A HISTORY OF FERTILITY
By Adam Bencard
Children will always be at the heart of our existence as a species. Having children, and surviving childbirth, has fascinated people through the ages. There have been stories of infertility as far back as stories have been recorded. Ancient Egyptian medical texts describe how to tell if a woman is fertile and provide advice for ensuring conception. The medical tradition of ancient Greece likewise contains copious descriptions of infertility problems and the appropriate remedies. The Hippocratic Corpus, a collection of medical texts from the classical world that figured prominently in Western medicine even up to the early 19th century, dedicates an entire work to fertility problems. Beyond the medical tradition, infertility and the desire to have children are a recurring cultural theme across cultures. Sarah and Abraham’s desperate wish for a child is a cornerstone of Christianity and Judaism. As Rachel, in another Old Testament tale, says, “Give me children, or else I die.” Stories of childlessness, miracle births, adoption and similar themes appear in Icelandic sagas, Greek myths and Indian epic poetry. Rare is the mythology that does not have at least one fertility god or goddess. Likewise, the story of birth care – the endeavour to understand and alleviate the dangers inherent in the complex biology of childbirth – is as long as humanity itself. Just as pregnancy has always been both natural and dangerous at once, so childbirth has been a cause of existential concern, scientific interpretation, and dreams of treatment. The story of midwifery and obstetrics is the story of medical science attempting to comprehend and control childbirth – a critical juncture for the mother, child, and society at large – and how those attempts, spreading like ripples in water, have changed society and how we live. Fertility, pregnancy, and childbirth have been the object of a vast scientific and scholarly effort that has fundamentally changed the limits and expectations of who can have children, and how and when they can have them. The following is a look at fertility and birth care from the perspective of the history of medicine.
Remedies and explanations have changed over the centuries. Religion has often played a key role through an impressive array of prayers, pilgrimages and saints. Medical ingenuity has also been great and varied. In the Middle Ages, crushed animal genitals were taken in the hope of boosting fertility. In the 18th century, spas and hydrotherapy were prescribed to calm the nervous system of the childless woman and prevent spasms in the womb. In the early 20th century, adoption was recommended for psychosomatically unclogging a blocked system. The variations are countless, the problem timeless. Equally timeless and culturally ubiquitous is that the interpretation of infertility, across cultures, has been distorted
by gender bias. There has been a disproportionate focus on the infertile woman, not the man. The childless woman has often been seen as less than a woman, less feminine, unseemly, an object of pity and social ostracism, even at times outright morally impaired or otherwise suspect. Nineteenth-century doctors linked childlessness to abortion, venereal disease and sexual promiscuity.
It is important to include this at once both eternal and ever-changing story in the often heated discussions and anxieties about fertility that have marked the last several decades, as it has become increasingly clear that many societies are no longer near the magical fertility rate of 2.1. Once an individual existential crisis, childlessness today encompasses a host of far greater, multilayered issues. Explanations range from social and cultural – access to birth control, changed patterns of education, shifts in the job market, increased pressure to self-actualize, to name a few – to medical and physiological, in the way of a declining sperm count, older first-time mothers, hormonal imbalances, and the like. The tension between the social and the physiological is particularly pronounced in terms of the many technological advances made since the mid-20th century. Even as we seem to be able to do more with the aid of technology, our ways of living are pulling in the opposite direction. The body is able to do less. It is still unclear what impact the invention and pervasiveness of fertility technologiesis having on our perceptions of the complex relationship between the body and technology.
Fertility technologies have fundamentally changed our view of pregnancy and childlessness. By the 1930s, it was already possible to measure progesterone levels in urine and, consequently, detect pregnancy much earlier. Home pregnancy kits have been available since the late 1960s. Ultrasound was developed in the 1950s and, by the 1970s, was a commonly used technology in obstetrics and midwifery. Enabling us tovisualize the foetus in the womb, these technologies have been hugely important to the understanding and politics of reproduction. Pregnancy has lost the fluid character it once had, where subjective exper ienceruled. Pregnancy is increasingly an absolute state. You are either pregnant or not. There is no grey area. What today is seen as a linear development from conception to birth used to involve a far more subjective reading of signs, and medical science was not an absolute authority. Technology is helping to define this state of affairs.
The technological development came to a head in the middle of the last century, symbolized by the birth of an English baby, Louise Brown, on 25 July 1978. The first child to be born after being conceived through artificial insemination (in vitro fertilization, or IVF), she was touted as a medical miracle, a victory over nature. IVF and later assisted reproductive technologies put infertility in a new perspective and changed how pregnancy is handled. Today, children born with the assistance of reproductive technologies like IVF and hormone treatments do not make headlines, while the perception of such technologies as pure miracles has also been dented by their variable efficacy and often great personal and economic cost.
