Posted in History of Medicine, Mrs Beeton, TV Programme

Call The Midwife – An Historical Perspective

The hit tv series, Call The Midwife, is a real gem in the BBC’s Sunday night viewing schedule and its popularity is supported by viewing figures topping nearly nine million. I am not at all surprised that a second series has just been commissioned.  The series finale is on Sunday 19th February, BBC 1 at 8.30pm. Based on the books by Jennifer Worth (formerly Lee) about her own real life experiences as a newly qualified midwife in London’s East End during the 1950s.  I am currently reading Call The Midwife and will then move on to In The Midst of Life.  There are two further books, Shadows of the Workhouse and Farewell to the East End.  These books are well-written, fascinating, at times heartbreaking and a must-read for anyone with an interest in the history of medicine.  Worth decided to write down her memoirs after reading an article ‘Impressions of a Midwife in Literature’ that appeared in the January edition of Midwives Journal, 1998. The article struck a chord with her, why were, as Coates concluded, midwives virtually non-existent in literature? Worth immediately decided to rectify this and thus her wonderful books and the subsequent television series was born.

The history of midwifery is a complex subject and when conducting research for this article, I discovered that there is definitely a shortage of academic books on this highly skilled branch of nursing.  I have listed a few at the end of this article which you may be able to source through your library or view at a specialist medical library.

During the 17th century, City of London midwives had to serve a seven-year apprenticeship before delivering a baby on their own.  Historically, midwives have had a strained relationship with physicians, who would often viewed their practices with suspicion.   Debates surrounding the creation of strict guidelines for the practice of midwifery are often found in contemporary newspapers and medical journals.  In a number of the examples that I found, it struck me just how vulnerable the midwife was at the hands of the law if a delivery went tragically wrong or simply that the midwife was poorly trained in the first place.

In one such example, from an 1845 edition of Provincial Medical and Surgical Journal, a thirty-five year old carpenter’s wife had died soon after giving birth and an inquest was launched into the circumstances surrounding her death.  Her medical history indicated that in two previous pregnancies she had suffered from retention of the after-birth and in her current pregnancy the scenario had occurred once more.  She was attended by a legally qualified practitioner who was an admitted licentiate of the Apothecaries’ Company since 1822.  This was a home birth that took place in a tiny rural English village. Following the woman’s death, the body was examined and found to be missing the entire uterus together with several feet of the large intestine, both of which had been forcibly extracted.  A verdict of manslaughter was put forward by the coroner and the midwife practitioner committed for trial at the next assizes.  This case had highlighted, once again, the need for a regulatory body to be established for all practitioners engaged in midwifery procedures.  A Petition was subsequently put forward to parliament.  The Petition read:

‘That your Petitioners, in the pursuit of their professional duties, have frequently witnessed and deplored the evil consequences ensuing from the indiscriminate practice of Midwifery, not only to themselves, but to society in general, for the want of some adequate legal protection or recognised body to test the competency and qualifications of those who practice in that peculiar department of the medical profession, the existing medical candidates for their diploma as to their obstetric knowledge; and your Petitioners are of opinion that the practice of Midwifery has not hitherto received that degree of attention from the Legislature, or protection from the Government, which is commensurate with its importance.’

In the UK today practicing midwives are governed by strict legislation and guidelines set-out by The Nursing and Midwifery Council which was established in 2002.

Historically, a majority of working class women gave birth at home, if this wasn’t possible then they would be admitted to a ‘Lying-in’ hospital.  The reason for this was often social rather than medical and the most common type of lying-in hospital would have been found in the work-house.  St. Thomas’ Hospital in London had lying-in wards during the fifteenth century and was set-up by a charitable donation by Richard Whittington for unmarried mothers. However, during the eighteenth and nineteenth centuries the number of non-workhouse lying-in hospitals in London was on the increase:

  • General Lying-In Hospital, York Road, Lambeth.  Originally, opened in 1767 as the Westminster New Lying-In Hospital in Westminster Bridge Road, Lambeth.  Single mothers as well as married women were admitted.  In 1818 it changed its name to the General Lying-In Hospital and moved to York Road, Lambeth in 1828.  The Hospital closed in 1971 but this fine-looking building still exists today.  Florence Nightingale took a particular interest in the Hospital’s midwifery training programme;
  • Queen Charlotte’s Hospital, Goldhawk Road.  The Hospital opened in 1809, moved to Marylebone Road in 1813 and Goldhawk Road in 1940.  The Hospital admitted both single and married women;
  • City of London Lying-In Hospital, City Road, Finsbury.  Opened in 1750.  The building was badly bombed in 1940-1. Eventually the Hospital was moved to Hanley Road, Islington and closed in 1983;
  • British Lying-In Hospital, Endell Street, Holburn.  Opened in 1749 and closed in 1913.  Only married women were admitted;
  • New General Lying-in Hospital, Oxford Road, near Hanover Square.  Opened in 1767 under the name Queen’s Hospital.  It moved to Store Street near Tottenham Court Road, where patients did include single women.  The Hospital closed in 1800.

