An Abridged History of Midwifery in Scotland
Scotland possesses a long and rich history of midwifery detailed in its medical literature, legislative records, and institutional development. From the man-midwives of the 1700s writing medical treatises; to the lay midwives, called howdies, who continued their work illegally after the government’s stipulations requiring midwife certification; to the legal developments surrounding midwifery synthesized by the scholarly pursuits of the Royal College of Midwives (RCM); an understanding of the roots of Scottish midwifery provides groundwork for understanding the current state of the institution today.
Prior to Scotland’s union with England in 1707 forming the Kingdom of Great Britain, records of Scottish midwives circle mostly around their association with witchcraft, and the unfortunate executions of many female healers during the region’s habitual witch hunts of the sixteenth century. During this period, midwifery went largely unregulated, the responsibilities of tending to women in labor mostly resting upon lay midwives. By the eighteenth century, however, male academics had begun making attempts to codify the practice, providing educational resources for midwives, including lectures, classes, and publications.
The medical literature produced in this period provides some insight into the gendered social issues surrounding 1700s Scottish midwifery. A Treatise on the Theory of Midwifery by obstetrician William Smellie, for instance, is addressed solely to male practitioners and heavily advocates the use of forceps, technologically improved by Smellie himself. This work, first appearing in 1752, was reprinted in many editions, including a volume in 1754 called A Sett of Anatomical Tables, With Explanations, and an Abridgment, of the Practice of Midwifery, which featured thirty-seven images of human anatomy and birthing tools.
On the other hand, man-midwife and professor at the University of Edinburgh, Alexander Hamilton, wrote A Treatise of Midwifery: Comprehending the Management of Female Complaints, and the Treatment of Children in Early Infancy in 1781 specifically for women. He was inspired by the “numerous obstacles” he discovered in reaching his female students.
“Books were often confused and uninteresting in their details; abstruse, imperfect, and unintelligible in their principles. Even those which were designed for women, are filled with technical terms, and specious, though delusive theories.”
This goal to create an accessible medical text coincides with Hamilton’s belief that “the confinement of midwifery to the hands of women was formerly injurious to the art and to the public” due to women’s ineptitude without men’s help.
Hamilton’s legacy was continued by his son, James Hamilton, who similarly felt dissatisfied with earlier obstetrical texts due to either their “inaccuracy in the detail of symptoms, or imperfection in the mode of treatment pursued,” and published an empirical book of Select Cases in Midwifery, amassed from his work at the General Lying-In Hospital he helped found in 1791, intended to help mothers in need.
The desire of these male university professionals to regulate midwifery to their standards remained unrealized legally until the early twentieth century. Parliament passed the Midwives Act in 1902, applying only to England and Wales. This act brought the practice of midwifery from one of a-legality to one that required registration with the government. Contemporary Scottish authorities, however, were well aware that the bill would require significant alteration to be applicable to their country, and thus it took another thirteen years to develop the Midwives Act for Scotland, passed in 1915.
Scotland’s specific midwifery needs that contrasted those of England and Wales largely had to do with rurality. As of the governmental classification in 2018, 70% of Scottish land is remote rural territory, where lay midwifery was a practical necessity for much of the twentieth century. Even with the existence of hospitals and maternity centers, modern scholarly estimates place 95% of Scottish births before 1915 at home.
Thus, even with the introduction of the Central Midwives Board for Scotland (CMBS) requiring registration and certification of all midwives, the unauthorized howdies were able to remain active as late as the 1960s. Lindsay Reid, a research midwife for the RCM, describes how these women had no formal training, but they developed both their skills and their reputation through experience. According to Reid’s research, it was often the case that patients preferred the familiarity of a local howdie to the jarring presence of a certified midwife, and even obstetricians preferred to work alongside howdies who were less likely than certified midwives to claim medical authority over the birthing process.
The institution of Midwifery developed significantly after its legalization. The Midwives Act gave the profession new status, granting midwives greater responsibility within the medical industry. In 1937, Scotland’s Maternity Services Act, another improvement upon a law of England and Wales passed in the previous year, made great strides to systemically refine maternity care. The bill notably specified the need for postpartum care and requiring midwives to fulfill such duties for mothers with newborns.