No matter how fertility, childlessness, and birth rates are viewed, the entanglement between body, society, and technology is all too apparent. Fertility technologies have crucially affected our sense of what a normal pregnancy is. From birth-control pills and abortions on one side to ultrasound and pregnancy tests in the middle and IVF and hormone treatments on the other, the effects of the scientific unfolding of fertility are ambiguous and m ultifaceted. There is a noticeable tension between how pregnancy has been unlocked as a technical and scientific problem and the increasing need for such technologies as our physical reproductive ability, for various reasons, appears to be declining.
Dangers of Childbirth
In 2002, Medical Museion in Copenhagen published A History of Birth Care by Mogens Osler, chief of surgery and obstetrics at the Department of Gynaecology at Copenhagen’s Rigshospitalet from 1969 to 1996 and professor at the Midwifery School in Copenhagen. The book surveys the long and complex history of birth care and the many technical and medical advances – from barber surgeons, superstition, and a high mortality rate for mother and child to ultrasound scans, safe surgery, and death in childbirth as an xtremely rare occurrence. All the same, an unresolved tension can be detected in the book’s epilogue, as Osler reflects on the history of his field:
“Through the ages, birth care has mainly been a matter of preventing death, damage and disease in the mother, the foetus, and the newborn child. In other words, normality has always been desired and sought: a normal pregnancy, a normal birth, a normal child. But today the course of a normal pregnancy and birth is far from equivalent to a natural one. On the contrary, modern obstetrics and its many preventive measures are increasingly widening the gap between the natural and the normal.”
In many ways, the long history of birth care hinges on this tension between a normality, whose boundaries are constantly shifting, and a naturalness that is inherently unpredictable and opaque. Much has been gained over the course of this history, but fundamental changes have also been made to the framework around pregnancy and birth.
Childbirth is dangerous. The WHO estimates that 15 percent of all women in labour develop serious complications requiring immediate and effective treatment to prevent chronic problems or death. Being born is even more dangerous. Through most of human history, child mortality rates have been at levels that are hard to fathom from the perspective of a hi-tech society. In 18th-century Denmark, roughly 20-25 percent of newborns died within their first year of life, and one percent of women are estimated to have died in childbirth. This statistic should be seen in light of the fact that most women used to give birth every two and a half years during their fertile years. Of course, these figures are skewed by the enormous diffeences in living conditions between rich and poor. Things are not much better today. About 2.5 percent of children in Bangladesh die before the age of one. In Denmark, the child mortality rate did not drop below 10 percent until the 20th century. Death has always been an intimate companion, a persistent shadow, and a visitor at childbirth. In Brought to Bed: Childbearing in America 1750-1950, the historian Judith Walzer Leavitt quotes from an 1885 letter from a woman describing the course of her third pregnancy: “Between oceans of pain there stretched continents of fear; fear of death and dread of suffering beyond bearing.”
Childbirth is at once both lethal and life affirming, routine and an existential abyss. That is why birth care has most likely always existed in one form or another; its history is as long as humanity itself. Only the form of the care has changed across historical, cultural, social, and economic divides. For the vast majority of history, the care was social and emotional rather than medical and technical, and was handled by family and women in the community. Long into the 20th century, almost all births in Denmark took place at home. The woman in labour was often assisted by female relatives and friends and perhaps a midwife (and in rare cases, a doctor). The midwife is a recurring figure: historical evidence shows the existence of a midwifery trade very early on. Midwives were women who not only had experience from their own births but regularly assisted at others’. For most of European history, there was no formal education, training rogrammes, or syllabi for midwives, much less professional licenses or official regulations. Women learned how to assist and support from practical experience and each other.
New Anatomy, New Insight
In the 17th century, the picture slowly begins to change. From the perspective of Western medicine, the history of obstetrics – especially with regard to improved knowledge and options for surgical intervention in difficult births – is inextricably linked to the history of anatomy. The mid-16th century sees the emergence of an anatomical tradition that is concerne dwith understanding the fabric of the body; Fabrica is the title of a pathbreaking 1543 work by Andreas Vesalius (1514-1564). Out of this anatomica lmovement grew new knowledge and insight into the structures of the body, including pregnancy and the baby in utero.
Three wax tablets shown above date to the early 19th century and once belonged to the Royal Danish Academy of Surgery, where they were used for instructional purposes. They show, respectively, foetal development in seven stages, a longitudinal section of a pregnant uterus with an approximately nine-month old foetus, and the posterior abdominal wall with kidneys, blood vessels, and more. The tablets represent the incremental collection and substantiation of anatomical knowledge that had begun in the Renaissance. They illustrate how knowledge about the anatomy of both the mother and baby is part of the institutionalization and professionalization that lay the foundation for the emergence of modern medicine in the late 19th century. Knowledge of human anatomy, especially the physiology of birth, gradually improves, transforming birth care and the relationship between the midwife and the doctor. The improvement in medical knowledge is an important element in the general professionalization and institutionalization of the medical science and profession that pick up speed into the 18th century – better knowledge, better education of both doctors and midwives, and new institutions, including philanthropic maternity clinics, which also serve as places of learning. In 1750, The Maternity Foundation opens in Copenhagen, allowing unmarried women to give birth without providing their name or that of the father. This development is linked to the gradual expansion of the nation state and the growing perception that the state has a role to play in the health and illness of the individual citizen.
