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OBSTETRICS AND SOCIAL CHANGE
1158 OBSTETRICS AND SOCIAL CHANGE
WCH RATHER THAN MCH
SIR,-In
your Round the World column
(Sept 30,
p
795) Dr
Tahzib reports on a World Health Organisation working group’s discussions on the measurement of maternal morbidity. One of us (R. B.) was a member of that group. Tahzib records our argument as "We should be talking of WCH rather than just MCH" but puts it
wrongly. The M in MCH (maternal and child health) used to be neglected but now it is receiving some attention.’ WHO and the World Bank are now focusing on maternal mortality, and attempts to measure maternal morbidity have begun. However, we find that the reproductive health problems of women (the W) are related to much more than maternity. Tahzib mentions vesicovaginal fistula, obstetric palsy, sepsis, psychosis, and prolapse. Most data on women’s health being hospital based, such morbidity (and cervical cancer) has been widely noticed but the prevalence of other reproductive morbidities of women have been neglected. In a community-based study on gynaecological diseases2 we found that 92% of the women in villages had 1 or more gynaecological or sexual diseases, and the average was 3-6. The most common were vaginitis, cervicitis, cervical erosion, pelvic inflammatory disease, and dysmenorrhoea. There was no case of vesicovaginal fistula or cervical cancer. The prevalence of anaemia was 91 % and of vitamin A deficiency 58%. 46% of unmarried girls had premarital sexual experience. Only 7-8% of women had ever received gynaecological care.
Unwanted pregnancies and the forcing of women to undergo unsafe abortions are common. One important cause of unwanted pregnancies is the failure of laparoscopic tubectomy, widely practised in India, or of vasectomy. This speaks volumes about the quality of birth control care given to the rural population. Spacing methods are practically non-existent. In our study only 7 women were using an intrauterine device (IUD) and only 5 were on oral contraceptives. The women thought that use of contraception led to health problems. That belief was not entirely misplaced for we found a significant association between tubectomy and past or present use of an IUD and of gynaecological conditions such as menstrual disorders, vaginal infections, and cervical disease. Moreover, tubectomy or introduction of an IUD often aggravated a pre-existing gynaecological disease, so such conditions must be excluded or treated before such contraception can be advised. The nurses and paramedics who form the backbone of the primary health care in rural areas cannot deal with these gynaecological conditions while the doctors in primary health centres are usually men, to whom women prefer not to reveal gynaecological or sexual
illegal,
problems. sex, and
illegitimate pregnancy are common, AIDS can not be far behind, and vaginitis, erosions, or Where
syphilis, premarital
ulcers may increase the rate of transmission of HIV infection.3 We argue4 that there is much more to women’s reproductive health care than maternity or contraception services, which is all that policy makers and health planners seem to understand. Also needed are services for the prevention, diagnosis, and treatment of gynaecological diseases, including sexually transmitted conditions; safe abortion services; and education on reproductive health and sex. These services must be community based and participatory. This new emphasis is not to belittle the importance of maternity care or contraceptive services. Nutritional deficiencies and occupational health problems, and discrimination against females, are all part of this wider understanding. So we should be saying WCH not just MCH. SEARCH (Society for Education, Action and Research in Community Health), Gadchiroli (Maharashtra) 442 605, India
ABHAY BANG RANI BANG
1. Conable BB. Safe motherhood. WHO Forum 1987; 8: 155-60. 2. Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. High prevalence of gynaecological diseases in rural Indian women. Lancet 1989; i: 85-89. 3. Cameron DW, Simonsen JN, D’Costa LJ, et al. Female to male transmission of HIV virus type I. risk factors for seroconversion in men. Lancet 1989; ii: 403-07. 4. Bang RA, Bang AT, and SEARCH Team. A community based approach to reproductive care to women. Presentation to Titze symposium at World Congress of the Federation of Obstetrics and Gynaecology (Rio de Janeiro, 1988). Int J Obstet
Gynecol (in press).
SIR,-Your Sept 16 editorial (p 657) is an appropriate reminder of the late Sir Dougal Baird’s work elucidating the importance of social conditions and social change in obstetric practice. What is less obvious is the part that obstetric practice may play in bringing about social change. In several ways Baird continued the work of Seebhohn Rowntree in York between 1899 and 1950,1-3 in which Rowntree recorded in great detail the social conditions and changes over half a century in the lives of what were then known as the wage-earning classes. The Lancet° described Rowntree as a "social diagnostician", but, detailed as his records were, they included little information directly concerning childbirth and unwanted pregnancy, a gap in social record which was to be filled by Baird in Aberdeen, over a similar period, but nearly half a century later. In England and Wales in the 40 years 1898-1938 the infant mortality fell by two-thirds and the birth rate by half to 15 per 1000. The reason for the fall in birth rate was not obvious, but it was not the "tyranny of excessive fertility" (your editorial) which was causing concern in 1938 but the possible dramatic fall in total population.5 The change was partly due to evolutionary legislation influenced by Rowntree’s work and which Rowntree favoured as being less disruptive of the roots of society than more radical solutions; and all this took place well before the inception of a comprehensive welfare state in 1948. Baird, on the other hand, was in a position to use the welfare state to influence social change and in so doing somewhat alter the demographic pattern of Aberdeen,6 so that, as you say, planned pregnancies were almost the rule by 1985. This was to some extent achieved by abortion and sterilisation, of which Baird was an early exponent, and which in turn improved
perinatal mortality. Not all social change has been for the better. In Britain today one in four of all children is born outside marriage and one in three of all marriages ends in divorce. It is from such a background of broken homes that many of the 100 000 young people under the age of 17 (about one in six of births of 16 years age) go missing every year.’ It is by no means certain that modem obstetric practice has made a contribution to these obviously complex social changes. However, Baird’s work shows that it is not only social change and physical and material benefit which have influenced obstetrics over the past 40 years. Obstetricians, working within a welfare state and close to the roots of society, can, for better or worse, influence social change. Forth Park Hospital, 30 Bennochy Road, Kirkcaldy, Fife KY2 5RA
E.
