of births were, and still are, normal, requiring no medical-
surgical intervention (Rooks, 1997; Ulrich, 1990). What advantage to midwives
would there be in placing themselves under the supervision of men to teach them what
they all ready knew in order to attend births they were all ready attending with results
as good as a physician? Early colonial physicians did not yet have access to power
relations that could effectively challenge the dominant midwifery birth discourse. They
were not yet organized, commanded little respect from other segments of society, and
were too few in number to attend a majority of births. Early colonial physicians were
putting their house in order, a step American midwives did not take.
Colonial midwives were not an organized group, a fact that would make them
an easy target for attack in later years (Ehrenreich & English, 1978; Wertz & Wertz,
1977). The suggestions for organization and formalization of training for midwives
made by male practitioners were not well received by most female practitioners.
Midwives reflected what would become a strong American tradition of local self-help
empiricism, in which their loyalty was to a local community of women (Ehrenreich &
English, 1978; Wertz & Wertz, 1977, p. 46). Midwives were very well respected and
had access to numerous power relations within their small communities. The types of
organization for regulatory purposes proposed by male practitioners would force
midwives to acknowledge the growing application of medical science to their art and
accept subordination to male physicians. Even at this early stage of the development
of medical science, the foundations of traditional female midwifery and medically
trained male physician practices, both theoretically and in actuality, were radically
different. Midwifery was a personal calling to assist the women of a specific
community (Ulrich, 1990). The nature of early midwives was solitary and experiential
based with gatherings of more than a few practicing midwives very rare. Information
was shared in the course of practice. Midwives of the late 18th century had too many
76


other responsibilities to be concerned with organizing. Since birth was not a medical
crisis, illness or injury, the midwives did not foresee the entrance of physicians into
their realm of practice.
Midwifery education programs were available quite early in Colonial America.
In 1765 Dr. William Shippen founded a midwifery course in Philadelphia (Rooks,
1997, p. 19; Suarez, 1993, p. 326; Wertz & Wertz, 1977, p. 44). The course followed
the English infirmary model of shared care; training women to attend normal
births and training male students in more surgical techniques to assist in complicated
births. This system reflected not only the lack of enough male midwives to attend a
majority of births, but also a general trust in the processes of nature that required little
or no intervention other than trained or experienced observation (Wertz & Wertz,
1977, p. 44). This trust in nature would evaporate in the early 19th century as more
male physicians sought to establish themselves through practicing midwifery and as
birth pain was defined as pathological.
While Dr. Shippen reserved a number of student positions for women, he
experienced great difficulty in filling them. Suarez (1993) and Rooks (1997) attribute
this difficulty to a Puritan belief that increasingly kept American women in the home,
receiving only enough education to survive in a small domestic community and
economy. It is also probable that the social place and activities of women, much as
was occurring in England, were being severely limited. The co-mingling of men and
women to educate them about intimate bodily functions was becoming increasingly
unacceptable (Wertz & Wertz, 1977, p. 47). Colonial women also faced the difficulty
of finding a way to pay tuition for the course, and possibly travel, room and board, as
midwifery education was not supported publically and women controlled very little
hard currency (Wertz & Wertz, 1977, p. 45). With few women applying to his
midwifery course, Dr. Shippen was forced to accept the economic reality and began
admitting as many tuition paying men as there were spaces available. With only men in
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the course, the surgical and pathological possibilities of childbirth were being
presented with more regularity to more and more men. The knowledge of normal,
uninterrupted childbirth would be pushed to the background. Male practitioners
would have less experience in letting a birth unfold and supporting a woman as
opposed to acting upon her. Fewer
and fewer women would be able to
pass on the knowledge of a non-
intervened birth experience either as
a midwife or as a mother. Birth
perception among more women was
being redefined by the actions of
male attendants who were more
likely to intervene and provide less
emotional support.
As medical schools were
founded in the colonies, midwifery
was the initial specialty to be taught,
preceding even surgery (Wertz &
Wertz, 1977, p. 49-50). Childbirth attendance was expected to be the cornerstone of
every new practice. The Medical College of Philadelphia was established in 1765,
followed by Kings College Medical School (later Columbia University) in 1767, and
Harvard Medical in 1782 (Wertz, & Wertz, 1977, p. 49). The prominence of
midwifery in American medical schools stands in contrast to the lack of consideration
given midwifery in English medical programs. It also is indicative of how early the
medicalization of childbirth, as indicated by a focus upon pathology and pain relief that
The Proper Course of Labor
As childbirth was medicalized, the timing
and events of labor and birth would be forced into
more and more arbitrary schedules. William
Smellie, Valentine Seamen, and other male
physicians who wrote texts on midwifery attempted
to create examples of normal births. These
examples were intended to serve as guideposts of
what is abnormal and when a surgeon should be
called. The difficulty with creating an average
labor model is that the individual circumstances of
births are ignored. Not all labors are similar, even
in the same woman. With a narrowing definition
of normal, more and more labors and births
would be labeled complicated requiring the
attendance of a surgeon.
(Ehrenreich & English, 1978;
Kahn, 1995; Wertz & Wertz, 1977)
78


