In case you’re curious what my work looks like when it’s full of footnotes, here’s a sample. It won a prize!
This article was originally published in Social History of Medicine, Volume 13, Number 3 (December 2000): 359-380, copyright Oxford University Press, and is reproduced here with the kind permission of OUP. Any citation of this article must refer to its printed version.
The 1998 Prize Essay of the Society for the Social History of Medicine
Pathology, Danger, and Power:
Women’s and Physicians’ Views of Pregnancy and Childbirth in Weimar Germany
This article shows how the very real risks of reproduction were culturally constituted by expectant mothers and physicians in Germany following World War I. Both saw a strong potential for maternal and foetal death and injury.However, expectant mothers and physicians differed in the extent to which they regarded risk as contingent or inherent. Most physicians believed that pregnancy and childbirth first became dangerous in conjunction with a wide variety of other ailments, including complications specific to pregnancy. This view of pathology held a promise of prevention or at least treatment. Physicians further participated in inventing new, modern understandings of pathology, which also encompassed factory work as a reproductive hazard. Expectant mothers, in contrast, viewed pregnancy and childbirth as inherently dangerous based on their experiences and those of the women they knew, which not infrequently involved illness, disability, or close encounters with death. Many of them also held the ancient idea that a woman could harm the foetus with her imagination. As a result, though women varied in their beliefs (influenced by class, education, region, and religion), as a group they feared childbirth. Paradoxically, competition among lay and medical ideas gave women new options while also gradually enhancing medical authority.
Early feminist scholarship on childbirth tended to accentuate its ‘natural’ aspects, with nature understood to be self-evidently benevolent. This literature, originating mostly during the 1970s, cast (male) physicians as villains who had imposed ideas of pathology upon pregnancy and childbirth in an attempt to wrest control of them from female attendants.1 More recently, feminist historians (most notably Judith Walzer Leavitt) have shown, especially for the USA, that this narrative is far too simple.2 This article, which deals with meanings invested in childbirth in Germany from about 1914 to 1933, discusses how competing notions of danger and pathology were constituted by expectant mothers and their physicians. Women and doctors differed on two main points: first, as to whether reproduction was inherently or only contingently pathological and thus dangerous; and secondly, in the degree to which they embraced older or modernized views of the causes of abnormality. Irrespective of class or geographical region, women tended to see the dangers of childbirth as intrinsic to it, and they continued to grant credence to older explanations even as they sometimes accepted more modern ones as well. An examination of women’s and physicians’ views, in turn, suggests that the competition between divergent conceptions of pathology gave women new options while at the same time enhancing medical authority. This article will explore the spectrum of medical and lay views on reproductive dangers by drawing on a broad range of sources: court records from a landmark sterilization trial, women’s autobiographical writings, medical monographs and journal articles, and prescriptive literature.
Divergent notions of what made reproduction dangerous were articulated within larger discourses on the importance of maternity to the German Fatherland. From about 1900 onward, heated debates raged—among politicians across the entire spectrum, governmental leaders, demographers, physicians, and members of the budding disciplines of racial and social hygiene—as to what accounted for the drop in the nation’s birthrate that had begun around 1870 and how the birthrate could be raised. The tremendous loss of life during World War I added further urgency to these debates. As a result, reproduction became politicized, with all parties to the debates apt to blame women for being ostensibly selfish in refusing the financial and physical sacrifices that more frequent childbearing would exact. It is not the purpose of this article to examine the myriad aspects of pronatalism, social and racial hygiene, sex reform and contraception, the abortion issue, or infant mortality, which other historians have very ably explored.3 Instead, it will look at physicians’ and women’s views of childbearing and its hazards at a time when official rhetoric thoroughly subordinated the problems of maternal morbidity and mortality to those of infant illness and death, all to the purported greater good of an abstract Volkskörper, which one can understand variously as the body politic or the body social.4
The appalling incidence of infant mortality, which, even in the 1920s, continued to claim about one in ten children before their first birthday, overshadowed maternal mortality not just in statistical terms but in public policy and rhetoric as well.5 Historical demographers estimate that, in the nineteenth century, women faced about a one in twenty lifetime risk of dying during childbirth.6 With the discovery that painstaking cleanliness could prevent childbed fever, birth became somewhat safer.7 But other causes of maternal mortality actually rose in the twentieth century. Deaths from causes other than childbed fever (which would not have been influenced by the rise in illegal abortions) increased from a low of 1.78 per thousand (1901—10) to 2.58 per thousand (in 1931).8 Yet the debates on the population question during the 1910s and 1920s devoted little attention to maternal risks, and the German federal government failed to collect comprehensive nationwide statistics on the incidence and causes of maternal mortality and morbidity. Paul Weindling claims that maternal mortality was high enough to excite government concern.9 However, only scattershot statistics are available—a reflection of official