The history of midwifery: a brief overview

Katerina Gardikas

In 1838 the Greek government, with only five years in office, decided to take stock of the sanitary conditions in the young kingdom and had state physicians conduct a “medico-statistical” survey, effectively an exploration of a country that was still unknown even to its own officials. Among other items, the survey listed the names of all medical personnel by department and community. If the survey is accurate, it showed a country of some 700,000 inhabitants being served by no more than sixty western-trained physicians, twice as many practical, or traditional, doctors and more than 700 midwives, that is four times as many midwives as doctors. Midwives were everywhere, even in the remotest districts and islands. 

The document makes these ladies collectively visible in the public sphere, which had previously been the exclusive domain of male doctors. It located both midwives and doctors in the country’s fragmented medical marketplace but also reflected the medicalising of midwifery by having midwives share an occupational space exclusively populated by men. The survey, moreover, coincided with a moment in their transition from the unregulated practice of traditional midwifery towards their submission to modern state control. My question is very elementary and I will answer it with further questions in concluding this paper: how do I study this transitional world? I thus became curious about how midwives have been treated in the recent western historical literature. 

In looking at the relationship between scientific and lay medicine in general recent scholarship has demonstrated that the practice of traditional male doctors drew at varying degrees from contemporary scientific medicine and often served a complementary role. The stereotype of the traditional doctor as a practitioner who resisted and rivaled western-trained physicians is not always borne out by the evidence. Quite often, traditional doctors, other than quacks, drew their knowledge from manuscripts and printed books -often handwritten copies or notes from printed books- that contained information and treatments that contemporary trained physicians considered valid. Conversely, trained physicians on missions in foreign lands collected information on local healers and medicines. In other words, traditional doctors contributed their expertise to unprivileged communities and social groups which had no other access to scientific medicine. Besides, before the age of nineteenth century hospital medicine, to use Nicholas Jewson’s terminology, there existed a continuum of knowledge which  doctors shared with their patients; this continuum was fractured by the rise of specialisation. Jewson is the author of the highly influential article “The Disappearance of the Sick-Man from Medical Cosmology, 1770 - 1870”. Several aspects, moreover, of the physical conditions and states of the human body still remained on the margin of the doctor’s purview, until their gradual medicalisation, most notably, childhood, old age and childbearing. Childbirth for one became a heavily contested ground which physicians claimed from midwives.

What does the recent literature tell us about the world of midwives? How did it evolve since antiquity? Did midwives share medical and philosophical questions about the origins of humanity?<note:Leigh Whaley, Women and the Practice of Medical Care in Early Modern Europe, 1400–1800 (Houndmills, Basingstoke, Hampshire ; New York: Palgrave Macmillan, 2011).> Recent literature on midwifery focuses on two broad themes, namely the place of midwives in society and gynaecological knowledge, and on their intersection, that is how knowledge affected their place in society.
Unlike most midwives, practical doctors were literate men and their lives and practices are better documented. In contrast, midwives practiced at the intersection between the private and the public sphere, one nonetheless that drew them to women’s life-and-death experience of giving birth.<note:Merry E. Wiesner, “The Midwives of South Germany and the Public/Private Dichotomy,” in The Art of Midwifery: Early Modern Midwives in Europe, ed. Hilary Marland, The Wellcome Institute Series in the History of Medicine (London ; New York: Routledge, 1993), 77–94.> This ambiguous meaning of pregnancy between the private and the public world is highlighted in art, specifically in a set of portraits from the Elizabethan and Jacobean age which belong to the genre of pregnancy portraits. They picture heavily pregnant ladies of the English aristocracy in the face of the dangers of childbearing.<note:Karen Hearn, “A Fatal Fertility? Elizabethan and Jacobean Pregnancy Portraits,” Costume: The Journal of the Costume Society 34 (2000): 39–43.>

In 1962, the history of midwifery was renewed when Thomas Forbes published an article titled “Midwifery and witchcraft”. Forbes stirred a debate by associating the witch-hunts that took place in Europe between the fifteenth and early seventeenth centuries and the high numbers of midwives among the victims on the one hand and, on the other, the key social position of women healers and midwives, in his own words “usually ignorant and incompetent  elderly women”<note:Thomas R Forbes, “Midwifery and Witchcraft,” in Journal of the History of Medicine and Allied Sciences (1962).>, in dealing with pain, pregnancy and childbirth. The literature generated by this debate focuses on the way the ability of these ladies to heal was linked with their ability to harm in parallel with their imputed association with the respective transcendental powers of good and, more importantly, evil.<note:Demos, 119, 43.> According to another author “it was their prominence as ‘cooks, healers and midwives’ that made women in general ‘vulnerable to the charge that they practiced harmful magic’.”<note:Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women Healers (New York City: Feminist Press at the City University of New York, 2010), 18–20 quotes Levack,  The Witch-Hunt in Early Modern Europe, 1995, 146, 127.>

