The Maltese archaeological record relating to items of midwifery interest for the subsequent centuries is scanty. The only archaeological record pertaining to midwifery came from the excavations performed in the 15th century medieval church at Hal Millieri. Skeleton remains from this burial site included the remains of a woman aged about 16 years buried with and lying on top of a 21/2 year old child. The burial of these two individuals was probably contemporary occurring some time before c.1480. The female showed bony evidence of a past pregnancy. It is likely that the 16 year old female was the progeny of the infant, suggesting an early age of motherhood at most 13 or 14 years [3]. The early age of motherhood suggested by the archaeological evidence of the 15th century further confirms the 1568 report that women commenced their reproductive life at the age of twelve years [4]. The majority of deliveries in the 16th century, in conformity with the times, must have been conducted in the home under the supervision of a traditional health attendant, possibly the mother of the mother-to-be, or a midwife. The first known midwife is Bernarda Micallef who practiced in 1598. She is reported as having had to deal unsuccessfully with a case of foot presentation [5].

The sixteenth century saw the advent of a new era in midwifery practice in Europe. This century saw the revival by Ambroise Pare in 1549 of podalic version, whereby the infant was turned around and delivered feet first, which enabled successful delivery in difficult cases. Pare's advocacy of podalic version was an enormous step forward and the greatest advancement in midwifery until the invention of the forceps. These advancements in midwifery were however intended for the surgeon. Midwifery, including very often its operative branch, lay entirely in the hands of midwives who often discouraged the calling-in of physicians even in difficult cases. Surgeons were therefore called only in the worst of cases. Midwives of that day generally entered their office without any other knowledge than that which they acquired from ignorant mistresses [6]. The advancement in midwifery practice initiated in the 16th century continued in the subsequent one. Midwifery in the seventeenth century experienced an advancement similar to but more considerable than that of its mother science - Surgery - from which it began now to emancipate itself. The fact that it began finally to pass out of the hands of midwives into the care of male obstetricians contributed significantly to this advancement. In its scientific aspect it was promoted by the acquisitions of anatomy and physiology. The 17th century must also be designated the century of version since it slowly became generally accepted. The invention of the obstetric forceps and vectis by the Chamberlains' was at first of little benefit to practical midwifery since it was kept secret. The French remained especially prominent as the promoters of midwifery with society permitting men to act as obstetricians in ordinary cases and not as heretofore simply in particularly bad cases requiring operative interference. The male-midwife was the chief practitioner of operative midwifery in difficult cases [7].

During the seventeenth century practical instruction in midwifery was not yet imparted to men. At most they merely studied the theoretical aspect of the art. The sole public institution where practical instruction in midwifery was imparted, the obstetric section of the Hotel Dieu established in the sixteenth century was firmly closed to men. Yet in spite of this, many surgeons became by their own training distinguished accoucheurs displaying scientific ability. Formal practical instruction for midwives was imparted in Paris alone by superior midwives who not infrequently were authoresses in their field. Elsewhere the old method of guild instruction still prevailed for the most part; i.e. old midwives apprenticing prospective students. In many places, the nurses were compelled to pass an examination by the city physician and only then sworn into practice [8].

There does not appear to have been any formal teaching of midwives in 17th century Malta, and it must be presumed that the guild method of training was in force. The first moves to introduce in Malta the formal teaching of the theory and practice of obstetrics to prospective midwives were made in the late 18th century [9]. Midwifery practice was however controlled by the state. The earliest evidence of the control of midwifery in Malta goes back to the regulations published by the Protomedicus in degrees of the 2 August 1624, 19 June 1662 and 24 September 1722. These enactments were later incorporated in the legal codes of 1724 and 1784. Accordingly no woman was allowed to practice midwifery unless examined and approved by the Protomedicus - the head of the medical services. An official register was kept by the Castellano at the Court of Law. Further state control was introduced during the French occupation when it was made obligatory by decree of 24 August 1798 for the doctor or midwife assisting at a birth to present certificates of the birth within 24 hours to the municipality under penalty of suspension of practice and the infliction of a fine and imprisonment. This enactment was the first attempt to introduce civil registration of the Islands. The Ecclesiastical authorities similarly maintained a limited control over the practice of midwifery through parish priests who were enjoined to teach and examine midwives on the proper administration of Baptism, and through the Inquisition Tribunal. As early as 1575, the first inquisitor to Malta Mgr Pietro Duzina enjoined parish priests to teach midwives the proper administration of the Sacrament of Baptism in casu necessitatis. These admonitions were repeated by the Maltese Synod of 1625 and by 1709 it was laid down that midwives were to be examined by the parish priests at least twice a year, on the Octave of Pentecost and Christmas [10].

The pastoral visit of Fra Paulus Alpheran de Bussan in 1774 records that if midwives were not found sufficiently versed in the administration of the sacrament of baptism, the parish priest was ordained to instruct them during which time they were precluded from practicing. Examinations were repeated whenever the bishop or vicar paid a pastoral visit to the parish. On this occasion the midwives submitted for inspection and renewal by the bishop the warrant of the Protomedicus and the licence of the Episcopal Curia. Fr Arcangelo Farrugia, parish priest of Ghaxaq in Malta, testified in 1798 that Maria Calleja was an honest woman, and she answered satisfactorily questions put to her about the rites of baptism, abortions and Caesarean sections. In spite of the control exercised over midwives regarding their knowledge in the administration of baptism, on 11 October 1794, Fra Labini found it necessary to instruct parish priests to rebaptise babies sub conditione in the presence of two witnesses [11]. Ecclesiastical control of midwives was further enforced by the Episcopal Court and the Inquisition Tribunal, and a number of cases dealing with abortion, and burial in unconsecrated ground are recorded [12].