indifference toward mothers’ health. Baden, Hamburg, and later Bavaria collected figures on obstetrical operations.10 Nationwide figures were broken down into childbed fever and other causes, which together amounted to 4.92 maternal deaths per thousand births from 1921 and 1925.11 Childbed fever accounted for over half of these deaths, but this category also included mortality from septic abortion. Data that first became available in 1934 suggest that about a third of maternal deaths were related to abortion or miscarriage.12 Obstetricians were forced to guess maternal mortality rates and causes because of the lack of complete data, and in the early 1930s the Reich Statistical Office, citing budget constraints, rejected the request of a group of elite obstetricians for governmental collection of statistics on the causes of maternal mortality.13 Obstetricians themselves often took a defensive stance on persistently high levels of maternal mortality. Frequent suggestions that criminal abortion was the major cause of the rise in maternal deaths drew attention away from the profession’s own failures to improve obstetrical procedures and medical education.14 Even critiques internal to the profession met with stonewalling from elite obstetricians and general practitioners alike: when obstetrician Max Hirsch excoriated the high rates of maternal and infant mortality, most of his colleagues not only condemned his proposed solution (more frequent caesarean sections) but also denied there was a problem at all.15
Hospital statistics shed some light on the causes of death in childbed, though hospital births cannot be considered representative of all births. Typically, women gave birth at home; only from about the mid-1920s did the number of hospital births exceed the number of home births in some large cities such as Berlin, Hamburg, and Frankfurt am Main. The question as to which was safer—home or hospital—lies outside the scope of this article and is unlikely ever to be answered definitively with the available data. Hospitals continued to handle more complicated deliveries than did midwives in their clients’ homes. This concentration inflated hospital mortality rates, as did complications that often resulted from medical intervention, such as infection. In Hamburg’s university hospital, the most frequent cause of death between 1919 and 1934 was infection (childbed fever) at 22 per cent of all maternal deaths; the next most frequent was toxaemia (predominantly eclampsia), followed by haemorrhage/shock and miscellaneous causes such as heart problems, embolisms, peritonitis, and pneumonia.16 This was a fairly typical picture, although the ranking of causes varied from one study to the next. Despite some variation, it should be noted that eclampsia and infection were always among the leading causes and usually the two most prevalent causes of death. This was true for infection even in the absence of epidemic childbed fever.17
Before proceeding further, a definitional caveat is in order: the very use of the term ‘pathology’ presents problems with respect to ordinary women and lay people in general. Pathology is a medical term that designates a deviation from the norm. This deviation is a manifestation of disease or a disease-like state. For the vast majority of expectant mothers, who faced childbirth with trepidation, a more appropriate term would be ‘danger’ or ‘jeopardy’. Very few of these women, with the exception of a handful who were highly educated or themselves physicians, would have employed medical terminology. Moreover, women did not necessarily view this danger as a departure from a norm; danger was itself the norm. However, a focus on pathology does provide a starting point for a comparative perspective on the divergent views of lay women and physicians. It also makes it possible to grapple with feminist arguments about medicalization.
German women and their doctors both saw generative processes as harbouring dangers that could kill or maim the mother, the foetus, or both. However, as will be shown below, expectant mothers tended to differ from physicians in the extent to which they perceived pathology to be inevitable. In the view of most women, danger was built right into the processes of pregnancy and, especially, of childbirth. These fears cannot be wholly captured by statistics alone (and, given the patchiness of the available figures, this is perhaps just as well). Historians disagree as to whether the approximately one in twenty lifetime risk of death in childbirth ought to be considered a ‘low’ risk.18 But along with the risk of death, women also faced a risk of long-term invalidism from puerperal infection, thrombophlebitis, or permanent injury resulting in incontinence and/or prolapse of the pelvic organs. An estimated 30,000 to 40,000 women suffered such serious, long-term, sometimes lifelong aftereffects of childbirth each year in Germany, resulting partial or complete inability to perform one’s usual work, as well as social isolation in cases of severe incontinence.19 However one values these figures, one cannot deny that childbirth did pose a real risk of death and disability. Its dangers were not merely a figment of the individual or collective imagination. At the same time, precisely how these risks were understood was a matter of cultural construction. That is, women and their birth attendants both colluded and collided in interpreting where danger (or pathology) lurked and when it was liable to strike. Shifting one’s focus to the discursively-shaped meanings women drew from their experiences with birth, one finds a remarkably consistent picture: In a wide variety of eras and societies in the West, women have dreaded childbirth.20
