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Childbirth, Midwives, Wetnursing

CHILDBIRTH, MIDWIVES, WETNURSING

Amanda Carson Banks

For the majority of western European history, childbirth was viewed as a normal process, and the community was content to allow nature to follow its course. The predominant practices and associated material items and indeed the very language were predicated on this understanding and approach to birth. The Encyclopaedia Britannica (1771) reflected such a philosophy by defining midwifery as ". . . the art of assisting nature in bringing forth a perfect foetus, or child from the womb of the mother." Intervention was rare; doctors were called only in the case of an impossible delivery, the death of the mother, or the death of the child in utero, and the beliefs and traditions of society governed this process.

Since the Renaissance, childbirth, midwifery, and early infant care in Europe have been influenced and shaped by societal issues, resulting in great changes, new understandings, and different practices. The history of this cycle provides an exciting opportunity to observe how broad changes in a society interact with each other to impact and influence a smaller, specific area. Specifically, these changes include the waning authority of the Catholic Church, the Enlightenment and its emphasis on reason, advances in technology and medical knowledge, industrialization and the move of large portions of the population to urban centers, changes in economic structures and the rise of the middle class, changes in belief patterns and structures in both organized religion and "household" or folk religions, and changing definitions and "new" understandings about women's bodies and health.

This history has been approached in a number of different ways and from a variety of perspectives. Until the mid-twentieth century, the history of birth was presented as a continuum of medical advances, charting the role not of the community but of technological developments in the birth process. Works like Albert Buck's The Dawn of Modern Medicine (1920), George Engleman's Labor Among Primitive Peoples (1882), and Herbert Spencer's The History of British Midwifery from 1650–1800 (1927) are examples and were based on a cultural evolutionary understanding of western medicine. Describing practices undertaken and advocated by medical professionals, they did not capture or discuss the experiences of the vast majority of women giving birth, nor did they address the issues of the surrounding society and how these intersected with the process.

In the nineteenth century, early folklorists and antiquarians began to collect what they regarded as "relics of the past," particularly the traditions and beliefs of the more rural areas. Examples associated with pregnancy, childbirth, and infancy were also gathered in this process and included items such as notions about dietary intake and prenatal marking, the divination of the sex of the child, practices and styles of delivery, methods of pain relief, postures for delivery, and the customs and rituals of birth-chamber attendants. These were recorded in large collections of folkways and rural practices and are great resources for historical information.

Later efforts to create a history of birth from a social or cultural perspective placed such traditions and practices in Europe within chronological periods that were seen as having similar or consistent trends and practices. A typical first period begins in the depths of the past with social birth, where women were highly involved in delivery as midwives, mothers, and assistants, practicing a noninterventionist approach that centered around serving the mothers. A second period begins in the mid-1700s with the growing importance of the profession of medicine and the increase in the study and practice of midwifery by male physicians. A third period, from the mid-nineteenth century until the early twenty-first century, is portrayed as a period of consolidation of medical control over birth, with an increasing definition of birth as a pathological, disease state that requires medical control and management.

SOCIAL BIRTH—THE RENAISSANCE TO 1700

In the time of "social birth," the process of labor and delivery was a community event. Near the time of delivery the neighborhood midwife was alerted that her services would be required in the days to come. When the moment arrived, the father, another child, or a neighbor was sent to bring her to the home to assist in the delivery. The midwife would bring along the tools of her trade—twine, scissors, cloth, and perhaps a portable birth stool or chair. The birth stool or chair would be assembled and the mother would spend her labor talking with the friends and neighbors who had gathered. When she reached the point of delivery, she would sit upon the birth stool and deliver her child. The birth stool or chair was an important artifact of birth in Europe well into the nineteenth century. It was the implement of choice for midwives, early man-midwives or accoucheurs, and even found popularity among early obstetricians. Birth chairs were used across national boundaries, by rural and urban women, and by both upper and lower classes for delivery. While exhibiting certain common characteristics throughout the continent, such as the semicircular opening in the low seat, an open and supportive back, and hand-holds for bracing during contractions, these items of traditional birth bore the distinctive qualities of various areas, including regionally unique ornamentation and construction. In fact, the birth chair was so intimately associated with birth and midwives until the mid-nineteenth century that it was used in both textual references and in art to symbolize the birth act. In some instances, the midwife of a region was recognized for her services to the community and provided with a chair or a stool. For example, an account from the records of Stadt Baden in Switzerland in 1427 records that a midwife was hired to serve the town, and in 1429 a kindbetterstul, a birth stool, was purchased for her use.

