Women and Birth
Volume 21, Issue 1 , Pages 21-25, March 2008

The politics of midwifery education and training in New South Wales during the last decades of the 19th Century

School of Nursing, University of Western Sydney, Building 3, Bankstown Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia

Received 9 October 2007; accepted 9 November 2007.

Article Outline

Summary 

This paper focuses on the introduction and development of midwifery education and training in Sydney during the last decades of the 19th century. The aim of the training, it is argued, was to displace the lay midwives by trained midwifery nurses who would work under medical control.

The lay midwives were one of the largest occupational groups among women and two-thirds of births in NSW were being delivered by them in the late 19th century. It was a period of professionalisation of medicine and medical men laid claim to midwifery as a legitimate sphere of their practice and saw it as the gateway for establishing a family practice. The lay midwife stood in the way of their claim.

The training programs were established purportedly to control maternal mortality. From the beginning in 1887 medical men were in control of midwifery nurse training. In addition to training at the Benevolent Society Asylum, three more women's hospitals were established in the 1890s in Sydney making it possible to train a stream of midwifery nurses.

The midwifery nurses were charged exorbitant fees for their training; the fees contributed substantially towards running the new hospitals that delivered birth services to the poor and destitute women mostly in their homes. The midwifery nurses worked hard in miserable conditions under the guise of clinical experience required for training.

When a critical mass of poorly trained midwifery nurses were in the offing, a Bill was introduced into the Parliament in 1895, restricting registration to midwifery nurses and this would have eliminated the lay midwife if passed. It took more than two decades to get a Registration Bill passed in the NSW Parliament.

Keywords: Midwifery, Education, Training, Lay midwives, Births, Maternal mortality, Midwifery nurse, Hospitals, Fees, Asylum

 

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Introduction 

Education and training of midwives in New South Wales (NSW) was introduced during in the last two decades of the 19th century in Sydney. First, in the Benevolent Society Asylum in the 1880s and later into three women's hospitals set up in the 1890s. The development of the NSW state economy in the 1880s, along with the depression of the 1890s highlighted the needs of women, particularly at the time of childbirth. The norm for most women at the time of childbirth, especially in the country, was to stay at home and make do with a local untrained lay midwife.1, 2 Trained birth attendants were rare, and most women considered them to be a non-essential luxury. Generally, women did not regard childbirth as a medical event requiring supervision of a medical practitioner.3

Childbirth, though not an illness, required a lying-in period for women up to two or more weeks to recover from the exertion of labour. The attending lay midwife, an independent practitioner assisted with the birth and often provided domestic help for the women during the lying-in period.2 Sometimes additional help was given by female friends and relatives and this was known as ‘neighbouring’.2 Some of the more affluent women, especially in Sydney, who could afford the services of a medical practitioner at childbirth, would hire a monthly nurse who would move into the home prior to the birth and stay for two or more weeks following the birth to care for the woman and family by providing domestic services.1, 2

This paper looks at the professional power exercised by medicine over midwifery in the introduction and development of midwifery education and training in NSW during the last two decades of the 19th century. This aspect is not covered in previous published works. Willis,4 in examining medical dominance covers the politics leading to the division of health care and the subordination of midwifery by medicine and Fahy,5 has provided an analysis of the strategies of power used in the subordination of midwifery by medicine. These works have not examined how education and training of midwives was used by medicine as the means to eliminate lay midwives by creating a new class of birth attendant, the midwifery nurse.

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Lay midwifery practice 

The number of lay midwives grew as population and the pace of urbanization increased during the last decades of the 19th Century. Lay midwifery flourished and there was no restriction placed on entry to the practice of midwifery.6, 7 From accounts, lay midwives in NSW hardly differed from the 19th century description of midwives in England; they were illiterate, middle aged multiparous women who gathered their experience from observing and helping an established midwife before going into practice themselves.8, 9 It was a tradition that a midwife was a married woman in midlife or older, had borne children and witnessed friends or neighbours births; personal experience tended to be an essential qualification 8, 9 The knowledge and skills of lay midwives were learnt in the bedroom and handed down from woman to woman.

