1998 Tht Soaayfcr the Seoul History ofMtdidnr

Profession, Skill, or Domestic Duty? Midwifery in Sheffield, 1881-1936

By TANIA MCINTOSH*
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SUMMARY. Midwives today trace their professional identity back to the period following the midwifery regulation of 1902, when provisions were made for the training and registration of all midwives, and for the gradual elimination of the untrained practitioner. Some historians have argued that this represented a definite break and signalled the willingness of midwives to move towards a professional status. A comparison of midwifery in Sheffield pre- and post-regulation demonstrates no significant change in the practice and profiles of those in the occupation; all midwives remained primarily married or widowed part-time workers. Training for midwives was instituted early in Sheffield. Those trained had fairly high caseloads for the period, but their social and economic status was no different from non-trained midwives in the area. Regulation had a significant impact on the attitude of doctors towards midwives, who were increasingly viewed as part of a medical structure of care. Some midwives attempted to pursue collective action in order to improve their prospects, but they were in the minority. The limits to their professional development were demonstrated by their lack of control over supervision, their subordinate relationship to doctors, and their inability to work in unison.
KEYWORDS: midwifery, professions, supervision, hospitals, 1902 Midwives Act, Sheffield,

Britain, nineteenth century, twentieth century I Modern midwives emphasize their status as professionals with a specific programme of training and a specialized body of'expertise'. Equally they stress their position as independent practitioners qualified to provide ante-natal, intra-natal, and postnatal care for the majority of women.1 Historians of midwifery have dated the growing self-awareness of midwives to the period around the time of the first Midwifery Act in 1902.2 There are, however, current debates about the extent to
* 62 Marlcliffe Road, Wadsley, Sheffield S6 4AG, UK. ' S. KitzingerandJ. A. Davies (eds.), The Place of Birth (Oxford, 1978); J. Garcia, R. Kilpatrick and M. Richards (eds.), The Politics of Maternity Care: Services for Childbearing Women in Twentieth Century Britain (Oxford, 1990); M.Jowittandl. Kargar (eds.), Radical Midwifery: CelebratingH YearsofA.R.M. (Ormskirk, 1997). 2 J. Towler andj. Bramall, Midwives in History and Society (London, 1986); J. Donnison, Midwives and Medical Men: A History of the Struggle for the Control of Childbirth (2nd edn., London, 1988); B. V. Heagerty, 'Gender and Professionalizarion: The Struggle for British Midwifery, 1900-36' (unpublished Ph.D. thesis, Michigan State University, 1990); B. V. Heagerty, 'Reassessing the Guilty: The Midwives Act and the Control of English Midwives in the Early Twentieth Century', in M. Kirkham (ed.), Supervision of Midwives (Hale, 1996), pp. 1327; N. Leap and B. Hunter, The Midwife's Tale: An Oral History from Handywoman to Professional Midwife (London, 1993); E. Fox, 'An Honourable Calling or a Despised Occupation: Licensed Midwifery and its Relation to District Nuning in England and Wales before 1948', Social History of Medicine, 6 (1993), 237-59. For midwifery research in other countries, see C. G. Boist, 'The Training and Practise of Midwives: A Wisconsin Study', Bulletin of the History of Medicine, 62 (1988), 606-27; C. G. Borst, Catching Babies: The Professionalisation of Childbirth, 18701920 (London, 1995); E. R. Declerq, 'The Nature and Style of Practice of Immigrant Midwives in Early Twentieth Century Massachusetts', Journal of Social History, 19 (1985-6), 113-29; M. J. van Lieburg and H. Marland, 'Midwifery Education, Regulation, and Practice in the Netherlands During 0951-631X Social History of Medicine Vol. 11 No. 3 pp. 403-^20

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which modern midwifery can be considered to be a profession as it lacks autonomy.3 It has been argued that a profession can largely be defined by the control it exerts over its own entry, training, and work.4 Midwifery, together with nursing, has been characterized as a 'semi-profession' in the service of the male dominated 'true' profession of medicine.5 This paper argues that these conditions were institutionalized in the period under consideration and that midwifery did not develop as a profession. Three factors impacted significantly on the occupation: (i) relationships between midwives and other health professionals, including doctors and the local supervising authority; (ii) the social position of midwives and the way in which they worked; and (iii) the lack of a common identity amongst midwives. This paper focuses on Sheffield, an English city dominated by the heavy industries of steel making and mining. Employment opportunities, for married women in particular, were very poor.6 Midwifery was one of the few areas where women did work. Yet despite midwifery training for a section of the midwives in the city from 1879, and the influence of the 1902 and 1936 Midwives Acts, the social profile of midwives did not alter dramatically over the period.7 Midwives in Sheffield remained primarily married or widowed part-time practitioners, without much sense of a common professional purpose. However, the attitude of local doctors and health officials to midwives became far more favourable over the period with a growing willingness to accept that they fulfilled a necessary role. This change in attitude was the most significant effect of the 1902 Act in Sheffield. Midwives in Sheffield belonged to one of three identifiable groups. The first group were trained midwives who worked under the auspices of the Sheffield Hospital for Women (later the Jessop), which opened in 1864; the second group were the independent practitioners in the city; and the third group were casually emthe Nineteenth Century', Medical History, 33 (1989), 296-317; see also H. Marland, 'Questions of Competence: The Midwife Debate in the Netherlands in the Early Twentieth Century', Medical History, 39 (1995), 317-37. 3 A. Symonds and S. C. Hunt, The Midwife and Society: Perspectives, Policies and Practice (London, 1996). 4 T.Johnson, Professions and Power (London, 1972). 5 A. Witz, Professions and Patriarchy (London, 1992); S. Robinson, 'Caring for Childbearing Women: The Interrelationship Between Midwifery and Medical Responsibilities', in S. Robinson and A. M. Thomson (eds.), Midwives, Research, and Childbirth, vol. 1 (London, 1989), pp. 8-41; S. Robinson, 'Maintaining the Independence of the Midwifery Profession: A Continuing Struggle', in Garcia, Kilpatrick and Richards (eds.), The Politics of Maternity Care, pp. 61-91; S. Kitzinger (ed.), The Midwife Challenge (London, 1991). 6 In the 1911 Census only 7 per cent of married women in Sheffield were employed. This compared strikingly with textile towns where the employment of married women was more common. The 1911 Census gave figures of 31 per cent of married women in employment for Bury, 40 per cent for Burnley, and 43 per cent for Blackburn: Census 1911, table 13; H. M. Govt., 'Maternal Mortality in Connection with Childbearing and its Relation to Infant Mortality', L.C.B. 44th Annual Report, 1914-15, Supplement, cd 8055, p. 122. See also T. Mclntosh, 'A Price Must Be Paid for Motherhood: The Experience of Maternity in Sheffield, 1879-1939' (unpublished Ph.D. thesis, University of Sheffield, 1997). Regulation of midwives started with the implementation in 1905 of the 1902 Midwives Act which laid down training schedules for midwives, together with a strict moral code and disciplinary procedure: Midwives Act, 1902 [2.Edw.7.c.l7]. The 1936 Act obliged local authorities to ensure provision of a salaried midwifery service, and to pension off any independent midwives no longer required: An Act to Amend the Midwives Acts, 1902 to 1926,1936 [26. Geo.5 & l.Edw.8.c.4O].