J. FAIRLIE
1. Rowntree BS. Poverty, a study of town life London. Macmillan, 1901 2. Rowntree BS Poverty and progress London. Longmans Green, 1941. 3. Rowntree BS, Lavers GR Poverty and the welfare state. London. Longmans Geen, 1951 4. Editorial. Lancet 1941; ii: 404. 5. Rowntree BS. Poverty and progress London: Longmans Green, 1941 289. 6. Anon. Sir Dougal Baird. obituary. Times, 1986 (Nov 18): 22. 7. Newman C. Young runaways. London. Children’s Society, 1989
LATE ABORTIONS
SIR,-Professor Wigglesworth (Oct 7, p 866) points out that, when there has been an antenatal diagnosis of fetal abnormality, medical rather than destructive surgical abortion allows full pathological examination of the intact fetus. In my previous letter (Sept 2, p 563) I emphasised the need to give the woman a choice of method. The woman having an abortion because her fetus has a serious abnormality will usually choose medical abortion for the
given by Wigglesworth. Wigglesworth is not correct in stating that the indication for most late abortions is fetal abnormality. In 1987 fetal abnormality was grounds for abortion in women resident in England and Wales in only 4% done from 13 to 19 weeks and in 13% of those with gestations of 20 weeks or more.’
reason
Department of Obstetrics and Gynaecology, St Mary’s Hospital Medical School, London W2 1PG 1. Abortion
D. B. PAINTIN
Statistics, 1987. London. HM Stationery Office, Senes AB no 14, 1988
WCH RATHER THAN MCH
SIR,-In
your Round the World column
(Sept 30,
p
795) Dr
Tahzib reports on a World Health Organisation working group’s discussions on the measurement of maternal morbidity. One of us (R. B.) was a member of that group. Tahzib records our argument as "We should be talking of WCH rather than just MCH" but puts it
wrongly. The M in MCH (maternal and child health) used to be neglected but now it is receiving some attention.’ WHO and the World Bank are now focusing on maternal mortality, and attempts to measure maternal morbidity have begun. However, we find that the reproductive health problems of women (the W) are related to much more than maternity. Tahzib mentions vesicovaginal fistula, obstetric palsy, sepsis, psychosis, and prolapse. Most data on women’s health being hospital based, such morbidity (and cervical cancer) has been widely noticed but the prevalence of other reproductive morbidities of women have been neglected. In a community-based study on gynaecological diseases2 we found that 92% of the women in villages had 1 or more gynaecological or sexual diseases, and the average was 3-6. The most common were vaginitis, cervicitis, cervical erosion, pelvic inflammatory disease, and dysmenorrhoea. There was no case of vesicovaginal fistula or cervical cancer. The prevalence of anaemia was 91 % and of vitamin A deficiency 58%. 46% of unmarried girls had premarital sexual experience. Only 7-8% of women had ever received gynaecological care.
