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Women’s health conditions and the establishment of the First Women’s Hospital during the rule of Pahlavi I

The policies of the government encouraged Iranian women to engage in health activities. Increased awareness of health and hygiene caused women to make more demands on their husbands, and to pay more attention to their husbands and children. To achieve this level of social development, it was required that laws and regulations be in favour of women. During the rule of Reza Shah, new issues arose regarding safeguarding the lives of mothers and children, the maintenance of public health, and women’s affairs.

Female nurses and physicians and especially American- and European- educated missionary women, who interacted with Iranian women, also played a key role in this period. Among them was the Russian female physician Dr. Ezgenarzadeh, who married a man from Mashhad. She established a charity clinic and examined women and their children three days a week free of charge. She worked until 1314 (1935) and offered mothers advice on methods of taking care of their infants and children. For this purpose, she prepared small pamphlets to address the minor complications of motherhood.20

These activities motivated Iranian women and political leaders towards progress and development. Dr. Speer, an American physician stated,

[W]hen the Shah made his notable visit to the Central Mission Hospital in Teheran, he asked particularly that the lady doctor should be pointed out to him, exclaiming, “Is it possible for a woman to have enough knowledge to become a doctor?” Upon being told that the slender, blue-eyed person, Dr Mary J. Smith, was she, he held out his hand, saying, “Feel my pulse and tell me the state of my health.

It happened that in 1906 the Iranian wife of the prime minister urged him to stipulate, when he was signing the permit of the American Missionary Hospital in Teheran, that no women should be allowed. After she herself was ill and taken for care there, she gave a sum of money for the establishment of a woman’s ward. This gift was duplicated by Mrs McCormick of Chicago, so the woman’s ward in Teheran came into being. It was maintained as a distinct unit of the medical work in Teheran until ill health compelled Dr Smith to resign, when the women’s work became part of the general work of the hospital.21

The newspapers of the Reza Shah era mentioned that there were more than three thousand female physicians in Britain, in order to introduce Iranian women to the efforts of women in other countries and encourage them to promote their social and educational status.22 Coursebooks were the most essential and effective means of applying the policies of the government regarding women’s affairs. They were compiled to create a new culture among young girls to improve women’s long-term health conditions. For this purpose, the models of other countries regarding women were used:

In civilized countries, there are several societies and associations with the participation of mothers and mature girls, helping other deprived mothers and taking care of poor children ... women’s charities are divided in most countries into four important classes, and each class has clearly defined tasks and duties. One of these classes is in charge of preparing clothing and garments for the infants of poor mothers given to them free of charge. Another class is responsible to prepare milk technically for those mothers who are not able to or are forbidden from breastfeeding. They take care of the infant by observing hygienic principles. The third class is in charge of hospitals and pharmaceuticals for infants. Deprived mothers refer to these hospitals if they feel their child is sick. The fourth class takes care of orphans and homeless children.23

After the Constitutional Revolution, Dr. Mary Smith served for several years in the public hospital of Tehran. However, during the rule of Reza Shah, health programs and the methods of administering hospitals were changed to nationalize the field of health and medical treatment, therefore no foreign physician or medical staff was authorized to work in Iran. From that time, Iranian staff were for the first time in charge of the supervision and management of the health affairs of their own country. For the purpose of this policy, Iranian-educated physicians increased in number.

In 1335q (1917), Dr. Amir Khan Amir A‘lam felt the need to establish a specialized hospital for women. Until that time, there was no hospital to admit women and children independently. Dr. Amir A‘lam did his best to build a hospital on land presented to him by the government. One part of this building was used as the central section, and the other parts were assigned to become a clinic and pharmacy.24 Moreover, as no male physician was authorized to examine a woman, a French midwife was responsible for examining women, and for several years she was in charge of the management of the hospital. The first midwifery school in Iran, the Amuzeshgah-e Mama’i, was established at this hospital, which was composed of two separate wards assigned to the treatment of children and women, and training of service providers for deprived women.25