Midwives and early midwifery texts. Midwives have a long history. They were long considered high-ranking members of their communities and were sources of advice in birth control, pregnancy, child rearing, and conception, as well as all elements of community health care. Midwives had an expansive knowledge of herbal treatments ranging from the early use of ergot, a wheat fungus that stimulates labor (later used and marketed as a medical drug), to anesthetics, aids for relaxation, and herbs to cause the contraction of the uterus. Midwives passed the bulk of their knowledge from one to another through oral communication and informal apprenticeship. Little written material was available regarding midwifery, and the available texts were in Latin (like the works of Hippocrates, Magnus, and Savonarola).

One of the first European books on midwifery written in the vernacular was Ortloff von Bayerland's Das Frauenbüchlein (Little book for women; 1500). Eucharius Rösslin, the city physician of Frankfurt-am-Main, soon followed with a similar book, Der Swangern Frauen und Hebammen Rosengarten (A garden of roses for pregnant women and midwives; 1513). Like Ortloff and others to follow, Rösslin directed his text to practicing and knowledgeable midwives, offering few suggestions as to actual delivery but rather advising that they follow nature and do what seemed best. The text of Jakob Rueff (1500–1558), director of midwives in Zurich, Ein schön lustig Trostbüchle in von den Empfangnissen und Geburten der Menschen (Cheerful, gay, and comforting little book about the conception and birth of people; 1544) is equally revealing of the general practice of delivery in its descriptions and detail about the practice and artifacts of birth, and of the basic tenor of societal attitudes toward the process. He briefly describes the process of birth, suggests some tools, primarily crochets for dissecting a blocked or dead infant in utero, and describes the attributes of a model midwife. Louise Bourgeois followed with a casebook of sorts, detailing her experiences as a midwife in Observations diverses de Lovyse Bovrgeois ditte Bovrsier, Sage-femme de la Royne (1617).

Of course, just because midwifery writers from various points of the continent were writing similar accounts does not prove that the general practices of birth were universal throughout England and Europe. The proof is in the fact that these were not the only works. Many texts were written throughout Europe that offered the same advice and understanding about birth, and these texts portrayed midwives as serving their community, government, and church and occupying a revered position in society.

Midwives and witchcraft. Despite the high status midwives held within the community, they also bore the burden of suspicion. Beginning in the Middle Ages, midwives in most European countries were required to be certified by parish priests, or in larger cities such as Paris, London, Frankfurt, and Cracow, by the bishop, as to their upstanding virtue and honesty and their lack of association with witchcraft in order to practice legally. Without this church approval and early licensing, a woman who acted as a midwife or healer was open to charges of witchcraft. The church became involved because midwives were required by law to baptize children, often in utero, in the event of a difficult or fatal delivery so the infant could be absolved of original sin prior to death. In addition, part of a midwife's duties, as dictated by church authorities, was to determine the identity of an illegitimate child's father. The Catholic Church was more interested, therefore, in the role of midwives as Christians than in their skills in delivery.

Suspicion related to witchcraft had dogged the reputation and careers of midwives since at least the time of the Dominicans Heinrich Kramer and Jakob Sprenger who wrote in their 1484 Malleus Maleficarum (Hammer of witches), "No one does more harm to the Catholic Church than midwives." This suspicion of witchcraft stemmed from various Christian doctrines that loosely supported the interpretation of illness or death as the will of God or the result of sin and association with the devil. In fact, Jacob Rueff believed that "monsters," children with deformities, were begotten by devils. By association, midwives were vulnerable to charges of witchcraft in case of failure to deliver a perfect child. Suspicion was also attached to their free access to objects long considered magical: the placenta, the umbilical cord, and the caul of an infant. In 1555 Würzburg, in Bavaria, instituted regulations that forbade midwives to take the placenta away from a birth and required that they throw it in running water (for purification) for disposal. As late as 1711 Brandenburg regulations forbade midwives to give away or sell any remains of birth like the membranes, caul, or umbilical cord.

