Midwifery Hermeneutic. Historiographical Implications And Life Stories
The following article, through a brief historicity and the life story of a midwife, analyzes the hermeneutics of the birth of midwifery in Chile, as a midwife discipline to matrons from a constant differentiation with medical hegemony and power of the men of science. The methodology consists of a review of the Chilean Journal of Obstetrics and Gynecology from 1935 to 2018, supported by documents in national archives, these are compared with the life story by semi-structured interview with a leading midwife. Categories such as biopower, sexual and reproductive rights, contraception revolution and sexuality were applied to the interview script. The results glimpse the development of the profession of the midwife as authentic, differentiating itself from the hegemonic medical power, being born with it the Midwifery: discipline of the care of being as an active subject of sexual and reproductive rights and not only as a sick passive subject. It is concluded that health professions must carry out the exercise of understanding themselves and the care of being, building their disciplinary knowledge, empowering themselves to exercise their profession in response to this new being or Dasein, subject not only to their mercy but as aware of their own rights. Therefore, studying Midwifery is to observe a discipline in constant evolution, promoting social changes and stressing power structures.
Keywords: Midwifework historyhermeneuticstory of lifesexualitycare
From Heidegger’s philosophy, the human being makes sense, since to be launched into the world (Dasein), in that “there”, where the fundamental sense of the factual activity is to care (curare) and to incorporate how life deals with its world (Heidegger, 1927/2006). In this sense, the exercise and the art of caring deserve appreciation and interpretation.
This is how the different areas related to health have been worried about the care of oneself, incorporating disciplinary knowledge as a kind of appropriation based on the truth. However, they have to make a hermeneutic exercise, that is, certainly, a challenge. This situation can be achieved by a field of questioning and investigation that guarantees it ( Gadamer, 1996).
According to Rodríguez Herrero ( 2015), unfortunately, the historiography about matrons is meagre, even though, their assistance practice (first as a trade, and then as a profession). The construction of the profession from the midwives to matrons is vitally important to understand the historical process that they lived about natality and, nowadays, about sexuality.
In this context, it seems that the care is not only associated to a passive subject, it is also associated to a subject of law, and, the relationship that it has with its world. For all that, midwifery becomes in a discipline that ranks the human being in their sexual and reproductive rights, oriented to take care of the other; that implies from the midwife until the formation of matrons in the 20th century.
Therefore, a set of processes and knowledge give body to midwifery, from a scientific perspective in a constant dynamic, and from an evolutionary perspective, centred in the care provided for women to other women. With this investigation, it is expected to consider the historical events that influenced in the development and consolidation of this discipline.
Since the beginning of midwives, as an occupation, it was orally transmitted from woman to woman, under the experience of each one. However, with the advent of science, the midwife evolutions into the professional figure of the matron. History shows us that the matron is an important figure, one of the oldest trades. The stories detail the Egyptian papyri of 1550 B.C. true gynaecological treatises, to which the women had access being the obstetrician admitted and recognized, therefore, excluded the male physician from these activities. For their part, Greeks recognized the importance of the midwife especially in the writings of Socrates inspired by the office of his mother, who was a midwife, even Hippocrates considered that matrons had greater knowledge in the matters of childbirth, which facilitated their exercise and gave them power in these tasks. In the Roman era, to the knowledge inherited from Greek medicine, it was added that women had access to greater instances of learning, the obstetrix was instructed from their experience and trained by doctors, and favoured its exercise due to the fact, that it was considered that the matter related to childbirth was a matter for the female sphere ( Conde, 2011).
Later, in the 13th century, Church was inspired by Roman law to establish the role of midwives in certain legal matters, such as divorce proceedings, as well as being the person in charge of executing procedures that needed to inspect female genitals. The curious thing is that, for these purposes, of inspecting a woman, the fact of having to inspect and intervene in the female genitals by a man was controversial, and a moral problem arose: the reluctance for a man to perform the intervention ( Moral de Calatrava, 2013). The above, considered a baseness for pundits and doctors to inspect women, so men were not interested in the area of midwives, and if they did it, they were punished, known is the case in the Middle Ages of a doctor from Hamburg in 1552 called Wertt, who disguised himself as a woman to study and attend natural childbirth, but upon being discovered was burned alive at the stake ( Valle, 2002).