In early 1337q (1919), the women’s hospital was inaugurated officially, presided over by Dr. Mohazzab al-Dowleh, and began operation with a budget of 200 tumans provided by endowment income (owqaf).26 Fifty-nine female patients were hospitalized in this hospital by the end of the same year. Additionally, ten students of the Teacher Training School (Dar al-Mo ‘allemat) were trained by Madame Frascina for midwifery. In late 1337q (1919) when Mirza Ahmad Khan Naser al-Dowleh Badr was minister of education, the Ecole Franco-Persane for girls changed to the Dar al-Mo‘allemat and it was decided that ten students of this school would be trained for midwifery in the women’s hospital three days per week. The educational program of the Dar al-Mo‘allemat consisted of a four-year education after obtaining the certificate of the sixth grade of elementary school.

Dr. Amir Khan Amir A‘lam was aware of the necessity of establishing maternity hospitals; therefore he took steps to educate and train proficient midwives, who were able to help mothers give birth to their children based on scientific and medical principles of gynaecology. He believed that maternity hospitals could be centres of progress in the profession of medicine, since in such hospitals the students of natural sciences could realize through practice the more abstract aspects of delivery.27 In a lecture on this subject, Dr. Amir A‘lam introduced maternity hospitals as centres for the education of knowledgeable and competent midwives. He also wrote,

The lack of such institutions, which were supposed to be established at least in the capital, explains why thousands of pregnant women and sometimes their babies lost their lives in the hands of ignorant and uneducated midwives. Unfortunately, in addition to the lack of maternity hospitals, the lack of health establishments was another cause of the chaos in the health sector of Iran.28

In 1337q (1919), when the Medical Department of the Dar al-Fonun was presided over by Dr. Mohammad Hoseyn Khan Loqman Adham, the medicine class changed its name to “medical school.” The school became administered separately and was assigned to an independent location. It was reformed and attention was paid to the field of midwifery, which had not been previously taught:

[F]ourthly, establishment of Iranian medicine and midwifery, since Iranian medicine, therapeutics, and ... psychology, which was for an Iranian physician an important means of practice, have not been taught for several years, as some years ago the shortage of foreign pharmaceuticals caused severe problems. A course of midwifery and microbiology, which previously had no instructor, will be taught by Dr. Yunes Khan three days per week in the Medical School (Madreseh-ye Tebbi). Whereas most physicians studying in Iran have not passed the course of midwifery, it is required that physicians have full knowledge of this discipline, therefore, this course has been incorporated into the program.29

Before the rule of Reza Shah, it was not common for midwives to study and most of them were illiterate. Indeed, many held superstitious views about birthing rituals. Because of this ignorance, midwives who were unaware of the scientific principles of delivery failed to save many mothers and infants during labour. If a baby was born feet first and unable to breathe, the midwife who was unaware of mouth-to-mouth resuscitation and instead used superstitious methods caused the infant to suffocate and die. Severe psychological traumas arose out of the deaths of children. The application of unsterile instruments and contamination of parturition space and midwives’ hands were other factors that led to infection, haemorrhage, and death of mother and child.

When during the Reza Shah period reforms were carried out to modernize Iran, the municipality was the executive organization assisting the government to establish centres and institutions to realize the objectives of such plans. One of the responsibilities of municipalities was to construct urban wastewater systems through proper piping, public toilets, and clean streaming water in the gutters of streets and alleys, since people thought that running water was not polluting.

