From MIDWIFERY MATTERS, Issue No.105, Summer 2005
This article considers the composition of the first Central Midwives Board (England and Wales) and the Central Midwives Board for Scotland, and examines the level of control that was given to midwives and non-midwives over midwifery education, registration and practice. It will consider the balance of gender, profession and class within the Boards, and explore the differences and similarities between these and the current composition of the interim board of the Nursing and Midwifery Council.
Background
Throughout the 19th century there was demand, mostly from numerous medical professions,
for legal control over the practice of midwifery. Various societies attempted
to take control of the education and certification of midwives over the years,
but without notable success. Many doctors were disgusted by the practice, and
regarded it as an affront to society (due to it being a traditionally female
activity and, particularly during Victorian times, associated with female sexuality),
though this did not prevent them from wanting control over its practice (Donnison
1988, Ridgway 2002, Towler and Bramall 1986). In 1825 with the formation of
the Obstetrical Society doctors finally claimed midwifery practice as a medical
specialty in its own right, and the Society attempted to bring about regulation
of the practice in an effort to exclude those who were unskilled and potentially
dangerous to the women in their care. In this, they included other medical practitioners
(usually from rival societies, such as the College of Surgeons and the Society
of Apothecaries) who claimed to have knowledge of midwifery, but were often
ignorant of basic facts of anatomy and physiology pertaining to midwifery.
After a number of attempts by other societies to offer certificates in midwifery
(usually to men only), midwifery education finally came under a degree of control
by the Royal College of Surgeons in 1872. However, when several members of the
Ladies Obstetrical College applied to undergo examination in 1875, the Board
of Examiners resigned in protest, despite the women meeting the criteria for
examination. During the latter part of the 19th century, there was a gradual
relenting of medical opinion, and midwifery certification was offered by the
London Obstetrical Society to young ladies of good moral character who underwent
specific training and education (Towler and Bramall, 1986).
Some of these midwives went on to form the Matrons' Aid Society (which became the Incorporated Midwives' Institute, and eventually the Royal College of Midwives), and campaigned for women's right to safe midwifery care and for professional regulation of midwifery (Cowell and Wainwright, 1981). There followed a protracted campaign, lasting over twenty years, to introduce legislation for the training and registration of midwives, which led eventually to the passing of the Midwives Act 1902, which applied only in England and Wales, and subsequently the Midwives (Scotland) Act 1915 which regulated Scottish midwives. The implementation of these Acts resulted in the formation of the Central Midwives Board (CMB) and the Central Midwives Board for Scotland (CMBS), which were to govern midwifery education and practice until the Nurses, Midwives and Health Visitors Act 1979 abolished them in 1983 establishing the UKCC (Towler and Bramall 1986).
Composition of the Central Midwives Boards
Membership of the English and Welsh Board was initially restricted to four medical
practitioners (representing the Royal College of Physicians, the Royal College
of Surgeons, the Society of Apothecaries and the Incorporated Midwives' Institute),
one representative of the Association of County Councils, two nursing representatives
and two appointees of the Privy Council. Of these members, only one (appointed
by the Privy Council) was required to be female and the midwifery representative
had to be a doctor, thus excluding women (who were still barred from medical
practice) from this crucial role, though in total three women were present on
the first board (Cowell and Wainwright 1981, Jenkins 1995). All of the members
were of high social status and thus could not be considered representative of
the majority of the midwives whom they were to govern, as midwifery at that
time was mostly the province of the poorer women in society, midwifery being
likened by the upper classes to domestic service of the lowest sort (Morrin
1992, Warriner 2002).
In comparison, the Scottish board was to consist of two practising midwives
and another person appointed by the Lord President of the Privy Council, five
registered medical practitioners (appointed by the universities and various
medical associations), one public health representative (another registered
medical practitioner) one nursing representative, and two other members appointed
by the Association of County Councils and the Convention of the Royal Burghs
of Scotland. This was a more eclectic selection of backgrounds, and though still
dominated by the medical professions and the upper and middle classes, the presence
of practising midwives on the Board was very progressive for the time (Mander
and Reid, 2002).
