Transforming childbirth practices: New style midwifery in China, 1912 – 1949

Infant and maternal mortality rates worldwide have been declining substantially in the past century, but the inequality of infant and maternal health between developed and developing countries is still apparent today. The decrease of infant and maternal mortality rates has been influenced by a variety of factors, such as the standard of living, the quality of medical services, the sanitary environment and cultural norms. In particular, the fall in infant and maternal mortality was found to be closely related to the international trend of improving infant and maternal care. Studying the history of childbirth and midwifery can help understand how human reproduction became less riskful across time and space, and can provide new insights into midwifery training programs in some developing countries today.
This dissertation focuses on the transformation of childbirth practices and its impacts on relevant mortality rates during Republican China (1912-1949). The first half of the twentieth century in China was marked by a range of socioeconomic and cultural reforms that significantly changed ordinary people’s lives. Although interrupted by wars and economic upheavals, the midwifery reform, namely, the implementation of new style midwifery, was meaningful as it promoted and enforced a standardized new midwifery service (consisting of prenatal and postnatal care, and hygienic delivery) that helped reduce the risks of childbirth, and triggered the establishment of diverse infant and maternal healthcare facilities. In addition, it fostered a large body of trained midwives, and spread the idea of using new birthing methods via formal education and propaganda. These became the cornerstone for the more thorough midwifery reform in Socialist China in the second half of the twentieth century.
Previous studies have analysed extensively the influence of medical missionaries and Western medicine, the institutional construction of infant and maternal healthcare, and the linkage between implementing new style midwifery and modernizing the state. Most studies concentrate on the transformation process before the outbreak of the Sino-Japanese War (1937-1945), and acknowledge the health benefits brought to mothers and infants. However, limited by sources, they have not explored in detail the practice of new style midwifery during the 1940s, nor have they elaborated on how “modernized” midwifery services prevented neonatal, infant, and maternal mortality. Considering this, this dissertation addresses two questions: 1) How did the transformation of childbirth practices commence and develop in the Republican period (chapters 3 and 4)? 2) What were the consequences of implementing new style midwifery in this period, in terms of neonatal, infant and maternal mortality rates (chapters 5 and 6)?
The dissertation has presented how childbirth practices were influenced by missionary activities in the nineteenth century and by state’s health initiatives in the twentieth century, and how new style midwifery was spread throughout the country by health institutions and programs. It argues that though the establishment of governmental health institutions was a vital step for the state modernization, the practical implementation of new style midwifery was rather limited and unbalanced from a quantitative perspective. From the nineteenth to the early twentieth century, only a small number of women in China enjoyed midwifery services provided by physicians or midwives with certain training. The coverage of trained midwifery- new style midwifery- may reach at least 2.5% of all normal births in China in 1938, and grew modestly to 4.7% in 1949. Yet among the small group of births treated by qualified midwifery, most occurred in the wealthier or politically important provinces, and particularly among upper and middle class women in urban areas. This means that most women who lived in rural and remote areas still depended on traditional means for childbearing in the late 1940s.
The existing literature has not yet explicitly addressed the continuing spread of new style midwifery in China during and after the Sino-Japanese War. This dissertation argues that the midwifery work in the 1940s was also crucial, for it stimulated the spread and use of new style midwifery on a wider scale, laying an important foundation of infrastructure and personnel for the post-1949 era. Official documents, hospital records and other sources of the 1940s show that there was a continuous implementation of new style midwifery across the country, and that positive effects on mothers and infants’ survival chances were still noticeable. The Sino-Japanese War disrupted governmental work to a great extent, but it also created an opportunity for the western part of the country to organize and strengthen its health work, with the help of leading medical professionals who had fled the Japanese-occupied areas. At the same time, the Communist government also arranged campaigns and programs to train birth attendants in areas under its control, with a focus on rural women. During the Civil War, support from international organizations like the United Nations Relief and Rehabilitation Administration made enormous contributions, supplying medical facilities, pharmaceuticals and health workers to both Nationalist- and Communist- controlled areas, and assisting in training health personnel in different specializations.
The empirical findings attest to previous studies’ argument that new style midwifery in Republican China was conducive to infant and maternal health. The case study of Beijing (1926-1937) shows that both infant and maternal mortality rates in Beijing’s first health district dropped as the provision of trained midwifery increased in the community. It implies that trained birth attendants, be they physicians, new style midwives or traditional midwives, achieved significantly better birth outcomes than untrained attendants. The better performance of these trained attendants was the result of their capability of keeping hygienic procedures to prevent infections that could turn fatal. More interestingly, it shows that traditional midwives were competent enough to prevent neonatal mortality as physicians or new style midwives could do if they were properly trained and carefully supervised. Nonetheless, positive effects of the midwifery reform were absent in the nearby rural community.
The case of Sichuan and the comparative analysis on neonatal and maternal mortality in chapter 6 further confirm that being delivered by a trained birth attendant at home during the 1930s and 1940s was safer than that by an untrained attendant. The ratios of neonatal and maternal mortality associated with trained birth attendants in this period were probably around 35-45‰ and 2.5-4.5‰ respectively. These were clearly lower than the estimated average rates in the late 1940s: 91.6‰ (NMR) and 15‰ (MMR). The results pinpoint the demographic effects of new style midwifery in Republican China, which have been overlooked by the existing literature. They also support the argument that medical and social interventions played a role in the mortality decline in the twentieth century.
The comparison of the maternal mortality in Paris, Amsterdam and Beijing during the first half of the twentieth century places the state of midwifery and maternal health of China in an international context. The findings reveal a sharp contrast in the provision of trained midwifery services between the above-mentioned Eastern and Western metropolises. It was not until the early 1950s that the coverage of qualified maternity services in Beijing caught up with its European counterparts, and that its MMR fell to the level that Paris and Amsterdam had reached some decades before. Additionally, the higher level of the MMR in Beijing may be partly attributed to its higher fertility rate in this period, for a larger percentage of Chinese women was burdened with extra risks related to the high parity of pregnancy and childbirth.
In all, this dissertation illustrates how childbirth encountered trained medical practices and how a standardized set of midwifery services was formulated and disseminated in China from the nineteenth to the twentieth century. The empirical findings ascertain that these changes were effective in preventing infection-related diseases during pregnancy and childbirth, and were hence conducive to reducing neonatal and maternal mortality rates. No doubt, the Republican efforts provided valuable experience for the Communist government to further emphasize public health and new style midwifery, and to roll out more stringent reproductive health programs across urban and rural areas in the Socialist era.