XII
MIDWIFERY AS A PROFESSION FOR WOMEN (OTHER THAN DOCTORS)
This is not a paper to discuss the suitability of women for midwifery. All through the ages it has been done by women, until early in the nineteenth century in England and its colonies, it gradually became customary for men-doctors to attend such cases; apart from this, the work of midwifery has never been in the hands of men, except when abnormal cases have required the assistance of a doctor with knowledge of anatomy and skilled in instrumental delivery. Even before the passing of the Midwives Act in 1902, statistics proved that three-quarters of all confinements in this country were attended by women.
Continental countries have been alive to the need for training the women who did this work. For instance, in the great General Hospital in Vienna with its 3,000 beds, 550 beds were kept apart for maternity wards, and of these, 200 were reserved for the State training of midwives—a course of one year's duration being obligatory, with daily lectures on every detail in midwifery from the Professor of Obstetrics. The present writer attended these lectures daily for six months in 1885, and was made to feel the importance in teaching of "hammering" at essentials and of questioning, so that the lecturer might discover whether he were talking above the head of the least clever of the audience.
England's population increased so steadily and rapidly during the nineteenth century, that it seemed to trouble no one that countless lives of mothers and babies were lost during the perils of child-birth; it remained the only civilised country of Europe where a woman could practise as a midwife without any training at all.
For nearly twenty years before the passing of the Midwives Act in 1902, a small band of devoted women laboured in season and out of season urging on Parliament the need of a bill requiring a minimum of three months' theoretical and practical training and an examination before trusting a woman with the lives of mother and child.
This historical fact alone is a sufficiently cogent reason for the now ever-increasing demand on the part of women for the parliamentary vote.
The Central Midwives Board (C.M.B.), a body of eight members (experts elected by various bodies, such as the Royal Colleges of Physicians and Surgeons, the British Nurses' Association, the Midwives' Institute, etc.), now exercises supervision over the midwives of the whole of England and Wales, though local supervising authorities also take cognisance of midwives' work and investigate cases of malpractice and the like. The address of the Central Midwives' Board is Caxton House, Westminster.
The training for the examination of the Central Midwives' Board is based on the method pursued in medical education in English-speaking countries, viz., there is not one uniform course, but each of the training schools attached to hospitals follows out its own plan of training, each hospital having been approved by the Central Midwives' Board as giving an adequate training for its examination. There are now seven maternity hospitals in London, where women students may train in midwifery. Of these, only one—the Clapham Maternity Hospital (with its training school founded by Mrs Meredith in 1885)—is, and always has been, entirely officered by women. Here the course advised is six months, viz., three months in the hospital (Monthly Nursing), and three months in the hospital and district doing Midwifery proper. During this time over 200 cases may be seen, and nearly 100 cases attended personally. The cost of this training is £35 to £40, which includes board and residence for twenty-six weeks. Students previously trained elsewhere may take one months' extra training at a cost of ten guineas. Private doctors and midwives may also take pupils if recognised as teachers by the Board.
Midwifery training is now required not only by those who are going to act as midwives, but also by most missionaries, all fully trained nurses (for matrons' posts or colonial posts) and by health visitors and inspectors before obtaining appointments.
But it should be borne in mind, especially in considering the present condition and future prospects of Midwifery as a profession, that even now a large though ever-decreasing proportion of registered midwives are still ignorant women who have never passed the Central Midwives' Board or any other examination, and have had no teaching from any one more experienced or better informed than themselves. For when the Midwives' Act came into force in 1903, it was necessary to move slowly, and so a clause was inserted, permitting women who had been in bonâ-fide practice for more than one year before 1902 to continue their work under inspection and supervision (with many attempts at teaching them by means of simple lectures and demonstrations). This plan, or some similar one, was necessary, not only in the interests of the midwives themselves, a set of decent and kindly, if ignorant women, who would have been ruined by too sudden a change, but also because a large number of mothers in England would have been left with no one to help them in their time of need unless they were prepared to run the risk of breaking the law. This, until recently, respectable English women disliked to do.
It is important to remember this fact, when considering the present and future prospects of the midwife. The untrained woman used to charge 5s. or 7s. 6d. for her services, and the fact that her name had been enrolled on the Government Register, that she was subject to the supervision of an inspector, without having spent anything on her change of status beyond the 10s. registration fee, did not suggest the need of any particular change in her scale of charges. Thus 7s. 6d. per case, unfortunately still remains the very common fee for midwifery, though this now involves, under the rules of the Midwives' Board, not only the long hours of watchful care at the birth, but ten days of daily visits to supervise both mother and baby, with careful records of pulse and temperature, etc., kept in a register. Naturally, the general public who employ midwives—viz., the poorer classes—do not differentiate between the trained certificated midwife and the untrained bonâ-fide midwife whose name is on the register, and thus the scale of charges remains very low and the profession, as one for educated women, is thereby greatly injured.
