Sally Marchant
The Princess was composed after her delivery, and, though of course much exhausted, every hope was entertained of her doing well. A little after twelve a change was observed in Her Royal Highness. Her quiet left her - she was restless and uneasy, and the medical attendants felt alarmed. From half-past twelve restlessness and convulsions increased, till nature and life were quite exhausted, and Her Royal Highness expired at half-past two this morning. (Jones 1885)
Introduction
The history behind the role of midwives and their sphere of practice has already been comprehensively described in a number of publications (Schnorrenberg 1981; Donnison 1988; van Teijlingen 2004). These texts describe how the attendance of the midwife, particularly to a woman in labour, has often been undertaken within a framework of conflict, tension and disharmony by a whole range of key figures in society. These include representatives of the main religions as well as most male medical practitioners. The impact of these influences on the work of midwives was very mixed, with some midwives gaining considerable skills and knowledge from working with doctors (van Teijlingen 2004) while others had less formal training and, where they often used a range of traditional remedies, they were viewed with suspicion and, to some extent, disdain (Donnison 1988; Southern 1998). It was only comparatively recently, considering the longevity of the work of midwives in society, that there was a more objective recognition of their role leading to professional recognition and registration (Cowell & Wainwright 1981; Donnison 1988).
While there is quite extensive literature on the work of the midwife when attending women in labour, there is less detailed information about what was expected of the midwife with regard to the care of the mother and the new baby after the birth had taken place. This lack of information hampers the interested researcher trying to tease out the more specific role of the midwife in relation to post-birth care and overall maternal and infant health. However, based on the contemporary textbooks and other literature available, this chapter will explore the status of the midwife and the role given to post-partum care and how it has evolved over the centuries but mainly within the context of care provision in the United Kingdom at the time the Midwives Act was passed in 1902. The main focus for the text will be on the relationship of the health and well-being of the mother and the care provided to her after birth. This will be addressed in terms of management of care for the most serious aspects of ill health post-partum, rather than in relation to the entire range of possible post-partum health problems. Care of the newborn is not included in this chapter.
Historical references to midwifery and post-birth care
There is evidence that midwifery as a female occupation was recognised in ancient Egypt between the period 1900 and 1550 BC as it is included in some of the text identified from the Ebers papyrus Encyclopaedia Britannica (2008). In ancient Egypt, midwifery was a recognised female occupation as verified in another text, the Westcar papyrus, and it would appear that midwifery was a well-recognised aspect in this culture (Chamberlain 1981; Towler & Bramall 1986). Midwives are also evident in Greek and Roman times, although their professional status is not entirely clear (De Costa 2002). Some texts suggest that midwives could be quite well educated, to the extent that they were then seen as medical physicians (French 1986). They used a wide range of herbal and other remedies in their practice and received payment for their work. However, where families could not afford the fees of these more educated midwives they appear to have been attended by other unskilled women who used a more dubious range of practices (Flemming 2000). Some midwives may have originally been slaves but it would appear where they could receive some payment for their work, it is possible that they were then able to buy their freedom, thereby achieving a more respected status in Roman Society (Flemming 2000).
On the demise of the Roman Empire and the emergence of Christianity, the work of midwives came to the attention of the Church (De Costa 2002) There are similarities between several of the main religions with regard to events after childbirth for both the mother and the new infant. In particular, the period of recovery after the birth appears in most cultures and is linked to religious rituals, although the duration of this period varies. A wide range of customs and rituals have been adopted but many appear to be underpinned by concerns over the woman's spiritual integrity and the need for her to undertake some form of cleansing as well as a period of recovery after the birth (Kitzinger 2000; Cartwright Jones 2002).
Focusing on mainland Europe, the Catholic Church appears to have had concerns about the need to have control over a woman's fertility and her influence on men (Biggar 1972; Ehrenreich & English 1973; Derbyshire 1985). It was generally considered that the pains of labour were entirely justified since all women were descendents of Eve and that they should 'pay' the consequences of Eve having led Adam astray. The work of midwives was therefore regarded with some suspicion where they had access to women for a range of conditions linked to sex often in preference to care from physicians or male healers. Where they then used a range of herbal remedies to relieve the pain of labour, this, in effect, was going against the will of God (Southern 1998; van Teijlingen 2004). This was in an era when good and evil were strong paradigms used to explain the causes of disease and death by attributing the outcomes to either salvation by God or damnation by the Devil. In order to exert some control over these 'women's affairs' the Church became involved in deciding who was fit to be a midwife by introducing a form of licensing. This was undertaken by a bishop and the midwife was required to swear an oath not to use magic when assisting women through labour (Field 1993; Wiesner 2004).