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Profession, Skill, or Domestic Duty? ployed 'handy women'. 8 The self-designation of'midwife' implied that a woman regarded herself, to some degree, as an 'expert' with skills and knowledge. Those found in the records who described themselves as 'midwives' were a distinct group, and not completely representative of all those practising. Women who practised very casually, such as handywomen, are almost impossible to trace.

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II In nineteenth-century Sheffield parturient women were attended by independent midwives or by doctors, each group attending about 50 per cent of births. Midwife births were concentrated in the working-class centre and east end. Doctors attended the majority of cases in the wealthier western suburbs. After 1833 mothers could engage a midwife retained by the Public Dispensary, later the Royal Hospital, although some local medical men fiercely opposed this service: 'The employment of women in midwifery cases is highly injurious, and does not afford that protection to the patient which is required at so critical a time.' 9 The Sheffield Hospital for Women opened in 1864 with six gynaecological in-patient beds and a domiciliary midwifery service.10 After 1912 its role in providing in-patient deliveries became increasingly significant. The founder of the Sheffield Hospital for Women was J. H. Aveling. After leaving Sheffield in 1868 he entered practice in London, where, in 1873, he cofounded the Chelsea Hospital for Women. He became a prominent figure in debates over a midwifery regulation in the 1880s and 1890s. Aveling had always supported the practice of midwives as an adjunct to general practitioner services, believing that midwives were of use primarily to working-class women, who were unable to afford the services of a doctor.11 He championed this belief in registration debates, but the idea was actually given its earliest expression back at the Jessop in Sheffield where, in the ten years after Aveling had departed, it was decided that to attract poorer women into midwifery training: 'the Staff are empowered to pay the Midwifery trainers a salary not exceeding 1 0 per annum to be paid quarterly.'12 This was in comparison to other regional hospitals where fees of up to 20 for training were common, and London where a trainee might pay 3 0 to 50. 1 3 Until 1905, when it became bound by the conventions of the 1902 Midwives Act, the Jessop Hospital was unique in allowing its trainees to be paid for their training
8 The main source for the Jessop Hospital is the Weekly Board Minutes (hereafter referred to asJessop Minutes). They are currently held by the Jessop Hospital. 9 Prior to the 1864 opening of the Hospital for Women, the Public Hospital had covered about 250 cases per year, by 1874 this had dropped to below 150, and the decision was taken to close the service: M. P. Johnson 'Medical Care in a Provincial Town; The Hospitals and Dispensaries of Sheffield, c.1790-1860' (unpublished MA Dissertation, Sheffield University, 1977), p. 122; Royal Hosmtal Minutes, 8 October 1874, Sheffield City Archives, 333/H1. It was renamed the Jessop Hospital for Women in 1878, in recognition of one of its major benefactors, Thomas Jessop (1804-87), a local steel magnate who provided the funds for a new building. 11 Aveling was also editor of the Obstetrical Journal and a co-founder in 1884, of the British Gynaecological Society: see Obituaries in British MedicalJournal, II (1892), 1349-50; Lancet, II (1892), 1477. 12 Jessop Minutes, 9 June 1879. 13 Donnison, Midwives and Medical Men, p. 120.

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period by working on the wards, although this was common practice for nurse training.14 In return for their wages, the Jessop expected twelve months work from midwives, followed by the take up of district work if it was available. Unfortunately no training schedules appear to have survived so it is hard to say what subjects were being covered in lectures by the medical staff. Women were expected to attend 30 cases of labour, suggesting a reasonable grounding in practical obstetrics.15 Midwives were trained only to attend 'natural labours' and to recognize complications which were beyond their skills, and for which they should summon medical assistance. However, despite this emphasis, midwives during this period probably were covering a far wider range of cases than a midwife would be happy to deal with in a home birth today.16 The Jessop's training programme aimed to train midwives to work for the Hospital. However, several cases illustrate the difficulties of this position.17 Emma Winter left her post for more certain remuneration as a nurse in 1891. She was granted a certificate in recognition of the time she had been at the Jessop on condition that: . . . it should not be written upon official paper. The Medical Staff at the same time beg to point out to the Board that the granting of this Certificate is a dangerous precedent, as the Nurse in question, Emma Winter, has broken her contract with the Hospital. It opens up the whole question as to training of Midwives for other than the purposes of the Hospital, and any conditions under which that can be done must be entirely different to those under which women have hitherto been trained for our own purposes. The concern of the medical staff pointed to the contradiction in their training system. If they were producing midwives of good calibre, whose services were marketable, there was then the question of how to retain the use of these midwives for the primary benefit of the Hospital. They faced a tension between providing training for the sake of the Hospital, and for the benefit of individual women, who, once trained, might choose to take their skills elsewhere. The seven or eight Jessop midwives covered between 50 and 200 cases in each quarter. Although the caseloads for some midwives, or some districts, might have been heavier than others, the average number of cases dealt with by each midwife per week was 1.4, an average annual caseload of 73. It is likely that the Jessop midwives were either working part-time, or were supplementing their income
Donnison, Midwives and Medical Men, p. 120. Jessop Minutes, 6 February 1888. 16 Both breech deliveries and twins could be dealt with as 'normal' births, as were older mothers, and those with a high number of previous pregnancies; all of which would be considered 'risk' factors requiring hospitalization today. Therefore, although midwives were trained to attend 'normal' deliveries, the boundary between what might be perceived as 'normal' or 'abnormal' was not a constant. Leap and Hunter, Midwife's Tale, pp. 14856; S. Inch, Birthrights: A Parents Guide to Modem Childbirth (London, 1982). 17 One trainee wanted to go to a job in a Poor Law hospital, which the Board felt would be in breach of her contract. They would not allow her to leave as 'she would be expected to take to charge of one of the Midwifery Districts attached to the Hospital' when her period of training expired {Jessop Minutes, 28 April 1883). A similar problem arose in 1893, when a trainee left with one day's notice, claiming that she had learned enough midwifery to practise in Africa where her husband was a soldier {Jessop Minutes, 1 November 1893). 18 Jessop Minutes, 14 July 1891.
15 14

