Research

19th May 2020

Giving birth at the Workhouse Infirmary

Last week’s blog looked at an article in the Birmingham Gazette of 9th March 1920 linking the problems of overcrowding and poor housing to the fear faced by many young women at the prospect of having to give birth at one of Birmingham’s Workhouses. In a follow up article a couple of days later the Gazette looked at the reality of the maternity ward within one of the workhouse infirmaries.

The Infirmary at the Kings Norton Union Workhouse was opened in 1897 and in addition to general wards there was separate provision for maternity cases. Although operated by the Guardians of the Poor the infirmary was separated from the Workhouse itself by a dividing wall and they were run as separate establishments. This Gazette article of Thursday 11 March 1920 provides a detailed description of the Maternity wards and is transcribed here in full:

CARE OF MOTHERS AT INFIRMARY.

Ideal Conditions for Maternity Cases.

They speak of the need for a municipal hospital, but what, after all, is this infirmary but a municipal hospital? Why people should think it less derogatory to go to a hospital supported by voluntary contributions, where they are really receiving charity, than to come to the Selly Oak Infirmary, which they themselves have been helping, to support by the rates they have paid for years. I cannot imagine,” said Dr. Martin, the infirmary’s chief medical officer, when I talked over with him yesterday the question of the housing shortage and the consequent need of more maternity hospital accommodation.

There can be no doubt that many of the expectant mothers, much as they resent the idea of being sent on to the Infirmary after having arranged to go to the Loveday-street hospital. settled down in a wonderful way when they find what the Infirmary is really like, and express their appreciation of the care and attention they receive from the trained staff there.

Restful beauty.

I have never seen a more beautiful part of any hospital than the large maternity ward at Selly Oak, which I was privileged to visit yesterday. The bright outlook, the windows arranged to catch every gleam of sunshine, the mothers’ beds and babies’ cots, with their dainty white drapery, the banks of flowers arranged on tables down the middle of the room, combined to give a sense of restful beauty. There were polished floors, the walls were painted in soothing tones of green and fawn. Nurses in their pretty uniforms moved up and down the ward., and happy looking young mothers lay in bed, with their babies in the cots by their sides. In a second ward I saw a group of expectant mothers, sitting round a table making swabs and dressings of cotton wool.

“Any work of that sort that they do is quite voluntary.” said the doctor. “but most of those who come in a few days before the birth of their baby prefer to occupy themselves in some quiet way during their waiting time.

Paying Patients.

There was a balcony outside each large ward overlooking the beautiful garden where masses of flowering currant were bursting into bloom. Even on a cold March day the air was pleasant in these sheltered nooks, with their south aspect, and I found one or two expectant mothers resting contentedly there. ” I very much prefer having my bed out here to being indoors,” said one of these, who chatted with me very cheerfully and told me she had been a tram conductress during the war. Of the forty cases in hospital this week almost all are paying patients.

“Their payments vary, of course,” the matron informed me, “but no distinction whatever is made. The nursing, the food, and the dress are the same for all.” Every patient, when she enters the hospital, has to change her own dress for the pink uniform of the infirmary. The dresses are a pretty shade of pale pink, and look fresh and clean, but it seemed to me rather a pity that they should be insisted on. To see one patient after another dressed exactly alike spelt “institution” more than anything I came across.

” Daddy Longlegs ” type.

The small separate room where each birth actually takes place is fitted up almost like an operating theatre—the white tiles, ample hot water supply, and special lighting and heating arrangements giving all the comfort and safety possible. I was introduced to the well-stocked library of clean, nicely bound novels. “These are kept entirely for the maternity wards.” the matron told me. “and we buy just what we think our patients would like to read. You see we have quite a number by Charles Garvice and Ethel M. Dell, and they like Rider Haggard and the ‘Freckles’ series ` and books of the ‘Daddy Longlegs’ type. I don’t accept presentation volumes for this library of ours. Spurgeon’s sermons? No, thank you!”

Each floor had its own bathrooms and linen storerooms, and it’s own small supplementary kitchen, where tea could be made or milk heated at a moment’s notice. All the maternity wards are shortly to be moved to the top floor of the hospital, where an entire reconstruction is taking place, and every room is being made as perfect and up to date as it can possibly be.

Met by Proud Husbands.

The food supplied to the patients is excellent. Never have I tasted more delicious bread than that which is made in the infirmary’s own bakery. Most of the mothers and babies, I found, were able to leave at the end of a fortnight when a proud husband and father probably arrives to escort them home. I left with the impression of having spent the afternoon in a hospital of an ideal description. And yet I felt that, as the old deep-rooted prejudice against going into a Poor Law institution can never be eradicated, it would solve the problem if we could change the name of the infirmary, and, instead of patients having to apply to the relieving officer for admission. have it run as a municipal hospital under the Ministry of Health.

C. H. C.

14th May 2020

Impact of overcrowding on maternity care

‘Homes fit for heroes’ was one of the rallying cries of the working class across Britain after the First World War and housing was one of the major political issues in the General Elections of 1918 and 1920s and the local elections too. But lack of housing and high rents had an impact on maternity services too as highlighted in this emotive article from the Birmingham Gazette of 9th March 1920.

