This post written by Jane Stojanovic (RM, RGON, MA [Applied], ADN) was first published in Birthspirit Midwifery Journal 2010; 2: 53-60.

Abstract Childbirth for European women in early twentieth century New Zealand was family centred. The majority of births took place in the home, accepted as a difficult but natural part of a woman’s role in life. Midwives were mostly married women who worked autonomously and had usually borne children themselves. By the 1970s this picture had dramatically changed. Virtually all births took place in hospital and were under the control of medical men and women. When legislation was passed (the Nurses Act 1971) that removed the right of New Zealand midwives to practice autonomously, New Zealand midwifery had largely been subsumed by nursing, controlled by medicine and displaced from a community based profession into a hospital based workforce. This article examines how the trends of medicalisation, hospitalisation, and nursification changed the New Zealand maternity services from 1900 to 1971, outlining the effect those changes had on the midwifery profession. The changes described here were also common to other western societies; examining how they occurred provides a context for understanding the history of midwifery in New Zealand.

 

Introduction

New Zealand midwifery became a regulated profession with the passing of the Midwives Act 1904.This article explores the changes that took place in New Zealand in the period following that Act until midwives lost their right to be responsible for the care of childbearing women without medical oversight with the passing of the Nurses Act 1971. In 1900 midwives were usually married women who had borne children themselves, and worked in the community. By 1971 midwives were mostly single women, and were almost invisible among the nursing dominated workforce.¹ I would argue that three interdependent and synergistic factors, medicalisation, hospitalisation and nursification created an environment that dramatically changed both the midwifery profession and the New Zealand maternity service. The Midwives Act 1904 established midwifery training schools and the registration of midwives, and a state midwifery service.² The Act also put midwifery under the direct control of medicine and began the introduction of nursing culture into midwifery by creating the nurse-midwife. With the ‘cause and effect’ cycle of the three synergistic and catalytic factors, medicalisation, hospitalisation and nursification, came a series of clinical and political changes that culminated in the passing of the Nurses Act 1971 with its resultant loss of autonomy for midwives.³

Maternity in the 1900s

A Wellington gynaecologist/obstetrician, Dr Kenneth Pacey describes maternity care in the early twentieth century:

The vast majority of women had their babies in their own homes. Since many of these were humble in the extreme, the environment left much to be desired. Yet here were dealt with the major complications of obstetrics. Some of the graver emergencies were sent to the general hospital, but others such as the high forcep deliveries, the breech deliveries, were coped with on the spot. ⁴

In 1900 the maternity service in New Zealand was provided mostly by lay midwives, some who had received tuition from other midwives or doctors. There were a small number of midwives who had some training in maternity from overseas hospitals and some who ‘took in’ women into their homes for birth.⁵ In urban areas there were private ‘lying-in’ hospitals owned by doctors or midwives, and these midwives often had no formal training. They were called by various names – ‘lay midwife’, ‘traditional midwife’, ‘handy-woman’, and sometimes, ‘the monthly nurse’- although the latter term can also be applied to women who visited the home and took over the care of the household for a month following the birth.6 Widows often provided midwifery services as it was a way of earning some money, or at least payment ‘in kind’.⁷ By 1900 the numbers of midwives in New Zealand who had done some form of training were beginning to increase but there was no training school available in New Zealand.6

It became apparent that the European populations’ birth rate was dropping in both Australia and New Zealand. This was highlighted in the findings of the New South Wales Royal Commission in 1904.6 Improving maternity care was seen as a method of reducing the high infant mortality rate thus increasing the numbers of live adults to help maintain a majority balance for New Zealand’s European population.6 A law regulating the practice of midwifery and providing for the education and registration of midwives was perceived as a method of achieving this improvement. This law, the Midwives Act 1904, was passed through the combined efforts of civil servants Grace Neill and Dr Duncan McGregor, and the Premier of New Zealand, Richard John Seddon.8 Grace Neill was a Scottish woman, a widow, who had joined the Department of Labour as the first woman Inspector of Factories. She was given the job of Assistant Inspector of Hospitals, Asylums and Charitable Aid by Dr Duncan McGregor, Inspector General of Hospitals for New Zealand, who, according to Neill’s son John, saw her as his “ideal assistant”.9 The findings of the Royal Commission gave Neill and McGregor an opportunity to support the Premier in introducing a Bill that they believed would improve maternity care by providing institutions that would provide both affordable maternity care for ‘the wives of working men’ and training for midwives.6 Neill suggested the hospitals be named the St Helens Hospitals after Seddon’s birthplace in England.1⁰

