The fall and rise, of (some) women.

"Gentlemen - it has fallen to my lot, in accordance with an old established custom, to inaugurate the academic session 1852-1853 at this hospital”.

These were the words uttered by Dr A G Malcolm, the Orator of the day, during his opening lecture to The Belfast Medical School, at a time when the General Hospital was in Frederick Street. There was no mention of women, as there were none in the audience. The 1850's were a low point for women in the history of Homo sapiens. A point from which some have managed to find the road back to the summit, but worldwide, most have failed to get back from whence they started. It was 1890 before an Orator was able to say, “Ladies and gentlemen - it has fallen to my lot to inaugurate this academic year”.

There were three Queen's Colleges in Ireland in the latter part of the nineteenth century, in Belfast, Cork and Galway, and in 1856 we saw the opening of the Dublin Catholic College. Intriguingly, and amazingly in retrospect, in 1856 an Act of Parliament debarred women from attending any university throughout the Celtic Islands. This act was only repealed some twenty years later. However, the decision to repeal the act was not supported by all of the apparently learned fraternity. The Professor of Midwifery in Belfast was particularly unhappy, commenting, “the culture and refinement of the age should have forbidden such a transformation”. Indeed, Sir William Jenner, of typhus and typhoid fame, although a man of great breadth and vision, had said at the time, “I have one daughter, and sooner than see her at the dissecting table, I would see her dead before me”. By now the reader will be developing an understanding as to why the women's liberation movement of the twentieth century was needed, and sadly, is still required in much of the world. Some women, I am delighted to report, overcame the odds. Dr Joy Darling (nee Pedlow) was born in Belfast in 1886. Her father had told her that “medical school is no place for a woman”. She was therefore encouraged to study languages, but by translating private documents at night she was able to raise enough money to put herself through medicine (personal communication). Not only that, she won most of the academic and sporting prizes on the way through, including becoming the Irish tennis champion. She also married, had four healthy children, and at the same time as being a General Practitioner, she was both an anaesthetist and an obstetrician in Belfast for many years, before retiring in the 60's. Dr Darling seems to have invented multitasking, for whilst also running a nursing home on the Antrim Road, providing private maternity care in order to raise money to enable her to care for destitute women that they would give birth safely, she also provided a shelter for injured servicemen returning from war. I was delivered by her, though my mother assures me that she was one of the private patients, rather than one of the destitute ones.

In 2004, I was elected Senior Vice President of the Royal College of Obstetrics and Gynaecologists based in London. I had responsibility for Education and also International Women's Health, working in the latter field for the next three years, and indeed beyond, as presently I remain a member of the International Executive Board. Internationally, it became very obvious to me very quickly that women are not in a good place. Let me present the reader with a multiple choice question : what do the following statements have in common? Failing to be born because of your gender. Having the labia and clitoris removed by a sharp stone at the age of eight years old. Forced into marriage at first menstruation. Non-consensual sex from your first encounter. No access to contraception or termination ever. Forced to abort your girl fetus. Dying in a field, guilt ridden and infected from unsafe home abortion. Being one of the 50% of women in the world with no antenatal care. Being one of the 95% of women in the world who deliver outside the birthing centres. Being an Afghan girl with a 1 in 8 chance of dying in pregnancy. Being shunned by all as a harlot if not delivered before sunset. Dying twelve hours after convulsing continuously during labour for the lack of exposure to Magnesium Sulphate, which is cheaper than table salt. Dying from uncontrollable bleeding just after giving birth to the beautiful baby for which you have always longed. Dying after 72 hours of obstructed labour because of immature pelvic development associated with no sunlight and Vitamin D deficiency. Dying from overwhelming pelvic infection, which could have easily been halted in its tracks by the simple application of first generation antibiotics. Allowed to die in labour by your partner as it is cheaper to take a new wife than to pay for a caesarean section. Being constantly wet with urine leakage, and rejected as a consequence of obstructed labour. Suffering from constant physical abuse and to be considered to be of less value than a domestic animal. Well sadly, in all parts of the world, the answer to the multiple choice question is that all the above only happen to women, and are silently happening to a lot of women, a lot of the time, right now. A mixture of man and nature is a heady mix indeed for women to endure, especially if the women in question are uneducated. The good news for womankind is that historically not all our accoucheurs, or midwives, appear to have been anti-woman. One such was Bartholomew Mosse, who a century before the Belfast General Hospital opened, was so affected by the plight of women in famine-ridden

