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Mrs Killer and Dr Crook: Birth Attendants and Birth Outcomes in Early Twentieth-century Derbyshire

  • Alice Reid (a1)


After the passing of the 1902 Midwives Act, a growing proportion of women were delivered by trained and supervised midwives. Standards of midwifery should therefore have improved over the first three decades of the twentieth century, yet nationally this was not reflected in the main outcome measures (stillbirths, early neonatal mortality and maternal death). This paper shows that there was a difference in the risks associated with delivery by the different attendants, with qualified midwives having the best outcome, then bona-fide (untrained) midwives and lastly doctors, even when account is taken of the fact that doctors were called in cases of medical need and may have been booked where a problematic delivery was expected. The paper argues that the lack of improvement in outcome measures could be consistent with improving standards of care among both trained and bona-fide midwives, because increased attention to the rules stipulating when midwives called for medical help meant that a doctor was called into an increasing number of deliveries (including less complicated ones), raising the chance of unnecessary and dangerous interventions.

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1. For Mrs Tipler this image naturally only works if you listen to rather than read the name.

2. Towler, J. and Bramall, J. , Midwives in History and Society (Croom Helm, 1986), 131, 169–70; I. Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800–1950 (Oxford: Clarendon, 1992), 221; N. Leap and B. Hunter, The Midwife’s Tale: An Oral History from Handywoman to Professional Midwife (London: Scarlet Press, 1993), 2.

3. Although there were female doctors by this era, they were still uncommon and all the doctors in this data set used in the course of this paper were male.

4. Reid, A. , ‘Birth Attendants and Midwifery Practice in Early Twentieth Century Derbyshire’, Social History of Medicine, 25 (2012), 380399.

5. Donnison maintained that ‘there was no doubt that the gradual replacement of the old “bona-fide” midwife by the trained woman had resulted in a great improvement in the general standard of midwife practice’ (J. Donnison, Midwives and Medical Men (London: Heineman, 1977), 187). V. De Brouwere, ‘The Comparative Study of Maternal Mortality over Time: The Role of the Professionalisation of Childbirth’, Social History of Medicine, 20 (2007), 541–62; U. Högberg, ‘The Decline in Maternal Mortality in Sweden: The Role of Community Midwifery’, American Journal of Public Health, 94 (2004), 1312–20; I. Loudon, ‘Midwives and the quality of maternal care’, in H. Marland and A.M. Rafferty (eds), Midwives, Society and Childbirth: Debates and Controversies in the Modern Period (London and New York: Routledge, 1997), 180–200: 193–6.

6. Woods, R. , ‘Lying-in and Laying-out: Fetal Health and the Contribution of Midwifery’, Bulletin of the History of Medicine, 81 (2007), 730759: 758; T. McIntosh, ‘Profession, Skill, or Domestic Duty? Midwifery in Sheffield, 1881–1936’, Social History of Medicine, 11 (1998), 403–20: 420.

7. For the background and professional struggle leading up to the 1902 Midwives Act see Donnison, op. cit. (note 5); Towler and Bramall, op. cit. (note 2). For a rare assessment of the quality of maternal care in the UK, see Loudon, op. cit. (note 5). Prior to 1902, there are few systematic records of midwife deliveries, and it is particularly difficult to assess the delivery practices and outcomes of untrained women: those records and accounts which do survive tend to be from literate, educated midwives who regarded themselves as professional, and most are from earlier eras and do not permit assessments of the effect of training on midwifery. For example, see Sarah Stone in R. Woods, Death before Birth: Fetal Health and Mortality in Historical Perspective (Oxford: Oxford University Press, 2009), also A. Tomkins, ‘Demography and the Midwives: Deliveries and their Dénouements in North Shropshire, 1781–1803’, Continuity and Change, 25 (2010), 199-232. Other accounts are more likely to have been anecdotal and highly selective.

8. Woods, R. , ‘Medical and Demographic History: Inseparable?’, Social History of Medicine, 20 (2007), 483503.

9. Dwork, D. , War is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England 1898–1918 (London and New York: Tavistock, 1987); G. McCleary, The Early History of the Infant Welfare Movement (London: H K Lewis & Co., 1933).

10. As with most services provided at a local level, provision varied greatly between local authority areas, and between village, town and city, so numbers of health visitors and percentages of infants visited differed substantially. E. Peretz, ‘Maternal and Child Welfare in England and Wales between the Wars: A Comparative Regional Study’ (unpublished PhD thesis: Middlesex Polytechnic, 1992).

11. Another such data set has been extensively used by David Barker and colleagues, see D.J.P. Barker (ed.), Fetal and Infant Origins of Adult Disease (London: BMJ Books, 1992).

12. Registration of births, deaths and marriages was introduced in 1837 but births did not have to be registered until six weeks after the birth, hence the rational for a parallel system to allow the visiting of newborn infants.

