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Reconsidering maternal mortality in medieval England: aristocratic Englishwomen, c. 1236–1503

Published online by Cambridge University Press:  27 July 2020

Rachel Podd
Rachel Podd*
Affiliation:
Department of History, Fordham University
*
*Corresponding author. Email: [email protected]
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Abstract

The characterisation of medieval childbirth as profoundly dangerous is both long-standing and poorly supported by quantitative data. This article, based on a database tracking the reproductive lives of 102 late medieval aristocratic Englishwomen, allows not only for an evaluation of this trope but also an analysis of risk factors, including maternal youth and short birth intervals. Supplemented with evidence from medieval medical tracts and osteoarchaeological data related to pubertal development and nutrition, this study demonstrates that reproduction was hardly the main driver of mortality among elite women.

French abstract

French Abstract

La mortalité maternelle en Angleterre médiévale revisitée: le cas des aristocrates anglaises, circa 1236–1503

On a toujours dit qu'il était profondément dangereux d'accoucher à l’époque médiévale, une opinion mal étayée par des données chiffrées. Cet article, qui s'appuie sur l'analyse longitudinale de l'histoire reproductive de cent deux aristocrates anglaises de la fin du Moyen Age, permet d’évaluer cette idée reçue. De plus, il autorise une analyse des facteurs de risque comme l’âge précoce de la mère à la maternité et la présence d'intervalles intergénésiques courts. Complétée par des exemples tirés de traités médicaux datant de cette période et des observations ostéo-archéologiques relatives au développement pubertaire et à la nutrition, cette étude démontre qu'enfanter n’était guère le principal facteur de mortalité chez les femmes de l’élite.

German abstract

German Abstract

Müttersterblichkeit im mittelalterlichen England neu überdacht: Aristokratische Engländerinnen, ca.1236-1503

Die Einschätzung, dass Entbindungen im Mittelalter hochgradig gefährlich waren, hält sich ebenso hartnäckig wie sie durch quantitative Daten kaum gestützt wird. Dieser Aufsatz, der auf einer Datenbank fußt, in der die Reproduktionsgeschichten von 102 adligen englischen Frauen im Spätmittelalter nachverfolgt werden, erlaubt nicht nur eine Überprüfung dieser Vorstellung, sondern auch eine Analyse der Risikofaktoren einschließlich jugendlicher Mutterschaft und kurzen Geburtenintervallen. Ergänzt durch Belege aus mittelalterlichen Medizintraktaten und osteoarchäologische Daten zur Pubertätsentwicklung und zur Ernährung zeigt diese Studie, dass für Frauen der Elite die Reproduktion kaum der hauptsächliche Mortalitätsfaktor war.

Type
Research Article
Information
Continuity and Change , Volume 35 , Issue 2 , August 2020 , pp. 115 - 137
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Copyright
Copyright © Cambridge University Press 2020

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References

Notes

1 The search ‘how many medieval women died in childbirth’ brings up a variety of blogs, articles and essays that characterise the reproductive experience as incredibly dangerous, though hard evidence to support these claims proves elusive. Sara Bryson's article in Tudor Society asserts that one in three women died during their fertile years (Sara Bryson, ‘Childbirth in Medieval and Tudor Times’, The Tudor Society, https://www.tudorsociety.com/childbirth-in-medieval-and-tudor-times-by-sarah-bryson/ [accessed 28 March 2018]. Another blog that appears as a top result, Medieval Woman, asserts that ‘many women suffered greatly and many more died in childbirth … [there was] little to relieve the stresses of childbirth other than poultices and prayer’; (Rosalie Gilbert, ‘Medieval births and birthing’, Rosalie's Medieval Woman, https://rosaliegilbert.com/births.html [accessed 28 March 2018]). Bryson cites four videos and one book, In bed with the Tudors, while the Medieval Woman entry lacks footnotes entirely.

2 Walden Abbey's monastic history, ‘Fundationis Historia’, transcribed in Dugdale (Monasticon Anglicanum: A history of abbies and other monasteries, hospitals, frieries, and cathedral and collegiate churches, 2nd edn (London, 1823), Vol. IV, 139) records the children of Humphrey with ‘Elizabethae illustris regis Angliae Edwardi’ as follows: ‘Margareta primogenital sua, apud Tinehmue sibi fuit nata; apud Knaresburgh, Humfridus filius suus primogenitus; apud Plesset, Johannes; apud Longmaban in Scotia, Humfridus; apud Caldecot, duo gemili nobiles, Edwardus et Willelmus; apud [illegible], Eneas; et apud quenden, quaedam filia de qua praedicta nobilis domina Elizabetha comitissa in puerperio mortua apud Walden sepulta est’. The exact date of her death is also noted in her psalter, British Library Add MS 24686 f.7r.