This period also sees the publication of the first noteworthy textbooks by midwives for midwives. Louise Boursier (1563-1636), a French midwife who trained at the Hôtel Dieu hospital in Paris, wrote the first such textbook in 1609. These books testify to the increase in dissemination, centralization and institutionalization of knowledge that distinguished the early modern period of medical science. But they also embody the divide that would mark birth care even into the late 20th century – the division between the midwife as female and the obstetrician as male.
Male Midwives and Doctors Enter the Arena of Childbirth
The growing anatomical and medical interest in childbirth gradually paved the way for the arrival of males into what had been an exclusively female domain. Where barber surgeons with razors and pliers, in rare cases, could be called to assist in births when the baby was stuck and endangered the life of the mother, a technological advance in the 18th century helped change childbirth forever: forceps. Originally invented in the 17th century, obstetrical forceps did not become widely used until the mid-18th century, when a British male midwife, William Smellie, popularized their use and significance in his book A Treatise on the Theory and Practice of Midwifery. The forceps made it possible to pull out babies that had become lodged in the birth canal. This tool represented a technological expansion of the options available during risky births, improving the odds of survival for both the mother and the child. It opened up a new role for the male doctor that went beyond the effort to save either the mother or the child during a birth gone wrong and instead constituted a real opportunity to intervene positively. The forceps represented both a technological advance that saved lives and a gradual overturning of the hierarchy and agency of the male doctor, the obstetrician, and the female midwife.
From the 18th century, as knowledge of anatomy grew, more tools were added to the obstetrician’s bag. The mid-19th century saw the arrival of the first effective treatments for pain – first laughing gas and ether, then chloroform, invented by the Scottish obstetrician James Young Simpson in 1847. Simpson immediately began to administer chloroform in his practice, despite the opposition of religious institutions to the use of painkillers during childbirth (as we know, Eve’s punishment for eating the apple is pain in childbirth). The critics slowly fell silent, however, and in 1853, when Simpson administered chloroform to Queen Victoria during the birth of her eighth child, the official seal of approval was complete. Likewise, the emergence of antisepsis toward the end of the 19th century led to much improved understanding of septicaemia and to new surgical practices based on cleanliness. Together, anaesthetics and antiseptics fundamentally changed the conditions of surgery.
In obstetrics, caesarean sections gradually became routine. Ever since, a host of medical and technical innovations have improved the power of medicine to understand and handle problematic childbirths: antibiotics, blood transfusions, epidural blocks, ultrasound scans, chromosome testing, and much more.
From a soaring bird’s-eye view, the history of birth care in the Western world can be described as a gradual medicalization, a process in which something natural (and often dangerous) has been annexed into medical normality. Childbirth has gone from almost exclusively taking place at home to almost exclusively taking place at maternity wards in hospitals, where childbirth is increasingly publicly supervised and part of a public healthcare system. The attendants to the woman in labour have gone from family, friends, and perhaps an uncertified but experienced midwife, to a highly educated, professional midwife who, in difficult or dangerous situations, can call in a (historically almost always male) specialist obstetrician. Childbirth has become a normalized part of a medical system, exemplified by the fact that, although home births are rising rapidly, more than 95 percent of all children are born in a hospital. One set of experiences has gradually been replaced by another.
Separating the Child from the Mother
The story of birth care is also the story of the power inherent in the enormous medical and technological change that childbirth has undergone, pulling our understanding of the body in the direction of the tools developed to treat it. Obstetrical forceps produce a birth situation that requires intervention with forceps more often. Ultrasound scans give the foetus an existence it never had before. Accordingly, the gradual medicalization of childbirth has also produced a large number of less measurable but no less significant consequences. As Barbara Katz Rothman, a sociologist who has extensively studied the history of maternity, puts it,
“Diagnostic technologies, from the most routine ultrasound to the most exotic embryo transplant, have in common that they work toward the construction of the fetus as a separate social being. The history of Western obstetrics is the history of technologies of separation. We’ve separated milk from breasts, mothers from babies, fetuses from pregnancies, sexuality from procreation, pregnancy from motherhood. It is very very hard to conceptually put back together that which medicine has rendered asunder.”
The history of birth care is a dual history. It boasts great advances all but guaranteeing the safety of what once was fraught with danger, fear, despair, pain, grief, disablement, and death. But it has also entailed a gradual medicalization process shaping the perceptions, experiences, and attitudes of all the parties involved: the pregnant woman, the family, the doctor, the midwife, the medical system, and, ultimately,the whole society in which we live.
This duality leaves us with the tension articulated by Mogens Osler. The boundary between the normal and the natural, between too little and too much control and intervention, remains an issue. All the medical advances have left everyone – the pregnant woman, her surroundings, the attendants at birth, and the medical system at large – with a number of choices for which no formula exists. Perhaps the current concern with the ambiguity of motherhood, as embodied in the Mother! exhibition, is a reaction to that duality.