The Nurses Registration Act had been passed in 1901, drafted and implemented by Neill, but there was much less support for the Midwives Bill. Enforced registration was a threat to the majority of midwives who were untrained therefore passing the Midwives Act was a more difficult proposition. Some doctors had part or full ownership of maternity homes and did not welcome the idea of the state intruding on their preserves. John Neill, Grace Neill’s son, wrote in her biography that the doctors were not as concerned about the “initial loss of patients as the threat of future state control”.1⁰ However, despite their protests, St Helens Hospitals and their associated training schools for midwives did come into being when, with the support of the Premier and some astute political manoeuvring, the Midwives Act 1904 became law.

Midwifery Registration

The Midwives Act 1904 established a national structure for training and registering midwives, a knowledge base for midwifery practice and a state midwifery service.2 The Act was passed to establish state control of midwives. Registration became a legal requirement. The loss from their communities of the traditional midwives would have left many country areas with no midwife, so the register of midwives was divided into two classes to accommodate the traditional midwives. ‘Class ‘A’ Midwives included women who had been trained in a recognised training school, in New Zealand or overseas. Midwives, who although untrained, had been in practice for at least three years and could show that they were of good character could apply to become Class ‘B’ Midwives. There is ample evidence that a number of lay midwives did not register but continued to practice for some years after the passing of the 1904 Act. In 1921 there was a report to the Health Department that nine women were still practising as lay midwives in the Hawera district.¹¹

St Helens Hospitals

The first St Helens Hospital to open was in Rintoul Street, Wellington, in May 1905, followed by Dunedin and Auckland. Slowly until 1920, others were opened in Christchurch, Gisborne, Wanganui and Invercargill. ¹² They were administered by the Department of Health until 1966 when they passed to the control of the Hospital Boards. Each St Helens hospital had a medical superintendent but was otherwise managed and staffed by midwives, who called on the Medical Superintendent’s help only when needed.¹³ Despite some successful efforts by the medical profession to take over these hospitals for the training of medical students, the midwifery schools continued until 1979 when responsibility for midwifery education passed into the tertiary education sector.

Hospitalisation

The maternity hospitals in New Zealand when the St Helens Hospitals were set up in 1904 had consisted of small private hospitals, usually owned and managed by midwives, doctors or both. The large public hospital catered for few maternity cases, usually only if there were also medical problems. Even in the early 1900s it was certainly more convenient for doctors to attend births in hospital. In the 1900s Sir Frederic Bowerbank attended women at the Alexandra Maternity Home in Hansen St Wellington and related that “where possible, to my great relief, I used to attend my patients there, because conditions in some of the homes were frequently most unsatisfactory”. ¹⁴

In 1920, 65 percent of New Zealand mothers still had their babies at home, or in small unlicensed one-bed homes. A hospital was defined as an institution having two or more beds.¹⁵ Many midwives took in only one woman at a time so that they would not be classified as a hospital and be subject to the attendant regulations. Twenty-six percent (26%) of births occurred in private hospitals, five percent in hospital board and charitable hospitals and a small percentage only (4%) occurred in the St Helens hospitals, (although the St Helens midwifery students also attended homebirths).¹⁶

Seven years later, in 1927 fifty-eight percent of New Zealand births took place in maternity hospitals. By 1936 this had risen to almost eighty-two percent.¹⁷ Joan Donley, a homebirth midwife and midwifery activist in the 1980s and ‘90s, believed that women accepted hospital birth because of “… their economic situation or living conditions, for a rest from house-hold chores and the care of large families, or because (increasingly) they were lured by the promise of ‘painless child-birth’ ”.¹⁸ The development of hospitalisation for childbirth was led by the medical profession and was closely linked to developments in anaesthesia and asepsis.