3 Benedictow, Ole Jørgen, The Black Death, 1346-1353: the complete history (Rochester, NY, 2004), 256, 267Google Scholar. Benedictow asserts that lowered female immune reactivity due to reproductive stress led to female supermortality during the Black Death. He further posits that the gendered division of labour led to increased exposure to illnesses for women. See Ole Jørgen Benedictow, The medieval demographic system of the Nordic countries (Oslo, 1993), 67.

4 For examples of charms and prayers employed by medieval women in childbed, see Hunt, T., trans., ‘A charm to be spoken during the birth of a baby, England, eleventh century’, in Skinner, Patricia and van Houts, Elizabeth eds., Medieval writings on secular women (New York, 2011), 13–4Google Scholar; Morse, Mary, ‘Alongside St. Margaret: the childbirth cults of saints Quiricus and Julitta in late medieval manuscripts’, in Cayley, Emma and Powell, Susan eds., Manuscripts and printed books in Europe 1350–1550: packaging, presentation and consumption (Liverpool, 2013), 187–206Google Scholar; Elsakkers, Marianne, ‘In pain you shall bear children (Gen. 3:16): medieval prayers for a safe delivery’, in Korte, Anne-Marie ed., Women and miracle stories: a multidisciplinary exploration (Leiden, 2001), 179–207CrossRefGoogle Scholar; Morse, Mary, ‘“Thys moche more ys oure lady mary longe”: Takamiya MS 56 and the English birth girdle tradition’, in Horobin, Simon and Mooney, Linne R. eds., Middle English texts in transition: a festschrift dedicated to Toshiyuki Takamiya on his 70th Birthday (York, 2014), 199–219Google Scholar.

5 The skeletal assemblage at the Anglo-Saxon cemetery of Raunds Furnell, for example, indicated that by the age of 35, only 29 per cent of women would still be alive compared to 54 per cent of men. See Andy Boddington et al., Raunds Furnells: The Anglo-Saxon church and churchyard, English Heritage Report 7 (Swindon, 1996), 30. Sayer and Dickinson's survey of Anglo-Saxon burials posits that up to 50 per cent of young female fatalities in the Anglo-Saxon kingdoms may have been cases of maternal mortality. See Sayer, and Dickinson, , ‘Reconsidering obstetric death and female fertility in Anglo-Saxon England’, World Archaeology 45, 2 (2013), 286CrossRefGoogle Scholar. This trend continued into the later medieval period: mortality among women interred in several cemeteries in the medieval cemetery of York also peaked between the ages of 25 and 35. Grauer, Anne L., ‘Where were the women?’, in Herring, D. Ann and Swedlund, Alan C. eds., Human biologists in the archives: demography, health, nutrition and genetics in historical populations (Cambridge, 2003), 277Google Scholar. In the recent literature, however, bioarchaeologists have proposed that this peak in female mortality between the ages of 25 and 35 is due to the linear progressions used to assess age-at-death and may not be reflective of historical reality. An alternative method using Bayesian statistics may alter the clustering of deaths between 25 and 35, though at present a reassessment of the medieval data is lacking. For an overview of the debate on determining age-at-death and the use of Bayesian prediction, see Rogers, Tracy L., ‘Skeletal age estimation’, in Blau, Soren and Ubelaker, Douglas H. eds., Handbook of forensic anthropology and archaeology (Walnut Creek, 2009), 209–11Google Scholar.

6 The data were downloaded from Roberta Gilchrist and Barney Sloane's ‘Medieval monastic cemeteries of Britain (1050–1600): a digital resource and database of excavated samples [XCLM76, XMAB85; XSME65]’, (York, 2005), doi: 10.5284/1000273 [accessed 25 March 2019]. The three nunneries analysed are the Benedictine nunnery of St. Clement, York, the Benedictine nunnery of St. Mary Nunnaminster, Winchester, and the Benedictine nunnery of St. Mary at Elstow, Bedfordshire. They were selected for their sample size, and because they were neither hospitals nor Black Death cemeteries. Excavations resulted in a total of 162 female skeletons. Excluding the 3 for which no age at death could be determined, and the 31 categorized as ‘general adults’ results in a sample of 128 female skeletons for whom age at death could be determined. Of these, 88 (68 per cent) were between the ages of 26 and 45 at death. I would like to thank Sandy Bardsley for alerting me to this resource.

Marilyn Oliva determined that the average age of nuns in the diocese of Norwich was 43 in the fourteenth century and 32 at the Dissolution; Oliva used 15 as the average age of entry and 16 as age of profession. See Marilyn Oliva, The convent and the community in late medieval England: female monasteries in the diocese of Norwich, 1350–1540 (Rochester, 1998), 46. In a more recent study of the necrology of the nuns of St. Agnes in Gorinchem, Holland, Jaco Zuijderduijn found that life expectancy decreased over the course of the fifteenth century, from 67.5 years in the first 25 years of the convent's existence to 41.6 in from 1505 to 1529. When compared to life expectancy in three male houses in England (Durham, Canterbury and Westminster), the sisters of St. Agnes fared much better, at least until the end of the fifteenth century, when life expectancy at Durham and Westminster surpassed that of Gorinchem. Prior to this, however, the crude average death rate of Gorinchem was much lower than that reported for either professional religious or secular members of English society. Zuijderduijn concludes that mortality in England was relatively high when compared to that experienced in Holland, perhaps because England was generally a less salubrious society. See Zuijderduijn, Jaco, ‘Living la vita apostolica. Life expectancy and mortality of nuns in late-medieval Holland’, CGEH Working Series 44 (2013), 1–23Google Scholar.

