Pan Macmillan 2009
Reviewed by Jo Murphy-Lawless
I have enormous respect for Alexander Gordon. His single work, A Treatise on the Epidemic Puerperal Fever of Aberdeen was published in 1795, soon after Joseph Clarke, Master of the Rotunda Hospital in Dublin, had struggled with his third epidemic there. Clarke, who described the fever as 'treacherous', watched helplessly as it scythed down the lives of dozens of women, despite his most diligent efforts at whitewashing the walls and floors of the affected wards in the hospital's attic storey and throwing open the windows, attempting to treat the fever, all the while keeping scrupulous notes as to the condition of each woman who contracted the fever. Distressed and puzzled by its seemingly vicarious pattern, one ward remaining entirely unaffected, Clarke wrote that the 'partial distribution of disease rendered it probable that this fever derived its origin from local contagion, and not from anything noxious in the atmosphere'1.
It was Gordon, quite outside the great system of lying-in hospitals in European cities that would lead to the dominance of the emerging medical specialism of obstetric science, who made sense of that observation on 'local contagion'. The Treatise is a punctilious account of the sudden appearance of puerperal or childbed fever in Aberdeen, killing a woman first in December, 1789, the epidemic continuing to March, 1792 when it had spent its force.
Puerperal fever was strongly associated with the large lying-in hospitals of European cities and thus Clarke had the dubious advantage of keeping an extensive registry on hundreds of women. There was no lying-in ward in Aberdeen and the nearest hospital was in Edinburgh (also stricken with epidemic fever : in 1750, all the women who contracted it died). There was a dispensary system which provided the services of a physician to visit poor families and there were local nurses and midwives who assisted women at the time of labour and birth. In a small city, Gordon had a much more limited number of women to observe.
Yet as Rebecca Abrams makes clear in her absorbing fictional account, Touching Distance, of how Gordon came to understand the cause of this puzzling and terrible affliction, practising within the community felt almost more claustrophobic than the delimited but remote space of a lying-in hospital. In the community, local feelings about who was a 'safe pair of hands' for the woman approaching her labour, and who not, ran to fever pitch during the extent of the epidemic. Abrams does not use the precise order of the names and the dates of the women brought to bed and their subsequent illness and death from the fever that Gordon records with such care, as he tries to comprehend the information to hand on each woman, to make it yield up patterns, hypotheses, answers, proof. Instead, she transforms them into a much shorter timeframe to evoke a compelling story of the suffering and dread for the woman and her family members and neighbours that accompanied the epidemic. Especially well captured is the fear men experienced as their wives lay dying and all about were powerless to prevent this happening. The turmoil and struggle this initiated in Gordon himself is wonderfully portrayed and enabled me to envisage better what lies behind the intensity that his Treatise conveys.
As Clarke suspected, puerperal fever was a 'local contagion'. Gordon's Treatise proved this and laid out who would be affected by this contagion and who not. Gordon wrote:
'this disease seized such women only, as were visited, or delivered, by a practitioner, or taken care of by a nurse, who had previously attended patients affected with the disease.'3
Lamentably, his proof and his careful steps to prevent transmission, especially burning the clothes of the woman who had given birth and those of the physician or midwife attending as well, lay ignored by the big obstetric names of the day for many, many decades. Whereas women died in their ones and twos from puerperal infections in isolated rural communities where traditional midwifery had less scope to transmit infection, they died by the scores in lying-in hospitals up to the early twentieth century where doctors themselves made birth unsafe. The findings of Semmelweis and Oliver Wendell Holmes from the mid-nineteenth century suffered the same fate as Gordon's work. The difference is that Gordon wrote his Treatise not only earliest but outwith the prestigious centres of obstetric medicine.
The Treatise is an example of good science, relying not on the conventions of the day, of how things have been or are done, observed and recorded, but reflecting on what needs to be construed as evidence in order to achieve sounder explanations. It brings to mind what the scientist Evelyn Fox Keller2 has written, that the work of systematically identifying information in the broadest sense, using a consistent methodology to build reliable explanations, is above all a 'social' task, that needs attention paid to the social and cultural norms of how science works, how it sees and what it does not see. Gordon's work makes me remember how good science demands genuine boundaries, which has not by any means been commonplace in relation to arguments about childbirth, as we know too well.