In case of a maternal death prior to the birth of the child, the parish priests were obliged to ensure that the woman was delivered by Caesarean section and the child baptised. In the edict of Fra Labini on 14 June 1788, parish priests under pain of suspension of their duties had to be on the lookout for any moribund pregnant woman. Opposition was to be overcome at all costs, and when entreaties proved to no avail, threats were to be used and the secular arm asked for help. If there was no one to do the operation or the family was unable to pay for the expenses, the parish priest had to do it promptly himself. If the operation could not be done immediately, the edict recommended that the mother's belly was to be kept warm with some cloth, and a perforated tube placed in her mouth so that fresh air got to the uterus. Anybody who obstructed the performance of the operation incurred excommunication, while anyone helping its performance was granted forty days indulgence [13]. These instructions were repeated by Mgr Gaetano Pace Forno in a circular addressed to all parish priests issued on 4 October 1867, after a number of cases of maternal deaths from cholera were reported not to have undergone postmortem section [14]. A licence from the Episcopal Curia remained a requirement to practice midwifery until 1906 [15].

Obstetrics in 17th century Malta was still practiced in the main by midwives. A midwife living in Valletta by the name of Paolina Perotto submitted a petition to the Grandmaster on the 4 June 1635 asking to be granted a site in Valletta to build a house for one of her daughters. A midwife also formed part of the professional staff of the Women's Hospital at Valletta [16]. In 1630 a midwife practicing at Cospicua named Oliviera Gambino submitted to the Episcopal Court an account of the birth of a deformed stillborn fetus. The account was apparently written to justify the fact that the deformed offspring was disposed by the midwife herself without any religious ritual. The description suggests that the parturient mother gave birth to two monsters - one with human and the other with avian features [17].

Congenital malformations were believed to originate on biblical lines by copulation between a woman and a male beast or between a woman and the devil. The belief was current in Malta during the 17th century that consort with the devil in an assumed form was possible. In 1647, 17-year old Gertrude Navarre accused herself before the Inquisition Tribunal of having over the previous six years had carnal relations with men and animals brought to her by the devil. She became pregnant and procured an abortion on a number of occasions [18]. In 1676 a Maltese physician's wife accused herself of having invoked the devil and invited him to have sexual intercourse with her if he destroyed her husband [19].

The eighteenth century saw a number of major advances in midwifery. As the 17th century was termed the century of version, the eighteenth century can be labeled as the century of the forceps. From the numerous and careful observations of the normal process of labour and the study of the contracted pelvis made by men with a scientific education, it became possible to understand the process of labour and identify the indications for instrumental or manual deliveries. Once these were established, physicians were then able to invent or improve suitable mechanical aids in accordance to a preconceived plan. The forceps were re-discovered and modified in the early part of this century, while midwifery hooks and embryotomy instruments were improved. Version and the forceps proved unsatisfactory when serious contraction of the pelvis was encountered. Because of the widespread desire to avoid the frequent operation of craniotomy in these cases, attempts were made to discover alternative modes of management aiming at delivering a smaller infant by restricting the mother's diet or the induction of premature labour. Operations to widen the mother's birth canal in the form of symphisiotomy was introduced, while delivery by Caesarean section remained controversial because of the associated high maternal mortality rate. This century also saw the introduction of formal teaching of obstetrics both to midwives and male practitioners. The first Chairs in Midwifery and lying-in institutions were established during the early part of the century. On the whole however, with exception of a few university towns and larger cities and their vicinity, the practice of midwifery still occupied an almost medieval position. Male assistance was still only resorted to when everything else failed - when the midwives had exhausted their strength and skill in the use of the labour stool, inunctions, manual twisting, external pressure of their 'handracks', etc. In the most favorable cases the practitioner took recourse to rude efforts at version, but in the majority of cases the surgeons resorted to dismemberment of the fetus under which treatment the mother frequently succumbed [20].

The socio-biological characteristics of the Maltese population in the late 18th century have been reviewed. During the period 1750-1800, the mean age of marriage for women approximated 22.6 years with only 5.7% of married women being aged less than 20 years. Marriage was soon followed by the birth of the first child, so that 58.8 - 66.8% of first born children conceived in wedlock at Balzan and Siggiewi were born before the first wedding anniversary. The mean household size in various town and villages in the Maltese Islands averaged 3.8 individuals. The mean annual number of registered baptisms during the period 1750-1800 was 3372.3 with a live birth rate in 1784 of 41.0 per 1000 population and of 37.6 per 1000 pop in 1797. The number of stillborn children is difficult to ascertain since with a few exceptions they are rarely marked out in the parish registers. Neonatal deaths buried in the first month of life at Naxxar amounted approximately to 163.8 per 1000 registered baptisms, while the infant mortality rate amounted to 283.1 per 1000 registered baptisms during the period 1750-1789 [21].

The high infant mortality rate helped maintain a check on the population growth maintaining the mean household size to 3.8 individuals. Marriage without children was inconceivable and children were the prime reason for marriage. Marriage was only for procreation and not for recreation, and all sexual acts which did not result in the insemination of the woman were venial sins. Besides the long period of postpartum lactation, coitus interruptus or a tergo and anal intercourse may have been used. An Augustinian friar made it a point to ask his women penitents whether their husbands had unnatural intercourse with them [22]. Abortion is also known to have been practiced on occasion, though it is difficult to ascertain its frequency. The method used to procure abortion was apparently the administration of abortive preparations. When Modesta Bravin got pregnant by a chemist, he gave her an abortive potion to drink. Likewise when Veronica of Birkirkara became pregnant, she took myrrh to procure an abortion. Maria Saliba obtained the services of a baptised slave who successfully procured her an abortion. Magical rites were also in vogue to procure abortion, as when Rosa Mifsud was given a piece of paper by a slave to put in a beaker of water which she was then to drink [23].

