INTRODUCTION: AUTHORITY, EXPERTISE AND GERMAN MIDWIFERYS CONTRIBUTION TO DEBATES OF NATURE VERSUS SCIENCE

Indeed, the skill ill befits men (haec enim ars viros dedecet) Portuguese-born Hamburg Physician Rodrigo a Castro, 16041 (T)here is naturally much important and valuable information a midwifery instructor must teach his students. Friedrich Kirstein, Leitfaden fr den Hebammen Unterricht (1912)2 In presenting this content, all of the textbook authors agree that a midwife today is much more than simply a set of hands, and requires knowledge that goes beyond rudimentary instruction. Her job is not a dying art the way it is sometime supposed here and abroad. Where there are no midwives, such as in the United States, the midwifes responsibilities are performed by nurses who have not necessarily undertaken any specialized examination in the subject. As publications and personal conversations have demonstrated, this is simply not as good as having a professionally trained birth assistant. Wichard von Massenbach et al. (eds), Hebammenlehrbuch (1962)3

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Women Do It but Men Teach It?

Throughout history and across the globe many have regarded midwives as protectors of natural knowledge, defined in this context as an intuitive understanding of a womans body rhythms and functions.4 According to this view, midwives are granted expert status because they themselves are women, and in most cases have already given birth to their own children. Through this experiential training and intuitive familiarity, the midwife garners trust from labouring women and her community alike. She becomes the communitys birthing authority, taking on the responsibility of assisting pregnant women through labour, as well as various stages of the prenatal and postpartum experience. The midwife becomes a wisewoman, symbolizing an image of the procreative process as a women-centred, holistic and above all else natural event.

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In contrast to such wise women are male medical intellectuals, medicalmen.5 Read from a Western-centric viewpoint, these medical men originated in Europe, later spreading via imperialism to the American colonies and elsewhere. Historically, medical men were those who sought the title of physician through scholarly rather than hands-on training, using their theoretical approach to acquiring knowledge as a way to elevate themselves above common healers like midwives and barber surgeons. These learned men, many of whom came from within the ranks of the clergy, became part of the assemblage charged with preserving institutionally based book learning. Versed in the workings of philosophy and scientific inquiry, these intellectuals solidified their expertise through the mastery of the written word; they used texts both as a vehicle from which to learn and also a means to communicate with the wider community of their peers. The conventional argument with regard to the interaction between these two groups typically focuses on the end of the nineteenth century as a period of transition from traditional midwifery (women-centred, holistic and natural) to modern, male-led, institutionally-focused obstetrics. Scholars tend to adopt one of two perspectives on this transition. Some see it as a negative, essentially gendered conflict in which men seized power from women; others regard it positively, and necessary for modern scientific advancement (because clean classrooms trump dirty midwives). Where the two perspectives commonly agree is that this transition from female midwife to male doctor occurred largely without resistance from midwives themselves. Lacking markers of professional identity such as an association and trade journal, individual midwives were unable, or unwilling, to speak up for themselves. In terms of scholarship on the history of childbirth in the industrialized Western world, it is often this separation of midwifery from modernity that becomes scholars primary focus. Accepting that the divided narrative is intransigent midwifery and modern medicine cannot co-exist scholarly focus shifts to examining the effect of dichotomies within modern Western birth practices: nature versus industrialization; tradition versus progress; and ultimately women versus men.6 However, if one examines modern German midwifery between 1885 and 1960, such assumptions do not supply a completely accurate picture. German midwives actually took an active role in the transition from traditional practice to modern institutionalized health care by organizing and working to achieve other markers of professionalization. Furthermore, the German case reveals a sort of perfect storm. Not only were midwives (often spearheaded by a small cadre of committed women) motivated to save their occupation, their interest coincided with state concern over falling birth rates and general interest in the medical community regarding midwifery. In the end, the history of modern German midwifery is not simply one of gendered competition, but rather about gendered cooperation regarding defining spheres of expertise and authority.

