Women-who make up 52 percent of the Texas population-are the major consumers of health services, the majority of health caregivers, and the traditional caretakers of family health. Women's health care and particularly the conditions under which women give birth have ramifications far beyond the health and well-being of the individual mother and child; they frequently serve as a gauge for society's conscience and faith in the future. Texas women have always had a nurturing role in matters of health: as women, wives, or mothers, they were responsible for maintaining a healthy environment, preventing illness, maintaining wellness, and treating the sick and injured. Among the nomadic populations and in agricultural villages, women cared for children, prepared food and clothing, and maintained the home. In the late seventeenth century the wives of Spanish soldiers were the first European women to settle in Texas in the presidios that supported the Spanish missions. Women in Spanish Texas continued to fulfill the chief roles of homemaker and mother amid the rigors of frontier life. Midwifery was important during this period, when women gave birth at home aided by friends and relatives. In 1809 Governor Manuel María de Salcedo ordered that all midwives register with the city council, pass an examination, and receive a license. This was an attempt to decrease infant mortality caused by the ignorance of women posing as midwives. Isolation from other women frequently removed the women of the Texas frontier from their sources of support, advice, and care when faced with illness. The major treatment in outbreaks of smallpox and cholera was Indian or Mexican folk medicine with prayer. Jane Long was probably the first Anglo-American woman to give birth in Texas. She, her daughter, and a slave named Kian spent the winter of 1820–21 on Bolivar Peninsula while James Long was on a military mission against Spanish forces. Kian successfully nursed Mrs. Long through both childbirth and illness during that winter. In 1850 men outnumbered women by 15,704. The housekeeping that was expected of Texas wives and mothers included care of the sick. During the turbulent decade of the Texas Revolution and Republic of Texas, women ran the farms, ranches, and plantations during their husbands' absence and organized the evacuation of their families as the Mexican armies approached. Susanna Dickinson accompanied her husband to the Alamo, where she and Andrea Castañón Villanueva served as nurses. Women in antebellum Texas, faced with the inconvenience and expense of getting a physician, turned to domestic medicine or alternatives to mainstream medicine. Women within families, particularly plantation owners' wives, assumed primary responsibility for family and slave health, nursing, dosing, and deciding when to call for professional help. Many black women, both slaves and free, also provided nursing care and midwifery services, and concocted drugs.
Texas women had access to a wide variety of domestic-medicine manuals. Popular journals and local newspapers were filled with domestic advice, remedies, and advertisements for cures. The Southern Lady's Companion ran articles on health and healing of special interest to women. Stores were filled with patent medicines claiming to cure ailments from cancer to coughs. From Lydia E. Pinkham's Vegetable Compound to Leidy's Female Pills, patent-medicine advertising was often directed to women, both as consumers and caretakers of family health. Bolstered by the therapeutic confusion and reform spirit of the nineteenth century, and mirroring the notion of frailty and invalidism among middle and upper class women, patent medicines claimed cures for a multitude of female disorders. Patent medicines also provided women an alternative to orthodox treatments they considered harmful and a sense of bodily selfcontrol. Some nineteenth-century physicians were active in the effort to educate consumers against dangerous or fraudulent remedies. The Texas Health Journal, founded in Dallas in 1888 and the official organ of the Texas State Sanitary Association, characterized itself as "a monthly magazine devoted to preventative and state medicine and the exposure of medical fraud, secret remedies and quacks." The strict regulation of patent medicines that developed was accompanied by increased reliance on doctors and therefore a loss of females' ability to manage their own and their families' health. As the nineteenth century evolved, it became fashionable for male physicians in the Northeast to attend middle and upper class women during childbirth. Women in Texas also invited male physicians into their birthing rooms to take advantage of the shortened labors and painless childbirth they promised. Physicians were also called by friends or midwives when complications developed. Once there, the physician validated his presence through his practices. Such "meddlesome midwifery" was not without opponents, and Texas physicians themselves debated the pros and cons of anesthetics, forceps, and other obstetrical interventions. The rural character of the state and scarcity of regular physicians, however, made the midwife a necessity. Some Texas physicians probably enlisted the aid of midwives to assist them in covering their rural practices, and some midwives received instruction and advice from local physicians. Midwives were protected in the first medical practice act of Texas passed in 1873. But later, at the 1881 meeting of the Texas State Medical Association, the assembly opposed the part of the act permitting "ignorant and irresponsible females, without any evidence of qualification, to practice midwifery." Galveston had a training program for midwives in 1890. "Midwife" was listed as an occupation in the Galveston City Directory from 1870 through 1919. The female midwife remained the major birth attendant for Texas women at least through the turn of the twentieth century, when 75 percent of births in Texas were attended by midwives.