Overall, the evidence is quite strong that in the early part of this century, German women, like their counterparts elsewhere, tended to view pregnancy and childbirth as inherently dangerous, and that their fears cut across lines of class, education, and region. One vivid illustration of this comes from testimony in a precedent-setting 1931 court case in southwestern Germany, the Offenburg Sterilization Trial, which ruled voluntary sterilization to be illegal because it constituted bodily harm. A general practitioner, Dr Merk, and two of his colleagues were accused of illicitly sterilizing forty-one women who lived in and around the small city of Kehl. The initial impetus for the trial came from a denunciation, but its purpose rapidly shifted toward establishing the illegality of sterilization as a birth control option that women could choose, rather than as a last-resort medical procedure to ward off a serious and immediate threat to a woman’s life or health. Cornelie Usborne has quite rightly pointed out that the line between voluntary and compulsory sterilization could be blurred and that women could be coerced into acceding to the procedure for eugenic reasons.21 However, many of the women involved in this case asserted a demand for sterilization as an escape route from the tribulations of childbearing.22 In about half of the cases on trial, the doctors were also charged with illegal abortion. While the illegality of abortion on demand was not disputed, its inclusion in the trial, which came at the height of the Depression and the zenith of the campaigns to decriminalize abortion, intensified public interest. Merk and his colleagues were found guilty on a substantial minority of the criminal charges. They initially received sentences ranging from six weeks for the least involved colleague to a year for Merk himself. In a second round of litigation in 1934, dramatically longer sentences were handed down, with Merk receiving two-and-a-half years. This draconian punishment underscored the National Socialist goal of making sterilization compulsory for those considered genetically or ethnically unfit but unavailable to all others.23
While Merk’s patients—for the most part, rural or small-town women of limited means who had already borne three or four children—were not on trial, they were forced to testify. Their testimony paints a portrait of their perceptions of the dangers of pregnancy and childbirth, which (along with economic considerations) impelled them to request abortion and sterilization. In describing these dangers, the women in the Offenburg Sterilization Trial drew on their own experiences and those of the women they knew. Nearly every woman would have known someone who suffered either death or serious injury as a result of childbirth, and this ubiquity of suffering accounts for the diffuse nature of their fears. When the death occurred in the woman’s own family, it implanted a highly personal sense of vulnerability. Constanze G. told the court ‘she begged Dr Merk to terminate her pregnancy and sterilize her, since she was living in poor economic circumstances and already had four children. In addition, she feared that she would fare as her mother did, who died in April 1917 in childbed.’24 Other women involved in this trial made similar references to female relatives having died as a result of childbirth.25 But, along with this sense of danger as ubiquitous, most of these women also testified about direct, personal traumatic experiences: disabling pregnancies, personal brushes with death during delivery, or slow and incomplete postpartum recoveries. Several of these accounts will be drawn on below. In some ways, their stories are not wholly representative of all women, since it is likely that these women had endured more difficult pregnancies and births than the average woman, and for this reason became candidates for sterilization. They also clearly came under strong pressure to justify their decisions in court, which may have led some of them to play up their suffering. Still, the court judged their stories to be credible in nearly every case, which suggests a broader cultural consensus on the pervasiveness and immediacy of reproductive hazards. Indeed, as Ellen Ross has shown, women in other countries also had similar fears at this time.26
The women in the Offenburg Sterilization Trial perceived pregnancy as a time of dramatically heightened risk. During her previous pregnancies, Constanze G., for example, was afflicted by a goitre ‘that got worse with every birth. She suffered from shortness of breath, and it was practically impossible for her to climb a flight of stairs.’27 Sometimes, the woman reported that her health problems had resolved after the delivery: Odette L. told the court about her previous pregnancies, during which she ‘always vomited, and for the most part had to lie in bed. … The births all went well; afterwards she had no more complaints.’28 But the trouble commonly persisted after confinement, as well. Friederike B. had been diagnosed with diabetes during her last pregnancy and had spent practically the entire previous pregnancy confined to her bed: ‘After the birth the complaints did not disappear immediately, but instead lasted several months; then they stopped little by little.’29 Gabriele K. ‘had a lung catarrh [a probable reference to TB] during her third and fourth pregnancies … Even after the births the sharp pains in the chest continued. During her third confinement she had, in addition, double pneumonia.’30
An uneventful pregnancy by no means guaranteed a safe delivery. Indeed, women regarded the birth itself as the locus of greatest danger. Diana S., whose pregnancies were unremarkable, related that ‘her first birth in April 1923 was very difficult, it was a forceps birth; the course of her second birth in 1926 went better. Since the second birth she had a fallen womb and prolapse [of the vaginal walls]. Before each period she had strong pains in the small of her back.’31 Franziska K. reported ‘phlebitis and heart trouble since the birth of the first child’.32 Even when pregnancy passed without incident and the child was safely delivered, the birth could conclude disastrously, as one of the physicians on trial described for Ellen M.:
Parturition went well; but two hours after the birth, Frau M. had atonic haemorrhaging [a form of postpartum haemorrhage in which the uterus no longer has any muscle tone]. When she [the doctor] was called, the patient was lying there exsanguinated, unconscious, and without a pulse. She immediately gave a cardiac drug and injections, but it took a long time before Frau M. returned to her senses.
