Bulletin of the History of Medicine

Expertise and Control:

Childbearing in Three Twentieth-Century Working-Class Lancashire Communities

Lucinda Mccray Beier

Introduction

This paper is a preliminary effort to summarize one component of a larger project that concerns working-class health, illness, and health care in the Lancashire communities Barrow, Lancaster, and Preston during the first seventy years of the twentieth century. Focusing on dramatic changes in the management and culture of pregnancy and birth, I consider both the reasons for those changes and their implications for working-class health culture. During the period under consideration, birth moved from home to hospital, and the management of birth shifted from informal, working-class, female, neighborhood authorities to formally trained and licensed midwives, health visitors, nurses, and physicians. Childbearing women made the transition from mothers to patients: their pregnancies were increasingly monitored, their deliveries [End Page 379] orchestrated and managed through mounting levels of intervention and technology.¹

The redefinition of childbearing as a medical process parallels the medicalization of other experiences and behaviors during the same period. Emerging from the burgeoning cultural authority of biomedicine;² from the growing power and coverage of public health services;³ from the development and expansion of hospital-based facilities, technologies, and medical specialties; and from the growth of policy-driven payment systems providing coverage for "official" medical treatment, the medicalization of childbearing was inevitable and irresistible. In Great Britain, this process was spurred by widespread official concern in the early twentieth century about plummeting birth rates, high infant mortality rates, and—particularly in the interwar period—high maternal mortality rates.⁴

While it is indisputable that infant and maternal mortality rates dropped at the same time that the medicalization of pregnancy and birth gathered steam, it may be incorrect to assume a cause-and-effect relationship between these developments.⁵ The same factors that extended expectation of life at birth from 46 for men and 49 for women in 1901 to 68 for men and 74 for women in 1961—factors that included improved diet, [End Page 380] housing, and general prosperity, as well as the widespread use of aseptic surgical techniques, immunizations, and (by mid-century) the introduction of antibiotics—also arguably reduced infant and maternal mortality.⁶

Furthermore, focusing on whether or not medicalization "worked" ignores its social and cultural impacts. In the twentieth century, biomedicine became perhaps the most effective tool of state, professional, gender, and class power in the industrialized world. Less contested than capitalism, technology, or any religious doctrine, and linked to the newly dominant scientific worldview, biomedicine was seen and employed as an unalloyed good. It also became an important instrument wielded by upper- and middle-class agents of state and professional establishments for the social control and acculturation of the working class.⁷ Its language marginalized working-class "old wives" and the "tales" they told regarding the appropriate management of health, illness, and childbearing, rendering these traditions old-fashioned, silly, and dangerous; its association with science, technology, and progress created policies and institutions that enforced change in working-class health behavior and, ultimately, culture.

Feminist scholars have interpreted the medicalization of pregnancy and birth in gendered terms, as the hijacking of midwifery and the female ownership of reproduction from laywomen by medical men.⁸ While there is no denying that the theft occurred, this new orthodoxy obscures both female collusion in the process and its class dimensions and implications. Middle-class mothers and female health-care providers, government officials, and members of advocacy groups embraced medicalization and became its agents;⁹ they shared the culture and social [End Page 381] status of the developers and proponents of biomedicine and were early and enthusiastic converts. In contrast, the medicalization of childbearing was, to a large extent, imposed on a working-class population that had maintained traditional community management of reproduction well into the twentieth century.

Inevitably, this process had the greatest impact on women as bearers of babies, traditional authorities in matters of health, and (along with children) those who inhabited the very bottom of the food chain in a male-dominated society. The agents of medicalization viewed working-class mothers and informal female health authorities as ignorant and dangerous—largely responsible for infant and maternal morbidity and mortality. Those agents regarded the adoption of healthy habits and medical treatment as solutions to the problems they observed—rather than other possible alternatives, including the reduction of poverty, family size, and labor exploitation.

The history of childbirth in the twentieth century is often told as the history of maternity care—midwifery, obstetrics, infant welfare services, and hospital provision. In this paper I take an alternative approach, observing through the contrasting voices of public health professionals and working-class women and men the processes by which pregnancy and birth were medicalized, regulated, and institutionalized in three Lancashire communities. I conclude with a discussion of the consequences of those developments for working-class health culture in the study communities and, by implication, in Great Britain.

Sources

This paper is based on two primary sources that offer important perspectives on pregnancy and birth in Barrow, Lancaster, and Preston: annual reports submitted by their Medical Officers of Health (MOH), and oral history interviews conducted with 250 working-class residents by Elizabeth Roberts and myself between 1974 and 1989.¹⁰ These sources are particularly appropriate vehicles for this research: MOH reports illuminate [End Page 382] the extent to which national concerns and policies—together with the social class, gender, and personal opinions of individual MOHs—influenced local official health cultures and activities; while oral history evidence documents both traditional ways of dealing with pregnancy and birth, and working-class experience of official health services and interventions that proliferated during the twentieth century.¹¹

Oral history techniques are an exceptionally useful way to explore the experiences of "ordinary" working-class people and, as Paul Thompson suggests, have the potential to both fill gaps in and correct the information offered by written sources—to give a voice to the inarticulate.¹² Widely used by feminist scholars to explore experience too often absent from the historical record, according to Penny Summerfield, the strength of oral history methods rests "on the importance of language within social relations. We are dependent upon language for understanding who we are and what we are doing. The meanings within language are cultural constructions collectively generated, historical deposits within the way we think, which constitute the framework within which we act."¹³ There is no reason not to apply this insight to the use of oral history interviews with men as well as with women. Indeed, the everyday experience of working-class men is arguably as undocumented and invisible as that of working-class women. The cultural constructions drawn upon for [End Page 383] this paper had to do with both female and male informants' memories of family planning, pregnancy, and childbearing. As is true in all interview situations, they result from the combined efforts of interviewer and interviewee.

Interview recordings and transcripts are the only form of historical evidence deliberately created by the historian. While the scholar's charge is always to select and interpret evidence responsibly, the oral historian bears an additional responsibility: she or he devises the questions and initiates the conversation. Elizabeth Roberts and I composed a lengthy interview instrument; used not as a straitjacket but as a guide for our semistructured interviews, it was thirteen pages long, covering multiple aspects of personal, family, and community life, including experience with ill health, childbearing, and medical care. Our intent was to elicit the type of life stories that Alessandro Portelli describes as full coherent narratives that do not exist in nature, but are created through the interview situation.¹⁴ Our interviews lasted an average of six hours and took place during an average of three visits to the informant's home. Each interview was transcribed; each transcript was subject indexed.

The informants' years of birth range from 1872 to 1958, with the preponderance of interviewees having been born between 1890 and 1940. All identified themselves as working-class, or of working-class origin.¹⁵ One hundred thirty-one informants were women; 119 were men (see Table 1). They were recruited mainly through personal networks and local organizations and services. The final group can be regarded as a snowball sample—not randomly selected, but (equally) not handpicked. Expanded discussion of the interviewees' backgrounds can be found in Elizabeth Roberts's books, A Woman's Place: An Oral History of Working-Class Women 1890-1940 (1984) and Women and Families: An Oral History, 1940-1970 (1995).

How did we interpret the huge volume of information we collected? Within any interview situation there are both power dynamics and the desire of the informant to present him- or herself in the best possible light.¹⁶ To some degree, multiple interviews enhanced the quality of the information provided: as trust and a certain intimacy developed between [End Page 384] interviewer and informant, accounts became fuller and less constrained by the desire to retain respectability. While it is never possible to determine either the fullness of recall after many years, or the extent to which memories have been altered by intervening experience, it is possible to compare many accounts of the same type of experience and intuit representative or contrasting stories. These stories, then, are used in this paper along with other evidence "as textual verifications of a historical interpretation."¹⁷

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Table 1 Oral history informants by sex and decade of birth

Why Barrow, Lancaster, and Preston? First of all, these communities were all located within the boundaries of the old county of Lancashire, which was selected by Michael Anderson for his authoritative study Family Structure in Nineteenth-Century Lancashire because it "typified or led industrializing Britain" in terms of the proportion of its population employed in manufacturing industry.¹⁸ Where better to study working-class culture? However, because of their differences, these communities also provided an opportunity to explore variations in circumstances affecting working-class individuals, families, and mores. Preston, the largest, poorest, least healthy, and most Roman Catholic of the communities, also had the highest proportion of women who worked (mainly in cotton mills) after marriage. Barrow, the newest, wealthiest, and most geographically remote, was a "company town" whose fortunes depended on its dominant employer, the heavy engineering and ship-builder Vickers-Armstrong. Lancaster, with a mixed economy that resisted the impact of the interwar depression more effectively than the economies of the other study communities, offered yet another alternative for exploring working-class experience and attitudes.¹⁹ [End Page 385]

Pregnancy, Family Planning, and Antenatal Care

In the late nineteenth and early twentieth centuries, working-class families were large and women were frequently pregnant. Nine or ten children were born to 13.5% of marriages celebrated during the 1870s in Britain, while only 12.5% of that decade's marriages produced as few as one or two children. Although this situation had changed dramatically by 1900-1909, when 4% of marriages produced nine or ten children and 45-50% produced one or two children, experts agree that working-class families remained larger than middle- or upper-class families until after World War I.²⁰ The experience of the oral history informants who contributed to this study reflects this situation: Thirty-three respondents born before 1920 came from families with ten children or more; one of these, Mrs. Dalkey, born in 1896, was one of twenty-one children born to a single mother.²¹ By contrast, only three informants born after 1920 came from families of ten or more children, and none of the 250 people we interviewed had families of their own with more than six children.