Ireland, that following the death of his own wife in labour, and seeing the plight of women in dire straits and in great need of warmth, food, shelter and medical care, built one of the world's first lying-in hospitals at the end of O'Connell Street in Dublin.1

At the Rotunda Hospital, Bartholomew Mosse's mothers were provided solace, support and simple obstetric remedies. He also was 300 years ahead of his time, by attaching the Gate and the Ambassador Theatres within the grounds of the hospital, where artistic productions by local artists would raise funds to pay for the running of the hospital. Bartholomew Mosse and Joy Darling were truly part of the true Big Society-well ahead of their time.

Bartholomew Mosse was the first Master of the Rotunda, and to this day there has still been no female appointed to this post. He was English by birth, being the son of the Rector to King William III and he was a unique man indeed. I would contend that his co-genderists were just coming to an end of a 3000 year experiment in patriarchy. However, when I say “coming to an end”, I speak in hope rather than expectation for it surely must come to an end if women are to regain their position in society worldwide.

Having babies in much of the world is still a very risky business. Nature is a tough obstetrician and in many ways believes in survival of the fittest. It has indeed been a pleasure to work in this part of Europe where we practice, to a greater or lesser extent, socialised medicine which, contrary to nature some may say, believes in survival of the weakest. However, half of the world's population are women, and they are the only ones with the ‘where-with-all’ to use their bodies for reproduction. Sadly, most of these women have little input into the decision as to whether to do so, nor equally importantly, indeed do not have the sexual rights associated with the process. Pregnancy for many women in the world is a death sentence.2,3

Working with the Liverpool School of Tropical Medicine, we in the RCOG have established a Life Saving Skills Emergency Obstetric Care Package, which provides a three day course for midwives and medical officers on how best to address the ten main causes of maternal mortality.4 Maternal mortality is extremely high in Africa, South East Asia and the less economically developed parts of the world.5 Indeed the global gap between rich and poor countries has actually increased in the past decades.6 Africa, as a whole, has a maternal mortality rate of 83 0 per 100,000. Sweden's is 4 per 100,000. In Africa, if a mother has six children, she has a 1 in 20 chance of dying.7 Yet, by addressing the main causes of maternal mortality within the country where the infrastructure problems have been addressed, success can be achieved very quickly. Malaysia and Sri Lanka have both done this over the past forty years.

The major killers of women in their reproductive years are childbirth, followed closely by HIV/AIDS, tuberculosis and malaria.9

The major causes of death associated with pregnancy are haemorrhage, sepsis, unsafe abortions and pre-eclampsia, all of which can generally be addressed successfully by the attention of a skilled birth attendant at the woman's bedside, armed with knowledge and simple drugs.10 However, this modest goal is much simpler to suggest, than to deliver. To address these and other problems traditionally considered primarily to be associated with poverty, the Millennium Development Declaration was signed by 189 countries in 2000 when they set targets for Global Action Against Poverty, that were to be addressed by 2015.6 The health related millennium goals are ; To eradicate extreme poverty and hunger. To achieve universal primary education. Promote gender equality and empower women. Reduce child mortality. Improve maternal health Combat HIV/AIDS, malaria and other diseases. Develop a global partner for development. Obstetricians tend to focus on millennium goals 4 and 5. In developed countries throughout the world there is an abundance of well-budgeted, earnest groups of government and non-government departments and management organisations that work with the United Nations and the World Health Organisation, and indeed many other groups, to try to “trickle down” help to the most needy in the under resourced world. Indeed, there is good evidence that maternal, child and infant survival can be shown to be directly proportional to the density of health workers on the ground.11,12

America has 10% of the world's disease yet employ 35% of the world's workforce. Europe has 15% of the world's disease, and 18% of the world's workforce. Africa, which has a quarter of the world's disease, has only 3% of the healthcare workforce. It has been calculated that 36 African countries have a one million deficit of doctors, nurses and midwives.13 Many of those reading this paper may be indirectly involved in “trickling down” to help the needy, but others will also be involved in “trickling up” through civil society or missionary work, offering consultancy, guidelines development, formal in -country assessments, building facilities and so forth. Indeed, “trickling up” is now considered to be at least as efficient and effective as “trickling down”. From my relatively short time working with others to help reduce child mortality and to improve maternal health, increasingly I have become more convinced that the answer to millennium goals 4 and 5, is in fact millennium goal 3, which is the “promotion of gender equality and empowerment of women”.6 By empowerment, I mean that: Women have necessities such as food and clothes. Their psycho-social needs have been addressed and they are in control over their own lives. She has political empowerment by having a voice.

