Midwifery in Italy:
From Ancient Rome to the Modern Day
This article is being published anonymously. It was written by one of the students in my Fall 2018 History of Midwifery course at Vassar College.
It seems reasonable to assume that giving birth before the advent of modern medicine was much more dangerous than it is today. However, historical evidence suggests that women managed just fine with assistance from one another. The practice of midwifery can be traced far back in human history. For as long as people have been giving birth, there have been friends, relatives, and experienced women attending the births. There’s even mention of midwifery in the Bible.
Soranus of Ephesus, a physician who worked in the 1st and 2nd Centuries BCE, described the qualities that midwives should have in order to be successful in the profession in his Gynaecology:
“A suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable…. since people will have to trust their households and the secrets of their lives to her”
The traits that define a good midwife are, for the most part, still relevant today. Italians who opt for midwife-attended births often do so because they want to have a personalized birthing process that is overseen by someone whom the expectant parents know to be trustworthy. Birth itself hasn’t gotten easier since antiquity, and those who pursue natural, medication-free options tend to be drawn towards the services offered by midwives.
The benefit of studying Italian midwifery in particular is the abundance of resources that span from Ancient Rome to the modern day. The volume of available texts, artwork, and artifacts allow us to assemble a fairly comprehensive account of what life was like in Italy in antiquity and how it has changed over the course of history. Using the historical evidence at our disposal, we can map out the cultural significance of midwifery in Italy all the way from ancient Rome to the present day.
Italian Midwifery Throughout History
Ancient and Early Modern Rome
Women contributed to Ancient Roman medicine in part through midwifery practice. While most medical texts were authored by men for other men, the medicinal recipes for herbal remedies used by midwives were referenced frequently by prolific and influential figures like Galen and Hippocrates.
In addition to their involvement with birth and healing, Italian midwives were involved in multiple aspects of the domestic sphere. The relationship established between midwives and the mothers they assisted was typically familial in nature; midwives sometimes carried babies they helped deliver in baptismal processions, contracted marriages in their communities, and even helped to negotiate dowries.
Midwives were a locus of authority with respect to recognizing, understanding, and reporting the “secrets of women”. As such, they gave expert testimony in cases of illegitimate pregnancies, virginity, and abortions. Midwives were called to examine criminals who claimed pregnancy in order to delay executions. In Andreas Vesalius’ famous De humani corporis fabrica (known more generally as the Fabrica), the title image depicts the public dissection of a female criminal who had been executed for her crimes — a rarity at the time. A huge crowd is gathered around the anatomy table, and among these spectators there is only one woman.
It has been speculated that this lone female observer was likely the midwife who performed an examination to determine whether the criminal was pregnant or not. The inclusion of the midwife in the scene attests to the status and authority held by these professionals at a time when women were excluded from academia and barred from attending such events.
Vesalius and his contemporaries pushed for an emphasis on anatomical knowledge obtained through direct observation, namely dissections. This shift in defining what constituted authoritative knowledge signified a massive change for the practice and authority of midwives. 16th Century midwives in Sicily were required to pass oral exams to earn their licenses. By the early 17th Century, Venetian statutes mandated that midwives attend anatomy lessons before they could become licensed to practice. The first Italian school of midwifery was founded in Torino in 1721.
Formalizing the licensing process necessitated training by physicians and surgeons (obstetrics wasn’t given status as its own specialized field in Italian medicine until 1761). An element of midwifery training at the time was reading instructional manuals and texts authored by men who, despite having limited knowledge and experience with regard to female anatomy, used their status and access to dissections as justifications to take over midwives’ work.
This male academic appropriation of female tactile, experiential knowledge created tension between midwives and physicians. Though Italy’s medicalization of birth did include a push to educate female midwives, it ultimately denied the knowledge that these women already possessed about the human body, pregnancy, and safe childbirth practices.
Perhaps more than in other countries, the male takeover of childbirth was hindered in Italy by opposition from the Catholic Church, societal enforcement of female modesty, and male obligation to protect female honor. Physicians weren’t formally trained in obstetrics until the 18th Century. Rather than completely forcing midwives to abandon their practice altogether, male physicians and obstetricians pressed upon the autonomy of the midwives by tightly regulating their licensing requirements.
Midwifery in Fascist Italy
Towards the middle of the 19th Century, educated, urban midwives started organizing to resist encroachment into their practice by physicians and obstetricians. Rather than rebel with ad hominem attacks like those employed by physicians to push midwives away from overseeing childbirth, these women sought to define their practices in medical terms. They formed professional societies, organized national congresses, and published journals to keep one another up to date with congressional activities and technological and scientific advancements.
Many of these journals promoted a medicalized attitude toward birth and decried lay (unlicensed) midwives for their lack of formal training and nonmedical involvement in the lives of their clients. Were these efforts enough to distance and distinguish licensed midwives from their lay counterparts? Probably not. The journals typically only circulated among midwives themselves and even then only reached a small fraction of them.
