Midwifery in the Lower Hunter River district 1940-1960: female entrepreneurial activities in a masculine work world.

Watts, Paula ; Ramsland, John

This article considers the professional activities of midwives in the Lower Hunter region of New South Wales between 1940 and 1960: a time of change and improvement to the care of women during pregnancy and childbirth. Several midwives took advantage of the rapidly increasing and unmet demand for public maternity accommodation because of the post-war baby boom and set up private lying-in enterprises in private residences where they cared for women at childbirth. In doing so, these women demonstrated considerable enterprise as businesswomen in a region with a predominant male-oriented work and industrial culture.

The modern system of hospitalised birth overseen by doctors, physicians, specialist obstetricians and nurses was gradually established in public metropolitan hospitals in Sydney from the early 1900s. This system did not spread to the rest of New South Wales until the middle of the twentieth century. In addition, four maternity hospitals established in the inner suburbs provided for women unable to pay for private care: The Royal Hospital for Women at Paddington, St. Margaret's Hospital Darlinghurst, The Women's Hospital, Crown Street, Surry Hills and South Sydney Women's Hospital. They were supported by several private hospitals owned or managed by licensed midwives. The model of hospitalised care in public hospitals was not available to women in the Lower Hunter River region until the late 1940s and early 1950s. The population growth in Australia after World War II, the so-called `Baby Boom', as well as the impact of Australia's mass post-war migration scheme created an unmet demand for maternity accommodation in the Lower Hunter. Due to financial constraints imposed by the war, development of public facilities in nonmetropolitan localities lagged behind the maternity system already available in Sydney.

Midwives in the Hunter River region had had a continuous tradition of promoting their expertise extending back to the first half of the nineteenth century. In 1843, for example, Mrs Mary Gordon sought potential customers through the local newspaper, stating that she `respectfully begs leave to acquaint the females of Maitland that she has commenced practising as midwife, and promises the utmost attention and care shall be applied on her part to those individuals who may honor her with their commands'. (1) Her aim of attracting maternity patients was supported by an outline of her moral conduct, qualifications and experience attesting to the delivery of more than nine hundred babies in eight years. (2) The shortfall in maternity accommodation in public hospitals was then met by one group of qualified women who responded to the needs of mothers and provided what was acceptable by the community as maternity care at first in the private homes of their patients. The enterprise pioneered by Mary Gordon in 1843 extended into the 1940s and 1950s. In that period Sisters Margaret Dick at Belmont, Ruby Brown in Stockton, Nurses Neal, Gordon, Metcalfe, Burch, Wells, Mears and Home offered their skills and experience to communities of the Lower Hunter, extending from the coalfields towns of Cessnock and Maitland and surrounding districts in the west to Newcastle and its growing inner suburbs of Mayfield and Adamstown in the east.

Qualification in a profession does not automatically confer the characteristics of enterprise, industry, or ambition--the very qualities demonstrated by local midwives in response to the lack of availability of maternity care in the locality under a strong masculine control in the public sphere of the mid-twentieth century. The success of district midwives in setting up businesses can be explained to some extent by the changes of the nursing profession from the late nineteenth century when `the job of nursing moved from low status male and female servants to become the work of educated women. An ideal rapidly developed and took hold of women who worked for the love of humanity and not for monetary reward.' (3) The transition in status in the profession was accompanied by stronger community acceptance, dependence and support.

In the decades after World War II, the middle-class ideology of the role of women as centred in the home as a homemaker for the family was tempered by an acute shortage of maternity care facilities for the district's wives and mothers anticipating motherhood. The ideal of service and devotion also exemplified by local midwives allowed their entry to the workplace normally regarded as a masculine world of medicine and its associated commerce.

Women's work in Australia is now well documented in many arenas. However, narratives of the practice and activities of midwives remain generally underresearched. With Courage & Devotion: A History of Midwifery in New South Wales is a brief history of the natural event of birth with very limited references to the day-to-day work activities of midwives themselves. The publication includes a single reference to Newcastle--the establishment of a midwifery training school at the Mater Misericordiae Hospital at Waratah, Newcastle, in 1946. (4) Noeline Williamson explored the career of midwife Nurse Mary Kirkpatrick in Kempsey near Port Macquarie to the north of the Hunter. However, this is an individual biographical study. Essentially, the practice of trained midwives outside the public maternity hospital system remains unexplored.

This article addresses the lower Hunter region in the two decades after 1940 as a site for private maternity enterprises, and contributes to the social history of midwifery by the use of oral history. General practitioners, licensed midwives, specialist obstetricians and a small number of the women who gave birth in the district in the 1940s and 1950s were interviewed to provide a direct access to the private world of pregnancy and birth during the period which otherwise remains hidden from historical view.

Working-class families in the Lower Hunter region began to follow the custom practised by the well-to-do middle class families and gave birth under the supervision of the local doctor. Widespread public education of mothers of all classes on the risks of confinement was accompanied by the financial incentives of the Maternity Allowance to engage a doctor for the delivery. Before the mid-1940s, the family doctor attended confinements assisted by the local midwife at a number of small private hospitals owned and operated by midwives in the suburb or directed the mother to arrange admission to the district hospital for the delivery in difficult cases.