I believe strongly that if we empower and educate women, they themselves could then decide whether to get pregnant, to whom, and to ensure that they maximise their and their offspring's chances of survival before, during and following childbirth.

The indicators for millennium goal 3 are ; The ratios of girls to boys in primary, secondary and tertiary education. The ratio of literate women to men in the 15-20 year old age group. The share of women in waged employment in the non-agricultural spectrum. The proportion of seats held by women in their national parliament. The ratio of girls to boys in primary education in Africa and South East Asia is actually improving.14 Indeed in the last 15 years there has been a statistical improvement with over 85% of girls now having primary education. However, the ratio against boys in tertiary education is not so encouraging. Indeed girls comprise only a third of the very few places in tertiary education in Southern Asia and sub Sahara Africa.15 The reader may not be overly shocked by these statistics from the under- resourced world, but it has been suggested recently by Joan Smyth, writing in the Independent on Sunday, that the overall pay gap in the UK itself is 21% in the private sector, and that it will be 100 years before parity is reached. So it's mostly a matter of degree.

The reader will not be surprised to learn that Norway is one of the leaders in “giving women a voice” and 46% of Norway's MPs are female. However, more surprisingly, in Rwanda the figure is 52%, and indeed a recent article in the Lancet suggests that Rwanda is one of the few African countries that has the potential to achieve millennium goals 4 and 5 by the year 2015, suggesting a direct correlation between the empowerment of women and maternal mortality.16 A SWOT analysis, (strengths, weaknesses, opportunities and threats) on Millennium Goal 3 proves revealing. The strengths and weaknesses are internal factors, which are those factors within the millennium development goals themselves. Opportunities and threats are external factors that have an external influence outside the millennium goals. The strength of millennium goal 3 is that it was welcomed by the feminist movement, and the MDGs provide a common language for the work of governments, United Nations Agencies and International institutions. The inclusion of maternal mortality, universal education, HIV and malaria, suggested that on these areas in particular, there was a commitment to gender equality.17

The weakness of millennium goal 3, however, was that the MDGs were silent on security and dignity unless they were affecting economics. They were also silent on women's human rights and all gender based violence. Particularly sadly, they were silent on sexual reproductive rights - a perfect example of an opportunity lost. The reader will have to consider the world politicians in power at the time of the conception of the MDGs and make their own judgement on the reasons.

Millennium goal 3, however, did provide opportunities. There have been many international conferences to address population, development and women's rights.17 Several women's groups and organisations have been established with government support around the globe and advocacy has increased.18 An example would be the recently established White Ribbon Alliance, which is supported by many female leaders, and partners of leaders, around the globe. Many countries are slowly, steadily and surely bringing in laws to protect women and women's rights.

There are also threats to millennium goal 3. There are too few secure paid jobs and there are still huge wage differentials and occupational segregation.17 Poor health conditions of women throughout the world are widespread and women have higher unemployment rates. Perhaps, most important of all is the fact that women do not have the ultimate power to decide, in all circumstances, with whom they wish to be sexually active; whose baby to carry; whether to carry the baby; where to have their baby; how to have their baby or how to avoid dying while trying to do so. If all women had these rights, then they truly would be empowered. Sadly most women remain poor, powerless or pregnant. It seems ironic that in Britain we have spent the last two decades concentrating only on one of the above list, “How and where to have your baby”. We really must try harder as a society to prioritise.

At the new millennium, the Native American Indians have decreed that in the last three thousand years, Mother Earth has been a “man's world” and that life is “out of balance”. The word that they use for this is “koyanisqatsi”. They have also made four major observations on the present state of the world. They have suggested that for the last three thousand years the male ego has run unchecked, that we have had far too many testosterone fuelled wars, that there has been a plethora of mysogenistic societies, and that homosapiens have shown s huge disrespect for Mother Earth. A powerful quartet that warrant a period of quiet contemplation.