Ellen M. confirmed this account, and added: ‘After the third birth, both Frau Dr Bauer and the midwife told her it would be her death if she had another child.’33 Women also saw deliveries as bringing on long-term health problems. Toni S. had constant but irregular bleeding after her second birth.34 Susanna B. attributed dizzy spells, loss of weight, and a ‘kinked womb’ to her last birth, which itself had passed unremarkably.35
Although these women recognized that specific other, non-reproductive, conditions such as heart trouble could complicate pregnancy and childbirth or be exacerbated by them, they frequently portrayed childbearing itself as a source of rather nebulous danger. Juliane S., who had borne six children and was pregnant with a seventh, requested sterilization simply ‘because she feared that she could not come through another birth’.36 When the births themselves were not seen as the root of the woman’s illnesses, they could be perceived as inhibiting recovery. In the case of Nathalie S., who suffered from weak spells and a lung disease: ‘Various tonics were prescribed for her; since she had a birth each year, however, these medicines did not help.’ Instead of questioning the efficacy of the tonics (which probably contained mostly alcohol), Nathalie S. blamed her five births in as many years.37
The testimony of these women, even if slanted to legitimate their conduct, suggests a general climate of fear surrounding childbirth that was more than the sum of these women’s individual experiences—a climate created discursively as these women talked about the risks they believed they faced. It should be emphasized again that, although the court frequently suspected the interpretations offered by Dr Merk and his colleagues, it almost never doubted their patients’ testimony. Women’s fears were acknowledged in other sources as well, including those penned by doctors who dealt with them directly. Throughout Germany, elite obstetricians’ writings confirmed what one called ‘a mental epidemic’ of ‘fear of pregnancy’ among women of all classes.38 Another elite obstetrician noted an increase in fear, which he attributed to the shocks of the First World War and correlated with more frequent complications of pregnancy and deliveries.39
Furthermore, the autobiographical writings of more privileged women indicates that, while education, class, and regional differences inflected women’s views, no one was immune from the general sense of danger. A vivid example of this is provided by Louise Diel, a Berlin writer who was in many ways the opposite of the mostly rural, poorly-educated women of modest means who appeared in the Offenburg Sterilization Trial. In stark contrast to those who had no choice but to testify, Diel wrote about her childbirth experiences of her own volition, as a self-conscious intellectual and career woman who was pregnant with a dearly desired second child in mid-life, and who also expressly aimed to offer advice and support to other expectant mothers. In her third month of pregnancy, she described a highly considered strategy of focusing on its spiritual aspects: ‘The physical interests me only to the extent that I must survey it in order to behave properly and follow my condition consciously. Apart from that, I perceive the importance of this novel bodily condition more through its effect on my metaphysical self.’40 For Diel, the physical experience of pregnancy was primarily a path to greater self-development and self-realization. Both its emotional joys and its physical trials presented opportunities for personal growth.
Yet, despite her optimism, Diel could not entirely hold fear at bay. Even as she expressed confidence in her own health, she suffered considerable anxiety about the health of her unborn child. When Diel was four months along, a chance acquaintance recounted how she had suffered a miscarriage due to heavy lifting. The miscarriage occurred six weeks after the action that triggered it. Disturbed, Diel asked her doctor if a dead ‘fruit’ could really remain in the mother’s body for so long. Her physician said yes, it could, but he tried to make Diel laugh at her fears. However, neither he nor her husband could wholly reassure her. She continued to fear both that the travelling necessary for giving lectures could harm the foetus, possibly resulting in a delayed miscarriage, and that her state of fear could disturb her ‘blood circulation’, with equally dire results. Her usual consolations, reading and music, could do nothing to distract her thoughts; even with her considerable—indeed, uncommon—psychological defences and intellectual resources, she continued to be wracked by worry. And the fear was reinforced by the daily changes in her body, which, by her own account, she observed almost obsessively now, laying her hand on her abdomen, listening and feeling for any new pain or alteration.41 While this gesture is one familiar to pregnant women in many times and cultures, for Diel it represented a need for ongoing reassurance that she had not felt so strongly at the beginning of her pregnancy.
Another upper-middle-class, educated woman, the prominent child welfare reformer Marie Baum, underscored the ubiquity of the threat childbearing posed even to women of her own privileged background. In her autobiography, Baum (who herself never became a mother) mentioned in passing the death of an acquaintance in childbed.42 Her brief description cast this event as sad but scarcely exceptional. A few pages later, she recounted in detail the harrowing confinement of her good friend, the writer Ricarda Huch. As was still customary, the delivery took place at home. Although Huch was already attended by a doctor, midwife, and her husband, Baum was called in to assist with the critical final stages of the delivery. Baum looked helplessly upon Huch’s ‘unconscious body, no longer subject to the law of her own, regal movements but instead the thrashing tool of violent, dreadful, and mysterious powers of nature; hardly to be tamed, alien, horrifyingly impersonal’.43 After the delivery, Baum reported, both Huch and her baby daughter went through some months of poor health before both managed to recover fully.
Juxtaposing Diel’s and Baum’s accounts with those of the women caught up in the sterilization trial suggests several theses about women’s views. For one, even women who wholeheartedly wanted to become mothers were by no means immune from the sense of danger that permeated pregnancy. Many expectant mothers were, like Louise Diel, caught between hope and fear. The historical literature on German women during the Weimar period has put more emphasis on their attempts to avoid pregnancy than on their maternal desires.44 However, motherhood continued to be highly valued—not just politically, as expressed in pronatalist legislation prohibiting abortion, restricting birth control, and guaranteeing maternity leave and benefits, which often placed motherhood as an abstract good over the needs and well-being of individual mothers—but also culturally and by a large number of individual women.45 Even as women sought to restrict family size and to exercise more control over the circumstances of their maternity, very few of them rejected maternity altogether. While urban women, in particular, usually wanted no more than one or two children, very few of them preferred to remain childless, as evidenced by a wide battery of tests and treatments that women were willing to undergo in hope of overcoming infertility.46 The desire for a child did not negate a sense of danger. Instead, ‘voluntary’ motherhood and a strong yearning for a child only doubled the stakes: The more a woman wanted a baby, the more she was apt to worry about her fruit’s well-being as well as her own. Indeed, Baum—who worked intensively with poor and working-class women to improve infant survival—noted that although a small minority of women felt relief upon the death of an unwanted infant, the vast majority grieved deeply.47
Secondly, women shared an anticipation of great pain during childbirth, which further augmented their anxieties. For example, Frau K.H., a 29-year-old former sales clerk in Berlin, claimed in the course of an abortion trial that she had sought to end her pregnancy ‘because as a result of the narrow build of my pelvis I had to endure extraordinarily strong pain during the birth of my first child and consequently I was afraid of a second birth’.48 In this case, a potentially serious complication provided a strong rationale for fearing an extremely painful delivery. In addition, pain was (and still is) generally associated with disease or injury. Childbirth is the single outstanding exception to this, in that a completely healthy process may still cause great agony; yet both its potential for complications and the pain itself suggest a structural affinity with disease-like processes, which some lay women found compelling, even as other women insisted that childbirth pain was productive.49 Thus it is not surprising that the expectation of pain merged with some women’s perceptions of danger and heightened their anxieties: the fear of pain reinforced the fear of death or disability, and vice versa. For example, a link between childbirth, pain, and death was reflected in and reinforced by advertisements for highly successful patent remedies aimed at expectant mothers that promised to alleviate pain and guarantee a safe delivery.50 This association was grounded in reason as well as emotion, inasmuch as protracted and difficult births that required intervention—be it due to a narrow pelvis (as in the case of K.H.), eclampsia, major tears, or other complications—were likely to inflict more pain than a spontaneous delivery, as well as endangering the survival and good health of both mother and child to a greater degree.