Twilight Sleep

With the introduction of strict asepsis and twilight sleep in the 1920s and 1930s, medical preference for birth in hospital increased. ¹⁹ Central to the development of hospitalisation as the preferred option for birth and postnatal care was the ‘selling’ of the idea that the medical profession and their hospitals could provide a safer, pain-free birth. ²⁰ The use of anaesthetic agents for pain relief had begun with Chloroform, but this was of limited use as it was really only useful with the delivery of the baby. When ‘twilight sleep’, invented by Professor Gauss in Germany, was introduced to New Zealand in the 1920s, the medical profession was able to advertise its ability to provide ‘painless child-birth’. ⁵

‘Twilight sleep’ did not take away all of the pain of childbirth but it did remove the woman’s memory of the pain, so the consumer’s perception was of a painless labour and birth. ²¹ To achieve the desired effect doctors used a cocktail of drugs, particularly the barbiturate known as Nembutal and Scopolamine (Hyoscine).These were often augmented by the use of Chloroform in second stage. This was a very labour intensive regime which required increased observation and monitoring of the semi conscious woman, necessitating interventionist techniques such as regular vaginal examinations because of the birth attendant’s inability to ‘read’ the progress of the labour by observing the behaviour of the woman.²² Normal childbirth behaviours were no longer present in the sedated woman. In the process of achieving ‘painless childbirth’, therefore, the woman gave up control of her birth process to the birth attendants and became an invalid to be tended, observed and monitored.

Labour changed from the normal to the abnormal because the woman could no longer obey her instincts and move into positions to aid the baby’s descent through the pelvis and reduce pain. She could no longer eat and drink during labour, to refuel her body for its increased energy requirements. Often she did not have the ability to push the baby out so forcep deliveries became much more common. The drugs did not only sedate the mother, but also her baby, increasing the number of babies requiring resuscitation at birth. These interventions created a cycle of intervention – increased risk – increased intervention. Because the women required intensive monitoring they had to birth in hospital where they and their babies were exposed to hospital pathogens and cross infection.²² The increased interventions, vaginal examinations and instrumental deliveries were linked to a corresponding rise in puerperal infection.²³

Puerperal Sepsis

Puerperal Fever became a political issue in the1920s due to the rise in maternal mortality and morbidity caused by its increased incidence. With the increasing number of cases it became publicly controversial. The medical fraternity was inclined to blame the increase in puerperal fever on midwives, although the increase in sepsis was linked to the use of more interventionist techniques. A Board of Health Special Committee had, in 1921, pointed out the link between puerperal sepsis and instrumental deliveries and advised that the medical profession and the public have it drawn to their attention. The public were advised by the Board that “childbirth is a normal physiological process, and to the healthy woman in healthy surroundings is attended with very small risk”.^24,25

In 1923, between July and November, there were six cases of puerperal sepsis at a respectable private maternity home in Auckland, Kelvin Hospital. Five of the women died. The fear and anxiety aroused by this led to an enquiry. The Kelvin Hospital Commission’s report defended the doctors and hospital staff and laid the blame on the Health Department.²⁶ As puerperal sepsis was a notifiable condition which had not been notified properly, and in some cases not at all, this blame was not accepted by the Department but, as a result, the Department launched the ‘Campaign for Safe Motherhood’ in 1924.The forceps rate was not mentioned. The campaign was directed toward antenatal care, asepsis, hospital policy and midwifery training.²⁴

As part of this campaign, severely restrictive practices were introduced by Dr Tom Paget, Inspector of Maternity Hospitals, in his effort to reduce the risk of infection.²⁷ Henry Jellett, who became consultant obstetrician to the Health Department in 1924, was also influential in the devising of Paget’s recommendations; the General Principles of Maternity Nursing and the Management of Aseptic Technique and the Puerperium (H-Mt.20) ruled maternity practice for twenty-five years,²⁸ but affected maternity practice in varying degrees for at least fifty years. One result of the draconian aseptic measures introduced with Paget’s regulations was that the woman’s need to be mobile in labour, even when not sedated, was sacrificed to the requirements for a ‘sterile field’ for the birth of the baby. It also meant that women could no longer birth where they laboured, needing to be transferred at the last, panting and pushing, to a special delivery room:

Thomas Paget, Henry Jellett and the hundreds of midwives who put their reforms into practice may be justly remembered for their crusade against sepsis and unnecessary maternal death. Yet a narrowly clinical approach ignored birth as an emotional experience, resulting in treatment both frightening and degrading for many women.²⁹

By the 1950s birth took place in a room very similar to an operating theatre, under very similar conditions to a surgical operation. These procedures persisted; in the 1970s, as a student midwife I remember spending a lot of time acquiring the skills of sterile technique, learning how to cover the woman correctly with sterile drapes which, of course, required the woman to remain in a horizontal position and that necessitated the use of the lithotomy position and ‘stirrups’ to hold her legs in place.