Unwanted pregnancies and the forcing of women to undergo unsafe abortions are common. One important cause of unwanted pregnancies is the failure of laparoscopic tubectomy, widely practised in India, or of vasectomy. This speaks volumes about the quality of birth control care given to the rural population. Spacing methods are practically non-existent. In our study only 7 women were using an intrauterine device (IUD) and only 5 were on oral contraceptives. The women thought that use of contraception led to health problems. That belief was not entirely misplaced for we found a significant association between tubectomy and past or present use of an IUD and of gynaecological conditions such as menstrual disorders, vaginal infections, and cervical disease. Moreover, tubectomy or introduction of an IUD often aggravated a pre-existing gynaecological disease, so such conditions must be excluded or treated before such contraception can be advised. The nurses and paramedics who form the backbone of the primary health care in rural areas cannot deal with these gynaecological conditions while the doctors in primary health centres are usually men, to whom women prefer not to reveal gynaecological or sexual
illegal,
problems. sex, and
illegitimate pregnancy are common, AIDS can not be far behind, and vaginitis, erosions, or Where
syphilis, premarital
ulcers may increase the rate of transmission of HIV infection.3 We argue4 that there is much more to women’s reproductive health care than maternity or contraception services, which is all that policy makers and health planners seem to understand. Also needed are services for the prevention, diagnosis, and treatment of gynaecological diseases, including sexually transmitted conditions; safe abortion services; and education on reproductive health and sex. These services must be community based and participatory. This new emphasis is not to belittle the importance of maternity care or contraceptive services. Nutritional deficiencies and occupational health problems, and discrimination against females, are all part of this wider understanding. So we should be saying WCH not just MCH. SEARCH (Society for Education, Action and Research in Community Health), Gadchiroli (Maharashtra) 442 605, India
ABHAY BANG RANI BANG
1. Conable BB. Safe motherhood. WHO Forum 1987; 8: 155-60. 2. Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. High prevalence of gynaecological diseases in rural Indian women. Lancet 1989; i: 85-89. 3. Cameron DW, Simonsen JN, D’Costa LJ, et al. Female to male transmission of HIV virus type I. risk factors for seroconversion in men. Lancet 1989; ii: 403-07. 4. Bang RA, Bang AT, and SEARCH Team. A community based approach to reproductive care to women. Presentation to Titze symposium at World Congress of the Federation of Obstetrics and Gynaecology (Rio de Janeiro, 1988). Int J Obstet
Gynecol (in press).
SIR,-Your Sept 16 editorial (p 657) is an appropriate reminder of the late Sir Dougal Baird’s work elucidating the importance of social conditions and social change in obstetric practice. What is less obvious is the part that obstetric practice may play in bringing about social change. In several ways Baird continued the work of Seebhohn Rowntree in York between 1899 and 1950,1-3 in which Rowntree recorded in great detail the social conditions and changes over half a century in the lives of what were then known as the wage-earning classes. The Lancet° described Rowntree as a "social diagnostician", but, detailed as his records were, they included little information directly concerning childbirth and unwanted pregnancy, a gap in social record which was to be filled by Baird in Aberdeen, over a similar period, but nearly half a century later. In England and Wales in the 40 years 1898-1938 the infant mortality fell by two-thirds and the birth rate by half to 15 per 1000. The reason for the fall in birth rate was not obvious, but it was not the "tyranny of excessive fertility" (your editorial) which was causing concern in 1938 but the possible dramatic fall in total population.5 The change was partly due to evolutionary legislation influenced by Rowntree’s work and which Rowntree favoured as being less disruptive of the roots of society than more radical solutions; and all this took place well before the inception of a comprehensive welfare state in 1948. Baird, on the other hand, was in a position to use the welfare state to influence social change and in so doing somewhat alter the demographic pattern of Aberdeen,6 so that, as you say, planned pregnancies were almost the rule by 1985. This was to some extent achieved by abortion and sterilisation, of which Baird was an early exponent, and which in turn improved
perinatal mortality. Not all social change has been for the better. In Britain today one in four of all children is born outside marriage and one in three of all marriages ends in divorce. It is from such a background of broken homes that many of the 100 000 young people under the age of 17 (about one in six of births of 16 years age) go missing every year.’ It is by no means certain that modem obstetric practice has made a contribution to these obviously complex social changes. However, Baird’s work shows that it is not only social change and physical and material benefit which have influenced obstetrics over the past 40 years. Obstetricians, working within a welfare state and close to the roots of society, can, for better or worse, influence social change. Forth Park Hospital, 30 Bennochy Road, Kirkcaldy, Fife KY2 5RA
E.
J. FAIRLIE
1. Rowntree BS. Poverty, a study of town life London. Macmillan, 1901 2. Rowntree BS Poverty and progress London. Longmans Green, 1941. 3. Rowntree BS, Lavers GR Poverty and the welfare state. London. Longmans Geen, 1951 4. Editorial. Lancet 1941; ii: 404. 5. Rowntree BS. Poverty and progress London: Longmans Green, 1941 289. 6. Anon. Sir Dougal Baird. obituary. Times, 1986 (Nov 18): 22. 7. Newman C. Young runaways. London. Children’s Society, 1989
LATE ABORTIONS
SIR,-Professor Wigglesworth (Oct 7, p 866) points out that, when there has been an antenatal diagnosis of fetal abnormality, medical rather than destructive surgical abortion allows full pathological examination of the intact fetus. In my previous letter (Sept 2, p 563) I emphasised the need to give the woman a choice of method. The woman having an abortion because her fetus has a serious abnormality will usually choose medical abortion for the
given by Wigglesworth. Wigglesworth is not correct in stating that the indication for most late abortions is fetal abnormality. In 1987 fetal abnormality was grounds for abortion in women resident in England and Wales in only 4% done from 13 to 19 weeks and in 13% of those with gestations of 20 weeks or more.’
reason
Department of Obstetrics and Gynaecology, St Mary’s Hospital Medical School, London W2 1PG 1. Abortion
D. B. PAINTIN
Statistics, 1987. London. HM Stationery Office, Senes AB no 14, 1988