Postpartum care, along with prenatal care, was actually advocated heavily by the aforementioned eighteenth-century physician, Alexander Hamilton, in his 1784 book Outlines of the Theory and Practice of Midwifery, in which he asserted that this was a critical component of the midwife’s role. While his idea took over 150 years to enact into law, Hamilton’s influence upon midwifery education remains in Scottish practice.
The value of midwives was particularly noticeable during the political crises of the mid-twentieth century. During World War II, there was a huge increase in the demand for midwives, given that many certified midwives were serving as nurses in the military. Immediately after the war, when the armies returned home, the birthrate soared dramatically, further requiring the services of midwives. This coincided with the growing awareness of the need for a national healthcare system, and in 1947, the National Health Service for Scotland (NHS) was established. Though it did not directly affect the CMBS or its responsibilities, the advent of the NHS fragmented some maternity services, and made hospitals and doctors more accessible to pregnant women, for better or for worse.
Reid’s book, Midwifery in Scotland: A History explores how more deliveries were taking place in hospitals as the twentieth century progressed and birth became a heavily medicalized process. This change can be attributed to technological improvements for sanitation and propaganda bemoaning the dangers of home birth. Additionally, Sir James Young Simpson was the first to use Chloroform as an obstetric anesthetic in Edinburgh in 1847, a process that continued into twentieth century Scottish medicine and had to be overseen by a medical practitioner. Due to the appeal of drugs, perceived safety, and institutional influence, over 99% of births in Scotland took place in hospitals by 1980. While the CMBS had, before the 1940s, required midwives in training to complete ten home births, such a feat was no longer achievable by the mid-twentieth century with the sheer lack of home births, and the requirements adjusted accordingly.
Reid points out that Scottish midwives within the context of a hospital were easily frustrated, not only by the technocratic approach that failed to adequately prioritize the health of the birthing person but also by the institutionalized expectation that midwives were to be subservient to doctors. Even the most junior obstetrician would take precedence over the midwife in signing a birth certificate, even if he was not in the room for delivery. District midwives who did not work with hospitals grew frustrated with their work as it mostly consisted of a few antenatal and postpartum visits while their patients gave birth and were confined in hospitals. Reid reports that this resulted in midwives’ loss of intrapartum skills, and their position in the medical industry became tenuous.
As maternity wards in Scottish hospitals grew more crowded in the 70s and 80s, the formerly required ten days of hospital confinement fell away to an average of 5.3 days for postnatal care. The unrest with the current systems of care became clear with the formation of the Association of Radical Midwives and the political action of the Association for Improvements in the Maternity Services in the second half of the twentieth century.
The House of Commons published the Winterton Report in 1992, a cumulation of research on antenatal, intrapartum, postnatal, and neonatal care, reverberating throughout the United Kingdom and inspiring a new philosophy of Woman-Centered Care. Based on the Winterton Report, birth outcomes fared best when birthing people were well-informed by dedicated healthcare professionals and had control over the kind of care they were receiving. While some midwives regarded this as an opportunity to claim lost autonomy over the profession, others feared that the new governmental requirements would place too much pressure on their role.
The new focus on midwifery in the Scottish medical industry initiated a host of studies to determine how midwives best fit into Woman-Centered Care. These projects have revealed that the Scottish midwifery system is both cost-effective and safe, even for inaccessible rural areas. The biggest concerns seem to be the need for more midwifery managers, the development of a recognized career pathway for midwives, and the further improvement of midwifery education.
In response to these studies, the Scottish government launched a five-year plan for maternity and neonatal care in Scotland, with family-centered goals; these include providing all birthing people with consistent care from a primary midwife, ensuring hir choice of birthing location, questioning the high rates of caesarean section and considering the community aspect of giving birth. These aims function in tandem with revisions to the NHS approaches to supporting nurses and midwives.
Fortunately for the United Kingdom as a whole, the Royal College of Obstetricians and Gynecologists has initiated a unified front with the RCM, and as of November 2017, the two organizations have resolved to work together as effectively as possible to promote the healthiest birth outcomes. Today, Scottish stillbirth and infant death rates are the lowest in the UK, at 4.72 per 1,000 live births. Maternal mortality rates are also low, with 8.54 deaths per 100,000 maternities in 2012–2014. Scotland has a solid foundation of government-sponsored midwife-led care and looking to the future, it will be important for the country to continue supporting midwives, encouraging more practitioners to enter the profession and further advance the field.