Maternity care was progressively transformed under a new scientific approach encompassing trained midwives, improvements in the status of obstetrics vis-a-vis surgery and medicine and developments in technology of operative obstetrics, improvements in Caesarian section and the modern application of forceps during difficult deliveries. Maternal mortality rates declined with skilled attendance at birth and the introduction of sulphonamides to treat serious infections during delivery.

Increasingly, from the early twentieth century to the 1930s, doctors and some women's organizations, such as the Ladies' Benevolent Societies and the Country Women's Association, took an interest in obstetrics. A significant stimulus for the growing concern was the Royal Commission which met throughout 1903 and 1904. It proposed improvements in maternity care to reduce the deaths of women in childbirth, particularly deaths within one month of their confinement which were occurring in numbers considered unduly high, (5) and `due to illness which has arisen in connection with their pregnancy, confinement, or subsequent puerperal state'. Increasing public hospital accommodation for pregnant women, in the city and in country, would make childbirth safer than before and enable more women to be trained as obstetric nurses. By the end of the 1930s major changes were underway; in particular, the extension of antenatal care, and of institutionalised, medicalised, male-controlled and directed labour and birth.

The public maternity hospital was a male preserve. Nurses were subservient to doctors in the hierarchy where physicians, mostly male, enjoyed a high social status in the community. Particular social forces led to the creation of nursing being aligned with medicine. However, a crucial difference was that nursing as a predominantly female occupation received subservient status and little or no autonomy. Consequently nurse-physician relationships were formal and hierarchical. Mothers were cared for in a system where midwives had limited involvement in decision-making over labour and birth.

The restricted autonomy of metropolitan hospital midwives was an important difference between the working activities of midwives in Sydney's public maternity hospitals and their counterparts in the Lower Hunter. Midwives in the Hunter fully realised the opportunities that were available for utilising their skills. They vigorously established private maternity accommodation and care, usually in their own residences or other private buildings. The features of the Lower Hunter sustained a system of small private maternity hospitals operated by the qualified midwives until the practice of hospital delivery, followed by specialist-obstetrician attendance at confinements, became more generalised from the mid' 1940s onwards. The geographic isolation of some sectors of the Hunter River region and the protracted nature and uncertain timing of childbirth meant that midwives and the general practitioner physicians relied on each other in the management of labour and delivery.

It is, however, important to emphasise that the region was characterised by a male dominated, working-class, unionised and industrialised community where public maternity services developed more slowly than those of the metropolis with its mix of social classes. The contrast in the practice of midwives in different social environments is an important characteristic of women's history. The lack of infrastructure in the region, exacerbated by the Second World War, substantially delayed the opening up of maternity accommodation in public hospitals. This particular study of a large non-metropolitan and working-class district seeks to deepen our understanding of women's history and women's contribution to the care of mothers during childbirth.

The principle of `self-help' to secure professional attendance at birth was accepted and flourished in the district until the Newcastle Mater Misericordiae and the general hospital in Newcastle opened in the late 1940s and early 1950s. Male wage-earners sought medical aid for themselves and their families during sickness, unemployment and maternity through `self-help' schemes administered through miners' lodges, cooperative societies and several suburban medical practices. (6) Many cooperative societies collapsed during the 1930s economic depression. District midwives took advantage of the increasing demand for maternity accommodation and successfully set up businesses in their residences where they cared for parturient women to exploit the lack of public maternity provision. In doing so, this group of professional women demonstrated unusual entrepreneurial skills outside the mainstream experience of women in a district with its predominantly male-oriented, industrial culture.

The social history of midwifery has been neglected, even though scholarly works and published manuscripts exist on a more narrow aspect dealing with nurse-midwife education and training. This view is supported by Bryan Gandevia, when he comments that `minimal attention has been paid to these subjects on a national basis or in terms of their social context'. (7) American historian, Judy Barrett Litoff, concurs in her history of American midwives. Litoff claimed that researchers have neglected the midwife's history, even though as late as 1910 the midwife attended one half of all births in the United States. Her book, American Midwives, was published in 1978, but the undervaluing of the professional midwife in history remains in Australia as evidenced by the absence of publications.

