Hospital confinement was a rarity and usually reserved for necessitous women or difficult cases. This situation remained prevalent well until the 1950's [5]. A midwife formed part of the professional staff of the Woman's Hospital in Valletta in the early eighteenth century [6]. Nearly all the patients delivering in the Victoria Hospital in Gozo during 1876-1893 were non-paying and registered as paupers having an occupation of lace-workers. The spouses occupation was more varied with 73.8% being artificers and laborers and 15.5% being mariners and fishermen. The illegitimacy rate of hospital deliveries was increased accounting for 8.6% [7]. The number of hospital confinements in Malta was so small that when the Midwifery School was re-opened in 1854, the teacher had to make use of a girl of ten years from the medical wards for clinical demonstration purposes to the great consternation of the Chairman of the Board of Charity Commissioners who threatened to report similar future occurrences to the Governor [8]. A number of female hospitals had been opened in Malta and Gozo throughout the ages, but these until the latter part of the twentieth century served mainly medical and surgical problems and contributed only minimally to obstetric practice. This state of affairs remained until the mid-twentieth century. In 1955 it was noted that whereas formerly patients looked at maternity services in the government hospital with indifference, their attitude was changing. In 1961 it was estimated that 43.5% of mothers were delivered in hospitals with resident medical staff, 9.8% in centres with no resident medical staff, and 46.7% in their own homes. The hospital deliveries were mainly conducted by the midwife (87.2%), while the obstetrician was the senior person present in 11.4% of cases and other physician in 1.4%. In the centres with no resident medical staff the obstetrician was present in 56.8% of cases, another physician in 6.2% and the midwife in 37%. In the patients' homes the midwife was the responsible person in 77% of cases, the obstetrician in 10% and another physician in 12%. A nurse (not a midwife) was present in 1% of cases. In 1980 the hospital confinement rate was 99.5% [9].

The first recorded hospital in Malta - Hospital of St. Francis at Rabat - was already functioning by 1372 under the rectorship of a Franciscan appointed by the King. During the same period the earliest known woman's hospital in Malta - St. Peter's Hospital was functioning at Mdina. This hospital ceased to function in 1418 when it was converted into a monastery for nuns. In 1433 the management of St. Francis Hospital was transferred to the Universita` since it was being mismanaged and its name was changed to Santo Spirito Hospital. From the middle of the fifteenth century onwards the hospital functioned normally. It is not known what the contribution of Santo Spirito Hospital towards the midwifery services on the Islands was during these early years, but the name of Santo Spirito was given to several medieval hospitals which were particularly intended for foundlings and maternity cases. The hospital in Malta is known in the early sixteenth century to have taken under its care infants who could not be cared for properly by their family, and in later years had a "ruota" a rotating-cot device for placing infants anonymously in the hospital [10]. Santo Spirito Hospital definitely gave a contribution to maternity services in later years, so that during the period 1750-1800 the hospital delivered about 7.1% of all baptisms in Malta in Gozo with 843 births (8.8%-) being from outside town. The hospital catchment area covered a wide range with the majority of patients coming from Valletta, Zebbug and Mosta, besides Rabat/Mdina [11]. The hospital continued to serve maternity cases well into the nineteenth century until it was changed into a convalescent sanatorium in 1883. In 1840 a request was made unsuccessfully by the Physician Surgeon of the hospital for midwifery instruments [12].