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through private work.19 Their average annual income by c.1900 was 20; t n j s p U t them in a high earning bracket for midwives generally, suggesting that being trained by and attached to a hospital at least guaranteed a certain minimum level of practice.20 However, even this was by no means a living wage in a city where wages for skilled male workers averaged 100 per annum.21 5 / - (5 shillings) per week rentals, which were common in Sheffield at this time, would have swallowed almost all of a midwife's income, even at such a high level of practice. The impact of different family structures on the ability of midwives to work is illustrated by two of the Jessop's midwives. In January 1901, midwife Christina Eckhardt, who had been attached to the Hospital since it first opened in 1864, retired at the age of 73. The Hospital Board were loath to award her anything in the way of a pension, but finally agreed to a suggestion by the medical staff to give her a certificate saying that she had been an efficient and satisfactory midwife, and to award her an allowance in kind of 5/ per week.22 The allowance granted to Eckhardt almost matched her weekly earnings from Hospital cases. By 1891 Eckhardt was a widow, but lived with her youngest daughter and her family; she did not therefore have to support herself entirely. Her family support structure had allowed her to continue working in this way. This was in contrast to her counterpart Emma Winter, who, as has been noted earlier, resigned in 1891, saying that: 'I find I can not obtain sufficient to even pay my lodgings. I have therefore applied to a Home as a Nurse and been accepted. I am out since January and earning 5/ a week.' 23 At 5 / - a case, this implies that she was attending one case a week, which was about the standard rate, although work in a nursing home would have meant more regular and certain remuneration. According to the Census taken in that year Mrs Winter was a 40 year old widow living in a lodging house, and would therefore have needed a regular income in order to support herself. After 1905, the Hospital no longer trained midwives who necessarily would work there. It was accepted that the Jessop was now only a training centre for most of its pupils, and that they would find employment elsewhere. From April 1905, there were four probationers, each paying 15/15/0 for three months' training, and supplying their own uniforms. This probably enforced the concept of'gentlewomen' midwives as working-class women would not have been able to afford the fees or the uniform. Some local councils took responsibility for the provision of midwives in their area by paying for their training.24 However, the Jessop experi19 Fees paid to district midwives increased from 3 / - per case to 5 / - between the opening of the Hospital in 1864 and the end of the system in 1905. 33 per cent of the midwives surveyed by the Midwives' Institute earned less than 5 0 per year; 14 per cent received more than 200 per year. 1 Nurses working in institutions around the turn of the century were paid between about 2 0 and 25-per annum, although they were provided with maintenance, laundry, and uniforms on top of that. Midwives had to provide all their own equipment, uniform, and accommodation. B. AbelS m i t h , A History of the Nursing Profession ( L o n d o n , 1975), p p . 2 8 0 - 1 . 22 Jessop Minutes, 10 D e c e m b e r 1 9 0 1 . 23 Jessop Minutes, 12 M a y 1 8 9 1 . 24 For example in 1908, Derbyshire County Council, which had rejected as too complicated the concept of establishing a midwifery training school in Chesterfield, was granted permission to send thirteen pupils a year to the Jessop, at a total cost of 200: Jessop Minutes, 10 March 1908.

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enced difficulties in recruiting sufficient trainees to ensure the smooth running of the Hospital. This had never been a problem before 1905. Ill The majority of midwives in Sheffield between 1881 and 1936 were independent midwives. Many advertised their services in trade directories. The entries gave names and addresses, and using this information, it has been possible to trace a proportion of them through the Census. Midwives were not listed as a trade category in the 1871 directory, and as the 1901 Census is not yet available, only those for 1881 and 1891 have been pursued. For 1881, it was possible to trace 17 out of the 20 midwives named in the directory; 10 years later 23 out of 35 were located. Tables 1 and 2 give details of the findings.25 The Table for 1881 (Table 1) illustrates that there was an even split between married and widowed practitioners, with their ages being in the same range whatever their marital status. It might be expected that widows needing to support themselves would have been more determined to style themselves 'midwife' than women with employed husbands. This was not the case, however, and midwives with working families were most likely to designate themselves as 'midwives' whatever their marital status. This may have reflected the fact that lessened domestic responsibilities meant that they had more time to devote to midwifery. Whether midwives were designated as such in the data, perhaps reflected the views of the head of the household or the enumerator as much as the midwife herself. The relatively high numbers returning as 'midwives' suggests that those who advertised their services were probably fairly professional in the way they viewed themselves and their work, in the sense that they felt themselves to have a specific occupational identity. Tables 1 and 2 both illustrate the family structures which allowed midwives to undertake their work. Sheffield midwives had primarily older children who often brought in extra income from their own employment, usually in the steel trade or as domestics.26 The husbands of married midwives were generally skilled workers, primarily in the light metal trades. Across the two tables, five of the widowed midwives, and three of the married ones supplemented their incomes by taking in lodgers. This was an extension of a family service in much the same way as midwifery. They were both roles which provided some income whilst being home or neighbourhood based. Additionally, of the 19 widowed midwives, six lived with their immediate family of unmarried children. A further seven had extended family living with them, principally married children. Finally three widowed midwives lived in the home of another family member, in these cases all daughters. None of these midwives relied entirely on their own income. The Midwives Roll, an annual list of all registered midwives, published after 1905, included two types of midwives, those trained, and those untrained but
25 As with many people of their class, they were geographically very mobile, and some were impossible to trace, not being at the address listed in the Directory at the time of the Census. 26 Borst has found that the same situation prevailed in Wisconsin, USA: Borst, Catching Babies.

