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Midwifes and Maternity Care in the Roman World
Ancient maternity practices
The following article is from a special issue of Helios entitled "Rescuing Creusa: New Methodological Approaches to Women in Antiquity," (Helios, New Series 13(2), 1986, pp. 69-84). This article is particular enlightening not only for its detailed discussion of midwives and maternity care, but also because it examines the gap between "professional" care (the midwifes and doctors) and folk medicine.
MIDWIVES AND MATERNITY CARE IN THE ROMAN WORLD*
By Valerie French
The birth of a child marks one of the great events of life in any culture, but in most societies it carries with it a high probability of death or serious illness for both mother and child. Neonatal mortality rates- deaths at less than four weeks- vary considerably in the modern world: in communities that do not employ asepsis in obstetrical care, neonatal mortality can be as high as 50 deaths per 1000 live births.(1) Maternal mortality rates for deaths associated with pregnancy and childbirth also range considerably, but even at their highest they fall significantly short of neonatal mortality. If we retroject the worst mortality rates of the modern world back into the GrecoRoman one, we would estimate that about 5% of all babies born alive would die before they reached the age of one month, and that among every 20,000 women giving birth, five would die.(2) If we include late fetal and inchildbirth deaths, the probability of infant mortality climbs from 5% to 8%.(3)
The dangers of childbirth must have made it an occasion of great anxiety for everyone concerned. The death of a woman or her baby was an all too common occurrence. Caesar's daughter Julia died in childbirth. The younger Pliny reports that both daughters of one of his friends, Helvidius, died during labor.(4) And the Athenian philanthropist, Herodes Atticus, was griefstricken when his first child, a son, died on the day of his birth.(5) The anxiety and grief of the elite was surely paralleled among the lower classes.
Accustomed as we are to the procedures of late twentiethcentury obstetrics with its emphasis on prenatal care, asepsis, and medical technology, our reactions to some of the methods and medications used for normal, uncomplicated childbirth in the GrecoRoman world are likely to range from mild amusement to outright revulsion. While we can make only educated guesses about the mortality rates associated with childbirth in antiquity, we can reconstruct a fairly detailed description of GrecoRoman maternity care and recover a partial picture of the women who attended this epochal life event- the midwives.
Both Pliny the Elder and Soranus provide detailed information about midwifery and obstetrical practices; other medical writers such as Celsus and Galen supplement their accounts and offer some additional evidence. We are fortunate that Pliny and Soranus treat maternity care from significantly different vantage points. In his Historia Naturalis, Pliny reports primarily on the practices of folk medicine, whereas Soranus's Gynecology describes the obstetrical care recommended by the medical profession. Together Pliny and Soranus probably cover the full range of the different kinds of maternity care found in the GrecoRoman world.
I. Folk Medicine
Pliny's descriptions of childbirth practices chiefly concern ways to hasten and ease labor. Boys, he says, are more easily delivered than girls.(6) According to Pliny, fumigations with the fat from hyaena loins produce immediate delivery for women in difficult labor; placing the right foot of a hyaena on the woman results in an easy delivery, but the left foot causes death.(7) A drink sprinkled with powdered sow's dung will relieve the pains of labor, as will sow's milk mixed with honey wine.(8) Delivery can also be eased by drinking goose semen mixed with water or "the liquids that flow from a weasel's uterus through its genitals." (9) Pliny also describes medications made of herbs and plants that were used for childbirth. The root of vervain in water, scordotis in hydromel, and dittany leaves are recommended for the lyingin woman.(10) Amulets and other objects were also thought to be efficacious. Pliny says that some people used the afterbirth of a bitch that had not touched the ground to withdraw the infant, placing the canine placenta on the thighs of the woman.(11) Others tied a snake's slough to the thigh of the woman but took care to remove it immediately after delivery. Some people believed that a "stick with which a frog has been shaken from a snake" was helpful.(12) A vulture's feather might be placed under the woman's feet to aid delivery.(13) Celsus remarks on other folk nostrums, reporting that sneezing relieves a difficult labor;(14) Celsus also recommends drinking hedge mustard in tepid wine on an empty stomach for difficult labor.(15)
It is difficult to determine just how efficacious-or harmful-these treatments might have been. Understandably, contemporary midwives and obstetricians are unwilling to experiment with any of them. At the very least, we can conjecture that the presence in the delivery room of hyaena's feet, snake sloughs, canine placentas, sticks, and vulture feathers may have increased the risk of infection for both mother and child, especially if such objects came in contact with the vaginal area. But we ought not to underestimate the potential for a placebo effect in some of these treatments. If a woman in the throes of labor were told, and believed, that a vulture feather or snake slough would ease her pains, she might well have relaxed and felt better. The practice of giving the parturient liquids, however, was probably beneficial since they would tend to prevent dehydration, a potentially serious problem in protracted labor.
