History of Obstetrics and Midwifery

The Ebers Papyrus, an Egyptian medical text copied around 1550 BCE, contains gynaecological and obstetric material, including advice on pregnancy, labour, and the care of the newborn. It is a compendium of older knowledge rather than a single author's work, but it shows that questions of fertility, labour, and the postpartum period were already being systematised in the ancient world.

In the Roman world, the physician Soranus of Ephesus (fl. c. 98–138 CE) wrote Gynaecia, the earliest complete treatise on midwifery to survive. It covers the management of labour, the recognition of complications, and the care of the newborn, and it reflects a world in which midwives did the practical work while physicians wrote the theory. Soranus is explicit that the midwife's skill lies in hands and judgment, not in books.

In medieval Europe, women's midwifery knowledge was transmitted orally and by apprenticeship. One of the few women whose work survives is Trota of Salerno, a twelfth-century Salernitan medical practitioner associated with works on women's medicine. Her case is a reminder that the written record over-represents male physicians: most midwives left no text at all.

The forceps are traditionally associated with the Chamberlen family in London, whose first recorded use is dated to around 1600. The family guarded the instrument and its technique as a private secret for roughly a century, charging high fees and refusing to teach it. This is a well-known example of a potentially life-saving technique being held as proprietary knowledge.

Forceps designs and case reports began to circulate in print in the 1730s. William Smellie's A Treatise on the Theory and Practice of Midwifery (1752) systematized rules for their use and helped train both male and female practitioners. Smellie and his French counterpart André Levret were central figures in the professionalisation of obstetrics in the eighteenth century.

Even once the design circulated, the forceps remained a double-edged instrument. Applied with skill and at the right moment, they could relieve a fatal obstruction; applied too early, too late, or without anatomical knowledge, they could injure mother and baby. The instrument did not remove the need for judgment—it made the consequences of bad judgment more visible.

London institutions such as Queen Charlotte's Lying-In Hospital, which traces its origins to 1739, and the Middlesex Hospital's inpatient lying-in service, opened in 1747, were among Britain's early maternity institutions. Lying-in hospitals were charitable, and they served women who had no other option. But the very conditions that made them necessary—crowding, poor ventilation, and the reuse of uncleaned hands and instruments—made them breeding grounds for infection.

Puerperal fever, or childbed fever, was a septic infection of the reproductive tract that killed a frightening proportion of women who gave birth in hospital. For much of the eighteenth and early nineteenth centuries, its cause was unknown. In a 1795 treatise on an Aberdeen epidemic that began in 1789, the Scottish physician Alexander Gordon argued that the fever was contagious and spread by attendants moving between patients, an idea that was not widely accepted for decades.

The most famous campaign against puerperal fever was led by Ignaz Semmelweis at the Vienna General Hospital in the late 1840s, who showed that handwashing before examination dramatically reduced mortality. His work was rejected by much of the medical establishment of his day. It was only after Louis Pasteur's germ theory and Joseph Lister's antiseptic surgery, in the 1860s, that the contagious, microbial explanation became generally accepted.

In 1847, the Edinburgh obstetrician James Young Simpson began using chloroform to relieve the pain of labour, and he published his findings the same year. The use of anaesthetics in childbirth was immediately controversial. Some opponents argued on religious grounds, citing the biblical injunction that a woman should bring forth children in pain, and holding that the suffering of labour was a punishment that should not be relieved.

The controversy was settled, in a practical sense, by the British monarchy. On 7 April 1853, Queen Victoria asked that chloroform be used during the birth of her son, Prince Leopold, and the anaesthetic was administered by the physician John Snow. Royal endorsement removed much of the social stigma.

By the late 1850s, professional opinion had largely shifted in favour of the practice, and anaesthetics became an accepted part of obstetric care. Anaesthesia did not end the debate about intervention in labour, but it shifted it: the question was no longer whether pain should be relieved, but how much of the birth process should be managed by medicine.

The decline in maternal mortality was gradual for centuries and then sudden. In England, maternal mortality was estimated at around ten deaths per thousand births in the early eighteenth century and fell slowly over the following two hundred years. The sharp decline came from the 1930s onward, as antibiotics, blood transfusion, and hospital obstetrics took hold. The causes of maternal death shifted accordingly: infection and haemorrhage, which had dominated, became more treatable.

Caesarean section, once generally attempted only as a last resort and often fatal to the mother, became a survivable and then routine operation as anaesthesia, antisepsis, and surgical technique improved. Its history is a good measure of how far obstetric medicine had come: the same operation that was a death sentence in the seventeenth century became, by the late twentieth century, a standard option for high-risk births.

Measurement expanded from the mother to the newborn. In 1953, Virginia Apgar introduced a simple observational score for assessing the condition of the newborn, which became a standard part of delivery. At the same time, routine interventions—episiotomy, forceps, induction, continuous fetal monitoring, and caesarean delivery—became common, and with them a recurring debate about whether institutional convenience was being confused with safety.

By the early twenty-first century, the pattern of maternal death had become sharply unequal. In 2023, an estimated 260,000 women died during or following pregnancy and childbirth, and about 92% of these deaths occurred in low- and lower-middle-income countries, where access to skilled care, blood, and antibiotics remains limited.

In high-income countries, the debate has shifted from survival to the quality and ethics of care. In 2018, the WHO published recommendations for intrapartum care that emphasised continuous support, freedom from routine interventions without evidence, and the dignity and autonomy of the person giving birth. These recommendations reflect a growing recognition that more intervention is not automatically safer care.

The framework of reproductive justice, coined by Loretta Ross and other Black feminists in 1994, joins the right to have a child, the right not to have a child, bodily autonomy, and the right to raise children in safe and sustainable communities. It insists that maternal health cannot be separated from the social conditions—poverty, racism, immigration status, and access to care—that shape who is at risk.