Introduction

Expertise, Authority and the Power of the Written Record

While the terms expertise and authority are often used synonymously, I am using them in the context of birthing assistance to describe two different, but related, ideas. Expertise refers to the mastery of a particular skill set, in this case the safe and successful assisting of labouring women. Authority means having the publically recognized power of determining who is permitted to claim expertise. In some periods of history and within certain cultures, primarily smaller non-industrial communities governed by direct representation, midwives have possessed both expertise and authority. However, in Europe from the rise of the city-state to the present this has not been the case. As articulated above, femalecontrolled midwifery and male-dominated obstetrics have commonly been cast in competition with each other. In the German-speaking lands, a more accurate description of the competition would be over who controls both birthing expertise and authority. Initially, church officials sought to use midwives authority in the exclusively-female sphere of the delivery room in order to impart religious salvation (performing emergency baptisms on newborns at risk of dying). Then church and state officials sought to control birthing authority because it dictated the public role for women but left birthing expertise alone. Beginning in the eighteenth century, public officials, having mastered authority, now sought to gain control over expertise as men began practising and teaching about labour and delivery. At the end of the nineteenth century, a group of committed Berlin midwives launched the fight to reclaim their authority and expertise. This struggle continued through the First World War and into the Weimar Republic. During the Third Reich, German midwifery received significant recognition of both their professional authority and expertise stemming from the Nazis interest in both pro-natalism and the Nazification of institutions and organizations. Finally, in the post-World War II period, each half of the newly-divided nation continued to recognize the usefulness of honouring midwives authority and expertise. Public recognition can be difficult to measure historically unless a given community leaves behind some kind of record for subsequent generations. For a host of reasons, written documents offer the most enduring form of historical recording. The problem with this assumption is that written records do not necessarily capture the entire truth. For example, proclamations such as laws and edicts do not necessarily reflect the mindset of the average citizen, but they do provide an understanding of the decisions enacted by public officials. As a result, one of the things this book explores is how the question of who controls birthing authority and expertise is closely related to who controls the written record. Control of the written record is important not only because it affects the transference of knowledge during a given time but also because it plays a large role in establishing historical memory. As the trite but true saying goes, history is

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written by the victors. Although expert knowledge of delivery practices survived for centuries by being passed down orally from generation to generation within the female domain of wise women, this changed in Europe with the emergence of print culture. That is not to say the oral tradition disappeared, rather that it lacked the permanence provided by a written record. Print culture allowed for a set of ideas to be circulated more widely and easily among contemporaries without the same degree of alteration that comes when a message is passed along verbally. Print culture also allowed multiple copies of a document to enter into the historical record, which increased the chances it would survive the passage of time. Furthermore, those who controlled access to the written record also controlled whose voice entered into that record and for what purpose. Finally, as future generations attempted to reconstruct the past, the narrative in these written records becomes the norm rather than an example of one position within a more complex narrative. We know how city officials went about dealing with midwives because the codes were written down and therefore became part of the historical public record. In contrast, the voices of midwives who either objected to the codes or were not affected by them, if not written down, are now lost. As a result, the transference of midwifery education from female-centred apprenticeships to male-driven textbook learning is tied up with the issue of literacy. This refers not only to the issue of whether midwives could read, a question Merry Wiesner-Hanks answers in the affirmative regarding early modern German midwives7, but also the degree to which midwives chose to write about their expertise and authority. As this book seeks to demonstrate, the women involved in guiding modern German midwifery through the process of professionalization made some significant choices about how and where they placed emphasis. What these midwifery professionalizing pioneers did well in their pursuit of integration into modern institutionalized health care is maintain the integrity of their craft as a holistic client-centred process. Here, they were highly successful in carving out enduring public recognition for the importance of midwives within modern German labour and delivery. What they did less well was to understand the importance of participating in the written historical record. When these midwives did participate, they often chose to forgo speculation and experimentation (fundamentals of scientific thought) in favour of practical applications. As a result, while contemporary German midwives benefit from a public recognition of their expertise, and indeed their authority when it comes to articulating the most effective methods of hands-on delivery, they still face struggles regarding authority as expressed in a scientific-educational context. For much of the twentieth century, even while German midwives were making tremendous strides in establishing a professional identity, the majority of their textbook authors and school directors remained men, creating an odd situation in which while women delivered children, men taught about it.