7 National Research Council (US) Committee on Population, The consequences of maternal mortality: report of a workshop (Washington, DC, 2000), 7.

8 Ganatra, B. R., Coyaji, K. J and Rao, V. N., ‘Too far, too little, too late: a community-based case-control study of maternal mortality in rural west Maharashtra, India’, Bulletin of the World Health Organization 76, 6 (1998), 565Google ScholarPubMed.

9 National Research Council (US), The consequences of maternal mortality, 8.

10 Ibid., 11.

11 For a general survey of birth scenes in this genre of literature, see Harris-Stoertz, Fiona, ‘Pregnancy and childbirth in chivalric literature’, Mediaevalia 29, 1 (2008), 27–36Google Scholar.

12 Finucane, Ronald, Miracle and pilgrims: popular beliefs in medieval England (London, 1977), 144Google Scholar. Peter Biller (‘Childbirth in the middle ages’, History Today (1986), 43) found a slightly higher number, 3.3 per cent, in a survey of canonisation inquests across Europe between 1301 and 1417. For a slightly longer discussion of childbirth in medieval miracles, see Finucane, Ronald, The rescue of innocents: endangered children in medieval miracles (New York, 1997)Google Scholar.

13 French, Katherine, ‘The material culture of childbirth in late medieval London and its suburbs’, Journal of Women's History 28, 2 (2016), 126–48CrossRefGoogle Scholar.

14 Lea Olsan, ‘Wellcome MS. 632: heavenly protection during childbirth in late medieval England’, Wellcome Historical Library Blog, http://blog.wellcomelibrary.org/2015/10/wellcome-ms-632-heavenly-protection-during-childbirth-in-late-medieval-england/ [accessed 28 March 2018].

15 Lieverse, Angela R. et al. , ‘Death by twins: a remarkable case of dystocic childbirth in early neolithic Siberia’, Antiquity 89, 343 (2015), 23–4CrossRefGoogle Scholar. Of these burials, three were from late medieval Scandinavia, one from an Anglo-Saxon burial in Hampshire, and most recently, excavated in a necropolis in Serbia. See pp. 23–4 for references to the reports including these cases.

16 Children's bodies skeletonize faster and are more prone to disarticulation by scavengers, and their crania are easily damaged during excavation. The burial practices employed may also complicate recovery of infant remains; for example, at Watchfield cemetery, Oxfordshire and Chantambre, France, the graves of children were much shallower, increasing the risk of damage and dispersal. See Lewis, Mary E., The bioarchaeology of children: perspectives from biological and forensic anthropology (Cambridge, 2007), 22–30Google Scholar.

17 Lieverse et al., ‘Death by twins’, 23–4.

18 T. H. Hollingsworth, Historical demography (Ithaca, 1969); Peter Laslett, The world we have lost, further explored (London, 1965), 81; Bertand-Yves Mafart, ‘Approche de la Mortalité Maternelle au Moyen Âge en Provence’, Dossiers de Documentation Archéologique 17 (1994), 207–19. See also Alfred Perrenoud, ‘Surmortalité féminine et condition de la femme (XVIIe-XIXe siècle). Une vérification empirique’, Annales de Démographie historique (1981), 89–104; Hector Gutierrez and Jacques Houdaille, ‘La mortalité maternelle en France au XVIIIe’, Population 6 (1983), 975–94; Alain Bideau, ‘Accouchement ‘naturel’ et accouchement ‘å haut risque,’ deux aspects de mortalité maternelle et infantile (Châtellenie de Thoissey-en-Thombes, 1660–1814’, Annales de Démographie historique (1981), 49–66.

19 David Herlihy and Christiane Klapisch-Zuber, Tuscans and their families: a study of the Florentine Catasto of 1427 (New Haven, 1985), 276–7. These Libri dei Morti are preserved after 1384, though only a few, including those for the years 1424, 1425 and 1430 include substantial numbers of individuals with a recorded cause of death. The authors calculate a Maternal Mortality Rate (MMR) of 14.4 per 1,000. They ultimately conclude that roughly one in five Florentine women would die due to risks associated with childbearing.

20 Stone, Lawrence, The family, sex and marriage in England, 1500–1800 (New York, 1977), 79Google Scholar; as pointed out by Lewis, Judith, ‘“Tis a misfortune to be a great ladie”: maternal mortality in the British aristocracy, 1558–1959’, Journal of British Studies 37, 1 (1998), 27CrossRefGoogle Scholar.