To provide safe and clean water, the decision was made to construct sanitary pipelines, which was vital to the improvement of health conditions, since such pipelines could supply potable water for all uses, including washing vegetables and other foodstuffs.30 All these issues were the responsibility of municipalities. For the purpose of improving the social and health situation of all people, and saving the lives of pregnant mothers from the ignorance of uninformed midwives, the municipality charted important plans and established a midwifery school, whose first program was completed in the academic year 1311-12 (193233). The first 18 female graduates of this school fulfilled the requirements of this field of study and began to provide the women of Tehran with health and welfare services.31

The most important objective of Reza Shah’s government was to establish special institutions and organizations to protect the lives of infants, like the numerous institutions of various foreign countries, which were established under different titles but with a unified intent to decrease the annual mortality rate of neonates, fight ignorance, and assist the deprived classes of society. Through lectures delivered to the public and essays published in newspapers, this goal was approached by supervising and promoting public health. For example, after the establishment of the Organization for Public Enlightenment (Sazman-e Parvaresh-e Afkar), several lectures were delivered on the subject of under-population in developing countries. One of the lectures published in the newspaper stated,

In social sciences and health sciences, there is no scale better than the number of newborns to assess a nation’s development. Any increase in the number of neonates improves the progress of the nation and helps people to protect themselves against the endless conflicts of everyday life. You are perhaps aware how the other countries try to increase their population and how much money they spend for this purpose. The increase in the population of the capital is an index of the increasing progress of our country. Our capital will be soon one of the most populous capitals of Asia. However, this increase in population is due to immigration from other cities to the capital; but when we claim that the population has increased by 25% during the past six years, we mean something else. The large number of births in Iran is subject to economic progress, whose effects have been observed in the capital sooner than in other regions in Iran. Certainly, following this economic movement, the number of newborns will increase and after provision of security and prosperity, the population will increase.32

According to the objectives of the government, these institutions should mainly aim to fight against ignorance and assist the poor and deprived classes of society. The most effective means of saving the lives of newborn babies were the establishment of centres to protect pregnant women free of charge, centres to examine babies and toddlers, orphanages for young infants throughout the country, distribution of milk among poor infants, presentation of lectures and conferences on health issues to introduce rich and poor people to the importance of hygiene, proper feeding methods, and infant care, and finally the ratification of the law on mandatory vaccination against smallpox and free public examinations of infants.

Gradually, along with the policies of the government to render social reforms and provide social services, intellectual and wealthy families began to go to hospitals to treat their diseases and give birth to their children. Moreover, the institute of the Dar al-Mo‘allemat, which was established thanks to the efforts of people like Dr. Amir A‘lam to teach specifically female students, used the knowledge of all scholars and was reasonably effective in the reduction of the mortality rates of newborns and women in labour. At first, Madame Frascina was the instructor of the midwifery school. At the beginning, people were hesitant to use the facilities, and the number of pregnant women and patients initially referred to the hospital was less than ten. Every 15 to 20 days only one or even no childbirth happened. After Madame Frascina, Dr. Dremsen, Dr. Pen, and Dr. Sarkisian were appointed respectively to administer the hospital and instruct the students of the Dar al-Mo‘allemat.33

The school of midwifery had no codified bylaws. The educational program was for three years, and the applicants had to hold a certificate of sixth grade (elementary school) and know the French language. Therefore, most students of the school of midwifery were graduates of the Dar al-Mo‘allemat. After the codification of bylaws for medicine, pharmacology, and midwifery in 1307 (1928), it was ordered that only the students who had completed the third grade of high school could enrol in the school of midwifery. Two years later, in 1309 (1930), the parliament passed the articles of association and bylaws of the midwifery school, and this school, which until then had been a branch of the school of medicine, was affiliated with the General Health Department (Edareh-ye Sehhiyeh-ye Koll-e Mamlekati). It was then ordered that only those students who had completed the fifth grade of high school could enrol in the school of midwifery. Moreover, a specified program was prepared for the field of study of midwifery. Dr. ‘Alim al-Molk Farahmandi, who was the head of the school, was appointed officially by the General Health Department as the principal of the school of midwifery. Dr. Bakhtiyar, Dr. Jahanshah Saleh, and Dr. Gholam Hoseyn Mosaddeq were appointed in 1313 (1934), 1315 (1936), and 1317 (1938) respectively.