Generally speaking, informants remembered a high degree of fatalism about family size before World War I. Mr. Townley, born in 1897, whose mother gave birth to seventeen babies (thirteen of whom survived), said: "Well, they never bothered. They [babies] just came along. People had more then. Next door, they had about six or seven and further up there would be another six or seven. Same as North Road [Preston], they would have so much and then another half a dozen. They were very big families in my younger days."²² Other respondents remembered frequent births and infant deaths less philosophically. Mrs. [End Page 386] Wilkinson, born in 1881, whose mother had twelve babies, four of whom died, said: "None of them lived to more than three months. . . . They come so quickly, one after the other, they cannot have a lot of stamina."²³

Did couples in this period attempt to limit family size? Oral history informants referred to abstinence, viewed as the "good" husband's responsibility, as one available form of contraception. Mrs. Dent, born in 1908, who was an only child, said: "My dad wasn't a lustful man. He could have had more [children] if he wanted."²⁴ Her comments reflect both the traditional perspective that a married man's frequent demands for sex were irresponsible, and the inference that her family's small size was attributable to her father's self-restraint. Mrs. Smith, born in 1895, whose parents had ten children, indicates both a similar point of view regarding male responsibility for sex, and an understanding of the consequences of unrestrained lust for the wife, who typically took charge of family finances: "You cannot understand people having so many children when there was so little money to keep them. Yet my father was the easiest going man, he didn't worry whether m'mother could pay her way or not. He was too easy going."²⁵ Mrs. Wentworth, born in 1910, remembered a neighbor whose stonemason husband insisted on sex when he had had too much to drink. This woman would sit on the window ledge and wait for her husband to fall asleep rather than risk a pregnancy: "The young ones today say, 'Serve you right you had a big family,' but they hadn't a clue what went on."²⁶

The main form of birth control practiced by women in this period was abortion, either self-induced or performed by another woman. In contrast to the interwar and post-World War II eras, when abortion was increasingly reported as a last resort to protect an unmarried pregnant girl from shame, in the years before World War I abortion tended to be used by married women with large families and small means.²⁷ The likelihood is that abortion was viewed as being more focused and less immoral than contraceptive methods, which might be regarded as a way [End Page 387] to indulge in sexual pleasure without fulfilling its primary purpose—reproduction. Mrs. Havelock, born in 1903—whose mother had ten babies, suffered routine spousal abuse, and died at age forty-four—remembered buying quinine from the chemist for her mother when she was "worried about her periods."²⁸ Mrs. Maxwell, born in 1898, knew people who used slippery elm or needles to dilate the cervix or took washing soda, quinine, and other abortifacients. She said about these practices, "I agree with them planning their families."²⁹ Mrs. Dorrington, born in 1905, who had six children, reported trying to limit her family's size: "[I] tried to stop one or two, I took my salts." Reflecting both collective memory and the desire to justify her own behavior, she said everyone tried; no one used contraception: "The doctor wouldn't help you."³⁰ It is noteworthy that the older informants had more to say about abortion than the younger ones, despite rising official concern about abortion during the interwar period.³¹

During the same period, contraception became both increasingly respectable and medicalized. Thus, it is not surprising that younger oral history informants reported having prevented pregnancy in a variety of ways. Before the 1950s, the most common method was coitus interruptus—a technique that was also usual in other parts of the country.³² After this time, informants employed a range of methods, invariably obtained through official health-care providers, including the cap (diaphragm), sheath (condom), coil (Intra Uterine Device), Pill, and surgical sterilization.³³

In the early years of the twentieth century, like their counterparts elsewhere in Britain and Europe, public health officials in Barrow, Lancaster, and Preston began to view declining birth rates with alarm. In 1883, Barrow's birth rate had been 42.1 births per 1,000 population— [End Page 388] compared to 31.7 in 1900, and 23.7 in 1910. Preston's birth rate declined from 42.35 per 1,000 in 1878 to 28.67 in 1900, and 23.58 in 1910. Comparable rates are unavailable for Lancaster; however, at 20.63 per 1,000 in 1910, its birth rate was the lowest of the three study communities. Preston's Medical Officer of Health, H. O. Pilkington, who served from 1872 until his death in 1920, was particularly concerned about the implications of this decline for national strength and local vitality. He blamed female employment (much higher than the national average of 10%, at 54.3% of females over age ten in 1911), abortion, contraception, and general selfishness—among the prosperous before 1912, and among all classes after 1912.³⁴ Pilkington wrote:

There would seem to be a growing desire in the case of some parents—from economical or other motives—to keep their families within certain limits. In doing this they receive instruction from books, pamphlets, and lectures, generally of American origin, and assistance from unprincipled charlatans, and from the black sheep that may occasionally be met with in the Medical Profession. But such proceedings, like all violations of Nature's laws, recoil upon those practicing them, and often result in sickness and disease, sometimes in death.³⁵

While also concerned about sustained high infant mortality rates, local Medical Officers of Health did not mention birth control as a way of improving both maternal health and the prospects for infant survival and vitality before the interwar period.³⁶ Indeed, Barrow was apparently the first of the three communities, beginning in 1938, to offer family planning services.³⁷ Preston's Medical Officers of Health were hostile or neutral to birth control until the 1960s, although the community's Family Planning Association began offering services in 1950. While Lancaster's MOH recognized as early as 1907 the likelihood that abortion accounted for the large number of premature births, nowhere in the available annual reports for that community are birth control services mentioned. [End Page 389]

To combat, first, the high infant mortality rates and, after 1920, high maternal mortality rates, public health agencies advocated the notification of births (legally mandated after 1908), home visiting, antenatal care, the employment of licensed midwives or physicians for deliveries, and, finally, hospital birth.³⁸ Health visiting, initiated in Manchester as a voluntary activity in the 1860s and as paid work in the 1890s, involved predominantly middle-class women in visiting working-class homes to inspect conditions and provide advice.³⁹ The idea had immediate appeal. In 1908 Barrow's MOH, John Settle, began recommending the employment of a female "Health Officer"; Lancaster's 1910 Report of the Medical Officer of Health indicated that the "Lady Health Visitor" had visited 2,259 infants; and Preston hired two "Female Health Visitors" in 1902 "to visit houses situated in the poorer parts of the town, to give instruction in household management, and in the care and feeding of young children, and in short to bring about a better sanitary condition, both of the house and its occupants."⁴⁰ Thereafter, health visiting remained an important component of public health surveillance and service provision in the three study communities throughout the period under consideration.

In 1901, Preston's MOH recognized some of the challenges inherent in health visiting:

Their [health visitors'] services would be especially useful in giving instruction as to the management of children, particularly during time of illness, and in abolishing those insanitary living conditions which are so frequently the result of ignorance and want of care. But the value of such instruction depends entirely upon the spirit in which it is received, and in the hope that its reception may be beneficial it must be given with tact, in a kindly manner, and with consideration for those shortcomings which too often have become habitual. Anything like ill-judged or unnecessary interference with domestic matters would be unwelcome in the home of a Lancashire operative; whereas a little judicious help, given during the trying time of sickness, would be gratefully acknowledged and received.⁴¹ [End Page 390]

In early years, health visitors called on families only after a birth. By the interwar period, as the antenatal-care movement got under way, health visitors also visited expectant mothers.

It is apparent that health officials held mothers responsible for infant mortality. In Preston, where the mortality rates remained comparatively high throughout the period under consideration, this attribution was clearest and most persistent. In 1896, Dr. Pilkington wrote: "There are few people with less knowledge or experience of household duties than the ordinary factory girl, and as a consequence she becomes a wife and mother knowing little of the duties required of her, and content, as regards the management of her children, to follow the example of her parents and the customs of those amongst whom she lives."⁴² He blamed infant deaths on female employment, early marriage, failure to breast-feed, unsanitary preparation of feeding bottles, infants sharing parents' beds, female drunkenness, consultation of elderly local women "whose nursing and feeding arrangements date back to the dark ages, but whose experience of sickness amongst children—undoubtedly and unfortunately a large one—enable [them] to pose as an authority on these subjects in the neighborhood," and insurance, "by which the death of a child brings a monetary gain to the parents."⁴³ While the language was modified and greater awareness was voiced about the poverty and poor living conditions challenging working-class mothers, the general tenor of these comments is echoed in MOH reports throughout the study period, which also indicated mounting eagerness that mothers attend antenatal and infant-welfare clinics and seek medical advice and treatment. In 1969, Preston's Medical Officer of Health wrote:

There would seem to be too ready an acceptance that babies are expected to die. There still remains, to a slight extent, the echo from the past when a mother was asked how many children she had, the reply would be, "ten, and I buried four." Insufficient public concern is manifested at this loss of infant life. It is clear that babies' lives can be saved if parents, or those responsible for the care of young babies, recognized the early signs of disease and took their children promptly to their doctors, or asked their doctors to visit early. It is sad to see children lose their lives because a doctor has not been called in time, or in some cases, not called at all.⁴⁴

The message was clear. If working-class mothers could only be persuaded to act like middle-class mothers, their babies would not die. [End Page 391] Barrow's Medical Officer of Health concluded in 1913 that the only way of dealing with high levels of premature birth was "to make an endeavor to get at the prospective mothers and instruct them in the antenatal care of infants, and education as to infant feeding."⁴⁵ In 1922, when Barrow's infant mortality rates dropped, the MOH concluded: "This fall in the infant mortality rate is more than a coincidence, and is, in my opinion, attributable to the supervision, treatment and educational work done by the Medical Officer in charge of the work . . . and her staff of Health Visitors. It should be noted that very simple skilled advice given to a young mother will, in many cases, save the life of a baby."⁴⁶ Lancaster's MOH went further in 1913, writing: "To reduce the number of deaths from this cause, increasing attention must be paid to the health of the expectant mother who should have medical supervision during the period of pregnancy."⁴⁷ Each of the study communities opened infant-welfare clinics before World War I and added antenatal clinics after 1919.