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TABLE 1. Midwives in Sheffield 1881

Name Mrs Charlotte Ashforth Mrs Eliza Broadhurst Mrs Amelia Brown Mrs Sarah Coldwell Mrs Mary Ann Gascoigne Mrs Martha Jennet Mrs Elizabeth Jarvis Mrs Sarah Law

Age 62 63 54 44 50 59 35 59

Marital status married married widow married (but husband not mentioned on census) widow married married widow

Children at home 3 4 2 24 year old lodger, (engine tenter) 1 (and 1 f. lodger) 3 living with her daughter, sonin-law, and their 4 children. 2 (and 1 nephew) (all working) 3 1 (and son-in-law) 4 2 2 (and 1 son-in-law) 1 (and 1 boarder) 1 (and 4 member family of lodgers) 1 (and son-in-law and 4 small children)

Age of children 28,24,17 (all working) 36, 19, 15,12 (3 working) 20,16 (both working) 23 (working) 13,5,6 m 30

Husband's employment saw grinder knocker up (mould maker for steel works) 'formerly mechanics wife' scavenger razor grinder

Midwife in Census? yes yes no yes no no no yes

Mrs Eliza May Mrs Mary Roberts Mrs Mary Scott Mrs Elizabeth Simpkins Mrs Mary Somerset Mrs Sarah Staniland Mrs Lucy Steedman Mrs Mary Warriss Mrs Emma Warren

57 49 55 50 51 54 53 60 49

widow widow widow married widow widow married widow married

17,14,19 21,13,9 (2 working) 28,22 (both working) 25, 19,16, 10 (2 working) 21, 14 (both working) 31,17,12 (2 working) 19 20 25

table knife grinder insurance agent steel maker pensioner

yes yes yes no yes yes yes yes yes

I
5

Sources: Trade Directory and Census.

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T A B L E 2. Midwives in Sheffield 1891 Name Mrs Emma Bartholomew Mrs Ann Case Mrs Susannah Coggan Mrs Sarah Copley Mrs Christina Eckhardt Age 50 50 66 65 63 Marital status married married married widow widow Children at home 4 3 (employed 1 servant) 1 (and 1 son-in-law, and 5 grandchildren) living with daughter, son-in-law and 3 grandchildren 2 (2 female lodgers) 2 (and 2 grandchildren) 2 (and 1 niece) 4 1 1 (and son-in-law, 1 grandson, 3 boarders) Age of children

Husband's employment joiner vice maker not working

Midwife in Census? no yes yes yes yes

20,18,16, 14 (all working) 2 1 , 1 9 , 1 5 (all working) 31

Mrs Emily Ibbotson Mrs Caroline Ingelby Mrs Eliza Innocent Mrs Elizabeth Jarvis Mrs Fanny Kaye Mrs Ann Kingston Mrs Jane Kirk Mrs Esther Longmore Mrs Mary Ann Martin Mrs Ann Pearl Mrs Charlotte Rodgers Mrs Sarah A Sheldon Mrs Maria Straw Mrs Hannah Timms Mrs Elizabeth Thompson Mrs Sarah Ann Wainman Mrs Jane Walsh Mrs Betsy Wilde

68 43 61 45 45 52 36 64 47 58 66 42 50 54 73 45 57 42

widow widow married married widow married married widow married widow married married married widow widow married widow single

2 4 , 1 8 ( 1 working) 21,17,11,8 15, 10, 5 (1 working) 18, 15, 12,10 (2 working) 12 30 29, 14, 12 (2 working) 36, 28 (both working) 19,18 (both working) 22,20, 18,16,14, 12, 9, 7, 6, 2 (3 working) 19 (working) 17,16 (both working) 34 (working)

engine tenter razor grinder file maker labourer 'helper' tool filer

yes yes yes yes yes no yes

3
2 2 grandchildren 10 (and 1 lodger) 1 (and 1 servant) 2 (and 2 grandchildren) 1 (and daughter-in-law and 1 grandson) 7 living with widowed daughter, grandchild, son and lodger living with widowed mother; who lives on own means

yes yes yes no yes no no no yes

I
I

a*

edge tool forger ('too old to work') spring knife cutter labourer scale cutter joiner 'accouchuee diplomec'

17,16,14,12,11,9,5 (2 working) 25, 16(1 working)

Sources: Trade Directory and Census.

Profession, Skill, or Domestic Duty? TABLE 3. Numbers of midwives in Sheffield, 1905-1939

Year Certified on Roll 54 46 46 36 . Certified practising

411

Bonafide on Roll
79 66 58 54

Bonafide
practising

Total on Roll 133 130 120 112 104 96 90

Total practising

1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1921b 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939

25 16 23 22 21 30 27 27 30 43 53 53 53 54 60 63 68 69 65 63 65 65 76 81 72 65 63 63

[28]" [21] [34] [32] [35] [45] [44] [44] [49] [75] [77] [77] [76] [79] [81] [86] [88] [88] [89] [90] [90] [90] [93] [95] [97] [100] [100] [100]

65 59 45 46 39 36 35 34 31 14 16 16 17 14 14 10 9 9 8 7 7 7 6 4 2 0 0 0

90 75 68 68 60 66 62 61 61 57 69 69 70 68 74 73 77 78 73 70 72 72 82 85 74 65 63 63

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' Figures in square brackets indicate percentage of total practising. b 1916-20 no data. Source: MOH Reports, Sheffield.

considered acceptable by virtue of long practice. This latter group were described as bonafidesand their inclusion was for the pragmatic reason that there were not enough trained midwives to cover the workload. Training was a necessary condition of practice for those applying for inclusion on the Roll after 1910, with the implication that the bonafideswould eventually become too old to practise. Table 3 illustrates the gradual decline in untrained midwives after the 1902 Act. National figures suggested 87 per cent of midwives were trained by 1925, rising to 97 per cent by 1935.27 Sheffield was slightly behind this average with 79 per cent of midwives trained by 1925, but had nearly reached the national average in 1935 with 95 per cent of midwives trained. Given that one bonafide leaving practice could make a substantial difference to the proportions, the difference is probably not significant. The growing influence of the trained midwives was undoubted, although
27

Heagerty, 'British Midwifery', p. 187.