Birmingham Daily Gazette - Tuesday 09 March 1920 — Birmingham Daily Gazette – Tuesday 09 March 1920

‘Why should my baby be born in the workhouse? I don’t care how well I’m looked after there, or how kind the nurses see. I simply hate the thought of it.” This was the cry of a young married woman who, because she and her husband were among the thousands of young couples unable to get a house of their own. had arranged to go to the Maternity Hospital in Loveday-street, only to find when the time came for her to enter the hospital that there was no bed vacant, and that the authorities could do nothing but draft her on to the workhouse infirmary. She is only one of dozens similarly situated who have no choice in the matter.

Landlady Gives Notice.

“We are sending young married women to the workhouse as paying guests all the time,” an infant Welfare Superintendent told a Gazette woman. ” Many of them find the idea of going there almost unbearable, but there is nothing else to be done. Their landlady—if she is the usual kind of landlady and not an exceptionally considerate one—gives them notice, to leave their rooms as soon as she finds that a baby is expected. They find it impossible to obtain new lodgings; the high fees of the private nursing homes are beyond their means.; the maternity hospital is crowded out; so the only thing left for people who would gladly pay a doctor and a nurse, if only they could find a home of their own is the workhouse.”

Very Pathetic.

The Gazette representative then asked Mrs. Sidney Walker, chairman of the maternity hospital committee, whether anything was being done to relieve the pressure there. “We are doing what we can,” she said, ” but things are very bad indeed, and a great deal more must be done. Even the workhouse is getting crowded out. There is only room for 30 bode at Loveday-street, and it is appalling to think that that is all the provision made for a great city like Birmingham. ”

A house at Erdington has just been taken over, and one in another suburb will probably be taken shortly, where normal cases can be sent, to relieve the pressure at the maternity hospital. But there will only be room for twelve in each of these, so a great deal more accommodation will have to be found somehow.”

Some of the cases which have lately been turned away from the crowded maternity hospital have been very pathetic. Respectable people. who deeply resent having to live and bring up their children in one cramped room, plead hard to be taken in. One of these the other day was found to have only been able to get one room for herself. her husband and five children: the hospital would have admitted her if it possibly could, but there was no possibility of finding room. Another was sharing a room with a sister and a brother of 18; even she could not get into the hospital.

Piggott Street Lee Bank c.1910 — Typical back-to-back housing in Piggott Street, Ladywood c.1920

Seven in One Room.

Other astonishing cases of overcrowding which the Gazette representative came across in the course of her inquiries showed what Birmingham people are having to endure in these house less days. There was a family of seven living in one furnished room, for which they were paying 30s. a week; the family consisted of parents, three daughters of 19, 17 and 15, and two younger boys.

Birmingham Daily Gazette - Friday 01 December 1922 — Birmingham Daily Gazette 1 December 1922

A suburban house, in which there are only three upstairs rooms, is being shared by four married couples. “I do feel so for all these young people.” said Councillor Mrs. Mitchell who is also a member of the Maternity Hospital Committee. “Some of them have waited years to get married, only to find that it is still impossible to get a home. It is a shame that a city like Birmingham should have nothing better than the Workhouse Infirmary. to offer so many young mothers As a mother I can realise how terrible it must be for them for the treasured first baby to be born in a workhouse. I want to see a municipal maternity hospital established as soon as possible. To provide the housing we need is going to be a costly business but prevention is better than cure, and no matter what the houses cost it will be cheaper in the end to build them than to cope with all the disease and crime which must inevitably follow continued overcrowding.”

In our next blog we can see another article from the Gazette which follows on from this piece by looking in detail at the maternity provision at one of Birmingham’s Workhouse Infirmaries.

28th Apr 202028th Apr 2020

Our Baby for Mothers and Nurses

The Royal College of Gynaecologists heritage Collections Blog shows details of one of the period babycare manuals for mothers: Our Baby for Mothers and Nurses

The book itself can also be seen in it’s entirety here in the Wellcome Collection: https://wellcomecollection.org/works/duazcum5

I’ve had a bit of a delve into the author – she was born Annie Martha Everard in Ramsden, Suffolk in 1861, eldest daughter of a Church of England Vicar, Rev George Everard and his wife, Martha. She married Joseph Langton Hewer, a surgeon in July 1886.
Annie’s entries in the Nursing Registers show that she trained at the Workhouse Infirmary in Manchester in 1881-2. And her entry in the Central Midwives Board Register shows that she was first registered in Nov 1904 (when Registration first started) & indicates that she qualified by virtue of having passed the London Obstetric Society examination in Oct 1883.
She published ‘Antiseptics – a handbook for nurses’ in 1888.
Her continued entries in the Nursing & Midwives registers show that she kept her registrations up. But did she continue to practice?
She died in 1940 in Kent and her husband Joseph in 1945.
Their son, Christopher Langton Hewer became an anaesthetist – his case is in the Wellcome Collection and can be viewed here: https://wellcomecollection.org/works/tzf9jqg5

Liz Palmer

20th Apr 2020

Infant Mortality Rates Birmingham 1913-24

We’ve become accustomed to hearing from the Chief and Deputy Officers of Health for England on a regular basis over the last few weeks. But did you know that each local authority also has a Medical Officer of Health (MoH) and that the first one for Birmingham was appointed back in 1872? The Annual Reports of the MoH make fascinating reading. Printed copies of the Birmingham MoH reports (& those of the School’s MoH) can be viewed on request at the Library of Birmingham when it is open, but they can also be found online at the Wellcome Collection http://search.wellcomelibrary.org/ – Simply search for “medical officer of health birmingham” and the year of interest between 1873 and 1973 and lose yourself for a few hours.