These hospitals were predominantly intended for the “wives of poor industrious tradesmen or distressed House-keepers and the wives of soldiers and sailors”.  London teaching hospitals did not admit women for childbirth before the late nineteenth century.  Medical students and staff sometimes delivered women in their own homes.

19th century midwifery instruments. Bottom right a 1850 copy of the Midwife’s Vade Mecum by Aristotle.

In the 18th century, male surgeons would often intervene in the delivery process and a new group of medical men emerged, men-midwives or ‘accoucheurs’. Developments in obstetrical instrument design helped to improve the chances of a successful labour, particularly for those women whose babies lay in different positions in the birth canal.  Pain relief options for women were limited and included, opium, brandy and after 1847, chloroform. The pioneer of the use of chloroform in childbirth was Sir James Simpson.  Ergotamine was also given to women to stem the flow of blood.

Florence Nightingale (1820-1910) is an important figure in the history of midwifery and pressed for midwifery as a career for educated women.  She established a training school for midwives in King’s College Hospital at the end of 1861.  A fully-equipped maternity ward was set-up at the Hospital and the physician accoucheurs agreed to give six months’ training to the midwives.  The midwives were trained to work in hospitals and also to deliver women in their own homes.  The tuition was provided for free but the students had to pay for their own board and lodging.  However, after just 2 years the scheme suffered a devastating blow – an outbreak of Puerperal Sepsis in the lying-in wards, following the delivery of a woman suffering from Erysipelas.   This event forced the training programme to be shut down.  Florence Nightingale was devastated and she immediately launched an investigation into the incident, writing to numerous physicians to seek opinion and advice.  She wanted to establish a set of reliable statistics of mortality in childbirth for women who gave birth in the lying-in wards.  She soon discovered that this information would be extremely difficult to come by.  The medical profession viewed her ‘interference’ with suspicion and many would not co-operate with her repeated requests for data.  However, Florence was not of the disposition to give-up easily and eventually, with the help of Dr John Sutherland (of the Sanitary Commission), was able to publish a slim volume of her findings in 1871, titled, Introductory Notes on Lying-in Institutions.  She calculated that the death rate for women giving birth in the lying-in institutions was 33.3 per thousand and the rate for home births was 5.1 per thousand.  The conclusion was drawn that death in institutions was due to the prevalence of Puerperal fever, an infection caused by insanitary conditions.  Florence advocated smaller hospitals, individual rooms for delivery, scrupulous cleanliness, shorter stays in hospital and banning medical students from attending births immediately after visiting the dissection room, which was common practice at the time.  She believed that in taking these measures the huge morbidity figures could be drastically reduced.

Puerperal Sepsis, or childbed fever as it is often referred to, has claimed the lives of many women over the centuries, including a number of famous individuals such as Henry VIII’s wives Jane Seymour and Katherine Parr, Mrs Isabella Beeton and Mary Shelley’s mother Mary Wollstonecraft.  The disease is a iatrogenic disease, caused by doctors and remained a common cause of death in childbirth until the early part of the 20th century. Infectious organisms on the hands of the birth attendants are transferred to the woman’s uterus.  The most common organism is  Streptococcus, the virulent beta-haemolytic (group A).  The disease usually begins on the third day after delivery.  Typical symptoms include: high temperature; severe headache; raised pulse; severe abdominal pain; vomiting and diarrhoea.  Death occurs when the infection spreads, resulting in peritonitis and septicaemia.

Obstetric forceps first appeared in the 17th century and many of the instruments were named after the obstetrician who invented them.  In each set of delivery instruments there would be two or three forceps, often with ebony or ivory handles, perforators, cranioclasts and decapitation hooks.  When there was no safe way of delivering a live baby, the delivery was obstructed and the mother’s life hung in the balance, gruesome measures were resorted to.  The perforators were used to open the baby’s skull, then the cranioclasts were brought in to crush it and finally the hooks were employed to remove the deceased infant in parts. The vectis, half a forcep, was a popular delivery instrument during the nineteenth century.  The vectis was used to manoeuvre the foetus into the normal position for child-birth.  Technically it converted the impassable brow or shoulder positions to the normal vertex (top of the head) presentation.  On the left of the image below you can see the spoon-shaped vectis with its wooden handle, metal shaft and elliptical hole in the scoop.