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several bonafides lingered on in practice for almost thirty years after their last point of acceptance on the Roll. The figures also demonstrate that the total numbers of midwives fluctuated, but was falling in the long term. Numbers fell from 85 to 63 between 1935 and 1939, although the numbers of midwife-attended home births were stable. Fewer midwives meant a more full-time practice for those who remained, which was the intention of the 1936 Midwives Act. As Table 4 demonstrates, however, the influence of the bonafidescontinued to be significant in the years immediately after the 1902 Act in that they retained the highest caseloads. It might be thought that these women were the archetypal parttime, non-professionally oriented workers, yet the figures suggest that they were successful in supplying a considerable amount of demand. In the mid-1930s the Midwives' Institute took 100 cases annually as a definition of full-time midwifery, in which case few of the trained or untrained groups were fulfilling this level of practice in 1916.28 In 1935, the Midwives' Institute conducted a survey into conditions of midwifery practice to ascertain the potential effects of the 1936 Midwives Act.29 Analysis of the results for Yorkshire (including Sheffield), Durham, Hampshire, and part of Lancashire demonstrated that 50 per cent of the 562 midwives surveyed in independent practice had fewer than 50 cases per year; only 20 per cent had more than 100. The Report of the Midwives' Institute noted that 'Except for a small minority, the practice of the independent midwife does not afford a living wage'.30 Midwives were far from being a homogeneous, 'professional' group, but were divided by age, training, level of practice and income, both before and after registration. To get an impression of the changing nature of midwifery practice in the decades after the introduction of the 1902 Midwives Act, lists of midwives advertising in the Sheffield Trade Directories were compiled for approximately five-year intervals (Table 5).31 They did not cover all of the midwives listed as in practice on the Roll, nor was it possible to trace the addresses of all of them, but enough of those practising have been recorded to give an idea of the development of the
TABLE 4. Annual caseloads of midwives in the West Riding, 1916 <10 Independent Trained dependent Total Untrained 37 29 66 10 10-20 10 8 18 84 21-40 12 12 24 92 41-60 4 2 6 44 61-100 8 0 8 37 >100 7 0 7 15

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Source: L. A. Bullough, 'Midwifery Service in the West R i d i n g Administrative Area', Public Health, 31 (1917), 1 2 6 - 3 2 .
28 Data for other areas bear o u t the impression that midwifery remained a largely part-time, l o w income, low status occupation. In 1933, of 110 practising midwives in Manchester, only 50 were solely dependent o n midwifery for a living, and 18 of those lived with relations. T h e remaining 60 w e r e all married, and of these 45 w e r e definitely stated not to be in full-time practice; Lancet, I (1935) p. 937. 29 For a full discussion of this survey, see Heagerty 'British Midwifery', p . 246. 30 Lancet, II (1935), 1 0 0 9 - 1 0 ; see also British Medical journal, II (1935), 8 6 2 - 3 . 31 The intervals are approximate because Directories are not extant for all years.

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TABLE 5. Midwives in Sheffield, 1881-1940

Year Total practising Midwives on Roll 1881 1891 1898 1905 1910 1916 1920 1925 1931 1935 1940
b

Total midwives In directories 20 35 29 35 52 50 50 56 47 59 58

Total midwives With address data 17 23 26 28 41 38 38 48 40 54 46 53 54 57 b

Average age M 8 [47] 12 [52] 6 [23] 5 [18] 10 [24] 11 [29] 11 [29] 6 [13] 11 [28] 14 [26] 16 [35]

Marital status' W 9 [53] 10 [43] 26 [77] 21 [75] 25 [61] 27 [71] 24 [63] 32 [67] 21 [53] 27 [50] 9 [20] S 0[0] 1[4] 0[0] 2 [7] 6 [15] 0[0] 3 [8] 10 [21] 8 [20] 15 [28] 21 [46]

68 68 70 85 63

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' Marital status: M = married; W widowed; S = single. Figures in square barackets are percentages. For the 45% of midwives where information was available. Sources: Trade Directories and MOH Reports, Sheffield.

occupation. The figures probably overestimate the numbers of unmarried midwives, and are probably over representative of those who were qualified, as it is likely that these were the more 'professional' full-time midwives, most likely to be advertising their services. The marital status of midwives in England changed significantly between 1911 and 1931, with the percentage of single midwives rising from 16 to 47 per cent. Midwifery as an occupation for single women was slow to develop in Sheffield. The sudden reversal in fortune for widowed and single midwives after 1936 illustrates the impact of the municipalization of midwifery. Widowed midwives, likely to have been older and possibly more resistant to medical hegemony in their practice, were among those pensioned off. There were more widowed midwives in Sheffield than nationally. In England the percentage of widowed midwives fell from 33 per cent in 1911 to 20 per cent by 1931.32 Possible reasons for the greater proportion of widowed midwives in Sheffield are speculative. They are perhaps connected to the industrial profile of Sheffield, with few married women working. The good wages paid to male workers meant that generally there was no economic need for their wives to work. Many women only needed their own income once they were widowed, and midwifery was an acceptable occupation. The activities of the handywomen who attended deliveries on what was probably a very sporadic basis, are impossible to identify. The very nature of their work, casual and intermittent, with reputations spread by word of mouth, does not lend itself to written records. The Medical Officer of Health (MOH) suggested that there were as many as 30 handywomen in practice in Sheffield before 1910, and that in 1909 more than 3 per cent of cases were handled by them. The practice of midwifery by unqualified women 'habitually and for gain' was prohibited after
32

Heagerty, 'British Midwifery', p. 189.

