Childbirth in the Early 20th Century

​Welcome to blog post number six about childbirth in the early twentieth century.
 
Writing historical fiction involves a lot of research to uncover information which informs the novel but isn’t necessarily included in it. This blog is to share some of the interesting facts I’ve learnt during the course of my research for Shakespeare Cliff.

This subject does not always make for pleasant reading. Be prepared for some horrors.

Giving birth in the early 20th century (Getty images).

A lot of children are born in the novel. The protagonist, Sarah, gives birth eight times between 1900 and 1914 (though only six daughters reach adulthood). Her daughters, Jane and Annie, also give birth in the 1920s. That they all survive is good going for the times, since childbirth was one of the major causes of death. Between 1850 and 1930, the rate of death in childbirth in the UK remained at between four and six deaths per 1,000 births. It is interesting that the risk of a mother dying in childbirth remained substantially the same for nearly a century despite improvements in medical care and standards of living during this period.1 With the advent of antibiotics and blood transfusions, maternal deaths reduced dramatically from the late 1930s onwards.
 
Because of the high mortality rates, childbirth was something to be dreaded. The risks were well-known:

Pictures in medical books covered it all: breech birth, stillbirth, the cord wrapped round the baby’s neck, its face blue and scrunched. Gracie had described the slow, dark-crimson soaking of bed sheets as one of her sisters-in-law died from blood loss.
Sarah’s own mother died giving birth to her. ‘Complications’ they said, without explanation.

Sarah’s mother died from one of the most common causes of childbirth deaths: puerperal sepsis, commonly known as childbed fever, an infection caused by a streptococcus bacterium. ‘Sepsis, due to casual use of sterile technique, remained the cause of half the total deaths until 1937.’ 1  With modern standards of hygiene and the discovery of antibiotics, the disease is rare nowadays.

Without access to transfusions and blood banks, severe haemorrhage was usually fatal in Sarah’s day. Often caused by a placenta previa where the placenta covers the cervix, the cervical dilations during labour can lead to severe bleeding. Nowadays with the aid of scans, the problem is diagnosed in advance and avoided by a caesarean section.

One of the dangers of childbirth not covered by Sarah’s list was eclampsia. In 1920, roughly 1,200 of the 6,000 maternal deaths each year in the UK were the result of this condition. Pre-eclampsia and eclampsia, the causes of which are not fully understood, are high blood pressure disorders. Left untreated, eclampsia can lead to convulsions, coma and death. Modern ante-natal care has greatly reduced rates of severe eclampsia.
 
Before WW1, antenatal care did not exist. Women called for a midwife or a doctor when they went into labour and most gave birth at home. Less than 5% of women went into hospital.
 
Most of Sarah’s deliveries are straightforward. Her sister-in-law, Elsie, who supports her through all the births, says:
 
“We’re old hands, you and me, and you pop out babies like shellin’ peas.”
 
But two of her labours are obstructed. The last time she gives birth in 1914, just after the outbreak of WW1, the baby suffers brain damage due to birth complications. Her nephew, Jack, tells this news to Bert, Sarah’s future son-in-law:

The birth was hard—I only discovered that recently—the cord tied round the neck, or somethin’ like that. Anyway, months afterwards, they found out…. Well, the boy wasn’t quite right.”
“What do you mean, not quite right?”
“Not sure, to be honest.” Jack struggled to describe the problem, as he understood it. “Not all there, you know—a shillin’ short of a pound. Anyway, he wasn’t three years old, and he died.”

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A woman handing a note to her physician after giving birth, the midwife is seated near her. Pen drawing by J. Ulrich. Wellcome Collection.(CC BY 4.0).

At the beginning of the 20th century, over seventy-five per cent of births were attended by a midwife, usually working on her own. Up until the mid-1930s, the majority of working-class women, like Sarah, were attended not by a professional but by an unqualified local woman:
 
At four o’clock Elsie arrived with Granny Makey, who was younger than her title implied. A large-boned, no-nonsense woman, her experience qualified her for her role: she had given birth to a dozen children, and attended the deliveries of dozens more.
 