Pliny also reports on ways to bring away the placenta. Here too the treatments are apt to strike us as distasteful. Among his recommendations are earthworms taken in raisin wine; the membrane covering newborn goats, dried and then taken in wine; and linozostis or parthenion. Another is hare's rennet applied with saffron and leek juice.(16) Celsus recommends a draught of four measures of ammoniac salt or Cretan dittany dissolved in water.(17)
Pliny's reports are no doubt drawn from a vast reservoir of traditional folk medicine. And it is important to recognize that Pliny, a highly educated and sophisticated man, did not make light of these treatments. He seems to think that they are sound and efficacious maternity practices. We are on firm ground in assuming that the maternity care of most women in the GrecoRoman world was conducted along the lines described by Pliny. Regardless of the lack of attention to hygiene and sanitation and the likelihood that the medications employed did little good- except as they exercised a placebo effect and prevented dehydration- we must remember that, at the very least, the maternity care described by Pliny was very personal and attentive to the mother. She was at home, not in a strange, alien environment; she was not left alone, sometimes for hours, to sweat out the initial stages of labor by herself. She had the constant company of some of her female relatives and the midwife to encourage her and to divert her mind from the pains of labor. On an emotional level, GrecoRoman maternity care is probably preferable to the production line, impersonal procedures of some modern hospitals. An intensely emotionally supportive atmosphere is of considerable importance to the health of both the new mother and the new baby.(18)
With the physician Soranus, who wrote in the early second century A.D., we find attitudes and beliefs about obstetrics more familiar to the modern world.(19) Soranus begins his discussion of childbirth with a description of the good midwife. To Soranus, the demands of the profession require a highly competent woman; he implies that some midwives are simply unfit for their work. "A suitable person," Soranus writes, "will be literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses [i.e., sight, smell, hearing], sound of limb, robust, and, according to some people, endowed with long slim fingers and short nails at her fingertips."(20) Soranus also insists that the midwife be of sympathetic disposition (though she need not herself have borne a child) and keep her hands soft, presumably so she would not cause discomfort to either mother or child.(21)
Soranus argues that the best midwives should be literate so that they can be knowledgeable about obstetrics and pediatric theory.(22) Soranus's demand for literacy presumes that there was material for the midwives to read. Soranus probably intended that midwives read his work; and it appears that he prepared a shorter, condensed version as a sort of vademecum.(23) One wonders whether Soranus would have put Pliny the Elder on his recommended reading list for midwives; probably not, for Soranus says the midwife must be free from superstition "so as not to overlook salutary measures on account of a dream or omen or some customary rite...." (24)
Soranus's references to other medical writings also indicate that obstetrical practice was not limited to midwives; a male physician might attend particularly difficult births.(25) But the literary sources make it clear that midwives normally attend childbirth.(26) Unfortunately, we can reconstruct only a partial picture of the women who practiced midwifery. In the Eastern end of the Mediterranean basin, some women advanced beyond the profession of midwife (maia) to that of obstetrician (iatros gynaikeios), for which formal training was surely required. Moreover, there were some gynecological tracts written by women with Greek names. It would appear that obstetrical care in the East was a respectable profession in which respectable women could earn their livelihoods and enough esteem to publish works read and cited by male physicians.(27)
In the Roman West, the situation appears to be somewhat different. Among the thousands of funeral epitaphs recorded in ClL, only sixteen commemorate the deaths of women who were identified as midwives.(28) Of those sixteen, nine either come from the columbaria of the great noble houses of Rome or are clearly members of the familia Caesaris. It seems, then, a reasonable inference that large, wealthy households had their own midwives.
Only one of these midwives died a slave; the others appear to be freed women or the daughters of freed women. Two hypotheses are suggested by this admittedly small sample. The first is that midwifery was not a profession to which freeborn women of families that had enjoyed free status for several generations were attracted; thus, it seems likely that most midwives were of servile origin.(29) Second, since midwifery is an occupation that can be practiced successfully into old age, emancipation cannot be explained by the owner's desire to shuffle off a useless slave.(30) Thus, we can propose that midwives were generally valued enough, and earned enough income, to be able to gain their freedom.
The praenomina of these women confirm a hypothesis of servile origin. Of the thirteen inscriptions in which the full name of the midwife is still extant, eight have Greek names; the Latinate names of the others- Secunda, Imerita, Hilara, Veneria- are also associated with slaves. Unfortunately, it is not possible to determine from their epitaphs alone whether these slaves, freed women, or daughters of freed women were born, raised, and trained in Italy or were brought to Rome from the East.
Nor can we tell how particular slave women were selected for training as midwives. Possibly mothers taught their daughters, or slave girls may have been apprenticed. Such training may well have begun at an early age; one epitaph records the death of Poblicia Aphe, obstetrix, dead at age twentyone (# 9723). Two others died in their early thirties (# 6647 and 9724).