The Knights of St. John established themselves in the southern part of the Island and built their fortified city named Valletta in 1565. After their arrival in Malta they established a Holy Infirmary at Vittoriosa which had provisions for taking care of foundlings including the "ruota". The Holy Infirmary in Valletta similarly had provisions for child welfare. In 1625, Catherine Scapi had set apart a small house, known as Santa Maria delle Scala, in Valletta for the care of poor infirm women, the house eventually being moved to different premises. This small hospital was closed down after the foundress died in 1655. A new Woman's Hospital known as the "casetta" was re-established in Valletta by the Grandmaster Martin de Redin in April 1659. A further substantial bequest was made to this hospital in 1717 by lady Flaminia Valenti, while Grandmaster Manoel de Vilhena in 1727 added two adjoining wards. The staff of this hospital by the end of the eighteenth century included a midwife. The "casetta" continued to function through the ages with extensive modifications to its organization and architecture [13]. A large proportion of women delivering in the Woman's Hospital in Valletta were unwed women who went to Valletta to deliver their child and conceal their pregnancy. This in part accounts for the high illegitimacy rate of 28.9% reported for Valletta in the period 1750-1800 [14]. In 1802 a midwife was available for normal deliveries while cases of difficult labour were attended by the Senior Surgeon. In May 1831, the Lying-in Ward was transferred from the Surgical to the Medical Division. At this time, parturient women were noted to be reluctant to avail themselves of the service of doctors during labour. The medical officer in charge of this ward kept a register wherein was recorded the number of women accepting or refusing the assistance of the male practitioner. It appears that more women refused assistance from the practitioner. In 1850 the casetta was reserved exclusively for incurable disease and the Lying-in Ward was transferred to the Central Hospital at Floriana [15]. The Colonial estimates for Malta for 1896 indicate that the specific midwifery staff at the Central Hospital comprised an Accoucheur and Teacher of Practical Midwifery and a midwife, these being assisted by assistant medical officers and female nurses. The situation remained similar until 1922 when the Medical Staff at the Hospital was augmented by the appointment of a Junior Accoucheur [16]. This hospital continued to serve as the main hospital in Malta until the onset of the Second World War. In 1938 the hospital accounted for 4.3% of all deliveries occurring in Malta. In view of war conditions, it was envisaged that a much larger population of mothers would seek admission to the hospital. An Emergency Maternity Hospital was opened at Hamrun in a newly constructed wing of the Adelaide Cini Orphanage increasing the number of maternity beds from 16 in the Central Hospital to 100 in Cini Hospital. The maternity services were transferred from the Central Hospital on 28 May 1940 initially to the Bugeja Technical Institute and eventually on 19 June to Cini Hospital. Cini Hospital during the war year 1941 accounted for 14.1% of all deliveries occurring in Malta. The rate of hospital confinements during the post-war period went down to the pre-war levels accounting for 4.6% of total Malta deliveries in 1943 [17].

Cini Hospital continued to function as a maternity hospital until September 1949 when the Maternity Division was transferred to a newly-built hospital at Gwardamangia - St Luke's Hospital. Forty five beds were allocated for obstetric patients in this hospital in 1951, a situation that persisted well into the 1970's. In 1956, the obstetric staff at St Luke's Hospital consisted of the Senior consultant and Professor of Midwifery and gynaecology, a junior consultant, a resident clinical officer, two assistant medical officers, and eight midwives [18]. The hospital confinement rate remained low until 1951-52 when the hospital accounted for 5.7% of deliveries in the Maltese Islands. By 1956 57 the patients attitudes towards hospital confinement was changing so that the hospital catered for 17.1% of all deliveries. The rate continued to increase so that by 1980-81 the hospital accounted for 93.8% of all deliveries [19]. In the early 1970s an attempt was made to have a new maternity unit, together with a children's hospital, housed at the Mtarfa Hospital which was due to be vacated when the British left the Islands. This scheme was dropped when a memorandum was drawn up by Prof. A.P. Camilleri and others arguing that it was by far more advantageous to have both units at St. Luke's Hospital [20]. On 26 November 1981 a new Maternal and Child Health complex was built in close proximity to St Luke's Hospital named Karin Grech Hospital. This complex has 26 antenatal beds, a labour ward with 12 first stage beds and 8 delivery rooms with a operating theatre, and 56 postnatal beds with an adjoining nursery, besides a gynaecological ward which admits patients with problems of early pregnancy. This hospital still functions as the major maternity hospital on the Island, though it is planned that maternity services will be eventually transferred to the new San Raffaele Hospital being built at Tal-Qroqq.

The first woman hospital in Gozo owed its origin to a bequest made by Francesco Bonnici on 22 February 1454. The establishment dedicated to St Julian (but also known as the Hospital of St John the Evangelist and of St Cosmos and St Damian) consisted of a few dwellings near the gates of the citadel at Rabat/Victoria. The hospital was also known as Santo Spirito Hospital. On 3 May 1783 the foundation stone for a new hospital was laid at Rabat/Victoria. This new hospital named St Julian's Hospital accommodated fifty patients and received also unmarried pregnant women who sought refuge under its roof at the approach of labour. It was also provided with a "ruota". It ceased to function in 1838 when the Hospital of St John the Baptist, also at Rabat/Victoria, was opened for both sexes. This hospital changed its name to Victoria Hospital on the occasion of Her Majesty's Queen Victoria Jubilee in 1887. Structural expansion was undertaken in the last century [21]. There did not appear to have been any regular specific midwifery staff employed in the hospital in 1896, though a midwife appears to have been responsible for the deliveries in the hospital, while any obstetric abnormalities were dealt with by the Medical Superintendent and Resident Medical Officer of the hospital. Consultant staff from Malta started visiting the hospital regularly after 1947 [22], while resident obstetric staff was introduced in the 1970's. During the period 1876-1893, 358 deliveries occurred in the hospital with a mean annual number of 21, accounting for about 4.4% of all the deliveries in Gozo. The catchment area for the hospital during this period included the whole of Gozo with a few cases from Malta. The patients delivering in the hospital came from the lower socio-economic groups with a high proportion of illegitimate pregnancies [23]. In 1938 the lying-in beds in this hospital numbered 10, a situation that persisted well into the 1970's. The hospital confinement rate in Gozo was always greater than that in Malta so that in 1938 22.2% of all deliveries in Gozo occurred in the hospital. The rate remained similar throughout the Second World War and decreased to 8.0% in 1944. A new hospital named Craig Hospital subsequently renamed Gozo General Hospital in 1989, was inaugurated in Rabat/Victoria on 31 May 1975. This hospital has 11 obstetric beds and two delivery rooms besides an annexed nursery [24].