is part and parcel of organized medical education, began in America2 (Kahn, 1995;
Suarez, 1993).
At the end of the century, Dr. Valentine Seamen established a short course on
midwifery based upon his series of lectures called The Midwives Monitor and
Mothers Mirror (Kahn, 1995, p. 90; Wertz &Wertz, 1977, p. 40). Dr. Seamans
lectures, in which he described the proper course of labor, were published and
widely available across the United States. Dr. Seaman hoped to implement the same
shared care vision held by Dr. Shippen. We have to assume that Dr. Seaman
attempted to attract female students and practicing midwives to his lectures based on
his desire to train women to handle uncomplicated labors.
Unlike the English situation where there still was some resistance to teaching
all male medical students midwifery. American medical schools taught midwifery as a
part of the general curriculum, clearly associating pregnancy, labor, and childbirth with
medical conditions of pathology and disease. The possible pathological medical
aspects of childbirth were, and still are, over represented in medical schools (Jones,
1991; Jordan, 1993; Kahn, 1995; Rooks, 1997; Rothman, 1982).
Early American male physicians were developing their practice at the same
time as scientific medicine as a whole was trying to gain a foothold over trial and
error empiricism and gain some of the cultural respect held by lawyers and the clergy
(Wertz & Wertz, 1977, p. 29). The disrespect and suspicion shown male birth
attendants in England was lessened in America. Male birth attendants benefitted from
2
It should also be noted here that while women were sought to attend some midwifery courses, they
were not considered appropriate, or capable, medical students or physicians (Ehrenreich & English,
1978). The assumptions of womens capabilities were beginning to focus upon the frailty of women
physically and their supposed inferior mental abilities. As in England, the assumption of female
delicacy is related to the rise of the middle-class urban dwellers who could afford to have the
mother/wife not work outside the home in favor of attention paid to fashion and social standing The
barriers to formal, complete medical education for women would take nearly the entire 19th century to
break down (Rossi, 1973).
79