FORCEPS

Obstetric forceps were invented in France in 1588 by Peter Chamberlain (1560–1631). The forceps were shaped like two large spoons and were inserted into the birth canal one at a time around the infant's head and then screwed together. The infant was then pulled out. Use of forceps increased the possibility that the infant might survive a difficult or otherwise impossible delivery, and was a significant improvement over past practices where the child had to be dissected in cases of impaction or impossible delivery. As Hugh Chamberlain, Peter's grandnephew, wrote, use of the forceps dispelled the notion ". . . that when a man comes, one or both must necessarily die." The forceps brought much honor and business to the Chamberlain family and they were jealously guarded, carried from one job to another in a large, locked, and highly ornate wooden box. When the Chamberlains arrived the mother was blindfolded, all birth attendants sent from the chamber, the room darkened, and bells and noises used to muffle the noise of the forceps. Due to this secrecy, forceps were almost unknown until 1699, when the design was sold to a Dutch college.

Wet nursing. While critical to the birthing process, a midwife could do little in the area of feeding or nurturing an infant unless she was also a wetnurse. Typically, a mother would feed her own child. In situations where a mother was unable to nurse, either because of sickness, inability to produce milk, or death, a wetnurse was employed to feed the child until weaning. Broadly conceived, wetnursing—the practice of a woman suckling another's woman's child for pay—stretched well beyond simply feeding the infant. It included all areas of childcare and early infant nurture. The majority of wetnurses in Europe were initially employed by foundling hospitals for the care and feeding of children who had been abandoned or handed over after the death of the mother.

However, the popularity of wetnursing among women who could feed their own infants but for a number of reasons chose not to grew more widespread among royalty and upper classes of Europe between the fifteenth and eighteenth centuries. For these classes, one of the primary reasons for choosing to send a child out to nurse was the need to keep the cycle of ovulation continuing, so that a mother could give birth and quickly conceive again. Often, a wet-nurse kept the child in her care long after the actual act of wetnursing ceased, which typically occurred after 24 months. The age that the child was weaned was determined not by a paid wetnurse but rather by the father, and varied according to the sex and birth order of the child. Eldest sons received nursing care the longest and youngest daughters received it for the shortest time. The wetnursing system was well organized early on. Networks of fathers and the husbands of wetnurses almost exclusively negotiated the contracts, and in many cases of extant documentation, theirs are the only names listed on contracts. There were also organized caravans for wetnurses returning from cities with their new charges, and government-managed bureaus. In many cases, at town or village celebrations, holidays, markets, and fairs wetnurses would gather to announce their availability. In Spain, Portugal, and Germany wetnurses wore special costumes or clothing that indicated their business.

A woman who had recently lost her own child was regarded as the ideal nurse. Second best was a woman who had recently weaned her child, but this was always regarded as a little questionable if the child remained in the home, due to concern that she would continue to nurse both children, thereby affecting the quality and quantity of the milk going to the paying child. Wetnurses were expected to be married women or very recently widowed. Traditional laws, rules, and expectations of behavior were both understood and often captured in the wording of written contracts. For example, nurses were not to associate with their husbands during their tenure as wetnurses. In fact, one of the nurses of the future Louis XIV was dismissed because she was overseen talking with her husband in a garden. This rule was in place because it was believed that the milk of women who engaged in sexual relations was less palatable for infants. Further, the milk of pregnant women was considered of substandard quality, since it was believed that the fetus would draw all the nutrients away from the milk, making it weak and useless to the nursing child. Parents were also upset if their wetnurse turned out to be menstruating while nursing, as this milk was also considered unhealthy and polluted and possibly dangerous for the child. They would often terminate the contract or, if they could not find a replacement nurse, reduce her wages to reflect their opinion about the quality of her milk. While early wetnurses were all married women who either lost a child or had weaned one early, gradually more and more women placed their own children out to poorer, rural wetnurses so that they in turn could take on higher-paying customers for their milk.

