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Women and Obstetrics
The Loss of Childbirth to Male Physicians
The shift from midwife to obstetrician and gynecologist occurred from the early eighteenth through the nineteenth centuries. Relinquishing control of their territory was not something midwives did voluntarily, rather it happened as a result of questions of women's place and innovations in technology. Men's access to education and to technology provided them with an advantage over female midwives. Female midwives and women in general were denied medical education. They were not exposed, nor allowed to use certain technologies. In order for midwives to keep their job, they were forbidden from practicing medicine. Using technology was practicing medicine; midwives could not use technology to ease labor or to diagnose gynecological problems. New technologies were in the realm of the male doctors. These male doctors could then promise better treatment, easier labor, etc. as a way of asserting their dominance in the field.
This dominance was over women, their bodies, and their bodies processes. The use of the vaginal speculum, forceps and anesthesia helped to exert men's control over women's bodies. The speculum allowed men sight in addition to touch. Forceps brought obstetricians into almost every birth that occurred. Anesthesia put women to sleep and let them forget their births, giving their doctors more control over the birthing process.
The speculum came into use during the early eighteenth century. It was rediscovered and popularized by Joseph Recamier, a professor of medicine in Paris. He constructed a slender tin tube through which he could examine and inspect the uterine neck and the vagina. Because of the sight the speculum gave to gynecologists, it became a very controversial technology. In the early eighteenth century, these was heated debate about the use of the speculum. Examinations by speculum involved exposure and penetration of what was "private". Most doctors felt that to look at and to touch female genitalia was unnecessary, sacrificed female delicacy and ignored medical ethics [1]. According to Dr. Charles Meigs, professor of medicine and diseases of women and children in Philadelphia, indiscriminate use of the speculum was an affront to women's modesty. Meigs felt that his duty as a doctor was to uphold the moral fabric of society, not to cure women's diseases. Meigs explained to his students that he was...
"...proud to say that in this country generally, certainly in many parts of it, there are women who prefer to suffer the extremity of danger and pain rather than wave those scruples of delicacy which prevent their maladies from being explored. I say it is fully an evidence of the dominion of a fine morality in our society."[2]
The speculum was also thought to "dull the edge of virgin modesty, and the degradation of the pure minds ... the female who has been subjected to such treatment is not the same person in delicacy and purity as she was before."[3] Male doctors felt that once a woman's erotic feelings had been stirred, through sight and touch, it would be easy to seduce her. The men were responsible for control of women's sexual desire, chastity, and loyalty to husband.
This importance of protecting female virtue seemed to apply only to the upper classes, however. As early as 1810, the speculum was being used to regulate prostitution. Parisian prostitutes had to register, and be examined by the speculum. If she was found to be suffering from venereal disease, she was detained and treated at a prison hospital. Already methods of control were in place.[4] The passage of the Contagious Disease Acts gave further control to men over women's bodies. The 1864 Act gave JPs, inspectors, magistrates and medical practitioners the power to apprehend a woman and force her to undergo an examination. The 1866 Act gave police the power to detain and examine any prostitute suspected of having a disease. Women could be detained against their will and without their consent. They could also be imprisoned if they refused the examination.[5] According to Ornella Moscucci...
"Anti-regulationists violently opposed the examination of prostitutes by the speculum, which they depicted at best as a voyeuristic intrusion in the womb, and at worst as the 'instrumental rape' of women. Women were forced to submit to brutal and degrading inspections to 'make vice safe for men', while the men who consorted with them were allowed to go unpunished."[6]
Lynne Tatlock, in her essay, "Speculum Feminarum", gives a more radical view of the meaning of the speculum to women and their bodies. Writes Tatlock...
"[A] new kind of medical -- indeed, a male/masculine -- gaze, enhanced by instruments, proceeded to analyze, organize, and ultimately reduce the experience in the service of nosology. This is the new medical "glance" that ... Foucault overtly linked to the view through the speculum at the cervix, a glance that simulates palpation of the cervix. ... [H]is description of it as an aggressive glance at woman's interior quite palpably demonstrates that it is not gender-neutral, that it is a "masculine" gaze. Indeed, Luce Irigaray, ... asserts that man's use of the speculum signifies the "masculine" usurpation of the right to look at everything. The glance through the speculum, Irigaray insists, leads man mistakenly to believe himself reconfirmed in his priority in the creation and thus as the sole contender for knowledge. Knowledge is the key word."[7]
The speculum allowed men to know and control the women they were examining. Woman's sexual freedom and bodily privacy were lost to men obsessed with the need to control women's bodies and the medical profession.
