Abstract
If you had asked an English physician in 1700 about the connection between medicine and midwifery, he would almost certainly have told you that the two had nothing whatsoever to do with each other. Midwifery was an activity confined to uneducated female midwives from which men were rigidly excluded. Occasionally a surgeon was asked to use some kind of surgical instrument in an attempt to deal with an obstructed labour, but that was all.
If, however, you had asked the same question at the end of the 18th century, you would have been told that an increasing number of women were choosing to be delivered at home by medical practitioners, especially the surgeon-apothecaries who were general practitioners in all but name. (It was, by the way, not until the early 19th century that the term ‘obstetrician’ came into common usage, replacing ‘man-midwifery’ and ‘accoucheur’.) By the end of the 18th century it is probable that about half the total deliveries in England and Wales were home deliveries by medical practitioners and the rest by midwives. Only a very small number of deliveries – well under 1% – were delivered in maternity hospitals. 1
Why did man-midwifery appear?
There are several possible explanations for the origin of man-midwifery. The introduction of forceps is often cited but was not an important factor. Knowledge of anatomy and therefore of the mechanics of normal and abnormal labours certainly played a part. But the most important was quite simply to make a living. 2 As a Bristol surgeon explained in 1800:
‘The man midwife … cannot be compensated at all by the mere lying-in fee, unless it leads to other business. I know of no surgeon who would not willingly have given up attending midwifery cases provided he could retain the family in other respects – but that is unprofitable as every accoucheur knows …’ 3
A few surgeon-apothecaries found obstetrics a rewarding part of their work but most complained of low fees and exhaustion. After attending two cases in succession, a Lincolnshire surgeon-apothecary wrote in 1770: ‘I have not been in bed nor my boots off for 40 hours’. He hated the tedium and the low fees, knowing he could have made much more money visiting the sick and prescribing medicines. But he knew that if he refused to attend a midwifery case the patient might leave him for one of his many competitors. 4 ‘Deliver the babies and you will have the family for life’ was an article of faith which bound together general practice and the management of childbirth.
Maternal care and home deliveries in the 19th century
In British medicine, political power rests almost entirely with the medical colleges. By the 19th century there were two: the Royal College of Physicians was founded in 1518, while the Royal College of Surgeons of London, founded in 1800 and changing its name to the Royal College of Surgeons of England in 1843, was founded with the express aim of creating a body of ‘pure surgeons’. It rejected all association with GPs and midwives. ‘Nothing’, said one President of the RCS, ‘was more unnecessary or unmanly than for a surgeon or physician to neglect his patients, to sit by a lady's bedside for hours together in a natural labour which any female of prudence could manage.’ 5 Delivering babies was ‘contrary to decency and common sense’ said another. If a member of the College of Surgeons was found to be practising obstetrics surreptitiously he was instantly expelled. Leaders of both medical Colleges scorned obstetrics as an activity ‘foreign to the habits of a gentleman of enlarged academical education’. 6 The glaringly snobbish attitudes of both medical Colleges (especially the Surgeons) were notorious and shameful. As a consequence obstetrics was marginalized, lying outside mainstream medicine. It was not until 1929 that the College of Obstetrics and Gynaecology was established, and even then its foundation was opposed onthe grounds that it was not a proper medical specialty. 2
From the 18th to the early 20th century a large majority of deliveries among the poor and lower middle classes were carried out either by an untrained, unregulated and often illiterate midwife, or by a GP whose training often left a lot to be desired but whose income was often dependent on midwifery fees. The middle and upper classes favoured the employment of a superior midwife in the form of the ‘Monthly Nurse’ – which was a high class of midwife who lived in the patient's house and provided nursing care from the time before the baby was born to three or four weeks after the birth. The GP delivered the baby and took the fee. It was a popular system designed for families who could afford the cost. There were also a few private clinics or ‘nursing homes’ in which GPs could deliver their middle and upper class patients. They first appeared at the end of the 19th century, but little is known about them.