Until the mid-eighteenth century medical writers and some midwifery manuals gave advice about the qualities and characteristics to look for during the selection of a wetnurse. It was believed that not only would a child pick up habits from the nurse, such as "coarse behavior," but also that the demeanor, style, manner, and appearance of the nurse could be transmitted through her milk to her nursling. There was also the belief in the sixteenth and seventeenth centuries that the sex of the child the wetnurse had recently given birth to would have an effect on the child she would nurse, in that the milk was designed for a child of a particular sex and could be damaging, or perhaps even deadly, when given to a child of the opposite sex. The belief that children took on the mental and physical qualities of the one providing the milk remained strong well into the eighteenth century. This belief not only influenced the choice of a wet-nurse, but also raised some questions and some hesitation about artificial feeding using animal's milk. Stories were told about children becoming goatlike or stupid like sheep for being fed the milk of these animals, and the later midwifery texts advised against anything but mother's milk unless as a last resort. In foundling homes where a shortage of available parish funds for paying wetnurses, or a general shortage of nurses made this necessary, goats, asses, and sheep were kept on the grounds so children could either be fed the milk via carved-out animal horns, or, most frequently, they were held straight to the animal's teat for feeding.

While maltreatment of the infant was rare, since it was a source of income and any damage or death would result in loss of pay, abuse did happen on occasion. The primary danger to nurslings, however, was the threat of being "over-laid," that is, the nurse rolling over onto them and smothering them while asleep and nursing in bed. Devices were designed to prevent this, and parents would often supply the nurse with such protection, along with swaddling clothes and infant wear. Infants also died of the many ailments and diseases that commonly affect children, and the graveyards of rural parishes throughout Europe have a disproportionate number of infant graves given the general population, for if a child died, the nurse would have it buried locally and then would notify its parents.

THE AGE OF ENLIGHTENMENT—1700–1850

With the Enlightenment, the authority of the Catholic Church waned and the pursuit of scientific study and reason increased. Medicine was freed from the outdated notions of Galen and other ancient writers and from the confines of religious orthodoxy concerning illness and health. In midwifery programs, male physicians were at last allowed access to the study of the human body, post-mortem dissections, and attendance and observation of pregnant and delivering women. While initially these physicians had access primarily to the difficult or deadly cases of birth, by the early eighteenth century physicians were attending difficult cases even outside the charity centers of the university, writing midwifery texts, and even founding lying-in hospitals exclusively for the delivery of indigent women.

THE FIRST USE OF A RECUMBENT POSTURE FOR DELIVERY

According to tradition, the first use of a recumbent posture for a normal delivery (and in some versions, the historic first use of a man-midwife by choice for a normal delivery) was by Louis XIV's mistress, Louise de la Valliere, in the late seventeenth century. It is said that Louis insisted that she lie down upon a bed so that he could observe the birth (a socially inappropriate activity of the time) from a hiding place behind the curtains. The legend follows that influential members of the French court then followed King Louis's lead and took to employing man-midwives when they wished to keep their illicit affairs a secret since a midwife's duties, as dictated by the authorities, included determining the identity of an illegitimate child's father.

The practices of birth changed as a result. Most evident are the change in posture for delivery from upright in a birth chair to recumbent in a bed, and the shift toward the male birth attendant. Changes were also apparent in attitudes toward women and in the language regarding pregnancy and birth. Such terms as "teeming" and "breeding" to describe pregnancy were replaced in contemporary diaries, literature, and other texts with terms such as "sick," "confined," and, tellingly, "ill." A writer in the London Gentleman's Magazine in 1791 commented on this.

All our mothers and grandmothers, used in due course of time to become with child or as Shakespeare has it, roundwombed . . . but it is very well known that no female, above the degree of chambermaid or laundress, has been with child these ten years past . . . nor is she ever brought to bed, or delivered, but merely at the end of nine months, has an accouchement antecedent to which she informs her friends that at a certain time she will be confined.

Midwifery and the rise of obstetrics. The declining influence of the church had made charges of witchcraft less frequent, and midwives continued to practice their art on a large scale throughout Europe. However, doctors began to question the role and ability of midwives. Midwifery manuals soon gave way to obstetrical texts that were less directed toward practicing midwives and more toward physicians. They covered the more fascinating aspects of labor and delivery, and in the titles of these works, pregnancy and birth were increasingly referred to as the diseases of women. The limited exposure of doctors to normal labor, and the popularity of texts that dealt almost exclusively with abnormalities such as poor presentation, impacting, narrow pelvises, and the birth of "monsters" (infants with acute deformities), cultivated an increasingly threatening picture of birth that quickly led to a perception among doctors, and eventually among the population they tended, that pregnancy was anything but normal. The texts that were designed for midwives became more directional and instructive, eventually becoming little more than advice booklets for matrons, not midwives. These books instructed women as to proper behavior during pregnancy examinations and birth, and provided general guidance for the selection and use of doctors. The gradually changing tone of these texts cultivated a changing attitude and approach to midwives and, by association, women. The discovery of the lucrative field of man-midwifery, as well as the growing influence of physicians' guilds and colleges proved to be real threats to the practice of traditional midwifery and to the livelihood of female midwives.

