Schafer on Williams, 'Women and Childbirth in the Twentieth Century: A History of the National Birthday Trust Fund 1928-93'

A. Susan Williams. Women and Childbirth in the Twentieth Century: A History of the National Birthday Trust Fund 1928-93. Stroud, England: Sutton Publishing, 1997. xviii + 331 pp. $35.95 (cloth), ISBN 978-0-7509-1209-9.

Reviewed by Elizabeth Schafer (independent scholar)
Published on H-Women (November, 1998)

Happier Birthdays

In a 1942 letter to The Lady, a British writer noted, "'One of the most cruel class divisions yet remaining in this country is that rich mothers need not suffer in childbirth as though we were still in the Stone Age, while poorer ones far too often do' (p. 143)." The issue of how women's socioeconomic status influenced their reproductive rights and health was debated by many groups, including the National Birthday Trust Fund (NBTF), during the twentieth century. A. Susan Williams, an historian for the Social Science Research Unit at the Institute of Education, University of London, chronicles the history of NBTF from its creation in 1928 until its merger with BirthRight to form the charitable organization WellBeing in 1993.

Williams presents a thorough analysis of how the NBTF evolved over its sixty-five years of existence while placing it in the context of British social and medical history. She claims that her book is the first in-depth analysis of previously ignored aspects of women's lives, particularly twentieth-century attitudes toward pregnancy and childbirth and the availability and accessibility of maternity services as viewed through the activities of the NBTF. Furthermore, she says that the NBTF has been ignored in histories of British medicine and its accomplishments credited to other groups and individuals.

Williams's focus on the relationship of poverty and childbirth offers fresh perspectives of twentieth-century women's history. Her work parallels that of her colleagues Ann Oakley, who initiated maternity research as director of the Social Science Research Unit, and Jane E. Lewis, who served with Oakley on the Steering Committee of the NBTF which funded Williams's research. Women & Childbirth in the Twentieth Century is a vital contribution to understanding humanitarian efforts to secure equitable medical care as a basic human right.

Williams presents material chronologically while also dividing discussion of NBTF's major programs topically; she describes the NBTF's transition from a pre-World War II source of charity relief into a post-war research patron. Williams states that the NBTF's history mirrors that of twentieth-century Britain because women's health issues were closely tied to changes in society. For example, the NBTF was founded in 1928, the same year that women's voting age was lowered from 30 to 21. The Depression caused crisis conditions that resulted in improved maternity services, and World War II was a catalyst for the development of advanced medical science and technology, the establishment of a welfare state, the waning of aristocracy, and the growth of a professional class. Her analysis investigates themes such as gender politics, the state versus volunteer control of health services, the development of social sciences, the commercialization of childbirth, and the expansion of the health research industry. She introduces NBTF leaders and activists such as Lady Juliet Rhys Williams and Margaret Wynn, examining their interactions with policy makers, scientists, physicians, volunteer workers, midwives, and mothers of all classes, giving voice to working-class mothers in addition to middle-class and aristocratic women. Although she is enthusiastic about the NBTF's work and successes, Williams also notes its faults and criticizes its early elitism.

She explains that the gradually increasing maternal death rate since 1911 was the reason for action. By 1928, almost one in two hundred British women died in childbirth annually. A royal announcement from Queen Mary stated that "The Queen views with grave concern the continued high rate of maternal mortality. Her Majesty feels that a every real endeavour should be made to remove this reproach from our national life (p. 1)." Aristocratic women, with powerful political and social connections, decided to establish a trust to accrue funds to finance a "'real crusade to solve the problems of maternal mortality' (dust-jacket)." Lady George Cholmondeley and Lady Londonderry founded the National Trust Fund for Maternity Services one year before the Royal College of obstetricians and Gynecologists (RCOG) was established. Lucy Baldwin, the wife of the Conservative prime minister, embraced the Trust's charity work because she said a woman in childbirth was "going into battle--she never knows, and the doctor never knows, whether she will come out of it alive or not (p. 2)." In 1930, the original trust was reconstituted as the NBTF, and its trust deed stressed that the group's goal was to acquire one shilling from every British citizen, donated in honor of their or their mother's or child's birthday, to invest in a trust account (in 1928, if donated, this would have totaled 42 million shillings or 2,100,00 pounds, worth approximately 714,000,000 pounds in the 1990s). Interest would finance the training of professional midwives and maternity nurses, enhance hospitals, and seek cooperation of maternity services throughout the British Empire and for "any other purposes connected with maternity and the welfare of maternity patients and newly born children (p. 259)." Initially, the NBTF provided money for the improvement of maternity hospitals in Britain, Kenya, Nairobi, and the provinces but had little actual impact on institutions' decision making.