The oral history evidence indicates that, while the oldest informants had no experience of health visitors or clinics, people born after the turn of the twentieth century were aware of these services. Many remembered hostility to health visitors and clinics, either due to their association with the hated Poor Law, or because health visitors were seen as either intrusive or useless.⁴⁸ Mr. Boyle, born in 1927, said his mother would not have attended a child-health clinic because "it was all linked somehow with welfare. It wasn't quite the same thing as the workhouse but the same sort of tradition of public help for individuals, it used to be avoided if you tended to keep your self respect and all the rest of it. . . . She would rather have been seen dead, I think."⁴⁹ Mrs. Dent, born in 1908, obviously aware of the inspection responsibilities assigned to these public health workers, remembered the health visitor finding her home "spotlessly clean. She couldn't find any complaints."⁵⁰

The oral evidence also indicates gradual working-class acceptance of clinics and health visitors. Many informants remember obtaining free or cheap food and supplies from clinics—a much more popular service than the advice that was also offered.⁵¹ Some also regarded clinic attendance as [End Page 392] "a social afternoon out."⁵² Mrs. Jenkins, born in 1932, recognized the generational shift in acceptance of official health advice that was occurring in the years after World War II. She took advice from health visitors herself, but reported that her mother-in-law, who was also raising a baby at the time, "wouldn't allow her [the health visitor] in the house. Said she was an interfering busybody or similar. But young people . . . I mean, I went regular to the clinic, my mother-in-law didn't, so you know."⁵³ Mrs. Jenkins's comments reflect both a traditional working-class method of resisting official authority—denying access to the home—and the mid-century transition to acceptance of both biomedical information about disease prevention and intervention of the agents of institutional health care in family management.

It is clear that some informants came to rely on advice from health visitors and clinic personnel; it is also clear that this reliance reduced both mothers' recourse to informal, working-class, female health authorities and their confidence about dealing with their own babies. For example, Mrs. Hunter, born in 1931, recalled taking her baby to the clinic: "It used to upset me because he never seemed to be gaining as much as they said he ought to be gaining. I fed him myself and of course breastfed babies don't gain like the bottle ones, and it was just across the road really, and I used to get quite upset. . . . They tried to persuade me to put him on a bottle, which I don't think they would do now, would they?"⁵⁴

Pressure for public health authorities to provide, and pregnant women to use, antenatal services was linked to the development of biomedical laboratory and diagnostic techniques. It is noteworthy that accurate laboratory diagnosis of pregnancy became available only in the 1920s. Routine testing of urine for the albumin that, with other symptoms, indicated possible toxemia of pregnancy, began during the same decade.⁵⁵ Public health officials expected antenatal care to detect obstetrical abnormalities, enable referral of at-risk mothers to physicians or hospitals, and reduce the number of premature births. Attendance at clinic facilities, interviews with officially garbed health-care providers, examination, and testing became routes to the medicalization of pregnancy and birth for both caregivers and what could now be described as patients (i.e., pregnant women). [End Page 393]

Preston's Health Authority opened its first antenatal clinic in 1919. By the early 1930s, the city's clinics were routinely seeing between 346 and 482 new patients each year—less than one-third of expectant mothers.⁵⁶ The clinics offered pregnancy tests and checked blood pressure, weight, urine, and presentation of the fetus. The MOH commented in 1934: "Most women appreciate the value of regular supervision, and seriously regard the advice given. Our difficulty is to reach the diffident, the unintelligent, the careless and the overburdened. To include them within the ambit of the organization is our constant care."⁵⁷ The main abnormality detected at the antenatal clinics in that year was tooth decay (109); other problems included albuminuria (44), anemia (34), varicose veins (33), constipation (18), contracted pelvis (16), breech presentation (16), heart disease (13), high blood pressure (6), and transverse presentation (98). Official provision of antenatal care changed dramatically with the introduction of the National Health Service in 1948: after this time, women could receive care at no charge from their general practitioners (GPs). In addition, with growing numbers of obstetrical consultants, after the mid-1950s pregnant women were increasingly seen by specialists as part of their routine antenatal care.⁵⁸

Few informants born before 1920 said that either their mothers or they themselves (or their wives) had had professional antenatal care. The traditional pattern was for a woman to plan for her confinement by "booking" the midwife. The mother remained firmly in charge of the process. According to Mr. Priestly, born in 1909: "They used to do the time [i.e., experience their pregnancy] and then, when everything was right and they had an idea of how long, they would go and book the midwife. And then the midwife when the time was coming would come round on a bicycle . . . and do what she had to do, you see. Examine them and say, oh well, when you're ready, give me a call."⁵⁹ A few respondents [End Page 394] remembered receiving traditional advice about caring for themselves in pregnancy to ensure an easier delivery. Mrs. Sykes, born in 1927, was advised by her aunty to drink raspberry leaf tea: "Your inside will be like jelly and you will have no trouble."⁶⁰ Mrs. Wallington, born in 1923, remembered: "My mum told me to take liquid paraffin and I took liquid paraffin every day, twice a day. And of course when the baby was born I didn't . . . have any pains or anything."⁶¹ Only informants who were ill during their pregnancies sought medical help.⁶²

Part of the challenge faced by authorities trying to get women to obtain regular antenatal care was traditional working-class modesty and shame regarding pregnancy, because of its association with sexual activity.⁶³ Mrs. Carter, born in 1919, spoke for many. She had no regular antenatal care, although she was examined twice in nine months: "I never went out when I were pregnant, not till it was over with. I used to feel ashamed, because I knew they would think what I'd been doing and I used to think it was terrible."⁶⁴ Preston's public health authorities ran into this problem in 1931, when they opened a new neighborhood antenatal clinic: "Working-class mothers will not attend an antenatal center near their own homes owing, in the earlier months, to a desire to keep the knowledge of their pregnancies a secret from their neighbors. A considerable proportion have objected to attending a clinic where schoolchildren are also present. Those mothers who were told that Cuttle Street was their center simply did not attend at all."⁶⁵ Despite this desire to hide it, for working-class mothers in the late nineteenth and early twentieth centuries pregnancy was both "normal," in the sense that it was considered both natural and expected, and "special," in that the condition was attended by risks not encountered by people who were not pregnant. Although pregnancy was not considered to be an illness, expectant mothers identified dangers associated with the condition, including overwork, special vulnerability to injury, and having babies too close together. However, birth and the lying-in period were thought to be [End Page 395] a much more perilous time, when the life and future health of the mother hung in the balance. Thus, the traditional working-class management of childbearing focused on confinement.

Most informants born after 1920 reported that their mothers did not have professional antenatal care, but that they or their wives had received regular care during pregnancy from a physician, midwife, clinic, or hospital.⁶⁶ The experience of Mrs. Jenkins (born in 1932) was typical:

You came and spent nearly the whole day at Risedale Maternity Home Hospital, and when I say the whole day, you were there from about 9 in the morning, I think everybody got the same appointment, from about 9 in the morning 'til say about dinner-time or 2 o'clock sometimes, and they did check everything, blood, blood pressure, weight, if there was any problems at all . . . they immediately took you into the Annexe [inpatient facility].⁶⁷

Respondents whose children were born after about 1955 remembered attending childbirth preparation classes provided through the National Health Service.⁶⁸

The medicalization of antenatal care led to increased medical management of and intervention in deliveries. For example, Mrs. Lewthwaite, born in 1920, was hospitalized for fourteen weeks before the birth of her only child: "It was high blood pressure I was troubled with, and I went in at the Whitsuntide, which was the end of May. . . . And he was born on the last day of August, and then I had to do a fortnight after that, so it was the 14th of September when I came out."⁶⁹ A consultant, nurse, and "lady doctor" were present for the birth, during which Mrs. Lewthwaite was given "gas and air" and a general anesthetic: "I was very small . . . and that was the trouble. So, of course, afterwards I had clips in, I was torn slightly, and I had clips in for awhile."⁷⁰

