Florence Nightingale: Maternal Mortality and Gender Politics
Paper for the History of Nursing Conference
of the Canadian Association for the History of Nursing
9 June 2006, St Paul’s Hospital, Vancouver, B.C.
by Lynn McDonald, PhD
Dept. of Sociology
University of Guelph

Florence Nightingale (1820-1910) addressed the issue of high rates of maternal mortality post-childbirth early on in her professional career, and continued to seek solutions over the next decades, indeed into her old age. The second project of the Nightingale Fund, raised in her honour in the Crimean War, was to fund a midwifery-nurse training program at King’s College Hospital, led by Mary Jones, the nurse (and Anglican sister) Nightingale most respected, and from whom she had learned much of her own nursing practice. But the maternity ward that was set up for this purpose--King’s did not then have a maternity ward--and the school itself were closed early in 1867 on account of excessive rates of puerperal fever.

There is comprehensive coverage of this whole complicated process in Florence Nightingale on Women, Medicine, Midwifery and Prostitution, 2005, volume 8 of the Collected Works of Florence Nightingale (8:141-408; later citations give volume and page number only). This volume includes a critical edition of Nightingale’s pioneering Introductory Notes on Lying-in Institutions, 1871 (8:249-329). Here I wish to focus attention on two aspects of the issue: the statistics on maternal mortality from puerperal fever (what was known, when, and how the knowledge was used) and the goal of developing midwifery as a profession for women (and why Nightingale effectively abandoned both it and that of midwifery-nursing).

A midwifery-nurse was considered qualified to deliver at a normal birth and to recognize the need to call in a doctor if there were complications. Nightingale was concerned that with a short period of training (three months, even one month) the pupil might not even have seen an abnormal birth, certainly not many.

Both midwifery and midwifery-nurses were Nightingale concerns. The training program at King’s was only for midwife-nurses, but she was often consulted on midwifery itself.
There was good reason to start the midwifery-nurse training program. At that time in Britain most women were delivered at home by midwives, most of whom had little training. Obstetrics was a new specialty and hospitals were cautious about having maternity wards on account of periodic epidemics of puerperal fever. Nightingale’s decision to fund the project was a response to considerable demand, especially from country parishes, for a trained midwife. More women died then from “accidents of childbirth” than from puerperal fever, so that one might reasonably suppose that a training program for midwife-nurses would help to save lives. (1)
The program was established with the best known practices. Nightingale evidently consulted Dr Edward Rigby, whose System of Midwifery, 1841, gave extensive coverage to puerperal fever, both how to prevent it and how to deal with it should it occur. Medical students were not supposed to attend at the maternity ward, although in fact they did. Careful attention was paid to laundry and ward cleansing, including alternation in use of delivery wards to permit thorough cleansing.

Nightingale did not know of the breakthrough made by Dr Ignaz Semmelweis at the Vienna General Hospital 1847-48, by requiring doctors and students entering the maternity ward to wash their hands in a chlorine solution. Semmelweis did not help matters much himself by not promptly publishing his results, although colleagues did. Semmelweis gave a paper in Vienna December 1847 on his results, published by colleagues in April 1848 (in German) in the Journal of the Medical Society of Vienna. (2) In Britain itself there was discussion of Semmelweis in the journal of the Royal Medical and Chirurgical Society of London journal, C.H.F. Routh, “Epidemic Puerperal Fever of Vienna” in 1849. It gives a highly positive account of Semmelweis’s results, with two tables, albeit only on the earliest results 1847-48. As well Semmelweis’s recommendations are carefully set out (oddly, Semmelweis’s name is mis-spelled, as it was in the earliest publication of his results by colleagues in Vienna). Routh also introduced some comparisons with Paris, Strasbourg and Prague, again in such a way as to make Semmelweis’s point appear even better. Routh explained that he obtained the data while in Vienna (augmented by some sent by a colleague later); he had made the trip specifically because he had had “two or three unfortunate cases” of puerperal fever himself.

The Routh article was further quoted in a UK public health report in 1858, John Simon’s introduction to Papers Relative to Sanitary State of People of England (Results of Inquiry into Proportions of Death Produced by Diseases in Different Districts in England). In that publication there was specific mention of avoiding contact with cadaveric matter, for the disease was often transmitted from autopsies, and that the doctor if he had had contact should never make a vaginal examination until the following day. Further, “that, besides very thoroughly cleansing their hands they should systematically disinfect them with a solution of chlorine. The latter precaution was not introduced till some months after the more general precautions had been adopted.” The drop of mortality 1847 to 1848 was given as 5? to 1? per 1000. (Simon, citing Routh, “On the Epidemic Puerperal Fever of Vienna,” Medico Chirurgical Transactions, xxxii. Le Fort’s citation on the same point is from 5.2 to 1.2 per 1000 for the doctors’ and medical students’ clinic.) That the midwifery clinic was safer than the doctors was well known. Le Fort’s table comparing the two 1854-63 gives 5.5 deaths per 1000 for the doctors, 3.4 for the midwives (17).

