“Discussions of the Present Situation of Midwives and Swaddling Nurses in Berlin” (1852)
Abstract
In the history of modern science, few social struggles engendered as much passion as the one between midwives and male medical practitioners. Midwives had been attending to pregnant and postpartum women since time immemorial, for it was assumed that women had special knowledge of childbirth. Beginning in the late seventeenth century, however, scientifically trained male practitioners began encroaching on midwives’ turf, claiming that their methods were more successful than traditional practices and folk remedies. In many countries, midwives lost their positions entirely, but in Prussia, as this selection makes clear, they were absorbed into the state medical apparatus. State regulation meant a loss of independence, but it also offered midwives protection from both elite obstetricians, who wanted them banished from childbirth entirely, and unlicensed practitioners, such as swaddling women [Wickelfrauen], whose charlatanry undermined midwives’ status as reputable caregivers. This 1852 account from Berlin offers evidence of the ongoing controversy over midwives’ legitimate domain of practice.
Source
Meeting of March 23
In the March 23rd meeting [of the Society for Obstetrics in Berlin], the regulation pertaining to midwives issued by the Royal Police Headquarters here on February 21 of this year [1852] was discussed. For the sake of our outside readers, we would like to take a closer look at the situation, which originally appeared to be of local significance only, but which, given the size and importance of Berlin, is also of general interest and has therefore, unsurprisingly, already attracted the attention of outside experts. (See: Hohl, “Obstetricians and Midwives,” German Clinic, 1852, no. 32).
For many decades, it has been rather customary for the Berlin population to seek the assistance of obstetricians for both regular and irregular births. Previously, obstetricians usually did not use certified midwives for female assistance during births but rather so-called swaddling nurses; every obstetrician employed one or more of these nurses in his practice. Such a swaddling nurse has not been thoroughly trained in midwifery, but instead has taken a three-month course at the university maternity hospital and has been instructed, according to the course-completion certificate, “in the care and treatment of pregnant and birthing women, women who have just given birth, and newborns,” as well as in the administration “of post-birth enemas, douches, and enemas for mothers.” In addition, she has also acquired more or less advanced skills in examination and in all aspects of midwifery, partly in the hospital and partly in the subsequent practice under special supervision of the physician employing her—it is, of course, in his interest to obtain the most reliable assistance possible. The swaddling nurse has no legal authority to assist in birthing matters, but the practice was such that the swaddling nurse was first called by the laboring woman, and she then saw to it that the appropriate obstetrician was informed and brought in. The swaddling nurse remained with the laboring woman from the beginning to the end of the birth. The obstetrician came and went at his discretion, stayed for an extended period at irregular births that required constant observation or immediate intervention, left in the other cases if they were taking a long time, leaving behind information on the place from which he could be quickly called in, and spent only the final hours at the birthing mother’s bedside to himself handle the actual delivery, perineal repairs, the cutting of the umbilical cord, and the removal of the afterbirth.
Whatever one thinks of this practice, the fact was and is that Berlin has 58 midwives, 158 swaddling nurses, and 256 obstetricians, of whom at least 150 operate in this way, and that approximately half of the deliveries in Berlin, and in particular the majority of deliveries in well-to-do families and the middle classes, and all the deliveries in polyclinics, are handled by obstetricians and swaddling nurses, while the other half is left to midwives.
At various times, attempts have been made to change these circumstances and to secure exclusive birthing assistance rights for midwives. The midwifery teachers, particularly the deceased Hauck, always endeavored to achieve this goal; the directors of the obstetrical polyclinic, Adam Elias von Siebold and Dietrich Wilhelm Busch, and the vast majority of Berlin obstetricians opposed it. At one point, this view caught on with the authorities, and the Altenstein Ministry issued an edict on January 17, 1825, to all the royal governments and the Berlin Royal Police Headquarters, demanding “that obstetricians use the appropriate midwives but not so-called swaddling nurses as their assistants for the deliveries entrusted to them.” (L. von Rönne and H. Simon, “The Medical System of the Prussian State,” I, p. 534.)
On October 20, 1828, a second edict followed, considerably altering the first one. That one read as follows:
“The obstetricians, however, should not be obliged to use any sort of help at all, if they believe that they can attend to the delivery themselves and if they are willing to accept responsibility for any attendant disadvantage to the women who just gave birth and to the newborns. Likewise, laboring women or those who have just given birth cannot be forced to entrust themselves to particular women brought to them by obstetricians; in fact, the women must remain free in all cases to select relatives or other trusted, honorable women to accompany them during delivery and confinement. As a result, they cannot be held responsible or penalized for not having called for a midwife in addition to the obstetrician.”
