The Midwife in England
For evidence of the actual value of the Midwives Act, I turned when in England to the midwife herself in her work over the individual patient. Wishing to study the…
From: 1902 C.E. To: 1913 C.E.
Location: England, United Kingdom
Note: This article has been excerpted from a larger work in the public domain and shared here due to its historical value. It may contain outdated ideas and language that do not reflect TOTA’s opinions and beliefs.
“The Midwife in England” from The Midwife in England, Being a Study in England of the Working of the English Midwives Act of 1902 by Carolyn Conant Van Blarcom, 1913.
For evidence of the actual value of the Midwives Act, I turned when in England to the midwife herself in her work over the individual patient. Wishing to study the most favorable interpretation of the law I very naturally inspected the work of midwives in those parts of England where the Act is being best administered.
It must be borne in mind that although the Act applies to all of England and Wales, sufficient time has not elapsed since its enactment for it to be enforced with uniform efficiency. For this reason a report upon the work which I observed is descriptive of what is being accomplished under the Act in certain localities, rather than of conditions existing throughout the entire country. It must also be remembered that although licenses are granted now to those women only who have been trained in accredited schools or by recognized teachers and have passed the Central Midwives Board examination, there are still practising in England and Wales three classes or grades of midwives. These are: (1) the so-called “bona fide'' midwives, certified by virtue of having been practising one year prior to the passing of the Act; (2) those certified because of their holding certificates issued by the London Obstetrical Society, or having been trained in one of several designated schools; and (3) those certified after having passed the Central Midwives Board examination.
A Group of English Midwives. Image from book.
It was inevitable that there should be these different grades of midwives during the transitional period, but by degrees the older, less competent women are being replaced by the younger ones who have had better training. There are two chief reasons for this gradual substitution. The unfit are giving up their work sometimes voluntarily, because of age, and sometimes because their names are removed from the Midwives Roil on account of unfitness to practice. Another very good reason is that the younger women, with their superior training and greater efficiency, have proved to be so helpful that they are more and more sought after by the poor in their confinements.
Midwives practice their profession in England and Wales in various ways. Some practice independently, arranging their own work, fees, etc., as they wish, so long as they conform to the Rules of the Central Midwives Board.
Sometimes, in fact usually, one finds that a group of visiting nurses (in England called "district" nurses) numbers one or more midwives on the staff to attend exclusively to midwifery work. Again, one finds a midwife partly subsidized by a church or private philanthropy, while in some communities there is a committee formed for the avowed purpose of raising funds to support a midwife to attend the poor in that district. In these latter cases a midwife may be paid full or part salary by the organization with which she is connected.
Any fees which the patients are able to pay are paid into the treasury of the society, and the midwife's salary is augmented in proportion to the number of cases she attends. By means of still another philanthropy, the Royal Maternity Charity, a number of midwives are at the service of the sick poor in the "town" of London. This organization, the oldest midwife charity, is a voluntary committee, supported by endowments and contributions. County cases may be referred to the Royal Maternity Charity midwives who are paid out of the funds of the Charity for each case which they attend.
Another interesting method by means of which the poor are provided with trained midwives is through local associations which defray the expenses of a midwife's training in one of the large Metropolitan schools, with the understanding that the midwife return after graduation and practice in her own neighborhood for a period of from two to three years, or long enough to justify her having been trained at the expense of the community.
There seemed to be a variety of arrangements and systems and plans, but after all, the whole thing worked out quite simply, for it only meant that in each city, town and rural district there were mothers and babies among the poor needing and deserving skilled medical and nursing care, and by some means this was provided in the shape of an available midwife.
The work of the women themselves varied, as will the work of individuals in any profession, but here, too, because of the admirable system of control and supervision, I found the salient features to be the same. The midwives are permitted to attend normal cases only and to give nursing care to mother and infant during the ten or twelve days following the birth, and instructions to the mother during both pregnancy and the puerperium. This latter office gives the midwife wide scope as a nurse and instructor in personal and infant hygiene.
Patients are encouraged to book with a midwife or nursing home early in pregnancy, in order that they may be watched for complications or abnormalities and be instructed as to their personal hygiene. Patients are always referred to a physician if there is evidence of complication. Moreover, the midwife visits her prospective patient's home and, in a friendly, practical way, advises her in preparing for the approaching confinement. Here the midwife may employ the greatest ingenuity in making use of the simple furnishings in the humblest home, and also in advising the mother in the preparation of the layette.
It was a revelation to see the satisfactory little outfits which the very poorest mothers, under the direction of the midwife, had been able to prepare for their infants—soft, warm little vests and plain simple slips, instead of the heavy starched garments usually regarded by members of that class as a necessary part of a baby's wardrobe. And these guides, counselors and friends—called midwives—would show the expectant mother how she could, with a folded quilt or pillow and a soap box or market basket, prepare quite a satisfactory basinette, explaining to the mother the many reasons why the baby should have its own little bed.
