Pussy Politics II: The oldest profession in the world

Titled ‘Pussy Politics,’ Kettős Mérce’s five-part series examines the horrific state of Hungarian obstetric care. In this second instalment, we trace how the oldest profession in the world became subordinate to modern western medicine.

In the history of obstetrics, examples of life-saving discoveries alternate with examples of violence never accounted. The inclusion of birthing into medicine happened with the simultaneous exclusion of midwives’ centuries-long knowledge and experience; and up until their full subordination, midwifery and medical obstetrics developed completely separately. Apart from women’s emancipation, the organising force behind the movement for extra-institutional deliveries is also the professional and political tension between doctors and midwives.

Obedient bodies

By the 18th century, the conception of power had changed: territorial expansion was replaced by an interest in the bodies already conquered. Bodies had come to be seen as a knowable, tameable, and disciplinable tool of production. Population regulation, a strict examination and control over family structures and sexualities are all modern developments, and are collectively called biopolitics.

None of this has anything to do with intimate relationships, but everything to do with territorial hegemony and power.

This attitude is still familiar today; instead of birth-rates, the respective ministry is controlling the production of human resources [The author is referring to the Hungarian Ministry of Human Capacities, a mega-institution overseeing everything from healthcare to education to social security to cultural and religious issues – Transl.] It’s a popular pastime of Hungarian government members to blabber about filling the Carpathian Basin with our babies, as if that would be the personal responsibility of individual citizens. None of this has anything to do with intimate interpersonal relationships, but everything to do with territorial hegemony and power. Therefore, contemporary population babbles are a direct consequence of early modern power technological evolvements.

Pussy Politics I: Gratuity, or the regulation of the trade in good will

A brief history of Hungarian midwifery

Up until the 16-17th century, any assistance around deliveries was exclusively female territory from which men were strictly excluded. Midwifery was a profession to be learnt through practice and knowledge was passed from midwife to midwife, with female relatives assisting in delivery as well. This profession offered women a living and an ability to assert their rights for a millennia, as well as providing them a special position within their communities. Enlightened absolutism, however, was not fond of independent women.

Part of the 17th century anatomical breakthrough was the mapping of the uterus’s physiology, which gave further momentum to the development of the field and meant the end of the female body’s particular necessities and intimacy. The end of the century saw the first male midwives and specialised obstetricians (at the time, naturally, only men), against whom, however, other doctors and midwives protested.

The Empress’s will

In 1770, Maria Theresa, Empress of the Austro-Hungarian Empire, issued the first systematic regulation which stipulated that only certified midwives could practice their profession in the Empire. The regulation, however, was more of a registration of wishes, and was realised only years later. Most rural midwives were illiterate and were unable to leave their profession for longer periods of time in order to get the certificate, as their communities required their continuous presence. The same regulation also founded a separate medical department at the University of Trnava [the legal predecessor of the Eotvos Jozsef University in Budapest – Transl.], which later moved to Buda, and then to Pest, and, taking up Ignac Semmelweis’s name on its 200th anniversary, became what is now the Semmelweis Medical University in Budapest. Since the language of tuition was German, only middle-class students could become midwives. The 1806 ‘Ratio Educationis’ regulation prescribed more frequent, five-months-long training periods and in 1806 training taught in the Hungarian and Slovak languages also began. By 1813, certification required an exam.

In exchange for medical services, women served as experimental subjects for doctors in training.

Maria Theresa also founded the first maternity ward – this, however, was mostly visited by women who could not afford employing a midwife, such as the very poor, women pregnant out of wedlock, or sex workers. In exchange for medical services, they served as experimental subjects for doctors in training – since as disgraced women they were considered to be of lower class, anyways. Most women were averse to such institutions and avoided them as long as they could. Part of the reason was childbed fever, which became endemic as a consequence of institutionalisation – although its cause became known only much later.

They didn’t know, how could’ve they

By the 19th century, the training of doctors and midwives went in parallel: they had their theoretical classes together, but the practical training happened at separate clinics. This is what piqued Ignac Semmelweis’s interest in Vienna in 1847: there were far fewer deaths at the maternity ward staffed with midwives than at the medical obstetric hospital.

Doctors and professors would run back and forth between deliveries and autopsies in top hats and tailcoats without washing their hands, in the process infecting many women themselves. Comparatively speaking, the situation in Vienna was glorious. The 10% death rate was considered pretty good – in some European hospitals every third mother died after a hospital delivery.

Hand-washing meant a 20-minute long procedure for doctors who considered live and dead bodies to be one continuous mass.

Semmelweis required all obstetricians, medical students, and nurses working at the Viennese Allgemeines Krankenhaus to wash their hands with chlorine. This had the simultaneous effect of dramatically lowering the number of infections and making Semmelweis widely despised among his colleagues. The handwashing routine at the time meant a 20-minute long procedure for doctors who considered live and dead bodies to be one continuous mass.

Semmelweis continued to work in Pest, where he managed to bring the death rate under 1%. He only published his discoveries much later in 1858 and in 1860 he published an entire book on childbed fever. Part of the medical profession celebrated while others refused Semmelweis’s insights, who died soon after in a psychiatric asylum. (The fifth instalment of Kettos Merce’s series on obstetrics deals with Semmelweis’s discoveries and his legacy in detail.)