Abortion was at least since the seventeenth century considered illegal by the state. A proclamation of the 31 January 1650 prohibited the administration of abortive remedies and condemned medical men convicted of this offense to work as oarsmen in the galleys for five years, while those using abortificients were punished by flogging and banishment from the Island at the Grandmaster's pleasure. It was illegal not only to counsel, administer or take abortive substances, but also to cultivate abortive plants - the latter offense being punishable by a fine of 20 oncie [24]. The church similarly condemned abortion. The Synod of 1709 warned the faithful that abortion was a sin reserved for the bishop. On the 13 June 1788, Bishop Labini found it necessary to remind his flock that it was a most vile murder. Those guilty of abortion included not only those who maliciously obtained it, but even cruel husbands who ill-treated their wives, careless mothers who performed heavy work during pregnancy, or went on long walks or dances, or did not take foods or were indiscreet in their fasts. Parish priests were to urge their parishioners to give alms to poor pregnant women to enable them buy the necessary food/medicine. Anyone knowing somebody who was to have an abortion was encouraged to report the matter immediately [25].

Illegitimacy was a relatively common problem accounting for about 4.7% of the baptisms in various towns and villages in Malta and Gozo during the period 1750-1800. Prostitution was not the only reason for illegitimate births. Pre-marital sex between engaged couples appears to have been a common feature. The rate of pre-marital pregnancy rates in Balzan and Siggiewi was calculated to be 4.9-5.8%. Virginity was not apparently valued, in fact its loss could be an asset proving the girl's fecundity [26]. Other illegitimate births were a result of sexual violations. Between 1750 and 1800 out of 117 cases regarding injunctions by girls against their men, 35% claimed they had been violated. A number of these were reported. On 11 September 1744 suspicion of defilement of a teenage girl by an English visitor was followed up by the examination of the girl by two midwives who found her to be a virgo intacta. Seventeen year old Maria Camilleri accused Matteo Bonavia of having violated her in November 1764. The midwife, Theresa Muscat, inspected her virginity reporting: "Signori, avendo per ordine di questa Gran Corte visitato ad una giovine, che disse chiamarsi Maria Camilleri figlia di Giuseppe del Zejtun, di anni 17, avendola toccata con le mie proprie mani nelle di lei parti pudende, ritrovai esser gia da piu giorni stuprata per piu d'una volta da membro virile, essendo io, come mammana, ben prattica in tal mestiere". Tomaso Has had sexual intercourse with 24-year old Vincenza Falzon who gave birth to a child on 3 August 1783. Sapienza Borg, the midwife, and Anna Borg, the child's godmother, swore that the child resembled Tomaso. On 17 December he was fined 18 scudi by the Bishop's Court, 3 tari' as payment for the mother's confinement, 20 scudi for the child's necessities such as swaddling clothes, as well as 2 tari' a day for a year. Pietro Mattia Scevalier was similarly fined 70 scudi, part of which was payment for the child's delivery and part for the child's and mother's maintenance, besides being sentenced to fifty-one days imprisonment. Not all cases of reported violations were invariably true, but could be a desperate means on the part of the women to make these men marry them. Such practices were illegal, the girls being made to serve for one year in one of the women's hospitals [27].

The cases described above suggest that midwives were often called in to inspect women by the state or church authorities in cases of alleged rape. The practice continued well into the 19th century. The diagnosis of pregnancy was still entrusted to women - matrone or married women. An ordinance of the Governor-in-General in 1838 provided for the appointment of three, five or seven matrone to examine and report in writing on the state of a woman on trial who alleged that she was pregnant in order to obtain a mitigation or postponement of punishment on conviction [28].

Generally, mothers gave birth at home, the midwife's fees amounting to about 3 tari' while the child's necessities amounted to about 20 scudi. Children were swaddled soon after delivery, the child being placed between two pieces of board which reached from the feet to the neck and were attached to the body with rollers of linen. Children were put to sleep in rocking cradles or hammocks. They were breast-fed for a long period of time, this protecting the mothers from an early subsequent pregnancy. Those who did not breast-feed did so only because they had inappropriate quantities of milk. In 1786 Vincenza Sacchett took into her service Maria Hellul as a wet-nurse for the period of eight months. Pio Vidal on being abandoned by his wife sent his 8-month old son to a wet-nurse for 3 scudi a month [29].

A few mothers delivered their child in the Women's Hospital at Valletta or in the Santo Spirito's Hospital at Rabat. During the period 1750-1800, 7.1% of all baptisms were born at the Santo Spirito Hospital, of which 893 infants (8.8% of deliveries) were from outside the Rabat area. The infants born in the Women's Hospital at Valletta were baptised in the parish of St. Paul. The women delivering in the hospitals came from various towns and villages, often delivering in the hospital to conceal their pregnancy [30]. Delivery could be fatal either before or after delivery of the child. The high number of remarriages recorded could be an indirect result of the maternal mortality. Remarriages amounted to a fifth of all marriages. Widowers preferred to marry unmarried mothers (10%), rather than a widow (7.1%). Some even married a third or fourth time. Marriages were neither sentimental nor romantic, but a hard and fast bargain, the widower needing someone to look after his children [31].

In the case of a maternal death prior to the delivery of the child, the parish priests were obliged to ensure that the woman was delivered by Caesarean section and the child baptised. The first postmortem Caesarean section recorded in Malta occurred on the 13 December 1780 on a woman of twenty-three years at eight months pregnancy who died suffering from malignant fever. The Assistant Surgeon Fedele Zammit performed the operation having been sent to the Lazaretto to attend her and be in readiness to perform the surgery should the patient die. The male child was extracted alive but died after an hour. A number of postmortem Caesarean section are reported during the nineteenth century, while the first section on a live woman was performed in 1891 [32].

The first moves to introduce in Malta the formal teaching of the theory and practice of obstetrics to prospective midwives were made in 1772 when Dr. Guiseppe Antonio Cren(i), a surgeon with the Order proposed to the Grandmaster a course of instruction consisting of lectures once a month or more to women intending to take up midwifery. The scheme was never initiated since the Senior Physician of the Infirmary considered this course impractical because the midwives were so ignorant that they could in no way derive any profit from the lectures. The official initiative to introduce the formal teaching of midwifery dates to the early nineteenth century when in 1802 Dr. Francesco Butigiec was appointed Teacher of Obstetrics at the Woman's Hospital to deliver lectures to medical students and midwives. The manuscript lecture notes of Dr. Butigiec outline the midwifery practice of the late eighteenth and early nineteenth century [33].