What is certain, thanks to this historical space attributed to the morality of the Middle Ages, the diversification of the space of the midwife towards the gynaecological and with it the opening to the field of the sexual opens the way. However, this empirical approval would not last, men would soon break into the field of the matron since the Middle Ages became a dark period for Europe, especially in the field of science concerning advances in childbirth and gynaecology, and judged all knowledge that women possessed in that field. The study of women and their sexuality, was considered something impure, often demonized, and relating to childbirth as witchcraft ( Conde, 2011). For the same reason, women linked to medicine and healing were considered witches and persecuted and even burned (Ehrenreich & English, 1973/2006).
The fracture, in the Middle Ages, with the hunting of women who were considered witches for their knowledge, transformed the profession of midwife. These changes did not happen in the same way in all parts of Europe ( Conde, 2011). On one side, in France the differentiation of health disciplines hung by a thin thread. In this regard, currents arose as that of barbers who advocated breaking into the field of health, these currents gained greater strength after the events mentioned in the Middle Ages, where the woman was displaced.
Remember that before the 13th century barbers-surgeons were considered artisans, but at the end of the 13th century, a group of them dedicated themselves to surgery, something rejected by the doctors of the time until the 17th century. This is how barber-surgeons who disputed field with the doctors, began to break into the field of midwives, which contributed to exclude them quickly, they were restricted their responsibilities being dominated by surgeons. In addition, the midwives were considered a threat to the fact that a woman has a leading role in the public sphere, something kept only for men. Thus, in France, from the 16th to the 17th century, the bourgeoisie and economic interests collaborated so that men could enter the realm, which was exclusive of women ( Sheridan, 2001).
According to Luque ( 2008), speeches were made about who should perform certain health procedures, whether the midwife or the surgeon. In other words, the medieval patriarchal structures, that also did not allow a female medical practice, derived in the exclusion of women from university life and from organizations for medical practice, which was unquestioned.
Nevertheless, Europe in the 16th century experienced a renaissance of the knowledge of childbirth and gynaecology, which, although midwives were considered experts because of their experience, they would not have access to these writings intended for men's knowledge ( Conde, 2011). Added to this, from the 17th century, an age of repression was installed, a dark period for sexuality, typical of bourgeois societies, and from which we might not be completely liberated yet ( Foucault, 2005). This affected the processes of emancipation of empirical knowledge of midwives, about women, regarding sexuality and gynaecology, therefore, the renaissance seems to favour the advancement of men who could access knowledge from their perspectives. Moreover, in Spain, midwifery until the beginning of the 18th century was exclusively for women, but also at the end of that century surgeons burst in and made it their profession. Oriented mainly to the attention of the childbirth of the women of the royalty, matrons for their part. Until that moment, they were able to continue attending childbirths, although primarily to the women of low classes, which provided greater empirical knowledge due to the quantity of attended childbirths, this motivated later the campaigns of discredit towards them on the part of the surgeons. However, in 1750, the Real Promedicato would begin to regulate the titles of midwives, and give them the permission to practice throughout the whole kingdom together controls their professional practice, which rather than contributing to the midwives, enhances the scientific practice of the surgeon in this area ( Ortiz, 1996). This is how the knowledge of midwives and matrons was taken away by the men who could access the sciences, relegating the midwife to maternal and child care, but in a secondary environment ( Martínez, Siles, & Martínez, 2014).
Since the 18th century, matrons were practically instructed by doctors; in Spain the term midwife was used to refer to women who were instructed and/or legally recognized as opposed to those who were not qualified ( Conde, 2011). At the same time, a new analytical economy of birth arises in all Europe, general police of the health. Population and demographic growth were studied, there was the need to control by means of power mechanisms. Their preservation and maintenance, as it was necessary, to study the population and demographic growth arose the biopower before the need to control by means of power mechanisms, the preservation and maintenance of the population ( Foucault, 1976). In short, biopolitics is established, the conservation of the work force is vital, the human body seems to be a work machine and the institutions insist on disciplining, reinforcing the hierarchies within the health professions.
