Kate, Will and the royal baby (George Alexander Louis)

In recently months, the media has been alight with news about the #RoyalBaby–the expected first child of Princess Kate (formerly Middleton) and Prince William. Hashtags like the one above are, of course, a little misleading; in many ways, the news that has been circulated, discussed, and endlessly retweeted has been less about the baby than his means of arriving here. Questions concerned Kate herself: How was the pregnancy going? Was there any morning sickness? Did the princess feel strange cravings? There were also more general (though often political) questions about succession if the new baby was a girl instead of a boy (“Last vestiges of the British empire” Washington Post)–and plenty about the naming process (“The Fresh Prince Still Has No Name” USA Today). But one of the primary questions–and one that garnered great attention in the past week–concerned how and where Kate would deliver the heir.

The headline for Bloomberg on July 23rd read “Duchess Casts Midwife Tradition Aside for Royal Birth.” The National Health Service of Great Britain provides for a midwife rather than an obstetrician. This was the method used by Queen Elizabeth (II) for her children, Prince Charles, Princess Anne, Prince Andrew (Duke of York) and Prince Edward (Earl of Wessex). That Kate chose to have obstetricians at the birth–“casting aside” tradition, as the title suggests–is registered with some amount of shock. After all, in the UK, two-thirds of deliveries are performed by midwives, while private care is sought only in complex cases (Bloomberg). Interviews conducted for the article by Andrea Gerlin and Michelle Fay Cortez seem to support the idea that Kate’s decision was entirely out of the ordinary and uncalled for, with midwives confessing bafflement. But how unusual is this decision? And why has it produced such a response? The issue has historical roots and–as usual–there is always much more to the story.

Queen Caroline and George, Prince of Wales

Who Decides, Who Delivers?

Prior to the 18th century in Britain, babies were delivered by midwives, women practitioners who had apprenticed under other women–or sometimes just an elder matron who had given birth many times herself. Then, suddenly, things began to shift. In a relatively short space of time, midwifery developed from the rare intervention of surgeons to a robust and nearly exclusive male practice. A confluence of events led to this shift, including changes in the “bodily and social event” of childbirth with the advent of lying-in hospitals, as well as changes in fashion, politics, and social structure.[i]  Medical technology was the male calling card, so to speak. With the invention of the forceps, skilled surgeons (who were always men), could deliver children even in difficult or near-hopeless cases:

William Hunter

The more it was known [the surgeon] could deliver a living child, the less women would fear him; the less they feared him, the earlier they would call him; the earlier they called him, the more often he could deliver the child alive; and the more other this was so, the further it would be realized that he could achieve this.[ii]

So, what does this have to do with royal choice? To begin with, it signals a change in the way people thought about pregnancy and birth. Birth became a subject of medical science and of medical men, and by 1764, Queen Charlotte made William Hunter her royal obstetrician. The new age of obstetrics did not put an end to the birthing debate, however! Instead, two schools of thought arose–one that favored intervention by the obstetrician with the forceps, and one that favored non-intervention (letting nature take its course). Like Queen Charlotte, Princess Charlotte (her granddaughter) also had a physician obstetrician overseeing her pregnancy and birth–Sir Richard Croft. Unfortunately for Charlotte, Croft followed non-intervention methods and Charlotte and the baby both died.

Princess Charlotte

Croft committed suicide, feeling that he had been responsible for two deaths (and royal deaths at that). Charolotte’s funeral attracted enormous crowds of mourners–and some have compared it to the national grief that followed the death of Princess Diana.[iii].  The tragedy and its response ushered in a new age of “rational intervention” including the use of stimuli (for contractions), blood transfusion, and anesthesia.[iii] For a period of time following, no one would have criticized a princess for preferring an obstetrician and the most advanced of medical tools!

What Brought the Midwives Back?

The National Health Service was launched in 1948 with a mission of bringing health care to everyone. It changed a great deal about the way healthcare was administered, and the midwife’s portion of this tale has been told recently through the popular PBS television series Call the Midwife. In the debates over national health care in the US, it can be easy to forget that the NHS in England is only sixty-five years old. Prince Charles was born the same year, and so it is somewhat misleading to suggest Queen Elizabeth II is part of a long-standing tradition of NHS midwifery care when she was the first royal to make use of it. The next queen-to-be who gave birth under the NHS system was Princess Diana, and she–like Kate–chose private obstetric care over midwives.

What makes a Tradition?

Another headline, this one from the Telegraph, reads “Duchess of Cambridge, open your eyes to the home birth revolution.” It seems we are always somewhere between tradition and revolution–and in many respects, traditions are made at the “top.” When Queen Charlotte chose a man-midwife or obstetrician in 1764, she made a statement about the kind of care expected by high society that could not help but ‘trickle down.’ When Princess Charlotte died tragically, another kind of statement was made–just as loudly. Queen Elizabeth II chose NHS midwives and home birth (rather than hospital birth). Diana and Kate chose hospital birth and obstetric oversight. Does one necessarily exclude the other? Not likely (and we should remember that Kate’s mother, a midwife, was in the delivery room, too). The effects of those decisions are wide-reaching, however, and often (unintentionally, perhaps) polarizing. As we greet the new royal arrival, we should remember that privileged choices are not nearly so important as the privilege of choice.