During the interwar period, the NBTF shifted its attention to impoverished mothers and attempted to mitigate conditions caused by poverty and unemployment intensified by the Depression; 2.5 million people were unemployed in Britain, and participants in Hunger Marches protested the lack of jobs. Williams notes that the early NBTF's primary weakness was that it excluded poor women from representation on its committees. Instead, the NBTF leaders distinguished between the wealthy Trust members and the impoverished women they aided. Williams describes how divisive the NBTF was in its distribution of charity and treatment of mothers. The Samaritan Fund was selectively given to families with pregnant women whom the NBTF considered deserving and respectable. Elaborate dinners and balls were held to raise funds for the NBTF; Williams provides statistics about salaries and expenses that show admission fees of three guineas to these NBTF events often cost more than one month of meals given to a relief family of four people. An average NBTF relief family received twenty-six shillings in assistance, of which ten paid for rent and the rest afforded such dietary basics as flour, condensed milk, bones for soup, minced meat, and potatoes. The idea for everyone to donate one shilling also reveals how unaware members were of economic realities for the poor: a shilling was one-fifth of many Briton's weekly income. Public support for the NBTF was weak. The NBTF sent annual birthday cards which many people resented; others misunderstood the trust's purpose because of its name, thinking they would receive presents instead of being expected to give money. Early NBTF members also arrogantly believed they knew best what working-class mothers needed and did not consult these women. Williams tells how at the March 1939 Guildhall Reception, attended by Queen Elizabeth and other notables, two hundred women who received NBTF funds were chosen to attend as a guard of honour. Tickets for this fundraiser cost two guineas and insured a hot supper. The working class mothers were provided a cold snack before the reception and instructed on their expected behavior. Mothers who had saved money for new clothes and hats for this special occasion were disappointed and insulted at the contemptuous attitudes of their hostesses toward the mothers' attire and etiquette.

In the 1930s, the NBTF became more politically involved as it competed with other charities. Williams describes how British leaders were concerned about the declining birth rate as compared to political rivals Germany and Italy. Some aristocrats promoted eugenics and the quality not quantity of births. Poverty, poor health, and lack of health insurance and birth control remained problematic for most British women. Groups such as the Maternal Mortality Organization and National Council for Maternity and Child Welfare were created about the same time as the NBTF, and the Women's Cooperative Guild was the first woman's group to support birth control publicly. Working class women joined these groups, but they still did not belong to the NBTF. The Charity Organization Society arranged for middle class workers to visit the poor in their homes, while the NBTF had minimal contact with the recipients of its aid. Ironically, in these organizations, men controlled the policy decisions, while women did the work, but in the NBTF women directed decision making and had financial strength. Because women, despite their social class and ties, shared the common experience of childbirth, Williams states that they were ultimately united in a feminist movement crossing class and political lines to ensure medical care for women. NBTF members supported suffrage, and when Lady Astor was elected Conservative MP, other women refused to oppose her. Ethel Snowden explained, "I am a Labour woman, but the work which Lady Astor is doing for women and children both in parliament and the country makes her services invaluable (p. 43)." Lucy Baldwin appealed to everyone in her 1935 Wireless Fund: "I want to speak to you just as a woman and as a mother, and as one who has for many years been pleading on behalf of mothers (p. 45)." She stressed that male prejudices against women were obstacles to the NBTF's campaign for safer childbirth. Politicians realized that they could benefit by supporting maternity policies as women voters had increased from 40 percent of the electorate in 1918 to 53 percent in 1929. Photographs of candidates' families began to be featured on election materials.