little organized support for female midwives, no specifically American tradition of
midwifery to overcome, and the initial inclusion of midwifery in most medical schools.
The practice of midwifery by men in colonial America also benefitted from a
very different perception of birth mysteries and the new birth science than existed in
England and Continental Europe. The Catholic Church, specifically, wielded far less
influence in the colonies than it had in Europe. Conceivably, that could explain the
more limited, although still effective, influence of the witch hunts on midwifery in the
colonies as well as mediate the superstitious view of conception, pregnancy, labor and
birth as mysterious acts susceptible to magic and evil doing (Wertz & Wertz, 1977).
Wertz and Wertz (1977) stated,
Doctors (in Europe) hesitated to practice where magic abounded, where the
distinction between natural and spiritual causes was unclear and unaccepted,
because doctors did not want to be thought of as magicians. In America,
however, the matter of magic was settled by more effectively applied
Protestant sanctions, and the comforts of magic did not exist to resist or offend
doctors. Also, historians have said that Protestantism bred a cultural
acceptance of new science and a particular willingness to intervene technically
in nature. Many American women, whether urban or rural, were more ready
than the majority of English women to look positively on doctors new
knowledge and technical skills (p. 25).
The desire to escape oppressive traditionalism and religion are hallmarks of the
founders of America. Protestantism in early America would play a role in changing
the perception of birth. The attitudes and beliefs that lead to the formation of most
Protestant faiths can be extrapolated to support the entrance of men and intervention
science into the birthing rooms of colonial America. The fears of magic and
otherworldly evil doing were lessened. Faith in man and his actions to improve the
situation of humanity was greater. Birth was more associated with the natural world,
and nature, under scientific scrutiny, appeared to follow regular laws that people
could understand and, importantly for medicine, act upon (Wertz & Wertz, 1977, p.
25). Bodies were clearly part of nature, subject to understanding and intervention by
80


man, with souls still mysterious and of God (Wertz & Wertz, 1977, p. 25).
Malfunctioning or diseased bodies should be fixed to conform to the laws of nature
as designed by God, but interpreted and controlled for all intents and purposes by man.
Faced with the choice of having her labor attended by a female midwife who could
offer support and prayers or a male physician who could intervene in some way to
speed labor or save her baby, colonial women began to accept the path of action and
intervention (Wertz & Wertz, 1977).
Childbirth in colonial America underwent a shift of perception and definition
that opened the door to different practices and practitioners. Childbirth was firmly
fixed as a foundational subject in colonial medical schools. Childbirth was beginning
to be viewed as an up and coming science subject to scrutiny, discovery, and
intervention based improvements. As Ehrenreich and English (1978) point out,
Womans body, with its autonomous rhythms and generative possibilities, appears to
the masculinist vision as a frontier, another part of the natural world to be explored
and mined (p. 19). And childbirth, being unique to women and a remarkable physical
event was atop the list of biological events to investigate. Womens bodies became so
much material to be dissected into component pieces and processes, and controlled by
man (Ehrenreich & English, 1978). The practice of midwifery by educated male
physicians placed childbirth firmly within the definitions of a medical event subject to
pathology as well as control. This medical view would pull birth away from the
social-based health practices of midwives.
But the shift of birth attendants away from exclusively women to include men
did not begin as a conspiracy by male physicians to oust all midwives. The laboring
women of the 18* century themselves made the choice of birth attendant (Wertz &
Wertz, 1977, p. 48). As more and more was learned about birth by physicians, the
news spread to women from the most literate and wealthy down to the middle class.
Childbirth, as a natural event with systematic, decipherable and sometimes controllable
81


processes began to be seen by more and more women as less a social event than a
scientific-medical one requiring the attendance of a physician just in case of
complication (Donegan, 1978; Donnison, 1977; Rooks, 1994; Ulrich, 1990; Wertz &
Wertz, 1977). The possibility of complications during birth became the focus of
women and male medical attendants.
The path of male childbirth attendance in colonial America was directed by a
convergence of numerous circumstances which set America apart from most European
countries. A great deal of midwifery tradition in America came from England,
meaning that midwifery knowledge was passed by example from one woman to
another with few formal educational programs and no professional organizations.
Unlike English midwives, colonial American midwives could not depend upon a
centuries-old tradition of support for their practice nor the dismissal of man-midwifery
by other medical professionals. Male physicians being educated in America were
expected to establish their practice, literally, upon pregnant women, whereas in
England most physicians and surgeons were still expected to stay away from
pregnancy and childbirth except in instances of disease or dramatic pathology. The
debate, that would dominate in England, over whether or not childbirth attendance
should be viewed as a medical crisis, was barely an after-thought to the founders of
American medical schools. Childbirth in America has been almost entirely under the
umbrella of medicine since medical education programs began. The largely protestant
religious make-up of the colonial population created an environment conducive to the
emerging relationship between scientific inquiry and medicine (Ulrich, 1990).
Scientific inquiry was redefining what was previously thought to be mysteries of
God as natural functions of the body and therefore controllable by man. As in
England, the growth of a cash rich middle class which could concern itself with fashion
aided the male physicians in attracting clients who wanted to distance themselves from
the working class and poor. These events, with many others on a local level, meshed
82