21 Alison Sim, The Tudor Housewife (Mt. Pleasant, SC, 2005), 21–2.

22 1236 was chosen as an appropriate starting date because the queen before Eleanor of Provence, Isabella of Angoulême, married Hugh X de Lusignan after the death of her first husband, King John, moving her beyond the geographic focus of this study, which is primarily interested in England. 1503 acts as an effective terminal date because it marks the beginning of a period of change in the reproductive experiences of English royalty, and of their utility for this analysis; Anne Boleyn and Catherine Howard were executed prior to completing their reproductive lives, and Anne of Cleves’ marriage was declared unconsummated after six months. The experiences of Henry's children are also limited for the purposes of this survey, as only Mary wed.

23 World Health Organization, ‘Maternal mortality’, http://www.who.int/healthinfo/statistics/indmaternalmortality/en/ [accessed 1 March 2018]. Multiple births, that is, twins and triplets, is also associated with higher of maternal death, but in this study, only two cases of multiple birth were observed.

24 With the most recent edition published in 2004, the Oxford Dictionary of National Biography (DNB) includes approximately 55,000 concise edited biographies of figures deemed influential in English history, written by 10,000 specialists worldwide. The DNB is ‘the standard biographical record of first recourse, an invaluable tool for researchers’. The 2004 edition also required sources and references, which constitute 7.5 million words across 60 volumes, 12 per cent of the total text. See Giles Foden, review of The Oxford dictionary of national biography, edited by Colin Matthew, Brian Harrison et al., The Guardian, https://www.theguardian.com/books/2004/sep/25/featuresreviews.guardianreview [24 September 2004]. See also Piers Brendon, review of The Oxford dictionary of national biography, edited by Colin Matthew, Brian Harrison et al., Independent, https://www.independent.co.uk/arts-entertainment/books/reviews/the-oxford-dictionary-of-national-biography-5351836.html [24 September 2004].

25 It is likely that pregnancies which resulted in miscarriages, stillbirths or short-lived children never entered into the documentary record and were therefore missed during the process of data entry. Sex ratios, however, offer a rough method for evaluating the completeness of the evidentiary assemblage. Worldwide, the sex ratio at birth is about 107 males born per 100 females; the ratio balances over time, as the immune system of females is generally hardier and more effective than those of their male counterparts. Of the BADE pregnancies, 446 (97 per cent) resulted in children of determinate sex, leading to a male:female ratio of 223:220, or 101:100. It seems, therefore, that some pregnancies resulting in male infants are missing from the evidence base, though if we take the number of pregnancies resulting in female children as accurate, the 223 male-resulting pregnancies represent 95% of the total number expected. This lacuna might be due to a lack of documentation, or because pregnancies which would have resulted in male children ended too early for observers to note the child's sex. The latter explanation, miscarriage, is discussed more fully below.

For overviews on sex ratios in medieval England, see Bardsley, Sandy, ‘Missing women: sex ratios in England, 1000–1500’, Journal of British Studies 53 (2014), 273–309CrossRefGoogle Scholar; Kowaleski, Maryanne, ‘Medieval people in town and country: new perspectives from demography and bioarchaeology’, Speculum 89, 3 (2014), 573–600CrossRefGoogle Scholar; Grauer, ‘Where were the women?’, 266–88.

26 See Geaman, Kristin, ‘Anne of Bohemia and her struggle to conceive’, Social History of Medicine 26 (2016), 224–44CrossRefGoogle Scholar.

27 This proportion of childless couples seems to have remained relatively constant through the early modern period. Thirteen per cent of Barbara Harris's assemblage of over 2,500 women living between 1450 and 1550 married but never produced offspring, while T.H. Hollingsworth found that 14 per cent of married peers’ daughters born between 1550 and 1574 experienced infertile marriages; Harris, English aristocratic women, 1450–1550: marriage and family, property and careers (Oxford, 2002), 276 n.1; Hollingsworth, T. H., ‘Demography of the British peerage’, Supplement to Population Studies 18 (1964)Google Scholar, Table 36.

28 Shapland, Fiona, Lewis, Mary and Watts, Rebecca, ‘The lives and deaths of young medieval women: the osteological evidence’, Medieval Archaeology 59, 1 (2015), 272–89CrossRefGoogle Scholar; Lewis, M. E., Shapland, F. and Watts, R., ‘The influence of chronic conditions and the environment on pubertal development: an example from medieval England’, International Journal of Paleopathology 12 (2016), 1–10CrossRefGoogle ScholarPubMed; Sayer and Dickinson, ‘Reconsidering obstetric death’, 285–97; Gilchrist, Roberta, Medieval life: archaeology and the life course (Rochester, NY, 2012), 46, 59Google Scholar.

