Lady Barrett's concept of maternity care

By Claudia Jessop

(Note: the photograph shows a mother-and-baby clinic in the Stepney area in 1917.  The author's great-grandmother, Sonia Levinson, is seated third from the right in the front row, with her fourth child Freda on her knee.  This would have been the kind of maternity and child welfare provision for the women of East London that Lady Barrett envisaged in her proposal of 1916.)

On 2 November 1916, Lady Barrett took part in a special discussion on the Need for Improvement in the Care of Pregnant Women at the Royal Society of Medicine, giving an address entitled The Importance of Linking up all Organisations for Maternity and Child Welfare in Local Health Districts. In this speech, she outlined a vision of what in today’s jargon might be called ‘joined-up’ maternity care, which seems radical, modern and intuitive even at a distance of more than 90 years. What comes across forcefully, in addition to the practical, down-to-earth nature of Lady Barrett’s approach to her subject, is her respect for the individual mother, and her understanding that the co-operation of the ordinary working-class woman with outside agencies can only be secured if she is treated with dignity and sensitivity, “befriended” rather than patronised or coerced. Her introduction states that in all maternity and child welfare endeavours:

“… the central factor is the mother, and mothers are self-respecting human beings, thoroughly British in resenting interference as to the best way of managing their own affairs, and particularly sensitive in regard to the subjects with which we are concerned, their homes and their children”.

She goes on to suggest that “the linking up of organisations for maternal and child welfare must be planned with the mother, her wishes, her prejudices, and her disabilities in the focus of our attention.” The phenomenon of outside agencies getting involved with the ante- and post-natal health of women, particularly of the poor, and with the health of their children, in any organised way was a very recent one, and Lady Barrett seems acutely aware of the danger of alienating some of those women who might most stand to benefit, by having a high-handed attitude, or by failing to understand the real everyday circumstances of their lives. At the same time, new developments in the medical understanding of pregnancy and infant health meant that much of a woman’s received wisdom on the subjects, passed down through the ‘folklore’ of previous generations of women, was being revealed to be not only unhelpful but positively dangerous, for instance the use of alcohol as an infant sedative. The need to educate women in health matters was urgent. It was a difficult balance to strike, but Lady Barrett gives the impression of being under no illusions as to the pressures and hardships suffered by working-class mothers:

“It is true that the mother does not yet know what she needs. So accustomed is she to a maximum of suffering and a minimum of comfort that she does not dream it possible that even the luxury of having time to be ill could ever come her way.”

Lady Barrett goes on to outline her vision for a new way of organising maternity and child welfare services whereby every expectant mother would have medical supervision during her pregnancy, skilled attention during labour, and continued medical supervision while breastfeeding. She was adamant that every woman should have access to a specialist obstetrician if her labour became complicated. It was only six years earlier, in April 1910, that the important Maternity Act of 1902 had come into full operation, including its requirement that the Central Midwives Board keep a Roll of certified midwives – the act made it an offence for any unqualified woman to “attend women in confinement ‘habitually and for gain’”. But it was not until 1918, two years after Lady Barrett made her address, that the Midwives Act made it a legal duty of a midwife to summon a doctor when complications exceeded her skills.  All of these developments were revolutionary, as most poor women prior to this period had been dependent on the skills of only basically-trained birth attendants or completely untrained relatives or neighbours, who struggled to cope if things became difficult, and who were of course unable to carry out surgical interventions. Lady Barrett envisaged a ladder of referral in such cases, with every midwife being able to call upon a doctor if she should find herself unequal to the complications, and every doctor in turn being able to call upon an obstetric specialist like herself.

Another part of Lady Barrett’s vision was the emphasis on preventative care: “It is better to provide a fence at the top of a cliff than an ambulance at the bottom”, as she pithily put it. She expressed the hope that the then new term ‘ante-natal clinic’ would come to be replaced by the term ‘maternity clinic’, to reflect the ongoing nature of supervision beyond birth. She emphasised the importance of education for mothers in how best to safeguard their children’s health:

“Most mothers need education in all the activities which pertain to the making of a home and the bringing up of children, for, while it is quite true that all the education in the world will not teach a woman to mother, yet a mother’s love for her children without knowledge has in the past led to many harmful practices.”