Nurse-training schools in Texas developed in the nineteenth century, when trained nurses established a public role for women that was fashioned from the domestic sphere and brought cleanliness, order, and respectability to the hospital. Catholic congregations of women supplied the first trained nurses in Texas; they staffed numerous hospitals, where nursing was eventually formally taught (see CATHOLIC HEALTH CARE). The first nursing school in Texas was John Sealy Hospital Training School, which formally opened in March 1890 with two students and was followed by six more nursing schools in the next fourteen years. Domestic virtues such as duty and self-sacrifice were a recurring theme in training schools as student nurses faced demanding physical labor, long hours, little leisure time, and exposure to serious illnesses. Nursing education became the bridge by which women extended their traditional domestic role of caring for the sick into the public world of work. Before 1891 physicians trained in Texas received their education in proprietary medical schools and their training through an apprenticeship system. Formally trained female physicians were quite new when they were first discussed in Texas publications in the mid-nineteenth century. Those who attempted to follow Elizabeth Blackwell, who had received her medical degree from Geneva College in 1849, were often frustrated. They frequently met opposition similar to that expressed by Fanny Fern in the March 26, 1853, issue of the Standard: "FOR MYSELF, I prefer prescriptions written by a masculine hand; shan't submit my pulse to anything that wears a bonnet." Others, such as Mrs. Sarah J. Hale, thought that women were "better qualified by nature to take charge of the sick and suffering...that mothers should know the best means of preserving the health of their children," and "that female physicians are the proper attendant for their own sex in the hour of sorrow." Thus the debate over women in medicine evolved: either women had no place in medicine because they were female, belonged in medicine precisely because they were female and had important qualities to impart, or belonged in medicine in spite of the fact they were female. Early Texas female physicians trained outside Texas include Dr. Sofie D. Herzog, who practiced in Brazoria from the late 1880s until her death in 1925; Dr. Margaret Holland, the first woman to practice medicine in Harris County, whose career lasted from the 1870s to 1921; Dr. Juliet Marchant, who practiced in La Porte from 1893 to 1929; and Dr. Minnie Archer, who practiced in Houston from 1894 to 1912. Other Texas doctors trained outside the state included Ellen Lawson Dabbs, Grace Danforth, and Frances (Fanny) Leak. In 1897 Marie DeLalondre Dietzel became the first female graduate of the oldest medical school in Texas, the University of Texas Medical Branch at Galveston, which opened in 1891. Female physicians continued to graduate from that institution, an average of one every other year, until 1920. Dr. Marie Charlotte Schaefer graduated in 1900 and after postgraduate work at the University of Chicago and Johns Hopkins, became the first female member of the faculty in 1901. She headed a department chair from 1912 until her death in 1927. The university also offered women a degree in pharmacology. Political activist Minnie Fisher Cunningham (1901) was one of the first women to earn that degree.
In late nineteenth-century Texas, women began to influence health concerns and social reform through political action and women's organizations (see WOMEN AND POLITICS). The suffrage movement of the late nineteenth century strongly advocated equal access to medical education for women. The movement was also intertwined with the popular health movement, which emphasized hygiene and dress reform. Texas women's clubs were a force in the debate over prohibition, anti-tobacco legislation, child labor legislation, pure-food-and-drug legislation, improvement of public health, sanitation, licensing standards for nurses, improved health-care facilities, and other health measures. In 1912 the Texas Medical Journal instituted a "women's department" conducted by the wife of the editor, Mrs. F. E. Daniel, and other physicians' wives, female physicians, and consumers. Mrs. Daniel's purpose was to devote a "few pages" of each issue to "articles of especial value to my sex." The department continued through 1914 and provided information on social issues, public health problems, and women's health. Although far from radical, the articles encouraged women to ask interesting questions of their physicians, such as "why so many joyous healthy girls become invalids after marriage?" and "why so many children are born blind?" The women medical students of Texas were as forward-looking in the arena of women's rights as the suffragists or the women who broke into medical education several decades earlier. The fifteen female students at UTMB in 1912 lobbied to have the position for the secretary-treasurer of the student association to be a permanent female office. Their efforts were defeated by a vote of 103 to 26. However, Violet H. Keiller, Class of 1914, was elected secretary-treasurer by acclamation. She was the daughter of a member of the original faculty and later joined the staff of the medical school. In 1914 the graduating class consisted of four females and forty males, and the top two graduates were women. In 1916 the women medical students at UTMB invited all the women physicians of Texas to a meeting. The Texas State Journal of Medicine listed the names of forty-nine women eligible to attend. The April 1916 issue of the Journal was devoted to Texas women of medicine. Contributors included Mary C. Harper (San Antonio), Ethel Heard and Violet Keiller (Galveston), Minnie Lee Maffett (Dallas), and Martha Wood (Houston). In 1920, Dr. Ethel Lyon Heard, a member of the faculty at UTMB, was appointed as the physician for women at the University of Texas. Almost thirty years after the first female graduated from UTMB, women were still encountering obstacles to their role in medicine. In 1926 the hospital board of John Sealy Hospital in Galveston, after vigorous debate, decided that Misses Edith Bonnett and Frances Van Zandt would be allowed to serve internships, though with certain restrictions. Some of the hospital staff considered work in the male genitourinary division particularly objectionable to women, and expected that the men in this division and the marine ward would not allow women interns to treat them. The women agreed to have other work substituted during those two six-week terms. Since the hospital would need to hire two senior students to fill in for them, the women stated they would not expect the hospital to pay them room and board during those two months.
