Place and Power: A History of Maternity Service Provision in Western Australia, 1829-1950 Briony McKenzie B.A. History, Hons. This thesis is presented for the degree of Doctor of Philosophy of Murdoch University 2015. ii Declaration I declare that this thesis is my own account of my research and contains as its main content work which has not previously been submitted for a degree at any tertiary education institution. …………………………… Candidate iii Abstract The nature and provision of maternity services is shaped by many different factors including location and time period. This thesis is a historical study of Western Australia’s maternity services during the period 1829 to 1950. It examines the influence of the medical profession, the state, midwives and women themselves in bringing about important changes to the provision of these services. The study adopts a post-revisionist feminist approach which prioritises the voices of women both as mothers and as midwives. In doing so, it questions established traditional understandings of the quality of the midwifery services offered in WA during the pioneering period and highlights the ways in which medical practitioners and governments undermined empirically-trained midwives and brought about greater state control of their activities. In this analysis, birth in the past is ‘re-normalised’ through an exploration of what birthing may have been like for everyday women and the home is reimagined as a safe and comfortable birthing place. This study further explores important themes which have relevance to maternity care in the contemporary context. It investigates the changing location of birth and the power structures that influenced women’s experiences in different birth locations in the past. Women’s ‘choices’ in childbirth are explored with a focus on the extent to which women were limited in their decision-making by their socioeconomic and geographic status. The study questions the extent to which contemporary understandings of the social importance of birthing, including the emphasis placed on ‘choices’ and birthing location, can be applied to women of the past. It is argued that early twentieth century women in Australia had a complex and somewhat ambiguous relationship to birthing which limits the extent to which modern understandings of birth can be transposed into the historical narrative. iv Table of Contents Page Declaration iii Abstract iv Table of Contents v Acknowledgements viii Acronyms x PART 1 Introduction and Methodology 1 Midwives, mothers and medicalisation in WA 5 Seeing choices in the past 6 Sanctums, surveillance rooms and total institutions 9 Challenges in the sources: feminist methods and women’s voices 12 Organisation of the thesis 16 Chapter 1 – Literature Review 19 Representations of the medicalisation of childbirth: midwives against doctors 19 Childbirth history revisionism: issues of safety and personnel 23 The development of the maternity hospital: discourses in risk and control 30 The importance of early Australian revisionists: critiquing the maternity hospital 33 Australian childbirth history writing in the 21st century 39 Childbirth history in Western Australia 42 PART 2 Chapter 2 – Birthing at Home in the Colonial Period 46 WA’s colonial medical fraternity 47 Midwives during colonial times 52 Housing and services at Swan River 56 Midwives in women’s homes 60 Doctors in women’s homes 63 Deaths associated with childbirth 67 The rural and remote experience 71 v Page Chapter 3 – The Changing status of Midwife and Doctor 76 The suppression of the midwife in its Australian context 76 The Western Australian experience 82 The ‘Golden Age’ of medicine 86 Chapter 4 – Birthing in Lying-in Homes 90 Choice and the lying-in home 91 Government and charity lying-in homes 92 The House of Mercy 95 Midwife-run lying-in homes 101 Women’s experiences of childbirth in lying-in homes 108 Regulation of lying-in homes 111 The regulation of Western Australian midwives 117 The beginnings of nursing and midwifery training in WA 122 The ATNA and the management of midwifery training 127 The end of independent midwifery 129 Chapter 5 – Social Factors and the Changing Face of Maternity Care 132 Midwifery, birth rates and abortions: Public reactions in WA 132 Midwives and Infant mortality in WA 138 The 1912 Maternity Allowance 142 Maternal mortality: the role of Puerperal Fever 144 Chapter 6 – Birthing in Maternity Hospitals 151 Early hospitals in WA 152 The question of government involvement in maternity care 154 Campaigning for a maternity hospital: the important role of women 157 Social pressure and the establishment of KEMH 164 The early years of hospital management at KEMH 168 The KEMH casebook: midwives as primary carers 171 Women’s childbirth experiences in maternity hospitals: silences in the sources 174 Twilight Sleep: the lure of ‘painless’ childbirth 180 Mothers’ attitudes to doctors: ‘a superior race of people’ 186 vi Page PART 3 Chapter 7 – Conclusions: Linking the Past to the Present 190 Reviewing the Revisionist