According to William Smellie (1697–1763), a British physician, when the British army and navy surgeons were put on half pay in 1748, many of them attended his lectures on midwifery in order to increase their incomes by practicing as "man-midwives," the common term of the day. Simply taking the training and advertising their skill was not sufficient for doctors to change the way birth had been practiced for hundreds of years. They accomplished this by increasingly defining birth as a dangerous, pathological crisis that warranted, in fact demanded, their professional services. This undermined the credibility of midwives, compromised society's belief in their skill, and fed the growing conception within society of the fragility of women. Society, led by the tone and tenor of these obstetrical authorities, began to suspect midwives of incompetence, evil, and squalor. Charles Dickens's description of a midwife in Martin Chuzzlewit (1843) was typical and reflected his cultural milieu.

The face of Mrs. Gamp—the nose in particular—was somewhat red and swollen, and it was difficult to enjoy her society without becoming conscious of a smell of spirits. Like most persons who have attained to great eminence in their profession, she took to hers very kindly' insomuch, that setting aside her natural predilections as a woman, she went to a lying-in or a laying-out with equal zest and relish.

THE ACCOUCHEUR

The term accoucheur was used in reference to man-midwives and appeared in the titles and texts of obstetrical works beginning in the late eighteenth century. The Oxford English Dictionary cites the first literary use of accoucheur, the French, and hence polite, term for obstetrician, as Laurence Sterne's 1760 novel, Tristram Shandy. "—yet nothing will serve you but to carry off the man-midwife.—Accoucheur,—if you please, quoth Dr. Slop.—With all my heart, replied my father, I don't care what they call you,—but wish the whole science of fortification, with all its inventors, at the devil;—it has been the death of thousands,—." Literary tradition credits Dr. John Burton of York (1710–1771) as the victim of Sterne's satire.

By the late eighteenth century, through guild membership and the concomitant persecution of nonmembers who attempted to practice medicine, physicians and surgeons controlled and regulated the medical profession as they saw fit.

Ill health and birth as a pathology. The practice of birth was also affected by shifts in the general attitude of the populace about femininity and womanhood and their role in the birth process. Other important factors included the industrialization of Europe, changing economic structures, and the emergence of the middle class. Each played a significant role in shaping the new beliefs about the process in general. For doctors and scientists in the nineteenth century, birth had come to be viewed as dangerous because women were at last understood to be as weak and fragile as they truly were. Exertion and activity were regarded as dangerous to their health and general well-being. If a woman did not experience illness as a result of such activities, she must not be truly female. Thus, fragility and ill health became acceptable and indicative of refined sensibility and social status. Members of the growing middle class sought to emulate the wealthy classes in all ways, and showing that active economic participation of their wives and daughters was not necessary was critical. Idleness, once considered sinful, was now a status symbol.

The cultivation of upper-class women's ill health as a sign of status and civilized behavior further contributed to the growing conception that the whole process of childbearing was well beyond a refined woman's capability. The social corollary to such thinking was that if a woman did not appear to suffer a difficult, possibly dangerous, labor and delivery, she was in action and demeanor like a "savage." "In proportion as we remove women from a state of simplicity to luxury and refinement, we find that the powers of the system become impaired, and the process of parturition is rendered more painful. In a state of natural simplicity, women in all climates bear children easily, and recover speedily" (Edward Murphy, 1862). If a woman was civilized, it was believed, she needed medical help in delivery.

In the nineteenth century birth did in some ways become more difficult. The idealization of women as fragile created an image of women as inherently unhealthy. Meanwhile, life in the industrialized city and the standards of fashionable dress in many ways made image reality. Years of use of women's undergarments and supports, such as corsets and straitlacing, seriously altered a woman's anatomy, and made delivery difficult or impossible due to a malformed torso and pelvic area, not to mention the damage done to the fetus by their continuous use throughout a pregnancy.