The NBTF's first political success was the passage of the 1936 Midwives Act. Members had identified the organization of a national midwife service as a priority. In the 1930s, 60 percent of all midwives were underpaid mainly because patients lacked money during the Depression. Midwives endured difficult conditions and competed with free clinics and community hospitals; the quality of service varied because the Midwives Act of 1902, which first established midwives as separate professionals from doctors, admitted anyone who had practiced at least one year when the act passed. Dame Janet Campbell, who had written the book The Protection of Motherhood (1927), worked on behalf of the NBTF to establish better working conditions for midwives; she sought doctors' approval of maternity nursing by midwives. With her leadership, the NBTF created a national midwives headquarters in 1933 and established the Joint Council of Midwifery (JCM) one year later in an attempt to change national policy about midwives' employment. "This was work that the Trust was best placed to do, because of its powerful connections," Williams explains. "It had no difficulty in persuading distinguished and influential members of the establishment to join the JCM (p. 52)." JCM members included Queen Mary's brother, the Earl of Athlone, and Lucy Baldwin. Midwives were expected to qualify for certificates, and the regulation of services benefited mothers as the maternal death rate decreased. Doctors and midwives competed for deliveries, but, ironically, wealthier women were often more at risk than poorer women because physicians were inexperienced at childbirth compared to midwives with ample practical experience.

Williams also examines the NBTF's nutritional work to supplement the diets of poor mothers. Half of the nation was underfed, and starvation existed in areas. Poor health was linked to poor nutrition as part of the 1930s health movement, and mothers were identified as the most undernourished Britons. The NBTF described a minimum diet for pregnant women and distributed Marmite, Essence of Beef, Ovaltine, milk, herbs, and minerals. Lady Juliet Rhys Williams urged the NBTF to conduct nutrition research, although physicians criticized the NBTF's studies as being unscientific and inconclusive. Social reformers, however, credited the NBTF's efforts to feed hungry mothers with saving lives and encouraging the World War II Ministry of Food for insuring adequate rations for pregnant and nursing women. Williams discusses the history of breast feeding and public attitudes toward nursing as well as issues such as breast milk's nutritional qualities and the modern need to screen milk for the AIDS virus. The birth of premature quadruplets in 1935 emphasized the need for milk supplies. Financed by Sir Julien Cahn, chairman of the NBTF, whose first child died as a newborn, the NBTF opened Britain's first milk bank in March 1939 at Queen Charlotte's Hospital and provided human milk for sick babies or infants of mothers unable to nurse. The NBTF transferred the milk bank to the National Health Service in 1953.

Williams briefly explores the NBTF's investigation of abortion in Britain through the 1936 JCM Committee of Enquiry into Non-Therapeutic Abortion. Committee members wanted to understand the reasons for non-medical abortions. Williams explains the vital role of abortionists, often a local woman, in communities and the economic and emotional reasons for abortions, noting that often women endured unsanitary conditions and incompetent practitioners. She stresses the secrecy surrounding abortion and scarcity of information for detailed sociological analysis. Pain relief during childbirth, however, was well documented and advanced from women being ignorant of such possibilities to having options. Lucy Baldwin and the NBTF campaigned for access to pain killing devices and drugs for all women despite their income. Opponents defended pain as the punishment for women's sins. A Mr. G wrote to the Minister of Health in 1949, stating "How can a woman have that motherly affection for her offspring if she bares[sic] it without any pain (p. 125)?" Many men assumed that women did not feel pain as intensely as they did, and some women were too uncomfortable to press this issue. Ladies George and Londonderry prevented Baldwin's Anesthetic Fund from being incorporated into the NBTF and insisted that she tone down her Wireless Appeal from "We know the agony we have had to face in giving birth" to "Mothers know what we have had to face." Baldwin demanded funds for more beds and "eventually anesthetics (p. 126)." Not to be deterred by her peers, she arranged for sales of stamps and flags on Mother's Day, in an effort to eventually provide access to analgesia for all women.

