The following article is from a special issue
of Helios entitled "Rescuing Creusa: New Methodological Approaches
to Women in Antiquity," (Helios, New Series 13(2), 1986, pp. 69-84).
This article is particular enlightening not only for its detailed discussion
of midwives and maternity care, but also because it examines the gap between
"professional" care (the midwifes and doctors) and folk medicine.
Midwives and Maternity Care in the Roman World*
by ALERIE FRENCH
The birth of a child marks one of the great events of life in any culture,
but in most societies it carries with it a high probability of death or
serious illness for both mother and child. Neonatal mortality rates- deaths
at less than four weeks- vary considerably in the modern world: in communities
that do not employ asepsis in obstetrical care, neonatal mortality can
be as high as 50 deaths per 1000 live births.(1) Maternal mortality rates
for deaths associated with pregnancy and childbirth also range considerably,
but even at their highest they fall significantly short of neonatal mortality.
If we retroject the worst mortality rates of the modern world back into
the GrecoRoman one, we would estimate that about 5% of all babies
born alive would die before they reached the age of one month, and that
among every 20,000 women giving birth, five would die.(2) If we include
late fetal and inchildbirth deaths, the probability of infant mortality
climbs from 5% to 8%.(3)
The dangers of childbirth must have made it an occasion of great anxiety
for everyone concerned. The death of a woman or her baby was an all too
common occurrence. Caesar's daughter Julia died in childbirth. The younger
Pliny reports that both daughters of one of his friends, Helvidius, died
during labor.(4) And the Athenian philanthropist, Herodes Atticus,
was griefstricken when his first child, a son, died on the day of
his birth.(5) The anxiety and grief of the elite was surely paralleled
among the lower classes.
Accustomed as we are to the procedures of late twentiethcentury obstetrics
with its emphasis on prenatal care, asepsis, and medical technology,
our reactions to some of the methods and medications used for normal, uncomplicated
childbirth in the GrecoRoman world are likely to range from mild amusement
to outright revulsion. While we can make only educated guesses about the
mortality rates associated with childbirth in antiquity, we can reconstruct
a fairly detailed description of GrecoRoman maternity care and recover
a partial picture of the women who attended this epochal life event- the
midwives.
Both Pliny the Elder and Soranus provide detailed information about midwifery
and obstetrical practices; other medical writers such as Celsus and Galen
supplement their accounts and offer some additional evidence. We are fortunate
that Pliny and Soranus treat maternity care from significantly different
vantage points. In his Historia Naturalis, Pliny reports primarily
on the practices of folk medicine, whereas Soranus's Gynecology
describes the obstetrical care recommended by the medical profession. Together
Pliny and Soranus probably cover the full range of the different kinds
of maternity care found in the GrecoRoman world.
I. Folk Medicine
Pliny's descriptions of childbirth practices chiefly concern ways to hasten
and ease labor. Boys, he says, are more easily delivered than girls.(6)
According to Pliny, fumigations with the fat from hyaena loins produce
immediate delivery for women in difficult labor; placing the right foot
of a hyaena on the woman results in an easy delivery, but the left foot
causes death.(7) A drink sprinkled with powdered sow's dung will
relieve the pains of labor, as will sow's milk mixed with honey wine.(8)
Delivery can also be eased by drinking goose semen mixed with water or
"the liquids that flow from a weasel's uterus through its genitals." (9)
Pliny also describes medications made of herbs and plants that were used
for childbirth. The root of vervain in water, scordotis in hydromel, and
dittany leaves are recommended for the lyingin woman.(10) Amulets
and other objects were also thought to be efficacious. Pliny says that
some people used the afterbirth of a bitch that had not touched the
ground to withdraw the infant, placing the canine placenta on the thighs
of the woman.(11) Others tied a snake's slough to the thigh of the
woman but took care to remove it immediately after delivery. Some people
believed that a "stick with which a frog has been shaken from a snake"
was helpful.(12) A vulture's feather might be placed under the woman's
feet to aid delivery.(13) Celsus remarks on other folk nostrums,
reporting that sneezing relieves a difficult labor;(14) Celsus also recommends
drinking hedge mustard in tepid wine on an empty stomach for difficult
labor.(15)
It is difficult to determine just how efficacious-or harmful-these treatments
might have been. Understandably, contemporary midwives and obstetricians
are unwilling to experiment with any of them. At the very least, we can
conjecture that the presence in the delivery room of hyaena's feet, snake
sloughs, canine placentas, sticks, and vulture feathers may have increased
the risk of infection for both mother and child, especially if such objects
came in contact with the vaginal area. But we ought not to underestimate
the potential for a placebo effect in some of these treatments. If a woman
in the throes of labor were told, and believed, that a vulture feather
or snake slough would ease her pains, she might well have relaxed and felt
better. The practice of giving the parturient liquids, however, was probably
beneficial since they would tend to prevent dehydration, a potentially
serious problem in protracted labor.
Pliny also reports on ways to bring away the placenta. Here too the treatments
are apt to strike us as distasteful. Among his recommendations are earthworms
taken in raisin wine; the membrane covering newborn goats, dried and then
taken in wine; and linozostis or parthenion. Another is hare's rennet applied
with saffron and leek juice.(16) Celsus recommends a draught of four measures
of ammoniac salt or Cretan dittany dissolved in water.(17)
Pliny's reports are no doubt drawn from a vast reservoir of traditional
folk medicine. And it is important to recognize that Pliny, a highly educated
and sophisticated man, did not make light of these treatments. He seems
to think that they are sound and efficacious maternity practices. We are
on firm ground in assuming that the maternity care of most women in the
GrecoRoman world was conducted along the lines described by Pliny.