Semmelweis had been humiliated in Vienna (although he had supporters as well as opponents) and was not well received in Britain either. I am not aware of either the Routh article, in a major British medical journal, or Simon’s recapitulation in his annual report, were ever taken up.
Nightingale corresponded with Sir James Y. Simpson, physician to Queen Victoria and the person who first used chloroform as an anesthetic in childbirth. But Simpson, whose views were similar to Semmelweis’s, and even pointed to the “fingers of the attendant” as crucial for spreading puerperal fever, did not mention Semmelweis to her, although he did later tell her about a good secondary source, Léon Le Fort’s Des maternités: étude sur les maternités et les institutions charitables d’accouchement à domicile dans les principaux états de l’Europe, 1866. Simpson’s own paper, “Some Notes on the Analogy between Puerperal Fever and Surgical Fever,” 1851, was based on observations of cases, not the systematic work of Semmelweis.
A full publication of Semmelweis’s results appeared only in 1861 in German (a language Nightingale read with facility), a translation from his (Hungarian) lectures: Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers [The Etiology, Concept and Prophylaxis of Childbed Fever], available in English translation from 1983. The beauty of this book-length study is that the crucial results arise in effect from a controlled study. That is, the comparison between the use of hand washing in a disinfectant and the “control group,” of no such use, occurred through the practice of sending women arriving for delivery four days of the week to the first division, staffed by doctors and medical students, and the other three days to the smaller, second, division, staffed by midwives and pupil midwives. Effectively this is random distribution between the experimental and control group. At this hospital only doctors and medical students conducted and attended autopsies.

Semmelweis performed many autopsies himself and came to recognize that he had caused needless deaths by going from an autopsy to attend a delivery without adequate washing. At the autopsy of a senior colleague, who had died after having been cut by a knife at an autopsy of a puerperal fever case, Semmelweis realized that he was seeing the same pus and abnormalities as those of puerperal women. He concluded that puerperal fever was nothing more or less than “cadaveric blood poisoning” and ordered that a bowl of chlorina liquida, a disinfectant, be used by doctors and students coming from the autopsy room before touching a woman; later chloride of lime was used (Semmelweis, English ed. 100).

Of course there were many other measures that had to be taken to get the rates of puerperal fever down, but this was a simple and effective one, and could have helped considerably. The actual cause of the disease was not identified until decades later, and effective treatment not until the development of the sulpha drugs in the 1930s and penicillin in the 1940s.

Why did not news of this important breakthrough travel rapidly and be speedily implemented? Doubtless cultural expectations that birthing was dangerous and women expected to die played a role. We are still today fighting to get equal attention, funding, etc., paid to women’s diseases as to men’s. Probably guilt among doctors, professional pride? also played a role. How terrible to have to admit to having been the means of killing a woman, sometimes also her baby, by attending her at childbirth.

What about hospital authorities? Was puerperal fever a nosocomial disease as well as or even more than it was iatrogenic? Certainly this was the case in Paris, where death rates from puerperal fever were routinely high, tragically so in some years. Let us look at Léon Le Fort’s Des maternités, on the cover up and delayed response to the statistics on the part of the Paris hospital system, the Assistance Publique. Its director, Armand Husson, commissioned the study, vigorously conducted by Dr Le Fort, who spent a great deal of time in London collecting comparative data, as well as amassing data from most European cities, including Vienna. It was only through Le Fort, in fact, that Nightingale learned of the Vienna data at all, then rather too late, and not well reported. Nightingale used Le Fort in her Introductory Notes on Lying-in Institutions, by then trying to find out what went wrong in the King’s College Hospital ward. In the course she discovered that their “high” rate of maternal mortality at King’s was modest compared with that of European hospitals, and not unusual for an English institution.
Briefly, Le Fort’s meta study showed rates of puerperal fever in Paris hospitals routinely high, in some years 10 percent of women delivered dying of puerperal fever. The King’s College rate was 33.3 per 1000 (27 deaths of 781 deliveries over 5 years), compared with 75.2, 56.7 and 60.6 per 1000 for 12 Paris hospital in 1861, 1862 and 1863 respectively (Table B 8:270). Queen’ Charlotte’s Hospital had a rate of 25.3 per 1000 (over 1828-68), 40 London workhouse infirmaries 7.8 per 1000, while the rate for “all England, 1867" was only 5.1, i.e., mainly home births. It is telling that Paris hospitals were routinely published as percentages, British data per 1000.

