Childbirth and obstetrics in antiquity

Childbirth and obstetrics in Classical Antiquity were studied by the physicians of ancient Greece and Rome, who established ideas and practices that endured in Western medicine for centuries. Gynecology and obstetrics were originally studied and taught mainly by midwives in the ancient world, but eventually also by scholarly physicians of both sexes, who wrote works setting the foundation of the later European study of obstetrics. Obstetrics is traditionally defined as the surgical specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium (recovery). In Classical Antiquity (here meaning the ancient Greco-Roman world), surgical intervention did not exist. Without the presence of surgical technology an alternative was necessary. In 2nd century CE, physician Soranus wrote a text on gynecology describing the occupation of the midwife.

Midwifery and obstetrics are distinctly different but overlap in medical practice that focuses on pregnancy and labor. Midwifery emphasizes the normality of pregnancy along with the reproductive process. Classical Antiquity saw the beginning of attempts to classify various areas of medical research, and the terms gynecology and obstetrics came into use. The Hippocratic Gynaecea (Diseases of Women) was written in two volumes, part of the larger Hippocratic Corpus collection of medical literature influenced by Hippocrates.

Women as doctors

A modern engraving of Agnodice, a midwife and obstetrician, who according to legend disguised herself as a man in order to practice as a doctor.

During the era of Classical Antiquity, women practiced as doctors, but they were by far in the minority, being confined to the traditional area of medicine for women: gynecology and obstetrics. The 2nd century CE was the beginning of the Hippocratic Corpus in ancient Greece. Greek physicians attempted to standardize medical practice. Aristotle was an important influence on later medical writers in Greece and eventually Europe. Aristotle concluded, similar to the writers of the Hippocratic Corpus, that women's physiology was fundamentally different from that of men primarily because women were physically weaker, and therefore more prone to symptoms caused in some way by weakness, such as the theory of humourism, that both men and women had several "humours" regulating their physical health, and that women had a "cooler" humour.^[1]

The traditional ancient practices of midwifery in Greece and Rome, as closely linked as they were to religious beliefs, were increasingly at odds with the male-dominated sphere of the scholarly physicians who worked as formal writers and lecturers on obstetrics and gynecology. The Hippocratic Corpus writers indicated that men were more rational than women, and that women's physiology made them susceptible to problems that would cause symptoms of irrationality.^[2] Continuing with this assumption that men were more rational, men dominated the profession of physicians, an occupation requiring rational research, and for which they believed women were not suited. Physicians studied medicine from the perspective of objective science and rejected supernatural influences on health, looking for purely physical explanations.

This did not stop women from sometimes becoming physicians, however; Agnodice was said by several ancient writers to have been a popular gynecologist who disguised herself as a man in order to practice as a physician. Philista was a popular professor of medicine who was said to have delivered lectures from behind a curtain, to prevent her beauty from distracting her students.^[3] In ancient Greece, there was also an intermediate occupation for midwives with some further medical training, known in Latin as the iatromea.^[4]

Women doctors may have offered specializations beyond gynecology and obstetrics, and in some instances they did, but in most cases there is not enough information to know how frequently women may have been able to practice medicine beyond these traditional areas for women. As obstetricians and gynecologists, they appear to have been numerous. The Law Code of Justinian presumed women doctors to be primarily obstetricians. The first medical text known to be written by a woman is by Metrodora, Concerning the Feminine Diseases of the Womb, a work in 63 chapters that was part of a series of at least two works that she authored. The earliest copy dates from between the 2nd century and the 4th century CE.^[5]

A doctor received training through an apprenticeship, often from a relative who was a physician. Receiving recognition as a physician carried civic privileges and responsibilities with it in ancient Greece and Rome, and it was usually a men's sphere. Pantheia, who was the wife of a physician, became one herself, a pattern also seen in the careers of Aurelia Alexandria Zosime and Auguste. Auguste received recognition as a chief doctor of her city, a title her husband also received. Metilia Donata was prominent enough to commission a large public building in Lyon. Anthiochis of Tlos, a doctor who was the daughter of a prominent physician, Diodotus, was recognized by the council of Tlos for her work as a doctor and had a statue of herself erected. She was also a widely discussed expert cited by Galen and others. Aspasia is quoted extensively by Aetius on gynecology.^[6]

Midwifery

Midwifery flourished in ancient civilizations, including Egypt, Byzantium, Mesopotamia, and the Mediterranean empires of Greece and Rome. During Classical Antiquity, the professionalization of medicine began to challenge the domination of this area by women. There were also male physicians who recognized a role for women health practitioners; Herophilus wrote a manual for midwives, an advance for midwifery's status. This was followed by the work of the Greek Soranus of Ephesus, who was widely translated into Latin,^[7] and Galen. This Greco-Roman approach differs greatly from other ancient civilizations, where women's role as medical specialists concerning gynecology and obstetrics was apparently unquestioned. Medical schools attached to temples in ancient Egypt were numerous, including well-known medical schools for women at Heliopolis and Sais, where women are also believed to have been the professors.^[8]

Soranus of Ephesus states that for a woman to be an eligible midwife she must be

A suitable person…must be literate to be able to comprehend the art through theory too. She must have her wits about her so that she may easily follow what is said and what is happening. She must have a good memory to retain the imparted instructions (for knowledge arises from memory of what has been grasped). She must love work, to preserve through all vicissitudes (for a woman who wishes to acquire such vast knowledge needs manly patience).

