Academic journal article Bulletin of the World Health Organization

Preventive Medicine in Obstetrics(*)

Academic journal article Bulletin of the World Health Organization

Preventive Medicine in Obstetrics(*)

Article excerpt

JOHN CLARENCE CUTTER, as has previously been mentioned, was born in 1851 and graduated at Harvard Medical School in 1877, after which he went to Japan as professor of physiology and comparative anatomy in the College of Agriculture in Saffara. Possibly the experience gained in the nine years he held this post strengthened his great belief in the part that preventive medicine might play in influencing the destiny of man. In his will he allocated half of the net income of his estate to the founding of an annual course of lectures on preventive medicine. I am proud to be, in this, the centenary year, the first obstetrician chosen to deliver a Cutter Lecture.

I propose to deal in this lecture with some of the environmental factors that affect the outcome of pregnancy, rather than with the effects of medical care and treatment during pregnancy or labor.

Reproduction is influenced by heredity and environment. The importance of heredity as a factor in reproduction is proverbial: "like father, like son"; "you cannot make a silk purse out of a sow's ear." There are fewer cliches about the effect of environment, although there is no doubt that reproduction is greatly influenced by custom, tradition, nutrition, standard of education and economic factors.

It seems reasonable to suppose that those who enjoy a high standard of living, -- that is to say, good food, housing and education, -- will show a higher standard of reproductive performance than those with a low standard of living. The Registrar General's reports in Britain provide a convenient starting-off place for studying death rates by standard of living. He has divided the population into five social classes. Social Class I comprises the more highly paid professional and business groups and Social Class V the casual and unskilled manual laborers. About 50 per cent of the population are in Social Class III, which includes the skilled craftsmen and lower-salaried professional and clerical groups. The classification depends on the social prestige of the occupation as well as on the rate of pay. Analysis of national figures shows that from Social Class I to V there is a steady decline in the stillbirth and infant mortality rates. The influence of social gradient is least in the case of stillbirths and most in the period from one to twelve months. Deaths in the latter group are nearly all due to infection, and the mortality in this period has now been recognized as a very delicate index of environmental conditions. Any deterioration in living standards is reflected immediately in a rise in mortality in the period of one to twelve months. The relatively small difference in the stillbirth rate between the social classes might suggest that superior environment of those in Social Class I did not have much influence in improving reproductive performance. I should like to examine this problem more closely by describing some of the results of our own work on this subject.

The City of Aberdeen is particularly suitable for social research in obstetrics, since there are about 3000 births per annum, a convenient number to handle. The population is genetically fairly uniform; very little movement in and out of the city occurs; and there is only one hospital group. We have studied primigravidas in the first place; 95 per cent of patients having a first baby are confined in hospital, 85 per cent being free (hospital) patients and 10 per cent private (nursing home) patients. The private patients are confined in a former private dwelling house converted for this purpose with a very few minor structural alterations. The total cost to the patient is between 30 [pounds sterling] and 60 [pounds sterling]. The others are confined in the large teaching hospital and pay no fees. Table 1 shows that both the stillbirth rate and the neonatal mortality are less in the private patients. In the case of neonatal mortality this is due entirely to the very small death rate in premature babies. …

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