The history of birth has also been shaped by changes in the structure of communities due to industrialization and urbanization. The strong bonds of female community, particularly noticeable through their earlier participation in the delivery of a community member, were weakened by the movement of large segments of the population to cities, where friends, family members, and neighbors were unavailable. Socially, pregnancy became an increasingly unacceptable topic of polite conversation. People rarely spoke about pregnancy and childbirth and when they did, they used euphemisms and told "where babies come from" stories (e.g., the stork and cabbage patches). Even practitioners used such euphemisms when advertising their services. For example, midwives in France had signboards depicting women in cabbage patches with smiling infant faces.

By the middle years of the nineteenth century the general practice of delivery was strikingly different from what it had been a hundred years earlier. Increasingly, birth was seen as a medical specialty that was practiced rather than a natural event that occurred. Birth chairs increasingly became more and more elaborate in order to compensate for the perceived inability of women to labor and deliver effectively alone. New postures for delivery were favored, from horizontal postures in special-made birth chairs to the fully recumbent postures in bed. Drugs were used to hasten delivery, bloodletting was practiced, and the extensive use of obstetrical tools was employed to remove the infant. Such changes made the doctor physically more comfortable and enhanced his feeling and appearance of control, but simultaneously increased the actual burden on the mother and removed control of the event from her. The elements and practices associated with the earlier, more natural, approach came to be regarded with apprehension and dread, representing a period before treatment was available: the dark ages of medicine and a time of "meddlesome midwifery."

Wetnursing in the eighteenth century. While midwifery experienced a great decline in appeal, the popularity of wetnursing reached its peak in the late eighteenth century. The economic and social conditions of the period played a large part in this. Early in the industrialization period, the increase of artisans, shopkeepers, and factory workers in the city expanded the market for the services of wetnurses. Such city workers found the cost of wetnursing was more affordable than the loss of their wives' salaries or labors. Doctors believed a nursing child could drain all the strength and health from a mother, and therefore encouraged women to find wetnurses (this follows the folk tradition that a woman loses a tooth per child nursed). The upper and middle classes, influenced by this thinking and the greater social freedom it permitted, continued to utilize wetnurses. It is notable that Catholic countries (France, Spain, and Italy) had stronger traditions of wetnursing, bureaus to manage the process, and governmental laws and regulations to control it. This wider use of wetnurses was in part due to the larger number of foundling hospitals and the higher number of abandoned infants. In Protestant countries fewer infants were put out to wetnurse; also, fewer children were abandoned. In fact, in countries such as Germany, Norway, Sweden, and Finland, children were not typically sent out to nurse at all. Rather, the nurse was frequently required to be resident in the family home while employed. In some cases, a wet-nurse was employed to visit the baby's home once or twice a day to feed the child.

THE CONSOLIDATION OF MEDICAL AUTHORITY—1850–2000

By the mid-nineteenth century, obstetrics had arrived as a legitimate branch of medicine almost entirely male dominated. Maternity hospitals or lying-in centers were first used only by poor women who were delivered for free in exchange for their use as test cases for medical students. However, in the early twentieth century upper-class women and paying customers increasingly gave birth in hospitals following the introduction of obstetrical anesthesia, most particularly, the Twilight Sleep. This method, introduced by Bernhard Krönig in Germany in 1899, used a combination of morphine and scopolamine and caused an amnesiac and unconscious state. It was regarded as a blessing to women since it removed all pain and erased most memory of the process. Like the changes brought about by other medical implements, such as forceps, the use of anesthesia affected the process and practice of birth significantly. It increased the number of medical personnel required for an effective birth; it limited the posture for delivery to a recumbent, often restrained, position; and it strengthened the portrayal of women as too ineffective to manage the process alone. Delivery in hospitals took place in operating rooms or theaters, with the women highly anesthetized on flat tables or hospital gurneys that included arm straps, shoulder straps, and stirrups with leg restraints, attended by licensed medical personnel. Midwives and mothers were literally and symbolically absent. The texts concerning birth were medical ones detailing procedures. The history of birth was written as an example of glorious advances of western civilization. The texts available and intended for women were treatises on home economics, advice for mothering, scientific housekeeping, diapering, and tips for care and nurture.