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1910.33 The following year, after three prosecutions for unqualified practice, the MOH remarked that 'the practice of the "handywoman" seems now to be almost a thing of the past in Sheffield'.34 There is no direct evidence for Sheffield to indicate whether this optimistic assumption was true or not, but information from other areas suggests that it was likely to have been somewhat premature.35 It was estimated that in Rotherham in 1907-8, 25 per cent of births were attended by handywomen. The handywomen were scathing of new midwives who only had three months training.36 As late as 1939 the Sheffield branch of the Midwives' Institute, the main representative body for midwives, was fulminating against the continued practice of handywomen in the city.37 IV Midwives faced competition from doctors and from hospitals for a share of the declining number of births. It has been argued that midwives contributed to their own decline in independence and status by failing to act as a cohesive profession in their own interests.38 The willingness of one midwife in Sheffield to have another prosecuted in 1906 for the supply of diachylon, a lead based abortifacient, bears this out.39 In 1909 a certified midwife complained in a local newspaper that trained midwives such as herself had been described by a doctor as 'scantily qualified practitioners' who took cases and fees that righdy belonged to GPs.40 This illustrates the batdes being fought between GPs and midwives over the division of cases, but also the tensions between midwives themselves. The same midwife accused handywomen of being 'old women, absolutely ignorant, very dirty, exceedingly deaf, and constantly drunk'.41 She further complained that it was an insult to
MOHReport (Sheffield, 1910), p. xvii. MOHReport (Sheffield, 1911), p. 42. 35 Loudon has found that many doctors continued to co-operate with handywomen, using them as maternity nurses: I. Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800-1950 (Oxford, 1992), p . 2 1 8 ; Leap and H u n t e r have found t h e same co-operation between trained midwives and h a n d y w o m e n : Leap and Hunter, Midwife's Tale, pp. 3 5 - 6 . 36 In 1917 it was remarked that ' T h e r e are 29 h a n d y w o m e n in Dewsbury and n o t o n e of t h e m possesses a bottle o f antiseptic'. In Birmingham in 1929, there were still believed t o b e about 100 h a n d y w o m e n operating, mostly under cover of doctors: M . Chamberlain, Old Wives' Tales: Their History, Remedies and Spells (London, 1981), p . 115; L. A. Bullough, 'Midwifery Service in the West R i d i n g Administrative Area', Public Health, 31 (1917), 126-32, p . 132; E . Cassie, 'Maternal Mortality and Allied Problems', Public Health, 4 2 (1929), 3 2 9 - 3 3 , p . 333. Data from Wakefield City Health Department shows that as late as 1930 there was still significant activity by h a n d y w o m e n in the area: J. B. Wilkes, ' T h e Last of the H a n d y w o m e n ' , Midwives Chronicle and Nursing Notes (July 1992), 1 7 8 - 9 . 37 Sheffield Branch, Midwives' Institute, Minute Book 1938-48, 14 March 1939. Sheffield City Archives, S63/H5/1-2. 38 Reagan has argued that in the USA midwives worked together only in a defensive way to resist claims that they were abortionists: L. J. Reagan, 'Linking Midwives and Abortion in the Progressive Era', Bulletin of the History ofMedicine, 69 (1995), 569-98, p. 584; Declerq 'Immigrant Midwives', p. 125. 39 Sheffield Telegraph, 2 4 O c t o b e r 1906, p . 3 . 40 Sheffield Telegraph, 3 M a r c h 1909, p . 6. It was true that there w e r e calls for training periods t o b e extended, but that this could not be done without further restricting the supply of midwives: Report of the Departmental Committee to Consider the Working of the Midwives Act, 1902, vols. 1 and 2, pp. 1909, xxxiii, cd 4822, vol. 1, p. 9. 41 Sheffield Telegraph, 12 March 1909, p. 8.
34 33

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trained midwives to have bortafideson the Register. This does suggest that they were distinct groups of midwives, and also that the development of midwifery education was increasing rather than reducing these tensions. Heagerty has argued that these tensions were deliberately fostered by the Midwives' Institute, who represented the midwifery leadership, in an attempt to professionalize the activity and to exclude older, working-class, ill-educated, and later even married midwives, who did not fit the middle-class standard. It was believed by the Midwives' Institute that working-class midwives were responsible for high infant and maternal mortality.42 Local tensions do not suggest conspiracy. Rather they were the result of midwives having different backgrounds and differing social and economic needs. This, together with the effect of a shrinking pool of work available for independent midwives, given the reduced numbers of births and increasing use of hospitals, meant that midwives were in fierce competition for work. There is only one recorded instance of a group of midwives working together in Sheffield, and this was a short lived and geographically limited action. In August 1910, it was reported that midwives at Pitsmoor and Brightside, heavy trade areas in the east of the city with high birth rates, had gone on strike to demand payment in advance for their services. One midwife stated that: We are simply sick and tired of being called out at all hours of the day and night to render the skilled attention needed when in so many cases we can not get our fees . . . they seem to think that because we are certified we are compelled to come at their beck and call. But we're going to teach them different. It was further commented that: 'I think its time we midwives in Sheffield had a union. The doctors sometimes refuse to attend cases until their fees are paid, and why shouldn't we be equally safeguarded?'43 A resolution was passed by the newly formed 'Damall, Attercliffe, Tinsley and Brightside Midwives Association' that no work would be undertaken without advance fees. A branch of the National Association of Midwives was set up, surviving until 1915, when the parent organization folded.44 The only effect of the action appears to have been that a midwife, Mrs Maria Goose, was censured by the coroner for the death of a child after she failed to attend a birth for which she had been booked. She argued that she did not attend when sent for because she was at another case, although she admitted that the rules of her Association would have prevented her from doing so anyway.45 Superficially it appears that this action, limited though it was, did demonstrate that midwives could work together for a common cause. However, in addition to the
42 Heagerty, 'British Midwifery', pp. xixii. Hannam has argued that the leadership o f the Midwives' Institute was far less h o m o g e n e o u s than Heagerty suggests, and that several were very supportive o f ordinary midwives: J. Hannam, 'Rosalind Paget: T h e Midwife, the W o m e n ' s M o v e m e n t and Reform Before 1914', in H . Marland and A . - M . Rafferty (eds.), Midwives, Society and Childbirth: Debates and Controversies in the Modern Period (London, 1997), pp. 81101; J. Hannam, 'Some Aspects of the History of the Royal College of Midwives', in S. Robinson and A. M. Thomson (eds.), Midwives, Research and Childbirth, IV (London, 1996), 1 0 - 3 2 . 43 Sheffield Telegraph, 5 August 1910. 44 T h e National Association o f Midwives was created from smaller groups operating in the M a n chester area: Heagerty, 'British Midwifery', pp. 1 0 2 - 1 1 . 45 Sheffield Telegraph, 7January 1911, p. 7.