The establishment of any scientific and educational centre requires planning, the selection of educational and testing materials, a method of recruiting instructors and admitting students, etc. Considering the attitude of the government towards social issues, this need in the field of the study of midwifery was reflected in the books and journals of that time:

The civilized nations of the world respect mothers and provide them with benefits and many advantages. The title of mother is one of the most precious titles. The highest rank in any formal or informal meeting is assigned to mothers. This respect conferred upon mothers is because they are in charge of educating the future generation of each nation. It can be claimed that the good fortune or misfortune of any nation is the result of the behaviors and education that are provided by mothers to the members of this nation. Mothers have more effects on their children than fathers and teachers. Therefore, wise mothers endowed with artistry give birth to great men.34

One of the most important measures set forth in the above publications specified “first aid stations and hospitals in many cities of Iran, especially in Tehran, establishment of health centres by municipalities and State General Department of Health, establishment of maternity hospitals, orphanages, establishment of women and children hospitals, erection of midwifery schools and nursing schools, whose annual graduates can serve people.”35 Ratification and enforcement of medical law was another step taken to regulate the health affairs of Iranian society. In principle, this decision not only covered the profession of medicine, but also other fields of study relating to the field of health. The government paid particularly close attention to the practice of midwives. The documents addressing these issues prove this claim. All students of midwifery abroad had to legalize their education documents through the Ministry of Education to be permitted to work in Iran, and in some cases their diploma had to be certified by the Ministry of Foreign Affairs to receive their professional permit; otherwise, they were not allowed to practice as midwives, and in case of practicing without such formalities, they could be legally prosecuted and their diploma deemed null and void. Considering the importance of these documents in explaining the activities of the midwifery school and the education of modern midwives, we studied the documents of the National Archives of Iran regarding the laws and regulations on midwifery, the articles of association and bylaws of the government, and individuals applying for the study of midwifery. The results of this survey follow:

  • 1. On 14 Mizan 1303 (6 October 1924), a letter was sent by the Department of Medicine to the Ministry of Education, stating “as some foreign and Iranian midwives practice without any medical diploma, therefore it is requested that all midwives be notified through newspapers to refer to the school of medicine and submit their supporting documents in order to register their names. Those individuals with medical diplomas will be distinguished and the others shall be prevented from practicing using the title of doctor.”36
  • 2. On 3 Qows 1303 (26 October 1924), a letter was sent by the Department of Medicine to the Ministry of Education requesting that the following decisions regarding the admission of students to the school of midwifery should be enforced:

[A]ccording to the letter no. 7338,37 and based on the decision made by the High Council of Education (Shura-ye ‘Ali-ye Ma‘aref), the applicants to midwifery school shall have the certificate of the third grade of high school, and any student who knows the French language is required to pass the examinations of the first grade of high school. Mr Amir A‘lam has the same opinion and states that these applicants shall have the certificate of the third grade of high school, or pass the required examinations.38