Besides the government-managed hospitals described above, a number of privately-managed hospitals contributed variably to the maternity services of this century. There were in addition naval and military hospitals whose main function was to provide facilities for the treatment of British seamen and their families. These in later years expanded their services to the civil population. The first private hospital to be opened in Malta was run by the Sisters of the Little Company of Mary (Blue Sisters) and named Zammit Clapp Hospital or Blue Sisters Hospital. The hospital situated at Sliema was opened after a deed of donation was made by the benefactress Zammit Clapp on 23 June 1911. In 1945 it started contributing towards maternity services. It continued to function in this capacity until December 1980 when it was closed down. It was the only privately-run hospital well into the 1950's. In 1957, it was the only privately-managed hospital of any size in the Maltese Islands [25] with 64 adult beds and 15 maternity beds and accommodated 34 infants. On 12 April 1959, the Dominican Sisters officially inaugurated another privately-managed hospital named St Catherine of Sienna Hospital at Attard. The hospital expanded its maternity services in line with the changing attitudes of pregnant women towards hospital confinements subsequent to 1960. Maternity services in the hospital were initiated in 1961 and continued until 1980 when the hospital was converted into a nursing home. A small 28 bed clinic St Dominic Clinic in Rabat/Victoria, Gozo was also run by the Dominican Sisters. This hospital, which catered also for maternity cases, opened in September 1974 and closed down its services in November 1976. During this short period of contribution the hospital delivered a total of 152 deliveries [26]. In the 1980's a number of small day-clinics in Malta were opened to cater for deliveries, notably St. James Clinic at Zabbar and Klinika Vella at Zebbug. Further private hospitals - St. Philipís Hospital and Capua Paalace Hospital - which serve maternity cases have recently been opened.

The British Military and Naval Hospitals in Malta also gave a small contribution to the midwifery services on the Islands. The maternity services were until 1962 administered and staffed by the Royal Army Medical Corps, after which until 1976 the administration was taken over by the Royal Naval Medical Service. The first naval hospital was organised in order to treat British seamen, but towards the end of the nineteenth century a Military Families Hospital was built on Mtarfa Hill in Malta. This was a fifty bed hospital for the soldier's families. The hospital after the Second World War was disbanded and re-formed under the name of David Bruce Military Hospital. This continued to provide a service for soldier's families and on 13 May 1975 opened its services for the civilian population. In the period 1976-77 it delivered 9.1% of all the deliveries occurring on the Islands. The hospital closed down just before the departure of the British services from the Islands [27]. Another hospital which gave an important contribution to the maternity services in Malta was King George V Hospital at Floriana in Malta. This hospital came into being in 1922 as a memorial to the men of the Merchant Navy who died in the First World War. Midwifery services were available in the hospital in 1939 but when the hospital was destroyed on the 7 April 1942 by enemy action during the Second World War, the maternity wards were transferred to Corradino Heights. King George V Hospital was rebuilt and inaugurated on 30 November 1948 when it continued to cater mainly for merchant seamen though members of services families and civilians were also admitted. A maternity scheme for maltese civilian women was introduced in the late 1950's and continued to function until the hospital's closure in January 1967 [28].

Maternity care has throughout the last two ccenturies been given particular attention by the authorities. With the aim of introducing safger midwifery practice in the community, the authorities during the nineteenth century introduced the formal training of midwives, while the Department of Health ensured strict vigilance in enforcing the sanitary measures stipulated by the Midwifery Regulations and the Sanitary laws formulated at the beginning of the twentieth century. The social circumstances occasioned by the Second World War resulted in a change in attitudes towards maternity care with a greater emphasis towards hospital and doctor supervised confinements, an attitude which has persisted into present times.

