Call the Midwife

by Jennifer Worth

She came to the door with me, and out onto the balcony, all the children following. “See you tomorrow, then. I’ll look forward to yer comin. I’ll ‘ave a nice cup of tea for yer.”

  I cycled off with much to think about. In her own surroundings, Lil was not a disgusting old bag, she was a heroine. She kept the family together, in appalling conditions, and the children looked happy. She was cheerful and uncomplaining. How she had come to pick up syphilis was none of my business. I was there to treat the condition, not to judge.

  The next day when I called, I was so pre-occupied with wondering how I could decline the offer of a cup of tea, that when the door opened, I stood staring awkwardly, stupidly, at Lil, who was not Lil. She looked a bit shorter and fatter, the same slippers, the same hair curlers, the same fag – but different.

  A familiar screech of laughter revealed toothless gums. She poked me in the stomach. “Yer thinks I’m Lil, don’ yer? They all thinks that. I’m ‘er mum. We looks like two peas, we does. Lil’s had a mis an’ gorn to ‘ospital. Good riddance, I sez. She’s got enough with ten o’ them, an’ him in an’ out all the time.”

  A few questions elicited the facts. Lil had felt ill shortly after I had left the previous day, and was later sick. She had lain down on the bed, and sent one of the children to fetch Gran. Contractions had started, and she was sick again. Then she must have become unconscious.

  Gran said to me, “I’ll cope with a mis any time, but not a dead woman. No, sir.”

  She’d called a doctor, and Lil was taken straight to The London Hospital. We later learned that a macerated foetus was extracted. It had probably been dead for three or four days.

  RICKETS

  It is hard to imagine today that until the last century no woman had any specialist obstetric care during pregnancy. The first time a woman would see a doctor or midwife was when she went into labour. Therefore, death and disaster, either for mother or child, or both, were commonplace. Such tragedies were looked upon as the will of God, whereas, in fact, they were the inevitable result of neglect and ignorance. Society ladies would have a doctor visiting them during pregnancy, but such visits were not antenatal care and would probably be more like social calls than anything else, because no doctor was trained in antenatal care.

  The pioneer in this branch of obstetrics was a Dr J. W. Ballantyne of Edinburgh University. (Indeed some of the greatest discoveries and advances made in medicine seem to come from Edinburgh.) Ballantyne wrote a paper in 1900 deploring the abysmal state of antenatal pathology, and urging that a pre-maternity hospital was necessary. An anonymous gift of £1,000 allowed the first ever bed for antenatal care to be inaugurated, in 1901, at the Simpson Memorial Hospital. (Simpson, another Scot, developed anaesthetics.)

  This was the first such bed in the civilised world. It is an incredible thought. Medicine was developing rapidly. The staphylococcus had been isolated; so had the tuberculous bacillus. The heart and circulation were understood. The functions of liver, kidneys, and lungs had been ascertained. Anaesthetics and surgery were advancing apace. But no one, it seems, thought that pre-maternity care might be necessary for the life and safety of a pregnant woman and her child.

  It was ten years later, in 1911, before the first antenatal clinic was opened in Boston, USA. Another opened in Sydney, Australia, in 1912. Dr Ballantyne had to wait until 1915, fifteen years after his seminal paper, before he saw an antenatal clinic open in Edinburgh. He, and other far-sighted obstetricians, were faced with bitter opposition from colleagues and politicians who regarded antenatal care as a needless expenditure of public money and medical time.

  At the same time the struggle by visionary and dedicated women was in progress to gain properly regulated training in the art of midwifery. If Dr Ballantyne was having a hard time, these women found it harder. You have to imagine what it was like to be on the receiving end of vicious antagonism: sneering, contempt, ridicule, slights about one’s intelligence, integrity and motives. In those days, women even ran the risk of dismissal for their opinions. And this treatment came from other women, as well as men. In fact, “in-fighting” between various schools of nurses who had some sort of training in midwifery was particularly nasty. One eminent lady – the matron of St Bartholomew’s Hospital – branded the aspiring midwives as “anachronisms, who would in the future be regarded as historical curiosities”.