The birth of an abnormal child during the eighteenth century has been recorded by Dr. Saverio Fenech, Principal Physician at the Gozo Hospital. The report which dates to 1788, records the birth of a monster born to a woman at Nadur, Gozo. The child had a head and ears like those of a cat, while the scalp from the forehead to the first three vertebrae was covered with black hair. The face was likewise similar to that of a cat, but was without hair or eyes. The upper-limbs were human-like but without articulations, the hands being similar to that of a cat without separation of the fingers, but with the thumb separated having only one phalanx. The genital parts were similar to those of a female cat, without an anus and umbilicus. The child was buried in church after examination by the parish priest. The superstitious beliefs about the origins of monsters current in the 17th century had slowly abated. The Maltese physician, Dr. Salvatore Bernard in 1749 adhered to the theory that the fantasy organ of a pregnant woman communicated by means of the animal spirits with the fantasy organ of the baby so that any perception aroused in the mother's mind produced similar impression in the brain of the fetus, which impression in turn reacted upon and molded the form of its body. He held that monsters having the shape of animals and devils were born to women who during gestation had been exposed to the sight of these creatures. These beliefs remained ingrained in Maltese mentality until relatively recent times. A special hazard of pregnancy was the emergence of longings or desires which could not be satisfied. According to popular belief, the newborn will bear the brunt of a birth-mark resembling in form and colour the object of the unfulfilled desire. If a person neglects to satisfy the wishes of a pregnant woman, he/she will be punished by suffering from a sty [34].

The obstetric practice in Malta at the turn of the eighteenth century is outlined in manuscript notes of the lectures delivered by Dr. Francesco Butigiec to medical students. The manuscript volume contains a series of lectures delivered in Italian, and belonged to the medical student (later doctor) Salvatore Bardon who qualified in 1818. The course of lectures was spread over a period of almost twenty months commencing on the 18 October 1804 and ending 11 June 1806. The manuscript comprises sixty-five chapters totaling 250 pages. The subject matter deals with the anatomy of the pelvis and pelvic organs, the anatomy of the gravid uterus, the clinical signs of pregnancy, abortion, normal and abnormal labour, management of the puerperium, twins and superfetation, manual correction of the various malpositions, the use of instruments and Caesarean section, and the care of the newborn. Dr. Butigiec apparently was well versed in the medical literature of classical times, the middle ages, and authors of the sixteenth to eighteenth centuries. He quotes authors from France, England, and Austria. His practice as described in the lecture notes was inevitably those of the eighteenth century [35]. Other midwifery lecture notes were published by Prof. S.L. Pisani in 1883 and by Prof. G.B. Schembri in 1896 and 1897 (73). Prof. Pisani wrote his textbook in the Maltese language to enable distribution to his midwife pupils at the end of the course. The book is divided into sixteen chapters and deals with anatomy and conception, changes that occur in pregnancy, antenatal care and advise, labour and its malpresentations and malpositions, postpartum care, twin births, miscarriages and molar pregnancies, and Caesarean section. Prof. Schembri prepared two textbooks for his midwifery students, one in English and a translation in Maltese. The book is divided into seven sections which deal with human anatomy and physiology, conception and fetal anatomy, pregnancy changes and abnormalities of early pregnancy, labour and its problems, and the management of the puerperium [36].

The teaching of obstetrics to prospective midwives was introduced during the nineteenth century, the previous suggestion of Dr. G.A. Cren having been turned down on the basis of the students' ignorance. An official initiative to teach midwifery was undertaken in March 1802 when Dr. F. Butigiec was appointed Teacher of Obstetrics at the Women's Hospital to deliver lectures to medical students and also to hold a separate class for midwives who were taught in Maltese as they did not have a good grasp of Italian. The school of midwifery functioned very erratically and was abolished in later years with a consequent deterioration in the practice of midwifery [37]. Fresh efforts were made to organize a School of Practical Midwifery in 1868. It was contemplated that a more respectable type of student will be selected, that there will be the teaching of both the theory and practice of midwifery following which the candidates were to sit for a qualifying examination. The low educational and social status of the applicants remained a problem [38]. The school was finally placed on a sound footing in 1915 when the course of midwifery was instituted under the auspices of the University leading to a Diploma of Midwife. The School of Midwifery reverted to the Medical and Health Department in 1946, the first group under this scheme qualifying in 1949 [39]. Midwifery training has in recent years reverted back under the auspices of the University.

The situation with regards to the training of medical students in obstetrics was much better. The first steps to establish a chair for the study of anatomy and surgery were taken in 1676 by Grandmaster Nicholas Cottoner, but the University with a Faculty of Medicine was only established in 1771. Prior to this time prospective physicians had to pursue their studies privately with a senior physician at the Holy Infirmary in Valletta for two years and then join a medical school or university in Italy or France [40]. A number of 18th century practitioners in Malta are known to have followed this course of studies which included also post-qualification training in midwifery practice. A Maltese doctor Giuseppe DeMarco proceeded to Montpelier in 1742 to finish his medical studies and is known to have assisted at a demonstration of the use of the forceps given by Andre Levret to the Paris Academy. At the same period Dr. Giuseppe Antonio Creni is known to have studied the art in Bologna. In 1778 Dr Saverio Micallef was sent to Paris for three and a half years to study surgery including midwifery. On his return to Malta he was appointed Professore delle operazioni chirurgiche e dell'arte ostetricia. This appointment suggests that midwifery was at this time at least being taught to Maltese medical students. Dr. Micallef in 1786 is known to have taught obstetrics on a model similar to that of the School of Cosmos in Paris [41]. The University was abolished by Napoleon Bonaparte by the decree of 18 June 1798, but the medical studies were retained in the form of a course of anatomy, medicine and midwifery at the Central Hospital at Valletta [42]. In 1802 Dr Francesco Butigiec was appointed Teacher of Obstetrics to deliver lectures to medical students and midwives. The manuscript notes of Dr. Butigiec lectures belonging to Dr Salvatore Bardon who qualified in 1818 have survived [43]. These notes suggest that Dr. Butigiec was familiar with the midwifery practices current on the continent in the eighteenth century referring to eight authorities of the 17th century and twelve authorities of the 18th century. He also refers to authorities from previous centuries, quoting four from classical Greek medicine, two from the early middle ages and a further two from the 16th century.