Introduction

Shifting Perceptions of Midwives

Generally, scholars agree that from the late eighteenth to the twentieth century, a transition took place throughout the industrialized world, including the German-speaking lands, in which birthing practices transformed from a holistic, women-centred experience to a medicalized, expert-centred process.8 This transition is often framed in terms of a gendered struggle: either medical men seized midwifery from women in a violent takeover, or midwives, isolated and lacking professional consolidation, were unable to keep pace with the changes brought by modernization. Either way the end result was the same. Midwives ultimately lost out to the patriarchal order of modern institutionalized knowledge, at least until the later twentieth century when, motivated largely by the womens movement, some began to question the appropriateness of this transition. Not surprisingly, scholarship is often divided on whether or not this shift from midwives to obstetricians was a good thing. On one side of the debate are those who advocate that medicalized childbirth taking delivery out of the home and placing it in the hospital under the watchful eye of institutionally trained professionals (male obstetricians) was part of progressive modernization. Theirs is the belief that applying scientific knowledge ultimately improved the practice of childbirth by placing emphasis on delivering in a sterilized hospital setting. One point often stressed is the work of Ignaz Semmelweis, a nineteenth- century Hungarian doctor who, by 1847, connected a lack of hand-washing among physicians to an increase in puerperal fever and deaths among hospital deliveries.9 Additionally, discussions centre on the introduction of medical implements, such as forceps, or the use of medicinal intervention, like narcotics (twilight sleep), to ease delivery. On the other side are those who believe that the intervention of formalized medical knowledge into delivery practices was an incorrect step, based not on what was best for labouring mothers-to-be but rather on a generalized, gendered power struggle between men and women.10 Their argument rests on the idea that because men controlled access to scientific knowledge, by medicalizing childbirth those same men could gain entrance to a domain that would be otherwise entirely female. To make specializing on obstetrics financially lucrative, the method of delivery was modified to suit the doctor rather than the labouring woman. This was achieved by shifting the level of attention provided to the labouring woman. In the new system, a physician saw the woman only for the actual delivery, unless there was a medical complication, while pre- and post-care became largely the duty of medical subordinates. It also meant a shift in delivery positions, most commonly having the woman resting prone with her legs elevated and secured in stirrups, which allowed a doctor easier visual and instrument access. While this position meant less strain for the doctor, it ultimately

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shifted the dynamic between birth assistant and labouring woman. Now the doctor became the authority because he had visual access, replacing an authority based on an internal sense; the first is quantifiable and can be demonstrated making it more scientific, the second is intuitive and therefore considered subjective. Despite their differing viewpoints, both arguments are largely predicated on the idea that at the heart of this transformation is a gendered split between science (male) and nature (female). Proponents of the pro-science view tend to focus on the rise of formal education as a process of replacing dirty midwives with clean classrooms.11 The division is gendered because classroom space is seen as male; instructors are most frequently male, textbook authors and editors are overwhelmingly male, and the lineage of midwifery schools is traced through male directors rather than female students.12 Furthermore, classrooms become sites of rationality, logic and scientific modernity, traits proponents often subscribe to men. In contrast, according to this pro-science view, the midwife was an uneducated, superstition-riddled woman who often appeared as a slovenly drunkard, ill-kempt and dirty. The resulting moniker is that of angel-maker or mother midnight, a woman more responsible for killing children than delivering them safely.13 Often such depictions are bolstered by reaching back to images in popular culture. Consider the gin-swilling Sairey Gamp from Charles Dickenss Martin Chuzzlewit (1843), or the 1811 caricature by Thomas Rowlandson which shows a corpulent woman in her nightclothes lumbering out to attend a delivery. Her fleshy, slackened lips and jowls indicate a tendency towards too-frequent imbibing of the spirit bottle she clutches in her left hand. The tools of her trade are knotted carelessly in a chequered handkerchief rather than a proper medical bag.14 Likewise, in American newspapers, articles and images published around the turn of the nineteenth century helped to provide support for the argument that midwifery was an immigrant skill and therefore dirty and dangerous. Such images promoted the idea of midwives as both dangerously backward and ignorant of techniques of modern medicine, such as hygiene and professionalism. On the other side of the debate are proponents of the pro-nature (natural childbirth) perspective who see the medical modernization of childbirth as a hostile takeover in which male doctors seized power and ousted wise women with little respect for their long-standing traditions.15 Instead of finding fault with the deportment of midwives, this group focuses a critical lens on the physician, depicting him as cold and calculating, so obsessed with clinical gadgetry that he, and it is almost without exception always a he, dehumanizes the pregnant woman in front of him. Proponents of this perspective argue that the doctor does not consider the pregnant woman as a complete person, but rather as a collection of reproductive organs. He is only interested in the necessary parts, which reduces a labouring woman down to the anatomy located between navel and knees. Furthermore, this perspective transforms childbirth from a natural occurrence to a medical condition requiring modern scientific intervention.