The aseptic techniques introduced in the1920s are credited with hugely lowering the maternal mortality from puerperal sepsis well before the introduction of antibiotics. ²⁹ It was considered necessary to teach doctors, midwives and nurses the importance of stringent asepsis, and perhaps the severity of such measures helped to disseminate the message, but it could be speculated that other ways of lowering the risk of sepsis such as keeping mothers at home rather than together in hospital, the separation of maternity wards from general wards, careful hand-washing and later, glove wearing would have done much to improve the situation without the need for such depersonalising procedures to persist for so many years.

The introduction of the H-Mt.20 regulations changed the way maternity care was delivered, requiring a special room for birth, and because the mothers were kept in bed and could not care for their babies, nurseries were set up to keep the babies in a separate room.³⁰ Perversely this exposed babies to the risk of cross-infection resulting in the Staphylococcus aureus (H-Bug) epidemics of the 1950s.^1,31 There were also added requirements due to the need for extra sanitary arrangements. These requirements, for many small maternity facilities meant costly alterations, which many could not afford, as the 1920s was also a time of economic depression.³² By the late 1930s many of the handy-women who had provided maternity accommodation were retiring, often in response to financial and political pressure:

Health Department regulations increasingly demanded new equipment and facilities in an attempt to meet the goal of safe maternity practice. During the depression years mid-wives in private practice or who owned private hospitals operated in a harsh economic climate and received poor financial returns. Constant concern about the effects of maternal death or hospital closures meant midwives had to constantly guard their good reputations for fear of financial ruin. Competition from untrained colleagues, strict legislation which allowed ‘one at a time’ hospitals to operate, and lack of support from doctors added to the stress. ³³

Although the Health Department introduced Paget’s measures to combat puerperal fever, generally the department supported midwifery with its lower rates of intervention. Midwives and Plunket Nurses were operating State ante-natal clinics in four cities. The Department had criticised doctors for ‘meddlesome midwifery’ and set up midwifery run antenatal clinics. The doctors felt undervalued and threatened, and did not want their practice controlled by “a set of busybodies in the bureaucratic hive in Wellington”.³⁴ In 1927 they formed the Obstetrical Society, the intention to do so being sparked “… because a sanitary inspector – a man licensed to inspect drains –had presented himself before a surgeon of the English Royal College demanding reasons why the latter had done a Caesarean Section”.³⁵

Obstetrical Society

Dr Doris Gordon was pivotal in the formation of the Obstetrical Society and was also successful in organising an endowment fund to establish a Chair of Obstetrics at Otago University. She believed that to maintain control of maternity, the doctors needed to change the public perception of birth. As Mein Smith points out, “because health officials insisted that childbirth was a normal healthy process, she believed that a fledgling Obstetric Society needed to educate the public to accept the alternative view that maternity was ‘highly dangerous’ ”.³⁶

Doris Gordon was a very enthusiastic proponent of pain-free labour and had been instrumental in the introduction and dissemination of the techniques of ‘Twilight Sleep’. As a powerful lobby group, the Obstetrical Society was able to alter the political power balance in their favour. ³⁷ In response to their lobbying hospitalisation came to be perceived by the public as a safer option for birth because of all the ‘things that could go wrong’, although hospitalisation and ‘painless childbirth’ actually induced iatrogenic effects. ³⁸

By 1935, the high maternal mortality due to sepsis had waned, and the Health Department had changed its relationship with the Obstetric Society, altering the balance of political power in the process to the benefit of the doctors. Although the Health Department continued to campaign against ‘meddlesome midwifery’ and the forcep rate did decline, caesarean section started to become more accepted and the medical profession became more politically powerful. ³⁹

Hospital Boards and Hospital Beds

By the late 1920s the increasing demand for birth in hospital, brought about mainly by medical lobbying and gate-keeping was straining existing obstetric accommodation. The Kelvin Commission had recommended that the Health Department and Hospital Boards should provide maternity beds for all classes of women, paid according to means. In response to this the Health Act 1932 legislated that the Hospital Boards must take responsibility for providing maternity beds where required.³⁰