13. It is, of course, possible that some births were missed by both systems, but registration of births is considered to be complete from the 1880s. See D.V. Glass, ‘A Note on the Under-Registration of Births in Britain in the Nineteenth Century’, Population Studies, 5 (1951), 70–88. For more assessment of the completeness of this data set, see A. Reid, ‘Infant and Child Health and Mortality in Derbyshire from the Great War to the mid-1920s’ (unpublished PhD thesis: University of Cambridge, 1999), 39–45.

14. Not all infants were visited for five years, and for some visiting stopped much earlier as they moved away, could not be found by the health visitors or were deemed not to need visiting. However, over 95% of infants received repeated visits. See A. Reid, ‘Health Visitors and Child Health: Did Health Visitors have an Impact?’, Annales de Demographie Historique, 101 (2001), 117–37.

15. See A. Reid, ‘Neonatal Mortality and Stillbirths in Early Twentieth Century Derbyshire, England’, Population Studies, 55 (2001), 213–32; ‘Infant Feeding and Post-Neonatal Mortality in Derbyshire, England, in the Early Twentieth Century’, Population Studies, 56 (2002), 151–66.

16. Woods, op. cit. (note 7).

17. Gourbin, C. and Masuy-Stroobant, G. , ‘Registration of Vital Data; are Live Births and Stillbirths Comparable All Over Europe?’, Bulletin of the World Health Organization, 73 (1995), 449460; Woods, op. cit. (note 7).

18. Midwives were further directed to resuscitate any infants born apparently dead (Directions to Midwives, reprinted in the Midwives Roll 1922: xlvi).

19. Mooney, G. , ‘Still-births and the Measurement of Urban Infant Mortality Rates c.1890–1930’, Local Population Studies, 53 (1994), 4252.

20. Because the poor and unmarried were more likely to have been delivered by uncertified midwives (see Reid, op. cit. (note 4)), their rates of stillbirth are also likely to be underestimated.

21. Midwives Act 1902, as reproduced in the Midwives’ Roll for 1922.

22. Donnison suggests this is also a product of the draining off of doctors to the war effort in 1914–19, and to the reduced importance of maternity work for doctors as the 1911 Insurance Act made the rest of doctors’ income more secure (Donnison, op. cit. (note 5), 185).

23. Loudon, op. cit. (note 2), 209.

24. Calculated from Derbyshire Medical Officer of Health Reports for 1919, 1920 and 1921.

25. Reid, op. cit. (note 4).

26. Of the forty women delivered in Derby Royal Infirmary, four were recorded as having been delivered by caesarean section.

27. Reid, op. cit. (note 4).

28. Reid, op. cit. (note 4).

29. Reid, op. cit. (note 4).

30. Reid, op. cit. (note 4).

31. Reid, op. cit. (note 4).

32. General Medical Council, 1889, quoted in Towler and Bramall, op. cit. (note 2), 166.

33. Fox, E. , ‘Powers of Life and Death: Aspects of Maternal Welfare in England and Wales between the Wars’, Medical History, 35 (1991), 328352: 350.

34. Eighty-eight per cent of the cases where reasons for medical help were noted were associated with a death to the mother or child.

35. Although the period included in studies of maternal death ranges from thirty to sixty days, the convention followed here is forty-two days (six weeks) which captures most of the direct and indirect maternal deaths but not too many deaths which are unrelated to pregnancy and birth (see S. Curtis, ‘Midwives and their Role in the Reduction of Direct Obstetric Deaths During the Late Nineteenth Century: The Sundsvall Region of Sweden (1860–1890)’, Medical History, 49 (2005), 321–50: 326; R. Schofield, ‘Did the mothers really die? Three centuries of maternal mortality in the world we have lost’, in L. Bonfield, R.M. Smith and K. Wrightson (eds), The World We Have Gained: Histories of Population and Social Structure (Oxford: Blackwell, 1986), 231–60: 234; I. Loudon, ‘Deaths in Childbed from the Eighteenth Century to 1935’, Medical History, 30 (1986), 1–41), and goes some way towards making sure that all maternal deaths are included, even those ‘hidden’ by a medical practitioner ascribing them to some other cause (Loudon, op. cit. (note 2), 36). In addition, not all of the deaths to mothers had a cause noted rendering it necessary to use a ‘time since birth’ rather than an ‘obstetric causes’ definition of maternal mortality. In this data set, 142 mothers were noted in the records as having died within six weeks of delivery, and a further seventy-one were noted as having died but with no date given: it is likely that most of these seventy-one did die within six weeks, as the maternal mortality rate is twenty-nine deaths per ten thousand deliveries when they are not included and forty-three when they are included, which is precisely the level in England and Wales as a whole at this time, and indeed for the county of Derbyshire (I. Loudon, ‘Maternal Mortality: 1880–1950. Some Regional and International Comparisons’, Social History of Medicine, 1 (1988), 183–228: 186, 207).