However, midwives were unable to sit on the first CMBS at its inception, due
to the requirement that the midwife members be registered on the Roll of Midwives,
and this could not exist until the Board created it. This situation was resolved
when appropriate midwife representatives became available, though there was
some delay while rules were drafted that would establish the Roll and allow
the Board to function initially. Two midwifery representatives finally attended
their first Board meeting in July 1916 (Reid 2003, Cowell and Wainwright,1981).
Out of a total of twelve members, six members of the first CMBS were medical
practitioners, so there was the possibility for the medical profession to exercise
substantial control over proceedings. However, it does show a certain regard
for their profession and ability that midwives in Scotland were regarded as
having some contribution to make to their own regulation and education (Mander
and Reid, 2002). The other four members of the board were lay members, and of
these, two were ladies who were reputed to have a good understanding of the
working conditions of midwives, though what this means in practice is unclear
(Cowell and Wainwright, 1981). Thus, the total number of women on the board
was four.
The Nursing and Midwifery Council Today
In contrast to the situation in the early 20th century, the current Board of
the Nursing and Midwifery Council (NMC) is made up entirely of nurses, midwives,
health visitors and lay members who are considered to have experience of value
to the NMC (Dimond, 2002). There is no statutory requirement for the involvement
of members of the medical professions though, as discussed below, there are
a significant number involved as lay members.
At present, the Council consists of three midwives (one position being unfilled),
four nurses, four health visitors and eleven lay members. There is also a group
of alternate members who can attend meetings if their equivalent registrant
member is absent; this consists of four midwives, four nurses and four health
visitors (NMC, 2004). This group appear to have little influence on the Council,
in effect it is there purely to maintain a professional majority for voting
purposes (Lewis, 2002).
The professional backgrounds of the lay members are of interest considering
the determination of the medical profession to control midwifery in the past
(and arguably the present). There are at present four members who are professors
involved in medicine, three National Health Service executives, three who are
involved in independent health-related organisations and only one member who
has declared a midwifery interest (NMC 2004).
Taken as a whole, therefore, only four members of the main council have any
declared interest in midwifery out of a total of 22. This is strikingly similar
to the proportions that were present in the CMBS in 1916, and demonstrates the
continuing reluctance of the establishment to allow midwives properly to regulate
their own profession, which was particularly signified by the merging of the
regulatory bodies of midwifery and nursing by the Nurses, Midwives and Health
Visitors Act 1979 (Jowitt 2004, House of Commons 1979). This abolished the CMB
and CMBS, and established a Midwifery Committee with advisory powers (similar
to that which exists today), which was easily ignored by the regulatory committees.
The gender balance on the Council is interesting, particularly in the division
between the registrant and lay membership. The registrant membership consists
of one man and ten women, whereas the lay membership has six men and only five
women (NMC 2004). While the registrant gender balance reflects of the gender
balance in the nursing and midwifery professions (though not of that in midwifery
alone), there appears to be a determination by 'laymen' to have a significant
influence on their regulation, despite there being relatively few men engaged
in these professions and lower health service usage by this group (Office for
National Statistics 2004).
Although the class system has undergone substantial change, and in the eyes
of some, disintegrated entirely, it can still be said that the NMC is dominated
by those who have substantial social, political and economic power. Of the registrant
members, the majority are managers, and all are in senior posts; and of the
lay members, the majority are professors and managers (NMC 2004). It is clear
that this is a significant theme, which is apparent from the earliest attempts
to govern midwifery (as discussed above) right through to today.
Discussion
It is seen by some that the main aims of the 1905 Act were to make midwifery
a profession to which, like nursing during the same period, young middle class
women would aspire, and also to eliminate the traditional, mostly uneducated
midwife by making registration difficult for her (Mander and Reid 2002, Heagerty
1996). This difficulty in registering was due to many midwives being unaware
of the of the existence of the Act (whether due to poor communication or deliberate
withholding of the information by Medical Officers), and of those who were aware,
many could not afford the ten-shilling registration fee (Towler and Bramall,
1986).
