Matthew Flinders Senior (1751–1802): Surgeon and ‘man midwife’

Introduction

The practice of midwifery was long the sole domain of women. However, intervention in birth has gradually, but irrevocably, moved more firmly into the hands of men. This paper offers an outline of the early stages of this transition and uses a year in the life of one man – Matthew Flinders, as an example of the early genesis of this transition. Flinders was the father of the famous navigator, with the same name, who circumnavigated the newly settled continent in the southern ocean in 1802–1803, and who coined the name ‘Australia’. ¹

Matthew Flinders Senior was a local surgeon and ‘man-midwife’ in Donington, a small Lincolnshire village. Fortunately for history, Flinders Senior kept records of his work and accounts, and these have been preserved by the library of Lincoln Cathedral, and published by the Lincoln Record Society,^2,3 making them accessible to interested researchers world-wide. Matthew Flinders Senior (1750–1802), and his ‘medical’ work is the subject of this paper as it offers an illustration of the rise of the so-called ‘man-midwife’, that contributed to the appropriation of midwifery ⁴ into the spectrum of medicine.

Background

By around the mid-eighteenth century in England, and to a varying extent in other European countries, the management of childbirth had moved from the domain of relatively uneducated females to one where childbirth was managed by a man-midwife. ⁵ Prior to this transformation, birth was the domain of women, usually senior women in the community, often married and who had themselves given birth. Men were excluded from attending births unless the female midwife or attendant deemed it necessary to call upon the expertise of a (male) medical practitioner to assist with an emergency. Although there is suggestion that men acted as midwives (sometimes called ‘accoucher’) in some countries ⁶ as far back as the biblical, Egyptian and Greek times, the role of women continued largely unquestioned until the late sixteenth century, when eminent surgeons, such as the French surgeon Ambroise Paré, began to make enquiry into the anatomy of childbirth and suggest the introduction of male attendance at childbirth, initially for complicated, but then also for routine cases. ⁷ Thus originated the role of the man-midwife, applied to men, usually surgeons, who added the role of midwifery to their practice. By the end of the 1700s, it was no longer considered improper for men to routinely be present at childbirth; indeed it may have been seen as ‘a badge of gentility for at least some families from the upper and middling classes’ ⁸ (p. 121). It is estimated that by the end of the century, only around half of the births in England and Wales were delivered by female midwives in the women’s homes, with the other half being delivered by male practitioners, also in the women’s homes. ⁹

This movement, whereby childbirth came under the control of men, ⁴ mirrored other social changes associated with the Age of Enlightenment, a greater reliance on science and resultant advances in medicine, and increasing industrialization, mechanization and professionalization. The invention and availability of forceps, from the 1600s (although Meadows ⁶ suggests they were invented some 600 years before) used to aid complicated deliveries, had significant impact as forceps were licensed only for use by surgeons and so were unavailable to midwives. ⁷ In addition, around this time, women were excluded from the sciences and from prestigious professions and the church licensing that had previously given the midwife her official standing was withdrawn. ¹⁰ This resulted in a much less authoritative role for female midwives in childbirth. Their access to education was restricted and the dissemination of medical knowledge was increasingly controlled by male doctors, although women did not necessarily acquiesce quietly.^8,9,11 Female midwives, even when literate, were rarely allowed to read the childbirth texts being written for male practitioners. ¹² The encroaching of men into the domain of midwifery left poorer rewards for midwives and meant the numbers of better educated women who might have previously invested in learning to enter the profession declined. The consequence of this was that female midwives were not able to differentiate themselves from the untrained women who gathered with a birthing woman, the ‘gossips’. ¹³ This reinforced and secured the domain of birth for men.

Many women gave birth in lying-in hospitals,^14,15 at such places as Middlesex General Hospital, where lying-in wards opened in 1747; the British Lying-in Hospital, Brownlow Street, London in 1749; the City of London Lying-in Hospital in 1750; the General Lying-in Hospital or ‘Queen Charlotte’s’ in 1752, and the Westminster Lying-in Hospital, which opened in 1763. The day-to-day running of the lying-in hospitals was undertaken by a matron (who was always a widow). She was responsible for normal deliveries, but subordinate to the medical officers who had overall responsibility for the birthing women. These medical officers were members of the board of the hospital who did the hiring and firing,^14,15 and the hospitals became the centres for teaching obstetrics and midwifery. While midwives could pay for instruction within these hospitals, students were mainly male and it was from this environment that the role of the man-midwife flourished.

