The First National Simulation Program – How Simulation Implementation from the Past Applies to Our Future

By Angela Blood

Madame Angelique Marguerite du Coudray is known as the first person to initiate a national medical education program utilizing simulation. With the blessings and patronage of King Louis XV of France, Madame du Coudray developed a curriculum including the use of a mannequin in order to educate women across the country in the art and science of midwifery. This initiative was a direct result of her experience with poverty, lack of education, and poor health outcomes in rural France. Du Coudray’s training and practice up until 1751 had been in Paris, where resources and education were more abundant. In rural settings, women without education or formal training acted as midwives in the absence of other trained medical professionals, the results of which were often disastrous. One estimate calculated that up to 200,000 infants were lost each year. Thus with this humanitarian motivation, she created her own curriculum and garnered political support to ensure its implementation.

Although hundreds of mannequins were produced, only one complete model is still in existence and on display in the Musee Flaubert in Rouen. The purpose of the mannequins, or “machines,” was to educate women regarding anatomy, as well as to help practice for both normal and rare circumstances. The mannequins were made from fabric, leather, and bone, and were created as close to life-like as possible. In addition to the basic anatomy, du Coudray included a fabric infant (both normal and abnormal presentations) and other components, such as fluids, necessary for a midwife’s education.

Madame du Cadrey

This is similar to the use of simulation today – we use partial mannequins, or task trainers, to educate novices about basic structure and normal presentation; we also use partial mannequins to educate intermediate or advanced learners about how to respond to the unexpected.

As with any historical figure, some aspects of du Coudray’s strategy appear admirable while other aspects appear less so, perhaps more self-interested than her initial intention. Without many writings from du Coudray herself, we can only use the evidence available in order to understand her motives and interpret her outcomes. Taken with a grain of salt, her experience can inform us about strategies to implement simulation in difficult environments.

Address barriers inherent in traditional education model. The traditional training for a midwife, as du Coudray knew herself, was a one-to-one apprenticeship model. A certified and experienced midwife accepted an apprentice for a three year period during which the apprentice paid tuition as well as room and board to her teacher. At the completion of this three year apprenticeship, a fee was required to be certified. Although the life of a midwife came with rewards, there were not many women who could afford to give up their families and pay tuition for such an extended period of time. It certainly was not a sustainable model for educating large numbers in rural areas, thus extenuating the inequality in both education and healthcare.

To address this problem, du Coudray designed her curriculum to be an intense, full day course over approximately two months. A two month commitment was certainly more feasible than three years.  While the education could not be called equal to a Paris-educated apprentice midwife, those who attended the two month curriculum were more able than those without any education at all, as the traditional model offered. Thus du Coudray addressed issues of practicality while designing her education plan, tailoring the program based on her understanding of the learners’ needs and barriers.

Find common ground with your learners and those with political influence. Why did du Coudray decide to “invent a machine,” or mannequin, as an instructional tool? In rural settings, most women were not literate; creating written materials would not have served her purpose. Du Coudray recognized that the women who attended her course would be “sensory learners,” and needed something they could place their hands on. She likely chose to refer to her invention as a “machine” because this type of language was typical in the Enlightenment period, thus aligning her goals with learned men of influence, speaking the language of University-educated leaders. 

Of her forty separate curriculum modules, her first talk began with the ethics and values related to midwifery. She appealed to women’s desire to be caretakers and protectors of human life. Although she and her students were from vastly different backgrounds and socioeconomic strata, many of her learners had Catholicism in common. She used her first opportunity to speak to the learners to establish common ground, and appeal to the women’s sense of duty in order to ensure they’d maintain their commitment to the two month program.

Initially, du Coudray struggled for national recognition (i.e. a pension), and when met with resistance, she decided to author a book. Du Coudray knew that most of her learners would never read the book (as many of them could not read), so then why go to the trouble? She chose to write a book to speak in the currency of the establishment. Although her mannequin had received praise, it took authorship to allow her to be recognized as someone worth paying attention to.

Align your agenda with interests larger than, or even outside, your own (i.e. the end justifies the means).  Pick your battles, and at times, let others fight your battles for you.  Du Coudray’s interest was to deliver her midwifery curriculum to women across France. She strategized in several ways to make this come about. She moved from Paris to a rural community where the intendant (King’s man) was happy to accept her “free” teaching; her curriculum had room to grow. Although personal recompense emerged as part of her agenda, she delayed introducing that into the conversation until she had documented successes. While in Paris, she, along with a group of midwives, when denied certification from the University, exploited a disagreement between the surgeons and medical doctors in order to ensure that their training needs were met.

Most importantly, when du Coudray was not receiving the resources and recognition she thought she deserved, she aligned her overall message with one that was appealing to a broader base. In 1754, France was at war with England, and the finance of the war had left little else for social service programs. Rather than emphasizing access to education and healthcare (her original agenda), du Coudray emphasized that birth should be a matter of national security and pride. Current practices were allowing up to 200,000 of “his majesty’s subjects” to perish each year; these potential subjects could have been soldiers and providers in France. She placed her opponents in a position of having to admit that if they were against her and her program, they were against France’s war, the King, and even their own country’s best interests.

Whatever our feelings about du Coudray’s strategies in accomplishing her goals, the undeniable truth is that her tactics were successful. Over the course of her travels, du Coudray spent more than 25 years traveling and reached nearly every corner of France. While privileged in her career and livelihood compared to most women of her time, she understood inequality in social institutions from her own personal experience–before initiating change, she lived with the community she intended to instruct, getting to know them and allowing them to get to know her. As a midwife and unmarried woman in a world that privileged others, she provided greater access to education, and thus access to health care. Her life’s work offers lessons to us all, as we continue to struggle for equity in healthcare.

Gelbart Rattern, N. (1998). The King’s Midwife: A History and Mystery of Madame du Coudray.
The University of California Press, Berkeley: CA.

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