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Analysis

The development of midwifery legislation in Scotland: a history to be proud of

17 June, 2008

The development of midwifery legislation in Scotland: a history to be proud of

This paper examines the background to the 1915 Midwives (Scotland) Act, how it eventually came about, some of the provisions of the Act and some of the differences between the Central Midwives Boards for England and Wales (CMBE&W) and for Scotland (CMBS).

 

This paper examines the background to the 1915 Midwives (Scotland) Act, how it eventually came about, some of the provisions of the Act and some of the differences between the Central Midwives Boards for England and Wales (CMBE&W) and for Scotland (CMBS). 

 

Midwives magazine: April 2003

 

When the 1902 Midwives Act was passed in England andWales, it was a major landmark in the professionalisation ofmidwifery. However, this Act did not legislate for Scotlandand Northern Ireland and preceded the Midwives (Scotland)Act by 13 years.

 

Background to the Midwives (Scotland) Act

 

Despite debates for the the 1902 Midwives Act takingplace at Westminster and including all members ofParliament, the proposals for Midwives’ Registration Billsunder discussion in the mid-1890s were not intended toapply to Scotland. One reason for this given in the Houseof Commons at the time was the different administrativestructure in Scotland. ‘A large number of provisions andamendments would require to be introduced to make theBill apply to Scotland’ (Jenkinson, 1993: 83).

 

The Rt Hon Eugene Was on MP (Clack mannan and Kinross) also explained to the House that ‘a joint Bill would have been difficult because of differences in the legal systems’. In addition, Was on suggested that the situation at the time in Scotland was satisfactory as ‘these things are managed better in Scotland’ (Dow, 1984: 151).

 

By arguing that legislation was not necessary, Was on reflected the view of a large and powerful section of the Scottish medical profession, the GPs and the consultants. While parliamentary debates were going on in the 1890s,members of the Edinburgh Obstetrical Society (EOS), made up of GPs and consultants, discussed the issue fully.

 

General opposition to midwifery registration

 

A majority of the members present demonstrated their opposition to registration of midwives in Scotland (EOS,1985: 167). Some thought that it would be a long time before the establishment of reasonable midwifery training, thus creating a danger of ‘launching a large number of unqualified women on the public’ (Jenkinson, 1993: 83).

 

There was also the continuing fear that the registered midwife would encroach on their livelihood. One member opposed registration of midwives, because ‘it is doubtful if we can persuade the Legislature to interfere with the right of any woman to call herself midwife’. Instead, he suggested midwifery nurses working under the direction of a medical practitioner should be trained and registered. Thus, ‘the public would more readily understand the position of such, and that the women themselves would not be put in the false position of being considered duly competent to attend labour caseson their own responsibility’. In short, while the uncertified midwife or how die would be there for a time, ‘he would leave midwives to die a natural death’. Another member, Sir William Turner agreed that ‘it seemed as if the midwife in Scotland was rather an accident. She did not seem to be required, but undoubtedly she was required in England’.

 

There was a dissenting voice when Dr Thatcher argued the case for examined, registered midwives and said that he considered that he was supported in his opinion by a great number of country practitioners, that midwives were absolutely essential in Scotland.

 

In large colliery districts and large manufacturing districts the practitioner had no time to do the work, and it was very important that women expecting to have children should be properly attended to. In summing up, the president, Dr A H Freeland Barbour commented that in Scotland there was no great need for the registration of midwives. However, he advised his colleagues to watch the progress of the Midwives Bill for England and Wales very closely as ‘if anything was passed for England it would sooner or later cross the border’. (EOS, 1895: 167-82).

 

Why was midwifery legislation implemented?

 

Despite all this opposition, one reason midwifery legislation was implemented in Scotland was because of the increasingly influential views of another section of the Scottish medical profession – the medical officers of health (MOH) – who argued that ‘these things were not done better in Scotland’.

 

They opposed the EOS and campaigned vigorously in the early 20th century for legislation for the training, registration and regulation of midwives in Scotland (Tait,1987: 415; Chalmers, 1914). The heart of their case was that infant and maternal mortality rates in Scotland in general, but more specifically in Glasgow, were very high. Key figures in this campaign were Dr A K Chalmers, MOH for Glasgow and Dr Campbell Munro, MOH for Renfrewshire, whose work along with other MOHs in Scotland formed the basis of the first Scottish Midwives Bill (Chalmers, 1914).