David Low, one of our volunteer researchers and an retired paediatrician made extensive use of the MoH reports in his research on the Infant Mortality Rate during our period of study. This is a summary of some of his findings:

Why so much emphasis on Infant Mortality Rate [IMR], deaths under 1 year of age per 1000 live births?

Dr John Robertson Medical officer for Health submitted his report of “Child Welfare in 1913” to the Public Health and Housing Committee in May 1914.

“the extent of Infant mortality in Birmingham…and the amount of permanent damage to young children done by the ignorance and carelessness on the part of parents is still so great …to consider whether something further cannot be done to prevent this unnecessary waste of human life”. In 1913 4257 [33%] of all deaths were in children under 3 and 3070 [23.7%] under 1. He considered that half were preventable, noted that areas of “careful artisans” had an IMR half that of areas of poverty and the resulting inefficiency & carelessness. His ward maps demonstrated the relationship of infant mortality to the gradient of socio-economic deprivation [my words not his], between the Central, Middle and Outer Wards.

He considers that much of the inefficiency of adults has its origin in their own preventable childhood illnesses. This equates with the concerns of the Infant Welfare Movement and its emphasis on physical development and the quality rather than the quantity of the population in an era of declining birth-rate.

He states that the real object of the report is “to suggest further methods of imparting information to adults as to the rearing of young children and to suggest methods of dealing with the health of parents so that a healthy stock may be produced”.

Was he successful?

The yearly MOH reports contain a plethora of statistics. As a retired Consultant Paediatrician, I have recalculated and reinterpreted them to try and answer the question

In 1913 86% of deaths under 1 could be classified as due to either Perinatal causes [38%] or Infection [48%].

Perinatal causes were classified as “largely due to some defect on the part of the mother” and were mainly responsible for deaths in the first week or first month of life; premature birth, congenital malformations and a complex heading of debility, atrophy and marasmus. Marasmus is derived from the Greek, meaning to waste away and is generally applied to the undernourishment of the child.

Despite the expansion of the Maternity and Infant Welfare Centres and their staff, and the increasing emphasis on improving antenatal care, there was no improvement in the IMRs for premature birth and congenital malformations by 1924. However, I think we can attribute the 50% fall in IMR for debility, atrophy and marasmus to the education on feeding in those centres and the referral from them to defined beds in Barnt Green in 1916 and later to Witton Babies Hospital in 1921, where 102 marasmic babies were admitted with “good results”.

These charts show the growth rate of selected babies at Carnegie Institute when specific support measures were put in place to support feeding.

Infant Mortality Rates are composed of the following: Neonatal mortality rate (deaths in the first 4 weeks of life per 1000 live births) which only fell by 13.2% [41 to 34.6], whereas the Post Neonatal Mortality rate (deaths between 4 week and 1 year per 1000 live births) fell by 45.32% [87.9 to 48.06]. This strongly suggests that the majority of the reduction occurred in infectious diseases. The death rate in the 0-5 year child population also fell by 34.8% over this period.

Infectious diseases

Diarrhoea and enteritis

This was the great success story, with deaths under 1 year reduced from 746 [25%] in 1913 to 160[11%] in 1924, and the IMR falling from 31.3 to 8.7. Dr Robertson described this as the “most easily preventable” and that “dirt in various forms is the exciting cause of the disease”. Hot weather, precipitating summer epidemics, was dreaded. Education by Health Visitors and the Maternity and Infant Welfare Centres about hygiene and feeding, especially breast feeding, was the key to this improvement. Handbills such as “Protecting Babies during Hot Weather” in 1914

and “Prevention of Flies” in 1915 were distributed to all houses in the poorest areas.

Public health issued byelaws requiring owners to provide portable galvanised dustbins, and a booklet for stable owners to remove horse dung and weekly emptying of ashbins and ashpits. Robertson also highlighted the lack of storage facilities for food and the dust from street horse dung blowing directly into many living rooms.

Nearby manure was still a problem in 1921 when Witton Babies Hospital had to cover babies with mosquito nets and empty fly traps containing 100-500 flies every 2 hours.