Renewed communication and alternative birth. Coupled with the growing trend toward forms of socialized or nationalized medicine in European counties, in the mid-twentieth century, women began once again to communicate with one another on the topic of birth. Bolstered by dialogue, women sought out information and brought about the growing popularity in Europe of natural methods of birth like Accouchement Sans Douleur (the Lamaze Method) and the methods of Grantly Dick-Read and Frederick Leboyer, who sought not only to reduce unnecessary intervention in their deliveries, but also to defeat patronizing attitudes of professional medicine toward women. The movement toward more natural birth was popular among both childbearing women and the medical profession as a way to better and more economically care for women in childbirth. Medicalized birth was lessened, and more natural and healthier approaches to childbirth reappeared. In addition, the last three decades of the twentieth century also saw the rise of a small movement for alternative birth. Encompassing a wide variety of natural, alternative, and noninterventionist practices, the movement for alternative birth placed value on the mother's role and strove for practices that worked in concert with birth, rather than attempting to dictate and manipulate it. This movement looked to traditional practices and the growing trend toward self-care for models of practice. Newer approaches were introduced, such as underwater birth, and older practices were revived, like birth as a community-attended event.

Midwives in the twentieth century. In the early years of the twentieth century, midwives in much of Europe, already professionally compromised, increasingly lost access even to indigent women as clients. Hired by governments and municipalities, midwives performed home visits following delivery to check on the mother and to monitor the infant's progress, and were infrequently, if ever, participants in the birth process. Only in very rural areas were midwives still the primary birth practitioners, as need dictated their participation.

With the growth of nationalized medicine, midwives made a return to delivery, caring for the majority of births, those without likelihood of complications requiring significant intervention. As an increase in births crowded available space and resources at hospitals, a trend emerged toward shorter stays, fewer "procedures," and the less expensive attendance of midwives at birth. Midwives practiced in hospitals as certified nurse-midwives, legally licensed and recognized. A large number of lay midwives (unlicensed) attended home births and other alternative forms of delivery. In England and on the continent, midwives delivered a large portion of infants with a physician merely attending, although the control and management of what is considered a normal birth, and what is deemed appropriate care, was still governed by professional medicine.

Wetnursing in the late nineteenth and twentieth centuries. As more and more women delivered in hospitals and stayed for extended periods, they began the process of nursing as advocated by the newer generation of obstetricians, and wetnursing experienced a demise. With the influence of reformers who campaigned throughout the nineteenth century for a closer mother-child relationship, and the development of adequate forms of artificial feeding, including bottles, infant cups, nipples, and spoons, and sanitary cow's milk, wetnursing was no longer useful, fiscally sound, or any more beneficial than any other means of feeding. While technological advances in artificial feeding did not immediately affect the rate at which children were given over to nurses, they did change the work of the nurse from wetnursing to dry nursing (hand feeding with bottles).

World War I, falling on the heels of decades of campaigning by social authorities about the benefits of mothers nursing their own children, was a primary cause of the demise of wetnursing. During the war, women found that, indeed, wetnursing was far more expensive than the new, alternative forms of infant feeding. After the war, fewer women worked outside the home, making wetnursing unnecessary. It was all but nonexistent in European counties in 2000. Friends and relatives might nurse a child while the mother was away, but there is almost no evidence of a paid market for wetnurses, and the trend toward bottle feeding remained fixed. The advent of effective breast pumps made even bottle feeding with cow's milk unnecessary.

CONCLUSION

While the history of childbirth, midwifery, and early infant-care has changed significantly since 1500, the forces that shaped this history have been consistent. Changes in knowledge and advances in medical science have made a great impact. The economics of the community, societal customs, attitudes about women's roles, changing social classes, and industrialization have also played a significant role in the history of birth. For this reason, the history of childbirth, midwives, and wetnursing provides a vibrant and tangible means of studying the power of cultural and societal norms and attitudes, and the changing face and values of society throughout European history. Likewise, this cycle will continue to reflect the ever-present changes in society.

See alsoBirth, Contraception, and Abortion; The Life Cycle (volume 2);Motherhood; Women and Femininity (in this volume); and other articles in this section.

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