to create a setting ripe for a new system of childbirth care.
The Remarkable Diary of Martha Ballard
American midwifery historians have an extraordinary, practical example of the
shift in childbirth attendance from an exclusively female, social, life event to a male
attended, medical crisis in the diary of Martha Ballard. The Ballard family was one of
less than a hundred pioneer families in Hallowell, Maine along the Kennebec river.
The location of Hallowed as the entrance to the frontier of the northeast provided a
constant flow of settlers, merchants and news (Ulrich, 1990). The Ballards arrived in
Hallowed in 1777 to set up their farm, although Martha served as the primary midwife
for the town and her husband, Ephraim, was a trained surveyor employed by state and
federal entities (Ulrich, 1990, p. 13, 62). Marthas diary begins in January 1785 and
ends May 1812, the last entry being three weeks before her death at 77.
During the 27 years of the diary, Martha attended 814 deliveries, recording
what has been caded the first full accounting of delivery practices and of obstetrical
mortality in any American town3 (Ulrich, 1990, p. 33). Marthas diary is not only
important for what it teds us about dving in and bringing babies into the world during
the last quarter of the 18th century, but for what the diary doesnt say. Marthas
recording style was minimalist, part ledger, part town record and part sermon (Ulrich,
1990, p. 7). She included medical detad only of compdcations or reasons for a return
visit to a mother or newborn. The normadty and relative safety of birth is represented
by the sdences and lack of detail for dedveries that were safe and successful.
Marthas diary was routine and predictable because most dedveries were routine and
predictable (Ulrich, 1990, p. 172). During her practice in Hallowed Martha saw one
3 As noted in the introduction, the terms obstetric and obstetrician were not frequently used until
1828, well after Martha Ballards lifetime. Ulrich is misleading in using the term, as it implies a
more scientific, medically based form of care than midwives offered.
83


maternal death for every 198 live births (Ulrich, 1990, p. 170). While that rate may
seem high to modem sensibilities, it is important to remember that the general health
of women has improved dramatically as well as the fact that Martha Ballard had no
instruments or pharmacological advances to rely upon (Rooks, 1997; Ulrich, 1990).
As recently as 1930 the maternal mortality rate in the United States was one for every
150 live births4 (Ulrich, 1990, p. 170).
Martha returned to treat 38 of the 481 mothers she attended between 1785 and
1796. In most cases she noted symptoms such as sore breast, fever, colds, sore
throats, headache, weakness, cramps or breast feeding problems (Ulrich, 1990, p.
191). During the life of the diary, Martha lost five women during the lying-in period,
the short time following the departure of the midwife until the mother resumes most
domestic duties5 (Ulrich, 1990, p. 192). The five post-delivery deaths noted in the
diary were most likely due to puerperal fever, caused, unwittingly, by Martha herself.
While childbirth can be fatal and pathological, the numbers indicate that historically
childbirth has been a safe life event.
Through the life of the diary, Martha only called a physician to a birth twice.
In the first year of her record, Martha arrived to a birth to find the mother greatly
injured by an inexperienced midwife6 (Ulrich, 1990, p. 180). Martha initially called a
4 The statistics support the arguments made by midwifery proponents in the 18th and 19th centuries,
that male physician attendance in itself was in no way inherently better or safer. It wouldnt be until
the development of certain bacteria fighting drugs and aseptic methods that midwifery could
reasonably be challenged as less safe than physician attended, and later hospitalized, childbirth. But
it must be noted that midwives who did formalize and continue their education employed many of the
newly discovered safety methods to the benefit of the healthy women they served.
5 Lying-in is a bit of a misnomer. There was very little relaxation or recovery time for a new
mother during the late 18th century. Barring significant financial resources, women without
complications were up and about well before their uterus had shrunk to near pre-pregnancy size, the
modem standard for hospital discharge (Ulrich, 1990, p. 189).
6 Martha served all who called upon her, not just for childbirth but all illness, injury and even help in
laying out the deceased. However, Martha frequently attended up to three laboring women in a
84