Home deliveries, 1900–1948
Looking at maternal care as a whole during the first half of the 20th century, we can see that the central position of GPs begins to fade while other parts of maternal care were advancing. The most striking advance occurred among the midwives as a result of the three Midwife Acts in 1902, 1918 and 1936. By 1948 midwives were certainly providing the most organized and regulated system of maternal care, carrying out more deliveries (mostly home deliveries) than any other professional group. 7, 8 There was also an increase in hospital deliveries. In 1927 only 15% of deliveries in England and Wales took place in a hospital; by 1932 the proportion had risen to 24%. These changes occurred against a background of a number of clinical advances which took place mostly in the 1930s and made childbirth much safer than it had been. The defeat of puerperal fever by the sulphonamides – the most important advance in the whole history of obstetrics – began in 1937. 9 In addition, antenatal and postnatal care were becoming routine in the late 1930s, the concept of the obstetric flying squad was introduced, and ergometrine played a large part in the treatment of postpartum haemorrhage.
All of these advantages were available to GP obstetricians, most of whom carried out home deliveries for the reasons mentioned above: the fee and the cementing of the relationship between the family doctor and his patients. Some GPs were appointed to institutions, especially provincial hospitals. For example the ‘honorary obstetrician’ to Winchester Hospital was always a leading local GP, and remained so for the first years of the NHS. Doubtless similar arrangements were made in other parts of provincial England.
Scarcity of records makes it difficult to judge quality of care in the first half of the 20th century, but we do know that the standard of maternity care in general practice was often low, even by the standards of the time, and that many preventable deaths were not prevented. This was shown by the response of GPs to a lecture on the practice of obstetrics which was published in the British Medical Journal. 10 There was nothing controversial about the lecture, which stressed the need for patience, minimal interference and strict antisepsis; but it provoked an extraordinarily hostile response. One GP boasted that he never used antisepsis because the idea of bacteria causing sepsis was nonsense. Another believed the crux of the matter was the fee:
‘This waiting midwifery, this scientific midwifery, cannot be done at the price, and the public must be taught this … the remuneration a general practitioner receives is probably a fraction of what the cabman would obtain for waiting at the gate … I use chloroform and forceps in every possible case and have done so for many years. The whole procedure occupies from 15 to 40 minutes, according to the difficulty of the case.’ 9
Similar comments were so common that it is difficult to know which is the most surprising: the fact that GPs held such views or that they published them so proudly.
General practice and obstetrics under the NHS
England and Wales. Total deliveries, deliveries in GP maternity units and home deliveries, at five-year intervals from 1955 to 1998
Reproduced with permission from: Macfarlane A et al., Vol 2, Table A7.16.2. 17
GP maternity units
An important aspect of maternal care which has not been mentioned so far are the GP maternity units in community hospitals. Many were small in size and in the annual number of deliveries performed, but large in their influence on obstetric care in general practice. Most were founded in rural areas far from district general hospitals. They had evolved from the cottage hospitals which were the invention of Dr Albert Napper, who opened the first one in Cranley in 1859. By the 1950s there were about 400 such hospitals scattered widely through England and Wales. 9 They tended to be friendly institutions in which GPs and group-attached midwives worked closely together providing continuity of care and delivering the patients close to their home. 11
These GP community hospitals give us a glimpse of a way in which an NHS obstetric service based on GPs and midwives attached to practices might have evolved. Take Oxfordshire, for instance. In the early years of the NHS, Oxfordshire had only a small number of consultant-led maternity hospitals, but it had six community hospitals with maternity beds. Hospital obstetricians in Oxford said at the time that they could not have coped with the demand for hospital deliveries without the help of the community hospitals. This close cooperation between specialist obstetricians, GPs and community midwives showed that they could work together successfully. But it ceased when a large new maternity hospital was built in Oxford in the 1970s. GP maternity beds were no longer essential. This led to such a rapid decline in the maternity side of the community hospitals that now, in the 21st century, there are only three community maternity units, all midwife-led, whose main activity is to take early discharges of patients delivered in the new maternity hospital. GPs no longer play any part in intrapartum care.