Midwives married, and three of the epitaphs record the name of the dead woman's husband or contubernalis (# 6647, 8192, and 9720). Two of the midwives were commemorated by their fathers (# 9724 and 8207), two by their sons (# 8948 and 9720), and only one by her husband (# 6647).(31)
Despite the paucity of evidence about the training of midwives, it seems a reasonable hypothesis that welltrained midwives were more likely to come from the Eastern, Hellenized end of the Mediterranean basin, and that midwifery and obstetrics were more highly esteemed professions, conferring greater prestige on their female practitioners, in the East than in the West. It also seems likely that wealthy Romans secured medical expertise in midwives- as they did in doctors- by purchasing highly educated and trained slaves from the East. The hypothesis of lower status for midwives in the Roman West is corroborated by legal commentary on the Lex Aquilia, passed probably in the third century B.C.; practitioners of medicine, including midwives, were placed in a relatively low social status.(32)
Whatever the regional or socioeconomic background of midwives, their services were not inexpensive. In Plautus's Miles Gloriosus, Periplectomenus complains that women always ask for more money- even the midwife, who protested the sum Periplectomenus had sent to her.(33) A midthirdcentury A.D. marriage contract from Oxyrhynchus in Egypt stipulated that the husband should give to the wife forty drachmae for her confinement if she was pregnant at the time of any separation; the sum probably was intended to cover more than the midwife's fee, but a substantial portion no doubt was to be used for her services.(34) Soranus admonishes midwives not to be greedy for money.(35) A number of Roman legal provisions strongly suggest that midwives enjoyed status and remuneration comparable to that of male doctors.(36)
But there were, no doubt, people who simply did not have the resources to pay for a capable midwife. There may have been some "midwives" who performed their services for a pittance. Soranus certainly implies that some midwives were much better trained than others. What poor women did is not known. We can only guess that if they could not afford a trained midwife, they turned to sagae, wise women who appear to have served at least in part as midwives in early Rome,(37) or to their female relatives who would have given whatever assistance they could. Whether the rate of maternal and infant mortality was lower for births handled by competent midwives, we do not know.
After his description of the good midwife and a highly dubious discussion of female reproductive physiology, Soranus turns to delivery proper. He describes in detail the equipment used for normal labor and delivery. The midwife must have
Soranus provides a good description of the midwife's stool; this chair was used only during the actual delivery, not during labor. Apparently both midwives and physicians believed that normal delivery was easier when the mother sat upright.(39) In the seat of the chair was a crescent-shaped hole through which the baby would be delivered. The sides of the chair had arm-rests, in the shape of the letter "pi," for the mother to grasp during delivery. The chair was to have a sturdy back against which the parturient was to press her hips and buttocks. Soranus's description implies, however, that some midwives' stools did not have backs and that an attendant stood behind the parturient to support her, a less desirable arrangement because of the danger that the parturient might recline or slip backwards.(40)
Soranus recommends that the sides of the chair from the seat to the floor be completely closed in with boards while the front and the back be left open for the midwife's work. Soranus mentions later that if a midwife's stool is not available, the parturient can sit on the lap of another woman, who, understandably, must be robust enough to bear the mother's weight and hold her still.(41) It seems a reasonable conjecture that the children of the poor may have been born without a midwife's stool if the midwives they employed did not have the wherewithal to purchase a birthing stool. Indeed, one of Alciphron's letters describes a midwife who carries with her only a kit.(42)
At the onset of labor, the midwife was summoned and the necessary equipment made ready. During labor, the parturient lay on her back on a hard, low bed with support under her hips; her feet were drawn up together, her thighs parted. Soranus directs the midwife to ease the labor pains with gentle massage, with a cloth soaked in warm olive oil laid over the abdomen and genital area, and with the equivalent of hot-water bottles- bladders filled with warm oil- placed against the woman's sides. As the cervix begins to dilate, the midwife is to encourage the process of dilation by gently rubbing the opening with her left forefinger (with its nail cut short); the finger is to be generously smeared with olive oil. When the cervix is dilated to the size of an egg, the parturient is moved to the midwife's stool, unless she has become very weak; in the latter case, the delivery is to be made on the hard bed.(43)
For the actual delivery, the midwife needs three assistants to stand on both sides of the chair and at the back. Soranus stresses that these assistants should be "capable of gently allaying the anxiety" of the mother.(44) The woman who stood behind the chair had to be strong enough to keep the parturient from swaying; in addition, she was to hold a small, flat piece of cloth at the anus to avoid hemorrhoids.(45) The midwife herself, covered by an apron, sat in front of the mother and throughout the delivery assured her that all was going well.(46)
Clearly Soranus, and presumably most midwives, expected the parturient to do the work of expelling the fetus from the womb during a normal delivery. There is no indication that anything like an episiotomy was performed. One of the midwife's duties was to instruct the mother on proper breathing and on how to push downwards during a contraction.(47) The assistants who stood by the sides of the chair were to assist in delivery by gently pushing downwards on the parturient's abdomen. Soranus's's discussion, supplemented by passages from later medical writers, is similar to the instructions now given to women choosing natural childbirth, except that the father plays no role in the delivery Soranus describes and, more importantly, the instruction in breathing and pushing comes during delivery rather than in a pre-natal training program.