29 World Health Organization, ‘Maternal mortality’, http://www.who.int/healthinfo/statistics/indmaternalmortality/en/ [accessed 1 March 2018].

30 Lewis, ‘Tis a Misfortune’, 43.

31 Her death is noted in Jean Froissart, Le Joli buisson de jonece, A. Fourrier ed. (Geneva: Droz, 1975), 55.

32 Of the 102 women included in the database, six (5.8 per cent) were considered cases of definite maternal mortality, while four (3.9 per cent) – Alice de Lusignan, Philippa, Queen of Sweden, Blanche of Lancaster and Beatrice Plantagenet, Countess of Brittany – were considered questionable, with insufficient evidence available to be considered definite cases of maternal mortality.

33 World Health Organization, ‘Maternal mortality’, http://www.who.int/mediacentre/factsheets/fs348/en/ [updated November 2016].

34 Conde-Agudelo, Agustin, Belizán, José M. and Lammers, Christina, ‘Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: cross-sectional study’, American Journal of Obstetrics and Gynecology 192, 2 (2005), 342CrossRefGoogle ScholarPubMed. A similar study, focused on mothers at seven Bangkok metropolitan hospitals, including over 2,600 individuals, found an increased risk of adverse maternal outcomes for teenage mothers (defined by the authors as less than 20); Thaithae, Suparp and Thato, Ratsiri, ‘Obstetric and perinatal outcomes of teenage pregnancies in Thailand’, Journal of Pediatric and Adolescent Gynecology 24, 6 (2011), 342–6CrossRefGoogle ScholarPubMed. It should be noted, however, that while a European study found an increased risk of death for the infants of young mothers, they did not observe an increased risk of maternal death; de Vienne, Claire M., Crevuil, Christian and Dreyfus, Michel, ‘Does young maternal age increase the risk of adverse obstetric, foetal and neonatal outcomes: a cohort study’, European Journal of Obstetric & Gynecology and Reproductive Biology 147, 2 (2009), 151–6CrossRefGoogle Scholar. For the history of the episiotomy, see Walfisch, A. and Hallak, M., ‘Episiotomy: a review of the literature’, Harefuah 141, 9 (2002), 833–838Google ScholarPubMed.

35 Judith Lewis, ‘“Tis a Misfortune’, 47. Lewis sampled every fourth reel of Hollingsworth's raw data from his work ‘Demography of the British Peerage’, preserved on 40 reels of microfilm at the Eisenhower Library at Johns Hopkins. The family reconstitution forms on these reels include information on about 26,000 individuals, of whom 5,339 were childbearing women. Lewis's sample of 1,251 women born between 1554 and 1908 comprises 23 per cent of all aristocratic childbearing women analysed by Hollingsworth. The sample skews heavily towards the 18th and 19th centuries, however; of the 1,251 women, only 73 (5.8 per cent) were born prior to 1600.

36 Benedictow, Ole Jørgen, ‘Demographic conditions’, in Knut, Hell, Kouri, E.I. and Olesen, Jens E. eds., The Cambridge History of Scandinavia, volume one: Prehistory to 1520 (Cambridge, 2003), 243Google Scholar. Sayer and Dickinson do not mention any burials under the age of roughly 15 in their survey of Anglo-Saxon burials of women and infants; Sayer and Dickinson, ‘Reconsidering obstetric death’, 291.

37 Quoted in Jones, Michael K. and Underwood, Malcolm G., The king's mother: Lady Margaret Beaufort, Countess of Richmond and Derby (Cambridge, 1992), 40Google Scholar.

38 Michael K. Jones, and Malcolm G. Underwood (2004). ‘Beaufort, Margaret [known as Lady Margaret Beaufort], countess of Richmond and Derby (1443–1509), royal matriarch’, Oxford Dictionary of National Biography, http://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-9780198614128-e-1863 [accessed 25 March 2019].

39 Jones and Underwood (The king's mother, 40) note that her marriage contract with Stanley makes no provision for any issue following their marriage, even though Margaret was only 29 years old at the time.

40 These women were Eleanor Moleyns, Cecily Bonville, Joan and Margaret Beaufort, and Eleanor of Castile.

41 Lewis, ‘Tis a Misfortune’, 47.

42 Alexandra Barratt ed., The knowing of woman's kind in childing: a middle English version of material derived from the Trotula and other sources (Turnhout, 2001), 49.

43 Shapland, F., Lewis, M. and Watts, R., ‘The lives and deaths of young medieval women: the osteological evidence’, Medieval Archaeology 59, 1 (2015), 278, 286CrossRefGoogle Scholar.

44 Ibid., 278.

45 Ibid., 283. The authors note that modern high caste girls in India experience menarche, on average, over one year before girls of a lower caste. British girls today are 13 on average at onset of menses.