Confinement: Personnel, Place, and Control

Before 1920, virtually all births in Barrow, Lancaster, and Preston took place at home. The birth environment, the people present, and the management of delivery were largely controlled by the mother, her [End Page 396] female relatives, informal health authorities (the "lady" of the neighborhood, who provided health advice, laid out the dead, and often served as midwife), and tradition. The majority of working-class babies were delivered by working-class midwives (called "handywomen" by public health authorities), many of whom had no formal training or qualifications. All but the poorest mothers stayed in bed for two weeks after delivery; female relatives and neighbors, participating in the mutual aid networks that also supported a wider range of needs, took on their housework and childcare responsibilities.⁷¹ Mr. Clarke, born in 1900, who was one of four children, described a situation that would have been familiar to all informants born before 1920, and many in younger age groups: "When my mother had all her babies at home, the neighbors helped and you didn't have to pay anybody. . . . Everybody helped, they came in and did your washing and looked after the rest of your children."⁷² Mrs. Washburn, born in 1899, whose mother had nine births, said: "The neighbors did a lot for each other because there was no district nurse. There was no National Health and so the doctors were very rarely called upon because they made charges. Often people would come and borrow things for a birth. With sickness, they would often come for advice rather than go to the doctor."⁷³

The lying-in period was considered crucial throughout the period under consideration by both traditional authorities and official health-care providers, although it became less common after World War II for women to be confined to bed, fed a special diet, or told to wear a belly binder. Women and their birth attendants believed that rising too soon after delivery was terribly risky. Mrs. Drake, born in 1899, remembered that midwives made mothers stay in bed for at least ten days: "They wouldn't let you get up because they said that your bones, the back bone where the child is, they have to knit together."⁷⁴ Mrs. Martin, born in 1914, remembered that she was "in [hospital for] a fortnight for Geoffrey, during which you never put your feet to the floor for ten days, and the old wives' saying was that if you put your feet to the floor you drop down dead."⁷⁵ Mrs. Critchley, born in 1926, said of her mother's confinements: [End Page 397] "They used to keep them in bed a long time as well and they used to bind them up, you know, afterwards, very tight to get the stomach flat."⁷⁶ Mrs. Fleming, born in 1921, stayed in bed for ten days after each of her six home deliveries. Her mother would not let her eat anything for three days after a birth, because "you couldn't stand a substantial meal."⁷⁷

There was a marked difference among the three study communities in the extent to which physicians delivered babies. In Preston, midwives delivered the great majority of births, whether at home or in hospital, throughout the study period. In Barrow after World War II, most deliveries were done by midwives, although a growing proportion of home deliveries were also "booked" with GPs. In Lancaster, physicians delivered 45% of total births in 1916—a proportion that declined to 25% in 1938, the last year for which figures are available. During the same period, the proportion of babies delivered by trained midwives rose from 42% to 72%. Although GPs' midwifery training improved during the study period, and their role in antenatal care was institutionalized after the establishment of the National Health Service, the proliferation of obstetricians, the employment by hospitals of trained midwives, and the increased hospitalization of birth increasingly pushed them out of the delivery room.⁷⁸

Almost all of the older oral history informants' mothers were attended by unqualified midwives. Mrs. Addison, born in 1892, whose mother had nine births, remembered "an ordinary woman with a white apron on. They didn't call them nurses, you called them 'missus.'"⁷⁹ Mr. Thomas, born in 1903, whose mother had had seven births, remembered: "Midwives are people that are special . . . always scrubbed clean. They were always heavy-looking women, never slim . . . and they always had a white apron on."⁸⁰ Mrs. Hampton's mother's six babies were delivered by "Mrs. Dixon . . . Number 4 Rawlinson Street, and if there was anybody in an interesting condition in the street she was always the woman to go and deliver"; she was not qualified, "only that she'd had ten of her own."⁸¹ Mrs. Garvey, born in 1888, was delivered by a midwife who "wasn't fully qualified. . . . The doctors told her what to do and what not to do, but she couldn't read a thermometer, but she brought babies into the world. There are hundreds of women in Barrow who've had to go under the [End Page 398] gynecologist through her."⁸² Mrs. Parke, born in 1898, said: "The doctor would come if he was called, but midwives used to like to deliver on their own if they could. They weren't specialized people, only women that had a bent that way."⁸³ In difficult cases, midwives would send for a doctor. Mrs. Musgrove's mother had ten babies, five of whom survived. She said:

When I was being born it was very difficult in 1886 and the midwife sent my father looking for a doctor and he found one. He had a look at mother and he sent for another doctor and then he sent him for another one. . . . When they were all there, they turned to my father and said, should they save the child or the mother. . . . My father naturally said that he'd have his wife.⁸⁴

The 1902 Midwives Act required local authorities annually to register midwives in their districts. Untrained ("bona-fide") midwives who had been practicing for at least one year previous to 1902 could be registered after the Medical Officer of Health's approval of their applications; only those new midwives who had certificates from either the Central Midwives Board in London or a recognized training institution could be added to the register after that date. Henceforth, local health authorities were responsible for the inspection of midwives and for reporting those found to have been negligent or to have caused harm. In 1905, Preston's MOH reported that fifty-three midwives were on the register, five with certificates from recognized institutions:

All [fifty-three of] these [midwives] have attended before me at the Health Office and have produced for inspection their Registers, Case Books, instruments, and other necessary appliances. Such an inspection, however, admits of preparation, and in future I propose to carry it out more in the line of a surprise visit. These midwives vary very much in character, experience, and education; some being absolutely illiterate, whilst other perhaps with less actual experience, have had more education, and some scientific training.⁸⁵

Barrow's MOH wrote in 1910: "A better administration in midwifery means the clearing out of the Sariah [sic] Gamp midwife—less meddlesome midwifery and cleaner domestic habits and sanitation all round. The old midwife is dying out gradually."⁸⁶ [End Page 399]

Despite the MOHs' disdain, unqualified midwives continued to practice, and until the 1930s many working-class women kept on consulting them in preference to physicians or the increasing number of trained midwives.⁸⁷ One factor may have been cost. Mrs. Harte, born in 1889, whose mother had eleven births, said: "Martha used to come, the midwife. . . . She wasn't certified or anything, but she was one of the good old midwives and it was only a few shillings for a confinement. I've heard m'mother say that she used to give her sixpence a week until she got it paid off. She was a grand old lass. In George Street that was."⁸⁸ Mr. Grove, born in 1903, remembered booking the doctor for one of his wife's home deliveries. The doctor charged 4 guineas; Mrs. Grove wept over the bill when it arrived on Christmas Eve.⁸⁹

Another possible factor in working-class loyalty to "bona-fide" midwives, according to Elizabeth Roberts, was that they "were generally thought to be friendlier, and less 'starchy'; and they were certainly less likely to tell the woman what to do, being more likely to cooperate both with her and her female relatives. It is an example of working-class women rejecting the invasion of their homes and lives by the professional."⁹⁰ Medical Officers of Health were aware of this attitude. Preston's MOH commented in 1918:

It might be expected that the work will gradually pass into the hands of the fully trained midwife, but there still remains an astonishing predilection for the members of the old school, many of whom possess only the merest rudiments of general education. This due to their "motherly" character and to the fact that they are bound by long acquaintance, and in some cases by relationship, with the members of their clientele.⁹¹

With the advent of National Health Insurance in 1911, insured women and the wives of insured workers obtained coverage for the services of qualified midwives. In some families, this served as an incentive to employ them. According to Mr. Grove, born in 1903:

Previous to 1911, the midwife was anybody that could do it. Some charged 5s. or something like that. Then it come 1911 and there was a grant of 30s. for every child that were born. Then they compelled them to have a registered nurse. Now, her fee was 30s., so the patient was not better off. But you got better treatment because you had a fully trained nurse instead of an amateur.⁹² [End Page 400]

Nonetheless, many families in the study communities continued to use unqualified "handywomen." Nationwide, in 1920, 80% of practicing midwives were trained, while the figures for Lancaster and Preston were 46% and 47%, respectively.⁹³ In that year, one Lancaster handywoman delivered 137 of the 963 babies born in the community; there were then fifteen midwives on the register.⁹⁴ Regardless of increasing legal pressure, handywomen practiced until the 1936 Midwives Act put them out of business. Lancaster's MOH reported in 1926: "Our enquiries show that a number of women were attended during confinement by handywomen who are debarred by the Act of 1926 from attending 'except under the direction and personal supervision' of a doctor. Unless they can satisfy the Court that such 'attention was given in a case of sudden or urgent necessity they shall be liable on summary conviction to a fine not exceeding ten pounds.'"⁹⁵

The 1936 Midwives Act required that all practicing midwives be formally qualified. By 1937, twenty-four months of training were needed for certification. At the same time, municipal domiciliary midwifery services, run by local health authorities, were established. This employment was attractive to midwives because it provided compensation and equipment and regulated their time commitment. The 1937 MOH Report for Preston described the new service:

The Municipal Midwives took up their appointments on September 1st, 1937. Outdoor and indoor uniform, midwifery bags and equipment were provided. Telephones were installed in the midwives' homes and suitable arrangements for traveling and laundry expenses, relief, off duty times and holidays were made. The bookings of each midwife were restricted to seven cases per month, apart from one midwife acting as tutor to pupil midwives, who was allowed ten cases per month. The fee payable to the Corporation for the services of a municipal midwife is 35/- for a first birth and 30/- for subsequent births. A woman has freedom of choice of midwife as far as is practicable with the limiting of number of cases to seven per month. Where a patient cannot afford to pay the fee, application for assistance may be made to the Council as heretofore.⁹⁶

By the end of World War II, most midwives in the study communities were employed either by hospitals or as municipal midwives; the establishment of the National Health Service eliminated fees. Few midwives [End Page 401] continued in private practice, and those who remained on the register handled declining numbers of births. For example, in Barrow in 1951, 444 births (98% of domiciliary cases) were attended by Municipal Midwives, and 9 by private midwives; of the five private midwives on the register, only three delivered babies in that year.⁹⁷ Midwifery was standardized, medicalized, and increasingly institutionalized; midwives had made the transition from traditional community-based participants in a normal healthy event to agents of official state-sponsored medicine, managing a pathological process.⁹⁸

It is clear that, despite the repeated experience of infant death, many early twentieth-century working-class women were happy with and loyal to the traditional midwives who delivered them. Their perspectives on home confinements were more mixed. Many working-class homes provided inadequate facilities for confinement. Mr. Burrell, born in 1897, remembered: "In a very small house, where a baby had been born . . . they only had two bedrooms and if they had what they called a bigger family house, it would have two bedrooms and a box room making three bedrooms. Now you see the baby was born in the house, there was no electric light, there was only a little gas light and in some cases not even gas in the house."⁹⁹ A home birth could require a major upheaval in household arrangements. Mr. Thomas, born in 1903, said of his mother's last confinement in 1915: "The bed came downstairs, the front room had to be fitted up and everything else."¹⁰⁰ Home confinements also required imaginative improvisation in cases when the birth did not go as expected. In 1932, Mrs. Turnbull's widowed twenty-two-year-old mother gave birth in her own mother's front room:

But like I said, my mother didn't know she was having twins until we were born. . . . No, didn't know. Got the shock of her life, my granny: I couldn't tell you what she said. No, shock of her life, you know, being left with two of us, just little things. They couldn't put real clothes on us, so they had to wrap us up in olive oil and cotton wool, they put us in a jug, you know, to keep us warm at the fireside.¹⁰¹

Due to the lack of appropriate facilities in their own dwellings, some women gave birth at a relative's home. Mrs. Becker, born in 1900, [End Page 402] remembered her sister-in-law, Lily, giving birth at her mother's house in 1919:

I walked home with her [Lily's] friend part way to where this friend lived and she said, "How was your Lily?" And I said, I didn't see her at dinner time, she was in the toilet all the time; my mother had made her go and sit in there because she was in pain, you see, and she was in labor. My mother was very hard, my step-mother, she had had 13, my step-mother, made her stay in there while we had had our dinner and got back to work.¹⁰²

Mr. Emery, born in 1895, said that his wife was delivered at home by a doctor and an unqualified midwife: "We were downstairs and I had this here wireless [radio] going and I could hear screaming upstairs and I put this wireless on as loud as I could so as her [wife's younger] sister couldn't hear it. . . . It was on a Sunday night was that. I always remember going upstairs after and the bed was here and when I looked at the wall there was blood all over it. I had to get it all decorated again."¹⁰³ Many respondents remembered as children being sent out of the house and waiting outdoors or at a neighbor's house while their mother gave birth.

Of course, throughout the study period many informants chose to give birth at home. Mr. Norton, born 1931, said his wife had the option to have her four babies in hospital, but decided to have them at home, explaining:

I don't know, possibly the freedom of access for visitors and that sort of thing. She felt more comfortable, I think, I don't think any of our generation, I think even now, don't enjoy hospitals. Because, I think, of the regimentation and . . . restriction and that sort of thing. I suppose it's part of our inbuilt way of life, that we don't like regimentation, we just don't like it. And the children have been born at home, well since dot, so why on earth change it? Thank goodness, we were very lucky, there were no complications. We were advised before the birth that there were no complications. She did visit the doctor. She did have visits from the midwife prior to the birth and we were told that everything was going to be natural, sort of thing. As indeed it was.¹⁰⁴

With declining infant mortality rates, in the years immediately following World War I, public attention shifted to maternal mortality, which actually increased in the 1920s and early 1930s. According to Jane Lewis:

Research into the clinical causes of maternal deaths led to a call for the medicalization of childbirth. Obstetricians and departmental committees advocated, first, techniques for the management of labor developed for use in [End Page 403] hospitals rather than in the home . . . and, second, for more scientific care by better trained doctors, midwives and medical officers working in local authority clinics. The first of these recommendations encouraged the hospitalization of childbirth, which resulted in a rise in the status of midwifery and this in turn reinforced medicalization.¹⁰⁵

Health authorities in each of the study communities articulated local need for hospital accommodation for confinement in terms of medical and social factors; after 1929, they took responsibility for administering and reporting on municipal hospitals.¹⁰⁶ In Barrow, where Risedale Maternity Home opened its doors in 1922, the MOH indicated "the need of some place where cases of confinement could be attended to with, at least, ordinary decency. . . . Owing to the congestion in the town, these cases could not be adequately dealt with in the homes of the people."¹⁰⁷ In Lancaster, the earliest hospital accommodation was at the Poor Law Hospital; the need for additional beds was justified in terms of circumstances "where danger to the mother or child is anticipated" (1925), and of reports from health visitors that "many women are confined in overcrowded and often insanitary dwellings" (1928).¹⁰⁸ In 1932, the Royal Lancaster Infirmary was expanded to accommodate eighteen maternity beds.¹⁰⁹ In 1919, Preston's MOH wrote:

There is a great need in Preston of a Maternity Hospital, especially for abnormal cases of confinement, as in many instances life could be saved if any operation necessary could be performed under the aseptic conditions prevailing in Hospital and with the skilled assistance available there. Maternity Homes and Hospitals are recommended by the Ministry of Health in the Act of 1918 and it would be well to consider the advisability of establishing such an institution in the near future in Preston.¹¹⁰

In 1921, the Preston Royal Infirmary opened a Maternity Ward, and by 1928 many mothers were also delivered at Sharoe Green Hospital (the former Poor Law institution).¹¹¹

Predictably, the use of hospitals for antenatal inpatient care and delivery began to rise. In 1938, of 868 Barrow births, 281 (32%) occurred [End Page 404] in institutions; by 1947, 54% were in Risedale.¹¹² In Lancaster, of 731 births in 1943, 301 (41%) were in institutions.¹¹³ In Preston, of 1,711 births in 1940, 790 (46%) occurred at Preston Royal Infirmary; in 1957, only 19% were born at home.¹¹⁴

The oral evidence indicates that many working-class parents welcomed the opportunity for hospital confinement. For some, a home delivery would have been inappropriate or inconvenient. Mrs. Burrell, born in 1931, who was living with her mother in a two-bedroom house during her first pregnancy, was told by her mother, "You can't have the baby here"; her three children were born in North Lonsdale Nursing Home.¹¹⁵ Mr. Boswell, born in 1920, said:

The first instance, when Robert was born, we lived in rented rooms, and the war was still on of course, and we lived in a place over town and it wasn't convivial to have it at the home, you know. And it was better off to go to the hospital, so we did do. When Christine was born, we did have our house . . . but again she [wife] decided she would go to hospital to have it, you know. If she had been at Wigan, where she hails from, near her own mother, I should imagine she would have had it at home.¹¹⁶

Medicalization—in the forms of greater awareness of biomedical arguments and pressure from physicians, health visitors, and trained midwives—affected some people's decisions about where to give birth. Mrs. Halls, born in 1931, said: "I think they realized, the health service, that everything was there if there were complications. And I think you were quite happy to go and be there where if anything did go wrong you were in safe hands. I know I wanted to go in hospital. . . . There was no way I wanted to stay at home."¹¹⁷ Mrs. Barlow, born in 1928, also had her three children in hospital: "It never occurred to me to have them at home"; she went on to explain: "My doctor, when I came to have my children . . . definitely pushed me towards hospital to have it. . . . They had all the antenatal care laid on at hospital."¹¹⁸

In addition, some women viewed a hospital or nursing home delivery as being something of a luxury. Mrs. Owen, born in 1916, who felt she "couldn't" deliver her only child at home, said: "I could have gone into Risedale Maternity Hospital, but you had to pay then, it went on your [End Page 405] husband's wages. And it wasn't much difference me going up there than in the nursing home, so we decided to go in the nursing home. . . . You paid five pounds extra, I think, to have your own doctor in the nursing home."¹¹⁹ Mrs. Becker, born in 1900, had her fourth baby in hospital: "That was private. . . . [I thought] I'm going to spoil myself a bit."¹²⁰

It is clear that, in the 1940s and 1950s, particularly after the establishment of the National Health Service eliminated both charges for hospital delivery and the traditional stigma of delivery in the workhouse, the demand for beds outstripped the supply.¹²¹ In 1946, Preston's MOH reported:

One of the features of the year has been the increase in the number of births in the Borough, which reached the highest total since 1923. This post-war increase was not unexpected, and it did prove a strain on the resources of the town to deal with the problem. The modern expectant mother, quite rightly, expects a higher standard in the surroundings for her confinement, and owing to the unsatisfactory housing conditions and other factors, which has led to an increased demand for confinements in hospital. This, in turn, has led to a very great strain on the maternity accommodation in the local hospitals, which has been increased by shortage of staff. There is no quick and easy solution to the problem.¹²²

Similar conditions existed in Barrow and Lancaster in the postwar period.¹²³

Preston's MOH reports indicate a commitment to home delivery that was supported by assiduous efforts to recruit domiciliary midwives in the 1950s. In 1936, the MOH wrote:

The financial and practical advantages to be gained by entering a maternity home for confinement and the enthusiasm and loyalty engendered in supporters of these institutions should not blind us to the fact that, for the majority of women, home is the natural place for normal childbirth and that our efforts should be directed towards securing for these women all the facilities in the way of medical and nursing help that are required in their particular case.¹²⁴ [End Page 406]

In 1960, the MOH celebrated the fact that 29.27% of births in that year had taken place at home—up from 19.24%.¹²⁵ The report for 1963 described the situation that had stabilized by the end of the study period (1970):

This service is organized on the basis of a highly efficient antenatal service with selection of cases for hospital confinement in the hands of the consultants who not only work in the hospitals, but also carry out regular weekly consultative sessions on behalf of the local health authority. Mothers having their first babies and those who already have had four pregnancies are encouraged and persuaded to accept hospital delivery whilst the remainder are carefully reviewed to determine whether, in the light of the clinical conditions, the past history and the social conditions home or hospital delivery is indicated.¹²⁶

In that year, 30% of deliveries took place at home.¹²⁷ Not until the 1970s would Preston follow the nation in hospitalizing virtually all births.¹²⁸ Nonetheless, it is fair to observe that home births had also become medicalized by the post-World War II era: officially trained and licensed midwives took birth technologies and drugs to parents' homes, and either called physicians or transported mothers to hospital according to conservative risk protocols.

As we have seen, the oral history evidence does not romanticize home birth. However, it does reveal both some negative aspects of institutional delivery, and a growing awareness of some implications associated with whatever choice was made. Some women who had had a bad birth experience at home chose hospitalization on later occasions.¹²⁹ Others found that hospital birth experiences varied. Mrs. Marley, born in 1914, chose to have her son in Ulverston Cottage Hospital, for which she and her husband paid £20—a fortune at a time when her husband's wage was £3. She remembered having considerable control over this birth: "We got to the hospital and the nurse said, 'Oh well, you've been a straightforward case, so Dr. Smith might say Matron can attend to you.' And I can [End Page 407] remember saying he better hadn't, he's been paid for this child, he had better come. Anyway, he came."¹³⁰ By contrast, Mr. Kennedy, born in 1930, said that his first four children were born at home and his last two in hospital:

You get different hospitals. I mean to say, one of my lads was born in Preston Infirmary, and they was very very strict. I was told off for picking the baby up when I went to see the missus, you know. I told the nurse, you know, there's no way I'm putting him down, he's my baby. And she said, you are not allowed to touch him, you'll have brought germs in. I said, well all the others that were born at home, I said, they've survived and there was no bother. People came in to see them and they brought germs in. Now, the other hospital where I think it was the fifth one was born, they were fantastic, you know. You could get hold of the baby and nurse him. You could feed him, actually, if he were on the bottle.¹³¹

Mrs. Hocking, born in 1933, had her first child in hospital and the last two at home, "because I thought it was more personal"; she also said that her husband was present for the home deliveries, but not for the hospital birth, "because it wasn't done in those days."¹³² In addition to what might be called cultural factors, it is also noteworthy that informants who delivered in hospital experienced more medical intervention, including anesthetics, instrument deliveries, and surgery.¹³³

Conclusions

In the late twentieth century, infant and maternal mortality ceased to be major problems in the study communities. Given public credit for these and other improvements in health and longevity, official health services completed the process of medicalizing pregnancy, birth, and childcare. Women of all social classes were encouraged to mistrust their knowledge of their own bodies and those of their children and, instead, to "call the doctor" for interpretation of all physical and mental sensations and for advice regarding all health-related decisions. This change rang the death knell for one important aspect of working-class culture—female authority [End Page 408] over and management of childbearing, childcare, illness, and death.¹³⁴ It occurred generationally, with older women resisting the services of qualified midwives, health visitors, and physicians, while younger women learned officially sanctioned health information and behavior, and then rejected as "old-fashioned" the advice of their mothers and neighborhood health authorities. As the "modern" generation, born after 1920, came of age, working-class health culture was increasingly regarded as quaint and backward—associated with gendered ignorance and superstition, encapsulated in "old wives' tales" and displayed in a variety of unhealthy behaviors. Dependence on the "scientific" health advice and care delivered by officially sanctioned medical professionals became a characteristic of the responsible parent; none of the informants contributing to this study who reached adulthood after World War II questioned the authority of these professionals—although some members of this group may sometimes display passive resistance by failing to follow medical advice.

The processes by which working-class health culture was transformed are beyond the scope of this paper. Future research will address messages delivered by school-based health education and popular media—principally magazines, radio programs, and films—regarding biomedical concepts and both unofficial and official health-care providers. It will also help to explain the lack of working-class resistance to the medicalization of childbearing in the twentieth century.

Footnotes

I gratefully acknowledge the assistance of Tom Dixon of Lancaster University, without whom the research for this paper would not have been completed.

1. See, e.g., Ann Oakley, The Captured Womb: A History of the Medical Care of Pregnant Women (Oxford: Blackwell, 1984); Edward Shorter, A History of Women's Bodies (Harmondsworth: Penguin, 1984); Judith Walzer Leavitt, Brought to Bed: Child-bearing in America, 1750-1950 (New York: Oxford University Press, 1986); Kathleen Doherty Turkel, Women, Power, and Childbirth: A Case Study of a Free-Standing Birth Center (Westport, Conn.: Bergin and Garvey, 1966), pp. 4-5; Jan Williams, "The Controlling Power of Childbirth in Britain," in Midwives, Society and Childbirth: Debates and Controversies in the Modern Period, ed. Hilary Marland and Anne Marie Rafferty (London: Routledge, 1997), pp. 232-47.

2. Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), pp. 9-21.

3. See, e.g., Dorothy Porter, Health, Civilization and the State: A History of Public Health from Ancient to Modern Times (London: Routledge, 1999); Ann Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856-1900 (Oxford: Clarendon Press, 1993); Bernard Harris, The Health of the Schoolchild: A History of the School Medical Service in England and Wales (Buckingham: Open University Press, 1995); Jane Lewis, What Price Community Medicine: The Philosophy, Practice and Politics of Public Health Since 1919 (Brighton: Wheatsheaf Books, 1986).

4. See, e.g., Richard Allen Soloway, Birth Control and the Population Question in England, 1877-1930 (Chapel Hill: University of North Carolina Press, 1982); Wally Seccombe, Weathering the Storm: Working-Class Families from the Industrial Revolution to the Fertility Decline (London: Verso, 1993); Porter, Health, Civilization and the State (n. 3), chaps. 8 and 10.

5. This relationship is presumed in recent works, including Lara Marks, Model Mothers: Jewish Mothers and Maternity Provision in East London, 1870-1939 (Oxford: Clarendon Press, 1994), p. 9.

6. Helen Jones, Health and Society in Twentieth-Century Britain (New York: Longman, 1994), p. 196; Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (London: Norton, 1997), pp. 691-93.

7. I owe these concepts to Michel Foucault and Robert Muchembled. For this paper's purposes, social control is the process by which the official public health and health-care systems controlled working-class behavior and bodies; acculturation is the process by which, through compulsory education, official health advice, and various types of popular media, traditional working-class health culture was virtually eliminated by the second half of the twentieth century.

8. See, e.g., Oakley, Captured Womb (n. 1); Leavitt, Brought to Bed (n. 1); Jean Donnison, Midwives and Medical Men: A History of Inter-Professional Rivalries and Women's Rights (New York: Schocken, 1977); Doreen Evenden, The Midwives of Seventeenth-Century London (Cambridge: Cambridge University Press, 2000).

9. See, e.g., Jane Lewis, The Politics of Motherhood: Child and Maternal Welfare in England, 1900-1930 (London: Croom Helm, 1980); Judy Giles, Women, Identity, and Private Life in Britain, 1900-1950 (New York: St. Martin's Press, 1995).

10. The reports of Medical Officers of Health were available for most years for Barrow from 1883 to 1968; for Lancaster from 1907 to 1960; and for Preston from 1878 to 1970. Regarding oral history informants: Elizabeth Roberts interviewed approximately 160 people in the course of projects funded by the Social Science Research Council in 1974-76 and 1978-81. With support from the Economic and Social Research Council, Dr. Roberts and I interviewed an additional 98 informants between 1987 and 1989. Transcripts of 250 interviews were consulted for this paper. Interview tapes and transcripts are housed at the Centre for North-West Regional Studies at Lancaster University.

