Medicalization of Birth in Transylvania

"Such Is a Woman's Fate" — A Birth in the Field

Around midday, all her stabbing pains suddenly ceased and she felt lighter. She crossed herself, took the basket, and set off slowly, leaving the house under the watch of old Dumitru Moarcăș, who had settled himself for good at Glanetașu, no longer daring to return to Paraschiva.

But despite all her effort, a long, piercing, and pitiful cry burst from her lungs, followed by heavy groans that dried her throat.

"Good Lord! Her labor pains must have started!" cried Zenobia, straightening up, a sickle in one hand and a sheaf of wheat in the other, looking toward the wild apple tree. "Yes, yes… that's it, just as I said! Look at her writhing!"

"Foolish woman!" muttered Ion, without even turning around. "She knows her time has come and comes to give birth in the field! God confound her senseless plans!"

Figure 1

Zenobia, the mother-in-law, hurries from the harvest field toward Ana — the elder woman who, "without ever having been formally trained," embodies the empirical knowledge that the medicalization of birth would gradually displace.

Source: Still from the screen adaptation of Liviu Rebreanu's novel Ion.

"What is it, Ana? Oh dear, really now… Couldn't you have stayed home if you felt the pains coming?" said Zenobia kindly, kneeling beside her and trying to ease her suffering.

Like most elderly women in the village, Zenobia knew how to assist a birth without ever having been formally trained. She loosened Ana's belt, removed her aprons, and gently rubbed her abdomen from top to bottom. Ana's groans sharpened into long, hissing breaths, and her dry lips whispered from time to time: "Mother-in-law… mother-in-law… I'm dying… I'm dying… I'm dy—ing…"

"Hush now, you won't die, my dear, hush… just endure a little longer, hush now, it will be over soon!"

The men continued harvesting. Glanetașu flinched at every one of Ana's cries; Ion worked more fiercely, yet kept listening, muttering angrily to drive away the pity slowly creeping into his heart. "Oh, the poor thing, the poor thing!" the old man shuddered, hearing a particularly piercing scream. "Well, such is a woman's fate!" said Ion, trying to sound calm, though his voice had softened.

In the nineteenth century, the modern state began to intervene, gradually transforming childbirth into a medicalized and institutionalized act. This transformation was far from linear. Literature often captures this reality more faithfully than statistics.

The scene above encapsulates an essential historical reality: childbirth occurs outside any medical institution, within the space of agricultural labour, in the midst of daily activities. Suffering is managed by other women in the community, and intervention is empirical rather than medical. The figure of Zenobia — who "knows how to deliver babies without having been trained" — represents the type of experiential knowledge that the process of medicalization would gradually replace. The line "Such is a woman's fate" captures a mentality in which childbirth is both naturalized and socially prescribed, prior to the intervention of the state and modern medicine.

Home Birth: The Natural Order of Things

Until well into the early twentieth century, childbirth remained a domestic event, embedded in the life of the community. Women gave birth at home, assisted by traditional midwives, relatives, and neighbours. There was no clear separation between the "medical" and the "social," and institutional intervention was minimal.

The subject of childbirth and midwives has drawn the attention of historians as part of the broader process of modernization. That process can be examined from many angles: the training of midwives and state intervention in regulating their activity; the trained midwife versus the traditional midwife (and women's reluctance to change); assisted childbirth in the village as opposed to assisted childbirth in the town; midwives versus obstetricians; gender roles — midwives as women, obstetricians as men.

One thread runs through them all: the association between birth assisted by empirical midwives and high rates of infant and maternal mortality, against the decline in infant mortality as childbirth became increasingly medicalized. And yet contemporary debates have begun to swing the other way — toward emphasizing the benefits of midwife-assisted home births, a return to tradition, to what the specialized literature calls "the good old times."

The Midwife: Between Recognition and Control

In the second half of the eighteenth century, the state began to regulate the activity of midwives. Professional training, certification, and sanctions became instruments of control. Yet local realities remained far more complex.

The history of midwifery education in Transylvania begins with the reforms implemented by Maria Theresa. Facing large categories of healers — quacks and untrained alike — who undermined the authority of certified physicians, the state issued regulations to better supervise medical services, the duties of practitioners, and the prices charged. János Torkus Justus, physician of Pozsony and author of Taxa Pharmaceutica (1745), ruled that every midwife had to be examined by an official physician in order to practice the craft of delivery. In 1770, Maria Theresa ordered an empire-wide census to obtain more precise information regarding the number, health status, and education of the population across the provinces of the Monarchy.

Figure 2

The opening page of the Generale Normativum in Re Sanitatis, 4 October 1770 — the first comprehensive sanitary regulation of the Habsburg Monarchy and the legal foundation of licensed midwifery.