46 Bergenroth, G. A. ed., Calendar of state papers, Spanish (London, 1862), Vol. 1, 176Google Scholar.

47 Jones and Underwood, The king's mother, 40.

48 Dockray, K. R. D., ‘Why did fifteenth-century English gentry marry? The Pastons, Plumptons and Stonors reconsidered’, in Jones, Michael ed., Gentry and lesser nobility in late medieval Europe (New York, 1980), 65Google Scholar. Elizabeth was the daughter of Thomas Clifford, eighth Baron Clifford.

49 Harris, English aristocratic women, 45.

50 Benedictow, ‘Demography’, 244.

51 The four exceptions are Margaret Beaufort, who gave birth to Henry VII at 13, Eleanor of Castile, who delivered a stillborn daughter at 13, Cicely Bonville to a son, Edward Grey, at age 14, and Blanche of Lancaster, who delivered a daughter, Philippa, at around age 15.

52 Marshall, J. and Raynor, M. eds., Myles textbook for midwives, 16th edn (Edinburgh, 2014), 251–3Google Scholar.

53 Ibid., 20.

54 A. E. Bye, History of the bye family and some allied families (Easton, PA, 1956), 275. Bye gives Cecily a date of birth of 30 June 1460. This would place her over the age of canonical majority at the time of her marriage.

55 Office for National Statistics, ‘Statistical bulletin: births in England and Wales: 2016’, https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/birthsummarytablesenglandandwales/2016 [uploaded 19 July 2017]; United Nations, World fertility patterns 2015 data booklet, 3, available at http://www.un.org/en/development/desa/population/publications/pdf/fertility/world-fertility-patterns-2015.pdf.

56 Harris, English aristocratic women, 99. Harris's intention was to create a collective biography of aristocratic Englishwomen during this 100-year period. She was able to gather information on about 1,200 aristocratic couples and their children. Because her goal did not include recording maternal age at delivery or date of birth; however, her sample size is much larger than my own, which is limited by the relative rarity of accurate recording of birth dates for both mother and child. There is some overlap in the two evidentiary assemblages, though Harris's work excludes royal women and members of the gentry who did not marry into a knightly family.

57 Ibid.

58 Ibid., 235–8.

59 Ibid., 242–3. At Wharram Percy, a 14-year-old child was on average the height of a modern English 10-year-old. See S. Mays, C. Harding and C. Heighway eds., The Churchyard, volume xi of Wharram: a study of settlement on the Yorskhire wolds (York, 2007), 99.

60 Ibid., 243–4.

61 Fred Hutch Cancer Research Center, ‘Reproductive and developmental toxicants’, https://extranet.fredhutch.org/en/u/ehs/hamm/chap3/section12/subsection14.html [accessed 11 November 2019].

62 Mays et al., The Churchyard, volume xi of Wharram: a study of settlement on the Yorskhire wolds, 98.

63 Frisch, Rose E., ‘Nutrition, fatness, and fertility: the effect of food intake on reproductive ability’, in Mosley, W. Henry ed., Nutrition and human reproduction (New York, 1978), 92Google Scholar.

64 Winkvist, Anna, Rasmussen, Kathleen M., and Habicht, Jean-Pierre, ‘A new definition of maternal depletion syndrome’, American Journal of Public Health 82, 5 (1992), 691–4CrossRefGoogle ScholarPubMed.

65 Lewis, ‘“Tis a Misfortune’, 45, 49.

66 The existence of 12 children is definite and there is slim evidence for a 13 child, possibly named Thomas of Windsor, who died in infancy of plague. In my opinion, it is unlikely that this child existed; British Library Bodleian MS Rawlinson 214 f. 130r includes a song mourning the death of Edward III and lists his children with Philippa, including Blanche, who died shortly after birth in 1342, but makes no mention of Thomas.

67 Anthony Tuck (2008). ‘Edmund [Edmund of Langley], first duke of York (1341–1402), prince’. Oxford Dictionary of National Biography, http://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-9780198614128-e-16023 [accessed 25 March 2019].

S. Walker (2008). ‘John [John of Gaunt], duke of Aquitaine and duke of Lancaster, styled king of Castile and León (1340–1399), prince and steward of England’. Oxford Dictionary of National Biography, http://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-9780198614128-e-14843 [accessed 25 March 2019].

68 For royalty in particular, the exact date of birth (day, month and year) was recorded in primary source material. These cases were in the minority, however, and for many entries in BADE only year and month (105 cases) or only year (352) were recorded. Of the 75 birth events lacking sufficient information for dating, over half were births to gentry women. For this reason, the interval analysis includes only dateable birth events and intervals are reflected in years.

69 Manuals of the time, including Bartholomaeus Anglicus's De proprietatibus rerum (c. 1230) and The Byrth of Mankynd (c. 1540) advocated for mothers to feed their own children, but also provided considerable detail on how to select a wet nurse, testifying to the continued popularity of the practice. See Valerie Fildes, Wet nursing: a history from antiquity to the present (Oxford, 1988), 33–42. Jennifer Ward (Women in England in the Middle Ages (New York, 2006), 52–3) discusses the role of wet-nurses among the English elite, noting that the practice was common after the Anglo-Saxon period. Records of payments for their services and letters from distant parents inquiring after their children testify to the continued practice through the end of the middle ages.