Many women were also unable to pay for midwifery training, which became a requirement
for registration by the CMB for those who were not already in practice, though
when the Midwives (Scotland) Act was brought in, provision was made to allow
the Local Supervising Authority to cover the cost of midwifery training when
necessary. The authorities by 1915 obviously realised that the greatest need
was to ensure that practising midwives were educated, rather than to exclude
from practice those who, through no fault of their own, were not (Mander and
Reid 2002, House of Commons 1905).
The status of the midwife went (and continues to go) through a spectrum of change.
In the late 19th century, she was seen as a domestic servant dealing with a
necessary but unmentionable chore. She has since progressed through a stage
akin to that of the manual trades (controlled by the authorities, and being
certified rather than registered) to the near-professional stage of the present
time, with midwives being registered practitioners governed, if not by themselves,
at least in conjunction with health professions having a similar status (Morrin
1992, Fleming 2002).
It could be said that this changing status reflects a parallel change in the
role of middle class women in society, as during the same period they went from
being 'mere' housewives to having a substantial contribution to make outside
of the home. It seems probable that there is a substantial connection between
the progress made in nursing and midwifery and the role of middle and upper
class women generally, with change in all these areas being largely driven by
reformers such as Emily Pankhurst, Florence Nightingale, Ethel Bedford Fenwick
and Rosalind Paget.
There is still much demand for change, with many midwives actively campaigning
for the removal of the new requirement for midwives to provide evidence of good
health (presumably by means of a certificate from a medical practitioner), and
to have their own governing body rather than one dominated by the nursing profession,
or at least an advisory committee within the NMC with substantially more powers
than at present (Dimond 2002, Woodford 2001, Privy Council 2002). There is also
a campaign to gain recognition, through the wording of the Nursing and Midwifery
Order 2001 (which currently uses the pronoun 'he' throughout), that the majority
of nurses and midwives are female (Association of Radical Midwives 2001, Privy
Council 2002).
It is ironic that the vast majority of campaigning midwives of the late 19th
and early 20th centuries, such as Rosalind Paget, rather than being practising
midwives, were upper class matrons, superintendents and managers of charitable
organisations who were unlikely to have put their nursing and midwifery training
(if they had any) to any real use, but who used their social standing to gain
control of the profession for their class rather than their gender (Heagerty
1997). They ensured that the practice of midwifery did not impinge on that of
the doctor, and created a new profession which dealt only with 'normal' labours,
and which was of suitable social status for upper and middle class ladies to
practise (Mander and Reid 2002).
It is clear that these women were not feminists - they did not fight for liberation
for all women, but they did ensure that there was a new outlet for middle class
ladies who wished to do something useful outside the home (Mander and Reid 2002).
Midwifery is still governed largely by those who do not practise midwifery themselves.
Despite the passage of one hundred years since the first Midwives Act, grassroots
midwives still have little or no control over the regulation and practice of
their own profession, and many practise in constant fear of breaching policies
set down by doctors and managers, which are not necessarily in the best interests
of the client (Warren 1988).
The reformers of the early 20th century have succeeded in turning midwifery
into a profession for the middle classes, due largely to the inexorable rise
in the level of education required for entry to the Register. This is reiterated
by the recent vote by the Royal College of Nurses, which hopes to see a requirement
for the degree-level education of all new registrants (Edwards 2004), and is
a strong theme running throughout the history of midwifery regulation. It would
appear that class, rather than gender, is the stronger influence in the campaign
for the regulation of midwifery.
Conclusion
Although there have been significant advances over the last century in women's
rights, there is still a long way to go before the people most affected by the
regulation of midwifery practice, namely working midwives and women, will be
able to claim that they have control of their own profession and the service
it is allowed by law to provide. In order to have that degree of control, the
profession needs to be governed by midwives from all levels and areas of practice,
with a significant input from the women whose health needs they are trying to
meet. It is difficult to see how this can be achieved while midwifery is governed
alongside nursing and health visiting under the control of a single statutory
body, and largely by people who are distant from grassroots midwifery practice.
The needs of women, and of the midwives who support them, would surely be better
served by a regulatory body whose sole interest is the education, registration
and standard of practice of midwives, and which is governed by those most affected
by these issues. Perhaps this should be the aim of the campaigning midwives
of the 21st century.
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Updated LW July 5, 2005