PANORAMA ON BENOXAPROFEN

475 PREGNANT WOMEN AT WORK

SIR,-Professor Chamberlain and Jo Garcia’s review (Jan. 29, p. 228) of the possible effects of a woman working during pregnancy the health of fetus and infant covered several controversial our own work on national samples of births in France. We report here more detailed results on occupation and outcome of pregnancy from the French national survey done in 1976 on a representative sample of births to 4685 women.’To analyse the effects of work during pregnancy, immigrant women, students, and the unemployed were excluded, as were multiple births. One region, Rhone-Alpes, had to be excluded because of the use of a different questionnaire. The results related to a sample of 3218 French women, 61% of whom had an occupation during

on

studies, including

pregnancy.2 Delivery before 37 weeks’ gestation was significantly less frequent among women who worked during pregnancy than among those who did not (5% versus 75%, table). As Chamberlain and Garcia BIRTHWEIGHT AND GESTATIONAL AGE ACCORDING TO

OCCUPATIONAL STATUS OF MOTHER DURING PREGNANCY

Figures in italic type show numbers of women. *Blrthwelght lower than the 5th percenule of btrthwetght

distnbutton

according

to

gestational age. tp<0’0t

pointed

out women

and pregnancy outcome may largely account for different effects on 3 pregnancy at different times.3 On the whole, evidence from recent research is more in favour of a "positive" rather than an "adverse" effect of work on pregnancy outcome, as measured by the length of gestation and birthweight. Several factors can explain these findings. In France, in all social groups, women who worked during pregnancy had better antenatal care than women who did not, this being reflected in birth planning, contraception, medical history taking, participation in antenatal classes, and breastfeeding. For most pregnant women in paid work legislation provides for 6 weeks’ antenatal and 8 weeks’ postnatal leave (plus 2 more weeks on medical advice), during which women get 90% of basic salary; for protection from dismissal during pregnancy and postnatal leave; and for the right to change job on medical grounds without a change in salary. Some firms provide full salary during maternity leave with shorter working hours (the legal working time has been 39 hours per week since 1981) and free time for antenatal visits or classes. There is no similar protective legislation for pregnant women who do not work outside their homes. In France, in 1976, there was only a small proportion of women (10%) for whom working conditions were associated with a higher rate of pre-term delivery than the rate observed for non-working women.3Further research on preventive measures should be primarily directed at employed women in high risk work and at nonworking women, and should take into account indicators other than birthweight and gestational age, such as the woman’s wellbeing during pregnancy. Epidemiological Research Group on the Mother and Child,

who work have

a

more

favourable social

background; but differences in parity, level of education, or social class did not completely explain the lower pre-term delivery rate we found.2,3 A separate study on immigrant women also showed that women who worked during pregnancy had a lower rate of pre-term delivery-5% compared with 11% for women who did not work outside their homes4-despite their generally heavy work. Because women employed during pregnancy were more often primiparous, smokers, and had a lower pre-pregnancy weight, one would have expected birthweight to be lower in this group. In fact, there was no significant relationship between work in pregnancy and either mean birthweight or intrauterine growth retardation (table). When maternal characteristics were taken into account the intrauterine growth retardation rate was slightly lower for employed women.3Similar results have been obtained in an Israeli population. These findings are less in contrast with those of Naeye and Peters6 than Chamberlain and Garcia imply. Naeye and Peters’ study sample was highly selected (7700 women out of 550007). It included only certain occupations, which might explain the low proportion of women employed (15-20%). From this sample it is not possible to estimate birthweight or length of 1.

gestation for working women as a group, but only for some categories. Some groups of women-women with a sit-down job, those who stopped working before 34 weeks’ gestation-the average birthweight was similar to or higher than that for the group of nonworking women. Moreover, the sample included only full term births. The data were collected in 1959-66, and major changes in women’s work, working conditions, family planning, obstetric care,

