Jürgen Schlumbohm, Claudia Wiesemann. Die Entstehung der Geburtsklinik in Deutschland 1751-1850: Göttingen, Kassel, Braunschweig. Göttingen: Wallstein Verlag, 2004. 144 S. (broschiert), ISBN 978-3-89244-711-5.
Reviewed by Patricia Stokes (Women's Studies Program, Ohio University)
Published on H-German (October, 2006)
Power and the History of Childbirth
The history of childbirth and obstetrics has flourished over the past few decades and spilled far beyond the bounds of medical history. Childbirth is a widespread individual experience, a central familial event and a prerequisite of social reproduction. Its history thus offers a window onto bodily experience, family dynamics, medicalization and professionalization, shifting cultural and national values and the workings of state policy.
Jürgen Schlumbohm and Claudia Wiesemann's edited volume on the origins of the maternity hospital in Germany is a welcome addition to this literature. While its topic may appear rather limited--the history of one medical institution, the maternity hospital, in three German cities--its scope is more ambitious. The authors explore a host of related developments: cameralism and inter-state rivalries; the consolidation of the medical profession; the medicalization of society; the objectification of maternity patients; and the evolution of scientific standards; and change relationships among childbearing women, doctors, and midwives. All of these phenomena were fraught with power relations expressed and negotiated in the maternity hospital. Each of these essays is well written, solidly researched and generally convincing, and each illuminates the workings of power in childbirth on a variety of levels. As a whole, the book is more cohesive than most essay collections, thanks to its tight thematic focus.
The volume does have one serious shortcoming: its lack of a synthetic introduction or conclusion. Precisely because the essays cover much common ground, the reader craves a synthesis that would draw comparisons and conclusions, supply the broader context and highlight the significance of the volume's findings. These well-written and often insightful articles look (appropriately, for a local study) at the micro-level. What is missing is the big picture.
Claudia Wiesemann's brief introduction does not supply this perspective, though not for lack of ambition or intent to do so. She frames the essays in terms of medical ethics and asks how history might illuminate present-day ethical issues in reproduction. But the volume's essays rarely address ethics per se. The authors do describe the genesis of teaching and research practices that are ethically problematic and that laid the groundwork for objectifying women's bodies. The process of objectification is historically and logically connected to Wiesemann's ethical concerns about reproductive technologies. However, neither Wiesemann nor the other authors explore these connections explicitly.
The title of Schlumbohm's essay foregrounds the problem of objectification: "'Die Schwangeren sind der Lehranstalt halber da': Das Entbindungshospital der Universität Göttingen, 1751 bis ca. 1830." As the first maternity hospital founded under university auspices and dedicated explicitly to teaching (and to a lesser extent, research), the Göttingen hospital set precedents. According to its influential director, Friedrich Benjamin Osiander, its top priority was to teach physicians; its second, to train midwives. The goal of reducing maternal and infant mortality took a distant third place. From the very beginning, patients' needs were subordinated to the exigencies of teaching. Patients, who typically spent their last month of pregnancy in the hospital, were subjected to frequent physical exams by groups of eight medical students. Their deliveries were attended by even larger groups of students who performed multiple cervical exams, exacerbating the laboring woman's pain and likelihood of infection. Osiander liberally used forceps for the sole purpose of teaching, again increasing pain and risk of injury.
With the exception of Osiander's aggressive use of forceps, the general pedagogical approach at Göttingen was adopted by other maternity hospitals, as Christina Vanja shows in "Das Kasseler Accouchier- und Findelhaus 1763 bis 1787: Ziele und Grenzen 'vernünftigen Mitleidens' mit Gebärenden und Kindern." In Kassel, pregnant women were required to enter the hospital a month before their due dates to guarantee their availability to students. In practice, though, many women flouted this rule and avoided the invasive prenatal exams. In "Das Accouchierhospital in Braunschweig 1767 bis 1800: Tempel der Lucina oder Pflanzschule für Ungeziefer?" Gabriele Beisswanger notes that women were formally required to submit to exams for teaching purposes, but no one enforced the rule. This neglect was not based on ethical or humanitarian considerations. Rather, medical incompetence, organizational mismanagement and deep feuds among Braunschweig's academic physicians shaped daily life in the maternity hospital. The resulting chaos spared women the indignity and risks of becoming teaching objects.