When the fascists came to power in the 1920s, the position of midwives as both birth attendants and providers of abortion services drew government attention. Pronatalism (government encouragement of reproduction) ideals placed midwives in a precarious position; they were both key players in bringing babies into the world — or, more specifically, bringing more Italian babies into fascist Italy — and professionals who had the tools and training to perform abortions. Midwives were subject to police investigations and could be arrested if they were suspected of offering abortion services.
The government emphasis on increasing the birth rate led to the unionization of midwives but also resulted in stricter regulations on their work and altering their training to include fascist ideology. While the professionalization process helped to define the scope of midwives’ duties, the combination of midwives’ official duties being largely defined by physicians and the increased state interest in the practice mostly served to institutionalize midwives into a secondary and subordinate role to doctors.
Modern Italian Midwifery
Italian midwifery education has been reformed five times since 1940. The establishment of the Italian National Health Service in 1978 resulted in a shift to the majority of Italian births taking place in hospitals and altered the social status of midwives, who subsequently began to take their business to the hospitals. Midwives who do work in hospital settings report difficulties in building relationships with pregnant women, whom they do not meet until they are well into their pregnancies or about to give birth. Many of these women don’t even know that a midwife will be attending the birth until they arrive at the hospital. The current system is a medicine-dominated one with three general types of midwives who operate within it:
The Naturalistic Midwife
The naturalistic midwife opposes unnecessary medical intervention. There is a focus on emotional support during birth and pregnancy as well as a tendency towards salutogenesis (the prioritization of health and wellness as opposed to focusing on curing illnesses). These midwives view birth as a natural process and avoid brining medication and medical instruments into the process unless absolutely necessary.
The Moderately Interventionist Midwife
A moderately interventionist approach to midwifery is exactly that — moderate. While support for a more natural birth is still reported, a moderately interventionist midwife isn’t necessarily opposed to medical intervention, especially when it comes to pain reduction. Amelioration of pain and discomfort seems to be prioritized over emotional support in some cases, though the desire to connect with women and promote a safe, happy birthing atmosphere is still present.
The Medicalized Midwife
A medicalized midwife works in a hospital setting and favors expediting the labor and birthing processes via medical intervention. This type of midwife is the least common of the three but also the least likely to experience tension with physicians.
Naturalistic and moderately interventionist midwives report lower levels of satisfaction in their careers and often feel subservient to physicians in hospitals. This suggests that there are divisions and potential resentment among midwives who subscribe to these different ideologies. There currently doesn’t seem to be a sense of community among midwives.
From the earliest representations of the profession to the modern day, midwifery has been viewed as a traditionally feminine job. The majority of practicing midwives in Italy and around the globe are female. Italy actually has one of the highest proportions of male midwives in Europe — a staggering 3.5%. In the future of the practice, perhaps the number of male midwives — rather than obstetricians — will increase.
Today, 76% of practicing midwives have a bachelor’s or master’s degree in Nursing and Midwifery, which is offered at several universities. The typical salary earned ranges from 47.184 € for an entry-level position to 83.738 € for a senior-level nurse midwife, with an average salary of 67.473 €. Though independent midwives may not have received the same level of education, this is not always the case.
Independent midwives are those who choose to work outside of the National Health Service (NHS). Independent midwives can practice in places like women’s shelters, birth centers, their own private offices, or patients’ homes. Although the costs of receiving care from independent midwives may not be covered, there are many potential benefits to choosing to work with them, including:
· Care by the same person during pregnancy, the birthing process itself, and during the first year afterwards
· A more personalized birth experience
· The potential to establish a meaningful relationship with the care provider
· Focus on Salutogenesis – prioritization of health and well-being rather than curing illnesses and solving problems
Ostetriche Parto a Domicilio e Casa Maternità website.
Birth outcomes in Italy are promising, with a maternal mortality rate of only 3 per 100,000 births and a fetal mortality rate of 3/1,000 births. About 91% of births take place in a hospital setting, and very few women (about 3%) receive care from midwives during their pregnancies. Some Italian hospitals do have spaces for more natural approaches to labor and birth, and some even offer water births.
In comparison to midwife-attended births at birth centers, hospital births have higher rates of medical interventions like cesarean sections and episiotomy. The large proportion of women who choose hospital births over birthing centers likely has to do with the coverage provided by Italy’s national healthcare system, which doesn’t always cover the expenses of birth centers or home births. Though midwives offer more personalized and extended care, they may be the more expensive option.
Ultimately, Italian midwifery exists in a highly medicalized system and almost seems to be a specialized form of nursing. While the positive birth outcomes seem to indicate that the Italian model is a successful one, it should be noted that those women who do receive care from midwives receive longer and more personalized care following birth. It seems that a combination of medical and personalized care is an optimal model for ensuring safe, successful, and positive birth experiences; and the emotional support provided by midwives should be an integral part of that system.