In a normal headfirst delivery, the midwife might stretch the cervical opening slightly to help the fetus's head and shoulders through, after which she gently pulled out the rest of the infant's body. The midwife was also to take care that the umbilical cord was not distended and to remove gently the placenta immediately after the birth of the baby. Soranus instructs the midwife to wrap her hands in pieces of cloth or thin papyrus so that the slippery newborn does not slide out of her grasp; Soranus seems to think that if the midwife's hands are so wrapped, she will not inadvertently squeeze the baby too hard in her efforts to maintain a firm hold.(48)
In the fourth book of his treatise, Soranus discusses difficult labor and delivery. In addition to physical problems such as an overly small pelvic opening, malnutrition, or obesity, he recognizes that a woman's attitude and state of mind can have an important bearing on the ease of her delivery: thus Soranus' counsel that midwives work hard to allay the fears and anxieties of the mother. When the parturient suffers from excessive "grief, joy, fear, timidity, lack of energy, anger, or extreme indulgence," labor and delivery are difficult.(49) Soranus notes that inexperienced women have more difficulty than those who have had babies before and that women who do not believe that they are pregnant also have more difficult labor.(50)
In a lengthy section, Soranus treats the conditions under which the fetus itself causes a difficult delivery and gives detailed instructions for handling various kinds of cases, including those in which the fetus is dead.(51) Unfortunately, it is impossible to tell even roughly what proportion of births were subject to these complications. But the very length of Soranus's discussion implies that midwives could expect to encounter a significant number of complicated births. And although the obstetrical procedures described seem basically sound, many otherwise healthy fetuses probably died during a difficult delivery.(52)
A number of small reliefs provide visual evidence for ancient childbirth. Plate I, a rather crudely fashioned, secondcentury A.D. terra cotta from the tomb of Scribionia Attice in the cemetery on the Isola Sacra at Ostia (tomb 100) depicts (three women: the parturient seated on a birthing chair; an attendant who stands behind the birthing chair with her arms supporting the parturient's upper torso; and the midwife who sits on a low stool in front of the chair and appears to be about to pull the infant from its mother's womb. The presence of this relief in the tomb may indicate that its owner was a midwife.
Plate II, a more elegantly crafted ivory relief from Pompeii (Museo Nazionale, Naples, No. 109905) depicts a similar scene. Here there are four women: the parturient sits in the birthing chair; an attendant stands behind and supports the new mother; the midwife, again seated on a low stool and holding a sponge in her right hand, assists the delivery; the fourth woman, who stands behind the midwife with her arms outstretched, appears ready to take the infant or to offer a blessing.
A marble relief from a private collection (Plate III) provides an even more detailed image of childbirth. Delivery has taken place in a well furnished room of an apparently wealthy household. The parturient, naked in this rendition, is sprawled across a chair (not a birthing chair) with a cushion at her back; her lower torso and legs are entirely off the chair, her left leg propped on a low stool. The midwife sits or crouches at the parturient's feet with the newborn baby on a cushion in front of her. A slave attendant stands behind the midwife. Standing behind the parturient are two men, probably physicians; one of them holds an instrument that appears to be an ancient version of obstetric forceps. Both men grip the left arm of the parturient. This visual evidence, meager as it is, confirms and perhaps supplements the verbal pictures of childbirth in Pliny and Soranus.(53)
IV. Care of the Mother
Soranus follows his description of normal delivery with a discussion of care of the new mother, which, unfortunately, is very fragmentary. The sole surviving section deals with care of the mother's breasts, including treatment of in tumescence or engorgement. He recommends preventive measures such as sponging the breasts with "mildly contracting things (such as diluted vinegar ... or tender dates triturated with bread and diluted vinegar)" or confining them with "a close fitting bandage."(54) If swelling occurs, however, poultices made of bread, water, and olive oil or hydromel, or of linseed, wheat or fenugreek, and water should be applied. If the breasts are too tender to stand the poultices, the fluids should be gently pressed out while soaking the breasts in warm oil. If the breasts become inflamed and suppurate, surgery is necessary to remove the pus and fluid.(55) Soranus also tells how to stop lactation in women who do not intend to nurse their new babies themselves.(56) Presumably, the midwife is to administer this care, at least up to the point of surgery for intumescence. The clear implication is that the new mother remained under the care of the midwife for at least several days after the delivery, and so probably did the newborn infant.(57)
If we compare Soranus's recommendations for the care of the breasts of the new mother with Pliny's descriptions of folk medicine, we again see significant differences. Indeed, the methods of treatment described by Pliny seem not only useless but also perhaps sufficiently distasteful to make breastfeeding and the attendant folk remedies something to be avoided. Pliny suggests drinking mouse dung diluted with rain water and ass's milk for intumescence.(58) Rubbing the breasts with sow's blood, goose grease with rose oil and a spider's web, or the fat of bustards is also supposed to relieve swelling.(59) And a poultice of partridge egg ash, zinc oxide ointment and wax might be used to keep the breasts firm.(60) For breasts that inflame to the point of suppuration, Pliny recommends laying earthworms across the breasts to draw out the pus and adds that earthworms drunk with honey wine stimulate the flow of milk.(61) We may reasonably doubt the efficacy of such treatments; if the breasts were at all abraded, these treatments could cause serious infections. We must assume, however, that these were the kinds of treatment employed for most mothers. Only a relatively few families had the money or the inclination to engage midwives trained according to the medical theories propounded by the leading physicians; nor were there likely to have been many such midwives even in major urban areas.