In England, earlier in the 16th century, some light was shed on the processes of compulsory training and state recognition of midwives. However, little by little the men who had access to the sciences also entered the field of sciences. Matrons, concerned about their theoretical training, proposed in the seventeenth and eighteenth century to demand the regulation of their profession in a process of vindication, along with it appear numerous writings concerning childbirth and birth provided by obstetricians ( Conde, 2011). The struggle ended in the 20th century, when matrons in England were grouped in the national register of midwives as their certification was regulated, this was accompanied by a strong demand for studies that allowed them to expand their role. Then, in 1902, they were assigned the task of prenatal, postnatal and neonatal care. And already in 1936, their work was fully regulated in his training programs. The midwives were forming their professional identity, in spite of possessing less power than the doctors and being forced to call them in cases of complication of the childbirths. Many of them did not do it or the doctors did not reach their calls, reason why midwives entered, regularly, in the territory of the doctors solving alone the emergencies, which gave them an identity character to the profession ( Rhodes, 2001).
Thus, the tensions were maintained and after the Second World War, in 1945, there was an explosion in the birth rate. The importance of medicine as social began to be understood. With this other historical fracture, the birth rate emerges as a primordial theme for the replacement of working bodies, where the midwife would have a preponderant role. Faced with this medicine with a social component, there is a need for other health professionals, despite the persistent medieval patriarchal structures that resist allowing female medical practice, with the exclusion of women from university life ( Luque, 2008).
Midwifery in Chile
As the processes of professionalization of midwives took place in Chile, since colonial times medicine had a precarious development, depending on the advances coming from Europe. However, the art of sharing and the role of the midwife were developed in pre-Columbian America. One example, is that the Aztec people before the arrival of the Spaniards already distinguished the midwife as a relevant figure ( Gallego, Miró-Bonet, Ferrer de Sant, & Gastaldo, 2005). Thus, the practice of obstetrics then had no professional character and it was restricted to childbirth care, but when the colonial process arrived, the doctors brought the ideas from Europe and installed the professionalization of childbirth in America and Chile.
As the years passed, childbirth and birth were accompanied by a high maternal and infant mortality, as a result of the epidemics that came with the conquest, among other causes such as poor hygiene and sanitation. In this way, midwives made this a profession in the face of the great recurrence of pregnant women towards them ( Lattus & Sanhueza, 2007).
The first school of Obstetrics and Childcare in Chile was founded in 1834 by Sazié. The career of matron establishes the access to the obtaining of the title in houses of studies. The profession of midwife, at the beginning of the XX century, was consolidated as Institutionalized knowledge. In 1928 requirements and a strong theoretical formation were established. One of the texts utilized at that time was the Bossi, dedicated to the training of midwives, it also included the area of Childcare, which was part of the training from the social approach. There was a growing concern for the problems of children and newborns improving indicators of maternal and infant mortality, but also that midwives are examined and regulated by doctors in their training, a European colonial heritage.
How did historical and social processes influence the conformation of the midwife as a professional? What were the discourses (turns) that implied the construction of Midwifery? How was Midwifery constructed between medical power and sexual and reproductive rights? What is the hermeneutic exercise to understand the profession from the care of a subject of rights?
Purpose of the Study
To analyse, from the hermeneutic approach, the birth of Midwifery, from the life story and historiography.
To describe the axes that support the discourses of Midwifery as a profession.
To recognize the paradigm changes that influenced the construction of the midwife as a profession.
