Downton Abbey, Maternal Death and the Crisis of Childbirth in Britain
Those of us who watch Downton Abbey regularly should not have been surprised that Sybil died. After all, series one began with the death of the Crawley heir on the Titanic as well as the untimely death of the Turkish gentleman during sex with Lady Mary; series two saw the death of the footman from war wounds and the sudden death of Lady Lavinia from the 1919 influenza epidemic as well as references to the deaths of thousands more during WWI.
So why was Sybil’s death so shocking? Was it because Sybil’s character was one of the most likeable in the series? Or was it that we don’t associate childbirth with maternal death anymore? Or was it the class-ridden patriarchal arguing amongst three men—middle-class Dr. Clarkson, knighted Sir Philip and hereditary Earl, Sir Robert—as Sybil exhibited what today are considered clear signs of pre-Eclampsia. The headache, swollen legs, proteinuria, epigastric pain and confusion were clinical signs that worried Dr. Clarkson and the other female members of the family, but not, apparently, Sir Philip. As the three men argued over whether or not the signs and symptoms were normal or pathological, the rest of the family, including Sybil’s mother and husband, stood helplessly by.
Perhaps the most distressing aspect of the whole scene was that Sybil was not included in the conversation. In fact, Sybil’s body during labor and postpartum appeared to be solely in the hands of her father and the medical man he chose to listen to. We really couldn’t be blamed for seeing the whole event as yet another example of patriarchy in action or another example of traditional versus modern; elite versus middle-class (Dr. Clarkson versus the elite Sir Philip and Sir Robert). And yet the historical evidence points to something more sinister– medical neglect. Eclampsia and pre-Eclampsia were known killers of women during labor and after in the 1920s and before. This disease in its two forms is peculiar to pregnancy and the weeks shortly after childbirth. They still kill women in Britain and worldwide today.
Sir Philip could be forgiven his arrogance on one level. The overwhelming concern in the late nineteenth and the first three decades of the twentieth century was infant mortality. Britain’s infant mortality rates were one of the highest in Europe. Midwives, who delivered the majority of infants in Britain at the time (and they still do) were blamed for their lack of training while mothers were blamed for their child-feeding ignorance. The infant mortality rate didn’t drop dramatically until the 1930s and affected all levels of society (although the working-class experienced larger numbers as they generally had larger families than the wealthy). So Sir Philip may well have been more concerned about the condition of the baby than the mother because infant mortality was higher than maternal mortality. Nevertheless, Dr. Clarkson did try to bring Sir Philip’s attention to the fact before delivery that the baby appeared small for dates–another clue that Sybil’s pregnancy and labor might not be completely “normal.” A small for dates infant might suggest some infarction or death of the placenta due, particularly in pre-Eclampsia, to high blood pressure that bursts the vessels that hold the placenta on to the wall of the uterus causing the placenta to “die” or “infarct” at that point. The infarcted areas then compromise the flow of nutrients from the maternal blood supply to the fetus and can cause slow or stunted fetal growth.
So why did Sir Philip choose not to identify such clinical signs and symptoms? And why did Sir Robert choose to exert his patriarchal role and make the decision that Sybil should be allowed to deliver at home and not in the hospital with its access to emergency surgery?
One such reason may well have been that women were more likely, in the 1920s, to die from hemorrhage than they were to die from pre-Eclampsia or Eclampsia. Hemorrhage could result from uncontrolled bleeding at the separation of the placenta during the third stage of labor or hours, days and even weeks after birth. Ergometrine, the drug used to control such bleeding was not widely used in Britain until the 1950s. Until that time, bleeding to death after delivery was the most common reason for maternal mortality (blood transfusions became more common in Britain by the end of the 1930s). The most common reason for maternal deaths, however, was sepsis. Until the common use of Sulfur and Penicillin in the 1930s and 1940s, women died in large numbers from childbirth injuries that became infected or from contaminated clothing, instruments, hands etc. The decision not to move Sybil to the local hospital where a surgical procedure –cesarean section–could increase the risk of uncontrollable hemorrhage or could introduce a deadly infection, may well be more reasonable than it first appears.
However, the fact remains that Sir Philip chose to ignore the clinical signs and symptoms of a common cause of maternal death. In 1920, for example, statistics suggested 1,200 of the 6,000 maternal deaths each year were caused by Eclampsia. The only “cure” for pre-Eclampsia and Eclampsia was the removal of the products of conception—delivery. The most common symptom was proteinuria, easily detected by a urine test. Midwives were encouraged, by 1920, to test the urine of each pregnant woman at least monthly.
Midwives were very much aware of the symptoms and dangers of pre-Eclampsia because they saw their patients with the signs and they read the articles about pre-Eclampsia and Eclampsia in their nursing journals—often reproduced entirely from medical journals such as The Lancet. Indeed, midwives read the notes from lectures give at the Midwives’ Institute in their weekly journal, Nursing Notes. One such lecture outlined clearly the signs and symptoms as “Albuminuria (protein in the urine)… oedema (sic) of feet, legs, face, abdominal wall and vulva…headache….Vomiting…Visual disturbances….Irritability and dizziness….Diminution in the amount of urine secreted….Epi-gastric pain which comes just before the onset of the fit and is most invariably succeeded by one.” While delivery was the only “cure,” Dr. Gordon Ley also advised “bleeding” the patient and administering morphine (and emptying the bowels with an enema—the number one treatment for pregnant women, apparently!). Neither of these were suggested for Sybil. Was Dr. Clarkson also at fault for not suggesting either of these? Could morphine have relaxed Sybil sufficiently to prevent the Eclamptic fits that killed her? Could “bleeding” Sybil have reduced her blood pressure sufficiently to reduce some of the other symptoms and lessen the likelihood of convulsions? Or was Sybil, despite her wealth and privileged background, simply destined to be one of the 1200 women who would die from the mismanagement of Eclampsia that year?