Introduction

For natural childbirth advocates, the physicians foil is the empathetic, nurturing midwife, full of warmth and empathy, wholly devoted to the well-being of the labouring woman and her littlest charge.16 According to this view, midwives across eras and cultures are seen to embody the key traits of comfort and compassion because midwives own gender allows them a unique connection for women in labour. For example, in her early twentieth-century biography, German midwife Anneliese Bergsteiger demonstrates repeatedly her devotion to mothers and the craft of midwifery as a whole. Recounting the day she received her accreditation, Bergsteiger writes, I could not sleep that first night, as I did not want to miss the first call. It was possible that a young mother would soon need my help. Over and over I went to the window whenever I heard steps, but no one came.17 Later she states, With so much love I wanted to take care of those children I had brought to the world. Those mothers who had given me their trust should have it good.18 Natural birth advocates often connect compassionate birthing location and demonstrations of self-sacrifice on the part of the midwife. While the doctor is associated with clinic births, where he presides over a standard birthing theatre to which the women must travel (he is comfortable in a familiar environment while the pregnant women must learn to fit into the new setting), the midwife symbolizes home births. She travels to her charge and it is she, not the pregnant women, who must adapt to different environments.19 Typical accounts of midwives travelling to a delivery often record the experience as taking place late at night or under adverse weather conditions, thereby heightening the image of the midwife as the tireless companion of women in labour, willing to put aside her own comfort for that of the new mother, always prepared to sacrifice personal time for the needs of expecting women. On her retirement in 1980, after fortyfive years of service, midwife Getrude Langefeld recounted what it was like to be on duty twenty-four hours a day.20 Depictions of the devoted midwife appear across cultures. Consider Terri Coatess account of the midwife, Lizaveta Petrovna, in Tolstoys Anna Karenina, who stayed by her charge during twenty-two gruelling hours of labour: Lizaveta Petrovona remains calm and resolute, and using skillful hands, delivers and resuscitates the baby. The midwife is known and trusted and her skills are respected and appreciated.21 It is also an image that carries into the present. The following appeared in a 1998 pamphlet put out by the Saarland Midwifery Association:
Even in the hard post-war period as midwives were poorly paid by wind or weather, day or night, most traveling on foot or with a bicycle ventured out to provide the laboring woman with advice and help, to stand by her side even then the midwife placed the woman and her family in the middle. Untiringly, and often under primitive conditions, the midwife accepted this great responsibility and afforded many women unforgettably the greatest experience of their lives.22

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Finally, among the midwifes skills, and beyond a desire to assist and protect labouring women, is the ability to recognize the woman in front of her as a complete entity rather than simply those parts directly identified with reproduction. The midwifes skilled hands are non-evasive and intuitive, conducting more external than internal examinations. For advocates of the midwife assisted natural childbirth movement, pregnancy is not an illness and the pregnant woman is not a patient. Instead, she is a client undergoing a natural stage in a womans life. While many of the pro-science and pro-nature advocates present the transfer of birthing expertise as an inevitable part of the modernization process, this narrative does not reflect accurately what took place in Germany in the late nineteenth and early twentieth century. German obstetricians did not simply seize birthing practices from midwives, nor did midwives passively accept the changes posed by obstetricians without giving their own input. Instead, during the last decades of the nineteenth century, German midwives grew increasingly more amenable to the modernization argument because it offered a way to rescue their occupation from its state of decline. They embraced new institutional training and accreditation, seizing upon these professional markers as a way to weed out those who came to the occupation without the proper skills or lacking motivation to assist women. By making choices to take an active role in transforming the occupation from the prevue of traditional wise women (Storchtanten) to book-trained medical professionals, German midwives were able to carve out a space for themselves within modern medicine. This allowed them to retain a level of occupational autonomy and tradition, while at the same time participating in the new standards of modernized medical professionalism. One of the reasons todays German midwives are so integral to the countrys childbirth practices is due in large part to their predecessors commitment to professionalization and acceptance of institutionalized education. The professionalizing pioneers recognized the importance of forming a national midwifery association and established the Organization of German Midwives (Vereinigung Deutscher Hebammen (VDH)) in 1890.23 The association, and its first president, Olga Gebauer, who served for twenty-eight years, played a major role in shaping the modern face of German midwifery. Today, German midwives undergo a standardized and rigorous programme. Students now train at formal institutions where their progress and skills acquisition are monitored through coursework and testing. Only upon successful completion of their schooling, and having passed the cumulative examinations, do newly minted midwives receive accreditation. Practising midwives continue to demonstrate their proficiency and comply with regulations by attending refresher courses and reviews. While some practise independently (Freiberufliche) and others work with birthing clinics or hospitals (Anstaltshebammen), all midwives have support and representation. Their interests are watched over by a professional association, the

