‘There was Mrs A. Now she was one of those kinds of people that everyone would run to, was Mrs A. There were two or three layers-out in the town too. And then there was Nellie M. – she was a handywoman. And she would often say, “We nurses” if she saw us. I don’t know if she used to deliver babies but she went round with the doctors – you know, she might have delivered them, certainly in the days before we came she might well have done. And she would recommend treatment to people and that sort of thing, our Nellie. She was a handywoman, but she thought of herself as a nurse – [laughs] “We nurses …!”’
Nellie M.’s wish to be called ‘Nurse’ is indicative of the status and power that came with the new title. However, it was not only among practitioners that this was felt. The title ‘midwife’ came to be used in a derogatory fashion as the denigration of the handywoman’s role permeated through to the people they had traditionally attended. Mollie T., a retired midwifery tutor who comes from a rather privileged background, explains:
‘People would refer to the “odd-job” lady who used to come in and help around the place, as ‘‘the midwife”, and the official midwives were known as ‘‘Nurses”. If their patients said, ‘‘Oh, the nurse has been” they meant the midwife. I was always introduced as a nurse and I still find my friends prefer to introduce me in this way. You ask why? I think some of it must go back to Sairey Gamp, the Dickens character – the belief that midwives were dirty, illiterate and drunk – it’s very difficult to get rid of that.’
It is interesting that nowadays midwives are anxious to make it clear that midwifery is not a branch of nursing. They are often insistent on reclaiming the title ‘midwife’ – ‘No, I’m not a nurse, I’m a midwife.’ The various connotations associated with the titles that midwives choose serve as a reminder of the speed with which midwifery politics have been shifting during previous decades.
The handywoman was derided as the arch-enemy of midwifery throughout the late 1920s and 1930s, and articles in Nursing Notes demonstrate the fervour of the campaign:
‘The clause in the Act [Third Midwives Act, 1926] concerning the unqualified person, or handywoman, is only just beginning to be felt, and though it was not as strong as we wished, there is evidence that it can be an efficient weapon against the depredations of our foe ‘‘the handylady” [our emphasis].’11
A retired midwife who wrote to us described coming across a handywoman who was still attempting to circumvent the law as late as 1945:
‘In 1945, I was a pupil midwife doing three months district training in a very poor area of Bristol. On two occasions a handywoman delivered my patients and then sent for Sister and me. Her story was that she happened to look in and the woman was too far on for her to do anything except deliver the baby. On both occasions, the baby had been separated and the placenta expelled.
‘Sister had met this good lady before, and decided to put an end to her “help”. She arranged to take her to the M.O.H. [Ministry of Health] so that she herself might notify the birth. I think this frightened her enough to stop any further incidents.’12
One of the major concerns about the handywoman was that, since she laid out the dead, there was a potentially high risk of her transmitting infection to childbearing women. Ruth Richardson, in her work on handywomen and the laying out of bodies, suggests that throughout the ages, women handed down their skills to their daughters and female relatives.13 These skills incorporated rituals around hand-washing, so the potential dangers of passing infections from corpses to labouring or post-natal women were unwittingly avoided long before sepsis and the transmission of infection were understood. When men became involved in childbirth there was no such tradition of hand washing, and the soaring rate of deaths due to puerperal sepsis has been well documented.
Early rules of the Central Midwives Board forbade midwives to lay out bodies as a means of trying to prevent the spread of infection, as retired midwifery tutor Mollie T. remembers:
‘This thing about laying out bodies was very much in the minds of people in those days. I remember being very aware of the regulations when a neighbour came over to my home and said, “Mum didn’t look so well and could I come over?” Well, Mum was sitting beside the bed and she’d been dead for some considerable time. I explained to them that she was dead – though I didn’t say “for some time” and could they get the doctor. So they went out to ‘phone and came back and said that the doctor had said that if she was dead, there was no point in coming. But this was quite common. I don’t think that in the late 1940s many doctors thought there were variations to dying: you were either dead or not. So I retreated, but they came back very shamefaced and said they’d tried to get the woman who did the laying out, but she had ‘flu, so would I do it. As I was then working as a general nurse, I went over and did it, but I remember thinking that if this had happened six months earlier when I was working as a midwife, I would have had to have refused because of the CMB regulations that a midwife does not lay out a body except in connection with her practice.
‘You still hear it being said that midwives in uniform should not mix with nurses. In the days when I was doing nurse training, a sort of caste-system developed in the hospital dining room, where the midwives had to sit at a separate table. This encouraged the belief that they weren’t to be trifled with – and they were quite a savage lot – I wouldn’t have trifled with them at all!
‘But you can understand why there was this ruling. So many women and babies did die from infection in those days …’
Maternal mortality
By the 1930s, only a few handywomen continued to flout the law by practising midwifery, and the number of bona fide midwives decreased steadily. (The last bona fide left the Roll in 1947.) In spite of these developments – and in spite of the advent of antenatal care and the increase in hospital births – the maternal mortality rate rose. From 1924 to 1936, it remained at over five per thousand births.