Dr. Colman, who was not known to attend deliveries, indicating that the problem was
of a non-childbirth related medical sort; however, Dr. Colman was unavailable and a
Dr. Williams arrived to treat the woman who apparently survived the ordeal (Ulrich,
1990, p. 180). Martha was clearly conscious of her own record of healthy births,
having worked into her diary tales of the difficult and tragic labors attended by other
midwives and physicians (Ulrich, 1990, p. 182). The second instance in which Martha
called a physician was for a woman with a prolonged labor that Martha determined to
be obstructed in some way (Ulrich, 1990, p. 181). She recorded that she was forced
to operate to remove the obstruction prior to the arrival of a Dr. Hubard. In the
margin of the diary, usually reserved for notations of payment, Martha noted that this
birth was the most perelous sien she had ever encountered (Ulrich, 1990, p. 181).
Despite being forced to operate without a physician, Martha was able to keep both
mother and infant alive. Marthas skills were often tested in attending breech births,
obstructed and prolonged labors, and fainting or excessively whining mothers, all of
which she handled without a physician (Ulrich, 1990, p. 181). Martha Ballard was
clearly a midwife of exceptional skill as evidenced by the demand for her services, her
ability to overcome and treat complications without reliance upon physicians, and her
low mortality rate.
Martha noted all of her interactions with the male physicians of Hallowell. In
doing so, she created a record of the subtle shift to male childbirth attendance in
America. Marthas references to two male physicians in particular illustrate the
change as it occurred in Hallowell.
Dr. Daniel Cony epitomized the Gentleman Doctor of the 18th century. Dr.
Cony was a well-respected founder of Hallowell, participating in philanthropic
twenty-four hour period. She would not leave the side of one laboring women to attend another until
all her duties were finished and she was relatively assured of a healthy baby and mother (Ulrich,
1990, p. 97). Therefore, Martha sometimes arrived to attend some women after they had labored for
a period and turned to someone less skilled for assistance.
85


endeavors as well as helping to establish all of the institutions necessary to create a
permanent community. Dr. Cony had lived in Hallowell for some time before Martha
and Ephraim Ballard arrived. His reputation as a physician was established, however
he appears to have looked upon medicine as a part-time, philanthropic responsibility
(Ulrich, 1990, p. 60). Dr. Cony was an elected statesmen, often gone to the capital,
and a land owner of proportion large enough to have sustained his family comfortably
without ever having to practice medicine for payment (Ulrich, 1990).
Martha displayed an uncritical understanding of the distinction between the
type of social healing she and other experienced midwives practiced and the
medicine professional doctors such as Dr. Cony practiced (Ulrich, 1990, p. 98). The
social healers, nearly all women, relied upon experiential learning and networks based
upon social relationships that extended before and after any type of treatment
(Ehrenreich & English, 1978). Social healers had no professional organizations and
were rarely known outside of a very small community or region (Ulrich, 1990, p. 62).
Professionals on the other hand participated in formalized education programs that
were completed quickly in comparison to experiential and apprenticeship based
learning. They met others that had nearly the same education and practices and
eventually form professional organizations to benefit themselves and research. As
Ehrenreich and English (1978) point out, The notion of medicine as a profession was
in some ways an advance over the unexamined tradition of female healing: A
profession requires systematic training, and, at least in principal, some formal
mechanism of accountability. But a profession is also defined by its exclusiveness and
has been since the professions of medicine and law first took form in Medieval
Europe (p. 34). Martha Ballard recognized that men using the title of Doctor
possessed a background very different than hers.
What Martha, and many others who began to prefer physicians over midwives
didnt realize is that, in the assessment of Kahn (1995) ...professionalization doesnt
86