This desire for control led men to seek greater status as obstetricians in the nineteenth century. The professionalization of obstetrics is one of the leading factors in the demise of midwifery. Doctors sought to improve their status by proving midwives uneducated and unprepared for medical emergency. This control over the birthing process came about with the increasing use of forceps in doctor attended births. Forceps allowed the male doctor to deliver live babies where previously the child or the mother would have died. Forceps were also used to shorten lengthy labor. Because midwives were not allowed by custom to use medical instruments in their practice, forceps became the exclusive domain of physicians. Childbirth started to become the expertise of men, instead of women.
Forceps improved the status of physicians by easing birth and increasing the chances of a live birth. A physician who used forceps in the majority of cases, necessary or not, would increase his chances of a successful and less painful birth. Until the use of forceps, the only way to remove a fetus that couldn't pass through the birth canal was to perform a craniotomy. Forceps represented the introduction of science to birth, the professionalization of physicians, the downfall of midwifery, and the loss of birth from women to men. Catherine M. Scholten writes...
"[T]he time seemed ripe to apply science to a field hitherto built on ignorance and supported by prejudice. Smellie [Dr. William Smellie, discovered the mechanics of parturition, perfected the design and use of forceps, and taught their use] commented on the novelty of scientific interest in midwifery. `We ought to be ashamed of ourselves ... for the little improvement we have made in so many centuries.'"[8]
Thomas Jones of the College of Medicine of Maryland wrote in 1812, "With the cultivation of this branch of science women could now reasonably look to men for safety in the perilous conditions of childbirth."[9]
What Jones failed to write about were the failures of the forceps to completely revolutionize childbirth. Forceps sometimes saving the life of an infant who would have been killed, or sped up labor; however, they also caused as much injury as they prevented. Forceps were responsible for rips in the perineum, head injuries to the fetus, and other obstetric complications. The overuse of forceps was an acknowledged problem in the nineteenth century. Accusations of "meddlesome midwifery" and cautions against forceps misuse suggest a serious problem existed. William Potts Dewees, professor and the University of Pennsylvania, wrote, "The frequency with which [forceps] have been employed in some instances is really alarming, and I had like to have said, must have been to often unnecessary." Another physician writing in the 1880s wrote "grave perineal lesions were more common now than formerly, and this increase has been coincident with the increased use of forceps and of anesthetics in labor."[10]
The increase of dangers to women was due to other interventions by physicians as well. Since most labor proceeded normally, any intervention introduced dangers that weren't already present. Germ theory was not yet in place, and doctors did not take action to sterilize themselves or the area they were in. Unwashed hands posed major threats to women's health, often carrying disease from other patients the doctor had examined. Some physicians also routinely used opium and other narcotics, and ruptured the water with their fingernails. These actions also placed unknown and previously nonexistent dangers to women.
Women, unlike the midwives who were being forced out of their jobs, were choosing physicians of their own volition. Unlike today, women were not forced to give birth in a hospital, or with a licensed physician. Women called on physicians to be present, often because the threats they might bring outweighed the fears the women had of childbirth. Women were also sometimes forcing intervention on themselves. Doctors who did not intervene at all were seen as not doing their job. Physicians might decide to intervene dependent on a woman's state of mind at the birth, her expectations of the physician, his standing in the community, or a number of other reasons.
According to Judith Walzer Leavitt, this choice of calling in a doctor allowed women to continue "to hold the power to shape events in the birthing room".[11] Women could choose what type of birth they would have and what actions would be taken. Write Leavitt...
"[F]or those women who chose physicians instead of or in addition to midwives, birth became a less natural, immutable process and more an event that could be altered and influenced by a wide selection of interventions. Middle-class birthing women and their physicians realized that fate no longer held women in such a tight grip and that decisions could be made ... that would determine what kind of birth a woman would have and perhaps whether she and her baby lived or died. This mental perception of the ability to shape the birth experience became even more important in the second half of the nineteenth century, when anesthesia emerged as the newest birthing panacea and physician interventions became more routine."[12]
While forceps were an invasion of the female world of birth, it was an invasion by invitation. And, according to Leavitt, a source of empowerment for women over the hazards of birth. Women were willing victims to the takeover by physicians.
Leavitt provides a similar interpretation of the use of anesthesia in birth. During the mid-nineteenth century, some physicians began using ether and chloroform to ease pain during labor. Many physicians were reluctant to use any anesthesia, unsure of the dangers and the risks it presented to women. Charles Meigs rejected both chloroform and ether. He believed that "a labor pain [is] a most desirable, salutary, and conservative manifestation of the life-force." Labor pains helped Meigs determine the progress of labor and felt the anesthesia would make him less effective.[13] In the beginning, women were more demanding of anesthesia than doctors were in offering it. Once women understood that ether or chloroform could ease their pains, they demanded its use, even when they were capable of having relatively easy births. With chloroform it was "nothing to have babies". As more women demanded anesthesia, more doctors began to use and to encourage the use of chloroform and ether. Says Leavitt, this "clearly illustrates the powers that women held in America's birthing rooms, the easy assertion of their decision-making authority, and the physicians' acceptance of the necessity to alter their own plans in the face of women's expectations."[14]
Like the use of forceps, anesthesia carried with it many risks. Physicians were well aware of these dangers, and many refused to use anesthesia until well into the nineteenth century. Medical literature "indicated that either ether or chloroform could increase the danger of hemorrhage, could lead to protracted labor, could decrease uterine contractions, and could cause a newborn breathing difficulty."[15] Many physicians warned against the routine use of anesthesia in birth for these reasons. Until the advent of twilight sleep in the early twentieth centuries, many doctors refused to use any type of anesthesia.
