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SMOKING AND PREGNANCY
905 PREPAID CHARGES
SMOKING AND PREGNANCY
IT is now widely accepted that babies born to mothers who have smoked during their pregnancy will be smaller than those born to non-smokers. The clinical significance of this observation will depend on whether the association is direct or not (smoking and birth-weight could be related, independently, to some third factor) and whether or not being small at birth is any disadvantage. Prof. C. Scott Russell and his colleagues in Sheffield have attempted to answer these questions in a prospective inquiry among women attending maternity units in Sheffield. They paid special attention to three points-maternal blood-pressure, a host of possible socioeconomic third factors, and the subsequent development of the infant.2 Analysis of blood-pressure in relation to smoking revealed that the proportion of regular smokers was highest (33%) in the group with pressures below 140/90 mm. Hg; in contrast, only a fifth of the women with high blood-pressure (150/100 mm. Hg or more) were smokers. Cases of high blood-pressure and multiple pregnancies were excluded from some of the subsequent analyses, which confirmed an association between low birth-weight and smoking. Furthermore, this association was found to be unequivocally independent of other factors, such as maternal age, parity, social class, and prematurity. Babies born to mothers who had smoked gained weight more rapidly at first, and head circumferences increased more quickly, but after one year there was little difference between the two groups. The clinical significance thus seems to be that smoking during pregnancy is directly associated with low birthweight and that this effect allows the children of smokers "
"
1. See Lancet, 1968, i, 702. 2. Russell, C. S., Taylor, R., Law, C. E. 119.
Br. J. prev.
in terms of physical development, for time after birth. Inquiry into any long-term effects must await further follow-up. The surprising bloodpressure findings remain unexplained: Duffus and MacGillivray3 noted a similar unexpected finding in a study of pre-eclamptic toxtmia-the incidence was twice as high among non-smokers as in women who smoked. In the Sheffield series, 4-1% of 1462 pregnancies where the mother was a non-smoker ended in abortion, stillbirth, or neonatal death: the figure for smokers was 7-9%Ła " highly significant " difference. The whole series included a number of " women threatening to abort, some with a bad obstetric history and others with medical, surgical, and obstetric disorders ". Russell and his colleagues do not say how these at-risk women fared is terms of unsuccessful outcome and how many of them smoked: that information might help the obstetrician in deciding what advice to give to women who smoke during
to
ritual of manipulating N.H.S. prescription another twist next Friday when prepaytakes charges ment certificates come into action. The aim of the season-tickets (30s. for six months and 55s. for a year) is to help patients who need frequent prescriptions but who are not otherwise exempt by reason of age, pregnancy, chronic illness,’ or financial need. The new arrangements will certainly help some of the chronically ill, but many of them who are on the fringe of need may continue to economise unwisely at 2s. 6d. per item rather than find 30s. at one go. Admittedly the prepayment scheme will, in certain circumstances, discourage benevolent overprescribing by doctors; and it will save some of the pharmacists’ and doctors’ time. But these gains could be substantially offset by the induction of a " getting our money’s worth " response from patients who feel the urge to take their prepayment certificates down to the surgery with excessive regularity. When cash has actually changed hands, not everyone will be able to resist the inclination to secure a bargain. Prescription charges were never a good idea, and the present system which exempts 20 million of the country’s inhabitants and allows the rest to pay in advance if they choose has precious little to recommend it. It is complicated, and it does not look as though it will save enough money to justify its existence. After all, the best controller of the drug bill is careful prescribing: charges have always been a feeble answer THE
soc.
Med. 1968,
22,
be
distinguished,
some
pregnancy.
WHERE NO EAGLES ...
THE golden eagle, observing that the talons of its fledglings grow daily sharper, drives the young birds from the nest and ferociously resists their efforts to
Junior medical staff in the National Health Service may have some fellow feeling for the eaglets. And if the maxim that age and youth can never live is true, they might well deny that this is because together " is youth full of pleasance and age is full of care." In the introduction to his report On the State of the Public Health,4Sir George Godber acknowledges the problems of young doctors. He calls for planned and purposeful training schemes, and suggests that until these doctors see before them the prospect either of modern medicine in general practice, or of responsible specialist work in hospital at a much earlier age than that at which consultants are now appointed, confidence will not be restored. In other respects Sir George’s comments are more optimistic. Last year he suggested that 1966 had been a turning-point for the Health Service,5and he believes that progress in 1967 bore out his words. The most return.
important development was the growing interdependence of hospital and community health services. The number of health centres had increased strikingly, and there were signs that family doctors, by making the fullest use of services provided by the local authorities, were substantially narrowing the gap between hospital and community. On the other side of the gap, many hospitals had accepted the recommendations of the Joint Working Party for the better integration of hospital work with community services-for example, the new hospitals planned for Frimley and Bury St. Edmunds would use a maximum of community care. The policy of building hospitals as part of a community complex, rather than to run as well as efficient. The report makes as good reading as it did last year, which is high praise. In general the picture it presents is encouraging. Sir George Godber may in many ways be an eagle, but those who read the report will see that he and his colleagues come from an enlightened brood.
in
isolation, would make them cheaper
more
3. Duffus, G. M., MacGillivray, I. Lancer, 1968, i, 994. 4. On the State of the Public Health: annual report of the chief medical officer of the Ministry of Health, 1967. H.M. Stationery Office. 28s. 5. See Lancet, 1967, ii, 816.