mean competence, although it may mean that. What it does mean is the control of an
elite few over various aspects of the life process. In medicine it means the control of
upper class white men over all women, who are the greatest consumers and providers
of health care, and over men of less privilege (p. 301). The completion of
educational programs as a requirement to be called doctor was attractive to members
of the fashionable and status conscious middle and upper classes, regardless of the
actual quality of care.
While Martha showed deference to Dr. Cony, he shared a respect for her
knowledge and efforts. Through no arrangement other than custom Martha and the
other social healers of Hallowell left bonesetting, tooth-pulling, bloodletting and the
administration of strong drugs to the doctors (Ulrich, 1990, p. 60). However,
childbirth and the care of minor injuries and illnesses were areas Dr. Cony left to
Martha and her colleagues (Ulrich, 1990, p. 49). In Daniel Conys view, childbirth
was not necessarily a medical event. He only participated in the truly pathological
labors after being called by the midwife. This type of shared care arrangement is what
many in Colonial America wanted. However, the explosion in the number of new
physicians exiting medical school would make practicing medicine for profit difficult if
most women were to continue to seek midwives to attend their labors.
Dr. Cony also shared some of his non-childbirth practice with Martha. She
assisted him in caring for the dying, the seriously injured, and performing autopsies7
(Ulrich, 1990). While her attendance at these events with Dr. Cony was in a role
clearly subordinate to his, her mere presence was an indication of the importance
social healers played within the community as well as serving as a learning experience
y
Autopsies and human dissection were becoming more common as experimental, scientific medicine
gained popularity in Britain and Colonial America. The study of anatomy was the first course of
medical education and increasingly encouraged for midwives (Donegan, 1978; Donnison, 1977;
Rooks, 1997; Ulrich, 1990, p. 248-250). This learning opportunity would be lost to social healers and
midwives as autopsies and lab work moved into schools and hospitals exclusively.
87


for Martha (Ulrich, 1990, p. 54). Marthas duties when attending neighbors with Dr.
Cony resembled what would today be considered more like nursing. She assisted Dr.
Cony during treatment and surgery, cleaned up the messes of treatment, and
prepared the dead for burial (Ulrich, 1990).
Martha attended both Dr. Conys sister and sister-in-law for a number of their
births, indicating that she was in fact the preeminent attendant at the time, preferred
over the male physicians of Hallowell (Ulrich, 1990, p. 59). Martha attended two-
thirds of all births in Hallowell through 1800 (Ulrich, 1990, p. 179).
Martha was an important member of the community, recording contact with
more than half of all the
households in Hallowell during
1790 (Ulrich, 1990, p. 62, 93).
Her broad network of social
contact permitted access to
numerous power relations. She
could operate outside some of the
social discipline place on women:
She traveled alone to attend
births, worked closely with male
physicians to treat and diagnose
patients, made independent
arrangements with local store
keepers to procure herbs and
other medicines. She was
practicing unsupervised and
making independent treatment
decisions based solely on her
Home Labor
In order to attend her neighbors during
labor, Martha required assistance in running her own
home. In addition to her own daughters, Martha had
a steady flow of nieces and neighbors daughters living
with her. This arrangement was not only necessary
for Marthas practice as it kept her household
running, but it also provided the young women and
girls with a valuable education. Martha and Ephraim
survived on fanning. Without consistent attention to
the crops, animals and herb garden, the family would
have been in peril. The women of the family wove
their own fabric, sewed all the clothes and linens,
canned, salted and dried foodstuffs for the winter
months, and maintained the home. In addition to
helping keep the Ballard farm running smoothly, the
women living there learned domestic skills. These
skills would be their responsibility upon their own
marriages. Thee also learned the general medical
skills Martha imparted to them as they helped tend
her herbs and make salves, teas, ointments and
various other emulsions used in Marthas medical and
childbirth work. Marthas diary includes the
struggles of running her household alongside her
birth attendance records, further indicating how birth,
death and laundry all fit into a normal cycle of life.
(Ulrich, 1990).
88