What happened in Oxfordshire happened in many parts of England and Wales. In rounded-up figures, the annual number of births in England and Wales in the 1950s was in the region of 800,000, of which about 200,000 were home deliveries; deliveries in community care hospitals amounted to about 100,000. By 1990, the number of deliveries in community hospitals had fallen to approximately 11,000 and home deliveries had dropped more steeply to only 7,000. 12 The exact figures can be seen in Table 1.
The question of safety
Even if such occasions are rare, everyone who has practised obstetrics knows that even the most normal of labours can go alarmingly wrong very quickly. This is why some (probably most) consultant obstetricians believe that deliveries in homes or community hospitals are now completely outdated. The conclusion of the Standing Maternity and Midwifery Advisory Committee in 1970 was:
‘We think that sufficient facilities should be provided to allow for 100 per cent hospital delivery. The greater safety of hospital confinement for mother and child justifies this objective.’
On the other hand, this plea that every woman should be delivered in a consultant-led hospital has been closely examined by several groups, including some distinguished obstetricians, who conclude:
‘There is no evidence to support the claim that the safest policy is for all women to give birth in hospital.’
This was the conclusion of the House of Commons Health Committee, Maternity Services in 1992. Others joined in this argument, stressing the part played by community hospitals. The results of a detailed and careful investigation, published by Young in 1987 with the title: ‘Are isolated maternity units run by GPs dangerous?’, showed that such units were as safe, if not more so, than large consultant-led hospitals. 13
Even if you employ the most sophisticated statistical analysis I doubt if a definite answer is possible, but the fact that there is such an argument has played a large part in the relentless tendency to abolish home deliveries and close down midwife-led maternity units in community hospitals. An analysis of maternity units in the North of England shows that in the years between 1960 and 2008 about 30 GP maternity units were closed down and about 15 were merged with another hospital. Some of the remaining hospital maternity units have become midwifery-led, leaving 11 district general hospitals with consultant-led maternity departments. 14
Why did the process of closing small maternity units occur? The main reason was the increasing capacity of large hospitals which allowed increasing numbers of women to book where their friends had booked. The only places where mothers could be booked in for delivery in small units tended to be remote areas which mounted vigorous local campaigns. But these small non-threatening community hospitals are gradually changing into midwifery-managed units. 15
Looking at what has happened to midwifery in general practice over the last 50 years, Young, 13 who is an enthusiastic GP for whom maternity care has always been the most demanding and satisfying part of his work, has noted with dismay the policies which have, in effect, abolished GP obstetrics altogether:
‘The retreat from maternity care has been partly because we [general practitioner obstetricians] were pushed … and partly because we jumped. The jump was in large part due to new out-of-hours arrangements and the new contract. These allowed general practitioners to opt out of 24-hour care and very few general practitioners were then prepared to run a secondary rota to remain on call for care at birth. Even before then, most general practitioners would have run a mile to avoid attending a woman in labour. There were very few general practitioners even in 1990 who delighted in intrapartum care – all very sad. As we abandoned care at birth so midwives (and women to a lesser extent) came to see general practitioners as irrelevant to care before and after birth … There is almost no opportunity for general practitioners to attend births … The previous “general practitioner units” … are now “midwifery-led units” and we are either considered redundant … or, worse still, an impediment to midwife care.’ 16
It seems that obstetrics in general practice is fading away. Most GPs are happy that this has occurred. The content of general practice in other directions such as immunization, screening, preventive medicine and psychological medicine leave no room for the time-consuming process of delivering babies. As we saw above, the new GP contract and ‘out-of-hours’ systems is incompatible with intrapartum care. Moreover, obstetrics has become increasingly specialized, with rising rates of Caesarean sections, forceps deliveries, epidural anaesthesia and induction of labour. Except, perhaps, in the most remote areas, it looks as if obstetrics will consist of deliveries confined to consultant-led hospitals and a few midwife-led maternity units. There are slight signs of a rise in home deliveries by the midwives who otherwise work in the community hospitals, but the active role of the GP in obstetrics is – or probably soon will be – dead.
Footnotes
DECLARATIONS
Footnotes
Acknowledgements
The author is grateful to Dr Edmund Hey and Dr Gavin Young for permission to publish part of their private communications to me