Twilight-sleep was a combination of scopolamine and morphine. It put women to sleep and caused an amnesia that led them to "forget" the birth process. Twilight-sleep was subject to many debates similar to those over the use of ether and chloroform. The use of twilight-sleep, however, was one which ignited a country of women demanding its use. The use of twilight-sleep was an example of women controlling their own births by choosing to go to sleep. These women were demanding the right to control their own birth and its process. Many leaders of the twilight-sleep movement were suffragists and women's rights leaders. Twilight-sleep represented women's control over birth decisions.
This control did not come easily, however. Doctors were fighting the use of twilight-sleep for a number of reasons. Some of these were safety, although many unsafe procedures were still being used in birthing rooms. The debate over twilight-sleep became a public debate and represented doctors' lack of complete control over birth procedures and decisions. As doctors were fighting for control over the entire birth process, they could not allow women to continue making decisions. Says Leavitt, "it was principally this question of power over decision making that separated the twilight-sleep movement's proponents from its opponents."[17]
What doctors had not yet realized that twilight-sleep was the first step to complete control by the physician. Twilight-sleep had to be administered in a hospital and the birth had to be overseen by physician and staff. Women were completely unconscious and so did not experience birth. The widespread use of twilight-sleep also paved the way for other anesthesia. By encouraging women to go to sleep, women were further distanced from their bodies. They lost control over a process as natural as any other bodily function.
This loss of control and medicalization of birth was well on its way during the nineteenth century. Physician intervention in birth, improved methods for combating puerperal fever and anesthetizing women for a medical procedure all contributed to childbirth's medicalization. The natural processes of a woman became medical procedure that required a male physician to step in and take control. This intervention was frequently more detrimental to a birthing woman's health than no physician would be. Physicians themselves carried many diseases. Yet women did not fight this invasion, rather they welcomed and in some cases demanded it. The loss of control of their bodies was not something they had anticipated, nor did they realize it was occurring. Writes Tatlock of the loss of control due to the speculum...
"Once male practitioners established their right to look and thus to know by seeing what the midwife knew by touching, the field of obstetrics and gynecology was changed forever. The bodies of women were thereby rendered objects of institutional knowledge, a knowledge contested and prescribed within "masculine" universities, regulated and deployed by male boards of health, and endlessly reproduced by sterile and unsexed specula, those keys that had opened the female body and locked it into its place within professional "masculine" medicine."[17]
Once birth moved into the hospitals and men gained the uncontestable right to look, women surrendered all control and knowledge of their bodies to medicine, and hence to men. What had been normal became abnormal. Women's bodies, specifically their reproductive organs were held responsible for their mental illness, and for other medical problems. Women had to protected and their organs controlled so that women would not suffer, die or go insane. Through increased technological use, and the exclusion of women to access education and technologies, men gained and held control over women's bodies and their functioning.
Apple, Rima D. , Women, Health and Medicine in America: A Historical Handbook (New York, New York: Garland Publishing Inc., 1990)
Declercq, Eugene R., PhD, "The Trials of Hanna Porn: The Campaign to Abolish Midwifery in Massachusetts" American Journal of Public Health 8 (1994)
Duffy, John, From Humors to Medical Science: A History of American Medicine (Urbana, Illinois: University of Illinois Press, 1993)
Leavitt, Judith Walzer, Brought to Bed (New York, New York: Oxford University Press, 1986)
Leavitt, Judith Walzer, ed., Women and Health in America (Madison, Wisconsin: The University of Wisconsin Press, 1984)
Mitchinson, Wendy, "Hysteria and Insanity in Women: A Nineteenth Century Canadian Perspective" Journal of Canadian Studies 21 (1988): 1199-208
Morantz-Sanchez, Regina Markell, Sympathy and Science: Women Physicians in American Medicine (New York, New York: Oxford University Press, 1985)
Moscucci, Ornella, The Science of Woman: Gynecology and Gender in England 1800-1929 (Cambridge, England: Cambridge University Press, 1990)
Tatlock, Lynne, "Speculum Feminarum: Gendered Perspectives on Obstetrics and Gynecology in Early Modern Germany" Signs 17 (1992): 725-56
Wajcman, Judy, Feminism Confronts Technology (University Park, Pennsylvania: The Pennsylvania State University Press, 1991)