During the depression of the 1920s and ’30s many women, unable to pay medical fees, had returned to midwifery care, and this was seen as a threat by doctors. When the 1937 – 1938 Committee of Inquiry into Maternity Services recommended doctor attendance at all births, this was partly in response to demands from women’s organisations who, having accepted the Obstetrical Society’s assurances that hospitalisation was necessary for birth, were now asking for hospitalisation to be free and home-help available so that all women could birth in what they considered were optimum conditions. The enquiry also promoted maternity care by doctors rather than midwives or clinics, by recommending continuity of care by the family doctors as the best care.³⁹

The Social Security Act 1938 provided free maternity care for all women including hospitalisation and care by the doctor that she chose. The Act can be seen as the ‘coup de grace’ for the autonomous midwife. Generally doctor attendance at birth had been favoured by the wealthier in society, midwives by the poorer; medical attendance had thus become a status symbol. With the combined effect of the Obstetrical Society’s promotion of pain-free, ‘safe’ birth and with free medical attendance and hospitalisation being offered by the Labour government, and strongly promoted as the preferable option, it is not surprising that the bulk of women accessed doctors for their maternity care, considering that now they could have both a doctor and a midwife attending their births, and a free fourteen day rest in hospital.⁴⁰

Midwives and hospitals were also catered for in the government payments for maternity services. Midwives could claim payment from the Health Department for home birth care and were still legally able to provide care without a doctor’s involvement but most women chose medical care and the midwives were, therefore, forced to work with doctors in hospitals.

Doctors had become the ‘gate keepers’ for maternity care and advised women to birth in hospital for safety reasons.⁴¹ From 1938, the maternity system was required to provide free maternity inpatient care to all women, with a fourteen day stay. Because the Hospital Boards had been given the responsibility of providing maternity beds, the late 1940s and early 1950s saw the mushrooming of Hospital Board owned and run maternity hospitals. Some of these, including the Wellington Hospital Maternity Annex, were hastily converted military hospitals, others, like the Levin Maternity Hospital, were purpose-built new buildings. The Annual Report of the Director of NZ Health Department states:

Hospital Boards have had to assume responsibility for an increased number of maternity beds due to (1) The majority of births now taking place in hospitals. (2) The number of private maternity beds having decreased, and (3) The birth rate having increased.⁴²

The baby boom following the Second World War combined with a nursing shortage to exacerbate the shortage of maternity beds. The five day working week introduced by the Labour Government made the nursing shortage even worse. Gordon sums up the situation:

… the five day working week, started kicking out of the nest all the good things socialism had tried to evoke. Costs soared and almost overnight came a crisis in staff shortages. Private maternity hospitals closed at the rate of one a month, and hospital boards, ordered to accommodate maternity cases, found they had neither space nor staff. ⁴³

The severe maternity bed shortage is illustrated by Gordon’s story of the graphic unofficial instructions she received from the Obstetrical Society (by then the Obstetrical and Gynaecological Society), on her appointment to the position of Director of Maternal Welfare in1946 (1955:105):

Whenever you come across an empty soldiers’ ward for God’s sake snavel us a maternity unit. We dread births on back seats of taxis, and taxi drivers are fed up with blood and tears. The remaining private hospitals fearful of fines, dare not admit a case a little out in her dates when they are overfull already, so the poor patients have to tear around all the other maternity homes asking in vain for a bed … the taxi driver, sensing urgency, lands the outfit at the general hospital and helps shove his fare into a wheelchair. The chair and a porter set off at a run for the women’s ward only to be met at the door by sister. ‘Maternity Case? Oh no! I cannot admit you here. I’ve no staff and no facilities for maternity. I’m sorry I can’t …’ ‘No such word as “can’t”’, says the baby …⁴⁴

Nursification and Medicalisation of Midwifery

The Midwives Act 1904 began the process of putting midwifery under the control of medicine and began the introduction of the nursing culture into midwifery by creating the nurse-midwife. A lay person could study for twelve months to become a midwife; a nurse registered under the Nurses Registration Act 1901 could train in six months. Having a double qualification was useful and increased the likelihood of gaining higher status in the profession.⁴⁵ I would argue that this was the beginning of the nursification of midwifery and that maternity’s move to the medicalisation and hospitalisation of birth increased the momentum of the nursification of midwifery.