Measles, Whooping Cough, Scarlet Fever and Diphtheria

The burden of these diseases for all children, especially the under 5s, was immense. Between 1914-24 there were 14,383 cases of diphtheria and 89,143 cases of measles reported [underestimate], and 12961 cases of whooping cough between 1916-18. There was no change in incidence. Being highly infectious they were no respecter of class or ward and carried important sequelae for adult life. Mortality remained high, particularly for young children, and 4 or 5 times higher in the inner poorer wards. Between 1916-24 deaths under 5 years from measles were 1441 and from whooping cough 1912. From 1914 Nursing Societies were contracted to supply a visiting nurse for severe cases of measles, and then whooping cough, as expert nursing was felt to be key. Whereas all diphtheria cases were admitted to hospital, there was debate about whether severe cases of measles and whooping cough especially from dirty and poor houses should be admitted to hospital, Capacity and expense were issues and in the case of whooping cough the “high mortality” “would alarm the community” and bring “any hospital into disrepute”.

Scarlet Fever was primarily a mild disease of older children but with important sequelae. There were 23,766 cases between 1916 and 1924, with a case mortality for under 5s reduced from 6% in 1913 to 2.7 % in 1924.

Diphtheria

Dr Robertson’s 1924 report describes advances in the management of this disease. The use of high doses of antitoxin to treat cases early was introduced in Birmingham in the 1890s and this, combined with hospital admission for all cases and skilled nursing, had resulted in case mortality dropping from 29.2% [1890-93] to 14.5% [1913-16] to 8.5% [1920-23], although case mortality for the under 5s was still 17% in 1923. Immunisation of nursing staff working on diphtheria wards introduced in 1921, using a mixture of toxin and antitoxin, meant that meant no nurse had contacted the disease compared to 13 in 1918

In 1924, it was approved that all children between 2 and 5 should be immunised by 3 weekly injections.

Pneumonia and Bronchitis

The IMR remained consistently high fluctuating between 15 and 21 for this collection of respiratory illnesses. In 1924, it was the cause of 661 under 5 deaths, of which 55% were under 1.

Summary

Between 1913 and 1924 there was a very significant reduction in “the waste of human life” to quote Dr Robertson. A 35.6% fall in the infant mortality rate from 129 to 83, a similar decline in children under 5, and these declines were not interrupted by World War 1 or the post war depression. These were reflected in the three ward area categories and compared favourably with the rates of England and Wales and other large towns. In 1924 2128 [19%] of all deaths were in children under 3, 1518 [13.56 %] under 1, and there had been significant reductions in deaths from marasmus and diarrhoeal disease. However, the burden of other childhood infectious diseases remained high.

David C Low

13th Apr 202013th Apr 2020

Two contrasting midwives

Following on from last week’s blog by Maggie about the changing role of midwives during the 1914-24 period here she looks at the lives of two midwives of the period.

Kelly’s directories found in the Library of Birmingham covering the period we are examining gives listings of all the Midwives who were permitted to practice in Birmingham year by year and can be used with the information on the Central Midwives Register and other genealogical records to trace the lives and career of some of these women who often remained in practice in Birmingham for many years.

Firstly a quick look at one of the old school – Hannah ARMISHAW.

The Central Midwives Register provides name and address of the women but also details when the midwife was enrolled on the register – and also the qualification they held. And other genealogical sources such as the 1911 Census can give us information about age and family circumstances.

The CMB Register for 1915 shows Hannah living at 77 Victoria Road Harborne and gives us the additional information that she was first registered in 24 November 1904 and her qualification was that she had been in practice prior to July 1901. The symbol before her name means that she had indicated to the Board that she intended to practice during 1915. Further searches in the annual Registers show that she was listed from 1905 until 1926.

From the 1911 census we can find Hannah Armishaw living with her husband William Illsley Armishaw, an Army Pensioner. Hannah was 61 years old – and according to the CMB Registers was to practise for a further 15 years until the age of 76! The census enumerator has added in red ink the word ‘Certificated’ next to her self-recorded occupation of midwife. The census also reveals that she was no stranger to childbirth herself having given birth to fourteen children of whom 12 were still living. Three of her daughters were still living at home – all working in the chocolate business (no doubt at nearby Cadbury factory at Bournville).

We have been lucky to discover that a descendant of Hannah ARMISHAW has posted this wonderful family image of the ARMISHAW family online – and very pleased to have been granted permission to use it. It is one of the only images we have found locally of a midwife in uniform.

In contrast, Lizzie Keeping was one of the new breed of qualified midwives.

Unlike Hannah Lizzie was not a local girl and appears to have moved in pursuit of her career. She was born in Reading in 1866 and the 1901 census shows her working as a staff nurse at Brentford Union Workhouse Infirmary Isleworth Middlesex. She was on the UK and Ireland Nursing Register from 1902 registration number 295.

Lizzie obtained her midwife qualification from the London Obstetrical Society in July 1903 and enrolled on the Midwives Roll on 24/11/1904 registration number 9472 whilst working at Lambeth Workhouse Infirmary.

Sometime prior to 1910 she moved to Birmingham – to Mary Street, Balsall Heath and practised from that address for a quarter of a century.