The Chair of Midwifery in the University of Malta was formally instituted in 1833, the first occupant being Dr Agostino Bonnici (1833-35). At this time the teaching of obstetrics appears to have been theoretical. Prof Saverio Arpa (1836-58) in 1839 requested the establishment of a midwifery ward for the purpose of imparting practical instruction to medical students. This request was turned down on the grounds that no accommodation was available in the hospital and that because of the repugnance of women to be assisted by men in their delivery is so strong and general amongst all classes that we (the Committee of Charitable Institutions) firmly believe not one of the women who are admitted in hospital for this purpose would however submit to be placed in the Clinical Ward. The Committee further considered that their was little to learn from normal deliveries and that the presence of the students 'about the patient's bed could consequently be both useless and indecorous'. Prof Arpa was however given the opportunity to conduct practical demonstrations to his students in cases of difficult delivery [44]. Practical instruction in midwifery remained limited to attendance only to case of abnormal labour, though the Department of Anatomy in 1860 acquired papier mache models of different stages of the development of the human ovum, of the generative organs and of the abnormal forms of pelvis. Most of these models perished with the destruction of the Anatomical Theatre in 1942 [45]. Prof Arpa was subsequently succeeded 1858 by Prof Salvatore Luigi Pisani. Prof Pisani graduated in medicine from the University of Malta in 1850, and subsequently qualified from the University of Edinburgh in 1853. Pisani concentrated his efforts towards the improvement in the instruction given to midwives with the publication of a book on midwifery in 1883 and another on the disease of childhood in 1885 [46]. During his tenure, in 1868 the medical students petitioned the Comptroller of Charitable Institutions to allow them to assist or at least be present during normal deliveries during their nine month clinical attachment. The Comptroller acceded to this request but cautioned that since many of the women were unmarried the presence of a sage-femme was essential. Prof Pisani relinquished the post in 1869 and was subsequently appointed Chief Government Medical Officer. He was instrumental in ensuring the legislation against the use of the birth-chair in 1883 [47]. The post of Professor of Obstetrics was filled by Prof G.B. Schembri (1880-1904). Prof Schembri similarly contributed towards the advancement in the training of midwives, with the publication in 1896-97 of two midwifery texts, in English and in Maltese. He was also instrumental in the formulation of the Regulations pertaining to Midwives published initially in the Maltese version of his textbook and subsequently legislated by Government Notice in 1899 [48]. He was succeeded by Prof S. Grech (1904-1909).

The nineteenth century saw the development of revolutionary concepts in obstetric practice. In Great Britain, James Blundell, whose lectures were published in the Lancet, proposed Caesarean hysterectomy in an attempt to decrease the maternal operative mortality, and also considered the possibilities of blood transfusion. His ideas were however not very enthusiastically received. Ergot of rye was introduced into midwifery by John Stearns in 1807 and popularized in 1822. The invention of the stethoscope and the identification of the fetal heart sounds by Jean Alexandre Lejumeau enabled the diagnosis of fetal well-being and the identification of fetal position. The first forty years of this century saw also a better understanding of the mechanism of labour, both normal and abnormal. The fourth decade of the nineteenth century was probably the most momentous and the most controversial in the history of midwifery. The infective aetiology of puerperal fever was identified, while Semmelweis demonstrated that careful attention to aseptic measures by the medical staff could reduce the maternal mortality significantly. The second momentous advance was the introduction of anaesthesia in surgery and later in midwifery by James Young Simpson (1811-1870). These advances, coupled with advances in surgical techniques, enabled practitioners to undertake more freely Caesarean operation. Edwardo Porro of Pavia, Italy reported the first planned Caesarean hysterectomy on 21 May 1876 where both mother and child survived. The Porro operation became outmoded, but not obsolete, when Max Sanger in 1882 popularized suturing of the uterus at Caesarean section. These advances continued well into the twentieth century. Caesarean section became gradually more and more freely undertaken for a variety of maternal and fetal indications. Furthermore pharmacological advances in the twentieth century enabled a better control of the antenatal and intrapartum period, while the advent of antimicrobials in 1935 enabled the introduction of effective treatment of puerperal sepsis and a marked reduction in maternal mortality. The twentieth century also saw a development of the concept of antenatal care and an increased attention to the developing fetus, with the development of investigative measures to assess fetal well-being. This brought a marked reduction in the perinatal mortality rate and the development of the specialty of fetal medicine in recent years [49].

The medical developments of the nineteenth century on the continent were closely followed by Maltese practitioners. Ether anaesthesia was first used in Malta in March 1847 in a case of partial amputation of the hand, and the first Caesarean section on a living mother was performed on the 28 May 1891. Following the first successful Caesarean section on a live patient in Malta, the operation was only slowly accepted as an alternative to vaginal delivery. Thus forty-five years later in 1937-38 only about 32 deliveries were delivered by the abdominal route [50]. Asepsis was also quickly introduced after the cause of puerperal fever became identified on the continent. Prof. S.L. Pisani in his lectures to midwives, like Dr. Butigiec in 1804, advised midwives to smear their fingers with oil or any other lubricant before performing a vaginal examination, which he advised should be kept to a minimum. He gave advise regarding the place of delivery and puerperium. The windows were to be kept open even in winter, so that no bad smells remained in the room. Any excreta was to be immediately taken out of the puerpera's room [51].