Only the better-off could afford a doctor, though doctors were not necessarily the better choice. The Medical Act of 1858 had instituted training and regulation for doctors, but it was not until 1886 that medical training had to include obstetrics. Often a midwife knew more about the birthing process than a doctor. When Sarah has a difficult breech birth, it is Granny Makey who knows what to do. Elsie tells Sarah:
 
“Listen, duck, when I looked just now, it weren’t the baby’s head I saw but its bottom. It’s a breech, so we’re goin’ to need Granny Makey’s help. She’ll know how to manage it.”
Sarah’s heart thumped so hard she was sure it was audible. What should she do now? The urge to push was overwhelming, but Elsie was right, she must try to hold back. No ingenue, she was aware of the dangers of a breech birth. If the baby’s head got stuck, it might die. So might she.
“Should we send for the doctor?” Her voice came out thin and high-pitched.
“No, duck, wait till Granny Makey gets here. She’ll know what needs doing better than any doctor.”

Early 20th century midwives

In 1902 Midwifery became legally recognised with the first Midwives Act, but many without formal training continued to operate as there were so few qualified midwives at the time. After 1910, uncertified midwives could no longer legally attend births without being under the supervision of a certified midwife or physician. In theory, an uncertified midwife could be prosecuted for attending a birth without the presence of a medical practitioner, ​but in practice a significant proportion of births nominally delivered by doctors continued to be largely or wholly managed by such women.

The choice of birth attendant was mostly determined by income, though the availability and reputation of midwives and doctors locally must also have been a factor:

Granny Makey, the neighbourhood’s unofficial mid-wife, assisted almost all the mothers in Tower Hamlets. She wanted payment, though. Sarah hoped Ed had worked a full day and earned a bonus.

The Insurance Act of 1911 and a payment of 30 shillings maternity benefit to the wives of employed men made it easier to pay for a birth attendant, but both doctors and midwives responded by raising their fees. ‘The average fee charged by independent midwives in 1917 was 15 shillings, with a higher charge for primagravidae than multiparous women’.2  At over 1£ per delivery, doctors were more expensive. Complicated labours cost more. When Granny Makey has employed her skills to good effect to safely deliver the breech baby, she says to Sarah:
 
‘Tell your husband it’ll cost a bit extra when he comes to pay my fee.’
 
Sarah knows that Granny Makey has likely saved her life and the life of her baby. Obstetric intervention in the case of difficult births has a long history going back to ancient times – the name caesarean section is said to derive, probably erroneously, from the birth of Julius Caesar. Most often this procedure was conducted to retrieve a living baby from an already dead or dying mother, though there are records, some as early as the Middle Ages, of successful operations performed on living mothers too.
 
If a foetus became stuck during delivery, for whatever reason, the dangers for both mother and baby were significant. Sarah sums it up when she first receives the news that the baby is in the breech position:

If the baby got stuck, there were few alternatives: cut her open to save the foetus, and risk her dying from blood loss. More likely they’d kill the baby in the womb and extract it piecemeal—an unimaginable horror, not without danger to her also. Was this it, then, her last day on earth?

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Obstetrical instrument set, England, 1851-1900 Science Museum, London. (CC BY 4.0)

Embryotome, Paris, France, 1855-1875 Science Museum, London (CC BY 4.0)

An embryotome, as its name implies, was used to cut the foetus up so that it could be extracted piecemeal.

Obstetrics, Blunt hook with transverse handle. (CC BY 4.0)

A range of obstetric instruments was available to help with these processes. Sarah catches sight of some in Granny Makey’s bag during her first labour, though she doesn’t then know what they are for:

She sat on the chair by the window, opened her bag, and took out her knitting. Sarah glimpsed metal instruments similar to knitting needles, including a huge crochet hook and an implement that looked like tongs. They did not bear thinking about.