Granted an intelligent woman is willing to give six months' work and study and £35 to £40 for her training, what chance has she of earning a decent living? If she could command 15s. or 17s. 6d. per case afterwards, she could make a decent living, given fairly hard work and the acceptance of real responsibility. If she had 100 cases a year, she would earn £75 at 15s. per case, and so on. This rise in the fees payable to midwives has just been made possible by the National Insurance Act of 1911, the framers of which appear to have recognised the necessary result of the Midwives' Act of 1902. As the bonâ-fide midwife, who has received no training, gradually dies out, it becomes necessary to provide the means of paying trained midwives, whom the people are obliged to employ in place of the old ones, but who would soon be non-existent were the means of paying them not also provided by the State.
A 30s. maternity benefit is now given for every confinement of an insured person or the wife of an insured person. As the patient may have free choice of doctor or midwife, it seems possible, now that it has been established that the benefit shall go direct to the mother or her nominee, that hereafter the greater part of it may be paid over to the person who can supply that most necessary item of the treatment, i.e., good and intelligent midwifery with nursing care of mother and child. Therefore, it is the right moment for the careful, well-trained popular midwife definitely to raise her fees to all "insured" patients, being still willing to help the poor at a low fee as before. It should be remembered that in about one-tenth of all her cases, medical help will be required, but this case could probably be guarded against by an insurance fund, if properly organised.
We frankly admit that as things now stand—apart from the possibility of the maternity benefit being made to help her—midwifery is financially but a poor profession. But to an enthusiastic lover of her kind, who has other means or prospects for her future than the proceeds of her profession, there is much that is attractive in this most useful calling.
Now let us turn to a consideration of the poor mother. Dr Matthews Duncan in 1870 put the puerperal mortality at 1 in 100 for in-patients and 1 in 120 for patients in their own homes—shocking figures for a physiological event! Miss Wilson, a member of the Central Midwives Board, stated in 1907 that the average mortality of English women, from puerperal fever, a preventable disease, is 47 in 10,000 or 1 in 213, but that in three of the best lying-in hospitals this figure has been reduced to less than 1 in 3,000. To quote Miss Alice Gregory in her article on this subject in The Nineteenth Century for January 1908: "We feel there is something hopelessly wrong somewhere. It becomes indeed a burning question: By what means have the Maternity Hospitals so marvellously reduced their death rate?"
The answer is not now far to seek in the opinion of the writer, who has worked continuously at Midwifery since 1st May 1884. It is probably wholly contained in the three following points:—
(1) All that makes for scrupulous asepsis in every detail for the surroundings of the mother.
(2) The absence of "Meddlesome Midwifery."
(3) Pre-maternity treatment, a factor which the writer considers to be of great importance, and of which she would like to have much more experience.
By this is meant the building up of the future mother's health by improved hygiene and careful, wise dieting and exercising and bathing during the last three months of pregnancy, which enables many a stumbling-block to be removed out of the way. Hence, the utility of pre-maternity wards wisely used. This is, one knows, a "counsel of perfection"; but every expectant mother should and could be taught how to treat herself wisely at this time.
These three points are all in favour of the well-trained midwife.
(1) Scrupulous Asepsis, if intelligently taught, can be learned in six months' training, though one feels bound to add it requires moral "grit" in the character to make one unswervingly faithful in observing it. The midwife, too, should run no risk of carrying infection from others, as a doctor might do.
(2) "Meddlesome Midwifery" is not so much a temptation for the midwife as the doctor, though she also may want to do too much. Patience combined with accurate knowledge when interference is urgently needed, is part of her training.
(3) The midwife who becomes a wise friend to her patients will be just the one to whom the mother will gladly apply early, and who will know if it is advisable to send for skilled medical advice. Contracted pelvis, threatened eclampsia, and antepartum haemorrhage are typical cases, which lose half their terror if diagnosed and treated early.
If ever it is recognised that good midwifery is at the root of the health of the nation and the new maternity benefit is made to help in obtaining it, it will at once become worth while for educated and intelligent women to take to the profession seriously. A practice could then be worked by sets of two or three midwives in co-operation, and with proper organisation as regards an insurance fund for securing operative midwifery from medical practitioners when necessary.
There is ample room for a much larger body of trained midwives than exists at present, if the health and welfare of the nation are to be secured, while the women themselves could, under these conditions, earn a sufficient livelihood.
Trained nurses also specialise in midwifery. They take the full course of training described above, completing this by passing the Central Midwives' Board Examination. They do not practise for themselves, but work only under doctors, thus replacing the monthly nurse. The improvement in health and comfort of both mother and child, when nursed by some one thoroughly competent, is very marked.
The fees which they receive for this work are usually 12 to 14 guineas for the month, and in some cases may rise to 18 guineas.