V. Care of the Newborn After Delivery
Once the baby had been safely delivered, the midwife carefully inspected it for any congenital deformities. Apparently the midwife made the initial recommendation about whether the newborn was healthy and fit to rear.(62) Soranus suggests several tests for determining the health of the infant. First, when placed on the ground, it should cry lustily; babies that do not cry, or cry only weakly, are suspect. Second, its body should be normal; the openings for the nose, ears, urethra, and anus should be clear; its arms and legs should bend and stretch readily. Finally, by pressing her fingers against the skin of the newborn, the midwife should be able to elicit a reaction, indicating that the infant is sensitive to such sensations.(63) Soranus also instructs the midwife to consider whether the mother has been in good health during pregnancy and whether the length of gestation was normal.(64)
We might well ask under what circumstances a midwife would declare a baby unfit. Not all weakly infants nor all those with some kind of congenital defect such as a club foot were regarded as unfit. Probably the midwife made a determination about the chances for the infant's survival and would likely recommend that a newborn with any severe congenital problem be exposed.
After inspecting the child and letting it rest a bit, the midwife severs the umbilical cord. Soranus recommends using a knife and castigates other methods as superstitious. He says that some midwives use a piece of glass or a potsherd (presumably unwashed), a reed, or even a thin crust of hard bread.(65) Soranus indicates that such materials are apt to cause inflammation, showing at least some awareness of a connection between dirt and disease. Instead of cauterizing the cord, as many midwives do, Soranus directs her to gently squeeze the blood from it, to ligate the end with a stout woolen (not linen) thread, and finally to gently press the bent cord into the umbilicus or navel.(66)
With the umbilical cord tied off properly, the midwife is then to cleanse the newborn. In the course of his discussion of washing the infant, Soranus describes the practices of many other groups of people and rejects them all as harmful to the newborn. Soranus recommends that the midwife sprinkle the infant with a moderate amount of "fine and powdery salt, or natron or aphronitre."(67) All these chemicals are mildly astringent and were recommended primarily for their ability to cut through the residue of amniotic fluid, vernix, and placenta on the newborn's skin and also to make the skin less prone to develop rashes; however, astringents would also tend to make the baby's skin dry out and flake or crack. Soranus suggests mixing the salt with honey, olive oil, or the juice of barley, fenugreek, or mallow so the granules are less likely to abrade the baby's delicate skin. The emulsion is to be washed away with warm water and the process repeated a second time. Next, the midwife is to clear any mucus from the nose, mouth, and ears and to clear the anus of any membranes that might impede regular bowel movements. She is to put a little olive oil into the infant's eyes to clear away any birth residue and to place a small piece of wool or lint soaked with olive oil over the umbilical cord. Soranus indicates that some people use cummin here, but he states that cummin is too pungent to be used on an infant.(68) Throughout his discussion of the care of the newborn, Soranus stresses the delicacy of the infant and recommends those treatments he thinks least likely to cause it discomfort.
The vast majority of women in the GrecoRoman world very probably received their maternity care (assuming they could afford to pay for it; no doubt many could not) from midwives who employed the methods and medications described by Pliny. While the traditions of folk medicine probably did little to make childbirth safer (and some practices may have been harmful), it does seem clear that efforts were made to give emotional support to the parturient.
There is insufficient evidence to reach any firm conclusions about the characteristics of the women who practiced midwifery. In the Hellenized East, they seem to have had a higher status than their sisters in the Roman West. Although some women of free birth went into midwifery as a profession, the bulk of them were probably of servile origin or the daughters of women of the lower classes. A very few women became obstetricians of some note.
For the wealthy elites, maternity care was potentially much better. The corpus of medical literature certainly shows that some physicians and midwives employed enlightened techniques that at the very least were unlikely to harm either the mother or the baby. It seems probable, therefore, that the rates of maternal and infant mortality in the Greco-Roman world varied with the socioeconomic class of the family and with the family's choice between traditional folk medicine and professionalized obstetrical care.
The American University
*An earlier version of this paper was read at the 1981 Berkshire Women's History Conference. I am very grateful to a number of people for their useful suggestions, particularly the anonymous referee; Sarah Pomeroy; and Ronnie Lichtman, a practicing midwife and member of the faculty of the Nursing Midwife Program, College of Physicians and Surgeons, Columbia University.
There is a rather scant bibliography on ancient maternity practices; most of the booklength studies of the history of obstetrics give only a cursory treatment of antiquity. See Hugo Blummer, Die romischen Privataltertumer (Munich: Oskar Beck, 1911), pp. 299306; Theodore Cianfrani, A Short History of Obstetrics and Gynecology (Springfield, Ill.: Charles C. Thomas, 1960), pp. 7083; Martial Dumont, "L'Obsterique et la gynecologie dans la Rome antique," Cahiers Medicaux Lyonnais, 41 (1965), pp. 8391; Palmer Findley, Priests of Lucina (Boston: Little, Brown, 1939), pp. 3865; Harvey Graham, Eternal Eve (Garden City, N.Y.: Doubleday, 1951), pp. 5670; Harold Speert, Iconographica Gyniatrica (Philadelphia: l: A. Davis, 1973), pp. 8384.