References and Notes

1. Bezzina J., Religion and Politics in a Crown Colony. The Gozo Malta Story 1798-1864, Bugelli Publ, Malta, 1985, p.52

2. Cassar P., Pregnancy and birth in maltese tradition. Chestpiece, 1975, p.25-29

3. Pisani SL., Ktieb il qabla, Debono & Co, Malta, 1883, p.58, 66; Schembri GB., The Midwife's guide book, Govn Printing office, Malta, 1896, p.65; Annual Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1937, Govn Printing Office, Malta, 1938, p.23-24

4. Cassar, op. cit. note 2 above

5. Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1951, Govn Printing Office, Malta, 1953, p.6

6. Cassar P., Medical history of Malta, Wellcome Hist Med Libr, London, 1964, p.72; National Malta Library, ms Treasury A 58(13); Piano per il regolamento dell'ospedale di Malta, Malta, 1802

7. Savona-Ventura C., A maternity unit in Gozo a hundred years ago, Essay awarded the MAM Prize, 1991

8. Cassar, op. cit. note 6 above, p.413

9. Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1955, Govn Printing Office, Malta, 1957, p.6; Study Group: F.I.G.O./I.C.M., Maternity care in the world: International Survey of midwifery practice and training, Pergamon Press, Oxford, 1966, p.296-297; Camilleri, AP., Obstetric deaths in Malta, J Int Fed Gynaecol Obstet, 1965, 3(3):179-186; Grech ES. and Savona-Ventura C., The Obstetrics and Gynaecological service in the Maltese Islands: 1987, Malta, 1988, p.28

10. Cassar, op. cit. note 6 above, p.23-36; Fiorini S., Santo Spirito Hospital at Rabat, Malta: The early years to 1575, Dept of Information, Malta, 1989, +199p.

11. Ciappara F., Marriage in Malta in the late eighteenth century, Assoc. News Ltd., Malta, 1988, p.85-86

12. Cassar, op. cit. note 6 above, p.532

13. Cassar, ibid, p.68-76,352; Annual Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health department for the year 1937. Government Printing Office, Malta, 1938, p.31

14. Ciappara, op. cit. note 11 above

15. Cassar, op. cit. note 6 above p.68-76; Piano ...., op. cit. note 6 above;

16. Colonial Estimates, Malta, 1896. Malta Govn Gaz, 20 December 1895, p.953; Reports on the working of Government Departments during the financial year 1922-23, Govn Printing Office, Malta, 1925, Q:p.1

17. Savona-Ventura C., Reproductive performance on the Maltese Islands during the second World War. Med Hist, 1990, 34:p.164-177

18. Report.....1951, op. cit. note 5 above; Report on the Health conditions of the Maltese Islands and on the Work of the Medical and Health Department for the year 1971, Govn Printing Office, Malta, 1972; Reports on the Medical Services and a Hospital Building Programme, Central Office of Information, Malta, 1957.

19. Report.....1951, ibid; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1952, Govn Printing Office, Malta, 1954; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1956, Govn Printing Office, Malta, 1958; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1957, Govn Printing Office, Malta, 1959; Grech and Savona-Ventura, op. cit. note 9 above

20. Vassallo-Agius P.: An outline of the development of paediatrics in Malta in the ywentieth century. Paediatric Update, University Press, Malta, 1991, p.119

21. Cassar, op. cit. note 6 above, p.90-92; Fiorini, op. cit. note 10 above, p.11

22. Malta Govn Gaz, op. cit. note 16 above; Savona-Ventura, op. cit. note 7 above; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department including the Emergency Medical Services for the year 1947. Govn Printing Office, Malta, 1948.

23. Savona-Ventura, ibid

24. Annual Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1938. Malta Govn. Gaz. supplement, 1939, 154:p.106-109; Report....1971, op. cit. note 18 above; Savona-Ventura, op. cit. note 17 above; Clews H.A., Malta Year Book, De La Salle Brothers Publ, Malta, 1976, p.74

25. Cassar, op. cit. note 6 above p.408-409; Reports on Medical Services...., op. cit. note 18 above

26. Cassar, ibid, p.409; Attard E., personal communication in letter 19 April 1989; Attard P., personal communication in letter 4 March 1991

27. Cassar, ibid, p.93-101; Savona-Ventura C. and Grech ES., Perinatal Mortality in the Maltese Islands. Int J Gynaecol Obstet, 1985, 23:25-30; Jackson MCH., personal communication in letter 1 August 1989; Clews H.A., op. cit. note 23, p.46

28. Cassar, ibid; Micallef D., Frau Trevisan. Civilization 1987, 33:p.904-906