  The medical opposition seems to have arisen mainly from the fact that “women are striving to interfere too much in every department of life”.* Obstetricians also doubted the female intellectual capacity to grasp the anatomy and physiology of childbirth, and suggested that they could not therefore be trained. But the root fear was – guess what? – you’ve got it, but no prizes for quickness: money. Most doctors charged a routine one guinea for a delivery. The word got around that trained midwives would undercut them by delivering babies for half a guinea! The knives were out.

  In the 1860s the Council of Obstetrics estimated that, out of around 1,250,000 births annually in Britain, about 10 per cent were attended by a doctor. Some researchers put the figure as low as 3 per cent. Therefore, all the rest – well over one million women annually – were attended by women with no training, or by no one at all, other than a friend or relative. In the 1870s Florence Nightingale wrote Notes on Lying-in Infirmaries, drawing attention to “the utter absence of any means of training in any existing institution”, saying “it is a farce or mockery to call women who attend childbirth, midwives. In France, Germany, and even Russia they consider it woman-slaughter to practice as we do. In these countries everything is regulated by Government – with us, by private enterprise.” The guinea earned by doctors for a delivery was a significant part of their income. The threat of being undercut by trained midwives had to be resisted. The fact that thousands of women and babies were dying annually for want of proper attention did not come into it.

  However, the courageous, hard-working, dedicated women eventually won. In 1902 the Midwives Act was passed, and in 1903 the Central Midwives Board issued their first certificate to a trained midwife. Fifty years later I was proud to be a successor of these wonderful women, and to be able to offer my trained skills to the long-suffering, cheerful, resilient women of the London Docklands.

  At the church hall, the antenatal clinic had been set up again. It was mid-winter, and the coke-stove was burning fiercely. It was well guarded on all four sides for the protection of the numerous little children running around. Lil had been in my mind on and off during the past fortnight – a curious mixture of revulsion and admiration. Whilst I admired the way she coped, I hoped I would not have to meet her again, at least not in the intimate patient/midwife relationship.

  The pile of notes on the desk told me it would be a busy afternoon – no time to brood about Lil and her syphilis. There were seven piles of notes, with about ten folders in each pile. Another seven o’clock finish, if we were lucky.

  I glanced at the top of the first pile, and saw the name Brenda, a woman of forty-six with rickets. She would be admitted to hospital for a Caesarean, and she was booked with the London Hospital in Whitechapel, but we were looking after her antenatally. At that moment she hobbled in, punctual to the minute for her two o’clock appointment. As I was at the desk, and the other staff were not available, I took her for examination and check-up.

  My heart went out to little Brenda. Rickets showed itself in malformation of the bones. For centuries it was not known what caused the condition. It was thought, perhaps, to be inherited. The child was thought to be “puny” or “sickly” or even just lazy, as rachitic children always stand and walk very late. The bones are shortened and thickened at the ends, and bend under pressure. The spine is deformed, as many vertebrae are crushed. The sternum is bent, and therefore the ribcage is barrelled and frequently twisted in shape. The head is large and square shaped, with a jutting, flattened lower jaw. Frequently, the teeth drop out. As if these deformities were not enough, rachitic children always had a lower immunity to infection, and bro
nchitis, pneumonia and gastroenteritis constantly occurred.

  The condition was common throughout Northern Europe, especially in cities, and no one knew what caused it, until in the 1930s it was found to be due to the simplest of causes: a lack of Vitamin D in the diet causing deficiency of calcium in the bone.

  Such a simple reason for so much suffering! Vitamin D is found abundantly in milk, meat, eggs and especially in meat fat and fish oils. You would think most children would have had an adequate diet of these items, wouldn’t you? But no, not poor children from deprived backgrounds. Vitamin D can also be made spontaneously in the body by the effect of ultra-violet rays on the skin. You might think there should be enough sun in Northern Europe to balance things. But no, the sun was not for poor children in industrial cities where the density of buildings virtually blocked out the natural light, and where children had to work long hours in factories and workshops or workhouses.