In his preface Le Fort explained that he submitted a preliminary report in April 1865 to the director of Assistance Publique, who advised him (25 June 1865) of his decision not to publish it. Le Fort made one last trip to England for data, and then published the work privately in 1866. We do not have the original report but only Le Fort’s comment that private publication gave him the freedom to be more critical of hospital administration (vii).

Oddly Le Fort gave no credit to Semmelweis in the book in the several pages devoted to his findings and failed to report the clearest and strongest of them (114-18). Nonetheless it was the source Nightingale used for her own interpretation of the Vienna findings. She stated, in Introductory Notes:

Some bad influence was at work...on the [medical] students' side which was not in force on the pupil midwives' side....We may assume the fact without attempting to explain it, as a proof of the necessity of separating midwifery instruction altogether from ordinary hospital clinical instruction. (8:288)

If she had seen the full analysis, however, she could have been clearer, and she would have realized that what was labelled the “students” clinic also included doctors. The lesson of the Vienna General Hospital was that puerperal fever was reduced by requiring both doctors and medical students entering the maternity ward to wash in a disinfectant. The exclusion of medical students from the ward would affect mortality rates by reducing the number of examinations of the women, hence the risk of infection, but this is another matter.

Midwifery as a Career for Women

This whole matter is complicated by the fact that Nightingale wanted women to be delivered by women, highly trained women, and saw midwifery as a worthy form of a medical career for women. She would have preferred that women seeking to become medical doctors, in general or family practice, would become “physician- accoucheuses” instead. (The term “obstetrician” was hardly in use then; the London Obstetrical Society was formed only in 1859.) Nightingale did not seriously promote her physician-accoucheuse proposal, but mentioned it privately to a number of people. For example, in arguing against a paper of pioneer woman physician Elizabeth Garrett, Nightingale told her brother-in-law, Sir Harry Verney:

If I were forming a female medical school in England, I should just cut the Gordian knot at once, and avoid all collision with men by beginning as closely as possible on the Parisian model. Then afterwards, if you extend it to all diseases of women and children, so much the better, or even to a more general education still. (8:38)

The goal was hardly well thought through, and one wonders how even a superwoman could be a specialist in obstetrics, pediatrics and all the diseases of women and children--in effect everything except male urology and reproductive diseases.

A further complication lies in the fact that Nightingale was highly critical of medical education as it then was and questioned why would women want to become like men doctors. J.S. Mill reasonably enough suggested that the "moral right of women to admission into the profession" should not at all depend "on the likelihood of their being the first to reform it," on which the two agreed (correspondence, in 5:379).

But the crucial point was that Paris, the place where women got the “best” midwifery training, a full two-year course, where midwifery instructors had high standing, published and were treated as experts, had the highest death rates. By comparison, in London Nightingale routinely had to argue against certifying women as midwives with one month’s training, yet the British mortality rates were much lower than the Parisian. Paris we see appearing frequently as a model in Nightingale’s writing, for its training, but increasingly with a qualification regarding the abysmal sanitary conditions in midwifery institutions.

Feminists will like Nightingale’s insistence that giving birth was “not a diseased, but an entirely natural condition” (8:259)--yet another reason for not “medicalizing” it, as we might say. But Nightingale read the statistics. Women delivered by male medical doctors, usually at home, had much lower mortality rates than those delivered by these highly-trained and highly-respected Parisian (women) midwives. With the benefit of hindsight we know that it was because Paris midwives conducted and attended autopsies, which were done on all women who died in or after childbirth. The results provided no useful information while the large number of autopsies ensured that further women would be infected--which could have been avoided, or minimized, by the use of disinfectant hand washing.

It is a sad fact that the entire literature on puerperal fever in Nightingale’s time was written by men. The leading Paris midwives did publish, but only case notes and techniques. I was unable to find any publication by a woman addressing the crucial issue of high mortality rates apart from Nightingale’s in this period. Hers stood alone for decades.

Introductory Notes on Lying-in Institutions itself was attacked in the British Medical Journal by an anonymous reviewer with a decidedly sexist slant. It was elsewhere treated as a good piece of work, but over time disappeared from the literature. When I began to work on Nightingale in the 1970s I could find only one microfilm copy of the book in Canada (at the University of Alberta). It is a fine piece of analysis on a matter surely of great importance: safe childbirth.

Nightingale was frequently asked to reopen or to establish another midwifery training program and ward. She never did, I believe because she could never solve the dilemma of providing adequate training for the midwife (which required a central institution with many cases) and safety for the birthing mother (better off at home avoiding contact with other cases). The goal of promoting a career of "physician-accoucheuse" gave way to that of saving lives. Nightingale was always the "passionate statistician" and saw her calling as that of saving lives. To save the most lives requires the careful use of statistics.