Abrams has handled skillfully the difficult 18th century medical language about the female body, so that we come to understand the diagnostic trail whereby Gordon reaches his conclusions. The one major drawback is that Gordon's story is presented as an example of Enlightenment progress. Thus Abrams brings in a conventional story line of the majority of the untrained or less well-trained local midwives, the 'howdies', in the contemporary dialect of the period, who treat birth and the threat of puerperal feververy differently and who react badly to Gordon's approaches. While it is true that midwives were excoriated in the writings of most 18th medics, I think it wise not to take this conflict at face value as a gendered struggle between backward-looking superstitious women and forward-looking men (and, one woman, in Abrams' account) of science. The evidence of the standard of midwifery in the early modern period is mixed on both sides of the gender divide. As ever, excellent tutelage of midwives in the making seemed to be crucial, so we have the seventeenth century Louise Bourgeois at the Hôtel-Dieu in Paris and the eighteenth century midwives, Elizabeth Nihell in London and Martha Ballard in New England, upholding far higher standards than their male counterparts in the surgical and medical professions, alongside countless unnamed peasant midwives who had good observational and other skills to support birth. However, Laura Gowing's work on the role of older married women and midwives in seventeenth-century England imposing restrictive and invasive control on young women who are entering into marriage and childbearing, often to their physical detriment, is not just the work of backward 'howdies': it is women maintaining that tight social order on behalf of a firmly entrenched male hierarchy. We might identify a theme that has resonance in contemporary accounts of what we must term obstetric nursing.
I am not a critical reader of fiction, so as to the novel itself and the way Abrams deals with the subplots of Gordon's life, I cannot comment, except to say that her research has been extensive. There is one sentence in the Treatise's Preface that gives a clue as to how Abrams has developed the novel. Gordon is speaking of what he considers his grave responsibility in 'laying before the public' his observations about puerperal fever and apologises for not discharging his duty sooner, the epidemic having ended in 1792, three years before the Treatise is published. Gordon writes:
'The delay was occasioned, partly by the laborious duties of my public office, but especially, by a complication of domestic calamities'
The sub-plots leave a powerful sense of 18th century Aberdeen physically and socially, at a time when its position as a port town allowed full engagement with the expanding imperial empire. This included the vexed issues of slavery, indentureship and child labour which were intrinsic to the success of that empire. If the novel encourages any of you to want to get hold of Gordon's Treatise, a search through the historical archives of Royal College of Surgeons, Edinburgh, or any of the three principal deposit libraries in England will yield a copy and a fascinating afternoon's reading. It will also contribute to an understanding of how intuition and hunches have a crucial role to play in moving towards best evidence.
Reviewed by Gill Boden
This book is mainly a collection of conference papers, (from Pollution and safety: exploring the 'dirty' side of women's health, Sheffield 2004.)
It is aimed at health professionals and students rather than mothers but does contain some ideas and discussion that could help all of us to understand some of the complexities of attitudes to women and their health. It also sheds light on relationships and power differentials between professionals, which are partially based on who does the 'dirty work'. In her introduction Mavis Kirkham states that 'Women leak, inevitably and often bountifully. Menstrual blood, birth fluids, breast milk and sometimes tears...' She goes on to say that 'Dirt is defined by Mary Douglas as "matter out of place."' The anthropologist, Mary Douglas's classic work is referred to by several of the authors to question what constitutes dirt and to draw attention to the fact that you can't answer that question without considering context. We are constructed by our particular culture and that determines how we feel about our bodies, what comes from our bodies and how polluting to others that may be.
The book is divided into four sections, the first is titled Mothers, midwives and dirt - past and present. The opening paper is Birth Dirt by Helen Callaghan, in which she distinguishes between 'sick dirt' and 'birth dirt' but shows how each is open to interpretation and will vary according to the time the place and the culture. The term 'birth dirt' was coined to describe the theory which explains the power and/or dirt relations in childbirth, for example there are many differences in how people both feel about and deal with the placenta. One statement she makes did make me sit up and I'll quote it at length, 'During labour the woman's reproductive passages but particularly the genitalia are a primary focus of the health professionals' attention or gaze. This is a cause of embarrassment for some women ... the need of the labouring woman for modesty and privacy during labour is sometimes forgotten by health professionals in modern Australia ... examinations ... can be a source of distress, discomfort and embarrassment for some women...' This struck me as massive under-statement! I did feel when reading this that the lay person might well have expressed this very differently. I suspect that part of the journey towards becoming a health professional means cutting yourself off from the normal reactions of shame and modesty, reactions that as a 'patient' we learn to hold back and inhibit. For myself and women I know the concepts of dirt and contamination are very different in a public place attended by strangers and at home with intimate others.
Rachel Newell's historical study examines the end of the post-partum period as marked by the Anglican rite of the churching of women and links it with the modern postnatal examination: giving a 'clean bill of health'. She goes on to discuss 'ritual purification' or cleansing in the health care system. I think many women in Britain today would think of a cleansing ritual as something very alien but it is something that has until relatively recently been a part of our culture and perhaps lingers on. Breast feeding as pollution, the second section, addresses the dilemmas and contradictions of breastfeeding in societies where the official rhetoric is at odds with the media-encouraged view of breasts as primarily sexual: consequently explaining women's difficulties in breast-feeding in the very public space which is the modern postnatal ward, and their use of flimsy curtains to give themselves some privacy. There is discussion of the historical antecedents to our present situation: the industrial revolution leading to the scientific discourse around infant feeding at the beginning of the twentieth century portraying breast milk as dirty and contaminating and formula as clean and scientific. Section 3, The Dais, examines the complexities of dirt and pollution in India and Pakistan where birth for many women is at home attended by family and an untrained traditional birth attendant, the dai. Dais are usually poor, illiterate low-caste women who could be skilled birth practioners but who may be made scapegoats for maternal mortality and morbidity and blamed for the effects of other macro-level processes. They do the 'dirty' work of birth. Section 4, Leakage and labelling, looks at such areas as gynaecology nursing, female urinary incontinence and sexually transmitted infections. I have often wondered about some of the important questions that are raised in this book. Unfortunately there are no easy answers. This book does offer a few clues as to how an understanding of how societies deal with the 'dirty' side of women's health might tell us a lot about how women as a whole are seen and explain something about the status of women health workers particularly midwives.