  So these children grew up crippled. All the bones of their bodies were deformed, and the long bones of the legs buckled and bent under the weight of the upper body. During adolescence, when growing ceased, the bones ossified into that position.

  Even today, in the twenty-first century, you can still see a few very old people hobbling around who are very short, with legs that bow outwards. These are the brave survivors who have spent a lifetime struggling to overcome the effects of the poverty and deprivation of childhood nearly a century ago.

  Brenda beamed at me. Her strange face, with an oddly shaped lower jaw, was alight with eager anticipation. She knew she would have to have a Caesarean section, but that did not bother her. She was going to have a baby, and this time it would live. That was all that mattered to her, and she was intensely grateful to the Sisters, the hospital, the doctors – everyone – but above all to the National Health Service, and the wonderful people who had arranged that everything should be free, that she wouldn’t have to pay.

  Brenda’s obstetric history was tragic. She had married young, and in the 1930s had had four pregnancies. Every baby had died. The tragedy for a woman with rickets is that, along with all the other bones, the pelvis is also deformed, and a flat, or rachitic pelvis develops. The baby therefore cannot be delivered, or at any rate can only be delivered with great difficulty. Brenda had had four long, obstructed labours, and each time the baby had died. She was lucky not to have died herself, as countless numbers of women did in earlier decades all over Europe.

  The incidence of rickets had always been slightly higher among little girls than among boys. The reason for this was probably social, and not physiological. Poor mothers of large families tended often (and still do!) to favour the sons, so the boys got more food. Boys have always been more mobile, and go outside to play more. In Poplar, it was always the boys who were down at the water’s edge, or in the wharfs or the bomb sites. So they were getting sunlight on their bodies, whilst their sisters were kept at home. Also, many holiday projects were organised by socially aware philanthropists. Summer camps, which took poor boys to the country for a month under canvas, were quite common, and these camps were lifesavers for thousands of boys. But I have yet to hear of summer camps for girls one hundred years ago. Perhaps it was not considered suitable to take girls away from home and put them under canvas. Or perhaps the needs of girls were simply overlooked. Anyway, one way or another, they missed out. The life-giving sun was withheld from them each summer, and rickety little girls grew up to become deformed women who could conceive and carry a child for nine months, but could not deliver the baby.

  It will never be known how many women died of exhaustion in the agony of obstructed labour: the poor were expendable, and their numbers not counted. Where was it I had read, in some ancient manual for the Instruction of Women attending the Lying-in: “If a woman is in labour for more than ten or twelve days, you should seek a doctor’s aid”? Ten or twelve days of obstructed labour, in the hands of an untrained woman! Dear heaven – was there no mercy, no understanding? I had to shut such agonising thoughts out of my mind, and quietly thank God that obstetric practice had moved on. Yet even in my training days, the most up-to-date textbooks taught that a woman with a rachitic pelvis should have a ‘trial labour of eight to twelve hours to test the endurance of both mother and foetus’.

  Brenda had been subjected to four such trial labours in the 1930s. Why on earth, after the first disaster, it had not been agreed that she should have a Caesarean section for the delivery of subsequent babies, I could not imagine. Possibly she could not afford to pay for it, because, before 1948, all medical treatment had to be paid for.

  Brenda’s husband had been killed on active service in the war in 1940, so she had not had any more pregnancies. However, at the age of forty-three she had married again, and now she was pregnant once more. Her joy and excitement at the prospect of a living baby seemed to fill the antenatal clinic, and throw everything else into shadow. She called out: “Allo’, sis, ah’s yerself?” to everyone in sight, and to queries about her health, she responded, “I’m wonderful. Never bin better. On top ‘o the world all the time.”