The most qualified midwife would be trained in all branches of therapy. She should be able to prescribe hygienic regulations for her patients, observe the general and individual features of the case, give advice by recalling from previous knowledge what medical decisions would work in every case and to be reassuring to her patients. It is not necessary for her to have had a child to deliver another woman’s child, but it is good if she has been in labor to enhance sympathy with the mother.

To obtain good midwifery habits, she will be well disciplined and always sober, have a quiet disposition sharing many life secrets, must not be greedy for money, be free of superstition to not overlook salutary measures, keeping her hands soft by staying away from wool-working as this may harden her hands and use ointments to acquire softness. She too needs to be respectable, the people of the household will have to trust her within their household, may not be handicapped in the performance of her work. Long and slim fingers with short nails are necessary to touch deep-lying inflammation without causing too much pain. Midwives that acquire of all these will be the best midwives.^[9]

Gynecology and pregnancy

Greek Attic funerary stele, showing a seated woman who died in childbirth bidding farewell to her husband, mother and newborn's nurse. Around 350 to 330 BCE.

The writers of the Hippocratic Corpus separated the Diseases of Women from the rest of the Corpus. There were also a number of influential Hippocratic treatises: Sterile Women; On the Nature of Women; Superfetation (the conception of a second fetus while already pregnant); Excision of the Fetus (on complications during delivery); On the Diseases of Young Girls (illnesses believed to be caused by delayed marriage); and other treatises covering the development of the fetus at different stages of gestation.^[10]

Labor and delivery

Midwifery and the process of labor and delivery in antiquity go hand in hand. Hospitals did not exist, so delivery took place in the home of the expectant mother with a midwife and the presence of other women to aid the midwife.

Religion played a major role in antiquity including childbirth. Women in labor called upon the goddess Artemis, who had the ability to bring new life into the world as well as the ability to take it away. Though she remained a virgin herself, it was said that she witnessed the pain of her mother during the birth of her brother, Apollo, and immediately assumed the position of midwife. If a woman died during childbirth, her clothes were taken to the temple of Artemis due to the fact the woman's death was attributed to her.^[11] If the birth was successful, the mother would make an offering of thanks by sacrificing some of her clothes to the goddess as well.^[12]

Herbs and other plants were used heavily in the delivery process, a practice also linked to religious belief. For example, a drink sprinkled with powdered sow’s dung was given to relieve labor pain, and fumigation with the fat from a hyena was thought to produce immediate delivery.^[13] Most of these practices had little to no medical efficacy, but they did probably provide some placebo effect. These superstitious practices were very common and differed from the medical training that scholarly physicians attempted to provide through their research and writing. Despite the attempt to use science in advancing medical knowledge, the experimentation and teachings of the Hippocratic Corpus were not necessarily more effective than the traditional customs of midwifery. For example, the Hippocratic writers believed that the womb could move out of place and cause health problems, and the prescribed treatment was to coax the displaced womb back into place using sweet-smelling herbs.^[14]

Significant advances were made in child bearing with the introduction of the Hippocratic Corpus in the 3rd century BCE, though this document still proved to implement many ideas concerning superstitions. Physician Galen also provided much advancement in medicine for women in the late 1st century CE, though he focused mostly on specific diseases with only some aspects of labor mentioned. Physician Soranus, who wrote several texts on gynecology in the 2nd century CE, has proven to be the most eminent authority on childbirth and obstetrics in Classical Antiquity.

Soranus described three main stages of pregnancy: conception, which regarded keeping the male seed within the womb; pica, which occurred 40 days into pregnancy and included symptoms of nausea and cravings for extraordinary foods. During this phase women were also instructed to exercise and sleep more to build up strength as preparation for the labor process. The final stage of pregnancy was described being the labor and the process of delivery. In preparation for labor, the woman was advised to bathe in wine and sweet-water baths to calm her mind before delivery. Her belly was then rubbed with oils to decrease the appearance of stretch marks and her genitals were anointed with herbs and injected with softeners such as goose fat.^[15]

The role of the midwife was very important during the process of childbirth and Soranus described her role in great detail. For example, the midwife was to have certain tools to ensure a safe delivery, including: clean olive oil, sea sponges, pieces of wool bandages to cradle the infant, a pillow, strong smelling herbs in case of fainting, and a birthing stool.^[16]