36. The lack of an illegitimacy penalty for perinatal mortality may be due to the possible omission of births to uncertified midwives, who may have provided a service for unmarried mothers. However, the delayed effect of illegitimacy on mortality has also been found elsewhere (E.A. Wrigley, ‘Births and Baptisms: the Use of Anglican Baptism Registers as a Source of Information About the Numbers of Births in England before the Beginning of Civil Registration’, Population Studies, 3 (1977), 281–312).

37. For an exploration of the effect of influenza during pregnancy on the risk of stillbirth and infant mortality, see A. Reid, ‘The Effects of the 1918–1919 Influenza Pandemic on Infant and Child Health in Derbyshire’, Medical History, 49 (2005), 29–54.

38. Midwives known to be uncertified delivered only 202 births in total, of which 131 were with a doctor.

39. The evidence for treating joint deliveries with certified midwives as ‘problem deliveries’ is derived from comparisons with Medical Officer of Health reports, see Reid, op. cit. (note 4).

40. Midwives Roll 1922, xlv.

41. In contrast to Britain today, in the early twentieth century simple breech presentations were regarded as uncomplicated and suitable for vaginal delivery by a midwife on her own.

42. See also A. Newsholme, 44th Report to the LGB 1914–15, Cd 8085 XXV (London: HMSO, 1914–15), 81. See also Dr M’Gonigle’s comment in the discussion following A. Topping, ‘Maternal Mortality and Public Opinion’, Public Health, 49 (1936), 342–49: 349.

43. Fairbairn, J. S. , ‘The Maternal Mortality in the Midwifery Service of the Queen Victoria’s Jubilee Institute’, BMJ (1927), 4750: 48.

44. Fox, op. cit. (note 33), 341; P. Dale and K. Fisher, ‘Implementing the 1902 Midwives Act: Assessing Problems, Developing Services and Creating a New Role for a Variety of Female Practitioners’, Women’s History Review, 18 (2009), 427–52: 440.

45. Lower rates of medical help calls among bona-fide midwives might also arise if such midwives were less likely to have been booked for deliveries where women considered themselves to be at risk. Previous research using this data set, however, indicates that although women who had suffered a previous stillbirth were slightly more likely to have booked a doctor, there was no effect on the choice of qualified or bona-fide midwife (see Reid, op. cit. (note 4)).

46. Campbell, J. , Report on the Physical Welfare of Mothers and Children. England and Wales. Volume Two (London: The Carnegie United Kingdom Trust, 1917), 62. For more detail on inspections, see Dale and Fisher, op. cit. (note 44) and J. Mottram, ‘State control in local context: public health and midwife regulation in Manchester, 1900–1914’, in H. Marland and A.M. Rafferty (eds), Midwives, Society and Childbirth: Debates and Controversies in the Modern Period (London and New York: Routledge, 1997), 134–52.

47. Derbyshire Medical Officer of Health reports. For more details, see Reid, op. cit. (note 4).

48. In addition, this group of midwives may also include some certified midwives who could not be found in the midwife rolls because they were practising in the district for only a short time or because mis-transcription prevented links being made.

49. Reid, op. cit. (note 4).

50. Midwives Roll (1922), xlii–li. In 1916, twenty-seven Derbyshire midwives were temporarily suspended from practice for being a possible source of infection. Sixteen of these were related to puerperal fever: of the others, five were cases of scarlet fever (Derbyshire Medical Officer of Health Report, 1916).

51. Loudon, op. cit. (note 5), 185, 196; Loudon, op. cit. (note 2), 186, 218–23; I. Loudon, ‘Puerperal Fever, the Streptococcus and the Sulphonamides, 1911–1945’, BMJ, 295 (1987), 485–90.

52. Donnison, op. cit. (note 5), 190; C.G. Pantin, ‘Maternal Mortality and Midwifery on the Isle of Man, 1882 to 1961’, Medical History, 40 (1996), 141–72: 160.

53. Although overall a doctor was booked for fewer deliveries, there was considerable variation and many doctors maintained midwifery case loads as high as many of the rural midwives. See Reid, op. cit. (note 4).

54. Fairbairn, op. cit. (note 43), 48.

55. Fox, op. cit. (note 33), 340.

56. Loudon, I. , The Tragedy of Childbed Fever (Oxford: Oxford University Press, 2000), 6.

I would like to thank Eilidh Garrett, Bob Woods and two anonymous referees for helpful comments on earlier versions of this paper. This work was supported by a Wellcome Trust for the History of Medicine PhD studentship, a Research Fellowship from St John’s College, Cambridge, with assistance from a British Academy Small Grant [grant number SG:31626], the Population Investigation Committee and the Simon Population Trust.

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