  • 3. Courses of midwifery were divided into two levels: preliminary and practical. The courses of the preliminary level were anatomy, physiology, health, medical principles of the Soviet Union, pharmacology, midwifery, women’s diseases, children’s diseases, maintenance of maternity hospital and infants, bacteriology, anatomy of pathology, surgery and therapy, principles of treatment and general supervision of patients, dermatological and genital diseases, and social information. The practical level covered all practical courses such as vaccination, chemistry and pharmacy, writing prescriptions, dressing wounds, orthopaedics, and first aid. Since most educated midwives were graduates from abroad and above all from Russia, the teaching materials were selected based on the medical principles of the Soviet Union.39
  • 4. Teaching regulations of the discipline of medicine and other disciplines related to medicine such as midwifery had to be enforced in the framework of the internal policies of modern institutions such as the Women’s Association (Kanun-e Banovan). According to the recommendation of the Ministry of Education, the Kanun-e Banovan was asked to pay attention to the following in amending the program of women’s schools: “programs of the different branches such as the technical-vocational branch, dressmaking, painting, midwifery, and nursing should be arranged by the women of the association themselves.” According to this order, the Women’s Association would prepare related programs and submit them to the Ministry of Education for the approval of the High Council of Education. Moreover, it was ordered that the students of medicine had to pass the theoretical and practical examinations in order to be eligible to receive the medical diploma. This order was applicable for those women and students who studied midwifery.40
  • 5. Several regulations and bylaws were passed pertaining to education in the school of midwifery and conferring diplomas; for example, it was ordered that the midwifery license had to be issued only under the following conditions:
    • • Obtaining a certificate.
    • • The applicants shall enroll in the school of midwifery; after education and receiving diploma, they are allowed to apply for the license of midwifery.
  • • Not only midwives who practice by experience rather than education are entitled to study midwifery to receive the midwifery license, but also volunteers are allowed to take the examinations held by the Department of Examinations (Edareh-ye Emtehanat) in accordance with the program of the school. If they pass the courses, they can receive the midwifery license.41
  • 6. After the abovementioned programs, the entrance exam of the midwifery school was held on 29 Hut 1302 (20 March 1924) for the female students of the women’s hospital.42 The following information is of particular importance:
    • • Applicants consisted of four women named A‘lam al-Moluk, Zinat Khanom, ‘Aziz al-Moluk, and Iran Khanom A‘lam.43
    • • Other students, who were prepared to take the exam, were asked to wait until after the return of Madame Dremsen from a trip.
    • • A‘lam al-Moluk and Zinat Khanom were permitted to receive the provisional certificate, until the final diploma was issued, but Ms. ‘Aziz al-Moluk Khanom was required to assist two women in labour to deliver their children, and Iran Khanom had to assist three women in order to be permitted to receive their diplomas.44
  • 7. The application for the establishment of a midwifery school in Tabriz in 1309 (1930) is worth mentioning here. According to the existing documents, Dr. Mohseni Azar, who was the physician of the Pahlavi hospital of the Red Lion and Sun Society in Tabriz and his wife Ms. Tanasob Mohseni Azar, midwife of this hospital, applied to establish a midwifery school in the province of Azerbaijan with the following reasons:45
  • • Providing the people of Azerbaijan with midwifery services and meeting their needs through the establishment of this centre.
  • • Making the head of the Department of Education (Edareh-ye Ma‘aref) of Azerbaijan Province familiar with such institutions, since they are of great service to the public.
  • • The physician (i.e. Dr. Mohseni Azar) is obliged to establish a private maternity hospital for the practical education of students.

The Ministry of Education replied to the Department of Education of Azerbaijan Province, which sent the application of Dr. Mohseni Azar and attached documents to the capital, as follows: “For the time being, the establishment of a midwifery school in Tabriz is not permitted.”46

8. On 8 Mehr 1312 (30 September 1933), a letter was sent from the Ministry of the Interior and State General Department of Health to the Ministry of Education, which belonged to the Personnel Department (Edareh-ye Personel). This letter requested that, considering the fact that there were not sufficient midwives with a diploma in the provinces, skilled midwives who had practical experience for many years but not the required diploma should be permitted to continue practicing, under the condition that they would not engage in any medical teaching or surgery and, in case of unnatural parturition, refer the woman in labour to a proficient physician.”47

The minister of education replied,

The opinion of this ministry is that individuals engaged in medical professions such as physicians, midwives, dentists, and pharmacists shall continue to practice, provided that they are equipped with regular education to prevent any problem for the public. If that department bears the responsibility of public health, ... it can take necessary measures through its health officials working in different cities and provinces.48