The 1911 census shows her living at 262 Mary Street Balsall Heath Birmingham with her occupation listed as trained nurse and midwife. Also in the house were her sister in law and children and also listed as Joint head of the household a Clare Bement, described as Trained Nurse & Midwife acting as Inspector of Midwives at City Health Department. Both of these women lived together on Mary Street until Clare’s death in 1938 and appear to have been working as midwives till this date. Both would have been in their late 60s.

Following Clare’s death Lizzie Keeping left Balsall Heath and retired to Devon – to Whitpot Mill, Kingskerswell, where she died aged 76 on 27/01/1942 leaving effects worth £1825.

Maggie Brownlie

6th Apr 2020

Midwives in Birmingham 1914-24

A key topic in our project has of course been Midwives. Here project volunteer Maggie outlines the impact of the Midwives Acts on the increasing professionalisation of midwifery in Birmingham.

100 Years ago the majority of Births in Birmingham took place in the home with the assistance of a local Midwife. The Midwives who were working at that time had little training unless they had been formally working as nurses and many were untrained, known as a local handywomen “the woman you called for “ when your baby was coming. She would often be involved in helping the sick and the dying and sometimes would offer home help service washing and assisting with childcare

The period we are looking at,1914-1924, was a period of much change in Midwifery and maternity . There was much worry over paying for health care . Childbirth was not seen as a medical process and in working class areas doctors were rarely called except in severe emergencies as people could not afford to pay the fees.

“the work of a busy midwife is very hard, holidays and off duty times are difﬁcult to secure the responsibility is exceptionally grave, the remuneration comparatively small. Midwifery, more than any other branch of nursing, unquestionably taxes to the utmost professional skill and judgment, physical capacity and endurance, patience and sympathy.” From { Dr Janet Campbell Senior Medical ofﬁcer at The Ministry of Health through throughout the 1920’s in a report on the Physical welfare of mothers and Children in England and Wales 1923}

Midwives Bag - Image Science Museum — Midwifery bag complete with contents, bag by Arnold and Sons, London, 1925-1955. Science Museum

The ﬁrst Midwives act of 1902 was an Act to secure the better training of Midwives and to regulate their practice and introduced the Central Midwives board {CMB} The board formulated restrictive practice requirements , a supervisory requirement and a disciplinary system which were apparently designed to make it impossible for working class midwives to continue practising . Midwives who had a recognised qualiﬁcation in Midwifery either from The London Obstetrical Society or from certain lying in hospitals could apply to enrol on the register of qualiﬁed midwives . There were several training centres for midwives in Birmingham:

Birmingham Aston Union Workhouse Gravelly Hill
Birmingham Union Inﬁrmary at Selly Oak;
Birmingham Maternity Hospital Loveday Street
Birmingham Workhouse inﬁrmary Dudley Road

The 1902 Midwives Act which came into operation on 1st April 1903 required newly registered Midwives to undertake 3 months training which was increased to 6 months in 1916 and subsequently to 12 months by 1926.

Women who had been in practice for at least 12 months and who could show they were of good character { usually by a reference from a clergyman} could also apply . They were known as bona ﬁdes . Any other women who wished to take up the practice of Midwifery had to pass an examination in competence to obtain a certiﬁcate . In order to be admitted on the Midwife Roll candidates had to satisfy the Central Midwives Board the they had reached

A sufﬁcient standard of general Education
A birth certiﬁcate showing the candidate is not under 21
Certiﬁcate to the effect that the candidate had undergone training
A certiﬁcate of good moral character
Must pass an examination

From 1905 only women certiﬁed under the Act would be entitled to use the title of “Midwife” and to recover any fee for attendance as a midwife .

Certified Midwife Badge c.1918 — Early Badge for Certified Midwife

Training

The cost of the training which usually took place away from home. The use of medical latin in the examination would have been prohibitive to many working class women . A pupil midwife would attend and watch the progress of no less than 20 labours including making abdominal and vaginal examinations and delivering the baby. She would be required to nurse 20 lying in women during the 10 days following labour. (lying in is an old child birth term involving a woman resting in bed for a period after giving birth) She would have to attend a course of instruction which should be no less than 3 months with an oral practical and written examination .

The course included :

elementary anatomy of the female pelvis pregnancy and its complications including abortion

the symptoms mechanism course and management of natural labour

the signs of of abnormal labour

haemorrhage treatment

use of a clinical thermometer and catheter antiseptics- the way to prepare and use them

management of the puerperal patient ( the period of around 6 weeks after childbirth when the mother’s reproductive organs return to their non pregnant condition.
management (including feeding) of infants and the signs of important diseases which may develop with the ﬁrst 10 days after birth.
Obstetric emergencies and how to deal with them until a doctor arrives ( to include the knowledge of drugs needed in such cases
House sanitation & disinfection of the person their clothing and appliances

Midwives were subject to regulation concerning equipment and clothing and it was noted back in 1905 in the Journal of Midwives that the cost then of required equipment and a lined midwifery bag would be one guinea – prohibitive to many handywomen who were so often paid in kind .