The British public's first awareness of anesthetics might have been when Queen Victoria was given chloroform when she gave birth in 1853. By 1902, Twilight Sleep, a combination of scopolamine and morphine which caused a patient to be semiconscious and have no memory of pain, was used in some British hospitals but was considered unsafe. In the 1930s, the NBTF realized that most women gave birth in their homes with the help of midwives, so the NBTF distributed free chloroform capsules that could be crushed and administered in a gauze mask. The RCOG declared these capsules unsafe when administered by midwives, and the NBTF studied options for both anesthesia, in which the patient was unconscious, and analgesia, in which the patient could respond to instructions. Williams addresses how the NBTF decided to support gifts of 1,775 Minnitt Gas and Air Apparatuses, which supplied a mixture of nitrous oxide and air, to hospitals and midwives. This machine was too heavy for some midwives to transport, and the Trust arranged for lightweight Queen Charlotte's Gas-Air Apparatuses to be issued. Many hospitals did not use their Minnitt apparatuses which NBTF workers found "covered with rust and dust (p. 139)." Physicians protested midwives using analgesia because of their lack of training. In 1946, one fifth of midwives were qualified to use gas/air anesthesia, and only seven percent of mothers received pain relief because of the limited number of certified technicians.

Access to pain relief improved after World War II when the National Health Act provided government-funded health services. The NBTF supported scientists' research to improve pain relief methods, secured midwives access to Pethidine, an injectable analgesic, and promoted the use of Trilene which was less toxic than chloroform. NBTF funds enabled Dr. Michael Tunstall to develop a mixture of oxygen and nitrous oxide called Entonox which could be pressurized and transported in cylinders. The NBTF also financed analgesia research by the Natural Childbirth Association in 1956. A June 1990 survey reflected the NBTF's successes in securing the right to pain relief during childbirth. Pain and Its Relief in Childbirth (1993) interviewed women, their partners, and their physicians about the effectiveness of anesthesia. The survey showed that choice was the issue not availability. Women could use Entonox and other traditional pain relievers or elect to use morphine or an epidural or alternatives such as hypnosis and acupuncture. Ignorance of pain relief had evolved into knowledge of a variety of choices, and pain relief had undergone a transition from being withheld to being plentiful. Williams praised the NBTF's efforts, stating that "Mrs. Baldwin and the Birthday Trust had taken a leading role in a revolution that not only transformed the experience of childbirth, but narrowed the gulf between the lives and the expectations of poor women and rich women (p. 146)."

Williams describes how the NBTF's role was redefined by World War II. During the war, the NBTF was inactive except for maintaining the midwives' headquarters because workers were busy helping expectant mothers evacuated to Emergency Medical Services maternity hospitals in the countryside. Britain emerged from the war as a welfare state without as much need for philanthropy. Also, postwar political changes as the Labour Party took power meant that the NBTF no longer had close alliances with policy makers. Many privileged and wealthy politicians were out of power, and Prime Minister Attlee spoke at his wife Violet's Save the Children Fund instead of supporting the NBTF. At the same time, many of the NBTF's pioneering leaders were aging and dying, and the remaining membership of NBTF wanted to adapt to postwar realities of the state being responsible for citizens' health care and to try to influence the new National Health Service (NHS). Williams explains that the woman's movement declined after the war, and no new generation of feminists were willing to lead the NBTF. To survive as an organization, the NBTF adjusted its programs to focus on research, especially addressing perinatal mortality. This decision reflects the absence of feminists in the NBTF who might have sought equity of health care and costs instead of investing primarily in research.

The Technical Advisory Sub-Committee (TASC), established in 1948, included physicians and scientists as consulting members to choose and advise research projects independently from NBTF members. Professional elites were replacing aristocrats as leaders in Britain, and the NBTF sought allegiances with medical organizations and prestigious experts. Although TASC and the Trust's Executive Committee suffered conflicts because of TASC's autonomy, the NBTF funded pioneering research about the Rhesus Factor, causes of cerebral palsy, Down's Syndrome, fetal hearts, early ultrasonics, toxemia, and placental diseases as well as educating the public about antenatal care. The postwar period was a time of scientific and technological advances and discoveries, and the field of obstetrics benefited from professional development of tools and pharmaceuticals. Williams discusses how although many women considered midwives the best deliverers of babies, obstetricians, mostly male, were empowered as knowing best. The NBTF's postwar booklet The Expectant Mother showed a male doctor standing up as he instructed a sitting woman about her pregnancy. Before the war, women were considered to have the most expertise about pregnancy and labor, but after World War II, men usurped this professional authority from women. There were more male members of TASC than women, and women predominated on other NBTF's committees but had less influence than male committee members. Williams reveals that the NBTF's female members' primary strength was raising money for male medical professionals who chose how to use it.