Conditions have, mercifully, changed since Nightingale’s time, but her book remains a stellar example of analysis: how to address a really difficult problem, even before the science is all in, collect appropriate data and work them through to draw conclusions for practice. Nurses and other public health practitioners today have to deal with diseases for which the causes are unknown, to make decisions based on the best available evidence, knowing its inadequacies.
Nightingale returned from the Crimean War August 1856 to begin her work as a social and public health reformer. August 2006 then marks the 150th anniversary of the launching of this effective career, for she saved more lives with careful research and administrative reforms after that war than by her more famous work during it. There is much to celebrate from that work, and a method that is still useful for the work that we need to do today to achieve health in today’s conditions.

Notes

1. Excellent sources on the issue are Irvine Loudon, The Tragedy of Childbed Fever and Jean Donnison, Midwives and Medical Men: A History of Inter-Professional Rivalries and Women’s Rights.

2. “Höchst wichtige Erfahrungen über in Gebäranstalten epidemischen Puerperalfieber,” with a typescript in English “Very Important Findings on the Etiology of Epidemic Puerperal Fevers in Maternity Hospitals,” 1847-48: 242-44; and “Fortsetzung der Erfahrungen über die Ätiologie der in Gebäranstalten epidemischen Puerperalfieber” [Continued Findings...] 64-65.

References

Donnison, Jean. Midwives and Medical Men: A History of Inter-Professional Rivalries and Women’s Rights. New York: Schocken 1977.

Le Fort, Léon. Des maternités: étude sur les maternités et les institutions charitables d’accouchement à domicile dans les principaux états de l’Europe. Paris: Masson 1866.

Loudon, Irvine. The Tragedy of Childbed Fever. Oxford: University Press 2000.

McDonald, Lynn, ed. Florence Nightingale on Women, Medicine, Midwifery and Prostitution. volume 8 of the Collected Works of Florence Nightingale. Waterloo: Wilfrid Laurier University Press 2005.

Review of Introductory Notes on Lying-in Institutions. British Medical Journal (11 November 1871):559.

Routh, C.H.F. “On the Causes of the Endemic Puerperal Fever of Vienna.” Medico-Chururgical Transactions. 14 (1849):27-40.

Semmelweis, Ignaz Philipp. Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers. Trans. from Hungarian by Ferenc Gyorgyey 1861. Reprint New York: Johnson 1966.
--. The Etiology, Concept and Prophylaxis of Childbed Fever. Trans. and ed. K. Codell Carter. Madison: University of Wisconsin Press 1983 [1861]. [Abridged]

Simon, John. “An Introductory Report.” in Papers Relative to Sanitary State of People of England (Results of Inquiry into Proportions of Death Produced by Diseases in Different Districts in England), by E.H. Greenhow. no. 2415. vol XIII. 1-xlviii

Abstract

“Florence Nightingale: Maternal Mortality and Gender Politics”
Proposed Paper for the History of Nursing Conference
Canadian Association for the History of Nursing
History of Nursing Conference June 2006
by Lynn McDonald, PhD
University professor emerita, Dept. of Sociology
University of Guelph

This paper explores Florence Nightingale’s work on midwifery, mainly through the establishment of a training program and midwifery ward at King’s College Hospital, London, 1861-67. The paper deals with the dilemma, which Nightingale never resolved, of providing midwifery-nurse training, which required an institution for deliveries, while providing safe childbirth to mother and child, higher in institutions than home births. Nightingale wanted not only the development of midwifery nursing but the founding of a whole new medical profession for women as physician-accoucheuses. Both goals had to be abandoned for the sake of safe childbirth. Puerperal fever post-childbirth was the reason for closing the midwifery ward.

An enormous amount of material was published on puerperal fever, the usual name for this great killer of women, but little of it was useful for policy purposes. Moreover the better studies, for practical purposes, seem not to have been heeded. The original work of Semmelweis and meta study of Le Fort are drawn on as well as Nightingale’s pioneering study on maternal mortality, Introductory Notes on Lying-in Institutions, 1871.

Material for this paper is taken from the comprehensive publication of Nightingale’s original writing in Lynn McDonald, ed., Florence Nightingale on Women: Medicine, Midwifery and Prostitution, now available as volume 8 of the Collected Works of Florence Nightingale. This includes with Introductory Notes correspondence and notes leading up to it and following it, drawn from archives worldwide.

Dr Lynn McDonald
Dept. of Sociology
University of Guelph
Guelph ON
N1G 2W1
email: lynnmcd@uoguelph.ca
website: sociology.uoguelph.ca/fnightingale