(1).World Health Statistics Annual ( 1979), pp. 16-28.
(2) Calvin Wells has recently argued that the incidence of female death in childbirth in antiquity has been significantly overestimated; a relatively poorer diet will account for the shorter lives of ancient women, Wells contends. "Ancient Obstetric Hazards and Female Mortality," Bulletin of the New York Academy of Medicine, 51 (1975), 1235-49.
(3) World Health Statistics Annual (1979). Keith Hopkins, Death and Renewal (Cambridge: Cambridge University Press, 1983), p. 225, estimates that 28% of Roman babies who were born alive died by their first birthday.
(4) Ep. 4.21.1-3.
(5) Fronto, ad M.Caesar 1.6.7 and Epis.Graec. 3.
(6) HN 7.6.41.
(7) HN 28.27.102.
(8) HN 28.77.250. The drying and powdering of the dung probably would have reduced its bacterial content, but ingestion of even some E. Coliform (colon bacillus) would be dangerous.
(9) HN 30.143.124 (Loeb translation). Semen has a high sugar content and would have supplied the parturient with energy.
(10) HN 26.90.160-61. Vervain (radix verbenicue) comes from the family of verbena and has been used for medicinal purposes, chiefly for fevers, colds, convulsions, and nervous disorders; it was valued for its nervine, tonic, emetic, and sudorific properties. Scordotis (tencrium scordium) is probably related to garlic and was thought to have antiseptic, sudorific, and alexipharmic properties; it has been used particularly for inflammations. Dittany (origanum dictamnus) is a pink flowered plant, probably of the mint family. For descriptions of the plants prescribed, see R. C. Wren, Porter's New Encyclopaedia of Botanical Drugs and Preparations (Devon: Health Sciences Press, 1975), and Walter H. Lewis and P. E. Elvin-Lewis, Medical Botany (New York: John Wiley, 1977).
(11) HN 30.143.123.
(12) HN 30.44.129 (Loeb translation). Although Pliny does not say specifically what was done with the stick, we can probably assume that it was not used in the process of delivery; rather it was valued for its presumed magical properties.
(13) HN 30.44.130.
(14) Med. 2.8.16.
(15) Med. 5.25.14. Hedge mustard is a common form of wild mustard and is said to be a digestive stimulant, expectorant, and diuretic.
(16) HN 30.43.125; 28.77.255; 25.18.40; 28.77.248. Linozostis is probably annual or perennial mercury (mercurialis annna or perennis), a toxic plant whose leaves can cause gastroenteritis and allergic reactions in the lungs; it is possible that the cramps of gastroenteritis were confused with uterine contractions and that the plant, therefore, seemed to aid delivery. Parthenion is a plant with white ray flowers; P. hysterophorus (the bastard feverfew) and P. intogrifolium are used medicinally. Pliny notes that linozostis and parthenion were recommended as emmenagogues, remedies to induce menstrual bleeding. None of the plants recommended by Pliny or Celsus are known at present to be oxytocic agents, substances that stimulate uterine contractions. But the emetic properties of some of them could induce vomiting which, with its abdominal spasms, is sometimes helpful in separating the placenta from the uterus.
The folk practices described by Pliny and Celsus are similar to contemporary folk medicine. See A. Mangay-Maglacas and H. Pizurki, The Traditional Birth Attendant in Seven Countries (Geneva: World Health Organization, 1981).
(17) Med. 5.25.13.
(18) Recent research has shown how important emotional support is. See Aidan Marfarlane. The Psychology of Childbirth (Cambridge, Mass.: Harvard, 1978), pp. 29-31; Joyce Prince and Margaret E. Adams, Minds, Mothers, and Midwives (New York: Churchill Livingstone, 1978) pp. 116f.; and Barbara Blum, ed., Psychological Aspects of Pregnancy, Birth, and Bonding (New York: Human Sciences Press, 1981), pp 144-45.
(19) A careful edition of the Greek text of Soranus was published by Johannes Ilberg as volume four of the Corpus Medicorum Graecorum (Leipzig and Berlin: Teubner, 1927). For Soranus' Gynecology (Baltimore: Johns Hopkins, 1956). A physician himself, Temkin presumes a fair amount of obstetrical knowledge on the part of his readers. Unfortunately, the section of Soranus' work treating normal delivery is fragmentary. But Temkin's translation fills in many of the lacunae with passages from later gynecological treatises that were based on Soranus, especially the works of Caelius Aurelianus and Muscio. Soranus' extant work, supplemented by later writers, provides the best description of the obstetric care in the Greco-Roman world.
(20) Gyn.1.1.3 (Temkin translation).
(21) Gyn. 1.2.4.
(22) Gyn. 1.1.3.
(23) Temkin, p. XXXVII.