70 Potter, R. G., ‘Birth intervals: structure and change’, Population Studies 17 (1963), 155CrossRefGoogle Scholar.

71 Mays, Simon, ‘The effects of infant feeding practices on infant and maternal health in a medieval community’, Childhood in the Past 3 (2010), 63–78CrossRefGoogle Scholar. See also Mays, S., Richards, M. P. and Fuller, B. T., ‘Bone stable isotope evidence for infant feeding in mediaeval England’, Antiquity 76, 32 (2002), 654–6CrossRefGoogle Scholar.

72 Tomkins, ‘Demography’, 209.

73 Allison, ‘Maternal mortality’, 26–7.

74 Tomkins, ‘Demography’, 224. Schofield, R. S., ‘Did the mothers really die? Three centuries of maternal mortality in “The world we have lost”’, in Bonfield, L., Smith, R. M. and Wrightson, K. eds., The world we have gained: histories of population and social structure (Oxford, 1986), 241Google Scholar.

75 Allison, ‘Maternal mortality’, 23. For comparison's sake, the MMR of Sierra Leone, the highest in the modern world, is 1,360 per 100,000 live births. The MMR observed by Allison for women giving birth to stillbirths is approximately ten times this. See also Galley, Chris, ‘The stillbirth rate in early modern England’, Local Population Studies 8 (2008), 75–83Google Scholar.

76 Green, Monica H. ed. and trans., The Trotula: a medieval compendium of women's medicine (Philadelphia, 2001), 99CrossRefGoogle Scholar.

77 Ibid., 101.

78 Frisk, Gosta ed. and trans., A middle English translation of Macer Floridus de Viribus Herbarum (Lundequistka, 1949), 73Google Scholar.

79 Barratt, The knowing of woman's kind, 65.

80 Ibid., 2.

81 James Craigie Robertson and J. Brigstocke Sheppard eds., Materials for the history of Thomas Becket, Archbishop of Canterbury, Vol. 2 (London, 1883), 196.

82 For discussions of the burial of unbaptized or stillborn babies in medieval Europe, see Hausmair, Barbara, ‘Topographies of the afterlife: reconsidering infant Burials in medieval mortuary spaces’, Journal of Social Archaeology 17, 2 (2017), 210–36CrossRefGoogle Scholar; Galley, Chris, ‘The stillbirth rate in early modern England’, Local Population Studies 81 (2008), 75–83Google Scholar; Schofield, Roger, ‘Perinatal mortality in Hawkshead, Lancashire, 1581–1710’, Local Population Studies 4 (1970), 11–6Google Scholar.

83 Tomkins, ‘Demography’, 200.

84 Ibid., 203–7. Tomkins’ survey of Shropshire midwife books includes several records which recorded stillbirths as well as live births. The man-midwife Thomas Higgins, for example, delivered 1,196 infants during 1781–1803, including 1,140 live births, 47 stillbirths and 9 miscarriages. Two of the other midwives studied, John Greene and Frances Johnson, recorded maternal burials, baptisms and miscarriages, but not stillbirths.

85 J. C. Parsons, ‘The year of Eleanor of Castile's birth and her children by Edward I’, Mediaeval Studies 46, (1984), 256–7, 263. Parsons notes that Eleanor usually spent 40 days confined after the birth of a son, but only 30 after giving birth to a daughter. This contrasts with her mother-in-law, Eleanor of Provence, whose lying ins lasted 40 days regardless of the sex of the child.

86 Lewis, ‘Maternal health’, 101. For this study, Lewis identified 48 aristocratic Englishwomen, c. 1790–1894, whose childbearing experiences could be effectively reconstructed through surviving correspondence and journals.

87 Tomkins, ‘Demography’, 219–20. Tomkins also notes that the English rate is high compared to that observable in similar Swedish evidence, which was 28 stillbirths per 1,000 live births.

88 Lisonkova, Sarka et al. , ‘Maternal age and severe maternal morbidity: a population-based retrospective Cohort study’, PLoS Medicine 14, 5 (2017)CrossRefGoogle ScholarPubMed.

89 Haldane, John and Lee, Patrick, ‘Aquinas on human ensoulment, abortion and the value of life’, Philosophy 78, (2003), 257CrossRefGoogle Scholar. See also Sara M. Butler, ‘More than mothers; juries of matrons and pleas of the belly in medieval England’, Law and History Review (2019), 353–90. As Butler notes on p. 383, Azo of Porticus wrote that the ensoulment of the foetus began at 40 days for males and 80 for females. According to the Mayo Clinic, 10–20 per cent of known pregnancies end in miscarriage. See ‘Miscarriage’, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/pregnancy-loss-miscarriage/symptoms-causes/syc-20354298 [updated 16 July 2019].