Williams shows how the NBTF changed its platform to securing medical care for all mothers, not just the poor, and expanded its interest to infants and reproductive health. Efforts to influence policy decisions faltered. Aneurin Bevan considered a bill for the statutory right to analgesia in childbirth as a "political stunt" by the Conservatives to undermine the government (p. 169). Although Bevan mustered sufficient support to kill the bill, the NBTF generated publicity which swayed women voters to view Bevan and the Labour Party critically. During the war, the NBTF had cooperated with social services to treat all British mothers equally and not distinguish between classes. Williams identifies a 1948 meeting called Safer Motherhood as a watershed in the NBTF's history because of collaboration with other groups, specifically the Married Women's Association and National Federation of Women's Institutes, and distribution of free tickets as well as a radio broadcast of the meeting so that everyone was included instead of being excluded like at the Guildhall Reception. The NBTF initially supported the NHS and even claimed credit for initiating the idea but criticized nationalized hospitals replacing local health authorities, fearing the former might discriminate against poor patients. Members such as Lady Juliet Rhys Williams gradually accepted nationalization after it was in effect. She wrote a draft for the Mothers' Charter in 1947 which listed expectations, especially pain relief for all mothers and "best service" for an ideal maternity service, but she never asked mothers what they wanted, writing from her own viewpoint as a mother. One year later, the NBTF, Married Women's Association, and National Federation of Women's Institutes established the Safer Motherhood Committee, holding meetings and publishing the leaflet "Safer Motherhood: Minimum Requirements of a Comprehensive Maternity Service" in an attempt to influence the NHS's maternity policy.

The NBTF's best known work was its maternity surveys to identify and help women at risk. Williams details how in financing and organizing surveys distributed to selected mothers the NBTF aided in the collection of data useful to generations of physicians, sociologists, and historians. The 1946 Maternity Survey was supported by the NBTF to investigate socioeconomic aspects of birth and to determine reasons for the decreased birthrate in Britain. Fourteen thousand women of all income groups were questioned the week of March 3-9, 1946 about their pregnancy and delivery. Ninety-one percent of women agreed to participate, eager to help improve maternity services for future mothers. Lady Juliet Rhys Williams insisted that a question be included about analgesia. This survey was the first time a national collection of data about British mothers occurred. The NBTF is most closely identified with the 1958 Perinatal Mortality Survey. The NBTF surveyed mothers about the risks of home and hospital deliveries and also investigated why babies died. Midwives interviewed 25,000 mothers during one week in March. The questionnaires were combined with clinical information from medical staff and records as well as postmortems. Mothers welcomed being questioned and having their babies receive additional medical tests.

The NBTF established a database of data from the 1958 survey, using computers to handle the overwhelming amount of information which enabled the evaluation of several factors simultaneously. Survey results were published in 1963 as Perinatal Mortality, revealing the most common causes of death were intrapartum anoxia and fetal asphyxia. Williams notes how researchers identified smoking as the cause of low birth weights because of oxygen deprivation. Now aware of the dangers of smoking to fetuses, the NBTF attempted to educate pregnant women not to smoke. The NBTF also demanded more hospital beds for women while reducing the time of their stay. By 1968, 80.6 percent of babies were delivered in hospitals. The 1970 British Births survey and three additional national surveys supplemented the NBTF's efforts to reduce high mortality rates among the poor as unemployment increased in the 1960s. During the survey week of April 5-11, 1970, mothers of babies born in Britain and Northern Ireland were questioned about the infant care within the first week of delivery. The mother's social background was also documented. This survey was the most comprehensive of all three surveys and collected information about 17,196 babies born to 17,005 mothers of which 398 had been stillborn or died within the first week. Results, published as British Births and issued as two volumes in 1975 and 1977, indicated that an increased number of women had smoked during pregnancy, causing low weight infants, that fewer women breast fed, and that there was an increased use of oxytocic, episiotomies, and caesarean sections. Gas and oxygen replaced gas and air as a means of pain relief, and early hospital discharge allowed more women to give birth in hospitals. Williams emphasizes that the survey's most vital information was that although clinical standards had improved and more mothers received antenatal care, evidence verified unequal health care accessibility based on income still existed. The surveys revealed that wealthier mothers received more medical attention than poor mothers.