Thirdly, a variety of sociological categories—class, education, religion, and regional or rural-urban differences—shaped the way women interpreted and coped with fear, without rendering any group of women immune from it. This is not to argue for an essentialized, universal experience of childbearing, but rather to suggest that women’s common ground outweighed socio-cultural distinctions. Nor did these categories operate deterministically: each individual’s experiences remained unique, even from one confinement to the next, and only imperfectly predictable according to social distinctions. The crucial category here was what we would now call gender, but what these expectant mothers would have viewed as womanhood. That is, these women would not have felt the very real danger they faced to be in any way constructed but rather to be inherent in the reproductive task of their sex. What we may now identify as cultural ‘constructions’ of danger were their attempts to interpret and make sense of it and thus to render it more manageable.
The problem for these women was that the diffuse character of the danger made it intractable, which raises a fourth point regarding women’s notions of pathology: Rather than facing the hazards of childbearing with a fatalistic attitude or viewing themselves as victims, women of all backgrounds sought help to avert risk to the extent possible. Of course, educated women were more likely to rely on physicians. But here, too, one must not exaggerate class and educational differences. Thanks to Germany’s health insurance system, a large majority of women had access to a physician’s advice at least in cases of serious complications.51 A tremendous proliferation of advice books for expectant mothers must be regarded as a response to women’s fears and need for reassurance, even as this literature often fed such fears by discussing complications, including extremely rare ones. Not just an attempt to exert medical control or to promulgate pronatalist ideas, these books were written by laypersons as well as physicians, by women as well as men, and for women of all educational and class levels, with one detailed booklet being distributed to working-class women by the insurance companies.52 Moreover, regard for the physician’s growing status as an expert was mingled with scepticism, so that women of all backgrounds might also rely on midwives, homeopaths, naturopaths, and other sources of support such as friends and relatives to help them face and overcome the danger.53 As Diel’s account confirms, women talked to each other about what to expect—a phenomenon that doctors also noted, and frequently condemned as only undermining women’s courage.54 And, indeed, physicians rightly noted that women often did reinforce each others’ fears. However, such conversations must have also validated women’s fears, made them feel less alone, provided potentially useful information, and confirmed that other women had survived despite the odds. These tales also brought women together who ordinarily would not have had much of a connection, and on a more level playing field than one might expect. The woman who told Diel about her delayed miscarriage lived in the provinces (in or near Chemnitz); she was working-class and less well-educated. Diel was there to deliver a lecture. Yet in this encounter, the roles reversed: Suddenly, the working-class woman became the expert. And Diel was unable to dismiss this woman’s story as mere superstition; she had to take it seriously, and it shook her to her core.
Finally, women clung to older notions of danger that would not necessarily stand up to strict scientific scrutiny. Perhaps the most important of these was the ancient idea of ‘Versehen‘, or ‘maternal impression’, which held that a pregnant woman could mark or harm the foetus with her imagination.55 For instance, a craving for strawberries might leave a red birthmark. Being startled by a rabbit could cause the baby to have a harelip. Many women and midwives continued to believe in Versehen well into the twentieth century.56 That this belief could be compatible with a faith in science is confirmed by Diel, who placed great trust in science while subjecting it to her own critical scrutiny. Even before her attack of nerves, Diel refused to discount the possibility that the mother’s thoughts could shape her child’s appearance, though she expressed disdain at the widespread idea that a systematic, rational approach to ‘pre-natal childrearing’ could implant desired characteristics; for example, musical talent could be inculcated by playing music to the fruit in the womb.57 Once Diel began to worry about a miscarriage, however, the possibility of Versehen—in this case, of harming her child with her worry—became highly immediate.58 As one young physician observed, the belief in Versehen remained extraordinarily resilient among expectant women of all class and educational levels, and it was unlikely to disappear any time soon, irrespective of the scientific evidence. For any time a child was born with a deformity, the mother would seek a retrospective explanation.59 This is not to say that every woman believed in Versehen, but neither was it merely a dying superstition that only the ignorant embraced. After all, educated women were among the strongest boosters of its modernized version, ‘pre-natal childrearing’.60Versehen and pre-natal childrearing can be regarded as magical beliefs that posited a mystical unity of all nature and that granted explanatory power to the inexplicable, the experimentally unprovable, and even the supernatural.61 Most doctors and scientists regarded the idea of Versehen dubiously, though only a small minority refused to dismiss it altogether.62
When one turns to doctors’ writings, one finds something that differs from this sense of pervasive danger. For physicians, danger was contingent rather than immanent. They distinguished clearly between ‘physiology’ and ‘pathology’ in their discussions of reproductive processes, though the line between these two categories could be thin, slippery, and hotly contested. Physicians generally believed that pregnancy and childbirth first became dangerous in conjunction with a wide variety of other ailments, including complications specific to pregnancy. Indeed, they often explicitly or implicitly categorized health problems as deriving from pregnancy itself or as being exacerbated by the pregnancy. The former category included hyperemesis gravidarum, narrow pelvis, toxic disorders such as preeclampsia, and even relatively minor ‘complaints of pregnancy’ such as varicose veins. The latter category included most prominently tuberculosis, followed by heart disease, kidney disease, and gynaecological disorders. ‘Nervous’ diseases (epilepsy, psychosis), pernicious anaemia, Graves’ disease, and even appendicitis could also fall into this category.