Narratives of the process of the professionalisation of nursing and midwifery form the greater part of any treatment of midwives that has been developed. Theses and other manuscripts examine the education, training and registration of midwives and focus on the organisational aspect, employment and the ongoing responsibility for nursing practitioners. These document the early organisation of the Australasian Trained Nurses Association and the concurrent establishment of government regulation to achieve uniform standards of training in New South Wales until the transfer of nurse education to the tertiary section during the 1980s. (8) This `professionalisation' approach is common, and collective histories document the formation of the Australasian Trained Nurses' Association in 1899, the interim period of individual hospital certification, culminating in the Nurses' Registration Act of 1924. (9) The Nurses' Registration Board's History of the New South Wales Nurses' Registration Board and Helen Creighton and Frank Lopez's A History of Nursing Education in New South Wales are narrow histories of general and midwifery nursing education. Similarly, Lynette Russell has written a history of the education of the general nurse in New South Wales from the introduction of the Nightingale model of nurse training in the second half of the nineteenth century. Hers is an examination of the hospital-based, apprenticeship system against a background of social change. (10)

Nita Purcal's thesis, The Education and Registration of Midwives in New South Wales, 1875 to 1935 is underpinned by extensive research with data on midwives' and doctors' fees for maternity care. She has appended statistics on births attended by midwives, pupil nurses trained at the various metropolitan maternity hospitals and maternal mortality rates for New South Wales. Milton Lewis explored the changes to birth, specifically the growing acceptance of the practice of hospital delivery and increase in the numbers of hospital births in Sydney in the early twentieth century in several major articles. He documented the midwife's history from the perspective of improvements in women's health and argued that the development of the modem maternity hospital was followed by a reduction in puerperal infection. (11) He emphasised the reputed `high levels of patient safety' achieved as a result of hospitalised birth in the great maternity hospitals of Sydney, but omitted the contribution of the midwife to the improvement in maternity care.

This article on the practices, craft and activities of midwives in the Lower Hunter River district builds on the work of Lewis and Purcal in childbirth attendance, and adds a further dimension to women's history. Most of the history of midwifery is written on the `grand scale'. This article adopts a different approach in following the example of Hilary Marland's work, which provided detailed local studies of early modem midwives in Europe. (12)

With Courage and Devotion: A History of Midwifery In New South Wales, was commissioned for the New South Wales Midwives Association. (13) It emphasises the heroism of mothers and the courage and devotion of midwives, qualities at the forefront of the tradition of midwives in New South Wales, extending from the voyage of the First Fleet to the mid 1980s. (14) The authors use a `slicing the past' methodology to trace the efforts of convict birth attendances by the untrained but experienced Margaret Catchpole and Phoebe Norton to the graduate midwife of the 1980s. The focus is the professionalisation of midwifery and the social changes which propelled improvements to modern standards. Threaded throughout the narrative are tantalising but fragmented references to the practice of Sydney midwives--Nurse Schwarzel in Panania, Kitty Bain in Bexley and the other women who served local communities throughout New South Wales. Midwifery history, though, is much broader than this account and needs illumination beyond the narrow confines of the maternity hospital environment. Noeline Williamson used a different approach, exploring the life of a single midwife, Mary Kirkpatrick, who practised around the turn of the century. Her account considers Kirkpatrick's endeavours in the opening of the first maternity hospital further north in Kempsey. (15)

Midwifery history is focused largely on institutions--hospitals for women--and by extension is evolutionary, idealist and celebratory. (16) This collection forms the core of `midwifery' history and supports the contention that a significant aspect of the history has been neglected. The dearth of collected and archived material in the field is in marked contrast to the record of the contribution of physicians and surgeons, predominantly male, to the documentation of women's maternity. The abundance of historical narratives on the profession of medicine is not surprising given the imbalance of income, power and resources to publish and record achievements vis-a-vis those engaged in the nursing profession. The absence of articles, essays and books on the midwife and the importance of her role at birth reflects the male bias of history. (17) Official belief in the superiority of male obstetric practice was reinforced by the Maternity Allowance Act of 1912 and the payment of five pounds to the mother. The so-called `Baby Bonus' was granted on certain conditions which entailed at least one visit to a legally qualified medical practitioner and a medical certificate attesting to the birth of a viable infant. Under the legislation payment was prohibited to certain categories of women; it was not paid to indigenous Australian mothers, foreign nationals nor to British women resident in Australia for a period of less than twelve months.

This article adopts an approach used by both Marland and Borst (18) whose studies are full of detailed local narratives of modern midwives in Europe and North America. It is a detailed, small, local study of independent midwives in the Lower Hunter River district between 1940 and 1960 and seeks to make visible the practice of midwives centred in local communities and towns without maternity units in large modem public hospitals.

The historiography of nursing between 1940 and 1960 has ignored the daily activities of professional women as midwives. Following the Second World War the aspects of nursing history which received attention from researchers were the shortage of applicants and strategies for recruitment, resistance by the New South Wales Nurses' Registration Board to attempts by the British medical Association and the Hospitals Association of New South Wales to overcome the manpower shortage by lowering the standards set down in the Nurses' Registration Act of 1925. (19)

In the Lower Hunter the main historical images of industry that endure and have become popularised are associated with a masculine world of labourers mining coal underground and on the surface labouring at the Broken Hill Proprietary Company steelworks, or timber getting in the cultivated pine forests. As these activities involved skilled and unskilled labour, with the attendant risk of serious injury and death, community standards dictated that female labour be excluded from those work activities, especially when the Second World War ended. In addition, local businesses were generally owned and operated by men. Men also controlled employment through the ownership of capital, with property owners more likely to be from the middle classes, including well-educated and professional men. Custom dictated that men were the ultimate managers of the family's income, amongst both the working-class and the middle-class, apart from the narrowerhome economy and day-to-day management which tended to be controlled by women.