Knowledge about the reproductive organs of the female body seems to have progressed after the thirteenth century for reasons that had very little to do with scientific inquiry and were closely connected to the social requirements of religious faith. In her Secrets of Women: Gender, Generation, and the Origins of Human Dissection, published in 2010, Katharine Park explains how such knowledge was extracted from embalming saintly women or from removing the fetus from deceased pregnant women by caesarian section in order to save the souls of unbaptised babies. In one of Park’s examples,  in 1308 the body of Chiara de Montefalco, a Franciscan nun, was embalmed by her sister nuns, who, apparently, knew how to dissect and eviscerate the corpse. The nuns also explored the innards of Chiara with the help of a physician who answered their queries in anatomy. Embalming was indeed a common Christian practice and formed part of the cult of relics. According to Katharine Park Renaissance scientific anatomy took off from such earlier explorations into the engendered human body. In terms, however, of physiology and development, it was believed that men and women contributed their semen to generate the fetus and that the fetus consisted of a fully formed human. Indeed, scientists faced the theological question as to when exactly the spirit or soul entered the human body. In a recent edited volume titled Blood, Sweat and Tears – The Changing Concepts of Physiology from Antiquity into Early Modern Europe Helen King points out the use of analogy as a research method in treating such issues in order to fill in what was unobservable.

Leonardo da Vinci’s anatomical drawings include several pictures of a fetus in the uterus and the placenta. These drawings, never published in his lifetime and therefore unknown to science, are now available online from the Royal Library at Windsor Castle.
Progress in anatomy helped in the education of midwives who continued to receive their training as apprentices to older midwives. Increasingly, however, they entered the world of literacy and read handbooks on midwifery produced after the sixteenth century, usually written by men. Sometimes effigies such as these seventeenth century ivory dolls from the Wellcome Collection contributed to their education. The dolls seem to have been also shown to pregnant ladies to take the mystery and the anxiety out of their condition. 

Perhaps the most astounding demonstration and reconstruction of pregnancy in 3D was used by the renowned French midwife Angélique du Coudray in her training tours all over France between 1760 and 1783. In her biographical study of this remarkable lady, Nina Gelbart traces Coudray’s career and places her work in the context of king Louis XV’s project for the country’s demographic revival. Under royal auspices over a period of twenty three years, the tireless du Coudray trained thousands of rural midwives, her audiences sometimes exceeding one hundred trainees. She produced a midwifery handbook but also her strange machine made of fabric and leather, which she used in order to demonstrate various phases and conditions of birthing. It consisted of a representation of the female reproductive parts and included embryos at various stages of development, twin embryos etc. Details from the only surviving copy of Coudray’s machine. Her contemporary, the Scottish obstetrician William Smellie, is also believed to have produced a similar machine but there is no surviving physical evidence.

Studies on the education and apprenticeship of midwives reveal that they became associated with licensing and state control. Some midwives like the notorious Roman Catholic London midwife, Elisabeth Cellier, tried to introduce formal midwifery schools controlled by women midwives in the mid seventeenth century, but was too much implicated in the political turmoil of Stuart London and never above suspicion for her politics.
The religious allegiance of midwives was a serious aspect of their profession, particularly in divided societies. As Merry Wiesner has shown in an article titled “The Midwives of South Germany and the Public/Private Dichotomy”, there existed several sources for this mistrust. Midwives entered people’s private homes, obtained the implicit trust of its women and were therefore feared for their propaganda powers. More importantly, however, they were responsible for performing emergency baptisms to save the soul of a newborn that was not expected to survive and could not be taken to church.
Placing midwives under state control became a step in the state-building process itself. For instance, according to Wiesner’s study, in fifteenth-century Germany “Midwives became sworn city officials” in 1417 in the case of  Nuremberg, in 1456 in Frankfurt, in 1480 in Munich, and in 1489 in the case of  Stuttgart” and received city licenses. The city, furthermore regulated and oversaw their practices.<note:Wiesner, “The Midwives of South Germany and the Public/Private Dichotomy,” 78.>  The nineteenth-century Greek instance cited in the beginning of this presentation falls into this state-building framework in the late eighteenth-century incarnation of a rational paternalistic state. The modern, consolidated state, to use Charles Tilly’s terminology, made use of such validated instruments of control.