11. See, e.g., Ann Cartwright, Parents and Family Planning Services (New York: Atherton Press, 1970); Oakley, Captured Womb (n. 1); Ellen Ross, Love and Toil: Motherhood in Outcast London, 1870-1918 (New York: Oxford University Press, 1993); Joanna Bornat et al., eds., Oral History, Health and Welfare (London: Routledge, 2000); Maureen Sutton, "We Didn't Know Aught": A Study of Sexuality, Superstition and Death in Women's Lives in Lincolnshire during the 1930s, '40s, and '50s (Stamford, U.K.: Watkinds, 1992); Nicky Leap and Billie Hunter, eds., The Midwife's Tale: An Oral History from Handywoman to Professional Midwife (London: Scarlet Press, 1993); Giles, Women, Identity (n. 9); Jocelyn Cornwell, Hard-Earned Lives: Accounts of Health and Illness from East London (London: Tavistock, 1984); Sophie Laws, Issues of Blood: The Politics of Menstruation (Basingstoke: Macmillan, 1990); Kate Fisher, "'She Was Quite Satisfied with the Arrangements I Made': Gender and Birth Control in Britain, 1920-1950," Past & Pres., 2000, 169 : 161-93; Lucinda McCray Beier, "Contagion, Policy, Class, Gender, and Mid-20th-Century Lancashire Working-Class Health Culture," Hygiea Internat. (Linköping University Press, Sweden), 2001, 2 (1): 7-24; idem, "'I Used to Take Her to the Doctor's and Get the Proper Thing': Twentieth-Century Health Care Choices in Lancashire Working-Class Communities," in Splendidly Victorian: Essays in Nineteenth- and Twentieth-Century British History in Honour of Walter L. Arnstein, ed. Michael H. Shirley and Todd E. A. Larson (Aldershot: Ashgate Press, 2001), pp. 221-41.

12. Paul Thompson, The Voice of the Past: Oral History, 2nd ed. (New York: Oxford University Press, 1988), pp. 1-21.

13. Penny Summerfield, Reconstructing Women's Wartime Lives: Discourse and Subjectivity in Oral Histories of the Second World War (Manchester: Manchester University Press, 1998), p. 11.

14. Alessandro Portelli, The Battle of Valle Giulia: Oral History and the Art of Dialogue (Madison: University of Wisconsin Press, 1997), p. 4.

15. By accepting informants' self-identification as working-class, Elizabeth Roberts and I took an approach similar to that adopted by Joanna Bourke in Working-class Cultures in Britain 1890-1960: Gender, Class and Ethnicity (London: Routledge, 1994).

16. This issue is discussed at length in Summerfield, Reconstructing Women's Wartime Lives (n. 13), p. 17.

17. Portelli, Battle of Valle Giulia (n. 14), p. 17.

18. Michael Anderson, Family Structure in Nineteenth-Century Lancashire (Cambridge: Cambridge University Press, 1971), p. 18.

19. Elizabeth Roberts, A Woman's Place: An Oral History of Working-Class Women,1890-1940 (Oxford: Blackwell, 1984), pp. 6-7; idem, Women and Families: An Oral History, 1940-1970 (Oxford: Blackwell, 1995), pp. 3-4. Barrow's population was 51,712 in 1891; 66,202 in 1931; and 63,460 in 1970. Lancaster's population was 31,038 in 1891; 43,383 in 1931; and 48,500 in 1970. Preston's population was 107,573 in 1891; 119,001 in 1931; and 100,140 in 1970. It is worthy of remark that Trevor Griffiths, The Lancashire Working Classes, c. 1880-1930 (New York: Oxford University Press, 2001), reveals additional variations in Lancashire working-class life by consulting the records of a colliery relief fund serving families in Bolton and Wigan.

20. Soloway, Birth Control (n. 4), pp. 8, 13; Seccombe, Weathering the Storm (n. 4), pp. 157-58. See Roberts, Woman's Place (n. 19), p. 85, for fertility rates for Barrow and Preston.

21. Interviewees were promised confidentiality; thus, the names used in this paper are fictitious. References to interview transcripts (housed at the Centre for North-West Regional Studies, Lancaster University) are given by the informant's code number and transcript page number: Barrow informants are indicated by the suffix "B," Lancaster informants by the suffix "L," and Preston respondents by the suffix "P." For the information provided here, the reference is Mrs. D2B, pp. 1-2.

22. Mr. T1P, p. 42. See also Mrs. M1P, p. 47.

23. Mrs. W1L, p. 7. See also Mrs. D2B, p. 19; Mrs. M1P, p. 47.

24. Mrs. D1P, p. 31. See also Mrs. H4P, born 1903, whose mother refused to sleep with her father after discovering his infidelity (p. 46).

25. Mrs. S2B, p. 29. Mr. R3L, born in 1890 and one of only two children, said his father "didn't want a big family due to economic conditions of the day"; he associated larger families with poverty (p. 57).

26. Mrs. W2L, p. 14.

27. See, e.g., Barbara Brookes, Abortion in England 1900-1967 (London: Croom Helm, 1988); Seccombe, Weathering the Storm (n. 4), pp. 158-59; Ellen Ross, Love and Toil (n. 11), pp. 104-6.

28. Mrs. H4P, pp. 31, 38.

29. Mrs. M3P, p. 13. See also Mrs. H8P, p. 37; Mr. W6P, p. 1; Mrs. P1P, p. 68; Mr. M10L, pp. 67-68.

30. Mrs. D3P, p. 30.

31. See, e.g., Brookes, Abortion in England (n. 27); Jones, Health and Society (n. 6), p. 67; James Thomas and A. Susan Williams, "Women and Abortion in 1930s Britain: A Survey and Its Data," Soc. Hist. Med., 1998, 11 : 283-309. Among younger oral history informants, Mrs. F1L, born in 1921, remembered "back street abortions," but said: "I think really more of that went on Victorian than when we were younger. . . . We hardly ever heard of it, did we?" She remembered people getting "pills" that never worked from a herbalist (p. 31). Mr. M10L, born to a very large traditional family in 1948, remembered gossip about a girl who was "commonly thought to have visited an illegal abortionist" (p. 67). Mrs. H5L, born in 1931, was the only respondent to talk about having had an early legal abortion in 1971 (p. 111).

32. Ross, Love and Toil (n. 11), p. 103; Sutton, "We Didn't Know Aught" (n. 11).

33. Roberts, Women and Families (n. 19), pp. 76-81.

34. See, e.g., Borough of Preston: Annual Report of the Medical Officer of Health for 1902, 1903, 1911, 1912, 1913, 1914, and 1918. Titles of the Annual Report of the Medical Officer of Health differ in minor ways from year to year. Citations in this paper will appear as follows: "Community" MOH Report, Year, page. For percentages of women at work in the period 1891-1931, see Roberts, Woman's Place (n. 19), p. 206.

35. Preston MOH Report, 1912, p. 15.

36. Birth control was generally viewed as immoral before the interwar period. Civilians obtained barrier devices (cap, condom, pessary, etc.) by mail order, from "rubber goods" shops, or clandestinely from barbers and chemists. See, e.g., Audrey Leathard, The Fight for Family Planning: The Development of Family Planning Services in Britain 1921-74 (London: Macmillan, 1980).

37. County Borough of Barrow-in-Furness Report of the Medical Officer of Health, 1938, p. 18.

38. See Lewis, What Price Community Medicine (n. 3), for an overview of public health provision in the period. Ann Oakley (Captured Womb [n. 1]) remains the authority on antenatal care. Irvine Loudon's research on infant and maternal mortality assesses the factors contributing to incidence, including socioeconomic conditions and quality of assistance at deliveries; see, e.g., "On Maternal and Infant Mortality 1900-1960," Soc. Hist. Med., 1991, 4 : 29-74.

39. Celia Davies, "The Health Visitor as Mother's Friend: A Woman's Place in Public Health, 1900-14," Soc. Hist. Med., 1988, 1 : 39-58.

40. Barrow MOH Report, 1908, pp. 198-99; 1910, p. 251; Lancaster MOH Report, 1910, p. 26; Preston MOH Report, 1902, p. 12.

41. Preston MOH Report, 1901, p. 17.

42. Preston MOH Report, 1896, p. 10.

43. Ibid. See also, e.g., Preston MOH Report, 1898, p. 7; 1899, p. 14; 1900, p. 13; 1902, pp. 10-12; 1906, pp. 8-9; 1911, pp. 10-11.