  I followed her over to the couch, and it stabbed my heart to see her little bow legs struggling to carry her. With each step the right leg in particular bent outwards, and her left hip swung precariously in the opposite direction. I had to arrange two stools and a chair before she could climb on to the couch, but she managed it, with awkward movements. It was painful to see. She was panting, and beaming in triumph when she got up. It seemed that every difficulty in life was a challenge to her, and every one successfully overcome was an occasion for rejoicing. She was not, by any stretch of the imagination, a good-looking woman, but I was not at all surprised that she had found a second husband who, I had no doubt, loved her.

  Brenda was only six months pregnant, but her abdomen looked abnormally large, due to her tiny stature, and also to the inward curving of the spine, which pushed the uterus forward and upwards. She could feel movements, and I could hear the foetal heartbeat. Her pulse and blood pressure were normal, but her breathing was laboured. I remarked on it.

  “Don’t mind me. That’s nothing much,” she said cheerfully. I did not feel confident about examining Brenda’s misshapen body, so I asked Sister Bernadette to confirm, which she did. Brenda was as healthy as could be expected, and was carrying a healthy foetus.

  We saw her every week for the next six weeks, and she struggled on with increasing difficulty, using two sticks to help her get about. Her happiness never left her and she never complained. At thirty-seven weeks she was admitted to The London Hospital for bed rest, and a Caesarean section was successfully carried out at thirty-nine weeks.

  A fine healthy daughter was delivered, whom she called Grace Miracle.

  * From Behind the Blue Door in A History of the Royal College of Midwives, Hansard, p. 23. This is a quote from the proposed Bill for the Registration of Midwives, 1890, from a speech made by Charles Bradlaugh MP.

  ECLAMPSIA

  Throughout history, and until after the end of the Second World War in 1945, most babies were born at home. Then the drive for hospital delivery started, and it was so successful that by 1975 only one per cent of babies were born at home. The district midwife became very nearly an extinct species.

  The fashion, or trend, is reversing slightly today, and the home birth rate is around two per cent. Perhaps this is because hospital delivery presents new and totally unexpected risks for mother and baby, and people are getting wise to this fact.

  Sally came to us because she believed her mother more than she believed the doctor, who had advised hospital for her first baby.

  Her mother had said, “Nark ‘im. You go to the Nonnatuns, luvvy. They’ll see yer right.”

  Gran had stepped in, too, with a wealth of ancient folklore, and hair-raising stories about the lying-in infirmaries, which used to be feared more than death itself by women.

  In vain the doctor tried to convince Sally that modern hospitals were not like the old infirmar
ies, but he was no match for Mum and Gran, so he retired from the ring, and Sally booked with the Midwives of St Raymund Nonnatus.

  We saw patients antenatally once a month for the first six months, then fortnightly for six weeks, followed by weekly check-ups for the last six weeks of pregnancy. All went well with Sally for the first seven months. She was a pretty little twenty-year-old, and she and her husband occupied two rooms in her mother’s house. She was a telephonist, and her mum, who attended every antenatal visit, was proud of her.

  I sat down with her, and went through her notes. Her blood pressure had been quite normal for the first six months. On the previous visit it had been slightly raised. I was concerned to find the BP even higher when I took it. I asked her to go to the scales, and found that she had gained five pounds weight in a fortnight. Warning bells were beginning to ring in my head.

  I told Sally that I would like to examine her, and followed her over to the couch. By so doing, I was able to see that her ankles were swollen. A diagnosis was taking shape in my mind. She lay on the couch and I was able to feel, quite certainly, pitting oedema up to the knees – not very pronounced, but palpable to experienced fingers. Water retention – that would account for the weight gain. I examined the rest of her body for oedema, but could find none.

  “Are you still getting any sickness?” I asked.

  “No.”

  “Any stomach pains?”

  “No.”

  “Any headaches?”

  “Well, yes, now that you mention it, I have. But I puts it down to working on the phones.”

  “When do you give up work?”

  “I gave up las’ week.”

  “And are you still getting headaches?”

  “Well, yes, I am that, but Mum says not to worry. It’s normal.”

  I glanced sideways at the mother, Enid, who was beaming and nodding wisely. Thank God the girl had come to antenatal clinic. Mum is not always right!