(24) Gyn.1.2.4 (Temkin translation). Soranus's reference to the dreams of midwives may parallel anthropological findings. In some cultures, women are selected as midwives on account of a dream vision in which they are taught the skills and knowledge of the profession. We do not know how Greco-Roman women became midwives, but Soranus's brief statement might suggest that dreams played a role in the selection process. See Shelia Cosinsky, "Cross Cultural Perspectives on Midwifery," in Medical Anthropology, eds. S. Grollig and H. Haley (The Hauge: Mouton, 1976), pp. 231-32.
(25) Temkin, p xxxvii. But the male physician gave directions; the midwife did the work (Galen, Nat. Fac. 3.3.151).
(26) In Plautus's comedy Amphitryon, Alcmena delivers twins without anyone present (lines 1070-72). However, the birth story here parallels that of Heracles so strongly that the absence of the midwife should not be taken too seriously, even though Alcmena's family surely could have afforded one.
(27) For women as midwives and physicians in the East, see Sarah B. Pomeroy, "Technikai kai Mousikai," AJAH, 1 (1976), 86, and Natalie Kampen, "Social Status and Gender in Roman Art. The Case of the Saleswoman," in Feminism and Art History, eds. Norma Broude and Mary Garrand (New York: Harper & Row, 1982), p. 70, and Image and Status: Roman Working Women in Ostia (Berlin: Gebr. Mann Verlag, 1981), pp. 69-72 and 116-17. Soranus (Gyn. 3.3.1) draws a clear distinction between the midwife (maia) and the physician obstetrician (iatros gynaikeios); in Latin, ob(p)stetrix and medicus/a parallel Soranus' Greek terminology.
(28) CIL, 6: # 4458, 6325, 6647, 6832, 8192, 8207, 8947-9, 9720-5, and 37810. We should not assume that because so few women are identified as midwives that there were very few midwives in general. Until more research is done onanalyzing the occupational titles recorded in funeral epitaphs, we cannot conclude anything about the relative numbers of people engaged in different occupations.
(29) Contra: Treggiari (above, note 27), 87; she sees the women commemorated by # 9720, 9722, 9724, and 9725 as just as likely to be freeborn as freed. Treggiari suggests, therefore "that free women might train for this work and that only in domestic service would slaves be the rule." Kampen (above, note 27), p. 116, argues for the servile background of most midwives.
(30) For midwives working expertly at an advanced age, see Cosminsky (above, note 24), p. 231.
(31) In the other eleven epitaphs, the name of the commemorator is not given.
(32) John Scarborough, Roman Medicine (London: Thames and Hudson, 1979), p. 19. See Dig. 22.214.171.124; Ulpian describes the application of the Lex Aquilia to obstetrices.
(33) M. Gl. 697.
(34) P. Oxy. 1273, lines 33-34. The potential income of a midwife suggested by this contract compares favorably with other wages from this period and region. Stewards, for example, earned approximately 40 drachmae a month (P. Lond. 1226 and P. Flor. 321 and 322); ox drivers made between 34 and 48 drachmae a month (P. Flor. 321); common laborers could expect around four to eight drachmae a month (P. Flor. 322); estate managers received between 60 and 128 drachmae a month (P Oxy. 1577-78). See Allan Chester Johnson, An Economic Survey of Ancient Rome, vol. 2, ed. Tenney Frank (Paterson, N. J.: Pageant, 1959), II, pp. 309-10.
(35) Gyn. 1.2.4.
(36) Cod. Iust. 6.43.3 provides that slave medici and obstetrices left to legatees had equal value (60 solidi). Dig. 50.13.1 gives a list of people for whom provincial governors were to hear suits on contracts for wages; at 126.96.36.199 the midwife is given equal access to the official because she is regarded as practicing medicine just as doctors do (quae utique medicinam exhibere videtur). See J. A. Crook, Law and Life of Rome (Ithaca: Cornell University Press, 1967), pp. 204-05, and Kampen (above, note 27), pp. 70 and 117.
(37) Scarborough (above, note 32), p. 18; W. W. Fowler, The Roman Festivals of the Period of the Republic (London: Macmillan, 1899), p. 292, connects the Carmentes, birth goddesses, with the sagae.
(38) Gyn. 2.2.2.
(39) Recent research indicates that an upright as opposed to a recumbent position is more comfortable for the parturient and reduces the time of both labor and delivery. See Susan McKay and Charles S. Mahart, "Laboring Patients Need More Freedom to Move," Contemporary OB/GYN, July 1984, 90-119. I am grateful to Dr. Celeste Phillips for her assistance on this question.
(40) Gyn. 2.2.3.
(41). Gyn. 2.3.5.
(42) Letters 2.7.1.
(43) Gyn. 2.2.3-2.3.4. Galen's brief description of the midwife's duties during delivery (Nat. Fac. 3.3.151-52) closely parallels Soranus's account. Midwives today use massage and warm oil to soothe the parturient during labor. But the practice of trying to hasten dilation by rubbing the cervix is potentially dangerous, for the midwife's finger, even if smeared with oil, is likely to introduce foreign bacteria. However, since birth took place at home, there was less likelihood that the parturient would be contaminated with bacteria from sick people.
(44) Gyn. 2.3.5.