Within this community, women were defined by their relationship to men and their family. Inside the home women played their roles as companion wife or mother who cared for and nurtured the children and the men. Outside the private sphere of home, unmarried female workers were usually employed in poorly paid and lower status positions. Before marriage, some gained work as shop assistants, while others found employment as attendants, receptionists and secretaries in banks and commercial institutions. Most women did not work outside the home after marriage. Banks, local councils and public utilities in the district, including the Hunter District Water Board, not only did not employ married women but forced female staff to resign on marriage. Following the Second World War women's `waged work' was viewed by the district's industrialised community as competing for men's work. The two decades between 1940 and 1960 were characterised by periods of unemployment in steel making, mining and manufacturing where male bread winners predominated, with major troughs identified in 1940 and 1950. (20) Historians of women have confirmed the absence of married women from the workforce, one account pointing out that `... business and professional work, particularly after marriage, was denied them, for it was not until well after the Second World War that women with children stayed in the work-force'. (21) In the 1940s and 1950s state intervention in social welfare protected families by developments like the Child Endowment Scheme. The assumption underlying the new schemes was of `the family as a single economic unit with the male bread-winner and the female necessarily his dependent chattel'. (22)

In the 1950s, trained nurses in the Lower Hunter were constrained in their efforts to continue in the workforce by the masculine culture of the district and the middle-class ideology of motherhood as the role of women which claimed that married women in the workplace were competing with men. After graduating as general trained nurses, women rejoined the nursing staff as single certificated nurses, enrolled in midwifery nursing courses or merely married and resigned. Nursing rosters drawn up for the needs of patients and with out-of-normal hours of work ensured that, with few exceptions, nurses experienced great difficulty in combining the duties of married homemaker and health professional. Anne Summers explored women's position in Australian society and concluded that `for those women who decided to use their education in professional employment it involved abdicating the right to marry and inevitable social disapprobation'. (23)

Commencing in the 1920s the practice of giving birth at home in the Lower Hunter and elsewhere began to decline as pressure for hospital delivery appeared. (24) Kerreen Reiger pointed out that the first stage of this development was still local confinement: birth taking place in a private `lying-in' home run by a midwife, with or without professional training. (25) This coincided with a rise in the number of women seeking medical attention during delivery in private hospitals and improvements in medical technology: the use of chloroform and analgesia to relieve pain during labour and surgical delivery using obstetric forceps for difficult deliveries. Many qualified midwives took advantage of the increasing demand for maternity accommodation and set up local businesses in their own residences where they attended mothers during birth and provided post-natal care for the women and their infants. Private maternity hospital care was usually of ten days duration until the mother recovered her strength sufficiently after birth to resume the responsibility of duties within the family. It is argued that in doing so, this group of professional women resisted by their entrepreneurialism the subordination of midwifery to the medical profession. By using the special features of the role of `district midwives', these women were able to assert themselves in local communities as competent and largely independent professional practitioners with strong local and societal recognition.

Local midwives were, in the main, owners of the premises where they practised their craft. Some buildings have survived to the present time and are remembered long after they ceased operating. Buses in Maitland used to stop outside the former home of Nurse Hanks, one well-known local midwife. Her substantial, two-storeyed building, where she delivered babies for many of the local women throughout the 1940s, has sweeping views over the surrounding farmland from its wide verandahs. Husbands and relatives used Maitland's public transport system to visit the new infant and its mother. So well known was the residence of the Maitland midwife that the locality was named `Hanks' corner' and local custom also dictated that midwives were referred to by the title `Nurse' followed by their surname. This title was accorded as a mark of respect and esteem for their valuable service to the community.

The authors are not suggesting that midwives were the only women, or even the first, to engage in entrepreneurial pursuits in this region. A Newcastle bicentennial history project team researched women's work in Dungog in the Northern Hunter region around the turn of the twentieth century. The findings of that study suggest that local women followed the earlier custom of women in Europe, noting that female family members, particularly when their labour was not needed on the farm or other family enterprise, seized opportunities to earn money, usually to shore up family finances rather than for the sake of independence. (26) The contemporary definition of femininity, which justified the non-productive housewife of the typical household of industrialism, dictated the kinds of work which women were prepared or allowed to undertake independently. From the Register of Births, Deaths and Marriages and the Dungog Chronicle, the evidence is that within the Dungog community married women held licences for dairies, engaged in auctioneering in property and livestock, and operated shops in the town. Enterprises of this type applied to only a small minority of women in the community. (27) Evidence of individuals interviewed for this study confirm that Sister Brown, Nurse Dick, Nurse Mears, and Nurse Hanks set up maternity hospitals in their residences to earn a living.