90 Magnus, Maria C. et al. , ‘Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study’, British Medical Journal 364 (2019), doi: 10.1136/bmj.l869Google ScholarPubMed.

91 Benedictow, ‘Demographic’, 243.

92 Buchanan, Robert, ‘Effects of childbearing on maternal health’, Population Reports 8 (1975)Google Scholar, J139. Among the 48 women analysed by Lewis (‘Maternal health’, 99), the average age at first pregnancy was 20, the same as in the BADE sample. Lewis's early modern aristocratic women, however, continued bearing children long after most of the medieval cohort had ceased; in her sample, the mean age at last pregnancy of 39.3 years. Harris (English aristocratic women) does not include any information on average age at first or last pregnancy.

93 Lewis, ‘Tis a Misfortune’, 33.

94 World Health Organization, ‘Maternal mortality fact sheet’, http://www.who.int/mediacentre/factsheets/fs348/en/ [updated November 2016].

95 253 birth events (55.4 per cent) had no risk factors; 51 (11.2 per cent) had two risk factors, and 9 (2 per cent) had three risk factors.

96 They were Mary de Bohun, Elizabeth of York, Elizabeth of Rhuddlan, Eleanor Holland, Anne Mortimer and Margaret of Scotland.

97 Lewis, ‘Tis a Misfortune’, 33. Table 2, ‘Maternal mortality by 50-year birth cohorts’, shows a peak between 1750 and 1799, with a total of 8 per cent of the 225 women dying in childbirth. In 1850–1899, a dramatic drop occurs, with only 2 out of 222 women dying due to childbirth.

98 Ibid., 34. Unfortunately Table 3 of Lewis's article recording maternal deaths per 1,000 live births is not broken down any further than ‘Before 1700’, ‘1700–1799’ and ‘1800–1899’.

99 Dr. Thomas Denman, for example, wrote that ‘the lower orders of women have more easy and favourable births than those who live in affluence’; Thomas Denman, An introduction to the practice of midwifery (Brattleborough, 1807), 188. Dr. William Buchan similarly observed that ‘inhabitants of every country are prolific in proportion to their poverty’; William Buchan, Domestic medicine: or, a treatise on the prevention and cure of diseases by regimen and simple medicine (Philadelphia, 1772), 340.

100 For a general overview of medieval diets and the role of social class in those diets, see Alixe Bovey, ‘The medieval diet’, British Library, https://www.bl.uk/the-middle-ages/articles/the-medieval-diet [published 30 April 2015]. See also Bullough, Vern and Campbell, Cameron, ‘Female longevity and diet in the Middle Ages’, Speculum 55 (1980), 317–25CrossRefGoogle ScholarPubMed. Their conclusions have since been challenged: Pearson's, Kathy ‘Nutrition and the early-medieval diet’, Speculum 72 (1997), 1–32CrossRefGoogle Scholar, provides a useful overview.

101 Allison, ‘Maternal mortality’, 17.

102 Ibid., 18.

103 World Health Organization, ‘Maternal mortality fact sheet’, http://www.who.int/mediacentre/factsheets/fs348/en/ [updated November 2016].

104 This is not a new conclusion. Even Dr. Buchan, writing in the 1760's, noted that though poor women seemed to have an easier time getting pregnant, they suffered more: ‘poor women, whose circumstances oblige them to quit their bed too soon, often contract diseases from cold, of which they never recover’; Buchan, Domestic medicine, 339.

105 Sullivan, Amy, ‘Prevalence and etiology of acquired anemia in medieval York, England’, American Journal of Physical Anthropology 128, 2 (2005), 259CrossRefGoogle ScholarPubMed. See also Müldner, Gundula and Richards, Michael P., ‘Fast or feast: reconstructing diet in later medieval England by stable isotope analysis’, Journal of Archaeological Science 31, 1 (2005), 39–48CrossRefGoogle Scholar; Müldner, G. and Richards, M. P., ‘Diet in medieval England: the evidence from stable isotopes’, in Woolgar, C. M., Serjeantson, D. and Waldron, T. eds., Food in medieval England: diet and nutrition (Oxford, 2006), 229–38Google Scholar.

106 Ibid., 256.

107 Don Walker, Disease in London, 1st–19th centuries: an illustrated guide to diagnoses, Monograph 56 of the MOLA Monograph Series (London, 2012), 261. Mays, The archaeology of human bones, 2nd edn (New York, 2010), 214.

108 Geoffrey Chamberlain, ‘British maternal mortality in the 19th and early 20th centuries’, Journal of the Royal Society of Medicine (2006), 559–63.

109 WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, ‘Maternal mortality ratio (modeled estimate, per 100,000 live births)’, (Geneva, 2015). Available at https://data.worldbank.org/indicator/sh.sta.mmrt.