She felt that such education would best be provided regularly in the home by a qualified advisor “who is regarded as a friend”, and also in the setting of maternity clinics which she saw as providing women with the opportunities for camaraderie of a social club, and allowing their children to continue to be medically supervised until the age of five. Implicit in her proposals is the idea of much new employment for women in the field of health and welfare, as it is taken for granted that any person a woman would be likely to “regard as a friend”, and feel able to confide in about her pregnancy and motherhood, would be another woman.

Further on in the speech, Lady Barrett lamented the terrible conditions in which many of the women she had encountered in the course of her work were forced to live and to give birth. She railed against the idea that a midwife should be required to adapt to insanitary environments that would never be considered suitable for surgery. With this in mind, she advocated that all women whose births were likely to necessitate surgical intervention, as well as all of those whose homes fell below a certain standard (homes where, for example, there was no room available for a woman to give birth in private, away from other family members), should be able to give birth in hospital. (There are many references in the Mothers’ Hospital Annual Reports to women’s experience of their sojourn at the Mothers’ as an interlude of undreamt-of luxury, compared to the hardships they would return to at home.) For the remaining women, those who were not expected to need surgery and whose homes met the minimal criteria for adequacy, Lady Barrett proposed the radical idea that they should be provided with domestic help and support around the time of the birth, so that they would not have to continue to shoulder the burden of cooking and housework at this time. This was, she asserted, just as important a contribution as nursing was to these women’s well being. She also pointed out that while it was beginning to be considered disgraceful for a pregnant woman to have to carry out hard manual labour as part of her paid employment, the physical strain inherent in women’s home lives was often ignored – she evokes vividly some of the harsh details of domestic life for working-class women at the time, painting a picture of pregnant women continuing to struggle against dirt with inadequate supplies of clean water, against cold with inadequate coal, against hunger with inadequate food, and regularly carrying heavy weights up many stairs in the course of their domestic duties. Her outrage is palpable when she says: “The sanitary arrangements of many dwelling-places of the poor are so bad that it is almost incredible that they have been tolerated in homes which rear the citizens of the richest Empire in the world.” We must assume that her experience of visiting homes in Hackney was part of what informed this view.

Lady Barrett saw the new maternity provision as being ideally organised at central Government level: “only control by a state department can make municipal work approach uniformity of standard … We hope that … a State department may one day be set up under a Minister of Public Health.” Over 30 years before the advent of the NHS, this was radical stuff indeed. Under the system she proposed “Poor Law infirmary midwifery would cease to exist, and I venture to suggest that this would be entirely beneficial to mother and child.” She advocated a network of local maternity clinics, recognising that facilities would only be “attractive to the mother” if they were situated within easy reach of her home, and would not require her to wait for a long time to be seen. (Descriptions from The Mothers’ Hospital’s Annual Reports of clients of the ante-natal clinic apparently good-humouredly waiting on staircases before adequate waiting areas had been built come to mind.) She waxes lyrical on an almost Utopian vision of maternity clinics where a woman’s pregnancy will be dealt with by the same doctor who will officiate at the birth, where all kinds of interesting and educational activities will be available for mothers, where health visitors, always treating women with “tact and sympathy”, will put to use their training in “sanitation, tuberculosis, health visiting, infant care and the nursing of children, and also some knowledge of midwifery and sociology.” (author’s italics).

Such a health visitor – who should have attained a standardised qualification – would be able to have a global approach to the problems a family might be experiencing; her duties would extend to reporting unfit living conditions to the housing authorities, putting unemployed husbands in touch with labour exchanges, and reporting suspected cases of tuberculosis. Her role would militate against too many overlapping home visits by too many representatives of different agencies: “One of the many trials of the working-class mother must be the desire of so many people to do her good, and their determination to invade her home for that purpose.”

Lady Barrett called for maternity clinics to advertise all fees charged by local doctors and midwives, so that women could make informed choices before engaging paid help. She points out that many women could afford only the fee of a midwife, and not the further fee of a doctor whose skills might be necessary should complications arise, and reminds her audience that it is not only undesirable but illegal for midwives to try to resolve difficult cases on their own. This problem, she says, has been solved by an agreement between the Local Government Board and the Local Health Committee, who would each pay half of the doctor’s bill in such cases. There must inevitably have been women for whom even the lowest midwife’s fee was out of the question, but Lady Barrett looks forward to the better solution of free consultation being available at the local hospital.

All in all, her submission to the Royal Society reads as an incredibly modern vision, and one which shows her intimate knowledge of and empathy with the kinds of often severely disadvantaged women she would have encountered in her work at the Mothers’.