Contrast through life story and historicity, the birth of a discipline such as Midwifery
The research has a qualitative character with a historical approach from hermeneutics, and includes a phase of information gathering in two stages, and an analysis phase that goes from the historical bibliographic research. The study presents a corpus, located in the Chilean Journal of Gynaecology and Obstetrics from 1935 to 2018. The journal is composed by one volume per year with various topics related to gynaecology and obstetrics. And, since 1935, it is in paper format, at its inception as a newsletter and, since 1961, as a journal. It has been available in electronic format since 2002. All of the above make up the corpus of analysis until its volume 83 in 2018.At the same time, this analysis is complemented with other digital articles used in Chile, such as the Monckeberg Manual with seven articles on topics related to obstetrics, plus two Obstetrics Magazines, and two Chilean Public Beneficence Magazines related to midwife issues. These documents from national archives are digitized on the Chilean Memories page and contain archives since 1834 when the School of Obstetrics was founded in Chile.
For data collection, field notes were used as the first part, which were transcribed in a chronological timeline. The search categories are: biopower, sexual and reproductive rights, contraceptive revolution or family planning, and sexuality. In the next stage of information gathering, a phenomenological approach was used, based on the life story of a midwife, carried out in 2018. This was supported by a semi-structured interview script. The interview was conducted with Marta Santana, a midwife by profession, trained at the University of Chile. Her work, in the commune of Los Lagos; her improvement as Magister in Rural Development, and later her career as director of the School of Obstetrics and Childcare of the Austral University of Chile until 2017, undoubtedly, contribute with experiences that include important milestones in relation to the formation of later generations of midwives. These respond to the change of mother-child paradigm to sexual and reproductive rights.
For the results, historical bibliographical events and life stories are incorporated, compared with the events experienced in the training of midwives that arise from the interview. A content analysis is established according to the categories mentioned above, including the theoretical framework, international bibliographic sources on the history of midwifery, and other knowledge concerning sexuality, sexual and reproductive rights.
As a result of the interview with Marta Santana, the chronological synthesis of her relationship with the discipline of Obstetrics and Midwifery is described, whether as a student in the 70's, a professional in the 80's and then director of the School of Obstetrics and Childcare of the Austral University of Chile. The results of the interview are mixed with excerpts from the Chilean Journal of Obstetrics and Gynaecology and other corpus documents.
Under the revision, it is considered that, in Chile, the incorporation of the woman as a thinking subject and recognized in the first school of Obstetrics and Childcare founded in 1834 by Dr. Lorenzo Sazié ( 1984), who issued a speech on the importance of the midwife, which granted, in those years, a higher character generally unrecognizable in the female sex. The development of the discipline was accompanied by the progress of science, which includes subjects centred on childbirth, anatomy, fertilization, embryo development, pregnancy and its diagnosis, although teaching was clearly focused on practice ( Monckeberg, 1898). Theory and praxis are possibilities of being of an entity that must be defined as care (Heidegger, 1927/2006).
First, Marta relates her years as a student, and how power relations were established in the health centres. Mostly under the protection of medical hegemony. The Chilean Journal of Gynaecology and Obstetrics, in 1976, states that "it used to be customary to enter the academic campus, the doctor first, followed by his entourage in strict hierarchical order" ( Mayorga, 1976). The above, measures the power of human relations and the order imposed by a strict hierarchy that endures over time, it also reveals the mantle of ceremony and ritual that invaded these spaces of power.
It follows that the medical professions are intimately intertwined by biopower and must maintain the hierarchy in their own ranks to achieve this. Marta says: "The school was run by doctors, the midwives were only instructors and they also had their share of power, they exercised power with us, the training was strict, hierarchical, structured...". (Marta, student period)
The whole hierarchy joins the formation of the strict subjects. The theoretical subjects were focused on childbirth, anatomy, fertilization, embryo development, pregnancies and their diagnosis, but the teaching was clearly focused on practice ( Monckeberg, 1898). In this respect, this training persists after the time when Marta was studying:
Therefore, a series of advice is provided to midwives for the care of childbirth and puerperium ( Vicencio, 1902). This emphasis on educating, and scientifically studying, the processes of childbirth and nativity. It lies in the fact that from 1920 to 1930 infant mortality was very high among children under one year old, and the number of births was very little higher than the one of deaths, the main factor of which was the syphilis of the era, poor hygienic conditions, and poverty. This decade in Chile is marked by the impact of the 1929 crisis. The progressive crisis of the saltpetre industry, the growth of the poor population in the cities ( Llanos & Lanfranco, 2017). This is how public policies promote the professionalization of childbirth and with it, maternal and infant mortality are controlled to some extent, thus population growth exceeds expectations.