The development of midwifery services in New South Wales in the first half of the twentieth century was unevenly distributed across the state. In the early decades, the majority of midwives pursued their craft within the mothers' homes through visits and attendance at home births. Eventually, midwives began to use their own residences to provide a private maternity system and these were referred to as `lying-in' hospitals. The introduction of the Maternity Benefit, the so-called `Baby Bonus', by the Fisher government in 1912, facilitated their use because the five pound bonus could be utilised for this type of accommodation and care. With the growth in the number of midwifery hospitals in Sydney and its suburbs, women found it practical to prefer hospitalisation, especially when it was available in their own suburb.

Interviews conducted with eight mothers who gave birth in the late 1930s and early 1940s demonstrate that the majority of women gave birth in the residence of a midwife or the maternity ward of a district hospital. One interviewee who delivered at home was dissatisfied with the experience and sought accommodation for her second confinement in the private hospital of a district midwife. (28) The demise of domiciliary births is supported. However, improvements to public maternity services in Sydney from 1920 contrast with the tardy development in the Lower Hunter, where almost thirty years elapsed before public hospitals in Newcastle expanded to provide maternity accommodation. First to take up the role was the Newcastle Mater Misericordiae Hospital when it registered as a training school for obstetric nursing in 1946, followed by the Royal Newcastle Hospital in June 1951. It is not known precisely when the district hospital at Cessnock began to accept women for confinement, but anecdotal evidence indicates that Singleton Hospital accommodated maternity cases from about 1933 onwards, and Maitland Hospital's obstetric facility opened in the early 1930s.

There are no statistics on women giving birth at home in the Lower Hunter after 1940. Most likely the practice had dwindled sharply. Data on births in the Hunter River combined sanitary districts between 1940 and 1960 was incorporated in Annual Reports of the Medical Officer of Health and included statistics on total births for each year, the number of ex-nuptial, stillbirths and the infantile mortality rate for the district. However, the place of birth and the domiciliary birth rate was not recorded and is therefore unknown.

The fertility decline in Australia commencing in the late nineteenth century has been historically well documented. (29) The phenomenon demonstrated a remarkable alteration during the six years from 1941 to 1946 when `there was a pronounced upward change in the fertility of New South Wales population due mainly to war and early post-war influences'. (30) The change was reported by the authorities as `the average annual birth rate over the six years was 20.31 per 1,000 mean population compared with 17.41 in the preceding six years'. It is reasonable to believe that this upward trend was experienced in the Lower Hunter with the post war influx of refugees and immigrants who were accommodated in the vacated army camp in the mining town of Greta.

J. R. Shannon, Medical Officer of Health, Hunter River Health District, reported in 1940 that the number of private hospitals totalled forty-nine and two private hospitals were closed and one new licence issued. By 1948 Dr A. J. Hope's analysis of the operation of the Private Hospitals Act, 1908, was that eighty-six of the 159 licensed hospitals in country New South Wales were licensed to receive lying-in cases, demonstrating strong support by rural and non-metropolitan communities. While this type of private hospital accommodation had experienced an overall decline across the state of 8.5 per cent, alternative accommodation in public maternity wards was expanding. This supported the contention that hospitalised birth had largely supplanted giving birth at home. By 1950 the medical officer for the district noted the demand for confinement within small private hospitals had fallen to fifty lying-in beds in thirteen institutions as the expansion of maternity blocks in public hospitals was under way. Public maternity beds, though, were limited to eighty-two, reinforcing continued support for confinement in the district's small private hospitals. Official surveillance of pregnancy and childbirth to improve maternal and infant mortality commenced with the legislation of the Private Hospitals Act, 1908 and the Public Health Act to control puerperal infection, the major cause of maternal mortality until the late 1930s. Whilst statistical evidence of the domiciliary birth rate does not appear to be readily available, the widespread community and public health authorities' acceptance of hospital delivery suggests that the incidence of giving birth in the mother's home was significantly reduced.

Despite the disruption to the lives of civilians by the Second World War, the Division of Maternal and Baby Welfare reported significant advances in care from 1941 to 1946. The Director, Doctor Grace Cuthbert, pointed to progress in pre-natal education, the setting-up of a mobile blood transfusion service for obstetric emergencies and a consultant obstetric service for patients unable to meet a specialist's fee. (31)

The development of medical facilities for childbirth commenced within the private hospital system and these hospitals were widespread in suburbs and towns across the lower Hunter region. The clientele were women with normal pregnancies who could afford to pay. Some private hospitals accommodated only lying-in cases, while others admitted medical and surgical patients as well. Private hospitals with maternity accommodation were located in Lorn, West Maitland, East Maitland and Raymond Terrace. The coalfields towns of Kurri Kurri and Cessnock also had private hospitals where women sought attention at birth. (32)

The greatest number of these establishments were in Newcastle, including one well-known hospital in Stockton, owned by Sister Ruby Eliza Brown. She graduated from the Royal Hospital for Women in Paddington with a midwifery certificate and in about 1926 came to Stockton. In 1929 she purchased a residence in Stockton where she lived and conducted `Gwandalan' Private Hospital, caring for the sick and providing midwifery services. Her most important service was to the women of the community as a resident midwife. Under her care, several generations of Stockton' s future citizens were born. (33) Many people in this isolated suburb took advantage of such a service and, as time went on, developed strong confidence in such a convenient necessity.