Source: Generale Normativum in Re Sanitatis, Concl. Cons. Nº 4689, 4 October 1770.

In the same year was issued the Generale Normativum in Re Sanitatis — the first comprehensive regulation concerning the organization of public health. The document represents the first attempt to systematize the activity of midwives, legislating not only the way they were to practice but also how they were to be trained. Enforced across all the territories of the Austrian crown, it provided that midwives, surgeons, and pharmacists should be examined by the official physician in order to obtain a practice licence.¹

As a consequence, Weszprémi István, a physician in Debrecen, published in 1766 the Bába Mesterségre Tanító Könyve — the first midwives' manual. Within the Faculties of Medicine, the first courses for midwives were opened: in Nagyszombat (1770), then in Cluj (1772). The activity of midwives was officially recognized.

Figure 3

An anatomical plate from an eighteenth-century midwives' manual depicting fetal positions in the womb (Figs. 8–13). Such illustrations were the visual core of formal training, replacing the experiential knowledge of village elders.

Source: Eighteenth-century midwifery manual, in the tradition of Weszprémi István's Bába Mesterségre Tanító Könyve (Debrecen, 1766).

With a large part of the population illiterate, poor, and living in superstition, with relatively few schools and courses for training, the craft of midwifery remained for a long time in the hands of neighbour women — able to provide care and assistance at the very moment of delivery. Most instructions remained only in the regulations; the norms were hard to encounter in practice. It is still a fact that at the end of the 18th century a kind of midwives' association was functioning in Hungary — Öreg Asszonyok Társasága, the Association of Old Women, set up in Debrecen.

The Cluj Institute — A New Centre of Gravity

Most historical interpretations converge in linking the beginning of formal midwifery education in Transylvania to the founding of the Institute of Surgery and Gynecology in Cluj-Napoca in 1775. This marked the moment when the provisions of the sanitary regulation began to be implemented in earnest: the training of midwives became the responsibility of the professor of obstetrics, who also prepared future obstetricians. All that remained was for empirical midwives to attend the institute in order to obtain certification — all that remained, that is, on paper.

The Chair of Obstetrics belonged to the Institute's structure from its very beginning, and the obstetrics course was taught in the second semester. The numbers, where we have them, were modest: in 1893, for example, the course was attended by twelve students. Across the long arc of the nineteenth century, the teaching was carried by a small group of professors whose names recur in every account of the institute's history — Laffer József, Eckstein János, Keresztes Elek, Pfenningsdorf Antal, Szabó József, and Maizner János.

Two decades after the institute opened, the situation on the ground was still far from aligned with the principles of the sanitary regulation. Consequently, a new special instruction for Transylvania was issued in 1787, reinforcing the mandate given to the medical authorities — particularly the protomedics — to ensure that women would no longer give birth assisted by untrained midwives, regardless of whether instruction was provided at the institute itself or by designated obstetricians.

Three Languages, One Classroom

From the outset, instruction at Cluj was offered in all three languages of the province — Hungarian, German, and Romanian — though the path to genuine multilingual teaching was uneven. A memorandum survives from a candidacy submitted for the position left vacant by the dismissal of Laffner: Joszef Osztrovics, a Master of Surgery and Obstetrics in Vienna, declared that he had instructed "Hungarian and Wallachian midwives" in their own languages by royal command, and was for that reason the preferred candidate of the Rector of the Institute, J. Winkler, to take Laffner's place.

In 1807, a letter from the Protomedicus of Transylvania pressed for the introduction of teaching in Romanian at Cluj, noting that in Sibiu Doctor Mihail Blasius was already instructing midwives in that language. As a consequence, in 1808–1809 the first Romanian-language courses were introduced at the Cluj Institute as well. Before 1852 we cannot be certain that they were held annually; but from that year onward the rule became explicit: "the lectures in surgery shall be given in Hungarian, and those for midwives in German and Hungarian by the titular professor, and in Romanian by the Adjunct, Mr. Anton Pfenningsdorf." After 1850, then, the courses for midwives at the Cluj Institute were held in all three languages of the province — German, Hungarian, and Romanian — while at Sibiu they were held in German and Romanian.

Until 1851, the courses themselves remained largely theoretical. What little practical preparation existed was conducted on so-called fantoșe — mannequins. Only from 1851 onward was practical training introduced alongside the early lying-in houses, the precursors of the maternity wards.

Schools, Scholarships, and the Stubbornness of Tradition

Efforts multiplied to persuade women who met the legal requirements to enrol in midwifery courses. Scholarships were introduced. Promotional campaigns were organized. Yet the number of trainees remained low.

