*Anija Dokter [2010] is a Gates Cambridge Scholar and a PhD student at the Faculty of Music, University of Cambridge, specialising in Sound Studies. Her research examines soundscapes and embodiment in childbirth, midwifery and clinical medicine. Picture credit: Sattva and http://www.freedigitalphotos.net.
Several months ago the Twitterverse resounded with dismay when the character Lady Sybil on Downton Abbey died shortly after giving birth. The grim portrayal of eclampsia shocked many viewers, who subsequently tweeted their frustration that Sybil was not taken to the hospital when pregnancy complications arose. However, in the period of the historical drama (1912-1920), maternal mortality was much higher in hospitals than at home. Maternal mortality in the general population was low, but outbreaks of postpartum injury and infection followed doctors wherever they attended births. Maternal mortality was in fact higher among rich women who could afford an obstetrician than among poor women who gave birth with the assistance of family and/or a lay midwife.
The time period depicted in Downton Abbey also featured transformations in maternity care and medicine. Increased awareness of how infections are spread prompted physicians and other birth attendants to begin washing their hands and sterilising equipment, greatly reducing the number of deaths in maternity hospitals. However, rapid urbanisation and escalating socio-economic inequalities also put women at higher risk of difficult labours - malnutrition, corsets and limited access to fresh air and sunshine caused profound physical deformities and weaknesses.
The Victorian effect
Early 20th-century concepts of motherhood remained dominated by Victorian sensibilities. The ideal Victorian woman was domestic, focused on childrearing and subservient to gendered notions of quietude, restraint and modesty. It was considered scandalous to speak or write about the bodily experiences of sex, pregnancy, childbirth and lactation. Even Victorian- and Edwardian-era obstetricians were suspect because of their interest in these taboo subjects.
The meek and mild mother was never a stable construct - Eve, the mother of sin, always provided inspiration for labelling women as being easily corrupted in flesh, mind and soul and deserving of pain and trauma in childbearing. The ultimate perversion of the ideal Victorian mother was the woman who killed her own child - late 19th- and early 20th-century media revelled in dramatic reports of infanticide. Similarly, medical literature increasingly focused on motherhood and madness. Many studies published during this time period focused on cases of 'insanity' that arose during pregnancy, childbirth, the post-partum period and lactation.
While Victorians are renowned for their obsession with lunacy, childbearing women featured disproportionately in this trend - contemporary sources report that between eight and 12 percent of all patients admitted to lunatic asylums were thought to have been driven mad by childbearing. The reports of symptoms, onset and progression are strikingly consistent over many decades and institutions.
Hysteria
Most of the studies produced during this time period strongly feature standard misogynist narratives that women are weak and hysterical, that they bring their illnesses upon themselves by immoral behaviours, that their physical states are inherently pathological and so on. However, a few medical practitioners recognised patterns in the personal histories of the women suffering from childbearing 'insanity' and argued that this affliction may be influenced by social factors.
One of the strongest proponents of this view was Dr. Alfred Lewis Galabin (1843-1913). He is most renowned as the author of an obstetrical textbook (modestly entitled Manual of Midwifery), published between 1886 and 1910. The textbook demonstrates a unique awareness of women's experiences, featuring descriptions of the sounds, movements, emotions and sensations of women in childbirth. Galabin insists that the melancholic states found in pregnant women have a mental cause in 'the fear or conviction, so commonly met with in pregnant women... that the result of the delivery will be fatal'.
This fear of death, he states, is exacerbated by exhaustion from many and closely-spaced pregnancies, poverty, extreme hard work, domestic abuse, political instability and war. He frequently emphasises that cases of violent or outrageous behaviours, such as infanticide, are the result of infections and fevers (which he insists are largely physician-caused) and suggests that these findings influence legal proceedings against women who have committed crimes during childbearing. Galabin offers an extraordinary set of recommendations for treatment, including avoidance of pregnancy, access to abortion and the complete removal of the mother from all domestic, marital and motherly duties for an extended period of time.
Motherhood
It is ironic that Victorian and Edwardian culture glorified, institutionalised and pathologised motherhood. Mothers themselves were suffering in epidemic proportions. It was rare for women to remain unmarried and most had many pregnancies and several losses as infant and child mortality remained high throughout the period. Access to birth control and pain relief were severely restricted for moral and religious reasons, while the concept of conjugal rights limited women's ability to consent to sexual intercourse and conception. Rape and domestic violence were rarely recognised and women did not generally have access to education or gainful employment. In his Clinical Lectures on Mental Diseases(1887), TS Clouston describes the reality of life as a woman compelled to work hard while enduring the strain of poverty and childbearing: 'The wonder is that any organism could possibly have survived in body or brain such a terrible strain and output of energy in all directions'.
While in developed countries a majority of women can approach childbirth without such profound fear and hardship, staggering inequalities still exist. The total lifetime risk of maternal death is estimated to be one in 14,000 in Sweden, but one in 16 in Somalia (WHO, UNICEF 2010). Such statistics do not even begin to address childbirth injuries and trauma, maternal grief and exhaustion, the restriction of women's choice in reproduction and parenting and the disproportionate suffering of women and mothers in situations of war, natural disaster and environmental degradation.
Unfortunately, recognition of the social factors involved in women's mental and physical health is rare, both in Galabin's time and in ours. Trends in medico-political discourse persistently construct the physiological as separate from the emotional, social and political, especially when it concerns women's bodies and wellbeing. Taking a lesson from history, we should be asking what social inequalities are contributing to women's and mothers' mental, physical and psychosomatic health problems. Traumatic, stressful, debilitating childbearing should never be accepted as the status quo.