Rules affecting Midwives

The rules laid down in the Midwives act were enforced by strict supervision undertaken by often local dignitaries many of whom were not trained in midwifery or nursing and the midwives had their homes investigated which was intrusive. After 1910 no person could “habitually and for gain “ attend a woman in childbirth except under the direction of a doctor. Any woman acting without being certiﬁed was liable on summary conviction to a ﬁne not exceeding £10. County boroughs were to be the local supervising authority over midwives within the area. they were to provide general supervision, investigate charges of malpractice negligence or misconduct and report to the CMB . They were also responsible for suspending any midwife from practice in accordance with the rules under the act During the month of January each year the supervising authority would supply the CMB with the names and addresses of all midwives who, during the preceding year, had notiﬁed their intention to practice in the area .The requirement was that every woman certiﬁed under the act would give notice in writing of her intention to practice . If any woman omits to give the said notice shall by summary conviction be ﬁned up to £5. The penalty for obtaining a certiﬁcate by false representation was a misdemeanour and the woman would be liable to imprisonment with or without hard labour for a term not exceeding 12 months.

Increasing professionalisation of midwives

The Medical Officer of Health Reports for Birmingham provide many statistics relating to the employment of midwives in Birmingham and can be used to show the impact of the Midwives Act over our period of study.

In 1914 253 midwives were registered to practise. 174 were admitted by reason of their having been bona ﬁde prior to the passing of the Midwives Act (1902) and the remaining 79 held recognised certiﬁcates of training in Midwifery. They attended 15,664 births during the year which was almost 70% of the total number of recorded births in Birmingham. .

16 attended over 200 births but most attended around 50 births each.

The reports also give details of suspensions and actions taken against midwives who did not comply with desired practice. In this year alone 62 midwives were suspended for poor practise. 53 for cases involving puerperal fever and 5 for cases of Pemphigus Neonatorum (see glossary)

Ten years later the proportion of certiﬁed to uncertiﬁed midwives had greatly increased. In 1924 here were 231 midwives of whom 170 were certiﬁed and 61 were bona ﬁde. Between them they attended 11459 births – 62 % of the total.

The reports also reveal the pay which depended on the status of the midwife:

Bona ﬁde midwives earned about £16 per year while trained midwives could command higher fees and earned £42 per year. In our next blog we will look at two different Birmngham midwives.

Maggie Brownlie

8th Mar 2020

Abortion in Birmingham: the hidden realities

We have been investigating many aspects of maternity services as part of our project but, of course, then as now, not all pregnancies were wanted. At our launch event back in September one of the visitors to the pop-up exhibition was Cambridge student Milly Coleman who has been researching the history of abortion in Birmingham. Here, appropriately on International Women’s Day, is a summary of her research.

Last summer, I spent a few weeks in the Wolfson Archives researching backstreet abortions and the women who had them in Birmingham in the late nineteenth and early twentieth century.

At that time, working class women wanted to limit the size of their family for a multitude of reasons, such as preventing overcrowding and maintaining the living conditions of their families.Moreover, industrialisation allowed women to work, giving them an extra incentive not to have more children.

To limit the size of their families, working class women had two legal options:

Abstinence
Contraception (which was unreliable and expensive).

Alternatively, but illegally, they could have an abortion if they did fall pregnant. All abortions were technically illegal before 1967, so finding records of them presented a challenge because abortionists necessarily needed to be secretive.

By criminalising the act of abortion, lawmakers created a stigma and forced women to risk their own health to avoid having a child. Additionally, they could not report malpractice or blackmail, and even if something went wrong many were reluctant to seek medical assistance.

The average woman would not have talked about procuring an abortion, but ‘bringing on a period’ using colloquially named chemicals – ‘bitter apples’ was colocynth and ‘hikey pikey’ was hiera picra – or using household chemicals such as washing soda or turpentine. [1]

Colocynth Bottle. Copyright Science Museum

Hiera Picra Pills. Flickr.com Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0)

Consequently, it was challenging to recover the stories of women who had abortions, as abortionists did not keep incriminating written records.

Inevitably then, many surviving documents originate from cases where the process went wrong and can be found in the medical records of Birmingham Women’s Hospital and Birmingham Maternity Hospital.

Birmingham Women’s Hospital served ‘a large number of poor women in Birmingham suffering from ailments peculiar to their sex, for whom no adequate means of treatment existed’, and was the largest women’s hospital in England around 1900.[2]

The annual reports of both the maternity and women’s hospitals demonstrate the patronising tones that the upper middle class governing board took towards their working class patients. The charities undoubtedly had good intentions and did very important work, but that middle class judgement is clear in the annual reports.

Through my research I wanted to understand who the women having abortions were, since so much of the contemporary debate focused on either cases of rape, or sex workers.

The voices of poor married women who couldn’t afford another child were largely overlooked in arguments about the legalisation of abortion, so I tried to focus on average women from Birmingham to counter this. Their stories have been accessed via medical records and the records of social workers and abortion reformers.

In the Report of the National Birth Rate Commission, written in 1916, Mrs [Florence Carol] Ring, a Birmingham-based social worker, estimated that one in four poor women attempted an abortion at some point, although this is likely to be an underestimate since a conspiracy of silence existed around naming abortionists and methods.