Rumeau-Rouquette C, and Unit 149. Naître en France. Paris: INSERM, 1979. 2 Saurel-Cubizolles MJ, Kaminski M, Rumeau-Rouquette C. Actlvité professionnelle des femmes enceintes. Surveillance prénatale et issue de la grossesse. J Gynecol Obstet Biol Reprod 1982; 8: 959-67. 3 Saurel-Cubizolles MJ Activité professionnelle des femmes enceintes Comportement médical et issue de la grossesse approche socio-historique et épidémiologique. Thesis, University of Paris I, 1982. 4 Kaminski M, Blondel B Déroulement et issue de la grossese chez les femmes immigrées: Approche médico-sociale Prévenir (in press). 5 Gofin J. The effect on birthweight of employment during pregnancy.J Biosoc 1979; 11: 259-67. 6 Naeye RL, Peters EC Working during pregnancy. Effects on the fetus. Pediatrics 1982; 69: 724-27. 7 Niswander KR, Gordon M. The women and their pregnancies. Philadelphia: WB Saunders, 1972.

INSERM Unit 149, 94800 Villejuif, France

MARIE JOSEPHE SAUREL MONIQUE KAMINSKI

PANORAMA ON BENOXAPROFEN

SiR,-In January, B.B.C. Television’s Panorama devoted two programmes, with the title "The Opren Scandal", to exploring the relations between doctors, drug regulatory authorities, and the pharmaceutical industry with special reference to the marketing of the non-steroidal anti-inflammatory agent benoxaprofen, a drug that was withdrawn last summer. As one who took part in the programme I would not disagee with any of the points made by Mr Tom Mangold or in your Jan. 29 editorial comment. When my own contribution was filmed, I thought I had given a balanced view, but Mangold used only those parts of my interview that were critical of benoxaprofen and which suited his own line of attack. For example, not broadcast was my point that, at the time benoxaprofen was withdrawn, it could not be shown to have been more dangerous, in terms of deaths in patients exposed, than aspirin, a non-steroidal anti-inflammatory drug for which drug-associated deaths do not even make the local papers and for which no prescription is necessary. However sure one may be of facts it must be remembered that in the interview game science is a secondary consideration. Mangold is one of the best in his profession and being interviewed by him was rather like me, an average golfer, taking on a top professional. Mangold stampeded the chairman of the Committee on Safety of Medicines, who was made to appear inept. Television programmes on medical matters should be viewed with caution since they are likely to show only the views of the professional journalists and interviewers in charge rather than those of the doctors who took part. Dermatology Department, Royal Infirmary, Sunderland SR2 7JE

T. C. HINDSON

476

SIR,-Your Jan. 29 editorial was rightly concerned at the alarming disclosures

,

in

the two B.B.C. Panorama programmes on were concerned that these programmes, full of We benoxaprofen. media expressions ("scandal", "sensation"), would seriously affect the doctor/patient relationship, especially with regard to research studies and even the routine prescribing of antirheumatic drugs. We consider patients’ reactions important and sought these in a brief survey. 66 patients with rheumatoid arthritis and other rheumatological conditions seen in the South Birmingham Health District within 10 days of the second programme were questioned. 35 (53%) had seen one or both programmes, and the reactions of these 35 patients are summarised in the table. PATIENTS’ RESPONSES TO B.B.C. PANORAMA PROGRAMMES ON BENOXAPROFEN

*5 patients

(14%) declined to comment.

Additional comments were invited where a positive response was declared. Nearly half the patients who saw the programmes had changed their attitudes to pharmaceutical companies. The attendant comments indicated concern that insufficient research and the profit motive had influenced the marketing of ’Opren’. There seemed to be little effect on the patients’ attitudes towards their physicians. More worrying was the fact that nearly half changed their attitude to taking medications. More detailed questioning, however, revealed that this only applied to "new" medications; no patient had stopped his or her current therapy. Most expressed a need for more detailed information about the drug and its side effects and this was also the opinion of those who had changed their attitude to participating in research trials. Only 1 patient, however, would have refused, as a result of the programmes, to participate in research. Most of those who saw the programmes found them enjoyable and useful, but 2 patients questioned had avoided the programmes because they felt they would be upset. The potential for such programmes to influence medical practice was all too evident after the Panorama broadcast on brain death. Of "The Opren Scandal" 1 patient wrote: "The media people are aiming for a spectacular story. We don’t know how reliable or unprejudiced they are. It would be unfortunate if the doctor/patient relationship was changed by such a programme". Our survey suggests that this will not happen in the West Midlands. While we may have to spend more time explaining matters to our patients-no bad thing-most patients are critical individuals who have seen through the sensational nature of the reporting. "’