Introduction

Bund Deutscher Hebammen e.V. (BDH), and a trade publication, Die Deutsche Hebamme, provides a forum for discussion. The BDH is itself part of a larger international consortium of midwifery associations, whose meetings provide an opportunity for international membership and exchange of ideas. In short, contemporary German midwifery meets the significant markers of modern occupational professionalization.

Midwives and Medical Professionalization

Modern German midwiferys professionalization was part of a larger trend of medical professionalization taking place throughout the industrialized world in the nineteenth and early twentieth centuries. In his book, The Social Transformation of American Medicine (1982), Paul Starr offers a sociologically based definition of a profession as A vocation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather than profit orientation, enshrined in its code of ethics.24 While written for the American, rather than the German, case, this checklist of professionalization markers nonetheless offers a compact definition of what constitutions a profession. Other scholars approach the question in terms of how and why professionalization took place. In terms of medical professionalization, this literature adopts one of two perspectives. Scholars basing their study on the emergence of professions in the United States and Britain point to the period between 1840 and 1880 as marking the height of the transformation. As Deborah Brunton points out, much of the professionalization within the Anglo-American model occurred as an internal manoeuvre. Physicians came together to create an environment of knowledge-based exclusivity designed to foster their status as experts. They were aiming for occupational autonomy, which meant the ability to define their sphere of expertise and regulate that sphere from within. This control of expertise brought both financial reward and increased recognition and respect, allowing the collective membership to benefit with upward social mobility.25 In German-speaking lands, the process of medical professionalization took a different path, specifically one influenced by the relationship between practitioner and state. Paul Weindling writes of the connection between German medicine and the paternalistic authoritarian state:
The German Absolutist States of the period leading up to the 1848 revolutions constructed elaborate medical hierarchies in which different orders of healers each received their own particular assigned status or position. The academically educated doctors (rzte) came above surgeons (Wundrzte) who were in turn subdivided into various grades. Public health services were a part of the Enlightenment heritage of so-called medical police (medizinische Polizei), which gave doctors a range of legal powers to detain and segregate the sick, and to remove public nuisances.26

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Claudia Huerkamp, in her work on Prussian doctors in the nineteenth century, reminds readers, Corresponding to the early formation of state-controlled administration, [Prussian] medical training occurred in institutions controlled and financed by the government even before the modernization of the traditional medical profession.27 As I discuss in Chapter 1, such argumentation can also be extended to midwives. Certainly, evidence presented by Merry Wiesner-Hanks, Sibylla Flgge and others indicate how midwives were bound up in the state apparatus centuries before midwives began a formal push for professional recognition.28 With regard to other elements, the connection between midwives and professionalization in Germany is less clear. For example, professionalization was also tied to the emerging power of bourgeois culture. For physicians in Germanspeaking countries, the point was not to make the designation of physician an indication of status in itself, but rather to utilize the title of physician as a marker of bourgeois society. One was not a member of the intellectual elite because one was a physician; one was a physician because one was already a member of the intellectual elite. Furthermore, politics, national identity and the implementation of bourgeois values came together in the process of modern medical professionalization. Physicians saw an opportunity to gain access to governmental power by framing their importance in terms of being able to offer the scientific betterment of society a particularly appealing idea in the rising age of eugenic philosophy. To this end, Weindling asks whether or not interaction with the state meant that the medical profession should be seen as an agent of social control by the ruling elite, or whether the doctors manipulated the state in order to secure a monopoly of power in medical care.29 At the beginning of the nineteenth century, physicians and surgeons shared the same acknowledgement of their skills, even while the first was book-based institutional learning and the other learned through hands-on training. As the century progressed, physicians pushed for a tightening up of accreditation, requiring the certification through a formal institute of higher learning to become the marker of a professional. Furthermore, the divisional marker became based in science. These institutionally trained physicians began emphasizing their expertise as it pertained to models of discovery: hypothesis test prove/disprove resolution. In this sense they were working towards big picture theories (germ theory, social evolution, epidemiology) rather than the practical application of solutions to immediate problems (dressing a wound, treating a colicky baby). As the nineteenth century progressed, many physicians sought to remove themselves from under the classifications imposed by the state, but not necessarily to divorce themselves from their relationship with the state. Proponents believed that medical deregulation would actually allow physicians to gain greater prestige. The only thing they wanted from the state was protection of their title so that the term could only be used by those possessing book-based institutional accreditation. In order