In 1751, Johann Georg Roederer (1726–1763) who was professor extroaordinarius of obstetrics, University of Göttingen, said that they needed, ‘learned men to replace midwives’ in his inaugural professorial lecture, De artis obstetriciae praestantia, quae eruditum decet, quin imo requirit (on the excellence of midwifery, which is absolutely decent for, nay requires, a learned man). ¹⁶ The rise of male practice was not without its opposition, and man-midwives were anxious to establish their own importance. They exaggerated the dangers of childbirth and frightened women into believing that extraordinary measures, and therefore male attendance, were necessary. ¹³ Man-midwives took every opportunity to denigrate the understanding and competence of midwives and to blame them when things went wrong. ⁷

One might expect that surgeons would willingly take on the man-midwife role, because of their familiarity with the use of instruments, drugs and operative procedures; however, many surgeons were reluctant to do so in the belief that it was beneath their social status. Although some surgeons, including the notable William Smellie, ⁸ and physicians, became esteemed man-midwives, many physicians thought that taking on the role would mean neglecting their other patients or that midwifery still lacked the academic standing that medicine deserved. ¹⁷ Midwifery, although it was still perceived by many surgeons and physicians as non-scientific, was a way that male practitioners could establish their practices. ⁹ Consequently, even in smaller towns, men who were known as surgeon-apothecaries appended the role of man-midwife. ¹² Matthew Flinders was a surgeon-apothecary from Donington, England, who built up his practice in this way, and this paper describes a year of his work as a man-midwife.

Flinders’ records

In 2007, the Lincoln Record Society published the first of two volumes called ‘Gratefull [sic] to Providence’,^2,3 (the second volume was published in 2009). Beardsley and Bennett collated all the workbooks, diaries and account books of Matthew Flinders Senior, dating from 1775 to 1802, some of which are held in the Lincolnshire Archives, while others are held privately by Flinders’ descendants. These volumes provide a convenient way to source the primary data of Matthew Flinders Senior and these records were investigated for evidence of Flinders’ work as a man-midwife for the year, 1775. We chose to include just one year in this analysis, to provide a ‘snap shot’ of how Flinders, as a man-midwife, worked in rural England in the time of the emergence of male domination of obstetrics and midwifery. While Beardsley and Bennett^2,3 have included all Flinders’ records until his death in April 1802, it is beyond the scope of this paper to analyse them all here.

A man-midwife’s work

Examination of Flinders’ workbook shows the work of a busy country doctor. In 1775, Flinders attended births for 43 women, nine of whom were multiparous. No maternal deaths were recorded, but two infants died. He used forceps for three women (something claimed by the man-midwives as a primary function of their practice and used to legitimise their work), ¹⁸ and once used the ‘crochet’ (an instrument with a sharp tooth at the end to pierce the membranes and rupture them to expedite birth). He also attended the birth of one set of twins. The times he gave to each case are recorded, and they range from 1 to 19 h, with a median of 5 h and a mean of 13 h. Of course, one must read these with some caution as they were Flinders’ own reckoning of time periods, and it is possible they are not entirely reliable, given his busy and erratic work schedule; perhaps completed retrospectively, and quite likely approximated after the events. The times of day he was called to birthing women indicates that most births took place in the early hours of the morning. However, there is no record of time for nine of the call outs.

The account books show Flinders’ charges for service for birthing infants. In 1775, there are 18 recordings of payment, some of which are probably part payment. Prices range from 8/- to £1/8/0 (8 to 28 shillings) with a median £1/1/0 (21 shillings with 20 shillings = 1 pound). Again, these data need some care in interpretation as they rely entirely on Flinders’ accuracy in book-keeping. In contrast, midwives at the same time were charging 1/6d (one shilling and sixpence) to 2 shillings for the same service. ¹¹ Using the retail price index, 28 shillings from 1775 equals £2138 ¹⁹ (A$3643) in 2016. To give further reference to place this in context, in 2016 in Australia, a private obstetrician will charge around A$3700 for the care of a woman in pregnancy and labour, while an independent private midwife will charge A$5000 (in the public health system, care is free). In England today, the great majority of this work comes under the auspices of the National Health Service and is free of direct cost.

Flinders made a good income from his midwifery work. His total income in 1775 (which included other surgical and medical cases) is outlined in his accounts. He brought in £222/8/10, from which he paid out £18/10/3½d for work-related expenses, making his net income for 1775 £203/10/6½ (an annual income in today’s terms of about £310,800 or close to A$700,000).

Another way to compare how Flinders earned a decent living from his man-midwifery is to examine the cost of common articles he would use in both life and work. The local newspaper, The Stamford News, cost 2½d (today, the Stamford Mercury costs £1, and a local rural newspaper in Australia costs about A$1.20). One item that cannot be compared across the years, but was an important ‘tool of trade’ for Flinders, was a pot of leeches. He received 17 of these for 1/5d. He paid 9d for half-a-dozen lemons, 7d for a sheet of writing paper. It cost Flinders 1/– to have a pair of boots mended, and he paid 2/3d for a blanket for Matthew Junior’s bed.

A point of interest is his final references to his sailor sons, Samuel and Matthew. On 30 June 1801 Flinders laments that Matthew Junior took no notice of his father’s warnings about his marriage to Anne, because of Matthew’s inability to take her with him on his voyage to New South Wales. In a reflection echoed by many parents in every era, he says ‘… I am seldom consulted by any of my young folks, except on the head of raising Money for them, then indeed I am sought too’^2,3 (p. 231). His final entry about Matthew and Samuel is January 1802, describing receipt of letters on 22 and 28 January, posted in October 1801 ‘at the Cape. I thank God all went well with them to that date’^2,3 (p. 238).