Regardless of the lack of attention to hygiene and sanitation and the likelihood
that the medications employed did little good- except as they exercised
a placebo effect and prevented dehydration- we must remember that, at the
very least, the maternity care described by Pliny was very personal and
attentive to the mother. She was at home, not in a strange, alien environment;
she was not left alone, sometimes for hours, to sweat out the initial stages
of labor by herself. She had the constant company of some of her female
relatives and the midwife to encourage her and to divert her mind from
the pains of labor. On an emotional level, GrecoRoman maternity care
is probably preferable to the production line, impersonal procedures of
some modern hospitals. An intensely emotionally supportive atmosphere is
of considerable importance to the health of both the new mother and the
new baby.(18)
II. Midwives
With the physician Soranus, who wrote in the early second century A.D.,
we find attitudes and beliefs about obstetrics more familiar to the modern
world.(19) Soranus begins his discussion of childbirth with a description
of the good midwife. To Soranus, the demands of the profession require
a highly competent woman; he implies that some midwives are simply unfit
for their work. "A suitable person," Soranus writes, "will be literate,
with her wits about her, possessed of a good memory, loving work, respectable
and generally not unduly handicapped as regards her senses [i.e., sight,
smell, hearing], sound of limb, robust, and, according to some people,
endowed with long slim fingers and short nails at her fingertips."(20)
Soranus also insists that the midwife be of sympathetic disposition (though
she need not herself have borne a child) and keep her hands soft, presumably
so she would not cause discomfort to either mother or child.(21)
Soranus argues that the best midwives should be literate so that they can
be knowledgeable about obstetrics and pediatric theory.(22) Soranus's
demand for literacy presumes that there was material for the midwives to
read. Soranus probably intended that midwives read his work; and it appears
that he prepared a shorter, condensed version as a sort of vademecum.(23)
One wonders whether Soranus would have put Pliny the Elder on his recommended
reading list for midwives; probably not, for Soranus says the midwife must
be free from superstition "so as not to overlook salutary measures on account
of a dream or omen or some customary rite...." (24)
Soranus's references to other medical writings also indicate that obstetrical
practice was not limited to midwives; a male physician might attend particularly
difficult births.(25) But the literary sources make it clear that
midwives normally attend childbirth.(26) Unfortunately, we can reconstruct
only a partial picture of the women who practiced midwifery. In the Eastern
end of the Mediterranean basin, some women advanced beyond the profession
of midwife (maia) to that of obstetrician (iatros gynaikeios),
for which formal training was surely required. Moreover, there were some
gynecological tracts written by women with Greek names. It would appear
that obstetrical care in the East was a respectable profession in which
respectable women could earn their livelihoods and enough esteem to publish
works read and cited by male physicians.(27)
In the Roman West, the situation appears to be somewhat different. Among
the thousands of funeral epitaphs recorded in ClL, only sixteen
commemorate the deaths of women who were identified as midwives.(28)
Of those sixteen, nine either come from the columbaria of the great
noble houses of Rome or are clearly members of the familia Caesaris.
It seems, then, a reasonable inference that large, wealthy households had
their own midwives.
Only one of these midwives died a slave; the others appear to be freed
women or the daughters of freed women. Two hypotheses are suggested by
this admittedly small sample. The first is that midwifery was not a profession
to which freeborn women of families that had enjoyed free status for several
generations were attracted; thus, it seems likely that most midwives were
of servile origin.(29) Second, since midwifery is an occupation that
can be practiced successfully into old age, emancipation cannot be explained
by the owner's desire to shuffle off a useless slave.(30) Thus, we
can propose that midwives were generally valued enough, and earned enough
income, to be able to gain their freedom.
The praenomina of these women confirm a hypothesis of servile origin.
Of the thirteen inscriptions in which the full name of the midwife is still
extant, eight have Greek names; the Latinate names of the others- Secunda,
Imerita, Hilara, Veneria- are also associated with slaves. Unfortunately,
it is not possible to determine from their epitaphs alone whether these
slaves, freed women, or daughters of freed women were born, raised, and
trained in Italy or were brought to Rome from the East.
Nor can we tell how particular slave women were selected for training as
midwives. Possibly mothers taught their daughters, or slave girls may have
been apprenticed. Such training may well have begun at an early age; one
epitaph records the death of Poblicia Aphe, obstetrix, dead at age twentyone
(# 9723). Two others died in their early thirties (# 6647 and 9724).