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to justify the uniqueness of this designation, German physicians strove to make medical institutions centres of scientific exploration and make that scientific exploration indispensable to the state. This endeavour was given significant assistance towards the end of the century as interest in racial hierarchies and definitions of fit and unfit populations grew under the rubric of eugenics. Restrictions on who could practise medicine, although not on the title physician, were lifted in 1869, as qualifications were eased and government authorization no longer required. Unfortunately, the field quickly became flooded with quacks, charlatans and those dangerously underqualified to help the sick or dispense heath advice. Midwifery was also thrown into chaos as the practice threatened to collapse under the weight of an over-abundance of under-employed midwives, many of whom were ill-suited for the task. While the situation appeared dire, it was at this point that the relationship between medicine and the state, the growing interest in eugenics and the disarray wrought by the granting of free occupational enterprise (freies Gewerbe) in 1869, actually helped to serve those midwives willing to work to improve their reputation. When occupational restrictions were reimposed on the practice of medicine only a few years after they were lifted, groups scrambled to create associations designed to protect practitioners interests. It would take midwives a while to form an association some fifteen years longer than the Physicians Organization, (Deutscher rztevereinsverband (DVB)) which formed in 1873. However, when midwives did come together they benefitted from the widespread interest in eugenics, specifically in pro-natalism. Midwives were in the business of birthing babies, and, as such, provided a valuable resource for a population and its government interested in improving demographic conditions. As German midwives began to come together to protect their livelihood, they found a climate receptive to the professionalization of their work. While institutionally-based physicians pushed for scientific eminence, there was still space for other groups to seek professional recognition. The key was not to press for autonomous control, as in the American system, but instead to prove usefulness within the state apparatus. In this regard, Gebauer and the VDH sought recognition from both the state and from physicians.30 The organizations aim was not to compete with obstetricians, but rather to gain fair access to participation within the social welfare system. In order to achieve a professional status, the VDH recognized the need for midwives to have access to representation (organization), information (journal) and education (school reform). Similar to Starr, Charles E. McClelland offers nine required characteristics as markers of a German profession: highly specialized and advanced education; special code of conduct (ethics); altruism/public service; rigorous competency tests, examinations and licensing; high social prestige; high economic reward; occupational career pattern or ladder; monopolization of market in services;

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and lastly, autonomy.31 In the following chapters, I examine how midwives, the German state and eventually midwifery school directors came together in an effort to address these points.

