During Middle Ages inadequate nutrition continued to affect population rates in several ways. The number of live births is determined in large part by the rate of conception and by maternal nutrition, both of which are directly related to diet. A third factor, obstetrical technique, is also important but changed little until the revolutionary developments of the nineteenth and twentieth centuries.

Rates of conception in a given population are determined in part by the total number of childbearing years available to a woman. Malnutrition, obstetrical accidents, and epidemic disease shortened life expectancy and reduced the childbearing years dramatically. They were also reduced by a far higher age of first menstruation than is now common. Though marriages were sometimes contracted at an early age, especially among the upper classes, medieval women are thought to have reached puberty at an average age of seventeen as opposed to today's average of 12.4. Nutrition is usually blamed for the difference. Inadequate nutrition can also prevent ovulation in mature women, which probably reduced conception rates even further.

After conception, poor maternal diet led to a high rate of stillbirths and complications during pregnancy. If a child were brought to term it then faced the hazards of childbirth. Babies were normally delivered at home in unsanitary conditions. The midwives who delivered babies were often experienced, but they knew nothing of sterilization and lacked the most elementary equipment. Forceps, for example, were not invented until the middle of the eighteenth century. Though Trotula, a woman physician, taught at the University of Salerno in the thirteenth century and published a treatise on obstetrics, most medieval physicians were men and knew no more than a competent midwife. They were, in any case, available only to the rich.

Infants who survived the obstetrical techniques of the day then faced the possibility that their mothers would be unable to nurse. Malnutrition interferes with lactation as does the stress of poverty, exposure to war, and other forms of physical and mental insecurity. The problem could be solved by turning the child over to a wet nurse, but this was not always a satisfactory solution. The wet nurse was normally another woman in the village who had milk to spare because she had recently lost her own baby. She had to be paid--a serious problem for a poor woman--and did not always care for the child as she might have cared for her own. Babies put out for nursing had a higher mortality rate than those who remained at home. Either way, the children of poorly nourished mothers were often weak and susceptible to disease. The birthrate was therefore by modern standards low and the rate of infant mortality high. Valid statistics are unavailable for medieval times, but deaths presumably ranged from 30 to 70 percent in the first two years of life, depending upon such variables as current food supply and the presence or absence of epidemics.

The spread of disease was encouraged by crowding and by a widespread indifference to personal hygiene. In the absence of a germ theory, personal cleanliness was a matter of aesthetics, and bathing was regarded with suspicion by Christian thinkers who associated it with pagan luxury or with Jewish and Muslim rituals. Its alternative was difficult and expensive to achieve. By the twelfth century, firewood, like timber, had become scarce and expensive everywhere in western and central Europe. Bathing in cold water in an unheated room was unattractive. Most people had better uses for their limited supplies of precious firewood. Rashes and skin infections were therefore common. Crowding, often for warmth, and the custom of keeping livestock and pets in the home added to the problem by ensuring that many Europeans would play host to a variety of insect pests. This encouraged the spread of epidemics because lice and fleas carried infectious diseases including typhus and, later, plague.

Contaminated drinking water accounted for another group of deadly ailments, while airborne viruses and bacteria were as numerous as they are today. Here, too, the absence of a germ theory rendered public health measures ineffective. Water that looked clean was thought to be safe, and indoor air was purified by scenting it with perfumes and herbs. Malaria, endemic in southern Europe, was thought to be caused by breathing miasmas, or foul air. It is actually spread by mosquitoes. The offending parasite remains in the bloodstream for life, causing recurring attacks of chills and fever even if it fails to kill its victim outright. Those weakened by malnutrition or other ailments were the most likely to succumb. . .

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