The emergence of male midwives and of the involvement of doctors in midwifery, as opposed to obstetrics, is not discussed here as the care of the lying in woman and her infant was almost entirely the province of women, unless complications required the assistance of a medical practitioner, where this could be afforded (Schnorrenberg 1981; Donnison 1988).
Historical aspects of care and support post-birth and its relevance to current health provision
However far back history takes us with regard to care after childbirth, it would appear that the main reason for maternal death then, as it is today in many parts of the world, was infection and haemorrhage and the interrelationship between the two. The post-partum period or puerperium describes the time after the birth where recovery takes place in the major organs and the body systems return to their pre-pregnant state, apart from the hormonal cycle, where the influence of prolactin for breastfeeding affects the production of oestrogen and progesterone, reducing the woman's level of fertility. The time frame for these occurrences has traditionally been around 6 weeks, or 40 days and as such, as noted previously, also appears to have been incorporated into many religious and social frameworks for motherhood and care of the new mother and her child (Southern 1998). The process of birth, especially where the mother continued to have vaginal bleeding or fluid loss, was treated with great suspicion and anxiety. In many religions, the woman was considered unclean until the vaginal loss had ceased. This time frame was linked to the sex of the baby and would have an effect on the length of time the woman was excluded from social and religious events, until such time as she could be 'cleansed' (Southern 1998).
This also meant that in some social settings, men were discouraged or even forbidden from being in contact with their wives and newly delivered babies for several days or weeks after the birth. This in turn also fuelled suspicion around the activities of the women, the new mother, and those who attended her, where there was doubt over the viability of the child as well as the health of the mother (Cartwright Jones 2002).
It is not possible in this chapter to explore these issues in great detail, but it is important to note that many of the customs undertaken today that have their origins from many centuries ago remain significant to the members of those cultures.
Life and death - midwives as helpers of God or the Devil
Infection poses one of the greatest threats to women's health after the birth. References to 'childbed fever' have been found in old Hindu texts and in the writings of Hippocrates and these identify the extreme concern attached to this where there was such a high risk of death (De Costa 2002). There was also some understanding of the basic nature of infection and that this disease could be passed on to other women, although the mechanism and identification of bacteria was not recognised until many centuries later. There appears to be very scant literature regarding the work of midwives attending women at the birth or afterwards throughout the early times of Christianity and into the Middle Ages. This might reflect that many midwives would not have had access to writing materials, or been able to read or write, and even if they did write this down, it is not clear who would have read it. The impression from one of the earliest English texts is that the work of the midwife was one that was passed down and that the midwife was expected to rely on experience and possibly, trial and error (Fraser 1984).
The frequency of maternal death from infection 'childbed fever' and the lack of knowledge about what caused it may have contributed to an overtly polarised religious framework of the work of God versus the work of the Devil. This led to great suspicion of the activities of women and the work of midwifery and threatened the control that could be achieved by the established Church. Midwives fitted both aspects of a spectrum by being called 'wise women' undertaking the work of God by assisting the safe birth of new life, to being 'witches' involved in the work of the Devil (Ehrenreich & English 1973). As witches, midwives were also seen as being responsible for a wide range of social ills related to sex, conception and abortion as can be seen from a text listing the main 'crimes' of witches that underpins the great suspicion about the powers of which many midwives were then accused of:
Now there are, as it is said in the Papal Bull, seven methods by which they infect with witchcraft the venereal act and the conception of the womb: First, by inclining the minds of men to inordinate passion; second, by obstructing their generative force; third, by removing the members accommodated to that act; fourth, by changing men into beasts by their magic act; fifth, by destroying the generative force in women; sixth, by procuring abortion; seventh, by offering children to the devils, besides other animals and fruits of the earth with which they work much charm ... (Malleus Maleficarum in Kramer & Sprenger 1928)
Post-partum treatments and rituals in the Middle Ages
Where midwives used a range of herbs and plant extracts as healing agents, these were called witches brews despite their ability, in some cases, to heal rather than harm the women (Biggar 1972; Ehrenreich & English 1979). There was also use of incantations and talismans, all of which raised suspicion during this period of religious fervour where there was a need to find someone on earth to blame for the actions of God or of the Devil and where death was such a frequent visitor to so many households. From the fourteenth to the seventeenth century in the main cities of Europe, this suspicion led to many midwives being branded as witches and being put to death, although this was less common in England (van Teijlingen 2004; Wiesner 2004). Historical writers reflecting on this time suggest that it was incumbent upon the key figures of society, both religious leaders and medical men, to try to make sense of these events although the Church and medicine were at some conflict themselves (Ehrenreich & English 1973). Therefore, to some extent, midwives were the perfect solution to fill that need where they had almost sole access to childbearing women and where, of course, they were women.