44. Preston MOH Report, 1969, p. 4.

45. Barrow MOH Report, 1913, p. 282.

46. Barrow MOH Report, 1922, p. 338.

47. Lancaster MOH Report, 1913, p. 88.

48. See, e.g., Mr. G1P, p. 60; Mrs. H4P, p. 16; Mrs. M1P, p. 50; Mrs. A3B, p. 51; Mrs. B5P, p. 48.

49. Mr. B9P, p. 10.

50. Mrs. D1P, p. 21. See also Mrs. C7L, p. 34.

51. See, e.g., Mrs. M1P, p. 50; Mrs. W4P, p. 20; Mrs. M11B, pp. 8-9.

52. See, e.g., Mrs. S3B, p. 75; Mrs. C8L, p. 17.

53. Mrs. J1B, p. 64. See also Mrs. L3L, p. 53; Mrs. W4L, p. 40; Mrs. Y1L, p. 52; Mrs. G5P, p. 45.

54. Mrs. H3P, p. 43. See also Mrs. B2B, p. 50.

55. Oakley, Captured Womb (n. 1), pp. 17, 277-79.

56. Preston MOH Report, 1933, p. 93. Beginning in the 1930s, Preston's expectant mothers also attended antenatal clinics at Preston Royal Infirmary and Sharoe Green Hospital. Oral history accounts indicate that women increasingly received regular antenatal care from their general practitioners as well.

57. Preston MOH Report, 1934, p. 98. It is noteworthy that these free clinics detected a range of health problems widely present in the working-class female population of the time and offered pregnant working-class women health screening that their nonpregnant contemporaries often could not afford before the introduction of the National Health Service. See Margery Spring Rice, Working-Class Wives: Their Health and Conditions, 2nd ed. (London: Virago, 1981), for information about working-class women's health collected by a survey begun in 1933.

58. Preston's consultative antenatal clinic opened in April 1954.

59. Mr. P6B, p. 51.

60. Mrs. S3B, p. 75.

61. Mrs. W4L, p. 38.

62. For example, Mrs. S1L, born in 1898, had her first baby in 1929. She said: "I was very ill and Dr. Kay was coming sixpence a week. He sent a bill for one pound one"; she had her husband enclose the radio in a cupboard "because I didn't want the doctor to know we have one" (p. 28).

63. I have discussed this at greater length in Lucinda McCray Beier, "'We Were Green as Grass': Learning about Sex and Reproduction in Three Working-class Lancashire Communities, 1900-1970," Soc. Hist. Med., 2003, 16 : 461-80.

64. Mrs. C5P, p. 30. See also Mrs. M6P, p. 31; Mrs. P2P, p. 23.

65. Preston MOH Report, 1931, p. 85.

66. See, e.g., Mr. R3B, p. 57; Mrs. H6L, p. 43; Mrs. L3L, p. 52; Mrs. W6L, p. 82; Mrs. C8P, p. 151; Mrs. G5P, p. 44; Mrs. K2P, p. 106; Mrs. R1P, p. 65.

67. Mrs. J1B, p. 12.

68. See, e.g., Mrs. P5B, p. 40; Mrs. C7L, p. 34; Mrs. C8P, p. 151; Mrs. T2L, p. 54; Mrs. H3P, p. 43.

69. Mrs. L3B, p. 24.

70. Ibid.

71. See, e.g., Roberts, Woman's Place (n. 19) and Women and Families (n. 19); Giles, Women, Identity (n. 9); Beier, "'We Were Green as Grass'" (n. 63).

72. Mr. C1B, p. 25.

73. Mrs. W1P, p. 11. See also Mrs. B11P, born in 1936, who compares a long lonely stay in hospital with her first birth to the neighborhood management of her subsequent four confinements (p. 47).

74. Mrs. D1B, p. 19.

75. Mrs. M11B, p. 7.

76. Mrs. C7L, p. 57.

77. Mrs. F1L, p. 85.

78. See, e.g., Lewis, Politics of Motherhood (n. 9), p. 147.

79. Mrs. A3B, p. 4.

80. Mr. T2P, p. 37.

81. Mrs. H3B, p. 60.

82. Mrs. G1B, p. 13. See also Mrs. D3P, p. 28; Mr. T3P, p. 45.

83. Mrs. P1L, p. 77.

84. Mrs. M3B, p. 3.

85. Preston MOH Report, 1905, p. 33. For an account of the process of registering and examining midwives in another northern English community, see Joan Mottram, "State Control in Local Context: Public Health and Midwife Regulation in Manchester, 1900-1914," in Marland and Rafferty, Midwives, Society and Childbirth (n. 1), pp. 134-52.

86. Barrow MOH Report, 1910, p. 250.

87. According to Marks, Model Mothers (n. 5), p. 98, this was also true elsewhere in Britain.

88. Mrs. H2L, p. 39.

89. Mr. G1P, p. 67. See also Mrs. N1L, p. 2; Mrs. W2L, p. 14; Mrs. W1P, p. 7; Miss T4P, p. 39.

90. Roberts, Woman's Place (n. 19), p. 107.

91. Preston MOH Report, 1918, p. 12.

92. Mr. G1P, p. 7. See also Jones, Health and Society (n. 6), p. 27.

93. Lewis, Politics of Motherhood (n. 9), p. 128; Lancaster MOH Report, 1920, pp. 27-28; Preston MOH Report, 1920, p. 73. The figure for Barrow is not provided in the MOH report for 1920.

94. Lancaster MOH Report, 1920, p. 28.

95. Lancaster MOH Report, 1926, p. 42.

96. Preston MOH Report, 1937, p. 106.

97. Barrow MOH Report, 1951, p. 12. See also Preston MOH Report, 1947, p. 47; Preston MOH Report, 1948, p. 40.

98. See Williams, "Controlling Power" (n. 1), for a useful discussion of trained midwives' participation in the power structure of official institutionalized medicine.

99. Mr. B1B, p. 24.

100. Mr. T2P, p. 37.

101. Mrs. T2L, p. 27.

102. Mrs. B1P, p. 45.

103. Mr. E1P, p. 42.

104. Mr. N2L, p. 60. See also Mrs. T2L, p. 55; Mrs. B11P, p. 47; Mrs. C8P, p. 150.

105. Lewis, Politics of Motherhood (n. 9), quotation on p. 119; see also p. 117.

106. Lewis, What Price Community Medicine (n. 3), p. 1.

107. Barrow MOH Report, 1922, p. 346.

108. Lancaster MOH Report, 1925, p. 24; Lancaster MOH Report, 1928, p. 37.

109. Lancaster MOH Report, 1931, pp. 10-11.

110. Preston MOH Report, 1919, p. 43.

111. Preston MOH Report, 1928, pp. 107-8. It is noteworthy that patients had been delivered at Sharoe Green Hospital since 1926, although the number of deliveries was not reported before 1928.

112. Barrow MOH Report, 1938, pp. 4, 17; Barrow MOH Report, 1947, pp. 8, 10.

113. Lancaster MOH Report, 1943, p. 10.

114. Preston MOH Report, 1940, pp. 38-39; Preston MOH Report, 1957, p. 33.

115. Mrs. B2B, p. 49. See also Mrs. R3B, p. 55; Mrs. G1B, p. 13.

116. Mr. B4B, p. 54.

117. Mrs. H5L, p. 65. See also Mrs. B4L, p. 66.

118. Mrs. B3B, p. 63.

119. Mrs. O1B, pp. 24-25.

120. Mrs. B1P, p. 25.

121. Mrs. N3L had her first child out of wedlock in the Lancaster Workhouse. When, after marriage, she chose to have her second baby in the same facility, her husband was furious, feeling she had shamed him. Mrs. N3L, p. 65; Mr. N3L, pp. 136-37.

122. Preston MOH Report, 1946, p. 3.

123. See, e.g., Barrow MOH Report for 1938, 1944, 1946, and 1947: hospital deliveries rose from 279 in 1938 to 822 in 1947. See also Lancaster MOH Report for 1940 and 1942: in 1940, 184 births occurred in the Royal Lancaster Infirmary; 254 births occurred there in 1942—an increase that "has led to a greatly increased strain on the accommodation available" (p. 6).

124. Preston MOH Report, 1936, p. 6.

125. Preston MOH Report, 1960, p. 35.

126. Preston MOH Report, 1963, p. 24.

127. Ibid.

128. Lewis, Politics of Motherhood (n. 9), pp. 119-41, provides an excellent discussion of mid-twentieth-century trends in official thinking about the desirability of hospital versus home birth. Enid Fox, in "Powers of Life and Death: Aspects of Maternal Welfare in England and Wales between the Wars," Med. Hist., 1991, 35 : 328-52, argues that the medicalization and institutionalization of midwifery changed midwives' professional identity and relationships with both patients and physicians.

129. See, e.g., Mrs. P1P, p. 18; Mrs. Y2P, p. 7; Mrs. B11P, p. 39.

130. Mrs. M11B, p. 7.

131. Mr. K2P, p. 13.

132. Mrs. H6L, p. 63. See also Mr. P5B, p. 51.

133. Mrs. M11B, p. 6; Mrs. O1B, p. 25; Mrs. W5B, p. 22; Mrs. W6B, p. 80; Mrs. H5L, pp. 65-66; Mrs. L3L, p. 52. Barrow's Medical Officer of Health noted dramatic increases in "surgical work" performed in the late 1940s: at Risedale Maternity Hospital in 1947, there were 467 normal deliveries, 91 cesarean sections, 51 inductions, 45 forceps deliveries, 5 sterilizations following delivery, and 4 hysterectomies (Barrow MOH Report, 1947, pp. 12-13).

134. I discuss traditional working-class health culture at greater length in Beier, "'I Used to Take Her to the Doctor's" (n. 11).