experiential knowledge.
When Marthas attendance of laboring women did decline after the turn of the
century, it appears to have been due more to her failing health, the distant location of
the new farm she and Ephraim worked, the lack of younger women to assist in running
her household, and the growth of the population in numbers as well as geographically,
than to lack of demand for her services or a physician conspiracy. Martha was simply
getting too old, too frail, and lived too far away to serve a majority of the women of
Hallowell (Ulrich, 1990). Marthas personal situation combined with the death of
Hallowells other notable midwife, Ann Mosier, in early 1809, and Dr. Conys
frequent absences opened the door for a new type of physician who would base his
practice on delivering babies.
Dr. Benjamin Page arrived in Hallowell in 1791, all of 24 years old and fresh
out of medical school (Ulrich, 1990, p. 177). Unlike Daniel Cony, Ben Page sought to
make a good, permanent living solely as a physician. While he may have seen
medicine as a noble calling, he also set up his practice as a for-profit business (Ulrich,
1990). Dr. Page arrived in Hallowell at the perfect time to assume a portion of the
childbirth attendance duties for community. Martha, Ann Mosier and older midwives
were unable to attend all the pregnant women
and there were no younger women wishing to
become midwives. Faced with no assistance at
all, relying upon a male physician didnt seem
too bad an idea for many women.
As Ulrich (1990) has summarized, The
technological simplicity of early medicine
meant that male doctors offered little that
wasnt also available to female practitioners
(p. 54). In terms of maternal and infant
Valuable Service
Midwives were the best paid of all the
female healers and out-earned women
in other fields such as weaving or shop
keeping. Midwives were not paid
better than other healers just because
they attended births, which were
usually celebratory situations where
men paid well for the care of their
families, but because midwives
possessed more skills and a longer
memory and experience than most
other healers.
(Ulrich, 1990, p. 64, 199)
89


mortality midwives and doctors sought and generally achieved similar results
(Ulrich, 1990, p. 58). That being the case, it is interesting to analyze the reasons
behind the fact that in 1800 Martha Ballard earned approximately $2 for attending a
birth while Ben Page earned $6 per birth (Ulrich, 1990, p. 179). The difference in fees
certainly had nothing to do with the amount of time spent with laboring women.
Martha frequently stayed overnight if necessary whereas Dr. Page preferred to arrive
shortly before delivery. Dr. Page also could not claim any experience of giving birth
personally whereas Martha had given birth herself nine times (Ulrich, 1990, p. 12).
Assuming his medical school education was consistent with the era, Ben Page may
have witnessed one or two actual births during his schooling followed by a short
apprenticeship in general medical practice (Donegan, 1978; Donnison, 1977; Rooks,
1997). A history of safe births and experience were not in Dr. Pages favor, so what
could account for the difference in fees that many citizens of Hallo well were willing to
pay?
Ben Page benefitted greatly from the fact that there were very few childbirth
attendants, midwife or doctor, in Hallowell at his arrival. Many paid Dr. Page his
higher fees because no one else was available. Babies arrive on their own schedules
with no regard to parental preferences. Ben Page also did not own a farm on which he
could depend for survival and income. He had to set his fees high enough to support
himself. Hallowell grew quickly during the early years of his career, giving Dr. Page a
steady supply of new patients.
Even in Hallowell, Maine forceps and fashion played a role in establishing
doctors (Ulrich, 1990, p. 180). It is reasonable to assume Ben Page used forceps in
his practice. His mentor was Dr. Thomas Kittredge of Andover, Massachusetts who
possessed many of the texts promoting forceps use as well as the instrument itself
(Ulrich, 1990, p. 180). The use of instruments to aid in birth was included in
medical education in late 18ttl century America as it was throughout Europe.
90