Midwives married, and three of the epitaphs record the name of the dead
woman's husband or contubernalis (# 6647, 8192, and 9720). Two of
the midwives were commemorated by their fathers (# 9724 and 8207), two
by their sons (# 8948 and 9720), and only one by her husband (# 6647).(31)
Despite the paucity of evidence about the training of midwives, it seems
a reasonable hypothesis that welltrained midwives were more likely
to come from the Eastern, Hellenized end of the Mediterranean basin, and
that midwifery and obstetrics were more highly esteemed professions, conferring
greater prestige on their female practitioners, in the East than in the
West. It also seems likely that wealthy Romans secured medical expertise
in midwives- as they did in doctors- by purchasing highly educated and
trained slaves from the East. The hypothesis of lower status for midwives
in the Roman West is corroborated by legal commentary on the Lex Aquilia,
passed probably in the third century B.C.; practitioners of medicine, including
midwives, were placed in a relatively low social status.(32)
Whatever the regional or socioeconomic background of midwives, their
services were not inexpensive. In Plautus's Miles Gloriosus, Periplectomenus
complains that women always ask for more money- even the midwife, who protested
the sum Periplectomenus had sent to her.(33) A midthirdcentury
A.D. marriage contract from Oxyrhynchus in Egypt stipulated that the husband
should give to the wife forty drachmae for her confinement if she was pregnant
at the time of any separation; the sum probably was intended to cover more
than the midwife's fee, but a substantial portion no doubt was to be used
for her services.(34) Soranus admonishes midwives not to be greedy for
money.(35) A number of Roman legal provisions strongly suggest that
midwives enjoyed status and remuneration comparable to that of male doctors.(36)
But there were, no doubt, people who simply did not have the resources
to pay for a capable midwife. There may have been some "midwives" who performed
their services for a pittance. Soranus certainly implies that some midwives
were much better trained than others. What poor women did is not known.
We can only guess that if they could not afford a trained midwife, they
turned to sagae, wise women who appear to have served at least in
part as midwives in early Rome,(37) or to their female relatives
who would have given whatever assistance they could. Whether the rate of
maternal and infant mortality was lower for births handled by competent
midwives, we do not know.
III. Obstetrics
After his description of the good midwife and a highly dubious discussion
of female reproductive physiology, Soranus turns to delivery proper. He
describes in detail the equipment used for normal labor and delivery. The
midwife must have
| olive oil [clean, not previously used in cooking], warm water, warm
fomentations [ointments applied to the body], soft sea sponges, pieces
of wool, bandages [to swaddle the infant], a pillow [on which to which
to place the infant], things to smell [pennyroral, dirt, barley groats,
apples, quinces, lemons, melons, cucumbers; these were used as we use spirits
of ammonia to revive someone who has fainted], a midwife's stool or chair
[this was the property of the midwife; she brought it with her to the home
where the delivery was to take place], two beds [a hard one for use during
labor and a soft one for rest after delivery], and a proper room [of medium
size and moderate temperature]. (38)
|
Soranus provides a good description of the midwife's stool; this chair
was used only during the actual delivery, not during labor. Apparently
both midwives and physicians believed that normal delivery was easier when
the mother sat upright.(39) In the seat of the chair was a crescent-shaped
hole through which the baby would be delivered. The sides of the chair
had arm-rests, in the shape of the letter "pi," for the mother to grasp
during delivery. The chair was to have a sturdy back against which the
parturient was to press her hips and buttocks. Soranus's description implies,
however, that some midwives' stools did not have backs and that an attendant
stood behind the parturient to support her, a less desirable arrangement
because of the danger that the parturient might recline or slip backwards.(40)
Soranus recommends that the sides of the chair from the seat to the floor
be completely closed in with boards while the front and the back be left
open for the midwife's work. Soranus mentions later that if a midwife's
stool is not available, the parturient can sit on the lap of another woman,
who, understandably, must be robust enough to bear the mother's weight
and hold her still.(41) It seems a reasonable conjecture that the
children of the poor may have been born without a midwife's stool if the
midwives they employed did not have the wherewithal to purchase a birthing
stool. Indeed, one of Alciphron's letters describes a midwife who carries
with her only a kit.(42)
At the onset of labor, the midwife was summoned and the necessary equipment
made ready. During labor, the parturient lay on her back on a hard, low
bed with support under her hips; her feet were drawn up together, her thighs
parted. Soranus directs the midwife to ease the labor pains with gentle
massage, with a cloth soaked in warm olive oil laid over the abdomen and
genital area, and with the equivalent of hot-water bottles- bladders filled
with warm oil- placed against the woman's sides. As the cervix begins to
dilate, the midwife is to encourage the process of dilation by gently rubbing
the opening with her left forefinger (with its nail cut short); the finger
is to be generously smeared with olive oil. When the cervix is dilated
to the size of an egg, the parturient is moved to the midwife's stool,
unless she has become very weak; in the latter case, the delivery is to
be made on the hard bed.(43)
For the actual delivery, the midwife needs three assistants to stand on
both sides of the chair and at the back. Soranus stresses that these assistants
should be "capable of gently allaying the anxiety" of the mother.(44)
The woman who stood behind the chair had to be strong enough to keep the
parturient from swaying; in addition, she was to hold a small, flat piece
of cloth at the anus to avoid hemorrhoids.(45) The midwife herself,
covered by an apron, sat in front of the mother and throughout the delivery
assured her that all was going well.(46)
Clearly Soranus, and presumably most midwives, expected the parturient
to do the work of expelling the fetus from the womb during a normal delivery.
There is no indication that anything like an episiotomy was performed.
One of the midwife's duties was to instruct the mother on proper breathing
and on how to push downwards during a contraction.(47) The assistants
who stood by the sides of the chair were to assist in delivery by gently
pushing downwards on the parturient's abdomen. Soranus's's discussion,
supplemented by passages from later medical writers, is similar to the
instructions now given to women choosing natural childbirth, except that
the father plays no role in the delivery Soranus describes and, more importantly,
the instruction in breathing and pushing comes during delivery rather than
in a pre-natal training program.