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restricted geographical spread of the action, it accurately demonstrated the disunity of midwives in the sense that it was the new certified midwives who were taking action. Their insistence on their expertise and professionalism as justification for their high fees, and their mention of a common cause with doctors, hints at attempts to be seen as professionals. It also highlights efforts by certified midwives to distance themselves from the bonafide midwives and from handywomen. The action was therefore at least potentially divisive. Heagerty has suggested that the National Association of Midwives, and a contemporary group, the British Union of Midwives. were representing rank and file midwives in calling for less disciplinary supervision and greater autonomy of practice, but those involved in the Association in Sheffield appear to have been the midwifery elite of the area.46

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In the nineteenth century midwives were often seen by doctors as rivals, and their inferiority of training and cognition was stressed. Dr Aveling, founder of the Hospital for Women in Sheffield, wrote in 1864 of the 'ignorance and incompetence' of midwives throughout history.47 One of his chief stated reasons for championing the establishment of a hospital for women was to relieve the suffering caused by 'ignorant' midwives: In Sheffield we have a few able midwives, who understand their business well, and prove themselves sources of comfort to many poor sufferers; but we also have a larger class, pretentious and ignorant, causing grief and misery . . . The ignorance met with among midwives in this town is notorious to every medical man.48 Such statements should be read in the context of the national debate over the place of midwifery in the practice of general practitioners and the position of unregulated female midwives in a 'professional' structure of male medical care.49 This was despite the fact that until 1886 doctors themselves had no compulsory midwifery element in their training, and that until the nineteenth century midwives could be literate and respected members of their communities.50 After 1902 the position of the midwife become far less contentious among hospital doctors. This was a result of the acknowledgement of the midwife's essential role in the provision of maternity services, as there were not enough institutional beds to cover all deliveries even if this were considered desirable.51
Heagerty, 'British Midwifery', pp. 102-11. J. H . Aveling, English Midwives: Their History and Prospects (originally p u b l i s h e d 1872, reprinted London, 1967); J. H. Aveling, 'On the Instruction, Examination, and Regulation of Midwives', British Medical Journal, I (1873), 3 0 8 - 1 0 . 48 Sheffield Independent, 12 D e c e m b e r 1863. 49 D o n n i s o n , Midwives and Medical Men; I. L o u d o n , Medical Care and the General Practitioner, 11501850 (Oxford, 1986); I. Loudon, 'Obstetrics and die General Practitioner', British Medical Journal, II (1990), 703-7. 50 D. Harley, 'Provincial Midwives in England: Lancashire and Cheshire, 1660-1760', in H. Marland (ed.), The Art of Midwifery: Early Modem Midwives in Europe (London, 1993), pp. 2748, on PP32-4. In 1934 there were 165 maternity beds across the city, which would have provided accommodation for only 25 per cent of the total births that year.
47 46

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The role of birth attendants in the causation of maternal mortality increasingly focused on the role of the GP. 52 The ideal for most obstetricians was for midwives to work under their direction, and totally to exclude the GP. For example, Miles Phillips, a senior obstetrician at the Jessop Hospital in the inter-war years, supported the total institutionalization of delivery: 'The midwife and the obstetrician of the future, working in co-operation, will, it appears to me, conduct more and more and finally all deliveries in specially equipped institutions.'53 By 1940, 40 per cent of births in Sheffield were occurring in institutions, a figure slightly above the national average of 35 per cent.54 Phillips' dream was on the way to being realized. The MOH also had little good to say about midwives prior to the 1902 Act. Midwives were perceived as at best ignorant and at worst downright dangerous. It was assumed that, for example, midwives were the principal carriers of puerperal fever, a streptococcal wound infection which caused 3050 per cent of maternal deaths. The MOH in Sheffield took this view, reporting in 1895 that: This disease [puerperal fever] is, with few exceptions, perfecdy preventable, provided the ordinary simple rules of practice be observed. Unfortunately, gross and culpable carelessness is too often shewn by so called midwives who attend puerperal women . .. few of them are specially educated women, and for the most part have very vague ideas of the precautions necessary to be taken to prevent any infection of their patients. This accounts for the large proportion of cases occurring in their practice as compared with those attended by medical men.55 The following year he complained about midwives being, 'wholly uneducated and ignorant of the first principles of cleanliness and methods of preventing this disease'.56 In 1907 the differences between doctor and midwife cases were made explicit: 46 cases of puerperal fever were notified, in 21 of which the confinement was attended by a midwife. In each of the latter cases arrangements were made for the midwife to have disinfectant baths, and for the disinfection of her clothes and outfit. In each case the possible origin of the disease was investigated and the midwife was temporarily suspended from practice.57 Doctors received no such attention, despite being responsible for the majority of fever cases in that year. However, obstetricians were not the only ones who took another look at midwives in the light of the 1902 Act. The changing attitude of the MOH to the possible value of midwives can be seen in the report of a dinner and entertainment
52 A n Honorary Assistant Surgeon employed by the Jessop studied 154 local cases of'failed forceps' occurring in the practice of GPs between 1924-8: J. E. Stacey, 'Remarks on "Failed Forceps'", British Medical Journal, II (1931), 1073-8. For similar cases in Liverpool, see M . D . Crawford, ' T h e Obstetric Forceps and its Use', Lancet, I (1932), 1 2 3 9 - 4 3 . 53 Lancet, II (1935), 1107-9. M C . Webster, The Health Services Since the War, 1, Problems of Health Care: The National Health Service Before 1957 (London, 1988), p . 7. 55 MOHReport (Sheffield, 1895), p. 18. 56 M O H R e p o r t (Sheffield, 1896), p . 22. 57 MOHReport (Sheffield, 1907), p. 42.