Professor Schembri in 1896 gave similar instruction as to the place and care during delivery. However he emphasises the use of antiseptic vaseline for lubrication of the fingers during vaginal examinations. Similar use was made earlier by Dr. G.F. Inglott in 1890 who used antiseptic vaseline when carrying out podalic version and further prescribed antiseptic irrigation of the uterus following these procedures. Prof Schembri appears to have been influential in introducing legislation towards asepsis in midwifery. He included in the published Maltese lectures in 1897 the regulations which were later published and formalised in the Government Gazette in 1899. These regulations determined the care a midwife had to give to her patient. The midwife, after sterilizing her instruments and hands with an antiseptic solution (5% Boracic acid of Condy's fluid) , was to wash the patient's perineum with soap followed by antiseptic solution. The vagina was similarly irrigated with an antiseptic solution. Vaginal examination was to be performed as seldom as possible. Similar antiseptic care was given for the first five days of the puerperium [52]. These regulations resulted in a fall in cases of puerperal sepsis so that while in 1902-03 31 cases of sepsis were reported from Malta and Gozo, the subsequent year 1903-04 only 14 cases were reported. However the regulations were not widely practiced and in 1903 the Medical Officer in charge of the Hospital in Gozo remarked that puerperal women in Victoria Hospital were being attended to by general nurses who took care of other hospital patients rather than the midwife. The specific mortality rate from puerperal sepsis in 1903-06 stood at 90.3 per 100000 births, while in 1911-14 the rate was 70.3 [53]. The situation had improved by 1937 but was still far from ideal. The use of sterile gloves was still not compulsory and many vaginal examinations by district midwives were performed without them. This was not surprising since up to the first decade of the twentieth century the surgical community was still debating the usefulness of using rubber gloves during surgery. The 1918 Regulations respecting midwives published in the Government Gazette still did not include the provision for the use of sterile gloves. In 1937 puerperal sepsis in the hospital was prevented by placing any cases developing fever or a septic discharge in the Isolation Hospital. In order to minimize the risk of spray infection, all personnel who came in contact with maternity cases were screened periodically for naso-pharyngeal Streptococcus haemolyticus or for an inflamed throat. Staff with either were not allowed to attend maternity cases. A system of using numbered bed-pans for each puerpera was also in force to prevent spread of infection. The introduction of the use of liquid Dettol or Dettol cream together with sterilized gloves for vaginal examinations in the hospital, had also helped to decrease the incidence of puerperal sepsis in the hospital. Established cases of sepsis were managed by intra-uterine injections of flavine in glycerin, the administration of sulfonamides, and the use of anti-gas gangrene serum in selected cases [54]. Sulfanilamide (Prontosil) was first tried in Malta in 1935 with encouraging results in infections caused by hemolytic streptococcus. It did not, however, come into general use until 1937, when it was tried also in the treatment of gonorrhea and other infections, including puerperal sepsis. Sulfapyridine appeared in 1938-39. Penicillin was first administered to a case of puerperal fever not responding to sulfonamides in August 1944. The mother survived the infection. The introduction of antimicrobials were an important landmark in the management of puerperal sepsis. However the incidence of sepsis decreased initially as a result of the preventive measures undertaken, so that the case fatality rate remained approximately the same until after 1943-45, when the case fatality rate decreased to about a third of the figure in 1937-39 [55].

Until the middle of the twentieth century the majority of confinements were conducted in the home under the supervision of a midwife or a traditional birth attendant, such as the mother of the mother-to-be, in the low socio-economic groups. Few women delivered in the hospitals, these usually being women from a very low socio-economic status. The mothers delivering at Victoria Hospital in Gozo during 1876-1893 have been shown to have a mean age of 32.26 years with a mean gravidity of 5.4 children, of which the total previous living children numbered 2.7. Nearly all the patients delivering in the hospital 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 labourers and 15.5% being mariners and fishermen. The illegitimacy rate of hospital deliveries was increased accounting for 8.6% of all admissions [56]. A shift in attitude towards hospital confinement was noted in the late 1950's when it was noted that whereas formerly patients looked at maternity services in the government hospital with indifference, their attitude was changing. By 1963 the hospital confinement rate approximated 53% [57]. The nineteenth century also saw the introduction in the Maltese Islands of regular censuses of the population. The first regular Census in a series of decennial censuses, interrupted during the Second World War and in 1977, was carried out on 21 March 1842. The total population in 1842 was 114499 with a birth rate of 38.3 per 1000 population and a crude death rate of 34.6 per 1000 population. By 1901 the population increased to 184742 with a birth rate of 38.5 and a death rate of 28.8. The population continued to increase to the 345418 figure reported in 1985. These censuses enabled a regular check on population growth and the prevailing death and fertility rates [58]. These statistical analysis of the population enabled health administrators to identify the population health and social requirements enabling the planning of strategies for better health.

Until fifty years ago pregnancy and labour carried a significant risk of death for the mother. The primary concern for all health professionals was the high maternal mortality. This was brought down before and after the second world war with the introduction of antimicrobials and freer access to blood transfusion. Prior to this a high fetal/neonatal wastage was acceptable. After the risks to the mother from pregnancy were minimised, then attention shifted to the perinatal mortality until this too was significantly reduced. Pari passu with developments in medical care, general improvements in the social conditions of the population have contributed towards the decline in obstetric morbidomortality. Nowadays the attention during pregnancy is towards the psychosocial aspects. Mothers, having been released from the overwhelming fear of a possible death for themselves and their infant, want to enjoy the experience of pregnancy and labour. This attitude, whilst encouragable, must not be promoted at the expense of the progress attained in this century.