In normal cases, when all goes well, the midwife conducts the delivery and often visits her patient twice daily for three days and subsequently once daily during the ten or twelve days following labor. The number of visits which a midwife may pay varies slightly according to the rules of different organizations, but the minimum of a daily visit during ten days is required by the Central Midwives Board. The midwife gives her patient general nursing care, such as any visiting nurse would give—records the temperature and pulse, and makes notes upon the general condition and symptoms, as required by the Central Midwives Board. She arranges with a member of the household or a neighbor to look after the patient's diet and such other details of care as may be necessary between visits.
An important phase of practical work done by the midwives was the teaching of the mothers to take care of their own babies. The midwife on her visit bathed the baby in the presence of its mother, making use of such homely equipment as she could find in the house, explaining and teaching step by step, and finally, upon the cessation of her visits, leaving the mother in possession of one of the most valuable influences against infant mortality—that is, the ability to care for her own child.
Dr. Newsholme says, "The mother is the natural guardian of her child, no other influence can compare with hers in its value in safeguarding infant life."
What I have described is the average routine which is followed when all goes well, but upon the appearance of any symptoms of complication or abnormality during pregnancy, labor or the puerperium, or any of the specified symptoms of complication with the infant, the midwife must summon a physician and notify the local supervising authority that she has done so. (Appendix C, p. 85, Rule 19.) The physician summoned may be one of the patient's or midwife's choice, if the latter be practising independently, or in case of midwives connected with an organization, definite arrangements are made with certain physicians to respond to such calls.
The rigid enforcement of this requirement to summon a physician is evidently one of the most valuable provisions in the whole Midwives Act, for since this has been in operation the percentage of cases in which midwives have secured medical attention for their patients has steadily increased. This seemed such an important feature that I spent much time studying the various health officers' records, to ascertain under what conditions and how frequently midwives sent for help.
I found in Kent County, for example, that a given number of midwives attending approximately the same number of cases during 1911 as during 1910, summoned medical aid twice as often during 1911 as in 1910. Searching still further, I was interested to find that the percentage of cases in which medical aid was summoned because of malpresentations, abnormalities or other obvious complications, remained about the same. But for those complications which required closer observation, such as a slight elevation of the mother's temperature, redness of the baby's eyes, etc., medical aid was secured in double the number of instances among the same number of patients. I found that this relative increase in the percentage of cases in which medical aid was summoned had been general throughout England since the passage of the Midwives Act. This in itself seemed evidence of more careful work than was formerly done by midwives.
It seems to be the opinion of obstetricians both in England and America that about 80 percent, of all labor cases are practically normal. They hold that all obstetrical cases require absolute surgical cleanliness, intelligent supervision and good nursing care, but that beyond this, broadly speaking, only about 20 per cent, of all obstetrical cases are in need of medical or surgical assistance. But these obstetricians are unanimous in emphasizing the fact that obstetrical patients presenting any symptoms of complication or abnormality need the most skilled and efficient medical care available, and not such attention as may be given by the average practitioner.
Bearing this in mind, I was anxious to learn, if possible, how nearly the working of the Midwives Act met these two needs,—i. e., providing cleanliness, vigilance and nursing for all cases, and competent medical care in complicated cases. I found that all but normal cases passed out of the midwives' hands, being referred to hospitals or physicians during pregnancy, labor, or the puerperium, so that, generally speaking, the bulk of the cases attended by midwives in the patients' homes were normal cases, while the majority of the patients in the lying-in hospitals presented some complications or abnormalities. On the other hand, I found, upon questioning the midwives in both the north and south of England in the cities and the rural communities, that they sent for doctors in from 10 to 15 per cent, of all their cases. It would seem from this that, so far as it lies in their power, the midwives in England secure the desired medical skill for their patients when necessary.
The main deductions to be drawn from these facts are that under the Midwives Act the obstetrical patients among the poor are given not only careful nursing and instruction, but also medical attention more frequently than formerly, and what is still more important, this medical attention is usually of a higher grade. Quite naturally, the old untrained, ignorant midwife arrogated to herself powers which an intelligent woman would not assume. When the "Sairy Gamp" type summoned a physician, she called in a man who knew but little more of obstetrics than she, while a trained, educated woman is in touch with the physician who is better able to give the skilled attention needed in an emergency.