In the early 1940s, Nurses Mears, Hanks and Horn conducted their practices in Maitland and cared for women in their private hospitals. These `lying-in' hospitals were usually small cottages, carrying as few as one or two beds and usually no more than ten. Some private hospitals in the district, however, were quite substantial. (34) The well-known Belmont maternity hospital `Roslyn' was a graduation gift to midwife Margaret Dick by her proud parents. `Roslyn' opened for lying-in patients in about 1922. Margaret Dick remained in full control of the hospital until 1960, when it closed its doors as the trend for confinements in public hospitals took over. Sister Dick had completed an intensive midwifery course at Crown Street Women' s Hospital in Sydney in 1922. (35) The competence of this midwife was demonstrated by the successful delivery at `Roslyn' of many sets of twins, as well as one set of triplets. Additional hazards accompany multiple births which are treated as complicated deliveries and usually take place in large public hospitals with more facilities. Before the opening up of maternity wards in public hospitals for complicated cases, mothers booked for delivery by Nurse Dick were reassured by the presence of the attending doctor and trusted status of this midwife in the local community.

The geographical isolation of some Hunter communities also helped district midwives to develop and maintain entrepreneurial control over their local practice. The Hunter River itself restricted travel for doctors in the 1940s and 1950s due to the lack of convenient bridges. The Hexham ferry was replaced by the first of the Hexham bridges in 1952, but it was not until November 1971 that the Stockton bridge was opened, replacing the vehicular ferry. Until then, the northern suburbs of Newcastle were separated from the remainder of the city to the advantage of locally resident midwives as entrepreneurs. Because they were available in the area at short notice, their role was significant in many cases. Isolation, poor roads and inadequate communications sustained the need for local midwives in other geographically difficult parts of the district.

The midwife's role during childbirth was important for the safety of a mother and her infant. During the day doctors were heavily occupied in their surgeries or attending to local house calls and could not spend long hours with mothers during labour. They, therefore, relied on the midwife to care for women and to keep them informed. The uncertain timing of births in the 1940s and early 1950s meant that the great majority of babies were born with a midwife managing the delivery by herself.

Midwives sought flexibility in their day-to-day practice by liaising with doctors over the management of confinements, and consequently achieved responsibility and control for some tasks usually undertaken by doctors. Written protocols, outlining each medical practitioner's management of maternity cases, referred to as `doctor's orders', were developed by district midwives and physicians. The instructions covered, for example, the form of analgesia and dose to be administered in the case of pain during labour. Pethidine was frequently given to ease pain during the often lengthy first stage of labour and the midwife's skill and experience ensured comfort for the mother was balanced against harm to the infant. The `orders' extended to preparation of the mother prior to delivery, whether internal examinations of the birth canal were to be performed and at what stage of labour the doctor was to be notified for the confinement.

Sister Anne Considine operated a private hospital at Raymond Terrace and was skilled at judging the time of delivery. A rural doctor recalled that the distance from his home in Morpeth to Raymond Terrace was twenty kilometres, adding that `she could time things to perfection because we had to cross the ferry and you never seemed to miss out on a confinement'. (36) By adhering to physicians' preferences in the management of childbirth, midwives gained considerable control and flexibility within their day-to-day professional activities. One prominent midwife of that era maintained that the rapport and excellent relationships between midwives and their medical colleagues developed because maternity facilities in public hospitals were much slower to develop than in Sydney. Consequently, medical practitioners' approach to childbirth was less formal and hierarchical. (37)

Midwives qualified to practise under the Nurses' Registration Act could attend normal deliveries without the presence of a doctor. (38) A former matron at `Hillcrest', the Salvation Army's maternity home in Merewether, recalled that she delivered around 1,000 babies in the three periods she was assigned to the home between 1942 and 1956. Normal deliveries were managed by her without medical supervision, although a doctor was always on call should any difficulty arise. (39) A Merewether doctor attending the hospital recalled that one of the midwives would hang a sheet out of the window of the labour ward as a signal when he was needed for a delivery during daylight hours. (40) Midwives were viewed as competent and experienced, and the presence of a medical practitioner was considered unnecessary in most circumstances. Although midwives could undertake normal deliveries on their own account, most of the women confined in the district's private hospitals also engaged a doctor. Trained midwives in the district were cognizant of the circumstances under which legally qualified medical assistance had to be sought or the relatives informed of the needs. Collaboration between the midwife and doctor booked for the delivery was essential for mother and baby's safety and particularly for the midwife's practice to flourish and secure further maternity cases. She had to protect herself legally as well.