The problem of objectifying pregnant women is addressed innovatively by Christine Loytved in "Die geburtshilfliche Sammlung und die Praxis der Entbindungslehranstalt an der Universität Göttingen." Her article begins with an overly exhaustive account of the evolution of the hospital's collection of historical obstetric instruments and anatomical preparations. But the reader's persistence is rewarded. The second half of Loytved's article presents a fascinating analysis of the collection as material culture, informed by her background as a practicing midwife. For instance, the "geburtshilfliche Phantom"--a manikin used to simulate a pregnant uterus and the birth process--allowed students to practice techniques on a non-living object and thus took some of the teaching burden off the patients. Yet this created two new forms of objectification. For one, the use of preserved fetal corpses to simulate delivery promoted a view of the fetus as an inanimate object to be acted upon, a view reinforced by Osiander's overuse of forceps. Secondly, Loytved argues convincingly that these models encouraged women's objectification, too, for students practicing on a manikin confronted neither the muscle tone of an actual patient nor her pain. When they shifted to a living woman, students lacked the inhibition that would have protected her from pain and injury.
Loytved identifies other novel developments that drove the objectification of women. For teaching purposes, obstetricians came to prefer that the woman assume a supine position in labor, which put her in a literally passive position. A burgeoning number of newly invented instruments allowed doctors to make anatomical measurements, both internally and externally; these intrusive exams literally impressed upon the patient that she had relinquished any right to self-determination. Loytved concludes that the instruments and procedures used by teachers and students at Göttingen's maternity hospital created a distance between practitioner and patient and violated modesty, shame and taboos. They disregarded the patient's pain and taught young doctors not to be concerned with her comfort. Finally, they put the patient in a passive role and the doctor in an active one.
The collection would have benefited greatly from a synthetic conclusion that might have considered how objectification of women in these early teaching hospitals fostered the medicalization of birth and the growing power of doctors over both midwives and expectant women--an issue all of these essays address. The authors' positions range from Loytved's contention that hospital birth stripped women of autonomy and modesty to Vanja's attempt to find nuance in physician motivations. The Göttingen maternity hospital offers a particularly interesting case study because as the first of its type, it certainly served as a model. Yet Osiander's extreme interventionist philosophy was far from typical. One wishes that Schlumbohm or Loytved had evaluated the strength of his influence beyond Göttingen.
Collectively, the essays make clear that birth in the teaching hospital drastically shifted the traditional balance of power between pregnant women and doctors. At home, a woman would be attended by a midwife, and if a doctor were brought in to handle complications, she and her relatives would still mostly call the shots. Women in maternity hospitals, by contrast, were largely isolated from their families and communities (and thus from potential advocates). They signed away most of their freedom upon admission, agreeing to abide by the strict rules of the hospital. Hospital physicians could interfere in the women's interactions with midwives. Under Osiander, as Loytved demonstrates, neither student physicians nor midwives learned how to deal with a "normal" home birth, or to cope with patient and family wishes; medical students scarcely learned how to deliver a baby without instruments. Loytved and Vanja show that in both Göttingen and Kassel, patients' bodily boundaries and modesty were violated in ways that never could have occurred in home births, and that indeed did not occur when the same physicians attended the deliveries of their private, paying patients.