Generally speaking, physicians took more seriously those ailments that predated the pregnancy. This attitude is reflected in the judgements made in teaching maternity hospitals as to when the danger to a woman—defined as a serious and immediate threat to her life or health—justified aborting a pregnancy. These elite, university-based physicians disagreed, however, on what constituted such a threat. For instance, some recommended abortion as a general rule in cases of TB, while others advocated conservative treatment in a sanatorium unless the woman’s life hung in the balance (and sometimes not even then).63 Within a given hospital, no single pathological condition would justify abortion in every case. But it is striking that abortion due to complications of the pregnancy itself was quite rare in these hospitals.64 The explanation for this may well be that, although these elite physicians held a contingent view of pathology, they were not insulated from the larger cultural sense that birth was inherently dangerous. Ernst Bumm, the chief professor of obstetrics at the Charité in Berlin, argued that abortion was not justified when there was ‘only the distant possibility of dangers, which exist for every birth, after all …’65 Bumm’s position here was the same as that officially expressed by the Ministry of the Interior.66 In this view, danger was not ever-present, as many women believed, but nor could anyone guarantee women complete safety. Women simply had to be prepared to bear a certain degree of risk. In this attitude, doctors were supported both by the courts and by a widespread cultural trope that equated women’s ‘service’ in childbirth with men’s risking their lives in battle.67
In comparison to these elite university-based obstetricians, general practitioners and specialists in private practice used a more expansive definition of what conditions posed a serious threat to expectant mothers’ well-being. Here, too, criteria for abortion serve as an indicator for perceptions of risk to the mother. Not just the doctors accused in the Offenburg Sterilization Trial but, indeed, most physicians in independent practice were much more likely than their elite counterparts to recommend an abortion in the face of potential complications—a situation that reflected greater vulnerability to patients’ pressure and economic dependence on patient loyalties as well as the more limited resources available to doctors outside of major research hospitals.68 Yet it would be a mistake to regard practitioners’ greater readiness to terminate or prevent pregnancy as disingenuous. In the Offenburg Sterilization Trial, the court questioned the appropriateness of diagnoses but often acknowledged that the physicians had acted in good faith. Merk and his colleagues articulated a most expansive view of contingent pathology, citing concerns such as difficult previous births with haemorrhaging or eclampsia.69 Elite obstetricians scoffed at such motivations for sterilization or abortion.70 Elite physicians also viewed the lack of uniform medical criteria for what constituted truly dangerous pathological conditions as providing unfortunate encouragement for physicians in private practice to do ‘nothing or everything’.71 Support for this standpoint came from official quarters, as well: the Ministry of the Interior condemned sterilization for reasons other than a serious and immediate threat to the mother’s health and life as illegal and counter to the state’s interest, which was defined in pronatalist rather than moral terms.72
Against the implication that practitioners who performed abortions or sterilizations acted solely in their economic self-interest, it should be noted that non-elite practitioners had longer-term contact with their patients than did their counterparts in the hospital. They had an opportunity to develop a fuller picture of the expectant mother’s overall health, family situation, state of mind, and other contextual matters—not just her potentially diseased organs. Thus, these doctors were more likely to develop a definition of reproductive pathology that took account of the ways in which adverse social and economic conditions could mix with pregnancy and make it harder to treat disease and complications effectively. They recognized that while a woman in comfortable circumstances could use bed rest to try to stop premature labour or visit a sanatorium to halt the progress of tuberculosis, poor and working-class women had no choice but to remain in their homes and carry out their grinding routine of daily work. Even the judges in the Offenburg Sterilization Trial concurred with the physicians on trial that poverty could interfere with necessary medical treatment.73 While the vast majority of elite obstetricians paid little heed to this conundrum, a handful of them attempted to understand women’s bodies in a holistic way, taking into account their psyches and social conditions, in a new subdiscipline they dubbed ‘social gynaecology’.74
Only rarely did physicians express a belief that pregnancy and childbirth were inherently pathological—and immediately so, as opposed to the remote dangers that attended every birth, in Bumm’s view cited above. One example of a medical view of pervasive pathology was developed by Wilhelm Liepmann, a leading practitioner of social gynaecology. Because women’s bodies, unlike men’s, were open to the world (with all its dirt and disease) through their reproductive organs, Liepmann believed women’s health to be continually and seriously endangered.75 Pregnancy and childbirth represented only a special case of this built-in pathology, and adverse social conditions only a further intensification of an irreducible underlying high risk. Here, as in much of his controversy-ridden career, Liepmann was an exception that proved the rule. Despite holding unusually liberal, modern views on abortion and birth control, Liepmann also echoed older medical views of pregnancy and birth as both roots and symptoms of women’s allegedly weaker constitutions, which made danger immanent to reproduction.76 While most physicians (both elite and rank-and-file) believed during the 1920s that reproduction could quickly cross the thin line from normal to abnormal, the vast majority also placed a great deal of faith in nature.77 In this respect, German physicians who practised obstetrics differed markedly from their contemporaries in the United States, who, during the 1920s, introduced an extensive array of prophylactic standard procedures designed to prevent complications before they could occur. This development reached its apogee with Joseph DeLee’s advocacy of routine episiotomy and prophylactic forceps, along with scopolamine in the first stage of labour (to induce amnesia), ether in the second, and ergot (to prevent haemorrhage) following the third.78 No parallel development occurred in Germany, where the leading obstetricians counselled patience.