SMOKING AND PREGNANCY
IT is now widely accepted that babies born to mothers who have smoked during their pregnancy will be smaller than those born to non-smokers. The clinical significance of this observation will depend on whether the association is direct or not (smoking and birth-weight could be related, independently, to some third factor) and whether or not being small at birth is any disadvantage. Prof. C. Scott Russell and his colleagues in Sheffield have attempted to answer these questions in a prospective inquiry among women attending maternity units in Sheffield. They paid special attention to three points-maternal blood-pressure, a host of possible socioeconomic third factors, and the subsequent development of the infant.2 Analysis of blood-pressure in relation to smoking revealed that the proportion of regular smokers was highest (33%) in the group with pressures below 140/90 mm. Hg; in contrast, only a fifth of the women with high blood-pressure (150/100 mm. Hg or more) were smokers. Cases of high blood-pressure and multiple pregnancies were excluded from some of the subsequent analyses, which confirmed an association between low birth-weight and smoking. Furthermore, this association was found to be unequivocally independent of other factors, such as maternal age, parity, social class, and prematurity. Babies born to mothers who had smoked gained weight more rapidly at first, and head circumferences increased more quickly, but after one year there was little difference between the two groups. The clinical significance thus seems to be that smoking during pregnancy is directly associated with low birthweight and that this effect allows the children of smokers "
"
1. See Lancet, 1968, i, 702. 2. Russell, C. S., Taylor, R., Law, C. E. 119.
Br. J. prev.
in terms of physical development, for time after birth. Inquiry into any long-term effects must await further follow-up. The surprising bloodpressure findings remain unexplained: Duffus and MacGillivray3 noted a similar unexpected finding in a study of pre-eclamptic toxtmia-the incidence was twice as high among non-smokers as in women who smoked. In the Sheffield series, 4-1% of 1462 pregnancies where the mother was a non-smoker ended in abortion, stillbirth, or neonatal death: the figure for smokers was 7-9%Ła " highly significant " difference. The whole series included a number of " women threatening to abort, some with a bad obstetric history and others with medical, surgical, and obstetric disorders ". Russell and his colleagues do not say how these at-risk women fared is terms of unsuccessful outcome and how many of them smoked: that information might help the obstetrician in deciding what advice to give to women who smoke during
to
ritual of manipulating N.H.S. prescription another twist next Friday when prepaytakes charges ment certificates come into action. The aim of the season-tickets (30s. for six months and 55s. for a year) is to help patients who need frequent prescriptions but who are not otherwise exempt by reason of age, pregnancy, chronic illness,’ or financial need. The new arrangements will certainly help some of the chronically ill, but many of them who are on the fringe of need may continue to economise unwisely at 2s. 6d. per item rather than find 30s. at one go. Admittedly the prepayment scheme will, in certain circumstances, discourage benevolent overprescribing by doctors; and it will save some of the pharmacists’ and doctors’ time. But these gains could be substantially offset by the induction of a " getting our money’s worth " response from patients who feel the urge to take their prepayment certificates down to the surgery with excessive regularity. When cash has actually changed hands, not everyone will be able to resist the inclination to secure a bargain. Prescription charges were never a good idea, and the present system which exempts 20 million of the country’s inhabitants and allows the rest to pay in advance if they choose has precious little to recommend it. It is complicated, and it does not look as though it will save enough money to justify its existence. After all, the best controller of the drug bill is careful prescribing: charges have always been a feeble answer THE
soc.
Med. 1968,
22,
be
distinguished,
some
pregnancy.
WHERE NO EAGLES ...
THE golden eagle, observing that the talons of its fledglings grow daily sharper, drives the young birds from the nest and ferociously resists their efforts to
Junior medical staff in the National Health Service may have some fellow feeling for the eaglets. And if the maxim that age and youth can never live is true, they might well deny that this is because together " is youth full of pleasance and age is full of care." In the introduction to his report On the State of the Public Health,4Sir George Godber acknowledges the problems of young doctors. He calls for planned and purposeful training schemes, and suggests that until these doctors see before them the prospect either of modern medicine in general practice, or of responsible specialist work in hospital at a much earlier age than that at which consultants are now appointed, confidence will not be restored. In other respects Sir George’s comments are more optimistic. Last year he suggested that 1966 had been a turning-point for the Health Service,5and he believes that progress in 1967 bore out his words. The most return.
important development was the growing interdependence of hospital and community health services. The number of health centres had increased strikingly, and there were signs that family doctors, by making the fullest use of services provided by the local authorities, were substantially narrowing the gap between hospital and community. On the other side of the gap, many hospitals had accepted the recommendations of the Joint Working Party for the better integration of hospital work with community services-for example, the new hospitals planned for Frimley and Bury St. Edmunds would use a maximum of community care. The policy of building hospitals as part of a community complex, rather than to run as well as efficient. The report makes as good reading as it did last year, which is high praise. In general the picture it presents is encouraging. Sir George Godber may in many ways be an eagle, but those who read the report will see that he and his colleagues come from an enlightened brood.
in
isolation, would make them cheaper
more
3. Duffus, G. M., MacGillivray, I. Lancer, 1968, i, 994. 4. On the State of the Public Health: annual report of the chief medical officer of the Ministry of Health, 1967. H.M. Stationery Office. 28s. 5. See Lancet, 1967, ii, 816.