In a normal headfirst delivery, the midwife might stretch the cervical
opening slightly to help the fetus's head and shoulders through, after
which she gently pulled out the rest of the infant's body. The midwife
was also to take care that the umbilical cord was not distended and to
remove gently the placenta immediately after the birth of the baby. Soranus
instructs the midwife to wrap her hands in pieces of cloth or thin papyrus
so that the slippery newborn does not slide out of her grasp; Soranus seems
to think that if the midwife's hands are so wrapped, she will not inadvertently
squeeze the baby too hard in her efforts to maintain a firm hold.(48)
In the fourth book of his treatise, Soranus discusses difficult labor and
delivery. In addition to physical problems such as an overly small pelvic
opening, malnutrition, or obesity, he recognizes that a woman's attitude
and state of mind can have an important bearing on the ease of her delivery:
thus Soranus' counsel that midwives work hard to allay the fears and anxieties
of the mother. When the parturient suffers from excessive "grief, joy,
fear, timidity, lack of energy, anger, or extreme indulgence," labor and
delivery are difficult.(49) Soranus notes that inexperienced women
have more difficulty than those who have had babies before and that women
who do not believe that they are pregnant also have more difficult labor.(50)
In a lengthy section, Soranus treats the conditions under which the fetus
itself causes a difficult delivery and gives detailed instructions for
handling various kinds of cases, including those in which the fetus is
dead.(51) Unfortunately, it is impossible to tell even roughly what
proportion of births were subject to these complications. But the very
length of Soranus's discussion implies that midwives could expect to encounter
a significant number of complicated births. And although the obstetrical
procedures described seem basically sound, many otherwise healthy fetuses
probably died during a difficult delivery.(52)
A number of small reliefs provide visual evidence for ancient childbirth.
Plate I, a rather crudely fashioned, secondcentury A.D. terra cotta
from the tomb of Scribionia Attice in the cemetery on the Isola Sacra at
Ostia (tomb 100) depicts (three women: the parturient seated on a birthing
chair; an attendant who stands behind the birthing chair with her arms
supporting the parturient's upper torso; and the midwife who sits on a
low stool in front of the chair and appears to be about to pull the infant
from its mother's womb. The presence of this relief in the tomb may indicate
that its owner was a midwife.
Plate II, a more elegantly crafted ivory relief from Pompeii (Museo Nazionale,
Naples, No. 109905) depicts a similar scene. Here there are four women:
the parturient sits in the birthing chair; an attendant stands behind and
supports the new mother; the midwife, again seated on a low stool and holding
a sponge in her right hand, assists the delivery; the fourth woman, who
stands behind the midwife with her arms outstretched, appears ready to
take the infant or to offer a blessing.
A marble relief from a private collection (Plate III) provides an even
more detailed image of childbirth. Delivery has taken place in a well furnished
room of an apparently wealthy household. The parturient, naked in this
rendition, is sprawled across a chair (not a birthing chair) with a cushion
at her back; her lower torso and legs are entirely off the chair, her left
leg propped on a low stool. The midwife sits or crouches at the parturient's
feet with the newborn baby on a cushion in front of her. A slave attendant
stands behind the midwife. Standing behind the parturient are two men,
probably physicians; one of them holds an instrument that appears to be
an ancient version of obstetric forceps. Both men grip the left arm of
the parturient. This visual evidence, meager as it is, confirms and perhaps
supplements the verbal pictures of childbirth in Pliny and Soranus.(53)
IV. Care of the Mother
Soranus follows his description of normal delivery with a discussion of
care of the new mother, which, unfortunately, is very fragmentary. The
sole surviving section deals with care of the mother's breasts, including
treatment of in tumescence or engorgement. He recommends preventive measures
such as sponging the breasts with "mildly contracting things (such as diluted
vinegar ... or tender dates triturated with bread and diluted vinegar)"
or confining them with "a close fitting bandage."(54) If swelling
occurs, however, poultices made of bread, water, and olive oil or hydromel,
or of linseed, wheat or fenugreek, and water should be applied. If the
breasts are too tender to stand the poultices, the fluids should be gently
pressed out while soaking the breasts in warm oil. If the breasts become
inflamed and suppurate, surgery is necessary to remove the pus and fluid.(55)
Soranus also tells how to stop lactation in women who do not intend to
nurse their new babies themselves.(56) Presumably, the midwife is
to administer this care, at least up to the point of surgery for intumescence.
The clear implication is that the new mother remained under the care of
the midwife for at least several days after the delivery, and so probably
did the newborn infant.(57)
If we compare Soranus's recommendations for the care of the breasts of
the new mother with Pliny's descriptions of folk medicine, we again see
significant differences. Indeed, the methods of treatment described by
Pliny seem not only useless but also perhaps sufficiently distasteful to
make breastfeeding and the attendant folk remedies something to be
avoided. Pliny suggests drinking mouse dung diluted with rain water and
ass's milk for intumescence.(58) Rubbing the breasts with sow's blood,
goose grease with rose oil and a spider's web, or the fat of bustards is
also supposed to relieve swelling.(59) And a poultice of partridge
egg ash, zinc oxide ointment and wax might be used to keep the breasts
firm.(60) For breasts that inflame to the point of suppuration, Pliny
recommends laying earthworms across the breasts to draw out the pus and
adds that earthworms drunk with honey wine stimulate the flow of milk.(61)
We may reasonably doubt the efficacy of such treatments; if the breasts
were at all abraded, these treatments could cause serious infections. We
must assume, however, that these were the kinds of treatment employed for
most mothers. Only a relatively few families had the money or the inclination
to engage midwives trained according to the medical theories propounded
by the leading physicians; nor were there likely to have been many such
midwives even in major urban areas.