 

Dr Chalmers’ investigations

 

In 1906, Chalmers, (1930: 259) stimulated by work on infection surrounding childbirth and an investigation into the causes of infant deaths, began the practice of keeping a record of who attended births in Glasgow. The 1907 Notification of Births Act, which required notification of births to the MOH within 36 hours of birth, reinforced this practice and revealed the absence of a systematic record of the qualifications of midwives and ‘a considerable proportion of them held no certificate of proficiency of any sort’ (Ferguson, 1958: 546; Chalmers,1930: 261).

 

At the same time, the growing acknowledgement of the poor physical stature of children of the UK, highlighted by the rejection of army recruits for the Boer War, further stimulated interest in the importance of maternal and infant welfare at the beginning of the 20th century. In the thick of this was Chalmers, who in 1908 met with the prime minister Herbert Asquith and pressed for a Scottish Midwives Act on the grounds that women who were attended by untrained midwives in Glasgow had a very high rate of puerperal fever. These women accounted for over half the annual births in Glasgow (MacGregor, 1967: 110).

 

Chalmers continued his investigations and came up with similar results in 1913 and stated that there were many more cases of mothers with puerperal fever where the mother had been attended by a midwife rather than a doctor. He reasoned that the higher rate was beyond the midwife’s control and not necessarily that the midwives were somehow deficient in knowledge or practice.

 

As midwives charged less than doctors for their services, the women the midwives attended were usually poorer, less well-nourished and less able to withstand infection than the clients of the doctors (Ferguson, 1958: 509). Nevertheless, Chalmers said that there was a definite correlation between the number of untrained midwives and the number of mothers suffering from puerperal fever and while removing some of the blame for maternal mortality from the shoulders of midwives, he implied that because of the high maternal mortality rate (MMR), midwives’ practice required regulation (MacGregor, 1967: 110). This reflected the claims of doctors to the House of Commons Select Committee on Midwifery Registration 1891-1893, who asserted that ‘the untrained midwife was the cause of much unnecessary maternal and infant mortality’ (Tew, 1995: 274).

 

Opinion on Chalmers’ findings

 

Although persuasive at the time, Chalmers’ data and views are contrary to other contemporary and recent studies, which show that maternal mortality figures in the UK for the late 19th and early 20th centuries were, on average, better for those mothers who were delivered by midwives than by doctors (Tew, 1995: 273-83; Loudon, 1990: 241).

 

According to Dr W C Grigg, physician to Queen Charlotte’s Lying-in Hospital, London, ‘more cases of ‘injury and physical disaster’ resulted from the imprudent use of forceps and turning [version] by medical men than from the negligence and ignorance of midwives’ (Tew, 1995: 274; Donnison, 1988: 137). In addition, Dr W S Playfair, consultant to the General Lying-in Hospital, London, criticised doctors’ incompetent use of antiseptics and accused them of being the ‘principal vectors of the devastatingly infectious puerperal sepsis’ (Donnison, 1988: 138; Tew, 1995: 274).

 

Fourteen years after the Midwives (Scotland) Act, in both England and Scotland, the MMR figures were better for mothers who were delivered by midwives than by doctors (Loudon, 1992: 244). And Irvine Loudon, an historian specialising in research into maternal deaths, has no doubt that midwives’ were able to provide a maternity service with a very low MMR (Loudon, 1997).

 

Schemes lay administrative basis for Act

 

A second major reason why legislation was enacted for midwives in Scotland was that the welfare legislation of the early 20th century provided the administrative basis said to be lacking in Scotland during the debate leading up to the 1902 Midwives Act. The Midwives (Scotland) Act was part of the Schemes of Maternity and Child Welfare. The Schemes emerged in Scotland in the early 20th century and resulted in other related acts which laid an administrative basis for the Midwives Act (MacKenzie, 1917: 535-61).

 

In 1907 the Notification of Births Act, although not compulsory, led to early notification of births and from there, care and supervision of infants by an emerging system of health visiting (MacGregor, 1967: 111).

 

The 1908 Children Act was designed to protect particularly disadvantaged children, by investigating infant deaths and their causes much more thoroughly than before, using the Notification of Births Act passed a year earlier. Thus, health visitors could use the knowledge that births had taken place to visit homes with infants and encourage good feeding and attendance at infant clinics. This Act preceded significant reductions in infant mortality rates (Chalmers, 1930:195-204; Ferguson, 1958: 551-553).

 

Also in 1908 the Education (Scotland) Act provided medical inspection and treatment where needed for school children (MacKenzie, 1917: 535).