The medical view of danger and pathology as contingent meant that reproductive complications could be prevented or at least treated. This idea, in turn, reserved a key role to the physician while making it possible to delegate routine tasks to midwives. Compared to laywomen, physicians viewed the dangers of childbirth as more predictable. They were not yet at a point where statistical methods would be used to predict a particular woman’s risk. Instead, they agreed that certain conditions already ascertainable in pregnancy (such as narrow pelvis or protein in the urine) and certain diseases (heart or kidney problems) heralded a riskier delivery. For example, protein in the urine could foreshadow the onset of eclampsia, which physicians would try to avert with a low protein diet and restricted fluid intake. A narrow pelvis indicated the woman should plan on a hospital birth, rather than giving birth at home with a midwife. Increasingly, elite physicians in particular were beginning to see such conditions as potentially treatable and thus controllable. As one university-based obstetrician stated, induced abortion as a solution for such problems was tantamount to a ‘defeat of the medical arts’.79 The trend in her hospital, as in others, was to explore other, less drastic means of treatment, which presumed that the pregnant woman’s medical problems would not prove to be intractable.
Constructing the pathologies of pregnancy as predictable was one way in which reproductive dangers were beginning to undergo a process of modernization led by physicians. The burgeoning discourse on women’s wage work and reproductive hazards was another. During the 1920s, gynaecologists and social workers produced a wealth of studies attempting to demonstrate the threat that paid work, especially in the factory, posed to a woman’s ability to carry a pregnancy to a successful conclusion.80 (Practically all forms of unpaid housework were considered safe.) Max Hirsch, another practitioner of social gynaecology, spearheaded this scientific effort, which was also always a political effort insofar as it influenced protective legislation and state-mandated maternity benefits. In the main, these were Hirsch’s arguments regarding the textile industry: Girls who began factory work during early adolescence paid for it later with pelvic deformities and difficult births. Female workers in their childbearing years suffered higher rates of mortality, illness, and exhaustion than did male workers. Those women who continued to work during pregnancy suffered a higher rate of miscarriage than those who did not perform wage labour. During pregnancy, textile workers suffered from varicose veins and other complaints of pregnancy; afterwards, from inflammation and prolapse of the reproductive organs. Only 27.84 per cent of them would have a ‘normal’ birth, Hirsch asserted (presumably a spontaneous vaginal delivery with no complications for mother or child—though Hirsch failed to define his terms, here and often elsewhere, too). Finally, Hirsch found foetal growth to be compromised in women who worked up until their due dates.81 Hirsch contended that these conclusions for the textile industry, which very rarely exposed its workers to poisonous chemicals, proved that factory work as such posed grave dangers to both pregnant women and their unborn children.82 Hirsch concluded: ‘Pregnancy and industrial work are irreconcilable opposites.’83
Historical studies of debates on women and work have tended to draw out the implications of studies such as Hirsch’s for protective legislation and gendered equity in the workplace.84 However, this story also has far-reaching implications for the history of childbirth. Like other forms of reproductive pathology, those allegedly produced by factory work were contingent yet extremely widespread. The discussion of these hazards usually focused on pregnancy as such while bracketing out the post-natal recovery period. There was a political reason for this. All participants in the debates on women and work already agreed that new mothers ought to be at home with their infants. Politics also shaped the somewhat less vocal opposition to Hirsch and his allies: a study by another obstetrician, Eduard Martin, contradicting Hirsch’s findings, was supported by employers in the textile industry.85 Not surprisingly (given the political stake of all participants in these debates), scientific standards of evidence were given short shrift, not only by today’s standards but also by the standards of that era. Arguments couched in statistics rarely stood up to closer scrutiny, and neither Hirsch nor Martin compared a test group to a control group. While women who worked double and triple shifts as mothers, homemakers, and paid workers clearly did suffer poorer health than women whose lives afforded some leisure, Hirsch failed to demonstrate in scientific terms that factory work was especially pernicious, or that the nature of such work (rather than overall exhaustion, poor nutrition, substandard housing, and the like) was the sole causative factor.