Matthew Flinders Senior died a wealthy man in 1802. His memorial plaque in the Church of St Mary and the Holy Rood in Donington describes him as ‘Mr Matthew Flinders, Surgeon… a man of exemplary life, amiable manners, and superior abilities’. His will, dated 1801, with a codicil added in 1802, is available electronically, thanks to Flinders University (http://library.flinders.edu.au/resources/collection/special/hitchcock/will.html). On his death in 1802, he left his fortune to his second wife, Elizabeth, with a complicated series of bequests to his children, grandchildren and others.

Discussion

The name Matthew Flinders is well known to Australians who learn about the famous navigator at school. ¹ However, few know about his father, the senior Matthew Flinders, and even fewer midwives or obstetricians, in Australia or elsewhere, know that Matthew Senior was helping mothers to give birth at the time the care around childbirth was being appropriated from midwives to the medical profession.^5–7 It would be too much of a long shot to say that Flinders influenced this transition, as he was a country doctor in a quiet corner of Lincolnshire, England. Nonetheless, his work is demonstrative of the way the transition occurred. Flinders’ work records provide valuable insight into the way that man-midwives worked at this time.^2,3 The financial aspect of Flinders’ records illustrates that the life of a country surgeon and man-midwife was a profitable one. This, in turn, offers lucid evidence and explanation of why obstetric care and the domain of midwifery were so attractive to medical practitioners in the first place. Also, why following penetration of that ground, they were so determined to maintain it, through persistent engagement in strategies to diminish and subordinate the practice of midwifes.

Attitudes to women played a role, and were perpetuated over time – to quote Meadows ⁶ in 1872 – ‘But the work and the genius of the men of the last three centuries, and most notably, of the last two, have not only secured to the male sex, almost the entire practice of midwifery.’ (p 639)

And ‘… that it is to men, and men only, that we owe whatever advance has been made in the scientific practice of midwifery’. And

‘… the fact is indisputable, the science and practice of midwifery owes literally nothing to women, who, nonetheless, monopolised it for 3000 years, but on the contrary, every single improvement that has been made in this department, has originated with the stronger sex’ (p. 640).

The charging of a higher fee, however, was also one of the reasons that facilitated the growth of the man-midwife. The emerging middle classes in England were at the time keen to find ways to demonstrate their wealth and it became fashionable for families aspiring to higher social status to have male practitioners attend births. ²⁰ This also enabled the ‘profession’ to flourish and persist and authors have argued that it was women and society who ultimately facilitated the establishment and growth of the man-midwife.^7,21

Flinders’ maternity caseload^2,3 provides a noteworthy perspective on the kind of practices with which these man-midwives might deal. The skill to use forceps was a distinct aspect of the man-midwife role, largely unavailable to midwives, and was consistently used as their trademark and marketing strategy, which was facilitated and legitimized by public concern over high rates of infant mortality in England. ⁴ This is possibly being replicated in recent times with the advancement of Caesarean sections as a medical procedure that is out of the reach of a midwife’s area of practice in most countries. Of note is that Flinders used forceps to assist birth on only three occasions out of 43 births. What this intimates is that many women, when allowed to do so, continued to birth normally and certainly the length of labour of the women on his caseload was not excessive. It is reasonable to suggest that in these cases there was no clinical benefit in the attendance of man-midwife over a midwife. This perhaps reinforces the notion that having a man-midwife was an esteem factor or underpinned by fear of complications, rather than predicated by medical need. That said, it seems that Flinders practiced with integrity at a time when many man-midwives actively marketed and used forceps unnecessarily to proliferate their trade.

Conclusion

The time in which Matthew Flinders Senior was working was a time of scientific and technological advancement. There was a growth in obstetric knowledge, teaching and practice, with works on anatomy and midwifery, written by men such as Smellie, which facilitated the application of scientific techniques, from which women were excluded. Man-midwives were advantaged over female midwives by their literacy and formalized shared knowledge. As Flinders’ accounts suggest, man-midwives did practice the art of midwifery and some were not over-zealous with the forceps. However, the consequence of the rise of the man-midwife was clearly the demise of the midwife as the central facilitator of birth. Flinders was part of a changing world of maternity care which culminated in an irrevocable change in the nature of midwifery practice, the ramifications of which many would argue are still being felt today.

Limitations

As with much in historical research, we have made conclusions from limited data. We are grateful to Beardsley and Bennett^2,3 for making the primary data of Flinders’ workbooks, accounts and diaries so readily available, and to Flinders University, Adelaide for making his will available online. Nevertheless, there may be gaps in our data because we have accessed primary sources remotely.

This paper is limited by the fact that we took only one year for analysis, but it gives a realistic picture of the life of a busy country doctor who was taking on the role of midwife. There is much information in the Beardsley and Bennett^2,3 books and historians and researchers could take advantage of the accessibility that they provide to usually difficult-to-access primary data.