19th obstetric instruments. Vectis forceps shown on the left. The Old Operating Theatre Museum, London.

Caesarean Section is now a much practiced form of delivery in the UK, with nearly 163,000 procedures performed in 2010-11. Caesarean delivery dates back to ancient times with Egyptian and Roman law sanctioning its use after the mother’s death in order to allow the infant a chance to survive. In medieval Christian times it was believed by some that those infants that survived such a procedure were in possession of great strength and special powers.  Although many medieval Christians also viewed this practice with suspicion and as an ‘unnatural’ birth.  In the Renaissance, midwives were brought in to perform post-mortem caesareans. The first successful caesarean on a live woman took place in 1500. In the eighteenth and nineteenth centuries there were even reports of women performing the operation upon themselves.  A midwife called Mary Donelly was the first to perform a successful caesarean operation in Ireland in 1738.  Although popular, the caesarean remained a rare procedure until the late nineteenth century.  Eduardo Porro (1842-1902) was an Italian obstetrician who pioneered a technique to minimize haemorrhage and sepsis risks in caesarean operations by removing the mother’s uterus at the same time. During the 1950s, when Jennifer Worth was practising as a midwife, the caesarean section rate was 3%.  Today the rate is approximately 25%.

Nipple shield and baby’s feeding bottle on display at The Old Operating Theatre Museum, London.

In 1928, Sister Mary Laetitia Flieger, R.N. published a report in The American Journal of Nursing on current midwifery practices in the UK.  She reports that pregnant women were instructed to take care of their breasts by washing them with hot and cold water, morning and evening, then rub the nipples with a rough towel.  In the last month women were told to clean the nipples with soap and water using a soft nail brush.  Sister Flieger reported that diet was taken seriously by the British midwives, who suggested that no red meat should be allowed during the last month and only a little chicken and rabbit, together with plenty of fish should be consumed.  Once labour had commenced, unless it was to be a breech delivery, a forceful enema would be given.  She also mentioned that The Central Midwives’ Board (the then governing body for UK midwives) recommended that the number of intimate examinations given to the women should be limited in order to avoid the dangers of sepsis.  It is interesting to note that by the 1920s the practice of infection prevention is taken seriously. Thanks must go to the hard work and research that Florence Nightingale conducted nearly seventy years previously.  Flieger also reported on the delivery style in the UK for a non-breech delivery.  The woman should lie on her left side and an assistant raise the woman’s leg to affect delivery.  If there is a pendulous abdomen, breech delivery or forceps delivery then the women is delivered on her back.  During the puerperium (lying-in period) the woman’s perineum is swabbed about five times a day with a weak solution of iodine or lysol under thoroughly aseptic conditions.  She also gives UK childbirth mortality rates for the mother in 1928 as being approximately 3,000 deaths in relation to 800,000 babies being born.

  • If you want to find out more about the BBC One series, Call The Midwife, click here;
  • The Florence Nightingale Museum, in the grounds of St. Thomas’ Hospital London. For more information click here;
  • If you want to visit The Old Operating Theatre Museum and Herb Garret, London, which I strongly urge you do if you are interested in the history of medicine, then Click here for further information.  I only feature museums on my blog which I believe are exceptional in terms of visitor experience.   This Museum is one of those and ranks in my top five.  I took a friend with me who is a nurse and we simply didn’t notice the time fly by as the exhibits are so engrossing and the staff, particularly the Curator, are helpful and friendly.  The museum is very small and can only accommodate a limited number of visitors at any one time.  You may find that you have to wait at the foot of the stairs before you are escorted up to the Museum, which to be honest actually adds to the whole experience.  It might be an idea to phone on the morning of your visit to check when would be the best time to arrive that day.  On the day we visited, we had to wait a while before going in as there was a large group of medical students booked in.  Also on that morning Channel 4’s Time Team had been filming there.  Please do persevere, you will be very glad that you did.

Suggestions for further reading

  • Ehrenreich, Barbara and English, Deirdre (2010), Witches, Midwives and Nurses: A History of Women Healers, Feminist Press at the City University New York;
  • Pam Lieske (2007) (12 Volumes), Eighteenth- Century British Midwifery, Pickering and Chatto;
  • Mangham, Andrew (2011), The Female Body in Medicine and Literature, Liverpool University Press;
  • Reid, Lindsay (2011), Midwifery in Scotland: A History, Scottish History Press;
  • Rutherdale, Myra (2010), Caregiving on the Periphery: Historical Perspectives on Nursing and Midwifery in Canada, McGill-Queen’s University Press;