V. Care of the Newborn After Delivery
Once the baby had been safely delivered, the midwife carefully inspected
it for any congenital deformities. Apparently the midwife made the initial
recommendation about whether the newborn was healthy and fit to rear.(62)
Soranus suggests several tests for determining the health of the infant.
First, when placed on the ground, it should cry lustily; babies that do
not cry, or cry only weakly, are suspect. Second, its body should be normal;
the openings for the nose, ears, urethra, and anus should be clear; its
arms and legs should bend and stretch readily. Finally, by pressing her
fingers against the skin of the newborn, the midwife should be able to
elicit a reaction, indicating that the infant is sensitive to such sensations.(63)
Soranus also instructs the midwife to consider whether the mother has been
in good health during pregnancy and whether the length of gestation was
normal.(64)
We might well ask under what circumstances a midwife would declare a baby
unfit. Not all weakly infants nor all those with some kind of congenital
defect such as a club foot were regarded as unfit. Probably the midwife
made a determination about the chances for the infant's survival and would
likely recommend that a newborn with any severe congenital problem be exposed.
After inspecting the child and letting it rest a bit, the midwife severs
the umbilical cord. Soranus recommends using a knife and castigates other
methods as superstitious. He says that some midwives use a piece of glass
or a potsherd (presumably unwashed), a reed, or even a thin crust of hard
bread.(65) Soranus indicates that such materials are apt to cause
inflammation, showing at least some awareness of a connection between dirt
and disease. Instead of cauterizing the cord, as many midwives do, Soranus
directs her to gently squeeze the blood from it, to ligate the end with
a stout woolen (not linen) thread, and finally to gently press the bent
cord into the umbilicus or navel.(66)
With the umbilical cord tied off properly, the midwife is then to cleanse
the newborn. In the course of his discussion of washing the infant, Soranus
describes the practices of many other groups of people and rejects them
all as harmful to the newborn. Soranus recommends that the midwife sprinkle
the infant with a moderate amount of "fine and powdery salt, or natron
or aphronitre."(67) All these chemicals are mildly astringent and
were recommended primarily for their ability to cut through the residue
of amniotic fluid, vernix, and placenta on the newborn's skin and also
to make the skin less prone to develop rashes; however, astringents would
also tend to make the baby's skin dry out and flake or crack. Soranus suggests
mixing the salt with honey, olive oil, or the juice of barley, fenugreek,
or mallow so the granules are less likely to abrade the baby's delicate
skin. The emulsion is to be washed away with warm water and the process
repeated a second time. Next, the midwife is to clear any mucus from the
nose, mouth, and ears and to clear the anus of any membranes that might
impede regular bowel movements. She is to put a little olive oil into the
infant's eyes to clear away any birth residue and to place a small piece
of wool or lint soaked with olive oil over the umbilical cord. Soranus
indicates that some people use cummin here, but he states that cummin is
too pungent to be used on an infant.(68) Throughout his discussion of the
care of the newborn, Soranus stresses the delicacy of the infant and recommends
those treatments he thinks least likely to cause it discomfort.
VI. Conclusions
The vast majority of women in the GrecoRoman world very probably received
their maternity care (assuming they could afford to pay for it; no doubt
many could not) from midwives who employed the methods and medications
described by Pliny. While the traditions of folk medicine probably did
little to make childbirth safer (and some practices may have been harmful),
it does seem clear that efforts were made to give emotional support to
the parturient.
There is insufficient evidence to reach any firm conclusions about the
characteristics of the women who practiced midwifery. In the Hellenized
East, they seem to have had a higher status than their sisters in the Roman
West. Although some women of free birth went into midwifery as a profession,
the bulk of them were probably of servile origin or the daughters of women
of the lower classes. A very few women became obstetricians of some note.
For the wealthy elites, maternity care was potentially much better. The
corpus of medical literature certainly shows that some physicians and midwives
employed enlightened techniques that at the very least were unlikely to
harm either the mother or the baby. It seems probable, therefore, that
the rates of maternal and infant mortality in the Greco-Roman world varied
with the socioeconomic class of the family and with the family's choice
between traditional folk medicine and professionalized obstetrical care.
The American University
Valerie French
NOTES
*An earlier version of this paper was read at the 1981 Berkshire Women's
History Conference. I am very grateful to a number of people for their
useful suggestions, particularly the anonymous referee; Sarah Pomeroy;
and Ronnie Lichtman, a practicing midwife and member of the faculty of
the Nursing Midwife Program, College of Physicians and Surgeons, Columbia
University.
There is a rather scant bibliography on ancient maternity practices; most
of the booklength studies of the history of obstetrics give only a
cursory treatment of antiquity. See Hugo Blummer, Die romischen Privataltertumer
(Munich: Oskar Beck, 1911), pp. 299306; Theodore Cianfrani, A Short
History of Obstetrics and Gynecology (Springfield, Ill.: Charles C.