Department of Rheumatology, Medical School, Queen Elizabeth Hospital, Birmingham B15 2TJ

G. R. STRUTHERS D. L. SCOTT D. G. I. SCOTT P. A. BACON

PATIENT/GP LIAISON GROUP

SIR,-While welcoming the establishment ofa patient/GP liaison group by the Royal College of General Practitioners I was concerned at the emphasis your Jan. 29 note on this project placed on "criticism" and "accountability". Doctors feel not only threatened but also considerably antagonistic as yet, to such moves, particularly if criticism is in the air. Fortunately, patient participation has very little whatever to do with the handling of grievances, but is all about the very positive contribution which lay people can make towards improving all aspects of the health care system. More than fifty practices in the U.K. now offer this opportunity to their patients, and very little of their time is spent handling grievances. Instead, such participation has led to all kinds of improvements in the health education, community care, and other facilities offered by these practices, as well as helping to

a productive and friendly relationship professionals and public. It is these aspects of participation which we all hope

cement

between the

new

group will concentrate their efforts upon. Whiteladies Health Centre, Clifton, Bristol BS8 2PU

T. P. PAINE

GENERAL PRACTICE AND THE INNER CITIES

SIR,-The responsibility for health care in inner London (the subject of your Parliamentary correspondent’s contribution to your Feb. 5 issue) should rest with the teaching hospitals. In most, perhaps all, peripheral centres there is a general practice health care unit that is integrated with the teaching group. If this were also true for London hospitals there would be no reason why they should not then be responsible for their own areas. It is common for such hospitals to complain about the misuse of their casualty departments by local residents who cannot obtain emergency care. Most London hospitals have a geriatric unit and they do supervise an accident-and-emergency department. With so many young doctors unemployed it would surely be reasonable for teaching hospital general practice units to employ several doctors at senior house-officer grade to back up the local GP service and at the same time to provide integration with hospital services. Such doctors might elect to continue in general practice, in which case that service ought to count as a first stage in GP training schemes, and those who volunteer for such duties could be given priority in applications for other posts (e.g., geriatric, obstetric, or paediatric) within their own hospitals. Work "on the district" was always undertaken by students in obstetric training. Such an approach would cost less than the 3million specially allocated for health care in the inner cities. And, given goodwill all round, it should be advantageous both to the teaching hospital and the local community. 33 Hawthorn Gardens, Kenton, Newcastle upon Tyne NE3 3DE

E. N. WARDLE

SMOKERS AND INSURANCE

SIR,-Dr Gullick (Feb. 5, p. 302) implies that offering insurance premium discounts to non-smokers might "increase the injustice" in a scheme where no such discount has been provided previously. His model for this increase is that of an ex-smoker who has an "early relapse" into smoking having been given a non-smoker’s discount. How a few such smokers ending up paying the same price as nonsmokers is an increase in injustice when compared with a scheme where all smokers are given the same price as non-smokers is not clear; surely, a few cases of inequity are better than wholesale inequity. If a current non-smoker were required not to smoke for a period of time sufficient to preclude much chance of a return to the habit this would be successful both actuarially and in natural justice. Presumably, those businesslike insurance companies which offer special discounts for non-smokers are convinced that their precautions to obviate injustice are also sufficient to make their schemes financially sound. May their entrepreneurial and equitable tribe increase. PHILLIP WHIDDEN, Association for Nonsmokers’ Rights, 82 St Stephen Street, Edinburgh EH3 5AQ Chairman

SIR,-Dr Gullick dodges the issue. Insurance companies do not lack the ability to devise ways of increasing premiums when proposers have a history of certain conditions and it cannot be beyond their capability to work out a similar arrangement for smokers. The question of family members is largely irrelevant. Medical insurance normally covers dependent children up until the age of 21; rather early to expect most of the major problems of smoking to be apparent. Sir Hugh Lockhart-Mummery (Feb. 5, p. 302) appears to imply that it is reasonable for the 90% of nonsmokers to subsidise the 10% who do smoke. I doubt the validity of this inference. Hambro Lodge, 141 Slough Road,

Datchet, Slough SL3 9AE

A. HOLMES PICKERING