Between 1940 and 1960, a marked change occurred in the pattern of attending women at birth in the Lower Hunter. Initially, private maternity hospitals conducted by trained midwives played an extremely important role in the local communities which were self-contained and sometimes isolated from one another. Legislation in New South Wales--the Nurses' Registration Act, 1924--established medical control over obstetrics, which incorporated the midwife's role into the occupation of hospital nursing. Evan Willis argued that doctor domination of midwifery:

 came about in considerable part as a result of a greater state concern for
 maternal and infant welfare which led to state patronage for the medical
 profession as they consolidated themselves into a position of dominance and
 control over other occupations within the health systems. (41)

The evidence for the lower Hunter region is that doctors and midwives shared the responsibility and midwives had extensive, immediate autonomy in an interim but extended period of time. The establishment of `medically managed' obstetrics, centred in general public hospitals from the mid 1950s, however, meant that few opportunities now existed for midwives to apply their skills and expertise in an autonomous manner.

With the gradual demise of the private maternity hospital system after the war, the autonomy of midwives was slowly eroded as specialist obstetricians were involved in decision-making at birth in public hospitals. Public hospitals became dominant sites for birthing activities. It is ironic that society's attitude appears to be turning a full circle so that birthing is again considered a natural phenomenon. Since 1993, John Hunter and Belmont Hospitals have promoted their maternity services with special emphasis being made in the public propaganda on the availability of midwives for women seeking this type of care and support. (42) Once again midwives have a significant role to play during pregnancy and confinement, but the former entrepreneurial activities in cottage lying-in hospitals have been displaced by public and private hospitalisation of a broader kind. However, mothers are now supported in the public hospital in obstetric units with sophisticated modern technology, such as ultrasound scanning for the detection of foetal abnormalities, specialised equipment to assist in difficult deliveries, Caesarian section should an emergency arise, blood transfusion and the transfer of mother and baby when necessary to neonatal intensive care. So midwives are able to practise their art in a newly tolerant situation.

RAHS members School of Liberal Arts University of Newcastle, New South Wales

Notes

(1) Mrs Gordon's announcement was published in the local newspaper, the Maitland Mercury on 16 December 1843, item 935.

(2) Maitland Mercury, 16 December 1843 wherein Mrs Gordon stated her experience and qualifications in the practice of her craft were gained under the superintendence of Surgeon Anderson of the Colonial Hospital at Parramatta.

(3) Glenda Strachan, Labour of Love: The History of the Nurses' Association in Queensland 1860--1950, Sydney, 1996.

(4) Winifred Adcock et al, With Courage & Devotion: A History of Midwifery in New South Wales, Sydney, 1984, p. 51.

(5) Royal Commission On The Decline Of The Birth-Rate And On The Mortality Of Infants in New South Wales, Report, vol. 1, 31 in New South Wales Parliamentary Legislative Assembly Votes and Proceedings, Second Session, Sydney, 1904.

(6) Paula Watts, `Midwifery in the Lower Hunter River District 1940-1960', B.A.(Hons) thesis, University of Newcastle, 1995, p. 46.

(7) Bryan Gandevia, `Medicine and Health' in D.H. Borchardt and Victor Crittenden (eds), Australians: A Guide to Sources, Sydney, 1987, p. 366.

(8) Cf N. Purcal, `The Education, Training and Registration Of Midwives in New South Wales, 1875 to 1935' M.Ed. Diss. University of New England, July 1985; History Of The New South Wales Nurses Registration Board, Sydney, 1988; R. Lynette Russell, From Nightingale To Now: Nurse Education in Australia, Sydney, 1990; Helen Creighton and Frank Lopez, A History of Nursing Education in New South Wales: A Comparative Analysis Of Australian and International Influences And Developments, Sydney, 1982.

(9) Russell, p. 22.

(10) Russell, synopsis, back cover.

(11) Purcal, thesis; Milton Lewis, `Hospitalisation for Childbirth in Sydney, 1870-1939: The Modern Maternity Hospital and Improvement in the Health of Women', Journal of the Royal Australian Historical Society, vol. 66, (December 1980); `Changing Attitudes to Hospital Delivery in the Late Nineteenth and Early Twentieth Century in Sydney', paper presented at seminar: History of the Royal Hospital For Women, 28 October 1989.

(12) Hilary Marland (ed.), The Art of Midwifery: Early Modern Midwives in Europe, London, 1993.

(13) Winifred Adcock and others (compilers), With Courage and Devotion: A History of Midwifery in New South Wales, Sydney, 1984.

(14) Adcock and others, preface.

(15) Noeline Williamson `"she walked.., with great purpose", Mary Kirkpatrick and the history of midwifery in New South Wales', in Margaret Bevege, Margaret James and Carmel Shute (eds), Worth Her Salt: Women at Work in Australia, Sydney, 1982.