The profile of the candidate likely did little to encourage enrolment: women were required to be married, between twenty and forty years of age, literate, and able to demonstrate impeccable moral conduct. The target group thus consisted primarily of young mothers — most likely, as demographic analyses suggest, women with households and families — who were understandably reluctant to abandon their domestic responsibilities. Moreover, the Instruction failed to clarify their prospective income after graduation and established no punitive measures for those who continued to practice without specialization.

Ignácz Farkas, a surgeon and man-midwife from Dumbrăveni, described himself in an 1803 pamphlet as, among other things, a veterinarian and a keen observer of sanitary realities in the seats of Sighișoara, Dumbrăveni, and Cugir. With authorization from the governor and approval from Vienna, he was permitted to organize training courses for rural midwives. On the basis of this authorization, Farkas established six-week courses for village midwives, held in two annual sessions, at the end of November and the end of March. In 1803, he himself noted that he was already conducting the second course, hosted in his own residence, which was sufficiently spacious to accommodate such activities.

It was not zeal alone that moved Farkas to act, but the conditions he saw around him. In the same pamphlet, he set down — with unusual frankness — the situation of women giving birth in the villages of his district:

Farkas's diagnosis is unsparing in two directions at once. He blames the untrained midwives for tormenting women through ignorance; but he also turns toward the women themselves, observing that they are "indifferent" to their lack of help, never demanding better. The picture is of a system held together by endurance — and the courses in Farkas's own residence in Dumbrăveni were one of the first concrete attempts to dismantle it.

Figure 4

The 1803 title page of Ignácz Farkas's Bemerkungen zur Kronologie der Hebammen-Kunst im Großfürstenthum Siebenbürgen ("Remarks on the Chronology of the Midwife's Art in the Grand Principality of Transylvania"), printed for the second course of village midwives at Elisabethstadt — present-day Dumbrăveni. Below, the seal of the Cluj University Library, where the volume rests today.

Source: Ignatius Farkas, Bemerkungen zur Kronologie der Hebammen-Kunst im Großfürstenthum Siebenbürgen, Elisabethstadt (Dumbrăveni), 1803 — Cluj University Library.

An Instruction issued in 1809 explicitly mentioned Farkas by name, stipulating that no woman within a given medical district should be allowed to practice obstetrics unless she possessed either an academic diploma issued within the domains of His Majesty or, at the very least, a certificate attesting to training received from Ignácz Farkas — or from a licensed physician or professor of obstetrics under whose supervision she had been instructed.

To facilitate women's participation in the courses organized by the Medico-Surgical Institute, the Court in Vienna expressly requested that the Governor exempt them from any public duties for the duration of their schooling. Candidates had to be literate, under thirty years of age, and of good moral standing. In the first years, twelve scholarships were granted; from 1835, their number doubled. Courses were offered in Cluj-Napoca and Sibiu. Candidates could be married or widowed, between twenty and forty years of age, while still fulfilling the criteria of literacy and moral conduct.

Initial offences were subject to pecuniary penalties determined case by case; repeat offences were punishable, in accordance with Article 98 of the Penal Code, by arrest. These measures were reinforced by Ordinance No. 57 of the Imperial–Royal Ministry of 6 March 1854 concerning the unauthorized practice of birth assistance, which imposed harsher sanctions on unlicensed practitioners.

In 1871, in a renewed effort to increase enrolment, the Minister of Religious and Public Education supplemented trainees' stipends by forty crowns and covered their travel expenses. The duration of the course was extended to five months, organized in a single annual session from 1 March to the end of July.

Between 1832 and 1872, an average of thirty-seven trainees per year obtained a midwifery diploma. After the opening of the medical faculty in 1872, the Orvos–Sebészeti Tanintézet trained, on average, forty candidates annually. Thus, by the time the public health law was adopted, the professional category of trained midwives had already taken shape — though their numbers remained wholly insufficient in relation to actual needs.

Across the four decades that followed the founding of the medical faculty, the composition of medical staff in Transylvania changed dramatically. Three trends, plotted on a single chart, tell the story of medicalization in numbers: doctors multiplied, the older category of surgeons (chirurgi) almost vanished, and the population of trained midwives doubled.

The most striking feature of the chart is the dramatic divergence after 1872. The 1872 law that restricted medical practice to graduates of the medical faculties extinguished the older category of "surgeon" (chirurg / sebész) within a generation: the 204 surgeons recorded in 1872 had fallen to 95 by 1892, 41 by 1900, and only 21 by 1910. They were replaced — and surpassed — by university-trained doctors, whose number more than tripled in the same period, rising from 148 to 511. The midwives, meanwhile, doubled. They remained, by an order of magnitude, the largest medical-professional category in Transylvania at the close of the long nineteenth century.