Man has much of which to be to be proud in the last three millennia, as well as much of which to be ashamed. Changez Sultan is a Pakistani artist of note, and is someone I have grown to admire. His writings and art depict a huge compassion for women worldwide, as he sees them as bearing the cross for much of the world, while they struggles to survive, knowing not who to trust, who to love, or whose children to bear. He believes that womankind is bearing the cross for man's many failings (Figure 1).

Fig 1

Having worked in International Women's Health for the last decade, and given much thought to what I have seen, I do feel that the journey that women have been on since being on this earth, has generally not been a good one.

The present place of women in society, however, is a relatively new one considering the length of time we have been on earth. There is good evidence that if we go back to pre- history civilisation that Mother Earth, as represented by Shomba the female goddess, was indeed worshipped as a powerful worker of miracles. In the absence of historical literature and records, we must look to art to see how women were represented, and the Venus of Willendorf is a fine example of how women were portrayed and considered. The Venus of Willendorf was found 30 metres above the Danube in Austria, some 30,000 years ago. She is just 12cm tall yet depicts the female goddess as a position of authority, because men realised at that time that you only had to give this Goddess a seed, and she could produce the miracle of a baby. The Goddess Earth Mother was a figure feared and revered in the ancient world, and so society at that time understandably was often matriarchal. As Dan Brown explains in his book, The

Da Vinci Code, “in pre- religious days women were seen as the essential half of the spiritual enlightenment”. The ancient, prehistoric, civilisations of Mesopotamia, Egypt and Anatolia appear also to have been matrilineal, as well as matriarchal. By prehistoric, I mean natural, primitive, uncorrupted and true. The natural state, however, was gradually destroyed as men established the unnatural condition of patriarchy, by subjugating women. My thesis to the reader is, that following tens of thousands of years of paganism and goddess worship, men decided to use religion to change the balance of power. What has followed has been a three thousand year experiment in patriarchy. This patriarchy has not been promoted by the great founders of religions, but it could be contended , has been terribly exploited for their own ends, by many of the men that followed these religions.

It is generally accepted that the move from matriarchy to patriarchy occurred approximately 3000 to 3500 years ago. Sculpture at that time, such as in Figure 2, reveals a couple at the time of the Pharaohs, showing great equality between the male and female, both sitting and both with appropriate dress code. However, mainstream religions subsequently demoted women to the role of spouse. This move has been accredited to Judean, Hebrew and Greek religious men who divided the one mother goddess into Aphrodite, Athena, Atemis, Henna and Hestia but suggesting that there was one male god concept which is still accepted by most mainstream religions - a classic case of “Divide and Conquer”.

Fig 2

The current theory is that male-dominated tribes from the East and North East invaded the Eastern Mediterranean and old Europe, bringing with them the concept of aggressive, male, Gods, who probably had experienced too much of the matriarchal society for their liking.

By historic times, patriarchy was preeminent in much of the world, and the female Pharaoh was now seen as submissive and subservient, standing by her man's side (Figure 3). Art and artists continued to reflect the times and Aphrodite of the Ancient World had women as dutiful wives and housekeepers that were a thing of beauty, as revealed by the artist who used materials such as marble, to reflect the smoothness of their skin. Women were also often depicted as naked, erotic, bathing, and were the “servants of men” (Figure 4).

Fig 3

Fig 4

With the establishment mainstream religions, women were increasingly depicted as the mothers of god and artists, now mainly commissioned by the churches, presented them as a frame for the adoration of the baby boy Jesus (Figure 5). The Church, remained, and some would say remains, frightened of the power of women. Dan Brown reminded us that the Heros Gamos, or holy wedding, depicting the act of sexual union between a man and a woman, was required to commune with God. However, in the Dark Ages, holy men feared their sexual urge as the “work of the Devil collaborating with his favourite accomplice, the woman”.

Fig 5

Almost all paintings of Eve portray her as naked, mostly showing that while her nakedness is tolerated by men, her thoughts and feeling were irrelevant. Women were untrustworthy, dangerous and were only complete when she became a mother (Figure 6).

Fig 6

Dan Brown also reminds us of the Malleus Malificarum where, at the end of the Dark Ages between the 10th and the 14th centuries, upwards of one hundred thousand free thinking women were burnt at the stake at the Church's command. Such victims included nature lovers, herb growers and midwives, the latter seen as particularly vile, as they used their theoretical knowledge of medical practice to ease the pain of childbirth, which was at odds with the teachings of Genesis.