Papps and Olssen point out that although Nursing and Midwifery as professions were closely aligned in New Zealand from the early twentieth century, they were two distinct professions with their own regulatory registration Acts. From 1925 that changed when both disciplines were regulated by the same Nurses and Midwives Registration Act. This Act enabled women to register as maternity nurses and changed midwifery training into a postgraduate course.^46,47 Some traditional midwives became classified as maternity nurses, able to care for women only under the direction of a doctor or midwife.

Midwives were numerically a much smaller group than nurses. They had no representative organization of their own and consequently were powerless to prevent negative changes to their profession. Nurses in the 1930s also supported the Obstetrical Society’s agenda to promote doctor/nurse care for women in St Helens hospitals over midwifery care.⁴⁸ It was expected, particularly by nurses and doctors, that maternity nurses would replace midwives completely and all maternity care would be under medical jurisdiction⁴⁹:

In 1937, the Committee of Enquiry into Maternity Services in New Zealand advocated the Obstetrical Society’s Policies and in 1946 the Committee of Enquiry into Maternal Hospital Staffing issued a report which criticised the St Helens training programme and questioned the need for midwives at all now that usual doctor attendance at birth had been established. Both committees’ recommendations were to have significant influence in the subsequent years. ⁵⁰

The grave shortage of nurses and midwives that followed the Second World War was intensified in maternity hospitals due to the post-war ‘babyboom’. Consequently there was a Committee of Enquiry into Maternity Hospital Staffing in1946 which looked beyond staffing and examined the maternity service. From this a commit-tee was formed which excluded midwifery representation but included medical and nursing representation.

The committee recommended inclusion of maternity into the general nurse training syllabus. They perceived nurse-midwifery as improving the service. This was resisted by a nurse and midwife, Mary Lambie, The Health Department’s Director, Division of Nursing, who recognized the problems inherent in the plan and managed to stop its implementation until after her retirement in 1950. However, in 1957, changes were finally made to the nursing curriculum to incorporate a basic maternity component. ⁵¹ These nurses were registered as ‘General and Obstetric Nurses’ and were able to register as midwives after undertaking an additional six months training in a St Helens hospital and sitting an examination for State Registration The opportunity for a woman to train as a midwife without first being a nurse was lost after the direct entry ‘maternity nursing’ stage of the programme was phased out over a few years. ⁵²

Nurses were taught to monitor, observe and care for patients; diagnosis was the prerogative of medicine. Midwives who had been autonomous practitioners were now being trained to be nurses with some extra midwifery knowledge. If they detected aberrations from the normal they were to call for medical help but over and above that they now often had to gain medical and nursing approval to care for the normal. This was particularly necessary if they were practising within the public hospital system which also provided training for doctors.⁵³ Midwives were forced into working according to the hospital rules and policies and routines, which were usually dictated by doctors. Nurses had been trained into this hierarchal hospital system. When they then trained as midwives they brought their nursing socialisation into midwifery. ⁵⁴

Women came to be perceived as ‘patients’ who were to receive care as dictated by the doctor, the hospital policies and the routines which both they and the midwives usually accepted as necessary and did not question. There was increasing resistance to the paternalistic medical model of maternity and to increasing birth intervention by consumers such as Parents Centre from the 1950s, and the women’s movements that began to rise in the 1960s and ‘70s.⁵⁵ Despite this, the ability of consumers to effect change was minimal prior to1971.⁵⁶ The woman’s childbearing role was perceived as a medical process rather than the fulfilling of a normal womanly function. Once direct entry midwifery was phased out, and only nurses could become midwives, the nursing discipline of caring for ill people with medical supervision became reinforced within the discipline of midwifery. Midwives became invisible, being addressed by hospital staff and patients as ‘Sister’, ‘Matron’, ‘Staff Nurse’ and ‘Nurse’. ⁵⁷ This invisibility was reflected in the absence of the word ‘midwife’ from the names of their regulatory body – the Nursing Council, the Nurses Act 1971 – that removed their autonomy, and their professional body, the Nurses Association. Instead of attending the woman throughout her pregnancy, birth and postpartum period midwives were attached to areas within the hospital; they worked in the antenatal clinic, nursery, or ward, or the delivery suite. They developed skills in their particular areas and lost the skills, knowledge and confidence to oversee the whole progression of childbirth. Most midwives lost the confidence to work outside the hospital and were indoctrinated into the ‘medical model’ perception of birth.⁵⁸ This transformation of the maternity system happened over decades and was a gradual change, accepted by most midwives with little resistance. ⁵⁹

