The Asclepion
Prof. Nancy Demand, Indiana University
- Bloomington
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*
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)
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.(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.
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]. (38)
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.
VI. Conclusions
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
Valerie French
NOTES
*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.
Footnotes
(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. 9.2.9.1; 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 50.13.1.2 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.