Few women died at home as a result of childbirth with midwifery care, and as most of the midwives we interviewed worked on the district, their experience of maternal death was limited. In her midwifery textbook, Alice Gregory describes with anguish the devastating effects of a mother dying in childbirth:
‘I have twice seen the desolation of a working man’s home when the mother is suddenly taken from her young children, and I never want to see it again. She went up to her room in apparently good health perhaps twelve hours before, and she will never come down again until her body is carried to the grave. The little children stand about crying because no one is attending to all their many needs. The father makes an effort with his clumsy hands and abandons it with a gesture of listless despair. A kindly friend probably volunteers to attend to the tiniest of all, but finding that it causes the inevitable gossip among the neighbours, she soon alters her mind, and within a very few months the unhappy man, still aching for the loss of his wife, is forced to put another woman in her place from sheer inability to carry on in any other way. There are few things so absolutely worth doing as the preservation of the life of working mothers – few professions that so satisfy the paramount need of our souls to be of some use to somebody.’14
Mary W. only saw one mother die in the 37 years that she was a district midwife in Yorkshire, but she still remembers the fear of infection that existed in hospitals in an age before antibiotics were available when over one third of maternal deaths were due to puerperal fever:
‘Yes, the maternal mortality rate was high in the 1930s because they had puerperal fever. That was our biggest dread – infection. I once saw a septic Caesar while I was in Leeds, which was terrible because at Leeds they wouldn’t do a Caesarean section if they’d even had one vaginal examination – they were so terrified of infection. Yes, infection was our biggest problem.’
Some midwives remembered situations where women were sent home to have their babies, when hospitals had to be closed down for ‘drastic disinfection’ following deaths from puerperal fever.
In 19
24, the first Government Report on Maternal Mortality was published. This and subsequent reports on maternal mortality, highlighted the fact that a large percentage of deaths were avoidable. Over the next decade, the issue of maternal mortality was the focus of much controversy and concern, particularly as it appeared that as many middle-class as working-class women were dying. For example, in 1934, deaths from puerperal fever were three times higher in London’s Hampstead, where many women could afford to be attended by doctors or have their babies in hospital, than they were in poverty-stricken Bermondsey, where women were attended by midwives at home.15
At a meeting held to debate maternal mortality at Central Hall, Westminster, on 28 February 1928, it was pointed out that of all the ‘dangerous occupations’ in the country, including mining and seafaring, motherhood was the most dangerous.16 The deaths of 3,000 women each year in England and Wales as a result of childbirth were described as ‘a stubborn problem’. It was also noted that thousands of mothers were unnecessarily damaged or invalided every year as a result of childbirth, and that the death rate did not reveal the incalculable loss resulting from unreported and untreated injury and ill-health arising from pregnancy. We have summarised some of the points made at that meeting by invited speakers – midwives, doctors, members of parliament, dignitaries and social reformers – as they offer interesting insights into the midwifery politics of the day:
• There is an urgent need to employ more midwives since the midwife more often secures physiological [normal] labour because she is prepared to wait.
• Doctors are ‘an expensive social instrument’ owing to their long training. It is quite impossible for the doctor to spare the time from his other patients to wait on nature, yet the securing of labour is the basic principle in preventative medicine.
• Maternal morbidity is lowest in those countries with a well-trained corps of midwives, e.g. Holland, Italy and Scandinavian countries. It is highest in the USA, where the services of midwives are not generally or systematically used by the citizens.
• The best trained women do not practise as midwives because though the work is responsible and exacting, the economic return is poor. The future prospects are bad, as 15 years is as long as even the strongest can stand the wear and tear of practice.
• The mothers prefer to be attended by a doctor because such attendance makes possible the use of anaesthesia and the rapid termination of the labour, but for all artificial interference a price has to be paid. The risk in the individual case might be trifling but spread over the country it means a serious increase in the mortality and morbidity rates …
• There is an urgent need for midwives to get more and regular teaching post qualification.
• There is a need to develop National Health Insurance, to develop the work of local authorities in regard to maternity and child welfare and to improve the general social environment. Expectant mothers should enjoy opportunities of healthy living, healthy homes, and a healthy environment.
• There is a need for more preventative work.
• Although Approved Societies are active in seeing that no person receives a benefit to which he or she is not entitled, there is no provision for seeing that all those entitled to benefit receive it … With regard to Maternity there is, of course, the Cash Benefit payable to the insured woman and to the wife of the insured man, but this is swallowed up in payments to the doctor or midwife … unless a woman is herself insured, she will have no treatment during pregnancy.
• The Queen Victoria’s Jubilee Nurses who work exclusively in the poorest districts have only half the number of maternal deaths that are recorded on an average for England and Wales.