Childbirth, especially with a first child or following a previous difficult labor, can be
frightening. Coupled with the fear of an obstructed, prolonged, or otherwise seriously
complicated labor, the availability of forceps or surgical removal of the fetus may have
been a comforting thought worth higher fees.
Ben Page was not the only young, urban, educated person to arrive in
Hallowell in the last decade of the 18th century. Part of the population growth in
Hallowell was a more urban, middle-class elite who was not only more accustomed
to male physicians, but possessed enough to finance new ventures or farms in
Hallowell. This new elite was sensitive to social standing, appearances, and reputation
(Ulrich, 1990, p. 178). Ben Pages age, bearing, education, completed apprenticeship,
and active pursuing of patients carried weight with many of the young up-and-coming
families of Hallowell (Ulrich, 1990, pg 179, 235). Building even a small childbirth
practice among the elite crowd could bring numerous referrals of new families as well
as begin a lifelong medical care relationship with the children he delivered.
The historical timing of Ben Pages career benefitted the young man probably
as much as any skills he could claim. Cultural attitudes limiting the role of women
combined with the professionalization of medicine, childbirth rightly or wrongly
included, to create an environment growing hostile to female education and practice
(Donegan, 1978; Donnison, 1977; Ulrich, 1990; Wertz & Wertz, 1977). As Ulrich
(1990) has stated, The late eighteenth century was not only an era of political
revolution but of medical, economic, and sexual transformation. Not surprisingly, it
was also a time when a new ideology of womanhood self-consciously connected
domestic virtue to the survival of the state (p. 27). Womans highest
accomplishment, as would be even more powerfully enforced in the Victorian
dominated 19th century, was in providing an arena of domestic tranquility for husband
and family and never jeopardizing her own virtue or family reputation (Ehrenreich &
English, 1978). Any woman straying from the compulsory domestic venue was
91


courting disaster as she was ill-equipped intellectually as well as physically to venture
beyond home. Women wishing to protect their virtue, and by extension support the
strength of the nation, had to choose and trust male physicians to attend them.
Medical men jumped on the mandatory female domesticity bandwagon.
Women were declared too delicate to survive a proper medical education and
therefore were unfit to practice any type of healing at all (Ehrenreich & English, 1978;
Ulrich, 1990, p. 254; Wertz & Wertz, 1977). Medical treatment for illness, health, and
birth attendance were all being confounded, the arts of healing and midwifery replaced
by scientific medical jargon and treatment. Organized, text based education was
gaining in cultural value forcing the experiential learning of traditional female
midwifery into the background8. An intensive period of text based education and a
clinical internship were determined to be the best method of becoming a doctor
(Ulrich, 1990). Women, whose domestic role could not be delayed, shifted to others,
or ignored as many men were able to do, were unable to find a position within the
increasingly restricted world of medicine (Ulrich, 1990; Wertz & Wertz, 1977). Ulrich
(1990) found that,
To allow women to continue to practice midwifery, or, by extension, any other
independent healing, deprived male doctors of the experience they needed and
at the same time perpetuated the notion that uneducated people could safely
care for the sick (p. 254).
Women were caught in a double bind that would thrive for over a century. They were
prohibited from higher education and higher education, according to male physicians
and eventually government bodies, was required to practice any sort of medicine
(Ulrich, 1990, p. 251).
Medicine during the late 18th century, as part of its continuing quest for respect
and exclusivity, ceased to be a part time endeavor of gentlemen such as Daniel Cony
Sadly, much of the common sense and homeopathic remedies of midwives were lost along with their
practices.
92