(45) Hemorrhoids usually develop during pregnancy, if they occur at all; Soranus's advice may well have prevented internal hemorrhoids from becoming external during delivery. The cloth held at the anus may also have prevented fecal matter from contaminating the perineum and vagina.
(46) Gyn. 2.3.5.
(47) Gyn. 2.3.6. According to Pliny, HN 7.6.42, women who do not hold their breath during delivery experience greater difficulty; Pliny also adds that gasping may prove fatal.
(48) Gyn. 2.3.6. It is hard to see how the midwife would be able to reach the cervix once the baby's head had emerged. Soranus may mean the perineum. More serious is the instruction to try to remove the placenta immediately after delivery. Premature removal of the placenta, especially if the midwife attempted to reach into the uterus, would be likely to cause infection and even hemorrhage. Modern practice is to allow the placenta to separate itself from the uterine wall and then to have the parturient push to expel it.
(49) Gyn. 4.2.2.
(50). Gyn. 4.2.2.
(51) Gyn. 4.2.3f.
(52) Galen says that infants present feet first, laterally, or with an arm or leg first in only one of many thousands of births (de Usu Partium 15.7). We should properly take this observation with a grain of salt, since neither Galen nor any one else in antiquity ever tried to make an accurate count of such occurrences. But clearly, Galen thought these births unusual. Modern statistics suggest that in about five percent of deliveries, the infant presents in a difficult position- breech, transverse, compound, or face/brow first. By far the most common, breech occurs in about three to four percent of deliveries. Breech presentations are especially associated with prematurity and poor nutrition, conditions at least as likely in the Greco-Roman world as today. As a general rule of thumb, 85-90% of all births in a generally healthy female population are normal and uncomplicated. See Harry Oxorn, Human Labor and Birth, 4th ed. (New York: Appleton Century Crofts, 1980).
(53) See plates I-III. For the Ostia and Pompeii reliefs, see Kampen (above, note 27), pp. 69-72. For the relief depicting obstetrical forceps, see Harvey Graham, Eternal Eve (Garden City: Doubleday, 1951), pp. 68-69. Professor Silvestro Baglioni, the owner of the relief reportedly found near Rome, dates it to the second or third century B. C., but its authenticity is not secure. For ancient obstetric surgical instruments, see John Stewart Milne, Surgical Instruments in Greek and Roman Times (New York: Oxford, 1907), pp. 152-58.
(54). Gyn. 2.5.7 (Temkin translation). A terra cotta figurine in the Athens National Museum (No. 5666) shows a woman bandaging both her breasts; since she has a rather flabby abdomen, the figurine may well depict this method of caring for the breasts after delivery, a method also used by modern midwives.
(55) Gyn. 2.5.7. Fenugreek (trigonella foenumgraecum), a leguminous annual herb with aromatic seeds, has been used as an insulin substitute. Plutarch's wife apparently underwent surgery for a "bruised nipple" incurred while nursing her son Charon; Plutarch praises her action as "noble" and indicative of "true mother love" (Mor. 609F). The tenor of Plutarch's remarks suggests that such surgery was very painful.
(56). Gyn. 2.5.8.
(57). Despite the fullness of Soranus's description of the duties of the midwife, she may have been expected to do even more. For example, Horace refers to a midwife washing the bloodstained cloths used in delivery (Epod. 17.51). It may well be that some midwives brought with them the cloths they used in childbirth; if so, one is relieved to learn that they were washed.
(58). HN 30.43.124 and 28.77.250.
(59) HN 28.77.250 and 30.45.131.
(60) HN 30.45.131.
(61) HN 30.43.125.
(62) Varro, apud Nonius 528.12; Soranus, Gyn. 2.6.10.
(63) Gyn. 2.6.10. The author of the biography of Clodius Albinus comments that normal children are red at birth (SHA, Clod. 4.4). Surprisingly, Soranus does not mention the newborn's skin color as an indication of its health.
(64) Gyn. 2.6.10. The normal period of gestation was believed to vary between seven and ten months. Without a system of prenatal care, the midwife would have to rely on the mother's determination of her health and length of pregnancy; such determinations were, no doubt, often in error.
(65) It is possible that poor midwives used such readily available implements in order to save the cost of purchasing a knife.
(66). Gyn. 2.7.11. The potential problem with cauterization, apart from the pain it probably causes the infant, is that it will not always completely close the blood vessels and thus increases the possibility of umbilical hemorrhage. Pressing the cord into the umbilicus is not likely to insure an indented naval.
Oribasius gives similar instructions for ligating the umbilical cord. It is to be cut at a distance of about four finger widths (about three inches) from the stomach with a sharp knife; neither a reed nor a piece of glass should be used in order to keep the contusion as slight as possible. After cutting, the blood should be gently squeezed from the cord, and then the end is to be wiped and bound with wool (Collect. Med. Liv. Incert. 12.1).
(67). Gyn. 2.8.12-13. Natron is the mineral, hydrated sodium carbonate, rather like baking soda; aphronitre is probably some kind of foaming saltpeter, either potassium or sodium nitrite.
(68) Gyn. 2.8.13. Cummin is a plant from the same family as parsley and celery and has a sharp, distinct taste and odor.