• Research into the causes of maternal mortality should take into consideration the whole circumstances and surrounds of the woman, not only the circumstances of confinement. Maternal mortality and morbidity largely depend on the circumstances of early life and the overall health of the family.
• The Medical Officer of Health can call a midwife before him, and if she has failed in any point he can report her to the Midwives Board. Why can we not do the same with our doctors when they fail?
• There is a need to bring maternity work within the reach of country mothers, including those in very scattered country districts. The first requisite is a good district-nurse-midwife, but the distances they have to cover are far too great and they should be provided with small cars to avoid the waste of strength in bicycling. Motor bicycles are unsuitable as nurses cannot arrive at their case clean and dry.
• Only doctors specially qualified should do antenatal care and no separate payment should be made to doctors for antenatal care under the National Insurance Scheme.
• The Midwives Institute considers that the mother’s home is the safe place for normal births – antenatal supervision would sift out the abnormal – and if the local authority would spend more money on improving housing rather than building maternity hospitals the maternal mortality would drop.
Although today the maternal mortality rate in the UK is less than 0.1 per thousand births, most of the above arguments are as familiar to those involved in the debates surrounding childbirth in the twenty-first century as they were to the speakers in 1928. However, unlike contemporary government reports, which advocate a woman-centred approach to childbirth, the most important message to come from the Maternal Mortality Committee Reports of the late 1920s and early 1930s was that the main fault lay with the mothers themselves. Despite evidence showing that 80 per cent of maternal deaths were due to conditions not detectable antenatally – sepsis, haemorrhage and shock – and even though the introduction of antenatal care had proved to be largely ineffective, women were blamed for not making use of what was heralded as the new innovation in preventing maternal deaths:
‘There is still a large section of the population that does not realise the advantages of obtaining competent prenatal advice … The patient herself is often her own worst enemy, whether from ignorance or apathy, ill health or prejudice. Until she is able and willing to co-operate, doctors’ and nurses’ attempts to assist her can never be fully effective.’17
The high maternal mortality rates were a major incentive to the government to pass legislation to integrate midwives in private practice within the growing system of public maternity services. The motivation behind the 1936 Midwives Act (see Chapter 3) was described in Nursing Notes as: ‘an all round tightening up as well as strengthening of each link in the chain of obstetric supervision’.18
During the Second World War changes that contributed to a dramatic decline in maternal deaths were introduced in health care, social services, housing, sanitation and welfare benefits. The government brought in measures to share available food resources throughout the population, control prices and equalise incomes (see Chapter 8). Advances in drugs to counteract infection and control haemorrhage, efficient flying squads (obstetric units that would come from the hospital in an emergency) and blood transfusion services also led to a dramatic decrease in maternal mortality by the end of the war. By 1943 the death rate had fallen to 2.3 per thousand registered births, which was just over half that of the rate in 1935.
The development of a profession
From the First Midwives Act in 1902 to the setting up of the National Health Service in 1948, a succession of developments enforced by statute ensured that eventually the original aim of the Midwives Institute was fulfilled – all women in Britain were entitled to the services of a well-trained corps of midwives (see Appendix 1 – Milestones in Midwifery).
Whatever we may think about the attitudes and class-ridden tactics of midwifery reformers such as Alice Gregory, who worked to oust the handywomen, there can be no doubt that their actions shaped the foundations of today’s profession. Their tireless campaigning and their manoeuvring within the powerful position accorded to them by society ensured that midwifery developed as a profession with autonomous practitioner status within a carefully planned legal framework.
It is worth noting than in the various ‘colonies’ such as the USA, Canada, Australia and New Zealand, where there was often no such opportunity for the campaigners to bend the ear of the ‘boys at the top’ or to fight the rising tide of capitalist enterprise on the part of doctors, the role of the midwife fast became relegated to the hand-maiden status of the obstetric nurse. In such countries, midwives have had to fight to build or re-build a midwifery profession with a similar potential and status as that of the British system.
From our interviews with midwives who worked in Britain in pre-NHS days, it was obvious that they remembered the 1936 Midwives Act as the most significant influence in terms of changes to their working lives, particularly as it implemented a national, salaried midwifery service (see Chapter 3). However, the women who gave birth at that time tended to describe the setting up of the NHS in 1948 as a turning point in their lives. They described the relief they felt in gaining access to a series of ‘free’ services, all of which made an enormous impact on the quality of their lives.
The underlying principle of the NHS was that the best of existing health care should be available to every section of the community. It was to be free at the point of service and financed by NHS contributions from those in employment, local rates and central government. While inequalities in health have persisted, there is no doubt that the 1948 Act brought immense relief to many people who were struggling with the consequences of poverty. In the words of Mollie T., who worked as both a nurse and a midwife in the 1940s:
‘The Health Service had to come in. People were so poor that they were unable to pay for their care. General patients were coming in too sick for remedial care so it was mostly terminal care, and women weren’t getting the care or the benefits that they needed in pregnancy. But it’s taken something away that we haven’t yet got back.’
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