Mrs Ring provides a unique perspective as she had the trust of the working class community she served, and she describes that ‘the poor begin by having children and then resort to abortion later on when the family increases in size’. [3] I wanted to understand a little more about the lives of these women and their motivations.

I used the In Patient Register at Birmingham Women’s Hospital to create a profile of the women admitted to the hospital due to a failed or complicated abortion. The staff recorded the name, age, marital status and address of patients, as well as the occupation of their husband or father if they were unmarried.

The cases of abortion recorded in the Register represent a tiny minority of all abortions, as women risked arrest by going to hospital, but they offer useful data on the age and marital status of patients.

From 1912-1916, 87.4% of the women admitted for complications from abortions were married. Although the average age fell slightly when World War One began, the lowest it reached was 29.6 in 1916. [4]

This illustrates that in Birmingham, married women who already had children were the principal demographic having abortions.

These women had abortions out of desperation, since any reaction to an unwanted pregnancy had its own dangers and potential stigma.

Working class women in Birmingham faced overcrowding and a lack of sanitation in the slum-like ‘back-to-backs’.

Miss Martin, a midwife from the Selly Oak area of Birmingham with nine years of experience, testified in 1916 that some landlords refused to house larger families so the birth of another baby could lead to homelessness for the whole family.

In addition, exposure to chemicals in industrial workplaces and previous births in quick succession meant that women’s health was put at risk by further pregnancies.

Brookes argues that contraception and abortion were essential to maintaining living standards, yet legally and in popular rhetoric, the health and sanity of women was portrayed as secondary to the unborn baby.

Women therefore faced a choice between abstinence, contraception, keeping the baby, adoption or abortion. Upper class voices criminalised and degraded the mother’s body regardless of her choice, leaving no easy solution. And in many cases, the cost and ease of access to abortion made it the best option for many working class women and their families.

Milly Coleman

[1] P. Knight, ‘Women and Abortion in Victorian and Edwardian England’, History Workshop 4:57 (1977), 57-68 at p58
[2] Article about Bingley Hall Charity Exhibition, Volume of press cuttings relating to Birmingham Hospitals (Birmingham: Wolfson Centre, HC WH/5/1/1, Library of Birmingham, c.1900). The headline and author of this article was cut off when the volume was compiled.
[3] ‘Testimony of Mrs Ring’, The Declining Birth Rate: Its Causes and Effects – Report of the National Birth-Rate Commission (London: Chapman and Hall Ltd, 1916), 277-281 at p280
[4] In Patient Register of Birmingham Women’s Hospital, vol.3 (Birmingham: Wolfson Centre, HC WH/3/1/3, Library of Birmingham, 1912-1916)
[5] ’Testimony of Miss Martin‘, The Declining Birth Rate: Its Causes and Effects – Report of the National Birth-Rate Commission (London: Chapman and Hall Ltd, 1916), 273-277 at p274
[6] B. Brookes, Abortion in England 1900-67 (London: Croom Helm, 1988), p12

1st Mar 2020

Infant Welfare Centres in Birmingham

Birmingham was a pioneering City when it came to the establishment of municipal Infant Welfare Centres (IWCs). Laurie has been looking at the role of IWCs and the changes during 1914-1924.

The purpose of Infant Welfare Centres (IWCs) was to reduce the high infant mortality rate (IMR), to improve the health of babies who survived their first year, and to look after the health of mothers before and after giving birth. They were enthusiastically promoted by Dr John Robertson, Birmingham’s Medical Officer of Health (MOH).

The first IWC in Birmingham was established in 1907 by voluntary subscriptions to Birmingham Infants’ Health Society using a room in the Medical Mission, Floodgate St, followed in 1908 by the first municipal IWC in New John St West, in two of the poorest districts in the city with the highest IMRs.

Selly Oak Infant Welfare Centre in the former Village Bells Inn

In May 1914, presenting his annual report to the Public Health and Housing Committee for the previous year, the MOH included a separate report on Child Welfare, in which he deplored the city’s 3,070 deaths of infants under 12 months of age as a great waste of life. Dr Robertson claimed that over half the deaths were preventable, such as those from diarrhoeal diseases and ante-natal causes. He believed that education of mothers was the best way forward, and he outlined the work already underway in the existing 4 voluntary and 4 municipal IWCs, the latter staffed by lady doctors appointed by the Committee. His aim was to expand such work across the city by creating 6 further ‘welfare stations for mothers and children’. The plans of the MOH were hampered by the outbreak of war, as rented accommodation suitable for use as IWCs became difficult to obtain, and many staff in the Public Health Department left for war work.

In 1915 a Maternity and Infant Welfare Sub-committee was established which included two women, one of whom, Mrs Dora Walker, was appointed Chair at the end of its first year. Training was organised for IWC workers at the Municipal Technical School. Government grants of 50% towards the running costs of municipal IWCs (and voluntary centres meeting certain requirements) became available and by the end of the war, Birmingham had 13 municipal and 8 voluntary centres; some had been relocated to more suitable premises from their original buildings.