A process to educate the mothers begins, therefore, the midwife takes protagonism due to the scarce number of doctors. Midwives attended most deliveries and can reach vulnerable mothers who lacked health-care education, reducing maternal and infant mortality ( Zarate, 2005).
After the two World Wars and the increase in the birth rate, in the 20th century the discovery of contraception was added, never again was the role of women limited to reproduction. In the 1960s, the "pill" revolution began, supported by the struggle for women's rights, which later led to the Cairo and Beijing conferences in 1994 and 1995 ( Cardona, 2014). In Chile, however, it was not until 1973 that, in the Chilean Journal of Obstetrics and Gynaecology, appears the concept of family planning, this allowed the couple, through behavioural analysis, to plan the children they wanted to have. This advance to address contraception, is due to the urgent need to catch up with modern progress. Thus, the Health Service provides economic resources that include training for professionals in these subjects ( Parker, 1973).
“When contraception arrived in Chile, it was because of this movement APROFA (Chilean Association for the Protection of Family) of family planning type….and I began for the first time to see other concepts and other subjects related to demography...the impact of the actions we developed….. in fact, has an impact not only with the methods, but with every death we avoid...". (Marta, professional)
In this regard, it is necessary to mention that the adoption of contraceptive methods is imminent, despite the opposition of the church, that is evident in an article of 1974, entitled: "The Social Approach of Obstetrics and Gynaecology", in which it is made evident that abortion was the bloody method of low-culture groups to regulate the birth rate and therefore, in these terms, family planning programs have been implemented as an alternative ( Arriagada, 1974). Concepts such as 'demography' arise, alluding to the study of the number of people who would request the methods and the shortage of specialized doctors. It is then that the midwife was gaining prominence in this new field and was trained for it, the State being a promoter and financier of such training.
On the other side, sexuality is a little mentioned topic. In 1965, the Chilean Journal of Obstetrics and Gynecology recently addressed the issue, but in a particular way, under the title "Some women's sexual problems" and established the idea that women's rejection of sexual intercourse is due to the fact that women have different kinds of neurotic personalities (aggressive, narcissistic, dependent) and the guilt due to women's independence is highlighted. The article gives little importance to the husband's technical amatory qualities ( Thonet, 1965). This patriarchal position on female sexuality was always of interest to the midwives, although they were not exactly in their training, the women asked them, and so they became self-taught, probably mostly women who watched over the humane treatment, emancipation, and vindication of other women's rights:
“As great thing, there was a doctor that we had confidence and he played the guitar with us as a manner of relaxing in some classes, and to him we said... Let's talk about love, about courtship, it was necessary, they were empirical approaches from our point of view, our feeling to talk to someone about that subject...” (Marta, student)
Sexuality was always an issue in this discipline. Sexuality is related to the care of people, it implies the communion of the human being with his environment, and the interactions that come from those relationships, therefore, in the sphere of reproduction was always included the subject of sexual and midwives were being trained for it:
It is interesting to remind ourselves of the emergence of HIV in the 1980s. In this regard, midwives were interested in these issues, more open to social medicine, with a vision of the subject and its interaction with the world, as a matter free of prejudice and discrimination:
“HIV didn't cost me to get in because we were already with the history of sexually transmitted diseases (STDs)…maybe because of HIV itself, because there were colleagues who worked on it, and they did workshops that anyone could have HIV, not necessarily gays, and so we started several studies that were done at the University.” (Marta, Teacher)
This expanded view of the subject, is opposed to the approach, which since 1976, the Chilean Journal Obstetrics and Gynecology expressed with the concept of "Government and direction of childbirth", recalling the atmosphere of power and total control of the professional over the woman and her childbirth ( Mayorga, 1976). The moment arises for midwifery to expands its horizons and tensions some structures. Marta retakes these concepts from the Direction of the career of Obstetrics at the Austral University of Chile, and the changes are incorporated.