Thomas, 1960), pp. 7083; Martial Dumont, "L'Obsterique et la gynecologie
dans la Rome antique," Cahiers Medicaux Lyonnais, 41 (1965), pp.
8391; Palmer Findley, Priests of Lucina (Boston: Little, Brown,
1939), pp. 3865; Harvey Graham, Eternal Eve (Garden City, N.Y.:
Doubleday, 1951), pp. 5670; Harold Speert, Iconographica Gyniatrica
(Philadelphia: l: A. Davis, 1973), pp. 8384.
(1).World Health Statistics Annual ( 1979), pp. 16-28.
(2) Calvin Wells has recently argued that the incidence of female death
in childbirth in antiquity has been significantly overestimated; a relatively
poorer diet will account for the shorter lives of ancient women, Wells
contends. "Ancient Obstetric Hazards and Female Mortality," Bulletin of
the New York Academy of Medicine, 51 (1975), 1235-49.
(3) World Health Statistics Annual (1979). Keith Hopkins, Death and Renewal
(Cambridge: Cambridge University Press, 1983), p. 225, estimates that 28%
of Roman babies who were born alive died by their first birthday.
(4) Ep. 4.21.1-3.
(5) Fronto, ad M.Caesar 1.6.7 and Epis.Graec. 3.
(6) HN 7.6.41.
(7) HN 28.27.102.
(8) HN 28.77.250. The drying and powdering of the dung probably would have
reduced its bacterial content, but ingestion of even some E. Coliform (colon
bacillus) would be dangerous.
(9) HN 30.143.124 (Loeb translation). Semen has a high sugar content and
would have supplied the parturient with energy.
(10) HN 26.90.160-61. Vervain (radix verbenicue) comes from the family
of verbena and has been used for medicinal purposes, chiefly for fevers,
colds, convulsions, and nervous disorders; it was valued for its nervine,
tonic, emetic, and sudorific properties. Scordotis (tencrium scordium)
is probably related to garlic and was thought to have antiseptic, sudorific,
and alexipharmic properties; it has been used particularly for inflammations.
Dittany (origanum dictamnus) is a pink flowered plant, probably of the
mint family. For descriptions of the plants prescribed, see R. C. Wren,
Porter's New Encyclopaedia of Botanical Drugs and Preparations (Devon:
Health Sciences Press, 1975), and Walter H. Lewis and P. E. Elvin-Lewis,
Medical Botany (New York: John Wiley, 1977).
(11) HN 30.143.123.
(12) HN 30.44.129 (Loeb translation). Although Pliny does not say specifically
what was done with the stick, we can probably assume that it was not used
in the process of delivery; rather it was valued for its presumed magical
properties.
(13) HN 30.44.130.
(14) Med. 2.8.16.
(15) Med. 5.25.14. Hedge mustard is a common form of wild mustard and is
said to be a digestive stimulant, expectorant, and diuretic.
(16) HN 30.43.125; 28.77.255; 25.18.40; 28.77.248. Linozostis is probably
annual or perennial mercury (mercurialis annna or perennis), a toxic plant
whose leaves can cause gastroenteritis and allergic reactions in the lungs;
it is possible that the cramps of gastroenteritis were confused with uterine
contractions and that the plant, therefore, seemed to aid delivery. Parthenion
is a plant with white ray flowers; P. hysterophorus (the bastard feverfew)
and P. intogrifolium are used medicinally. Pliny notes that linozostis
and parthenion were recommended as emmenagogues, remedies to induce menstrual
bleeding. None of the plants recommended by Pliny or Celsus are known at
present to be oxytocic agents, substances that stimulate uterine contractions.
But the emetic properties of some of them could induce vomiting which,
with its abdominal spasms, is sometimes helpful in separating the placenta
from the uterus.
The folk practices described by Pliny and Celsus are similar to contemporary
folk medicine. See A. Mangay-Maglacas and H. Pizurki, The Traditional Birth
Attendant in Seven Countries (Geneva: World Health Organization, 1981).
(17) Med. 5.25.13.
(18) Recent research has shown how important emotional support is.
See Aidan Marfarlane. The Psychology of Childbirth (Cambridge, Mass.: Harvard,
1978), pp. 29-31; Joyce Prince and Margaret E. Adams, Minds, Mothers, and
Midwives (New York: Churchill Livingstone, 1978) pp. 116f.; and Barbara
Blum, ed., Psychological Aspects of Pregnancy, Birth, and Bonding (New
York: Human Sciences Press, 1981), pp 144-45.
(19) A careful edition of the Greek text of Soranus was published by Johannes
Ilberg as volume four of the Corpus Medicorum Graecorum (Leipzig and Berlin:
Teubner, 1927). For Soranus’ Gynecology (Baltimore: Johns Hopkins, 1956).
A physician himself, Temkin presumes a fair amount of obstetrical knowledge
on the part of his readers. Unfortunately, the section of Soranus’ work
treating normal delivery is fragmentary. But Temkin’s translation fills
in many of the lacunae with passages from later gynecological treatises
that were based on Soranus, especially the works of Caelius Aurelianus
and Muscio. Soranus’ extant work, supplemented by later writers, provides
the best description of the obstetric care in the Greco-Roman world.
(20) Gyn.1.1.3 (Temkin translation).
(21) Gyn. 1.2.4.
(22) Gyn. 1.1.3.
(23) Temkin, p. XXXVII.