The law of 1876 required women residing within seventy-five kilometres of a midwifery school to obtain their diploma through formal schooling, while those living beyond this radius were required to complete a special course and certify this training through documentation issued by the district medical officer. The legislation thus acknowledged a reality that could no longer be ignored, and demonstrated a degree of flexibility — provided that some form of instruction, however rudimentary, had been completed. Licensed midwives nevertheless held priority: those practicing solely on the basis of a local certificate (the so-called țidulă midwives) lost their right to practice if a fully qualified midwife became available in the area.

In theory, after the law came into force, women practicing without either a diploma or a certificate were required, should they wish to continue, to obtain one or the other within a year (Art. 51). The law also introduced fines and penalties for unauthorized practice and malpractice, mandated investigations of such cases, sanctioned the disclosure of personal information, penalized refusal to aid, and established the obligation to report births. Consequently, 1876 may be regarded as a turning point in the regulation of this professional body — which further justifies the need to examine the situation on the ground prior to the law's enforcement.

A Census of Hands: The Landscape in 1875

An 1875 survey identifies 897 midwives in the historical Transylvanian counties. The few characteristics recorded by the source — age, religious affiliation, age at qualification, and age at the time of data collection — make it possible to reconstruct a set of socio-demographic and professional features of this category of medical personnel.

More than half of these women had attended courses in Cluj, while the remainder, in their overwhelming majority, had trained in Sibiu. A small number — approximately twenty-five or twenty-six — completed their training in Budapest, Vienna, Prague, or Milan. With the exception of Sibiu town, which maintained its own midwifery school and attracted women from the surrounding seats and towns (Sighișoara, Sebeș, Mediaș), women from most other administrative units overwhelmingly gravitated toward Cluj.

The distribution of certified midwives reveals significant disparities between urban and rural environments. Urban centres display a relatively high concentration of trained practitioners, reflecting both administrative priorities and better access to educational institutions. In contrast, rural areas remain severely under-served, with vast territories relying on a minimal number of certified midwives or none at all.

These disparities point not only to logistical and infrastructural limitations, but also to deeper structural differences in the organization of care. While urban settings facilitated the penetration of state-regulated medicine, rural communities continued to rely heavily on informal networks and traditional practices — on the Zenobias of every village.

Figure 6

A page from a midwife's register kept in Sibiu, 1894 — births recorded one by one in her own hand, with dates, family names, and street addresses. After 1876, reporting each delivery was no longer a courtesy but a legal obligation; this is what compliance looked like.

Source: Midwife's birth register, Sibiu, 1894.

Toward the Hospital: Cluj at the Turn of the Century

Figure 7

The Karolina Országos Kórház (Carolina National Hospital) in Cluj — for decades the principal site of institutional birth in the city, and the workplace of head midwife Maria Kriszte and her assistants.

Source: Photograph of the Karolina Országos Kórház, Cluj (late 19th – early 20th century).

Moving toward 1900 and examining the baptismal registers of the various denominations in Cluj, one can observe that a significant proportion of births took place in hospitals — spaces still largely reserved for illegitimate births and preferred by single women, urban workers, most often coming from other localities, for whom the hospital remained the only viable option in such circumstances.

Between 1880 and 1910, approximately 25% of births in Cluj occurred in hospitals, attended by qualified midwives.

According to the 1915 sanitary book,² Maria Kriszte was the head midwife of the maternity ward. We do not have further data to help complete her profile; however, she appears in all the community registers, with her name spelled variously as Krizste, Criste, or Criste. She was assisted by Faltin Kristina, Mesztek Józefa, and Bóer Rozá.

In conclusion, at the beginning of the 1900s there were three major midwifery schools in Transylvania: the one in Cluj, whose existence is linked to the establishment of the Medico-Surgical Institute in 1775, which in the period under discussion offered a single annual course running from 1 September to 31 January, taught in all three languages; the midwifery school in Sibiu, founded in 1809, which organized two courses per year — spring–summer (February–June) and autumn–winter (September–January) — again with instruction in Hungarian, German, and Romanian; and the school in Oradea, operating since 1873, also offering two five-month courses per year, with Hungarian and Romanian as languages of instruction.

Coexistence, Not Replacement

The expansion of trained midwives reflects significant progress in the institutionalization of health services. Yet that development remained uneven and incomplete. The persistence of empirical midwifery underscores the resilience of community-based practices and highlights the gap between normative frameworks and lived realities. The state issued laws; villages kept their elders. The institute graduated forty women a year; thousands of births still took place beside the wild apple tree.

To walk these rooms in order — from Ana writhing in the harvest field to Maria Kriszte heading a maternity ward in Cluj — is to walk a century and a half. But the journey is not a march. Zenobia and Maria Kriszte were, for decades, contemporaries.

"Such is a woman's fate," said Ion. The fate would change. The pace at which it changed depended on which side of the line — institute or village, town or field — one happened to be born.