The midwife would ready her supplies as labor began. During the labor process, the mother would lie on her back on a hard, low bed with support under her hips. Her thighs were parted with her feet drawn up. Gentle massage was implemented to ease labor pains as cloths soaked in warm olive oil were laid over her stomach and genital area. Against the woman's sides were placed hot compresses in the form of warm oil-filled bladders.^[17]

During the actual birth, the mother would be moved to the birthing stool where she was seated with a midwife in front of her and female aids standing at her sides. In a normal headfirst delivery, the cervical opening was stretched slightly, and the rest of the body was pulled out. Soranus instructed the midwife to wrap her hands in pieces of cloth or thin papyrus so that the slippery newborn did not slide out of her grasp.^[18]

Caesarian sections

The word “caesarian” possibly derives from the ancient Roman ruler Julius Caesar, because it was believed that Caesar was delivered through this procedure.^[19] However, this is probably based more on tradition and myth than historical accuracies. Another possibility for the etymology of the word “caesarian” is the Latin word caedere, meaning “to cut”.^[20]

This practice is probably much older than Julius Caesar, but "C-sections", as performed by the Romans, were done to rescue the baby from a dying or already dead mother, and were performed post-mortem.^[21]

Evidence suggests that Jews in ancient Rome successfully practiced C-sections on living mothers who were not in danger of dying.^[22] Evidence of these procedures is found in several collections of ancient Roman Rabbis, the most famous of which is called the Mishnah.^[23]

Greeks and Egyptians did not perform C-sections, either post-mortem or on living mothers. However, Greeks would have had at least some knowledge of the caesarian operation and the procedure involved. The Greek god Aesclepius was fabled to have been extracted from his mother’s womb through this procedure.^[24]

Other than the evidence of Jews practicing C-sections in antiquity (very little in ancient Rome, even less in ancient Greece), not much more evidence exists regarding caesarian-operation birth. One reason could have been that C-sections were not performed very often because of medical complications or superstitions surrounding C-sections.

In early Christian Rome, C-sections were almost non-existent.^[25] Loss of skill is a possibility for the lack of C-sections. Infant mortality rates were high in antiquity, so C-sections certainly could have been useful. However, early Christian doctors could have disregarded C-sections as a socially acceptable surgery because of religious beliefs.^[26]

The lack of education for women (who would have been the most knowledgeable about childbirth procedures) and the social norm that women remained in the private sphere of life (as opposed to public) is theorized to also have contributed to a shortage of C-sections.^[27] Midwives were the primary persons involved in the childbirth process. Midwives were women, and in ancient Greece and Rome were not considered actually physicians. They did not record their medical practices in writing like Soranus or Galen. Thus, C-sections could have potentially occurred on a fairly regular basis, and accounts were simply not recorded.

Disease, a perceived need for secrecy, and social discouragement could also have been factors that lead to the decline in C-sections among early Christians in Rome. Almost no evidence exists for C-sections in the Christian world until the 10th century.^[28]

Death and childbirth

Mortality is considered to have been quite high in antiquity, due to a few factors: a lack of sanitation and hygienic awareness, no understanding of micro-organisms, and a dearth of effective drugs all contributed. In the context of childbirth, however, maternal and infant mortality were seriously raised by modern standards. This inflation resulted from the toll childbirth took on women, and the increased risk of infection following labor. Infants are fragile compared to adults, and the lack of sanitation mentioned above contributed further to this fragility.

Maternal

Maternal mortality figures are available only through comparison. While well-attested in the sense that sources are not lacking, all evidence is anecdotal and difficult to extrapolate valid statistics from. Therefore, maternal mortality is thought to be comparable with figures for similar, but much later, societies with more surviving records, such as eighteenth-century rural England, where maternal mortality averaged 25 per 1000 births.^[29]

Infant

The question of infant mortality in antiquity is complicated by infanticide and exposure, neither of which reflect on medical ability during the period, though both remove children from family records. The former does this through intentional death of the child, and the latter through abandonment, and possible death. These reflect instead on social conditions and norms. While valuable, this is not the information sought, and scholars having painstakingly attempted to eliminate the noise from their inquiries.^[30]

While it is difficult to construct actual figures of the infant mortality rate in antiquity, comparisons have been made between ancient societies and modern non-industrialized societies. The figures suggested for these are then compared with those of modern industrialized societies to put them in perspective. While infant mortality is less than 10 per 1000 in modern industrialized societies, non-industrialized societies display rates from 50 to 200+ per 1000. Scholarship using model life tables and assuming life expectancy at birth of 25 years produces the figure of 300 per 1000 for Roman society.^[29]

See also

• Aspasia (physician)
• Galen
• Hippocrates
• Ancient Egyptian medicine
• Metrodora
• Women in Ancient Egypt
• Women in medicine
• Women in hospitals

References