Labour disputes

Two medical men, Michael O'Dowd and Elliot Philipp, the latter celebrated for his pioneering work in keyhole microsurgery, have produced a monumental tome that will prove immensely serviceable. It is hailed as a "classic" in a foreword contributed by the president of the International Federation of Gynaecology and Obstetrics, yet it is a book many historians of medicine are sure to find problematic.

No one can deny the pressing need for such a volume. The history of gynaecology has always been neglected, while the history of obstetrics was long poorly researched. Not surprisingly, a radical critique was launched some years back, accusing the extant literature of Whiggism, of uncritically trumpeting supposed "progress" with the dubious privilege of hindsight. Above all, feminist historians have shown that "Obs. & Gynae." history has systematically been interpreted through the eyes of male practitioners rather than from the viewpoints of the mother (and baby) or of traditional birth-attendants such as midwives.

In their 700-page overview, richly illustrated and packed with helpful tables and charts, O'Dowd and Philipp survey the field and make massive additions to our stock of historical information. As befits two practitioners, their strengths lie in coverage of recent developments, and especially in presenting plain accounts of gynaecological innovations in the context of the growth of medico-scientific specialties.

Rather than run a single story line throughout the book, the authors divide up their subject into some 40 sections, thematically organised around such topics as hormones, dysmenorrhoea, and anaesthesia, each being handled in self-contained capsules. Separate chapters are devoted, for instance, to cancer of the vulva, the vagina, the cervix, the uterus and finally the ovary.

Extensive coverage is given to the transformative role of science in chapters dealing with the diagnosis of pregnancy, the role of genetics, and advances in pathology. Blocks are also devoted to congenital malformations, microbiology, the menstrual cycle, menorrhagia and so forth. O'Dowd and Philipp explore the evolution of distinctive delivery techniques, including caesarian section, paying special attention to surgical advances. Considerable space is devoted to innovations in diagnostic technology, including laparoscopy and hysteroscopy, six pages on the speculum and a substantial chapter on radiology and imaging. The diseases of mothers and neonates are also examined, with a section on eclampsia and no fewer than 16 pages on premenstrual syndrome.

Much of the material presented here, especially on modern gynaecology, has never before been distilled within a historical survey. All scholars concerned with the transformation of childbirth, especially during recent centuries, are bound to find this an indispensable quarry, albeit one marred by minor inaccuracies and burdened with a prose style that never rises above the pedestrian and is often downright clumsy.

The trouble is that the selection of material and the resulting balance are highly problematic. It is not only militant feminists who will judge that midwives deserve a chapter of more than 16 pages. The fact that this is less than half the space devoted to fetal monitoring (in itself a superbly documented account) demonstrates the leanings of the authors towards the modern age and towards medicalised, high-tech childbirth.

The coverage can also be rather blinkered. After a few early remarks, hardly a word follows on birthing practices outside the western tradition. There is a thundering silence on the critique of institutionalised childbirth levelled during the past half-century by advocates of alternative practices, notably "natural childbirth". It is very strange that such an encyclopaedic history lacks a discussion of "twilight sleep", fashionable from the 1920s, and mentions only in passing the man who, in his day, was the world's most famous obstetrical reformer, Grantly Dick-Read. Nor is there a word about the National Childbirth Trust, set up in Britain in 1956 to bring Dick-Read's ideas to a wider audience and put them into practice via NHS midwives and doctors.

Equally, one does not have to approve of figures like Fredrique Leboyer, author of Birth without Violence, and Michel Odent to recognise that they are historically of some significance. Leboyer at least gets a fleeting mention, while Odent is absent. The omission of such developments in a vast book like this raises questions about its tacit biases.

Above all, what is all too often absent in this text is any real attempt to grapple with the significance of the developments charted in exemplary but isolated detail. We look, for instance, for some judgement as to whether the introduction of forceps from around 1700 proved a boon or a bane. In the light of the discussion of antiseptics, we wish to know whether Semmelweis was a persecuted genius or deeply paranoid. We seek an appraisal of the introduction in the 19th century of highly invasive gynaecological surgery, perhaps in the light of the critical analysis offered by Ann Dally. On such issues, the historiography is mentioned but not evaluated.

To take just one example, O'Dowd and Philipp present a graph showing the rapid decline in perinatal mortality and maternal mortality from the 1930s. They comment as follows: "Tackling a number of factors influenced the maternal mortality rates, and advances on many fronts, medical and social, gradually effected a large reduction in maternal mortality over the years." This is flannel. Irvine Loudon, by contrast, has pinpointed a very specific cause for this change: the introduction of sulphonamides at that time.

O'Dowd and Philipp have thus produced a text teeming with facts but lacking vision as to what those facts tell us about the great forces shaping the history of childbirth. Thanks to their data mountain, it will be possible for future historians to approach key questions far better informed than before. The historical meaning of this information remains to be decided.

Roy Porter is professor of the social history of medicine, Wellcome Institute, London.