Historians have rarely addressed these and other shortcomings, although German maternity law today still rests on assumptions from the Weimar period.86 An exception to this is the work of Usborne, who rightly points out that concerns about the declining birth rate underlay the attack on factory work and perhaps made physicians, scientists, and government officials more amenable to overlooking the methodological sloppiness of these studies.87 While a genuine concern for women’s health was another force driving these debates, it is impossible to sort out where the humanitarian impulse ended and where expectant mothers began to be regarded as a mere means to an end. These debates were a curious mixture of old and new. Pseudoscience was used to update older restrictions on pregnant women’s activities, giving them modern populationist rationales and adapting them to the modern conditions of factory work. The discussion of pregnant women in the workforce reinforced taboos regarding the propriety of pregnant women moving freely in public spaces, and it reflected magical thinking not so very different from the mode of thought underpinning Versehen; for instance, Hirsch’s controversial contention that vibrating machines could induce miscarriage through a kind of sympathetic oscillation of uterine muscles.88 Despite the lack of scientific rigour in these studies, a broad coalition of politicians (especially but not exclusively in left-wing parties), physicians, and social workers supported their conclusions and their implications that strict protective legislation was urgently needed. Privileged women in the bourgeois and socialist feminist movements joined in this coalition.89 But a great many working women, impelled by straitened family finances, did their best to evade restrictions, often working illegally during the last six weeks of pregnancy and sometimes right up until their due dates.90
All of these ideas—older ones such as maternal impression and newer ones such as the reproductive threat of factory work—were very much in flux during the 1920s. For women, the consequences of this were mixed, but decidedly less dire than a totalizing narrative of medicalization would imply. It is true that physicians and their social worker allies exhorted pregnant women to comply with various forms of social control (ranging from advice books and pre-natal counselling to maternity leave), which they promised could help prevent pathological pregnancies and deliveries. These new areas of expertise did invest physicians with added prestige and authority. Some of these new techniques of power may have benefited most pregnant women most of the time. Many women may have drawn an advantage from more time off work, more information available about how danger could be limited during pregnancy, more precise insight into the changes in their bodies. Others may have suffered financial hardship from mandatory leave, resented the bureaucratization of advice-giving, or resisted attempts to rationally explain the mystery of new life.
To what degree did expectant mothers during this period begin to internalize modern, contingent conceptions of pathology as expressed by physicians? This is an important question in that it provides a window onto women’s readiness to accept the medicalization of childbirth. Women’s behaviour in two areas suggests that most expectant mothers continued to regard the dangers of childbearing as diffuse and largely unpredictable during the 1920s and indeed for some decades to come. First, while pre-natal care and counselling centres enjoyed increasing popularity in some of Germany’s larger cities (especially Berlin), the vast majority of women did not seek out pre-natal care, apart from perhaps a visit to a midwife in late pregnancy to secure her assistance at the birth.91 In the absence of regular, universal pre-natal monitoring, the predictive models of elite obstetrician were of little practical use. However, most educated middle-class women saw a doctor throughout pregnancy, which put them in regular contact with medical ideas. This suggests that they increasingly accepted the paradigm of risk as contingent and measurable even while they continued to feel free to challenge the physician’s wisdom on occasion, as when Louise Diel admitted that she and her husband sometimes allowed love to ‘claim its rights’ despite her caution due to her doctor’s warnings that sex could be dangerous in pregnancy.92 Secondly, the number of women choosing hospital birth remained a minority during this period, reaching a peak of just over 16 per cent in 1931.93 A rising number of educated women—including some relatively well-off urban working-class women—did choose hospital birth because they perceived it as safer, which suggests some acceptance of physicians’ authority. Less privileged women chose the hospital primarily for social reasons such as illegitimacy, homelessness, or an inadequate apartment.94 Some women who developed overt symptoms of illness during pregnancy or knew they had long-standing conditions were also referred to the hospital for delivery, regardless of social background. But the fact that most women continued to give birth at home with only a midwife in attendance indicates both persistent trust in midwives’ skills and scepticism toward physicians’ ways of viewing childbirth and its hazards.
Economically- and educationally-privileged urban women should thus be seen as the narrow edge of a wedge that would eventually result in a majority of women seeing the dangers of childbirth as foreseeable and thus manageable within a medical model of care. At the same time, as long as new conceptions of pathology competed with older ones, women also could make tactical choices as to which ideas and practices they could most easily integrate into their everyday lives and their worldviews: those that made pregnancy and childbirth physically easier, and those that promised them material or psychological rewards. Their choices would be circumscribed first by National Socialist racial and population policies, which—along with coercively preventing or promoting childbirth, depending on whether a woman was considered racially and genetically ‘fit’—also discouraged hospital birth.95 In the post-war years, the growing power of the medical profession increasingly defined childbirth, especially after hospital birth and pre-natal care began to be universally covered by insurance in the 1960s.96 By the late 1960s and early 1970s, German women saw childbirth as basically safe—and were poised to begin a feminist critique of its medicalization.
Acknowledgements: I want to thank Sierra Bruckner, Bernhard Debatin, Maria Mitchell, Jean Pedersen, and the anonymous referees for their thoughtful and helpful comments on earlier versions of this article, as well as Isabel Hull for her unflagging support and sage advice. I would also like to express my gratitude for generous research funding from an Olin Foundation/Cornell University grant and the Berlin Program for Advanced German and European Studies.