The lay midwife came from the working class and many were illiterate as were most working class women of the period.10 Some women, who were faced with adversity like widowhood, would resort to lay midwifery to support their family; others would practise to supplement a husband's meagre income. The services of lay midwives were in great demand; in the country they were highly regarded and known as friends, “rich in common sense, kindness and with skilful hands”.1 A rural doctor in the 1890s during the debate in the NSW Parliament on midwifery training and registration stated that he had no hesitation in leaving childbirth in the hands of the local lay midwife as they were patient and less inclined to interfere in the process.11

Lay midwives were powerless women without professional organisation. They used the title of ’midwife’ which meant ‘with woman’ at childbirth to describe their occupation and most worked in solo practices. Some of these women are listed in late 19th century Sydney directories.12, 13, 14 The midwives and monthly nurses in 1891 numbered 1696 and they formed one of the largest occupational groups among women of the period. Three quarters of the women practising midwifery were more than 45years old in the 1891 Census report.15, 16

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Medical practitioners of the period 

In 1891, the number of medical practitioners working in NSW was 673.16 They were a powerful group and were united through their membership of the Medical Associations. Some were members of the NSW Parliament, others had leadership roles in organisations such as the Benevolent Society through their appointment as medical officers to the Benevolent Society Asylum.

Most of the medical practitioners in NSW during the second half of the 19th century were overseas trained, predominantly from the United Kingdom.17 Medical education was only introduced in NSW in 1883 with the establishment of a medical school in the University of Sydney.18 The overseas trained doctors came to NSW in the mid century when there was an oversupply of professional men in the United Kingdom.17

There were also quack doctors practising, their numbers increased so much that NSW gained the reputation as being a “paradise for quacks” with more than 200 practising by 1890.19 There was one B. Fawcett who set up a lying-in hospital in Bathurst and appointed himself as the medical officer and accoucheur.20

In the second half of the 19th century, NSW was sparsely populated and during the closing decades, town and city developed. The sparse population and relatively young people, with four fifths of the population under 44years of age in 1880, placed little demand on the medical services. Families relied on medical guide books that gave remedies and cures for most common ailments and even contained considerable information on childbirth.21 The most demand placed on the medical services was during epidemics. During other times doctors depended on surgery and childbirth among the middle class to earn a living, some supplemented their incomes by farming or acting as the local postmaster or doing clerical work at the local courthouse.17

Medical practitioners had to compete against quacks and lay midwives to earn a living. While the quacks could be controlled by tightening the rules of the Medical Registration Act, the profession faced the real threat of lay midwives extending their practice among the growing number of middle class women. This was also a period of professionalisation of medicine and doctors were laying claim to midwifery as they believed it to be part of their legitimate sphere of practice. Midwifery was also their gateway for establishing a general practice.7, 22, 23 The profession resented the competition lay midwives posed.6, 7

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Maternal mortality 

Maternal mortality was high, between 4 and 5 per 1000 births in NSW between 1875 and 1880 and with improved data collection was noted to be as high as 7 per 1000 by the late 1890s.24 Puerperal sepsis and accidents of childbirth were the major causes of maternal mortality. With advances in knowledge of bacteriology during the 1870s in Europe the medical profession was accepting that puerperal sepsis was preventible by using aseptic and antiseptic methods.25 There were no efforts made to pass the advances in knowledge or technique on to lay midwives. Medical practitioners blamed lay midwives, who were delivering two thirds of the births in NSW,23 for the high mortality rate and highlighted poor standards of practice.26 Rare incidences of maternal mortality in lay midwifery practice was used as an index of their incompetence.23, 25

The occasional accidents of childbirth in cases attended by lay midwives were highlighted by the medical profession and used to advocate that the lay midwife should be dislodged and replaced by trained women who would be ancillary workers complementary to the medical practitioner role.23, 25

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Midwifery training 

The only institution suitable for midwifery training purposes at the time was the Benevolent Society Asylum in Sydney that had a lying-in section for destitute women who were predominantly single mothers.27 Established hospitals in the city did not have lying-in facilities as public hospitals, in general, avoided taking in women for confinements for fear of puerperal infection.28

By the 1880s between 200 and 300 women were being delivered in the Asylum and most deliveries were “natural, peculiar and instrumental” and were conducted with reasonable safety according to Dr Arthur Renwick, resident medical officer in the 1870s.29 With such a record, the Asylum was regarded as an appropriate choice for midwifery training.