Generally doctors were seen as important, knowledgeable and benevolent. Men and women listened to them and accepted their advice, and doctors were teaching the student nurses and student midwives. Midwifery leaders were also qualified nurses as generally ‘Ward Sister’ status would not be awarded to a midwife unless she was also a registered nurse. Midwifery educators were also nurse-midwives and usually had the status of ‘Sister’. ^1,45 This meant that the clinical and theoretical components of midwifery were taught by doctors and nurse-midwives who, of course, imbued their teaching with the cultures and expectations of their particular disciplines. When in 1971, the law removed midwives’ ability to attend women without the participation of a doctor it merely legitimised what was, by then, the established pattern of hospitalised maternity care. This is demonstrated by the total omission of comment in New Zealand Nurses Association Journals (Kai Tiaki) of 1971/72 on the effect that the passing of the Nurses Act 1971 would have on midwives, also indicative of the powerlessness and invisibility of the minority midwife membership within that organization.

Conclusion

Medicalisation, hospitalisation, and nursification were the most important influences to shape both the maternity service and midwifery. The professionalisation and nursification of the midwifery service started with the passing of the Midwives Act 1904 and the formation of the St Helens Hospitals and Training Schools for Midwives. This placed midwives under medical control and encouraged the nursification of midwifery. Despite homebirth and midwifery being supported by the Health Department, technological progress, especially the developments in asepsis and anaesthesia, aided the medical profession in making hospital and medically controlled birth attractive to women. The Obstetrical Society was formed to resist control from the Health Department, and once formed became a strong lobby group, achieving both of its aims – the setting up of a Chair of Obstetrics at Otago University and the reforming of the maternity service. The Social Security Act 1938 that benevolently granted free medical, midwifery and hospital care to women accelerated the hospitalisation of birth and aided in the almost total transformation of midwives into ‘obstetric nurses’ who were skilled in their own areas of hospital nursing, but who had lost the knowledge and confidence to care for birthing women outside the hospital system. As in other Western countries, by the 1970s the medicalisation and hospitalisation of birth changed most midwives’ perception of birth; they accepted iatrogenic outcomes (such as breast engorgement in the lactating mother) as the norm and lost the experiential knowledge of birth that had been handed down for centuries from woman to woman.⁶⁰ This situation continued until pressure from women’s groups and midwives, and a providential political climate facilitated the passing of the Nurses Amendment Act 1990 returning autonomy to New Zealand midwives and allowing them to practice in the community again, providing individualised continuity of care for women.

