MIDWIVES AND MATERNITY CARE IN THE ROMAN WORLD

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. 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. If we include late fetal and in­childbirth deaths, the probability of infant mortality climbs from 5% to 8%.

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.  And the Athenian philanthropist, Herodes Atticus, was grief­stricken when his first child, a son, died on the day of his birth. 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 Greco­-Roman 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.  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.  A drink sprinkled with powdered sow's dung will relieve the pains of labor, as will sow's milk mixed with honey wine.  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."  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. 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.  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.  A vulture's feather might be placed under the woman's feet to aid delivery.  Celsus remarks on other folk nostrums, reporting that sneezing relieves a difficult labor; Celsus also recommends drinking hedge mustard in tepid wine on an empty stomach for difficult labor.

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. Celsus recommends a draught of four measures of ammoniac salt or Cretan dittany dissolved in water.

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.

II. Midwives 

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.  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." 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.

Soranus argues that the best midwives should be literate so that they can be knowledgeable about obstetrics and pediatric theory.  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.  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...."

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  But. the literary sources make it clear that midwives normally attend childbirth. 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.

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.  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.  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. 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).

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.

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.  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. Soranus admonishes midwives not to be greedy for money. A number of Roman legal provisions strongly suggest that midwives enjoyed status and remuneration comparable to that of male doctors.

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, 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.

III. Obstetrics 

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  olive oil [clean, not previously used in cooking], warm water, warm fomentations [ointments applied to the body], soft sea sponges, pieces of wool, bandages [to swaddle the infant], a pillow [on which to which to place the infant], things to smell [pennyroral, dirt, barley groats, apples, quinces, lemons, melons, cucumbers; these were used as we use spirits of ammonia to revive someone who has fainted], a midwife's stool or chair [this was the property of the midwife; she brought it with her to the home where the delivery was to take place], two beds [a hard one for use during labor and a soft one for rest after delivery], and a proper room [of medium size and moderate temperature].

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. 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.

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.  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.

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.

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.  The midwife herself, covered by an apron, sat in front of the mother and throughout the delivery assured her that all was going well.

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. 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.

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.  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.

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.  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.

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.

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."  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.  Soranus also tells how to stop lactation in women who do not intend to nurse their new babies themselves.  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.

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.  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.  And a poultice of partridge egg ash, zinc oxide ointment and wax might be used to keep the breasts firm.  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.  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.  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.  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.
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. 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.

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." 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.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.

VI. Conclusions 

The vast majority of women in the Greco ­Roman 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.

NOTES 

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.

By Valerie French available in http://www.indiana.edu/ Digitized, adapted and illustrated to be posted by Leopoldo Costa. (An earlier version of this paper was read at the 1981 Berkshire Women's History Conference.)