In 1871, Mrs. Elizabeth Blundell, a Nightingale trained nurse, was appointed as Matron of the Benevolent Society Asylum.30 The Benevolent Society that managed the Asylum, influenced by the developments in midwifery training in England in the 1870s, proposed the introduction of midwifery training in 1878.29 Dr Warren, a medical officer at the Asylum supported the training of midwives and in his report to the Board in July 1878 suggested,

…a school be established for training competent nurses for lying-in women, were this done (each pupil nurse being charged a fee by the society for instruction imparted) we could soon send out a number of trained obstetric nurses thus fill the void which in my opinion is much needed and confer a boon on the general public not only in Sydney but the colony.29

The Society, expecting a shift in location of the lying-in section did not act on the proposal. In the meantime training of medical students became a priority, Professor Anderson Stuart was keen to affiliate the new medical school with the lying-in section for clinical training.31 In 1886, the demand for clinical experience in the lying-in section, on a regular basis, forced the Benevolent Society to develop rules for the guidance of medical students undertaking clinical experience. When the rules were formulated, they included guidelines for training midwifery nurses and stipulated that they serve a period of six months training, attend 30 cases of accouchement and pay a fee of two guineas for training.32 Lectures were given by the doctors and clinical supervision of the midwifery nurses was the responsibility of the resident midwife.

Following the formation of the midwifery school and training in 1887, two students were trained and by 1893 forty-six midwifery nurses had completed training in the Asylum.32 They were issued with certificates of competency after passing a final examination and certified capable of performing the duties of a midwife or monthly nurse.32

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Birthing services for the poor 

With the small number of midwifery nurses being trained in the Asylum, there was no critical mass of trained midwifery nurses to meet the needs of the poor or to displace the untrained lay midwives. During the depression of the 1890s, families were faced with extreme hardship, even stark poverty. The lying-in section of the Asylum could not meet the increasing demand for childbirth services from the poor and was often forced to turn pregnant women away.33

The misery of the people in the emerging slums of Sydney led to appeals from philanthropists and religious leaders for assistance to relieve the suffering of the poor. Three maternity hospitals were set up with the aim of providing charitable services to birthing women. They were the Women’ Hospital and Dispensary established by Dr James Graham and Watson Munro in 1893 which developed as the Women's Hospital, Crown Street; St Margaret's Maternity Home 1894, becoming St Margaret's Hospital in the 20th century and the Home Training and Lying Hospital in 1895 that became the South Sydney Women's Hospital.34, 35, 36, 37

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Training of midwifery nurses 

The new hospitals that were established in the1890s were small with few beds, the training was unregulated as there was no state authority to set standards. Applicants for training were expected to have “…a certain degree of intelligence, that she can read and write, that she is a woman of good moral character”.38 The emphasis of training was on a midwifery ’nurse’ not ’midwife’ as some members of the medical profession feared the title ’midwife’ would encourage women, once trained, to invade the lucrative field of women's diseases.22

Each hospital developed its own rules and regulations for training the midwifery nurses and there was a major emphasis on clinical work.39 The doctors who held visiting appointments at the training hospitals featured prominently in the training program and were able to exercise power over the midwifery nurses as teachers and professionals in the hierarchical structure of the organisation. They set the course of instruction, examinations and marked the papers.39 The only trained midwife who appears to have played a role in the teaching in the 1890s was Mrs Ardill.

The clinical training of the midwifery nurses included indoor and outdoor work, especially in the homes of poor women.34 In outdoor midwifery, the midwifery nurse under supervision was responsible for the proper care of the woman in her home which included a daily visit for a minimum of ten days post delivery.39

Outdoor midwifery gave the students a broad introduction to charity work as they worked predominantly among the poor. The students were exposed to great risk of their personal safety as they were often required to attend births in the worst slums of Sydney,

…the nurses duties are decidedly hard for they have to go at all hours of the day and night to all sorts of places. After midnight they have often to travel on foot or in rough carts of conveyances. Frequently, they are many hours without food as it is impossible for them to eat or drink in such disagreeable surrounding.39