Unsurprisingly, some expectant mothers resisted hospital discipline, as Schlumbohm most strikingly shows for Göttingen. A few kept their contractions secret and gave birth alone, which spared them intrusive and arguably dangerous interventions. Some sneaked out before giving birth, without paying the high fees that early discharge entailed. Schlumbohm suggests that a network of women, including midwives, may have operated to trump the midwives' duty to the physicians; this claim would be more convincing if he could offer more than one supporting anecdote. However, he shows persuasively that the patients banded together in cahoots against doctors on several occasions. Loytved acknowledges the forms of resistance Schlumbohm describes but ascribes far less importance to them. In the end, she argues, the power of the physicians and the hospital were so overwhelming that patients' small acts of rebellion made virtually no impact. Vanja and Schlumbohm both identify the most important form of patients' resistance: many waited until they were in labor to seek admission and left as soon as they were physically able, thus refusing to be used for teaching purposes. These women voted with their feet against the routine violations of patients' bodily integrity--a point that Schlumbohm develops well, while Vanja underplays it.
Why did pregnant women use the hospital at all? Beisswanger, Vanja and Schlumbohm all describe the typical patient as poor, unmarried and in her twenties. Vanja argues that women gave birth in the hospital mainly in order to place their infants in the foundling home, and not primarily to escape the fines levied on fornicators. However, she fails to explain why only a fraction of unmarried mothers sought hospital admission--the solution of last resort. Schlumbohm's essay is more satisfying in this regard: he finds that most patients were domestic servants, far from their family of origin and lacking a local support network. Servants routinely lost both their work and their lodgings in late pregnancy, which left them with no alternative but the hospital.
Another form of power that this volume addresses is that of the enlightened, absolutist state. In "Die Entstehung des klinischen Unterrichts an den deutschen Universitäten des 18. Jahrhunderts und das Göttinger Accoucierhaus," Isabelle von Bueltzingsloewen traces the impact of cameralism on the founding of university-affiliated hospitals, a topic that Schlumbohm, Vanja and Beisswanger also address, albeit in less detail. In all three cities (Göttingen, Kassel and Braunschweig), populationist concerns drove the establishment of maternity hospitals. By preventing infanticide and training more competent midwives and doctors, states intended to enhance their military, economic and political strength. Some individual women did derive benefit from these hospitals. At the same time, cameralist population measures constituted yet another form of objectification of women as (potential) mothers by treating them as a means to an end. Of these essays, Schlumbohm's most richly explores the implications of such policies for ordinary women and their children.
A final way to frame this essay collection would be in terms of evolving scientific standards. How "scientific" was medicine, and obstetrics in particular, during the late eighteenth and early nineteenth centuries? More than most branches of medicine, obstetrics and gynecology have been characterized by practices (such as routine episiotomy or near-universal recommendation of hormone replacement therapy) unsupported by contemporary standards for sound science. These essays demonstrate that early German academic obstetricians fit squarely within this problematic tradition. Osiander and his colleagues laid claim to scientific standards, methods and authority between 1750 and 1800, but they generally fell short of their own standards. Beisswanger's depiction of the Braunschweig maternity hospital most vividly exemplifies this gap between claim and reality. Physicians at the time believed that miasmas could infect patients and cause fatal childbed fever. While the Göttingen hospital took steps to prevent crowded conditions, the Braunschweig hospital failed miserably. Beds were worn so thin that pregnant women slept on bare straw, and rooms were infested by lice, fleas and bedbugs. The abysmal hygiene not only violated obstetric standards of the day, it also drove away patients, some even before they gave birth.
Overall, this volume includes a satisfying, cohesive collection of well-researched articles. They are not all equally innovative; the pieces by Schlumbohm and Loytved--not coincidentally, the only specialists in the history of childbirth--use the sparse available sources most creatively. While this work is certainly aimed at professional historians, its readership should not be limited to historians of childbirth: those who study women, medicine, science and the absolutist state should also find some or all of these essays rewarding.
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Patricia Stokes. Review of Schlumbohm, Jürgen; Wiesemann, Claudia, Die Entstehung der Geburtsklinik in Deutschland 1751-1850: Göttingen, Kassel, Braunschweig.
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