Chapter Overview
Focusing on the period from 1885 to 1960, the following chapters examine how German midwives, instead of rejecting the advancement of scientific institutionalization within health care, embraced these new standards as a way to save their livelihood. Identifying shifts in education, including changes in school structure, student body, course curriculum and textbook content, I unravel the process by which German midwives weathered the transition from traditional practitioner to institutional professional without becoming subordinate to physicians, or subsumed within the practice of nursing. Instead, German midwives, with support of the state and midwifery school directors, worked to maintain occupational autonomy, while actively transforming their craft into an integral part of the modern health-care system. This adaptation is what allowed them to become an essential part of modern German childbirth culture, a role they continue to occupy to this day. The first chapter is intended to assist those more familiar with systems elsewhere, such as the United States and Britain; it provides a historical overview of German midwifery from the early modern period to the middle of the nineteenth century. Utilizing the first three of Gernot Bhmes four-phase construction of German midwifery (women-centred community, official position, traditional independent vocation and modern occupation), it also draws on the work of Merry Wiesner-Hanks, Wolfgang Gubalke, Richarda Scherzer and others.32 Moving from the midwifes role as trusted authority within the private sphere of labouring women, I discuss how the proliferation of regulatory codes emerging in the fifteenth and sixteenth century, like the Catholic Churchs Frankfurt Code (1573), pushed midwifery into the public political sphere. During this time municipal officials and the clergy began using midwives as a vehicle for carrying out social and political policies, such as preventing indigent women from giving birth inside city walls and thereby gaining access to municipal funds. Gender and class issues also come to the fore as town councils began appointing upper-class women (Ehrbaren Frauen) as intermediaries, overseeing the actions of midwives and reporting back to council officials. Also within this chapter, I address the creation of German midwifery schools, and medical schools more generally, tracing the divide between theoretically trained clergymen as book physicians and the hands-on practical anatomy instruction of midwives and barber surgeons. Through this I explore the degree to which control of print culture attempted to silence midwives experience by writing them out of the

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historical record. Finally, as a transition into the rest of the book and in order to explain why modern German midwives felt the necessity to adopt markers of medical professionalization, I examine what is called the great mistake of 1869. As the German guild system crumbled and new laws allowed for free occupations (the right to practise without formalized education and licensing), a glut of ill-prepared women declaring themselves midwives caused financial hardship and significant damage to the practices public reputation. Picking up from the devastation of 1869, Chapter 2 opens with the examination of a funeral in Berlin that led midwives to form the first professional association and trade journal. Focusing on Olga Gebauer, the associations first president and major force behind the journal, this chapter examines how midwives began to carve out their sphere of professional influence, despite physicians and religious leaders who, as they had done in earlier centuries, wanted to prescribe midwives place in society. The first half of the chapter contains a detailed examination of articles and columns from the midwifery journal, revealing where and how individual midwives, as well as the ever-expanding network of regional organizations, chose to separate their profession from encroachment by other health-care workers. In addition to male obstetricians, these health-care workers include other women, such as nurses and doulas. The second half of the chapter demonstrates how Gebauer, in conjunction with state officials and midwifery school directors, was able to trim the perceived deadwood of over-aged, improperly trained and otherwise dangerous practitioners through education and licensing reforms, like reintroducing the quota system. The chapter concludes by following these reforms into the Weimar period, looking at the effect of Prussias releasing the first scientifically oriented midwifery textbook in 1928, and also at how the national midwifery association became a victim of its own success, as the organization began to splinter into different collectives. Centring on the figure of Nanna Conti, devoted National Socialist and head of the newly consolidated Reichfachschaft Deutscher Hebammen, Chapter 3 discusses the role of midwifery in Nazi racial ideology. It demonstrates how the state and midwifery association worked in tandem to make midwives feel special and vital to the regime, while at the same time restructuring the educational system in order to recruit ideologically sound practitioners willing to carry out the Partys eugenic bidding. Similar to the previous chapter, this one examines how the midwifery journal became a significant tool for educating midwives about their duties. Making clear how the nation was trapped in the policy of dying rather than living, the journal reveals methods used by physicians, state officials and midwives to advance pro-natalist aims of the Third Reich. This included participating in the Law for the Prevention of Hereditary Illness (1933), and later addendums which required health-care professionals to report infants exhibiting signs of various physical and mental disabilities. Midwives were offered a small