“Well here came Debbie Guerra (anthropologist) and with it, she opened up the world to me. Before that, I had heard about sexual and reproductive rights, but with her I went deeper and met Foucault…. we do not have a language of social sciences... I told her Government and direction of labor…” (Marta, headmaster)
With this openness to social sciences, and the understanding of being, the School of Obstetrics would no longer be the same. Remember what Doctor Sazié said, in his 1835 speech at the opening of the Obstetrics course in Chile, that the midwife "would have a nobler role reserved for you in the world; you are going to arbitrate the interests of society". Thus, the social component was incorporated in the curriculum, through the Bachelor's degree, which formally granted this broader perspective ( Sazié, 1984):
Finally, it is evident how midwifery is being built in Chile and evolves as society changes: it is reborn, restructured, transformed, and developed, hierarchizing its knowledge around being, a discipline is born.
Midwifery was born as a kind of formal doctrine for matrons and as a discipline in Universities. It was born out of the imperious need to control the population (biopower), derived from a hierarchical structure that became the modern hospital. Midwives and their empirical and informal knowledge were left behind, these were taken away by science and the human being to turn them into disciplinary knowledge controlled by male doctors. This dispute for care was accompanied by a series of social changes around social medicine and the transformation of populations, which, at the rhythm of the prevailing religiosity of past times, contributed to the fact that midwives, as women, burst into diverse subjects such as sexuality, discovering that being goes beyond oneself, and relates to one's environment, being is a subject of rights.
This understanding of being has revitalized and recognized Midwifery as a primordial profession since its formation; impacting on the holistic way that provides its care not only to pregnant women, but also to subjects of sexual and reproductive rights, whose body is subjugated to the control of medicine and medicalization. The birth of the Midwifery as a discipline, responds to the understanding of the being itself and its cares, to that subject or Dasein characterized by the historicity that surrounds it, in a world where the disciplines predominate.
As societies develop, Midwifery has paradoxically gestated. Its embryogenesis comes from the sexual division of labour, sexual and reproductive rights, feminist movements, contraception, gender notions, sexual diversity, and power tensions with other disciplines. In this way, as the midwife has tried to construct herself as an autonomous subject from the medical and social sciences, this is how Midwifery was born. Without a doubt, Midwifery has traveled along with the emergence of social medicine, from reproduction and the mother-child approach as the main theme for women, to the discovery and discourse of multiple ways of living sexuality. In all the themes, it seems that there is a constant struggle between the hegemonic of patriarchy and the banners of the humanization of health. It seems to be beyond the positioning of a discipline, Midwifery from its beginnings, deploys a discourse that surpasses the technical.
The contemporary life story emerges as an experience of the prolongation of these changes, understanding that new future scenarios are presented with their own power structures. It should be highlighted that the role of midwifery in issues such as obstetric violence, legalized or free abortion, assisted fertility, gender transition, affective-sexual diversity, homoparentality and male contraception has yet to be investigated.
Midwifery will continue growing, and Chile is a referent, for its amplitude in the formation towards other subjects that not only underlie the childbirth and puerperium. That is why it is worth saying that we move from the perinatal maternal approach to the sexual and reproductive rights approach; from the women's agenda to the sexual and reproductive health program, from the care of women to the care of men and rather to the care of the individual, to the care of being, this new Dasein, which no longer has the tendency to be at the mercy of its own assumed tradition, but is a human rights subject. The epistemology of the midwife is developed as a discipline and the philosophy of her work, has always been present in the countless women who built the knowledge transmitted. Moreover, in a field of technology and science, and in which patriarchal models of power still persist, Midwifery struggles to be authentic, it evolves, it positions itself before the subject, and consolidates itself as knowledge, the human, the autonomous, socio-historical advances; the consolidation of sexual and reproductive rights, claim to be its discourse of difference.
Expressions of gratitude I thank my colleagues especially my great teacher Marta Santana.
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