  • 9. On 8 Mehr 1312 (30 September 1933), it was emphasized based on Article 1 of the medical law that unauthorized midwives were not permitted to practice midwifery.49
  • 10. If the practicing midwives would not improve their educational status, they would be prevented by the officials of the State General Health Department from practicing and their license deemed null and void. For example, according to document no. 12, a midwife named Khanom Qajari was prevented from obtaining a midwifery permit due to defects in her diploma, and her documents were returned to her until the remedy of such defects: “Regarding the diploma of midwifery, it is required that a comprehensive decision will be made to prevent any problem in the future. Local physicians (atebba-ye shahr) are not authorized to issue certificates of midwifery. The examinations shall be officially valid. Therefore, the diploma of Khanom Qajari is returned in order that you, after consideration and in conformance with the proposed new regulations, send it again.”50
  • 11. Another fact discovered during this study of midwifery documents was the scope of activities by midwives. As mentioned above, midwives were not permitted to engage in medical practices or prescribe medicines like physicians.51 Moreover, in case any problem occurred in relation to parturition and women in labour, midwives were not allowed to engage in any type of surgical operations. Based on this decision, the higher education section of the Health Department of Tehran stipulated, “according to the received report, some midwives perform surgery, while they are only allowed to practice simple midwifery and are not authorized to do such operations. It is ordered that the first aid stations of every neighbourhood receive a commitment from the midwives, that in case of the necessity for any surgical operation, the midwives would hold officially confirmed certificates. If this order is breached, the individual engaged in surgery is deemed responsible.”52
  • 12. A survey of the historical documents regarding the applications for midwifery school examinations and for the extension of the midwifery diploma indicates that the number of applications increased from 1311 (1932) to the second half of the year 1314 (1935). The government paid close attention to this process and midwifery licenses were conferred based upon the following procedures:
    • • The applications were processed based only on legal principles and in accordance with the government’s legal decrees.
    • • The priority of the government was to centralize examinations in terms of time, manner of holding the examinations, educational level, and instructions.
    • • The personal conditions of the applicants attending examinations, such as pregnant applicants, the degree to which they did or did not attend classes, and even excused or unexcused absences were observed.
  • 13. The study of these documents from the Reza Shah period reveals the objectives of the government on the one hand and the effects of the ideas of intellectuals and female social activists on the other hand. For example, Ms. Tarbiyat, the head of the Women’s Association stated,

to prevent the consequences of unemployment, which is the main cause of any maliciousness among our daughters, it is required that we train them in manual arts and crafts such as painting, dressmaking, typing, bookkeeping, etc. and assist them to be admitted in the faculty of medicine and its branches such as dentistry, pharmacology, midwifery, nursing, etc. ... The minister of education has acknowledged in one of the meetings of the Women’s Association that women are required to pass senior school in order to engage in any occupation or industry. Therefore, it is necessary that the second cycle of our female high school is assigned to the professions and in these senior schools, female students can study different types of craft such as dressmaking, painting, nursing, midwifery and other crafts suitable for women.53

14. Another important point is that there were foreign or Armenian-Iranian women engaged in midwifery in Iran for many years. These midwives, who had either become Iranian citizens through marriage or had simply developed an interest in Iran, were eager to stay and work inside the country, even after the government had started to implement new laws that barred foreign physicians from practicing in Iran in the 1930s. On the other hand it is interesting to note that most of these women and even Iranian girls, who prior to Reza Shah’s reign had enjoyed an academic education in this profession, were graduates of the universities and schools of Yerevan, Baku, Tbilisi, or elsewhere in the Caucasus, or Istanbul. A few of these women had graduated from the Beirut midwifery school. In addition, one of them had studied in Warsaw. There were also British women who had studied in London. These midwives, 21 Iranians and 6 foreigners, applied to receive the midwifery license by submitting their diplomas after the nationalization of health fields and the ban on the practice by foreign subjects. They encountered difficulties during the processing of their applications, which proves the exactness and seriousness of the government and reflects the diligence of these women seeking to exercise their social and working rights. Certainly, there were also breaches of rules and regulations. However, the changes in this arena shall be regarded as one of the most important achievements aiming to prevent the mortality of mothers and children arising from the ignorance of traditional midwives who failed to observe modern health principles.

 
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