The practice of obstetricians using swaddling nurses without calling in a midwives remained uncontested after this point; the police only intervened if they became aware of bungling by the swaddling nurses, that is, cases in which the swaddling nurses had conducted deliveries without calling in a physician for supervision, an occurrence that was generally rare and that even more rarely led to the imposition of penalties because of the difficulty of proving such cases.
The deceased Privy Councilor Josef H. Schmidt was appointed to the ministry on 1843; as a former midwifery teacher and as someone unfamiliar with the situation in Berlin, he was understandably vehemently opposed to swaddling nurses and therefore endeavored from the beginning to remove them from their positions. He repeatedly shared with the Society [for Obstetrics] his views and plans, which deviated in this regard from those of the other members, and he arranged for the ministry to issue a circular order, which read as follows:
“In the circular order of January 17, 1825, the royal governments were already made aware of the ills that result from obstetricians using so-called swaddling nurses instead of midwives as assistants before and during deliveries, and leaving tasks to them that only midwives are authorized to perform. For their part, the swaddling nurses, who can be viewed only as orderlies, had to limit themselves to services relating to the care of women who have just given birth and to infants. To eliminate these ills, it was ordered back then that obstetricians were prohibited from using swaddling nurses as assistants and that midwives had to decide whether care for women who had just given birth could be transferred to swaddling nurses under the midwives’ supervision. Since then, this regulation has given rise to protests from some governments, and it appears to have been implemented only in a very piecemeal manner and most recently not at all. However, several communications that have arrived here leave no doubt that the ills that were supposed to have been remedied by the said regulation not only continue but have even become more prevalent, especially in large cities. In fact, many obstetricians, who, out of greed for profit and to the detriment of midwives, endeavor to be called in for regular, easy births, do not actually devote the obligatory care to deliveries but generally rely instead on the assistance of swaddling nurses. While “the obstetrician pursues his practice elsewhere, the swaddling nurse stays with the laboring woman in order to call in the doctor at the moment of birth, but usually delays doing so for too long and delivers the baby without the midwife or obstetrician, under the pretext that the birthing woman was surprised by the birth or that the obstetrician could not be found quickly enough. In the process, many unacceptable methods are said to be used by the obstetrician, on the one hand to expand his practice and on the other to be able to operate with as light a workload as possible, preferably by using swaddling nurses. This especially includes mutual attack [on the midwives] by obstetricians and swaddling nurses and the recommendation of the latter parties by the participating public and even by public newspapers. As this dreadful state of affairs is primarily prevalent here in Berlin, the ministry has first demanded from the local police headquarters an expert report on what methods might be most effective for control.”
Police headquarters considers reinstatement and strict enforcement of the regulation of January 17, 1825, to be most appropriate. However, if this regulation is found to be inadequate or too difficult to implement, the following is proposed:
1) Instruct the public every so often through police notices about the limited authority of swaddling nurses and the limits of their knowledge and competence;
2) Likewise, warn swaddling nurses about interfering with the functions of midwives and obstetricians under threat of express police penalties and issue severe reprimands in the event of any such contravention;
3) Introduce police birth certificates analogous to the police death certificates that were already introduced to prevent charlatanry—a special regulation was enacted a short time ago for their general introduction; the birth certificates would be issued under oath of office by the obstetrician or midwife who had attended the delivery with the express statement that the delivery had been performed by the obstetrician, midwife, or whomever.
Police headquarters considers such certificates an especially effective means to track down, or prevent, charlatanry by swaddling nurses. Finally, it is proposed to
4) Hand out, as is the case for physicians here, a copy of the regulation that cautions medical personnel to exercise care in issuing certificates or warns them in some other suitable form against using illegal assistance for deliveries.
Before the ministry undertakes anything further in this matter, it wishes to hear the royal government’s comments on whether there is need in the district there, or in particular parts thereof, to intervene with special requirements against the chicanery of the swaddling nurses, whether possibly the proposals of the local police headquarters, in particular the reinstatement of the regulation of January 17, 1825, are to be regarded as useful, or how the ills under discussion might be more effectively remedied in some other way.
The ministry expects the report on this subject within two months. Berlin, September 9, 1847
Ministry for Religious, Educational, and Medical Matters [Ministerium der geistlichen, Unterrichts- und Medizinal-Angelegenheiten]
[…]
Source: “Erörterungen der bisherigen Verhältnisse der Hebammen und Wickelfrauen zu Berlin,” Verhandlungen der Gesellschaft für Geburtshilfe in Berlin 6 (1852), pp. 39–44.