The NBTF sent annual birthday cards to keep track of the infants whose mothers were interviewed, and these children became an excellent research sample for scientists and sociologists who interpreted and compared data from different survey years as the children matured into adulthood. Collected information revealed how social class affected maturation, educational achievements, and health, among other topics. The large number of children enabled investigators to consider isolated characteristics such as being intellectually gifted. Numerous papers, articles, and books were published from the data collected which Ann Oakley praised as providing facts about what would have been otherwise unknown aspects of British social life. Such information enables Williams, Oakley, and other medical sociologists to assess and criticize how medical care has socially controlled women by limiting their options and making their health decisions.

By the late 1960s, the NBTF's leadership and funds were dwindling, but the Trust continued efforts to fund research during the next two decades, even selling its midwives headquarters. In 1993, the NBTF merged with BirthRight, the research branch of the RCOG, and the combined group is called WellBeing. Sponsoring more clinically-oriented medical research than the NBTF, WellBeing promotes advances in understanding menstruation, menopause, infertility, and cancer in women and published a self-help manual, WellBeing of Women (1995). Unfortunately, in the 1990s an estimated one of three British babies is born into poverty, and conditions of poor mothers resemble those at the beginning of the century. The middle and upper classes have the most maternity choices, have a voice in women's health services, and face the least childbirth risks. Williams predicts that the issues the NBTF faced will continue as long as socioeconomic differences are considered essential to health care providers. "From its earliest years in the interwar period, the Birthday Trust campaigned to establish the equal right of poor and rich women to a safe childbirth and a decent start in life for their children," Williams states. "But at the end of the century, despite a huge overall improvement in maternal and perinatal outcome, this has by no means been achieved. The dreams of Lady Baldwin and Lady Rhys Williams have yet to be fulfilled: they will be the urgent work of the new twenty-first century (p. 258)."

Williams's book contains a comprehensive chronology of the NBTF's complex history and appendices listing the NBTF's objectives, committees, and prominent members. Her endnotes provide details such as the value of a shilling at specific times, individual's personalities, food prices, and how Lady Juliet Rhys Williams was aware of the suffering of the poor because she saw coal miners near her home. Illustrations, including photographs, advertisements, flyers, and labels accentuate the text. A. Susan Williams utilizes a variety of sources. The NBTF records in the Contemporary Medical Archives Centre at the Wellcome Institute for the History of Medicine are the primary records she consults. She also reviews the manuscripts of other women's groups, both predecessors and contemporaries of the NBTF, as well as public and private papers of diverse organizations, individuals, and interests, including the British Medical Association, RCOG, London Medical School, the Public Records Office, Royal College of Midwives, Ministry of Health, Conservative Party Archives, Eugenics Society, Ann Oakley, Margaret Wynn, Lady Juliet Rhys Williams, government acts, committee reports, and the NBTF surveys. She uses interviews with participants such as NBTF members, medical professionals, mothers, midwives, and children. Contemporary newspapers and NBTF pamphlets and publications are other primary sources. Williams has grounded her analysis in secondary sources discussing the sociology of medicine, public health, welfare, gender, and philanthropy. She also cited British fiction by authors such as Virginia Woolf that included maternity themes and observations about British society.