In this vein, Gülhan Balsoy has analysed the policies of control put into effect by the nineteenth century Ottoman government in her study “Gender and the Politics of the Female Body: Midwifery, Abortion, and Pregnancy in Ottoman Society (1838–1890s)”.  The details and chronology of the modern Greek case indicate a parallel development along the same policy lines and highlight the importance of licensing and its association with education. The first act in Greek medical education occurred two full years before the foundation of the first university medical school; following the licensing law for midwives and doctors of December 1834, in May 1835 the Bavarian regents ruling Greece cut through the medico-political haggling and created a medical school that offered courses in surgery, pharmacology and obstetrics, the first immediate government priorities, free of charge to unqualified practitioners as well as a public laying-in clinic in Athens later in the year.

The role of midwives in the public sphere also satisfied the need to ensure social stability and public morality. This has been demonstrated by a number of authors. Midwives were called as court witnesses in paternity cases and were charged with reporting instances of premature births to the authorities. Conversely, however, their morality was often questioned for their ability to conceal sexual transgressions, to condone lustful behaviour in unmarried females, to present the illegitimate infants of their clients to foundling institutions,  and, worst of all, to perform abortions. Because their house calls were monitored, women in trouble would often visit midwives homes in secret.

A considerable proportion of studies treats the rivalry between female and male midwives and doctors, particularly in Britain and France, for a share of the medicalised market of pregnancies. As shown by two radical feminist writers, Barbara Ehrenreich and Deirdre English, Witches, Midwives, and Nurses: A History of Women Healers, as obstetricians such as William Smellie popularised the obstetrician’s forceps, they also promoted a technological barrier directed against the gentle and affective approach of the female midwife, who was derided as ignorant and reactionary. Midwives, in turn, responded to the challenge by deploring the dangers for the mother and fetus inherent in the use of such metal instruments. According to these authors, the opposition of male midwives and doctors entered a new phase in the era of medical specialisation, when state authorities placed midwives under medical control, obliged them to receive formal state training, thus depriving them of their autonomy and social status. 

The gradual medicalisation of midwifery in the West was a mixed blessing as shown by Ignaz Semmelweiss’s observations on the statistics of puerperal fever in mid-nineteenth-century hospital obstetrical wards in Vienna. These observations helped Semmelweiss clarify the source of the high maternal mortality and led to the introduction of antisepsis in 1847. In typical fashion, however, the medical establishment resented the implication of his findings, namely the sanitary superiority of midwives maternity ward, and rejected them outright.

The final blow to the status of midwives, as shown by Ehrenreich and English, was dealt by the reform in medical education in North America following the Flexner report of 1910. As a result of this reform, which affected all major teaching hospitals in the US and Canada, the practice of midwifery was banned and replaced by the service of specialised nurses within a predominantly male medical hierarchy. The radicalisation of midwives is therefore a byproduct of decades of persecution.

To conclude: Most of the available sources for the history of midwifery gain a view on the role and standing of midwives in the public sphere, their professional careers, conflicts, status and occasional radicalisation. They consist of legal documents, court records, city archives, treatises on midwifery. On first sight, this type of material provides very scant insight into the domestic, affective landscape of women, the world of confidence and the conditions of inequality that one may expect to be associated with risk, knowledge and power. 

I expect nonetheless that, once such research questions are posed, a close reading  through the cracks and possible incongruities in the sources may yield some relevant answers. My favourite such crack in our knowledge of early nineteenth-century Greek society is the emergence of some four Muslim ladies as midwives in the “medico-statistical” survey of 1838. My absolutely favourite puzzle though is the survival in an all Christian environment against all odds of Aise, an elderly Muslim midwife, a fifty year-old “Ottoman lady” according to the record, who practiced in the town of Filiatra, in an area that had experienced a brutal war of sectarian cleansing. Aise had other choices, which she didn’t take; unlike Aise, a considerable number of her former correligionist midwives chose the way of assimilation by converting and are identified as neophytes in the survey. Assimilated or not, what did these ladies do when they entered a Christian private home? How did their communities appreciate their work? Or was it a service? Or perhaps an authority or even an extraneous source of wisdom and comforting?



Bibliography
Ehrenreich, Barbara, and Deirdre English. Witches, Midwives, and Nurses: A History of Women Healers. New York City: Feminist Press at the City University of New York, 2010.
Forbes, Thomas R. “Midwifery and Witchcraft.” Journal of the History of Medicine and Allied Sciences, 1962.
Hearn, Karen. “A Fatal Fertility? Elizabethan and Jacobean Pregnancy Portraits.” Costume: The Journal of the Costume Society 34 (2000): 39–43.
Park, Katharine. Secrets of Women: Gender, Generation, and the Origins of Human Dissection. New York: Zone Books ; Cambridge, Mass.: Distributed by the MIT Press, 2006.
Wiesner, Merry E. “The Midwives of South Germany and the Public/Private Dichotomy.” In The Art of Midwifery: Early Modern Midwives in Europe, edited by Hilary Marland. The Wellcome Institute Series in the History of Medicine, 77–94. London ; New York: Routledge, 1993.