The late nineteenth and early twentieth century brought a massive attack waged by physicians on the character, cleanliness, integrity, training, abilities, and safety of the midwife. Texas physicians echoed this attack in their journals, although some admitted that midwives were still necessary. The early twentieth century was a period of struggle for professional cohesion, high standards, and the exclusion of alternative practitioners among medical professionals in general. Obstetricians were attempting to expand their influence and raise their status. To eliminate the economic competition of the midwife and general practitioner and to establish their superior expertise, obstetricians defined pregnancy and childbirth as pathologic and themselves as the only safe, successful and qualified attendants. The substitution of scientifically trained specialists and the hospital for the lay midwife and the home removed childbirth from the female domestic sphere and placed it in the hands of "experts" in the male-controlled professional sphere. In Galveston, with an abundance of physicians and hospitals, the percentage of midwife-attended deliveries decreased from 35 percent in 1910 to 2 percent in 1923. The campaign to eliminate the midwife was less successful in rural Texas, however. In 1924, the Bureau of Child Hygiene of the State Department of Health estimated that 4,000 midwives were practicing in Texas and, at least in certain eastern and southern counties, midwives were attending over 50 percent of the births. The bureau concluded that many of these midwives "have no training, not even in the simplest rudiments of surgical cleanliness" and recommended licensing and training to remedy the problem. The twentieth-century public-health movement was effective in analyzing, publicizing, and helping to remedy many of the deficiencies of health care in America. In the effort to improve maternal and infant morbidity and mortality the focus was placed on the expertise of the obstetrician. Midwives were generally recognized only as a stopgap measure by health reformers, and efforts to improve their practice were meager. Training for midwives was provided by public-health nurses in Texas through money allocated by the 1921 Sheppard-Towner law, the first federal legislation to provide federal dollars to states to improve the health of mothers and children. Opposition to Sheppard-Towner was vigorous. Physicians opposed it as socialized medicine or as government intrusion into the business of states and the domestic life of American families. Consequently, its provisions were allowed to lapse in June 1929 and none of the fourteen bills introduced to reinstate it were approved. If the passage of Sheppard-Towner was the culmination of the Progressive Era women's-health movement, its defeat reveals the movement's declining effectiveness. The conservative political climate, continued opposition of organized medicine, recognition that women did not vote as a bloc, and inability to maintain a sustained women's-health movement were factors contributing to the bill's demise.
The first half of the twentieth century found the majority of women in Texas still the keepers of the home, whether that home was on a cotton farm or in an oilfield. About a third of Texas women had entered the workforce by 1930, including a growing number of married women, but most were confined to occupations seen as "women's work" (clerical jobs, retail sales, teaching, nursing). The world wars brought women into traditionally male-occupied jobs. Female nurses from Texas contributed to the war effort in both wars. During World War II an estimated 51 percent of Texas nurses were serving in the armed forces or private war industries. An extreme shortage of nurses resulted. Other female-dominated jobs in allied health sciences developed as further evidence of the specialization and professionalization of women's nurturing qualities. Physical therapists and occupational therapists have been active in Texas since the 1920s. But the legacy of midwives in Texas did not end in the mid-twentieth century. In Texas in 1970, midwives attended slightly more than 3 percent of live births. In 1983 the Sixty-eighth Legislature enacted the Lay Midwifery Act, which mandated the annual identification of persons practicing lay midwifery, delineated the scope of practice, and provided for voluntary educational preparation for those attending births. With the addition of certified nurse midwives in Texas, almost 5 percent of Texas births in 1989 were attended by midwives. This small but important resurgence in midwifery is illustrative of the different perspective of the feminist health movement of the 1960s and 1970s when compared with the earlier woman's health movement. No longer was motherhood seen as woman's primary destiny or the role that guaranteed her a public voice. Instead, motherhood is seen as one role among many available to women. The recent feminist health movement has also encouraged women to be an expert on their own bodies, to gain understanding of their biology without submitting to medical control. Women have been encouraged to alter the terms under which care is provided and to demand demedicalization of such functions as uncomplicated childbirth.
Women's health issues remain complex and challenging. By the 1980s the majority of mothers worked outside the home, yet they still had major responsibilities for family health, whether caring for ill children or elders or decreasing fat and cholesterol in the family diet. Women were expressing skepticism about the male-dominated biomedical model and asking why women, particularly pregnant women, are so underrepresented in clinical-research trials and why research into women's health is underfunded. Women consumers of health care were attempting to understand and shape that care in a way that recognized the larger context of their lives. Whether as female AIDS activists, in foundations such as the Houston-based Susan G. Komen Breast Cancer Foundation, or Right-to-Life or Pro-Choice groups, women were becoming more active in influencing the direction of their health care. See also HEALTH AND MEDICINE, MEDICAL EDUCATION.