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provided by the Health Department, and the Mayor for city midwives in 1906, just after the implementation of registration.58 The midwives were described as attending in their 'official dress', consisting of white caps and aprons. More significant was the way they were addressed by the Mayor, who commented that midwives should possess: 'a high idea of their calling, and endeavour to exercise an educational influence wherever they went.' He was referring specifically to Council efforts to reduce infant mortality in the city, but the notion of midwifery as a 'calling' was repeated several times in his speech: He appealed to the midwives to take the highest possible view of their calling, and not to be content merely to fulfil those duties they were paid for. They must not only do just what was necessary but must also try to do good to others if they possibly could, and he could conceive of no other body of people who had greater opportunities for good than had midwives. Midwives were being rehabilitated in a manner which carried overtly religious overtones. They were conceived as potential 'missionaries' in the spread of ideas concerning health and hygiene to mothers, and particularly in the fight against infant mortality.59 The Health Department did not distinguish between the trained and bonafide midwives, but appropriated them all as potential propagandists for its message. The 1902 Midwives Act provided for the supervision of midwives, to ensure cleanliness and safe practice, although the Act did not specify by whom this supervision should be undertaken.60 The influence of individuals on the local implementation of the 1902 Act can be demonstrated. In Sheffield midwives were subject to supervision by the Women Sanitary Inspectors, themselves all certified midwives, a less overtly medical model than in areas such as Manchester.61 The MOH in Sheffield was committed to the work of the Women Sanitary Inspectors and believed that they were havirig a significant impact on improving infant health. He hoped to extend this benefit to mothers by placing the Inspectors in charge of midwives. This contrasted with Manchester where supervision was placed in the hands of one particularly zealous doctor.62 Although the Women Sanitary Inspectors were non-practising midwives, they at least had some sense of not only the conditions of service of the midwives, but also of the type of women and the areas with which they had to deal. Midwives
Shield Telegraph, 30 O c t o b e r 1906, p . 3. This moral tone of address was h o t unique to Sheffield. I. D o v e , 'Powerful and Peripheral: A History o f Alice Gregory, Lelia Parnell and M a u d Cashmore, Founders of the British Hospital for Mothers and Babies, W o o l w i c h and the National Training School for Midwives' (unpublished M A Dissertation, University of Kent, 1985). 60 T h e background t o the passing of this Act has been comprehensively covered by Donnison, Midwives and Medical Men. 61 Sheffield was the first area in the country to demand of its Women Sanitary Inspectors (WSIs) the triple qualification of nurse, midwife, and sanitary inspector, implemented in 1907. For other areas see C. Davies, T h e Health Visitor as Mothers Friend: A Woman's Place in Public Health 1900-1914', Sodal History of Medicine, 1 (1988), 3 9 - 5 9 . 62 For contrasts between different systems, see J. Mottram, 'State Control in Local Context: Public Health and Midwife Regulation in Manchester 1 9 0 0 - 1 9 1 4 ' , in Marland and Rafferty (eds.), Midwives, Society and Childbirth, pp. 134-52.
59 58

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Profession, Skill, or Domestic Duty? were visited in their homes by Inspectors. The years immediately after registration saw high levels of visits, with a peak of five per midwife per year being reached in 1910. These were probably concerned with the adaptation of midwives to new regulations concerning clothing, equipment, and practice. Thereafter visits varied from between one and three a year. The frequency of visits did not diminish with the increasing hegemony of the trained midwife, suggesting the continued desire to keep an eye on them. Heagerty has discussed the punitive use of supervision as a deliberate method of excluding working-class midwives, and has recorded cases across England of midwives being struck off for drunkenness or illegitimate pregnancy.63 The evidence for Sheffield does not bear out this assumption. Two midwives were struck off for classifying infants that had been born alive as stillbirths. One midwife was censured for lack of cleanliness, and another two for failing to summon medical help quickly enough. None of these three last cases was referred to the Central Midwives Board or struck off, suggesting that relations between the supervising authority and midwives were not particularly confrontational. The majority of prosecutions concerning midwives involved the continued practice of unlicensed midwives, the 'handywomen' who were not on the Roll in the first place. In 1906 the MOH gave a course of lectures to all midwives in the city. These included demonstrations of suitable uniforms, and on the use of thermometers, as well as talks on hygiene, and infant feeding. Leaflets were handed out giving details of acceptable baby feeding and rearing practices, and drawing attention to 'various harmful superstitions which are found to be very prevalent in this district'. It is not known whether these were practices indulged in by midwives or by their clients. It does suggest a belief by the MOH that neighbourhood midwives might have more success than the educated Women Sanitary Inspectors in getting mothers to change their habits. It is impossible to say to what extent midwives absorbed the information they were being asked to spread, and whether they passed it on to their patients. In 1932 the MOH set up a domiciliary midwifery scheme which safeguarded a certain level of home births for midwives. Midwives had an average of 33 cases each in 1935; 39 in 1936; 45 in 1937; 49 in 1938; and 46 in 1939. It was GP deliveries which were most badly hit by the competition from hospitals, perhaps not surprising given their supposed responsibility for incompetence and intervention, and consequent high mortality. The creation of such a scheme demonstrates how far the midwife had come since 1902 in the eyes of the Health Department. Many of them were now salaried officials of the Department, a position extended by the 1936 Midwives Act which extended municipal provision. VI Superficially it appears that early attempts to professionalize midwifery did occur in Sheffield; the Jessop Hospital for Women in Sheffield was among the first in the
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Heagerty 'British Midwifery', pp. 21-2, 82-3.

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country to develop training for midwives, and was the first to pay its trainees, which it did from 1879. This pioneering role appears, however, to have had little impact on the way that midwifery was practised in the city. This was probably deliberate; the medical staff at the Jessop had no intention of creating a large professional and articulate body who would compete with doctors for wealthy patients. Instead they wanted to ensure the survival of midwifery as a necessary and safe craft, but one ultimately subordinate to the medical profession. This was consolidated after 1902, when the registration and regulation of midwives increasingly allowed them to be seen as part of a medical team, who help to tackle such problems as infant and maternal mortality. The Midwives Act of 1902 had more of an impact on doctors' impressions of midwives than on the way that midwifery actually was practised, or the type of women undertaking it. Throughout the period, midwives generally continued to be older women, who were married or widowed part-time workers. They remained individual, independent practitioners, and there was only one shortlived attempt by a group of them in Sheffield to take collective action. There appears to be no local evidence to support Heagerty's conspiracy theories about the takeover of midwifery by an-educated elite. This may have been for the pragmatic reason that in a predominantly working-class city like Sheffield there were not enough single middle-class women to make an impact. The regulation and training of midwives allowed them to consolidate their position, by allowing them increasingly to be seen as an important facet of maternity care, rather than as dangerous amateurs. Their role was safeguarded, whilst the influence on their style of practice was minimal. Some trained midwives were seeking a more professional view of themselves, but this had little general impact. The lack of a common identity among midwives remained. Their work continued to be more of an extension of their domestic roles than to be self-characterized as either professional or indeed skilled work.
Acknowledgements

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I am grateful to the University of Sheffield for granting me a part-time fees Bursary for the Ph.D. project from which this paper is drawn and to the Wellcome Trust for a grant towards research expenses. I would like to thank John Woodward, Hilary Marland, and the two referees of this paper.