The main functions of the IWC were to monitor the progress of infants by weighing them, followed by consultation with the doctor if necessary. Minor ailments were dealt with in the centre, and more serious cases referred as appropriate. This enabled earlier diagnosis and treatment of problems which otherwise might have worsened, as mothers living in poverty may well delay seeking medical advice they had to pay for. The Superintendent (a qualified nurse, midwife or health visitor) oversaw the maintenance of records and was available at each consultation to provide advice for mothers. Older infants (aged 1-5) had their own sessions in some centres, or were supervised in a separate room.

Mothers would be encouraged to attend health talks on a wide variety of topics related to correct methods of feeding and rearing infants. Particular importance was attached to the benefits of breastfeeding, the constant need for cleanliness, and the value of fresh air for babies. The topics sometimes included mental and moral training of children. Visits to mothers, and antenatal and postnatal consultations were also introduced.

Alongside the activities within the centres, the visiting of infants in their homes was crucial in the education of mothers. Infant Visitors attached to the IWCs aimed to see every new baby in their area within 10-14 days of birth to give advice on its feeding and care, the mother’s health and general household matters. An initial record card was completed and the mother encouraged to bring the baby to the local IWC, with repeat home visits if necessary.

IWCs had different frequencies of consultations and varying facilities, depending on the location and population of the district they served: there were 108 notified births in rural Northfield in 1921 compared to 1,636 in inner-city Hope St. Nearly all centres held sewing classes, where used garments were altered to make clothes for children, and some held cookery classes, Mother-craft competitions, and savings clubs. Dried milk was available at a reasonable price, with assured stocks throughout the war. Social activities such as summer outings and Christmas parties were often arranged by voluntary helpers, who were considered invaluable, giving a welcome extra dimension to the centre’s work.

MS4101 New Year’s Social Gathering at Green Infant Welfare Centre

At some centres in poorer districts, maternity feeding stations were set up for mal-nourished pregnant and nursing mothers. They were given a hot dinner for which they were asked to pay 1d if they were able. This provision was gratefully accepted by the mothers and improvements were noted in their own and their babies’ physical health and mental wellbeing. Weekly dental clinics were introduced in 1917 for mothers and children attending IWCs. It became increasingly difficult for the voluntary IWCs to attract sufficient funding by subscriptions, even with government and city grants of 80%, and eventually most opted to be taken over by the municipality.

The archives contain many references to the appreciation of mothers for the benefits they and their children gained from attending IWCs. The numbers of home visits and attendances of children at the centres in Birmingham show a healthy increase between 1918 and 1924:

	Births notified	Total visits to children	Total child attendances
1918	12333	111070	67080
1924	15981	232708	126998

Growth in work of Infant Welfare Centres from 1918-1924

Laurie Spencer

1st Jan 2020

New Year’s Greetings

11th Nov 2019

John Robertson – Medical Officer of Health 1903-1927

As we have met together recently as a newly-formed team to consider our project

Born in Birmingham : Maternity, Midwives and Infant Welfare: 1914-1924

a frequent name on our lips has been ‘John Robertson’, the formidable Medical Officer of Health (MOH) for Birmingham for a great tranche of the early twentieth century.

John Robertson was born in Warminster in 1862 but educated in Edinburgh taking his MD with honours in 1887. His graduation thesis was ‘on the causation and distribution of consumption in England and Wales’ – a subject which he pursued throughout life. His early career in Public Health was as MOH for St Helens where he investigated the combating of diphtheria – a major killer of babies, children and adults at this time. From St Helens Robertson moved to an equivalent post in Sheffield and here he was active in promoting a local Act of Parliament to require the compulsory notification of tuberculosis.

In 1903 Robertson was appointed to the MOH post in Birmingham, succeeding Dr Alfred Hill. An obituary in the British Medical Journal describes him as a man who took ‘a broad view of his responsibilities … a town planner long before the term came into common use’. In Birmingham again he concentrated on schemes to minimise tuberculosis and infant mortality. He also held the Chair of Public Health at Birmingham University. In 1925 he was knighted for his services to the community, having previously received a CMG and OBE. Robertson retired from the Birmingham Corporation in 1927.

Whilst living in Birmingham Robertson, his wife, Jane and two daughters were resident at The Hollies on Court Oak Road in Harborne, where he died in December 1936, aged 74.

We look forward to finding out much more of the contribution this man made to public health in Birmingham.

The Annual reports of the Medical Officer of Health to the Chairman and Members of the Public Health and Housing Committee are a key resource for our project. They provide a detailed and comprehensive analysis of medical well-being of Birmingham and its inhabitants and provide many useful statistical tables which can be used to research the health of newborn infants and their mothers.

For example the Appendix to the 1917 Report includes a special report on ‘Maternity and Child Health during 1917’. This highlights that whilst the infant mortality rate overall continued to fall there had been no improvements over the last ten years in the mortality rate of babies under 1 month old. The MoH wished to see more gathering of statistics relating to stillbirths and newborn babies to try and pinpoint some of the causes. In another section he refuted the suggestion that many of the deaths due to ‘overlaying’ were as a result of women’s drunkenness.

Alison Smith (with additional notes by Liz Palmer)