If the foetus was deemed to be undeliverable, the crochet was used to crush the skull and pull the baby from the womb.  

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Replica of forceps, bronze, encrusted. December 1934 - Surgical congress, 1947 (CC BY 4.0)

Prince Leopold

Forceps were introduced in the seventeenth century but did not become widely used in England until the eighteenth century. Their use saved the lives of many babies, though it was not without danger to both mother and baby.
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Another aspect of childbirth which has changed greatly is access to pain relief. ‘In 1847, James Young Simpson, the prominent Edinburgh obstetrician and physician to Queen Victoria, had shown that chloroform could effectively eliminate the pangs of labour’.3  At the birth of Queen Victoria’s eighth child, Prince Leopold, in 1853, she is said to have inhaled chloroform from a handkerchief, describing it as ‘blessed chloroform, soothing, quieting and delightful beyond  measure.’4 

​In 1848, Edward Murphy invented a portable inhaler for administering chloroform during childbirth. A sponge soaked with the liquid was held in a small drum and the vapours breathed in through a mouthpiece. Of course, there was a price to pay and only the privileged could afford it. Until the mid-twentieth century, the vast majority of women struggled through labour with no pain relief at all.

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Murphy-type inhaler, Dublin, Ireland, 1848-1900 Science Museum, London (CC BY 4.0)

Even after more analgesics became available later in the century, there remained an entrenched view that pain was a natural part of childbirth. Religious and moral influences came into play: the Christian belief that suffering was a reminder of original sin, or the view that sex was sin and the pains of childbirth were the punishment. ‘A physician, Isabel Hutton, recalled in her 1960 memoir that, before the First World War, a mother of a “love-child” would not be offered any pain relief because “this would teach her a lesson that would keep her in the path of virtue ever afterwards!”’ 3
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Nowadays, it is normal for a woman’s husband or partner to be present during the birth. At the beginning of the century, men, other than a doctor, were kept strictly out of the way, as illustrated in the cartoon below from a 1928 edition of Punch.

During Jane’s difficult labour, her husband, Charles waits downstairs, no doubt listening to her screams.

When the mid-wife offered her the baby to hold, Jane turned away. Sleep was all she wanted. Annie took him downstairs to Charles, who was pacing the floor in the parlour.
“Congratulations! A big, bouncing boy, almost ten pounds.” She passed the bundle to Charles, who held him as though he might break.

Thankfully, childbirth today in the UK is a much less risky business. The latest statistics show neonatal deaths are 2.7 per 1000 live births, and the maternal death rate is 9.1 per 100,000, rather different from the four to six deaths in every 1000 of Sarah’s time. 

A bemused husband querying a doctor as to how his wife of only six months can have already given birth to a child. Wood engraving, 1838. Wellcome Collection.

​Footnotes:
 
1 Deaths in childbed from the eighteenth century to 1935 by Irvine Loudon. National Library of Medicine.
2 Birth Attendants and Midwifery Practice in Early Twentieth-century Derbyshire, Alice Reid, Social History of Medicine, Volume 25, Issue 2, May 2012
3 Childbirth in the UK: suffering and citizenship before the 1950s, Joanna Bourke, The Lancet, April 2014.
4  From an article by Ellen Barry, New York Times, May 6, 2019.
 
Sources:
 
1. Midwifery in Britain in the twentieth century (Memories of Nursing website) 
2. Birth Attendants and Midwifery Practice in Early Twentieth-century Derbyshire, Alice Reid, Social History of Medicine, Volume 25, Issue 2, May 2012. J Drife, PubMed.gov May 2002 
3. Geoffrey Chamberlain, Journal of the Royal Society of Medicine, November 2006
4. A History of Childbirth in the UK, Tania McIntosh, The Conversation, January 2021