References

1. Stojanovic J. Leaving your dignity at the door: maternity in Wellington, 1950–1970. [MA (Applied) Thesis]. Wellington (NZ): Victoria University of Wellington; 2003.
2. Cooper M. The Midwives Case, 1920 to1930. In: Chick N, Rodgers J, eds. Looking back, moving forward: essays in the history of New Zealand nursing and midwifery. Palmerston North (NZ): Massey University, 1997.
3. Autonomy was returned to New Zealand midwives with the passing of the Nurses Amendment Act 1990.
4. Manson C, Manson C. Dr. Agnes Bennett. Michael Joseph: London, 1960; pp. 48-49.
5. Ibid; p. 50.
6. Donley J. Save the midwife, New Women’s Press: Auckland, 1986.
7. De Vore C. Midwives as business women. In: Chick N, Rodgers J, eds. Looking back, moving forward: essays in the history of New Zealand nursing and midwifery. Palmerston North (NZ): Massey University, 1997; pp. 44-57.
8. Manson C. Op cit.
9. Neill J. Grace Neill, the story of a noble woman. Peryer: Christchurch, p.27.
10. Ibid; p. 51.
11. De Vore, Op. cit; p. 48.
12. McLean H. Nursing in New Zealand, history and reminiscences. Tolan Printing: Wellington, 1932; p. 59.
13. Stojanovic J, Op. cit; p. 35
14. Bowerbank F. Doctor’s story. Wingfield Press: Wellington, 1958; p. 81.
15. Mein Smith P. Maternity in dispute, New Zealand 1920–1939. Historical Publications Branch, Department of Internal Affairs: Wellington, 1986; p. 1.
16. St Helens Outdoor Casebook 1913–1918.
17. Donley J. Op cit; p. 39.
18. Donley J. Op cit; p. 40.
19. Mein Smith. Op cit; p. 81.
20. Papps E, Olssen M. Doctoring childbirth and regulating midwifery in New Zealand. Dunmore Press: Palmerston North(NZ), 1997; p. 111.
21. Ibid; p. 119.
22. Ibid; p. 122.
23. Also known as childbirth fever or puerperal sepsis.
24. Mein Smith. Op cit; p. 23.
25. Special Committee on Maternal Mortality in NZ(1921) AJHR1(H-31B):4.
26. Mein Smith. Op cit; p. 21.
27. Parkes C (1991) The impact of the medicalisation of New Zealand’s maternity services on women’s experience of childbirth 1904–1937. In: Bryder L, ed. A healthy country: essays on the social history of medicine in New Zealand. Bridget Williams Books: Wellington.
28. Donley J. Op cit; p. 42.
29. Mein Smith. Op cit; p. 64.
30. Donley J. Op cit; p. 45.
31. Gordon D. Backblocks baby doctor. Faber & Faber: London, 1955.
32. De Vore, Op. cit; p. 46.
33. De Vore, Op. cit; p. 55.
34. Gordon D. Doctor down under. Faber & Faber: London, 1957; p. 53.
35. Gordon, 1955. Op cit; p. 207.
36. Mein Smith. Op cit; p. 43.
37. Mein Smith. Op cit; p. 41.
38. Papps, Olssen. Op cit; p. 120.
39. Mein Smith. Op cit; p. 119.
40. Stojanovic J. Op cit; p. 48.
41. Jackson JF. Oral history tape, Personal records, Stojanovic Family Archive, 2009.
42. Annual Report of the Director of Health(1945),AJHR1(H-31):7, p. 7.
43. Gordon, 1955. Op cit; p. 103.
44. Gordon, 1955. Op cit; p. 105.
45. Wassner A. A labour of love, childbirth at Dunedin Hospital 1862–1972. Wycliffe Press, Dunedin (NZ), 1999.
46. Tully L, Daellenbach R, Guilliland K. Feminism, partnership and midwifery. In: Du Plessis R, Alice L, eds. Feminist thought in Aotearoa/New Zealand, differences and connections. Oxford University Press: Auckland, 1998; p. 44.
47. Papps E, Kilpatrick J. Nursing education in New Zealand – past, present and future. In: Papps E, ed. Nursing in New Zealand, critical issues and perspectives. Pearson Education New Zealand, 2002; p. 4.
48. Papps, Olssen. Op cit; p. 125.
49. Pairman S. Towards self-determination: the separation of the midwifery and nursing professions in New Zealand. In: Papps E, ed. Nursing in New Zealand, critical issues and perspectives. Pearson Education New Zealand, 2002; p. 16.
50. Papps, Olssen. Op cit; pp. 125-126.
51. Donley. Op cit; p. 99.
52. Dobbie M. The trouble with women: the story of Parents Centre New Zealand. Cape Catley: Christchurch. 1990; p. 17.
53. Pairman S. From autonomy and back again: educating midwives across a century. Part 1. New Zealand College of Midwives Journal 2005;33:6-10.
54. Davis D. Spoilt for choice: consuming midwifery care. British Journal of Midwifery 2003;11(9):574-578.
55. Kinross N. Politics and power. In: Smith M, Shadbolt Y, eds. Objects and outcomes, New Zealand Nurses Association 1909–1983 commemorative essays. New Zealand Nurses Association, Wellington, 1984.
56. Miller N. Post-basic nursing education, in Smith M, Shadbolt Y, eds. Objects and out-comes, New Zealand Nurses Association 1909–1983 commemorative essays. New Zealand Nurses Association: Wellington, 1984.
57. Stojanovic. Op cit; p. 53.
58. Katz Rothman B. Giving birth, alternatives in childbirth. Penguin: New York, 1982; p. 23.
59. Douche J. Personal communication, 2007.
60. Odent M. Primal health. Century: London, 1986.

Reprinted with kind permission. Stojanovic J. Midwifery in New Zealand, 1904 – 1971. Contemporary Nurse 2008; 30:156-167. ©eContent Management Pty Ltd.