1. T. Zammit and C. Singer: Neolithic representations of the human form from the islands of Malta and Gozo. J. Roy Anthropol Instit 1924, p.76, 92, 96-97

2. T.C. Gouder: Some amulets from Phoenician Malta. Heritage, 1978, I:311-315; T.C. Gouder: Phoenician Malta. Heritage, 1978, I:185; A. Bonanno: Roman Malta: The archeological heritage of the Maltese Islands. World Confd Salesians, Rome, 1992, p.24

3. J.L. Pace and S. Ramaswamy: The Finds: Skeletal remains. In: T.F.C. Blagg, A. Bonanno, and A.T. Luttrell (eds): Excavations at Hal Millieri, Malta: a report of the 1977 campaign conducted on behalf of the National Museum of Malta and the University of Malta. Malta University Press, Malta, 1990, p.84-95

4. Biblioteca Vaticana: Urbinato Latino ms.833, ff.140v-141p; A. Bonnici: Maltin u l-Inkizzjoni f'nofs is-seklu sbatax, K.K.M., Malta, 1977, p.48, note 87

5. Curiae Episcopalis Melitensis 78B, fol.457; P. Cassar: The Maltese Midwife in History. Midwives Assoc Malta, Malta, 1978, p.11

6. W. Radcliffe: Milestones in Midwifery. J Wright Ltd, Bristol, 1967, p.20-21; J.H. Bass: Outlines of the history of medicine and the medical profession. Kriegger Publ Co, Huntington, original ed 1889, translated and expanded by H.E. Hanerson, 1971, vol.II, p.462-463

7. J.H. Baas, ibid, vol.II p.521-526

8. J.H. Baas, ibid, vol.II p.560-561

9. P. Cassar: Medical History of Malta. Wellcome Hist Med Libr, London, 1964, p.412

10. National Malta Library: ms.2, fol.601; NML: ms.439, fol.422; NML: ms.429, vol.1 fol.20; Leggi e costituzioni prammaticali. Malta, 1724; Del dritto municipale di Malta. Malta, 1784, p.296; P. Cassar, 1964: ibid, p.417, 277; NML: ms.643, fol.589; Constitutiones in diocesana synodo melivetana. Rome, 1625; Synodus diocesana Fr. David Cocco Palmieri. Rome, 1709 p.26; P. Cassar, 1978: op. cit. note 5 above, p.11-12

11. Curiae Episcopalis Melitensis AO693, fol.115r-125v; Archieposcopal Archives Melitensis Corr.XXIII, fol.268r; Parish Archives (Zejtun) - Lib. Bpt. X, unnumbered; P. Cassar, 19788: ibid, p.1-12; F. Ciappara: Marriage in Malta in the late eighteenth century. Assoc News Ltd, Malta, 1988, p.106

12. F. Ciappara: ibid, p.88-90; P. Cassar: The birth of monsters in the Maltese Islands in the 17th and 18th centuries. Mediscope, 1983, 1:p.6-9

13. Archiepiscopal Archives Melitensis - Edicta Labini, vol.12, f.175r; C. Savona-Ventura: Caesarean section in the Maltese Islands. Medical History, 1993, 37:37-55

14. L'Ordine, 4 October 1867, p.3; The Malta Times, 10 October 1867, p.2; P. Cassar: The Church on Caesrean section in Malta in 1867. St. Luke's Hospital Gazette, 1969, 4(1):48-52

15. P. Cassar, 1978: op. cit. note 5 above, p.12

16. National Malta Library: Archives 1184, fol.97, NML: Archives 1194, fol.220; P. Cassar, 1978: ibid, p.11

17. Curiae Episcopalis Melitensis AO508 n.s.; P. Cassar, 1983: op. cit. note 12 above

18. Archivum Inquisitionis Melitensis - Criminalia 1644-1648; A. Bonnici: op. cit. note 4 above p.102-104, 199-200

19. Archivum Inquisitionis Melitensis 79, fol.174; P. Cassar, 1983: op. cit. note 12 above p.8

20. J.H. Baas: op. cit. note 6 above, vol.II p.679-688, 782-783; H.R. Spencer: An address on some changes in obstetric practice since the foundation of the Medical Society of London. Lancet, 13 October 1923, ii:817-821

21. F. Ciappara: op. cit. note 11 above, p.33-35, 107, 124-126

22. Archivum Inquisitionis Melitensis - Processi 131A, fol.155r-207r; F. Ciappara: ibid, p.90

23. Archivum Inquisitionis Melitensis - Processi 127B, fol.1181r-1205v; AIM - Processi 135B, fol.597r; AIM -Processi 136A, fol.188v-189r; AIM - Proceess 125C, fol.1203r-v; Curiae Episcopalis Melitensis AO696, fol.286r; F. Ciappara: ibid, p.88

24. National Malta Library ms.439, fol.307; P. Cassar, 1964: op. cit. note 9 above, p.474; Del Dritto......, op. cit. note 10 above, p.174, 296

25. Synodus diocesana........, op. cit. note 10 above, p.26; AAM - Edicta Labini, op. cit. note 13; P. Cassar, 1978: op. cit. note 5 above, p.12; F. Ciappara: op. cit. note 11, p.88-90

26. F. Ciappara: ibid, p.76-84

27. National Malta Library: ms.638, n.p., entry dated 11 Sept 1744; Curiae Episcopalis Melitensis AO672, fol.153r-188v; CEM AO696, fol.286r-367r; CEM AO677, fol.165r; Del Dritto......., op.cit. note 10 above, p.183; F. Ciappara: ibid, p.30-31

28. Il-Portafoglio maltese, 10 November 1838, p.250

29. Curiae Episcopalis Melitensis AO696, fol.286r-367r; A. Anderson: A Journal of the forces. London, 1802, p.181; Archivum Inquisitionis Melitensis - Processi 137, fol.70r-97v; CEM AO693, fol.408r-417v; F. Ciappara: op. cit. note 11 above, p.71,109

30. Parish Archives - Lib. Bapt. IV-VI, 1716-1803; F. Ciappara: ibid, p.85-86, 104

31. F. Ciappara: ibid, p.58-60

32. National Malta Library - Registri degli arrivi di bastimenti in quarantina. Arch 6531, fol.69t 11.12.1780, fol.74t 1.12.1780, fol.76 13.12.1780; P. Cassar: Clinical Case histories and postmortem reports from the Malta Lazzaretto in the 18th century. Mediscope, 1989, 13:p.9-13; C. Savona-Ventura: op. cit. note 13 above, p.38-42