 

In 1915 the Notification of Births (Extension) Act made compulsory the provisions of the 1907 Notification of Births Act and its particular timing was used in an appeal for a Midwives (Scotland) Act:

 

‘In favour of taking immediate action, we would further urge the recent precedent by which the Notification of Births Act was by special legislation made applicable to the whole country in order to meet a national emergency arising out of the war conditions. This measure will fail of its full beneficial effect in Scotland unless it is supplemented by the Midwives Act for which we desire to plead (Memorial, 1915).’

 

The Notification of Births Act gave wide powers to local authorities (LA) in Scotland through the Local Government Board for Scotland (LGBS).

 

‘Any Local Authority within the meaning of the principal Act may make such arrangements as they think fit, and as may be sanctioned by the Local Government Board for Scotland, for attending to the health of expectant mothers and nursing mothers, and of children under five years of age… (MacKenzie,1917: 535).’

 

Although enabling rather than compulsory, the powers of Scottish LAs, thus extended, were put to even greater use with the passing of the Midwives (Scotland) Act in 1915 and in the same breath, with LA powers in place, any objection to a Midwives Act for Scotland was invalid.

 

Thus, in the long term in Scotland the increasing influence of the MOHs and the welfare legislation of the first decade of the twentieth century overcame the initial opposition of GPs and consultants.

 

Moving toward legislation for midwives in Scotland

 

The first Midwives (Scotland) Bills were put forward before the outbreak of World War I. There is evidence that opinion had shifted in Scotland to unanimous support and the Act might have passed sooner but for the outbreak of war. Nevertheless, the war put the Act’s passage beyond doubt when its provisions were portrayed as part of the war effort. The first reading of a Midwives (Scotland) Bill took place in the House of Commons on 23 April 1912, but it fell through. (Hansard, 1912, 942; Chalmers, 1914).

 

The next Bill was put forward in April 1914 (Dow, 1984: 152). In February 1914, representatives from the hospitals of the four cities prepared for a privately sponsored Bill promoting the legislation for midwifery in Scotland. The result was the presentation of an amended Midwives (Scotland) Bill to the House of Lords on 1 April, 1914. Lord Balfour of Burleigh who was ‘in charge’ of the 1902 Midwives Bill for England, emphasised the changes in attitudes in Scotland towards midwifery legislation and how in 1914, opinion in favour of a Bill was ‘practically unanimous’ (Hansard, Lords, 1914: 877).

 

This included opinions from the committee of the British Medical Association (BMA) for Scotland, the LGBS, the Medical Service Committee for the Highlands and Islands of Scotland, the MOHs of many large towns, the medical staff of the ‘four great centres of medical education – Edinburgh, Glasgow, Aberdeen and Dundee’ and nurses at an ‘important nursing conference in Glasgow’, held the previous month (Hansard, Lords, 1914: 879).

 

There is no mention of any opinion from midwives. However, because of the frequent use of the term ‘nurse’ for ‘midwife’ it is possible that some of these nurses were midwives. This Bill was held up for a long time. It might have become law that year but war broke out, which turned Parliamentary attention away from it, and it was ‘dropped in the House of Commons mainly for want of time at the end of a busy session’ (Dow, 1984: 152; Memorial, 1915). There were also Parliamentary rules about measures Parliament could address during wartime. There was a disagreement in the Commons over a Scottish Bill taking precedence over English measures, especially during wartime, with the argument that the Midwives (Scotland) Bill was not directly to do with the war. However other members saw it as an emergency measure and it also had the approval of the Minister of Munitions (Hansard, Commons, 1915a: 1167 and 1915 b: 814). The lord president of the council, defending the Bill’s passage during wartime, declared that the Bill was urgent and a war measure due to the mortality of war, the current awareness to preserve new life and the fact that war was instrumental in many doctors being called up for military service. Their absence created a void in maternity care that was rapidly being filled by midwives, many of whom were unqualified and uncertificated (Hansard, Lords, 1915: cols 569-70).

 

According to Sir John Halliday Croom (1917), the action of influential medical personnel was the origin of the 1915 Midwives (Scotland) Act. The Memorial anent a Midwives Bill for Scotland was sent with 30 influential signatures to the Secretary for Scotland and the lord president of the Privy Council on 19 August, 1915. The urgency of the need for a Midwives Bill for Scotland was made clear at its second reading in the Commons on 25 November, 1915, by Mr McKinnon Wood:

 

‘As the House is aware, the medical profession has been sadly depleted. A great many doctors have gone to the front, leaving rural districts inadequately provided with medical practitioners; so that competent midwives are absolutely necessary throughout Scotland ... The Scottish midwife is not able to obtain a formal qualification except in England.When she returns to Scotland she is not under the same control as the English midwife is. Altogether, I think, the case for treating this as a matter of urgency is virtually made out on very high authority indeed (Hansard, Commons, 1915b, 480-481).’