The 14th century heralded The Renaissance and the flowering of literature, art and science; and the resurgence of learning based on classical sources. The key Renaissance Men were Leonardo Da Vinci and Michael Angelo. Many of their paintings portrayed women as objects of theory and study (Figure 7).

Fig 7

The 16th century marked the beginning of the Baroque period of Reubens and Rembrandt. Ruebens was a Flemish artist and in his early work had an extravagant style that emphasised movement, colour and sensuality. But by the early 17th century, Reuben, whose father had been a Calvinist and his mother Catholic, had become a leading voice of the Catholic Counter Reformation style of painting, to the point where he stated, “my passion comes from the heavens and not from earthly musings”. He is well known for his self portraits, and one of his paintings (Figure 8) shows him and his wife, beautiful and clothed, but below him who is deemed to be her master.

Fig 8

Rembrandt was the true master of the Baroque, and he was commissioned by the Protestant Church to illustrate the ethic of work, prosperity and a stable home. In Figure 9 we see the husband very busy solving scientific and technical problems, while his wife is portrayed as a willing and subservient helper.

Fig 9

By the 19th century men dominated Europe. Patriarchy was at its height, and women were in their place. One hundred years before Germaine Greer, women were beginning to learn how to use their beauty and then their brains. They were becoming more powerful by making men want them and not just use them. Integral to the great revolution in the 19th century, was their demolition of the hedonist patriarchal society. They were definitely on the comeback trail in the developed world at least. Delacroux epitomised this comeback in his 1830 painting “Liberty, Leading the People”. (Figure 10) He presents our female leader as working class, Parisian and a revolutionary, albeit with naked breasts and carrying a rifle. This is almost a suggestive French version of our present Deputy First Minister's erstwhile call for battle with a vote in one hand and an armalite in the other.

Fig 10

The 19th century brought us, among others, Bronte, Austin and Nightingale. Women were to be quiet no longer, and were truly on the comeback trail, at least in the first world.

Changez Sultan believes that two thousand years ago, when Christ was crucified, this was symbolic of the women's place in society being crucified at the same time (Figure 11). He does not blame Christ for this, but rather the 46 “XY” men who have been managing most religions since. Management of religion is generally in men's hands, and frankly, leaves much to be desired. There is little wrong with religion itself, or indeed most of it's founders, but the male followers have often been found wanting.

Fig 11

Freud asked, “Woman! What does she want?” There is no doubt that having spent thirty five years as an obstetrician in the western world, and for the last ten being very involved in International Women's Health, I personally believe that the first three things women want, or certainly need, are education, education, education, and with that will come a woman's ability to control their own sexuality and fertility.

We spend a lot of time nowadays phaffing around the edges of this problem by trying to offer “CHOICE” of, for example, where and how to deliver. The key questions surely are, however, should women have the choice with whom to make love, with whom to have a baby and when to have it? Women want and should have control over their own fertility and sexuality. Sadly this is not a fact for most women in the world.

Women also want to have equal rights and they want and need Millennium Goal 3 implemented worldwide, immediately. I was privileged to have numerous conversations with Derek Bingham, a well know local intellectual evangelist, prior to his tragic and untimely parting. On one such occasion we talked of the issues in this paper and he reminded me that Jesus had a particular compassion for fallen women, despite the fact that his apostles were all male. Three weeks before the crucifixion He came across an apparent fallen woman being stoned for being a harlot. He walked to the front of the crowd and said, “Let him who is without sin cast the first stone”. When the crowd bowed their heads and left, He then went to the woman and said, “I find no fault in thee, go thy way”. Just pause and think on those words. Three weeks later Christ was crucified and I am reminded that when Changez said that women's rights were crucified with Christ, he did not mean that it was His intention that this should happen, but sadly, it is what appears to have happened.

It is perhaps timely to remember that on His final day on earth, before his ascension, Jesus chose a women, Mary Magdalene, the woman of seven devils, to receive the greatest message that was ever to be passed onto mankind (Figure 12). It is a great shame that the men left behind by THE Master, failed to heed the significance of that act. When I say men, I mean most men, but not all men. Not the other Master, Bartholomew Mosse and not, I hope, any male readers of this oration.

Fig 12