Williams's presentation of a complex subject and its related issues is a valuable contribution to recent scholarship in women's, British, and scientific and technological history. Other scholars have mentioned the NBTF in books, but Williams's treatise is unique because she focuses on this single charitable organization and elaborates its history while placing it in context with major themes in medical history. Her assessment of the NBTF's contributions to maternity services and significance to maternity history is unbiased even though the book was sponsored by the NBTF and Josephine Barnes, who was president when the NBTF ceased in 1993, wrote the forward. Through examination of British culture and demographics, Williams effectively explains how social class affected maternity services in Britain and how the NBTF initially provided relief then funded research in an attempt to aid all mothers. She shows how birth moved from homes with midwives present to primarily physician-assisted deliveries in hospitals as medicine became professionalized. Birth expertise shifted from being female-dominated to being controlled by male authority figures, at least until more female physicians offered birth services. Even though the NBTF failed to achieve an equity of childbirth for all women, through research funds the NBTF provided women more choices about analgesia and delivery and the hope of healthier pregnancies, deliveries, and infants.

Williams knows her subject well. Earning a doctorate from the University of London, she has written numerous articles about literature and medical and social history and was employed by the Ministry of Health and worked for UNICEF in Zimbabwe. Williams edited The Politics of the Welfare State (1994) with Ann Oakley and also Mother Courage: Letters From Mothers Living in Poverty at the End of the Century (1997) as well as writing The Rich Man and the Diseased Poor in Early Victorian Literature (1987) and compiling three anthologies of women's writing. Williams's strengths are in giving voice to the impoverished mothers as well as aristocratic philanthropists, especially in her analysis of political and social interactions. Her information is well organized, but short chapters, such as the one on the milk banks, seem choppy and could have possibly been combined with related topics. Perhaps because she focused on one group, she sometimes provides an overabundance of details where more focused analysis would have explored issues suggested by other researchers. Williams introduces her subject and poses questions, such as what defines health and adequate medical care, that other scholars have scrutinized about the history of pregnancy and childbirth. Related books researchers might want to consult to complement Williams's work include those written by Oakley who addresses the interaction of public policy and women's health issues. These books include: Women Confined: Toward a Sociology of Childbirth (1980); Becoming a Mother (1980); The Captured Womb: A History of the Medical Care of Pregnant Women (1984); with Susanne Houd, Helpers in Childbirth: Midwifery Today (1990); Social Support and Motherhood: The Natural History of a Research Project (1992); and Essays on Women, Medicine, and Health (1993). Jane E. Lewis's works are also valuable contributions to women's medical history. Suggested books are Politics of Motherhood: Child and Maternal Welfare in England, 1900-1939 (1980); editor, Women's Welfare: Women's Rights (1983); Women in England 1870-1950: Sexual Divisions and Social Change (1985); What Price Community Medicine? The Philosophy, Practice & Politics of Public Health Since 1919 (1986); and with Kathleen Kiernan and Hilary Land, Lone Motherhood in Twentieth-Century Britain: From Footnote to Front Page (1998).

Other books of interest to maternity historians are Richard Soloway, Birth Control and the Population Question in England, 1877-1930 (1982) and Demography and Degeneration: Eugenics and the Declining Birthrate in Twentieth-Century Britain (1990); Simon Szreter, Fertility, Class and Gender in Britain, 1860-1940 (1996); and Carol A. Mossman, Politics and Narratives of Birth: Gynocolonization from Rousseau to Zola (1993). Linda Gordon's treatises Woman's Body, Woman's Right: A Social History of Birth Control in America (1976); editor, Women, the State, and Welfare (1990); and Pitied But Not Entitled: Single Mothers and the History of Welfare, 1890-1935 (1994); Charlotte G. Borst's Catching Babies: The Professionalization of Childbirth, 1870-1920 (1995); Sally G. McMillen's Motherhood in the Old South: Pregnancy, Childbirth, and Infant Rearing (1990); and Kriste Lindenmeyer's "A Right to Childhood": The U.S. Children's Bureau and Child Welfare, 1912-46 (1997) discuss similar issues as related to American attitudes toward maternity services, the health of women and children, and governmental and voluntary assistance to the poor.

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Citation: Elizabeth Schafer. Review of Williams, A. Susan, Women and Childbirth in the Twentieth Century: A History of the National Birthday Trust Fund 1928-93. H-Women, H-Net Reviews. November, 1998.

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