Churchill Livingstone, 2008
Reviewed by Gill Boden
This is a tough book in several ways. It was first published in 2004 and now in a revised edition in 2008 it addresses probably the most crucial question in our understanding of how women give birth: what does normal, physiological birth look and feel like?
There is plenty of debate on this question and I think anyone with an interest knows that the generally accepted view of what is 'normal' now includes interventions which are patently not normal although they may be common or indeed usual: induction and acceleration of labour ; ARM; episiotomy and epidural analgesia all are examples of this. But these essays add up to a powerful argument that, despite what we have observed as a radicalisation of ideas within Britain over the last 20 years reflected in government policy and a belief generally in the ability of women to give birth without intervention, what is happening is a 'normalisation' of a medical model in this country and worryingly in the rest of the world too. AIMS Journal Vol:20 No:2 2008 painted a sombre picture of childbirth practices in Europe and a future issue will examine how the rest of the world may be influenced to adopt Western practices.
In the first section, Ways of Seeing, Soo Downe and Christine McCourt tackle the difficulty of applying a research model based on 19th century science. They argue that although this is well suited to evaluating the efficacy of drug A as opposed to drug B this model is not so well equipped to tease out the complexities involved in normal physiological childbirth including the crucial social, psychological and spiritual aspects. These aspects are not optional 'add-ons' either for women and their families, or for their midwives. So while we are relieved to see NICE collecting together research evidence so that our heath ser vice can benefit both practically and, of course, economically from the best evidence available, we must also contemplate the limitations of the evidence that we have.
The gold standard of the randomised controlled trial, (RCT), has not helped us with such important and basic questions as the relative safety of hospital birth compared with home birth for women without complications of pregnancy. The NICE Intrapartum Guidelines might be useful in many ways but can't address this central question satisfactorily because the research doesn't really exist. There are no RCTs on home birth versus hospital birth nor, to take another example, are there any large scale RCTs on the benefits of routine ultrasound screening in pregnancy. The model of science employed has a tendency to investigate ever more advanced technical solutions to human problems. Alongside this it would be naïve to ignore the role of commercial interests in funding research; 'where health is framed by a constant expectation of danger there is money to be made in providing investigative, preventative or curative products to counteract the risks' (Page 10). There is no commercial interest in investigating normal birth. I had been looking forward to reading Nicky Leap and Tricia Anderson's essay on 'the role of pain in normal birth and the empowerment of women' so was pleased to find this in the first section: it met all my expectations. I agree that pain plays a big part in childbirth and has its uses and I think it would benefit every woman contemplating birth to consider their arguments. The second section starts with a chapter which is collaboration between the NCT and AIMS, written by Beverley Beech and Belinda Phipps. They look at women's birth experiences and the effects on their lives, including post traumatic stress reactions and deal with the definitions of normality and what they mean. This is a clear and, in my view, unarguable case which needs underlining. They outline the paradox that despite the successful campaigning over the last fifty years by childbirth organisations, we have witnessed not just the increase in caesarean sections but also the insidious acceptance of interventions which are not clearly of benefit. Subsequent chapters deal with midwives' practice, in the UK and in New Zealand and they underline how easy it is for midwives to be pushed, often against their wishes, into an acceptance of medical thinking and procedures.
The third section, 'Evidence and debate' concludes the book with some more optimistic writing on normality, for example 'Promoting normal birth: weighing the evidence' by Dennis Walsh. I particularly enjoyed reading the chapter, 'Fetal to neonatal transition: first do no harm', and its straightforward account of what harm is done to both mothers and babies by the usual early cord clamping and removal of baby. I have felt that many women expecting their first babies find it almost impossible to imagine the moment after the moment of birth and can be unprepared for the barbarity of a managed third stage. 'The current birthing environment is a contested context in which medicalisation remained the dominant construction of birth... There is increasing intervention in the birthing process and increasing normalisation of intervention despite midwives' efforts to protect normal birth'.
The conclusion on reading this book is that labour and birth are being increasingly centralised in mega units and intervention rates are escalating all the time. A vicious circle of iatrogenesis feeding yet more litigation and yet more defensive practice is becoming apparent. So I found this a tough book to read and the message is not very cheerful but this is a book which could equip midwives to be aware and prepared to fight. It is also a book that lays out for us what the nature of the task is to wrest the possibility of normal birth back as a real option for women in Britain.
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