(24) Gyn.1.2.4 (Temkin translation). Soranus’s reference to the dreams
of midwives may parallel anthropological findings. In some cultures, women
are selected as midwives on account of a dream vision in which they are
taught the skills and knowledge of the profession. We do not know how Greco-Roman
women became midwives, but Soranus’s brief statement might suggest that
dreams played a role in the selection process. See Shelia Cosinsky, "Cross
Cultural Perspectives on Midwifery," in Medical Anthropology, eds. S. Grollig
and H. Haley (The Hauge: Mouton, 1976), pp. 231-32.
(25) Temkin, p xxxvii. But the male physician gave directions; the midwife
did the work (Galen, Nat. Fac. 3.3.151).
(26) In Plautus's comedy Amphitryon, Alcmena delivers twins without
anyone present (lines 1070-72). However, the birth story here parallels
that of Heracles so strongly that the absence of the midwife should not
be taken too seriously, even though Alcmena’s family surely could have
afforded one.
(27) For women as midwives and physicians in the East, see Sarah
B. Pomeroy, "Technikai kai Mousikai," AJAH, 1 (1976), 86, and Natalie Kampen,
"Social Status and Gender in Roman Art. The Case of the Saleswoman," in
Feminism and Art History, eds. Norma Broude and Mary Garrand (New York:
Harper & Row, 1982), p. 70, and Image and Status: Roman Working Women
in Ostia (Berlin: Gebr. Mann Verlag, 1981), pp. 69-72 and 116-17. Soranus
(Gyn. 3.3.1) draws a clear distinction between the midwife (maia) and the
physician obstetrician (iatros gynaikeios); in Latin, ob(p)stetrix and
medicus/a parallel Soranus’ Greek terminology.
(28) CIL, 6: # 4458, 6325, 6647, 6832, 8192, 8207, 8947-9, 9720-5,
and 37810. We should not assume that because so few women are identified
as midwives that there were very few midwives in general. Until more research
is done onanalyzing the occupational titles recorded in funeral epitaphs,
we cannot conclude anything about the relative numbers of people engaged
in different occupations.
(29) Contra: Treggiari (above, note 27), 87; she sees the women commemorated
by # 9720, 9722, 9724, and 9725 as just as likely to be freeborn as freed.
Treggiari suggests, therefore "that free women might train for this work
and that only in domestic service would slaves be the rule." Kampen (above,
note 27), p. 116, argues for the servile background of most midwives.
(30) For midwives working expertly at an advanced age, see Cosminsky (above,
note 24), p. 231.
(31) In the other eleven epitaphs, the name of the commemorator is
not given.
(32) John Scarborough, Roman Medicine (London: Thames and Hudson,
1979), p. 19. See Dig. 9.2.9.1; Ulpian describes the application of the
Lex Aquilia to obstetrices.
(33) M. Gl. 697.
(34) P. Oxy. 1273, lines 33-34. The potential income of a midwife
suggested by this contract compares favorably with other wages from this
period and region. Stewards, for example, earned approximately 40 drachmae
a month (P. Lond. 1226 and P. Flor. 321 and 322); ox drivers made between
34 and 48 drachmae a month (P. Flor. 321); common laborers could expect
around four to eight drachmae a month (P. Flor. 322); estate managers received
between 60 and 128 drachmae a month (P Oxy. 1577-78). See Allan Chester
Johnson, An Economic Survey of Ancient Rome, vol. 2, ed. Tenney Frank (Paterson,
N. J.: Pageant, 1959), II, pp. 309-10.
(35) Gyn. 1.2.4.
(36) Cod. Iust. 6.43.3 provides that slave medici and obstetrices
left to legatees had equal value (60 solidi). Dig. 50.13.1 gives a list
of people for whom provincial governors were to hear suits on contracts
for wages; at 50.13.1.2 the midwife is given equal access to the official
because she is regarded as practicing medicine just as doctors do (quae
utique medicinam exhibere videtur). See J. A. Crook, Law and Life of Rome
(Ithaca: Cornell University Press, 1967), pp. 204-05, and Kampen (above,
note 27), pp. 70 and 117.
(37) Scarborough (above, note 32), p. 18; W. W. Fowler, The Roman
Festivals of the Period of the Republic (London: Macmillan, 1899), p. 292,
connects the Carmentes, birth goddesses, with the sagae.
(38) Gyn. 2.2.2.
(39) Recent research indicates that an upright as opposed to a recumbent
position is more comfortable for the parturient and reduces the time of
both labor and delivery. See Susan McKay and Charles S. Mahart, "Laboring
Patients Need More Freedom to Move," Contemporary OB/GYN, July 1984, 90-119.
I am grateful to Dr. Celeste Phillips for her assistance on this question.
(40) Gyn. 2.2.3.
(41). Gyn. 2.3.5.
(42) Letters 2.7.1.
(43) Gyn. 2.2.3-2.3.4. Galen's brief description of the midwife's duties
during delivery (Nat. Fac. 3.3.151-52) closely parallels Soranus's account.
Midwives today use massage and warm oil to soothe the parturient during
labor. But the practice of trying to hasten dilation by rubbing the cervix
is potentially dangerous, for the midwife's finger, even if smeared with
oil, is likely to introduce foreign bacteria. However, since birth took
place at home, there was less likelihood that the parturient would be contaminated
with bacteria from sick people.
(44) Gyn. 2.3.5.