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recompense for their efforts. Despite official rhetoric, not everyone accepted the validity of such eugenic principles. The chapter also includes a detailed examination of the first national midwifery laws released in 1938. Disregarding the regimes exterminationist legacy, many post-war midwives look back at the Third Reichs issuance of this law as the reason their profession survived. The law was based on existing templates from Prussia (1922) and other states, but what made it unique was its third paragraph, which required that every pregnancy receive consultation by a midwife, and carried a fine for pregnant women and physicians who failed to call in one. This law, a version of which is still in operation today, greatly increased the power midwives possessed. Related to this, I discuss the role of home versus hospital births and how official state support by Nanna Contis son, Reich Health Minister Leonardo Conti, resulted in gynaecologists fearing the power granted to midwives, prompting the men to circulate a petition in an effort to save their occupation. This chapter concludes by following the narrative beyond the end of the Second World War, to the creation of a divided Germany. In addition to increasing birth rates and dealing with large numbers of displaced persons, including midwives and pregnant women alike, both the new nations of West and East Germany had to come to terms with their Nazi legacy. In studying their respected views on midwives and midwifery education, my work helps to illustrate each states larger priorities, including the decision that fighting the new Cold War enemy was more important than removing the ideological educational rhetoric left behind by the Third Reich. Chapter 4 shifts from the chronological narrative to focus in greater detail on how individual midwifery schools functioned in the modern period. Drawing from extensive school records and governmental correspondence, the chapter begins with a vignette summarizing one students journey from application through graduation. This narrative provides a starting point from which I discuss how the process of defining and admitting ideal candidates shifted to meet societal and occupational needs. Factors such as age, the presence of biological children, and physical stature all come into play. Using student application forms, I am also able to determine how issues like socio-economic background, marital status and religious affiliation changed over time. Likewise, aptitude tests (general reading, writing and arithmetic questions given to candidates) reveal how students could be screened simultaneously for general intelligence as well as their commitment to a given political ideology. Chapter 5 looks at the specifics of course curriculum and its role in training midwives. Ranging from the expected, basic biology, to the less typical, driving lessons, these courses reflect events and attitudes within the larger society. Focusing primarily on three ideologically and politically different governments (Third Reich, Federal Republic of Germany and German Democratic Republic), I talk about the role of social education and ideological training in shaping midwives

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to serve as a conduit between the private sphere of physical birth and the public sphere of childbirth as a construct. While Nazi ideology focused on Aryan superiority and eugenic rhetoric, East German students were exposed to the dominant philosophy of the social collective and later the power of the Farmer and Worker State. While the teaching of a specific ideology is not as formal and readily apparent in West Germany, I show how traces can also be found there nonetheless. The last chapter offers a close comparative reading of German midwifery textbooks published from the end of the nineteenth century through to the post-Second World War era. It opens with a general discussion of textbooks as cultural markers and how a societys educational practices reveal its broader priorities. Following this, the chapter provides a brief history of midwifery textbooks published in Germany, including the mammoth Nazi-era tomb released in 1943. Similar to the overview offered in Chapter 1, the purpose here is to show that these modern creations are part of a much longer tradition, one dominated almost exclusively by male authors. Keeping such authorship in mind, the main focus of this chapter is to show how modern midwifery textbooks address the growing interest in science along with traditional interests in defining midwives role in society. Breaking my analysis down into sections, and drawing on appropriate obstetrical texts for comparison, I address the following issues: the presence/lack of a historical introduction; the degree and detail to which human biology is explained; the use of technology like forceps and narcotics; the defining of the relationship between midwives, obstetricians and pregnant women; and how the choice of typeface serves to separate textbooks into scientific and cultural artefacts. The chapter also offers a discussion of how textbook descriptions of what constitutes a normal and an abnormal body correspond to social norms dominant at the time of their publication. This includes both representations of the maternal and infant bodies. The chapter concludes with an examination of the shifting role of midwives in post-delivery care. In the conclusion I take the story of German midwifery into the present day. While laws are still in place guaranteeing midwives a role in the birthing tableau, practitioners are still finding themselves facing occupational challenges which should resonate with midwives elsewhere. Today, those midwives who chose to work as independent agents (freiberuflich) face an increasingly difficult time as health insurance programmes are again trying to restrict coverage for home births. However, midwives working in hospitals and birthing centres (again, as autonomous professionals and not as physician assistants or nurse-midwives) find less effect on their practice. The result is a competitive divide between home and hospital which echoes the situation a century earlier. The difference today is that German midwives find themselves working on both sides of that divide. While midwives may have the opportunity to secure work in hospitals, independent practitioners have not given up the same willingness to fight for their

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Modern German Midwifery, 18851960

occupation as seen in women like Olga Gebauer. To this end I discuss the massive rallies and online campaign launched by midwives in 2010 aimed at petitioning the German government to recognize the intrinsic value of their profession within the modern health-care system. Tying past and present events together, I end with a consideration of where German midwifery education, so vibrant a century ago, may be headed in the twenty-first century.

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