 

The Midwives (Scotland) Bill received royal assent on 23 December 1915 and came into operation on 1 January 1916.However, as Jenkinson (1993: 84) says, ‘the remarkably rapid enactment of the later Bill owed more to the overstretched resources of the Scottish medical profession, rather than to a feeling that the profession of midwifery was long overdue this measure of recognition for its position in the scheme of the nation’s health care.’

 

Provisions of the Midwives (Scotland) Act 1915

 

The Provisions of the Midwives (Scotland) Act are very similar to those of the Midwives Act 1902. As in England and Wales, a Central Midwives Board (CMB) was set up in Scotland as an examining and supervisory body and to establish a roll of midwives. Also, as in England and Wales, the Scottish CMB recognised three categories of midwife to begin with – those who were enrolled ‘by virtue of bona fide practice’ who were nicknamed the ‘bona fides’; the ‘certificated midwives’ who had obtained a certificate from one of a variety of institutions ... and were enrolled ‘by virtue of prior certification’; and those who had taken and passed the CMB examination (Loudon, 1992: 208).

 

Differences between the CMBs

 

To a certain extent, the CMB(S) benefited from observation of the working of the CMB(E&W) and the introduction of certain improvements within the Scottish Act not yet acquired by the other CMB.

 

An important difference between the two CMBs was that the CMB(E&W) comprised nine members. Having 12 members on the CMB(S) made room for the statutory inclusion of two midwives. The CMB(E&W) to begin with had no statutory midwife members, although midwives sat on the CMB(E&W) as representatives of other bodies (Donnison, 1988: 177; Dingwall et al, 1988, 158; Cowell and Wainwright, 1981: 36).

 

Other differences were financial. Scottish LAs had authorisation to contribute toward financial costs of training of midwives (although for many years midwives in Scotland had to pay for their training andhad no income), of midwives’ expenses, for example compensation for loss of income due to suspension, of payment and supply of official forms and stamped envelopes, and payment of a doctor’s fee when called out in an emergency by a midwife. This fee was recoverable from ‘the husband or guardian of the patient’ if possible (Midwives (Scotland) Act). These differences were eliminated with the implementation of the 1918 Midwives Act for England and Wales. This included the Treasury’s decision in 1919 to make a grant of £20 to each pupil midwife in England and Wales who guaranteed to practise on qualification (Towler and Bramall, 1986, 185-205).

 

The Scottish CMB also had the power from its outset to suspend midwives who broke the rules – the CMB(E&W) only had the power to take the more extreme step of striking from the roll midwives whose behaviour warranted this (Midwives (Scotland) Act; Cowell and Wainwright, 1981: 49).

 

Another difference between the two Acts was to do with reciprocity of midwifery practice. The Midwives (Scotland) Act contained a clause enabling certified midwives from, for instance England, to be certified in Scotland. This was not reciprocal to begin with, but was amended with the 1918 Act and further amended in 1950, which allowed midwives to practise freely within the UK without re-enrolling (Cowell and Wainwright, 1981: 50; National Board for Scotland for Nursing,Midwifery and Health Visiting (NBS), 1998: 13).

 

Also, early in 1918 the Midwives Act in Ireland was passed and made provision for the establishment of a Central Midwives Board in Ireland (CMBI), which continued until 1950 when An Bord Altranais was established in the Republic of Ireland to take over the functions of the CMB(I) and the General Nursing Council in Ireland. The CMB(S) noted the 1918 Midwives Act for Ireland and later that year commented favourably on the new reciprocity of midwifery practice between Scotland, Ireland, and England and Wales and resolved to try and keep the three Boards as closely associated as possible (CMB Minutes, Vol (2):45 and Vol (3):28). After the partition of Ireland in 1922, a new regulatory body was set up in Northern Ireland – the Northern Ireland Joint Nurses and Midwives Council. (Davies and Beach, 2000: 162, 9n).

 

Conclusion

 

Before 1915, midwifery in Scotland was ‘alegal’, indicating having no existing regulations or licensing requirements (Relyea, 1992: 139-69).