(45) Hemorrhoids usually develop during pregnancy, if they occur
at all; Soranus's advice may well have prevented internal hemorrhoids from
becoming external during delivery. The cloth held at the anus may also
have prevented fecal matter from contaminating the perineum and vagina.
(46) Gyn. 2.3.5.
(47) Gyn. 2.3.6. According to Pliny, HN 7.6.42, women who do not
hold their breath during delivery experience greater difficulty; Pliny
also adds that gasping may prove fatal.
(48) Gyn. 2.3.6. It is hard to see how the midwife would be able to reach
the cervix once the baby's head had emerged. Soranus may mean the perineum.
More serious is the instruction to try to remove the placenta immediately
after delivery. Premature removal of the placenta, especially if the midwife
attempted to reach into the uterus, would be likely to cause infection
and even hemorrhage. Modern practice is to allow the placenta to separate
itself from the uterine wall and then to have the parturient push to expel
it.
(49) Gyn. 4.2.2.
(50). Gyn. 4.2.2.
(51) Gyn. 4.2.3f.
(52) Galen says that infants present feet first, laterally, or with an
arm or leg first in only one of many thousands of births (de Usu Partium
15.7). We should properly take this observation with a grain of salt, since
neither Galen nor any one else in antiquity ever tried to make an accurate
count of such occurrences. But clearly, Galen thought these births unusual.
Modern statistics suggest that in about five percent of deliveries, the
infant presents in a difficult position- breech, transverse, compound,
or face/brow first. By far the most common, breech occurs in about three
to four percent of deliveries. Breech presentations are especially associated
with prematurity and poor nutrition, conditions at least as likely in the
Greco-Roman world as today. As a general rule of thumb, 85-90% of all births
in a generally healthy female population are normal and uncomplicated.
See Harry Oxorn, Human Labor and Birth, 4th ed. (New York: Appleton Century
Crofts, 1980).
(53) See plates I-III. For the Ostia and Pompeii reliefs, see Kampen
(above, note 27), pp. 69-72. For the relief depicting obstetrical forceps,
see Harvey Graham, Eternal Eve (Garden City: Doubleday, 1951), pp. 68-69.
Professor Silvestro Baglioni, the owner of the relief reportedly found
near Rome, dates it to the second or third century B. C., but its authenticity
is not secure. For ancient obstetric surgical instruments, see John Stewart
Milne, Surgical Instruments in Greek and Roman Times (New York: Oxford,
1907), pp. 152-58.
(54). Gyn. 2.5.7 (Temkin translation). A terra cotta figurine in the Athens
National Museum (No. 5666) shows a woman bandaging both her breasts; since
she has a rather flabby abdomen, the figurine may well depict this method
of caring for the breasts after delivery, a method also used by modern
midwives.
(55) Gyn. 2.5.7. Fenugreek (trigonella foenumgraecum), a leguminous annual
herb with aromatic seeds, has been used as an insulin substitute. Plutarch's
wife apparently underwent surgery for a "bruised nipple" incurred while
nursing her son Charon; Plutarch praises her action as "noble" and indicative
of "true mother love" (Mor. 609F). The tenor of Plutarch's remarks suggests
that such surgery was very painful.
(56). Gyn. 2.5.8.
(57). Despite the fullness of Soranus’s description of the duties of the
midwife, she may have been expected to do even more. For example, Horace
refers to a midwife washing the bloodstained cloths used in delivery (Epod.
17.51). It may well be that some midwives brought with them the cloths
they used in childbirth; if so, one is relieved to learn that they were
washed.
(58). HN 30.43.124 and 28.77.250.
(59) HN 28.77.250 and 30.45.131.
(60) HN 30.45.131.
(61) HN 30.43.125.
(62) Varro, apud Nonius 528.12; Soranus, Gyn. 2.6.10.
(63) Gyn. 2.6.10. The author of the biography of Clodius Albinus comments
that normal children are red at birth (SHA, Clod. 4.4). Surprisingly, Soranus
does not mention the newborn’s skin color as an indication of its health.
(64) Gyn. 2.6.10. The normal period of gestation was believed to vary between
seven and ten months. Without a system of prenatal care, the midwife would
have to rely on the mother's determination of her health and length of
pregnancy; such determinations were, no doubt, often in error.
(65) It is possible that poor midwives used such readily available
implements in order to save the cost of purchasing a knife.
(66). Gyn. 2.7.11. The potential problem with cauterization, apart from
the pain it probably causes the infant, is that it will not always completely
close the blood vessels and thus increases the possibility of umbilical
hemorrhage. Pressing the cord into the umbilicus is not likely to insure
an indented naval.
Oribasius gives similar instructions for ligating the umbilical cord. It
is to be cut at a distance of about four finger widths (about three inches)
from the stomach with a sharp knife; neither a reed nor a piece of glass
should be used in order to keep the contusion as slight as possible. After
cutting, the blood should be gently squeezed from the cord, and then the
end is to be wiped and bound with wool (Collect. Med. Liv. Incert. 12.1).
(67). Gyn. 2.8.12-13. Natron is the mineral, hydrated sodium carbonate,
rather like baking soda; aphronitre is probably some kind of foaming saltpeter,
either potassium or sodium nitrite.
(68) Gyn. 2.8.13. Cummin is a plant from the same family as parsley
and celery and has a sharp, distinct taste and odor.
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