Where the midwife was seen as the 'wise woman', she was usually a local woman of more mature years, was usually married and had given birth herself (Wiesner 2004). These women offered their skills in attending women in childbirth and often received no overt payment for this. Prior to the extreme suspicion and witch hunts of midwives, the established Catholic Church had already required midwives to be involved in law enforcement where this concerned conception, pregnancy and childbirth. Midwives were used as 'expert witnesses' for a number of situations, examples including confirming a pregnancy to mitigate the death penalty where a woman had committed a crime as well as to ascertain virginity or impotence in a prospective bride or husband or evidence of a pregnancy where abortion was suspected (Weisner 2004). The Church also involved midwives in post-birth rituals where it was the midwife who presented the infant for baptism at the christening and who was also part of the female group that gossips at the ceremonial churching of the post-partum mother. Churching was a ceremony undertaken to purify the woman's defilement of carrying the unconsecrated fetus and was performed around 6 weeks after the birth when the woman was also considered to be free from the pollution of uterine blood (Donnison 1988; Newell 2007). Baptism of the infant was an essential part of mediaeval Catholicism. If there was insufficient time to get a dying child baptised by a priest, it was considered appropriate that the midwife should do so to ensure that the infant would not be consigned to remain forever in purgatory (Wiesner 2004). The midwife would be instructed not only on the correct words to use, according to the religious laws at the time but also to ensure that no subversive or satanic incantations were used instead. If there was any suspicion of this, the midwife would be removed from practice. Various artefacts from the birth including the placenta, membranes and umbilical cord, were all considered to have mystical (benevolent and malevolent) as well as healing powers and the midwife was involved in either the protection of these or in their appropriate disposal. This again placed the midwife in a position apart from the medical men or church leaders of the time, fuelling the concern for being linked with the the work of the Devil.
From some contemporary notebooks, it can be seen that the midwives and physicians used a range of resources to ward against haemorrhage and sickness after the birth. In her detailed account of midwifery during this time, Jane Sharp gives detailed accounts of what action should be taken to assist the haemorrhaging woman (Hobby 1999). While it is of perhaps rather morbid interest to note what was used, these 'remedies' included a range of substances. For example, to reduce the risk of haemorrhage it was advised to use poultices and suppositories of hogs dung and ashes of toad, as well as laying a newly flayed sheep skin over the abdomen to assist in the delivery of the 'after burden' (Hobby 1999). Donnison (1988) in her seminal publication on midwifery history comments that Jane Sharp's adherence to such practices noted above were founded on superstition and poor knowledge, and were no longer in use by other contemporary midwives. However, the list of remedies recounted by Jane Sharp and the observations of physical disorder (uterine prolapse, oedema, infection) demonstrate how much concern and diligence was held about the services a midwife could offer to relieve women's pain and distress associated with pregnancy, childbirth and the puerperium (Hobby 1999). Therefore, in some instances, treatments are noted that are still in common use today - an example being fennel to ease gastric pain in the infant.
At the same time there were practices that clearly encouraged infection and poor health where, for example, there was great adherence to 'sealing up' the birthing room and where women remained in bed in what could be very overheated rooms for up to 9 days after the birth. Charms or talismans were given to the women in the form of necklets and girdles made of blue thread and worn by the new mother as they were thought to ward away sickness and ensure a good milk supply (Biggar 1972; Hobby 1999). The health of the infant was directly dependent on a healthy mother who could breastfeed; however, where this was not possible, there were alternatives and a range of substances were given to babies who were in need of supplementation (Hobby 1999). Alternatively, there were the services of a wet nurse that was available to some, not always on a payment basis, as women in the community would be likely to offer their services when this was needed (Tait 2003).
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Excerpted from Essential Midwifery Practice by Sheena Byrom Grace Edwards Debra Bick Copyright © 2009 by John Wiley & Sons, Ltd. Excerpted by permission.
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