The Central Midwives Board quite frankly concerns itself with all matters relating to the welfare of mothers and infants. In addition to the admirable Rules drafted to safeguard the lives and health of these patients, it issues various leaflets and bulletins dealing with specific questions. The leaflet on ophthalmia neonatorum (p. 97) relating to the care of infants' eyes is particularly gratifying to American workers for prevention of blindness who see in the midwife a powerful ally in safeguarding the eyesight of infants.
Blindness is, however, but one of the preventable diseases which may result from lack of skill and cleanliness on the part of accoucheurs. This is forcibly expressed in the following statement by Dr. Arthur Newsholme, the recognized authority in the United Kingdom on all matters relating to infant mortality. Dr. Newsholme writes:
"Of the total deaths in the first year of life nearly 10 per cent, occur within 24 hours after birth, and one out of every 22 of these deaths, according to the Registrar-General's returns, is caused by 'injury at birth.' Although, doubtless, a large proportion of these deaths occur irrespective of the skill of the doctor or midwife in attendance, their degree of skill must have influenced greatly the number of deaths at and soon after birth; and it is probable that the injurious effects of unnecessarily protracted and ill-managed parturition can be traced in the infant far beyond the first day of life.
"The dangers to infantile life associated with parturition are followed by the dangers associated with errors in infantile management, especially as to food, clothing and cleanliness. The results of such errors are especially seen during the later months of infancy; but their origin dates commonly from the first month of life, during a considerable part of which, probably in something like 50 per cent, of the total births in England and Wales, midwives are in attendance. The fact that, of the total deaths of infants in the first year of life, a third (34.6 per cent.) occur during the first four weeks, and a fourth (25.8 percent.) during the first two weeks of life must be regarded as the result in doubtful proportions of congenital defects, of improper attention at birth, and of bad management after birth."
In offering recommendations for the reduction of infant mortality Dr. Newsholme says: "The evidence already available points to the conclusion that infant mortality can be lowered by giving adequate training and help to midwives. This especially applies to the saving of infant life at and soon after birth. It has also to be remembered that the midwife's influence with the mother, whom she has helped in her need, is very great; and it is her advice as to the management and particularly as to the feeding of the infant which is most likely to be followed."
Since the interest in the working of the Midwives Act, resulting in this brief study, grew out of a desire to prevent unnecessary blindness among infants, these comments upon the work of the midwife herself would be incomplete without an expression of profound admiration for the work being done in Liverpool to prevent blindness from ophthalmia neonatorum.
This admirable work is accomplished by the close and harmonious cooperation of three agencies: St. Paul's Eye Hospital, the midwives themselves, and, through the Department of Health, the inspector of midwives and a nurse who is entirely devoted to the supervision of ophthalmia neonatorum cases.
With infinite patience and enthusiasm, Mr. A. Nimmo Walker, Honorary Surgeon to St. Paul's Eye Hospital, has lectured to groups of practising midwives upon the dangers of "babies' sore eyes" and the tragic consequences of its neglect. The midwives thus instructed contribute to the work by unfailingly reporting to the Department of Health all cases of reddened or swollen eyes of infants, while the Department of Health in turn sends at once the ophthalmia neonatorum nurse, who was specially trained by Mr. Walker at St. Paul's Hospital for this particular piece of work. Each infant thus reported to the Department of Health is taken to the hospital for clinical and bacteriological diagnosis, upon which rests the decision whether the child shall be treated in the ophthalmia neonatorum ward or in its home, or once, twice or three times daily in the hospital dispensary. Home treatment by the nurse, working under the joint direction of the eye hospital and the Department of Health, or home treatment plus daily dispensary treatment, is encouraged.
If, however, the seriousness of the infection indicates the necessity for residence in the hospital, the infant and its mother are admitted together. The wisdom of this provision is evident; maternal nursing is desirable for all infants. A baby with sore eyes is a sick baby, and therefore at this time above all others should be breastfed.
An appreciation of this work is expressed as follows by Dr. Hope, Medical Officer of Health of Liverpool: "A large amount of this good result (prevention of blindness) has been due to the provision of a small ward of four beds at St. Paul's Hospital (now nine) and the interest taken in the cases by Dr. A. Nimmo Walker. In this ward the infants but a few days old can be received with their mothers, in order that the necessary treatment may be carried out, and also that they may not be deprived of their natural nourishment. This last point is most important as Dr. Walker reports that he is “more and more impressed with the difficulty of saving severely infected eyes in bottle-fed babies.”
One could dilate at length upon the details of this admirable work and the great care and thought with which it was planned, but the highest tribute that can be paid to it is to report that largely by this means the occurrence of blindness from ophthalmia neonatorum has been practically wiped out in Liverpool.
Van Blarcom, Carolyn Conant. The Midwife in England, Being a Study in England of the Working of the English Midwives Act of 1902. Wm. F. Fell Company, 1913.
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