33. P. Cassar, 1964: op. cit. note 9 above, p.412; F. Butigiec: Trattato dell'arte ostetrica dettato e spiegato del Perille Signor Dr Francenco Butigiec nello studio publico del Grand Ospedale Nazionale di' Malta. Principiato li 18 Ottobre 1804. m.s. 1804, In P. Cassar: Teaching of midwifery in Malta at the beginning of the nineteenth century. St Luke's Hospital Gazette, 1973, 8(2):91-111

34. S. Fenech: Public Records Office Misc.76: Report of the birth of a monster with its sketch, Malta, 1788; P. Cassar: The Neuro-psychological concepts of Dr S Bernard. Scientia, 1949, 15:p.29; P. Cassar, 1983: op. cit. note 12 above, p.7-9; J. Cassar-Pullicino: Studies in Maltese Folklore. 1992, Malta University Press, Malta, p.213-215

35. F. Butigiec, op. cit. note 33 above

36. S.L. Pisani: Ktieb il Qabla. P Debono, Malta, 1883, +105p.; G.B. Schembri: The Midwife's Guide Book. Government Printing Office, 1896 +111p.; G.B. Schembri: Taghlim ghal istudenti ta l-iskola tal kwiebel ta l-Isptar Centrali, Malta. Government Printing Office, Malta, 1897 +111p.

37. P. Cassar, 1964: op. cit. note 9 above, p.413-415

38. Malta Government Gazette supplement, 26 June 1915, p.54; P. Cassar, 1964: ibid, p.414

39. Report on the health conditions of the Maltese Islands and on the work of the Medical and Health Department including the Emergency services for the year 1946. Government Printing Office, Malta, 1947; Report on the Health conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1949. Government Printing Office, Malta, 1950

40. P. Cassar, 1964: op. cit. note 9 above, p.437-464

41. J. Galea: Dr. Guisepe Demarco (1712-1789). A biographical and bibliographical study based on hiterto unpublished material. St Luke's Hospital Gazette, 1972, 7(1):p.3-13; P. Cassar, 1964: op. cit. note 9 above p.413; P. Cassar: French influence on medical developments in Malta. Ministry of Education, Malta, 1987, p.12; National Malta Library - Archives 1195, fols.66,136,138

42. P. Cassar, 1987: ibid, p.17; H.P. Scicluna: Acts and Documents relating to the French occupation of Malta in 1789-1800. Archivum Melitense, s.a., 15:p.5,100

43. F. Butigiec: op. cit. note 26 above

44. P. Cassar, 1964: op. cit. note 9 above, p.450-452; Medical & Health Archives - Minute book, 13 September 1837 to 27 June 1843, fols.107,114; L'Arte, 7 July 1864

45. J.L. Pace: The History of the School of Anatomy in Malta. Royal University of Malta, Malta, 1974, p.16

46. S.L. Pisani: op. cit. note 36 above; S.l. Pisani: Fuq il-mard tat-tfal u kif nilqghulu. Malta, 1885; P. Cassar: Profile. Professor Salvatore Luigi Pisani M.D. (1828-1908). Malta Today, 1982, 17(3):14-16

47. Medical & Health Archives: Register of References to Comptroller of Charitable Institutions, 5:fol.74; P. Cassar, 1964: op. cit. note 9 above, p.415, 457; P. Cassar: Vestiges of the parturition chair in Malta. St Luke's Hospital Gazette, 1973, 8(1):58-60

48. G.B. Schembri, 1896: op. cit. note 36 above; G.B. Schembri, 1897: op. cit. note 36 above; Regulations respecting midwives. Malta Government Gazette, 7 August 1889, p.774-775

49. W. Radcliffe: op. cit. note 6 above, p.69-85

50. G.B. Schembri: Prima operazione cesarea in Malta. Rivista di Ostetricia e Ginecologia, 1891, +3p. (reprint); C. Savona-Ventura, 1993: op. cit. note 13 above, p.42-50

51. S.L. Pisani: op. cit. note 36 above, p.70, 89-91; F. Butigiec: op. cit. note 33 above; P. Cassar, 1964; op. cit. note 4 above, p.530

52. G.B. Schembri, 1896: op. cit. note 36 above p.65-66, 94-95; G.F. Inglott; Distocia. La Rivista Medica, 15 April 1890, Anno I(3):p.6; G.B. Schembri, 1897: op. cit. note 36 above; Regulations respecting midwives, Malta Government Gazette, August 1899, p.774

53. October 1904, 4761:p.+35p; Gozo Hospital Archives: Correspondence book for Victoria Hospital, 6 September 1893 to 20 August 1903, fol.228-229; General Health Reports 1903-06, Malta Government Gazette supplement, October 1904 4761:+35p., October 1905 4854:45p., August 1906 4927:+42p.; Reports on the working of government departments during the financial years 1911-14. Government Printing Office, Malta, 1912-14, 3 vols.

54. Annual report....1937, op. cit. note 49 above; J. Randers-Pehrson: The Surgeon's Glove. Charles C Thomas Publ., Illinois, 1960, +95p.; Regulations Respecting Midwives. Malta Government Gazette. 25 October 1918, 6103:p.873-876

55. C. Savona-Ventura: Reproductive performance on the Maltese Islands during the second world war. Medical History, 1990, 34:p.164-177; H. Ganado: Rajt Malta tinbidel. Interprint (Malta) Ltd, Malta, 1977, vol.3, p.222

56. C. Savona-Ventura: A maternity unit in Gozo a hundred years ago. Essay awarded the M.A.M. Prize, 1991, +29p.

57. Report on the health conditions on the Maltese Islands and the work of the Medical and Health Department for the year 1955. Government Printing Office, Malta, 1956, p.6; A.P. Camilleri: Obstetric deaths in Malta. J Int Fed Gynaecol Obstet, 1965, 3(3):p.179-186

58. Census '85: Vol.I - A Demographic profile of Malta and Gozo. Central Office of Statistics, Malta, 1986, p.10