Of course, one could say that it doesn’t make much sense to judge 18th century doctors, since at that time nobody knew anything about bacteria. Even Semmelweis thought that perhaps there was some sort of poison in corpses’ bodily fluids. The midwives, however, knew something which scientific medicine refused to acknowledge.

Midwives were forbidden from touching the soil or killing animals – in order to keep their hands clean.

For centuries, midwives worked according to very strict rules of hygiene. In many villages they were supported by their communities who provided them with servants, as they were forbidden from touching the soil or killing animals – in order to keep their hands clean. This is probably why there were much fewer deaths at their wards. The discovery that a traditional and female profession could lead the way, however, harmed the interests of medical doctors who had just gained access to deliveries from which they had been excluded for so long.

How Many Doctors are Missing from the Hungarian Health Care System?

Traditional knowledge or charlatanism

Modern medicine is based on the anatomical discovery, takeover, and possession of the body. It practically led a campaign – and in many cases, it still is leading a campaign– against any other medical knowledge. It considers the positivist scientific method as the only possible method: that is, only those things matter which can be replicated in a lab, and everything else is a hoax, charlatanism, or superstition. This did indeed expose a lot of unfounded healing practices; but a lot of professional knowledge fell victim to this as well – such as midwifery.

Midwifery distinguishes its approach from the medical one linguistically too: they don’t conduct but assist the delivery.

Midwifery approaches birth completely differently than medicine, which is oriented towards internal intervention. It considers the birth a natural, bodily process which requires assistance, but is primarily done by the woman. It doesn’t reject interventions completely, but only accepts them when they are necessary and when milder methods don’t help. Accordingly, it puts a lot of emphasis on the mother’s mental wellbeing. It even distinguishes its approach from the medical one linguistically: they don’t conduct but assist the delivery. Thus, it offers a solution to numerous problems experienced during industrialised obstetric procedures. The C-section, the oxytocin injections, and many other procedures are important medical discoveries and they can save lives. But instead of their nowadays common routine application, they ought to be used only when they are really necessary.

Into the institutions

Three decades after Semmelweis’s death, the microbiological revolution broke out: Louis Pasteur discovered bacteria, validating Semmelweis, from then on known as “the saviour of mothers.” Midwifery, however, did not get rehabilitated and what’s more, it became more and more regulated and subordinated to the doctors.

In 1897 the first Hungarian woman was awarded a doctoral degree: Vilma Hugonnai finished medical school in Zürich in 1879, but had to wait 18 years till her diploma was recognised in Hungary. In the meantime, she completed the midwifery training, and worked as one.

World War I incapacitated the institutional infrastructure and even the maternity wards were treating soldiers. After the Treaty of Trianon in 1920, [Signed at the end of WW1, the treaty dissolved the Austro-Hungarian Empire, and detached roughly 2/3s of Hungary’s territory – Transl.] several training institutes closed, while others were transferred from the detached territories to Hungary and new ones were founded, as well. As a result of rapid urbanisation, the rate of institutional births against home births grew. Obstetric education shifted to institutional obstetrics, as well, where midwifery was already subjugated to medical obstetrics.

Stalinist pace

We know just how much the Soviet experiment liked to modernise – and not in the gentle sense of the word. In 1950, extra-institutional deliveries were banned overnight, although rural midwives could bypass the ban till the end of the decade. Midwives working in small towns, however, had to gradually give up their profession, or practice in secret.

The last midwives to study in higher education graduated in 1977, marking the end of independent midwifery in Hungary.

A few years later, in 1968, specialised medical secondary schools – a speciality of Hungarian midwifery training – opened their doors for the first time. The students received their midwife certificates after a one-year “specialisation training” and were clearly subordinated to doctors within hospital hierarchies. Thus, midwives lost their professional autonomy completely. The last midwives to study in higher education graduated in 1977, which marked the end of independent midwifery in Hungary.

Hospital cleaners in a failing health care system

I’d like to be more independent…but only a bit

Midwives’ attempts at professional independence resurfaced around the Fall of Communism. That was the time of the first press conferences, where representatives of the profession openly claimed that they wanted their autonomy back. So, in 1994 midwifery trainings resumed in higher education, the prerequisite for which did not have to be a specialised secondary diploma, but the general secondary final exam. Extra-institutional deliveries, however, remained banned and midwives remained subordinate to medical doctors.

Deliveries became industrialised and standardised, and mothers were reduced to reproductive units.

By tracing the history of obstetric education we can clearly follow the development of midwifery and the power relations in maternal medicine: by World War I, institutionalisation had already been carried out to a great extent. This was further surpassed by banning extra-institutional deliveries in the 1950s and ending higher midwife education in the 1960s, which meant that the previously parallel profession became decisively subordinated to medical doctors. Deliveries became industrialised and standardised, and mothers were reduced to reproductive units whose full utilisation is assisted by the midwives.

It’s no surprise, therefore, that proponents of extra-institutional deliveries hit a brick wall when they tried to tackle the authoritarian medical regime: as I wrote in the first part of this series, there are huge amounts of money at stake around deliveries – and in this instalment we see that we are dealing with a historically, deeply embedded power struggle.

 

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The article was originally published on Kettős Mérce. Translated by Anna Azarova.