Narrative 192 Childbirth location in the past: power structures at home and away 198 The problem with choice 204 Normalising Birthing: past and present 208 BIBLIOGRAPHY 211 vii Acknowledgements The creation of such a long and complex document requires the assistance of many people. I am indebted to a great many friends, colleagues and family members who have supported me through the process of writing this thesis and who have provided endless reassurance and enthusiasm. A good deal of the initial momentum for the project can be attributed to the encouragement I received from my mum. Ali, in all truth, I could never have achieved this without you. Your constant support, inspiration and positive outlook have made my job easier in so many ways. Thanks must also go to my dad, Brenden for his insightful comments, and tireless efforts as a reader and editor of this thesis. Other family members including Rob McKenzie, Vahri McKenzie, Yvonne and Sydney Sampey and Lachy McKenzie have provided invaluable assistance along the way and my thanks go to them for their help, kindness and love. To Associate Professor Jan Gothard, my primary supervisor for the majority of the last six years spent on this project, I send my heartfelt thanks and appreciation. Jan, in your unique way, you have managed to say the right thing at the right time, every time. Your hard work reading and editing along with your continued enthusiasm and support gave me greater confidence in my own ability to complete this project. I also wish to thank Professor Michael Sturma who, despite coming to the project late, was able to provide me with great insight. Michael, your suggestions and ideas have undoubtedly made the thesis a more rounded and powerful document; thank you for all your commitment and hard work. A special thank you must go to Jennie and Bevan Carter who showed great interest in this project and assisted it in numerous ways. I also send my thanks to my fellow postgraduate students with whom I have shared this journey, in particular Claire Maltas who has shown great understanding and kindness as we shared a small writing space. Finally, to my partner Alrick who has shared this journey with me I send all my love and gratitude. We have done this together and my hope is that in having committed these last six years to this project we will now be able to continue our journey on to bigger and better things. The act of giving birth is what sparked my interest in studying childbirth from an historical perspective. In this way, my beautiful girls Maali and Kaaja have been the true viii inspiration for this project. Thank you for all you have given me and all you are teaching me. I am so proud of you both. ix Acronyms AMG Australasian Medical Gazette AMJ Australian Medical Journal ATNA Australian Trained Nurses Association BMA British Medical Association KEMH King Edward Memorial Hospital MJA Medical Journal of Australia NSW New South Wales NSWMG New South Wales Medical Gazette PODs Post Office Directories WA Western Australia x 2 Introduction and Methodology Many contemporary academic discussions about childbirth examine factors affecting women’s personal experiences of birthing. These debates are concerned with conflicts around medicalised birth and ‘natural’ birth, over home birthing and hospital birthing, or between obstetricians and midwives.1 Conflicts around decision-making and choice in childbirth are also factors affecting contemporary understandings of birth. Recent research has concluded that having choices and being involved in decision-making leads to better birth outcomes for mothers and most women approach childbirth with the expectation that they will be able to make some choices about their birthing experience. 2 Debates of this sort suggest the need for further research into the merits of different birthing systems and different birth attendants.3 Consistent criticism of medical management of childbirth in British, European and American research also demonstrates a growing disconnection between the expectations of mothers and the service provided in maternity hospitals.4 Indeed, many Australian state and Federal government reviews regularly advocate a decrease in interventionist medical care during childbirth. As researcher Alphia Passamai- Inesedy has noted, the 1999 Australian Senate Community Affairs References Committee’s Inquiry into Childbirth Procedures and the World Health Organisation’s Principles of Perinatal Care report of 2001 both suggest that with regard to childbirth in Western nations: unnecessary medical intervention and overuse of technology during perinatal care continue to be practiced widely despite the acceptance of evidence-based principles and care. Of the various points 1See for example Barbara Katz Rothman, Giving Birth: Alternatives in Childbirth, 1984, Penguin Books, Middlesex; Sheila Kitzinger, The Politics of Birth, 2005, Elsevier, Edinburgh; Suzanne Arms, Immaculate Deception: A new look at women and childbirth in America, 1981, Bantam Books, Toronto.