(16) Cf Betty Capper, 75 Years of Tender Loving Care: A History of the Newcastle Mater Misericordiae Hospital, Newcastle, 1996; Ian Cope and William Garrett, The Royal: A History of the Royal Hospital for Women, 1820-1997, Sydney, 1997; Ron Rathbone, A very present help: Caring for Australians since 1813: The History of The Benevolent Society of New South Wales, Sydney, 1994, chapter 14; Adcock and others; Janet McCalman, Sex and Suffering: Women's Health and a Women's Hospital, Melbourne, 1998; Margaret Press RS J, Sunrise to Sunrise: The History Of St Margaret's Hospital Darlinghurst 1894-1994, Sydney, 1994; Crown Street Centenary Committee, The Women's Hospital (Crown Street): A Family Remembers, Sydney, 1994.

(17) Evan Willis confirms the paucity of published material on midwives and bias towards male histories of childbirth written by obstetricians who provide a particular `reading' of its development in Evan Willis, Medical Dominance: The division of labour in Australian health care, Sydney, 1983, p. 94.

(18) Marland (ed.); Charlotte G. Borst, Catching Babies: The Professionalisation of Childbirth, 1870-1920, Cambridge, 1995.

(19) Nurses' Registration Board of New South Wales, History Of The Nurses Registration Board, chapter iv.

(20) J.C. Docherty, Newcastle: The Making of an Australian City, Sydney, 1983, statistics on Newcastle: Industrial Employment, p. 69.

(21) Cynthia Turner, `Welfare and women: changing conceptions of welfare and problems of women's identity' in Norma Grieve and Patricia Grimshaw (eds), Australian Women: Feminist Perspectives, Melbourne, 1981, p. 173.

(22) Turner, p. 176.

(23) Anne Summers, Damned Whores And God's Police: The Colonization of Women in Australia, Melbourne, 1975, p. 330.

(24) The contention of the decline of domiciliary birth in the locality is supported by evidence drawn from articles in the Newcastle Morning Herald and Miners Advocate extending over the 1940s. On 29 March 1941 the shortfall of maternity accommodation throughout New South Wales was explored under the heading `More Babies born in Hospital' wherein the annual report of the Hospitals Commission of New South Wales revealed that the `demand for bed accommodation for maternity cases presented an almost insurmountable problem'. A sample of birth notices in the same newspaper was conducted for each month during 1940 and 1941. While the number of births in the district exceed the number of birth announcements, the largest number of babies identified in the sample were delivered in private hospitals throughout the district. The trend to the practice of delivery in large public hospitals in Newcastle is evident as early as 1941 when the Mater Hospital, Waratah was accepting women for confinement. On 1 April 1941, Mr and Mrs W. Firth of 114 Railway Street Merewether announced the birth of a daughter, Marjorie. Official statistics on the place of birth for the period have not been located.

(25) Kerreen Reiger, The disenchantment of the home: Modernizing the Australian family 1880-1940, Melbourne, 1985, pp. 94-95.

(26) Glenda Strachan, Ellen Jordan and Hilary Carey, `Women's Work In A Rural Community: Dungog and The Upper Williams Valley 1800 to 1899', paper presented at Labour and Locality Conference, Sydney, 14 June 1977, p. 8.

(27) Strachan, Jordan and Carey.

(28) Watts, pp. 40-55.

(29) The fertility decline in Australia noted here refers to the white population. Peter Moodie discussed the capacity of the Aboriginal population to control its fertility prior to European settlement in Family Planning Population Education Issues in Australia, 1974, cited in Elspeth Browne (ed.), The Empty Cradle: Fertility Control in Australia, Sydney, 1979, p. 16.

(30) Report Of The Director-General Of Public Health New South Wales 1941-1946, Sydney, p. 8.

(31) Dr Grace J. Cuthbert, Report for the Years 1941-1946, inclusive, section 1, C. Division Of Maternal And Baby Welfare, Extract from the Report of the Director-General of Public Health, New South Wales, 1941-1946.

(32) Interview with Dr C. Allanson 30 August 1995, Dr. W. Irwin 3 July 1995, and Dr. M. Peters 1 April 1995, in Watts, p. 42. In order to protect the confidentiality of the doctors interviewed for the thesis, pseudonyms have been used. Tapes, transcripts and notes of the interviews are in the possession of the author.

(33) Stockton Messenger, vol. 14, no. 9, 10 July 1995, unpaginated.

(34) Watts, 42.

(35) Newcastle Morning Herald and Miners Advocate, 26 September 1975, p. 6.

(36) Interview with Dr M. Peters, 1 April 1995, in Watts.

(37) Watts, p. 50.

(38) In New South Wales in the period 1940 to 1960, a certificate to practice as a midwifery nurse was issued under the authority of the Nurses' Registration Board (NRB). This authorisation was granted to the NRB under the authority of the Nurses' Registration Act, 1924-1946, and deemed to be made under the Nurses Registration Act, 1953, as amended. Cf Nurses' Registration Regulations and Syllabus of Study, Issued Under Authority Of Nurses' Registration Board New South Wales 1953, Sydney, 1953 p. 2.

(39) Ibid, p. 42.

(40) Ibid, p. 51.

(41) Evan Willis, Medical Dominance: the division of labour in Australian health care, Sydney, 1983, p. 111.

(42) Newcastle Herald, 30 November 1992, p. 6.