 

After the 1915 Midwives (Scotland) Act and its implementation on 1 January 1916, midwives enrolled with the CMB were no longer alegal.

 

They were legal practitioners, permitted to practise normal midwifery under the terms of the Act. Also, no one could legally imply that she was a midwife without being enrolled by the CMB.

 

Nevertheless, the terms of the Act dictated that the doctor-dominated CMB and LSAs would control and supervise midwives in Scotland.

 

Although there were two designated places for midwife members on the original Board, in contrast to none at all on the CMB(E&W), it was a long way from self-regulation.

 

Acknowledgements

 

This paper forms part of a chapter of my work for a PhD at the University of Glasgow. I acknowledge with thanks the help of my supervisors, Dr Marguerite Dupree and Professor Edith Hillan. Thanks also to Dr Margaret McGuire.

 

 Lindsay Reid is a research midwife at the University of Glasgow

 


 

References

Acts of Parliament, (1915) Midwives (Scotland) Act, 5 and 6 Geo. 5 Ch 91.

 

Central Midwives Board for Scotland. (1918) Minutes, 12 December 1918, Vols 2 and 3.

 

Chalmers AK. (1914) On the need for a Midwives Act in Scotland. The Journal Of Midwifery/The Nursing Times, February 21: 251-4.

 

Chalmers AK. (1930) The Health of Glasgow: 1818-1925. Corporation of Glasgow: Glasgow.

 

Cowell B,Wainwright D. (1981) Behind the blue door: the history of the Royal College of Midwives 1881-1981. Baillière Tindall: London.

 

Croom JH. (1917) The Midwives (Scotland) Act: its object and method. Read before the Maternity and Child Welfare Conference, March, Glasgow.

 

Davies C, Beach A. (2000) Interpreting professional self-regulation. Routledge: London and New York.

 

Dingwall R, Rafferty AM,Webster C. (1988) An introduction to the social history of nursing. Routledge: London.

 

Donnison J. (1988) Midwives and medical men. Historical Publications: New Barnet.

 

Dow AD. (1984) The Rottenrow: the history of the Glasgow Royal Maternity Hospital: 1834-1984. The Parthenon Press: Carnforth.

 

Ferguson T. (1958) Scottish Social Welfare: 1864- 1914. E and S Livingstone Ltd: Edinburgh and London.

 

House of Commons. (1902) Hansard 24 June: vol 109: cols 58-9: 6-24. Quoted in Jenkinson. Scottish Medical Societies: 83.

 

House of Commons. (1912) Hansard 15 April – 3 May: vol 37: col 942.

 

House of Lords. (1914) Hansard 1 April: vol 15: cols 877-9.

 

House of Commons. (1915a) Hansard 10 Nov: vol 25: col 1167.

 

House of Commons. (1915b) Hansard 1 Dec: vol 26: col 814.

 

House of Lords. (1915) Hansard 8 Dec: vol 20: col 569-70.

 

Jenkinson J. (1993) Scottish medical societies: 1731-1939. Edinburgh University Press: Edinburgh.

 

Loudon I. (1992) Death in childbirth. Clarendon Press: Oxford.

 

Loudon I. (1997) Midwives and the quality of maternal care: In: Marland H, Rafferty AM. Midwives, society and childbirth. Routledge: London: 180-200.

 

MacGregor A. (1967) Public health in Glasgow: 1905-1946. E and S Livingstone Ltd: Edinburgh and London.

 

MacKenzie WL. (1917) Report on the physical welfare of mothers and children. Vol 3. The Carnegie United Kingdom Trust: Dunfermline: m535-61.

 

Memorial anent a Midwives Bill for Scotland, 19 August, 1915. (ref: National Archives of Scotland, CMB 4/2/6).

 

NBS. (1998) Supervision of midwives in Scotland. NBS: Edinburgh.

 

Relyea J. (1992) The rebirth of midwifery in Canada: an historical perspective. Midwifery 8: 139-69.

 

Tait H. (1987) Maternity and child welfare: In: McLachlan G. (Ed.). Improving the common weal: aspects of Scottish Health Services: 1900- 1984. Edinburgh University Press: Edinburgh: 413-40.

 

Tew M. (1995) Safer childbirth? A critical history of maternity care. (2nd edition) Chapman and Hall: London.

 

Towler J, Bramall J. (1986) Midwives in history and society. Croom Helm: London. Transactions of the Edinburgh Obstetrical Society (EOS). (1895) Vol 20, Session 1894-95. Oliver and Boyd: Edinburgh: 167-82.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

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