Extensive charity work was undertaken by the unpaid midwifery nurses in the course of their duties under the guise of clinical experience. Their work was seen to be more worthwhile than the many visits of judicious distributors of charity; the matrons of the hospitals were duly recognised for the coordination of the work.40 Poor women who received the midwifery services from the trainees made statements like “Though I had no money to pay I was as well treated as if I were a rich woman”.41

The unpaid students who carried out the charitable duties worked long hours for which they had to pay a prescribed fee on entering training. Fees were set as a means by which a better class of woman could be attracted to midwifery.42 Fees ranged from twenty to twenty one guineas and covered live-in accommodation, those students who lived out paid between five and six guineas. The fees of students in St Margaret's Hospital in 1897 were 45% of the hospital's total income and in1899 the fees increased to 63% of the total income.43 Student fees made a significant contribution to the income of the hospital, “The principle support of the hospital is the fees of the resident pupil nurses who receive a regular course of training in midwifery…”44

Income of the Women's Hospital from student fees amounted to 41% of its total income in 1898.38 The income from fees contributed toward reducing the annual average cost of a bed from 48.55 to 11.30 pounds in the Women's Hospital “The income from nurses fees considerably assisted in providing this result and the directors gratefully acknowledged the kindness of the lecturers for the financial assistance”.38 For the contribution made by the midwifery nurses fees, the Annual Report of 1898, gave credit to the doctors, implying that it was the doctors lectures that attracted the fee paying midwifery nurses.

The midwifery nursing students were looked upon by the hospitals as an important source of income. Consequently, the number of students recruited was at times far in excess of the clinical resources available for their training. This became clear from the evidence cited in the Report of The Royal Commission on the Decline in Birth Rate, 1904. Taking into account the available resources for training midwifery nurses, the Report stated that it was not possible to train more than 40 or 50 midwifery nurses a year in NSW.45 In 1899 St Margaret's Hospital alone had exceeded that number.

The increased training in the 1890s had no positive effect on maternal mortality. Between 1893 and 1900 maternal mortality increased from 5 to 7 per 1000. The increase in mortality was attributed to better data collection and the effects of increased poverty during the economic depression of the 1890s on women's health.46

With a stream of midwifery nurses being trained in the 1890s steps were afoot to get them registered, so as to eliminate the lay midwives. A Midwifery Nurses Bill was proposed by Dr James Graham in 1895 to restrict attendance at birth to midwifery nurses who held a certificate from a training hospital. Several unsuccessful attempts were made by Graham and others in the 1890s to have the Bill passed in the NSW Parliament.9, 47 It took more than two decades to get a Bill passed for the registration of midwifery nurses. If the Bill had been passed in the 1890s into a Registration Act, lay midwifery practice would have become unlawful by 1900.

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Conclusion 

Lay midwives in the late 19th century formed a large occupational group of women with a traditional right to practice. They lacked formal education or organisational support and were powerless to voice their traditional right to practice. The medical profession was well organised and used their professional power to ride roughshod over the lay midwives. The lay midwives were largely unaware of the campaign to displace them. It was being argued in the medical journals and staged in the training hospitals and the state Parliament.

In establishing midwifery training the medical profession was able to create an ancillary and subordinate class of midwifery nurses who were complementary to their practice; in this way the stage was set to eliminate competition from lay midwives and registration was the next step.

The training of midwifery nurses was purported to reduce maternal mortality. However, the training programs established in the last two decades of the 19th century showed no reduction in maternal mortality.

Training of midwifery nurses was also an important adjunct to the philanthropic work of the 1890s, when poverty was widespread and the access of pregnant women to public hospitals was barred because of the fear of puerperal sepsis.

Midwifery nurses paid exorbitant fees for training, the fees were a significant contribution to the development of the pioneering maternity hospitals. The hospitals rendered birthing services to the poor in and around Sydney, by utilising the service of the midwifery nurses in training who worked long hours in miserable conditions. In short, they were the work-horses of a philanthropic movement that served the poor in the developing city and in the process, the midwifery nurses were financially exploited and received poor training.

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References 

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PII: S1871-5192(07)00118-7

doi:10.1016/j.wombi.2007.11.002

Women and Birth
Volume 21, Issue 1 , Pages 21-25, March 2008

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