This post is part of our Public Health Classics series. Sara Gorman is a frequent contributor to that series, and her Classics post on the Whitehall studies addresses a topic similar to today's subject: the influence of socioeconomic status on health.
By Sara Gorman
How much of a patient’s social context should physicians take into account? Is an examination of social factors contributing to disease part of the physician’s job description, or is the practice of medicine more strictly confined to treatment rather than prevention? In what ways should the physician incorporate public health, specifically prevention, into the practice of medicine?
These are the questions at the heart of Dugald Baird’s 1952 paper in The New England Journal of Medicine, “Preventive Medicine in Obstetrics.” The paper originated in 1951 as a Cutter Lecture, so named after John Clarence Cutter, a 19th-century medical doctor and professor and physiology and anatomy. Cutter allocated half of the net income of his estate to the founding of an annual lecture on preventive medicine. Baird was the first obstetrician to deliver a Cutter Lecture. Baird’s paper draws much-needed attention to the role of socioeconomic factors in pregnancy outcomes.
Baird begins by describing the Registrar General’s reports in Britain, which divide the population into five social classes. Social Class I comprises highly paid professionals while Social Class V encompasses the “unskilled manual laborers.” In between are the “skilled craftsmen and lower-salaried professional and clerical groups”; the categorization recognizes that job prestige as well as income is important in social class. Baird proceeds to present data on maternal and child health and mortality according to social group as classified by the Registrar General’s system. He makes several essential observations: social class makes relatively little difference in the stillbirth rate, but mortality rates in the first year of life are lowest for the highest social class (Social Class I) and highest for the lowest social class (Social Class V). Social inequality is thus felt most keenly in cases of infant death from infection, which Baird calls “a very delicate index of environmental conditions.”
Baird goes on to analyze data on stillbirths and child mortality from the city of Aberdeen, Scotland, which he chose because the number of annual primigravida (first pregnancy) deliveries at the time was relatively small and therefore manageable from an analytic standpoint and because the population in the early 1950’s was relatively “uniform.” When comparing births in a public hospital versus a private facility (called a “nursing home” in the paper, although not in the sense generally understood in the U.S. today), many more premature and underweight babies died in the public hospital than in the private nursing home, even though only the former had medical facilities for the care of sick newborns. The difference could not, therefore, be explained by the quality of medical care in the two facilities.
Baird concludes that this discrepancy must have something to do with the health of the mothers. Upon closer examination, Baird recognizes that the mothers in the private nursing home are not only healthier but also consistently taller than the mothers in the public facility. According to Baird, the difference in height must have to do with environmental conditions such as nutrition, a reasonable conclusion although Baird in fact did not have available data on ethnicity or other factors that might have also contributed. As the environment deteriorates, the percentage of short women increases. Baird notes that height affects the size and shape of the pelvis, and that caesarean section is more common in shorter women than taller women. Baird began classifying patients in the hospital in one of 5 physical and functional classes. Women with poorer “physical grades,” who also tended to be shorter, had higher fetal mortality rates. He also observes that most women under the age of 20 had low physical grades, stunted growth, and came from lower socioeconomic statuses. Baird spends some time examining the effects of age on childbearing, looking at women aged 15-19, 20-24, 25-29, 30-34, and over 35. Baird found that the most significant causes of fetal death in the youngest age group (15-19) were toxemia, fetal deformity, and prematurity. Fetal deaths in women aged 30-34 tended to be due more frequently to birth trauma and unexplained intrauterine death. The incidence of forceps delivery and caesarean section grew sharply with age, and labor lasting over 48 hours was much more common among the older age groups.
In a turn that was unusual at the time, Baird considers the emotional stress associated with difficult childbirth and quotes a letter from a woman who decided not to have any more children after the “terrible ordeal” of giving birth to her first child. This close consideration of the patient’s whole experience is a testament to Baird’s concern with the patient’s entire context, including socioeconomic status.
Baird concludes by making a series of recommendations for remedying social inequalities in birth outcomes, some of which make perfect sense and some of which now strike us as outrageously dated. An example of the latter is his suggestion that “the removal of barriers to early marriage” would improve birth outcomes among young women. In fact, we now know that early marriage can have a negative impact on women’s sexual health, sometimes increasing incidence of HIV/AIDS.
Despite the occasional “datedness” of Baird’s paper, his analysis is not only a public health classic in its attempt to bring social perspective back into the practice of medicine but it also contains lessons that are still crucial today. Baird’s paper reminds us that gender is often at the very center of health inequities, and that maternal and infant mortality constitute a major area in which socioeconomic inequalities directly and visibly affect health outcomes. While maternal and infant mortality rates are not high in the developed world, they still constitute serious health problems in developing countries. Infant mortality in particular can be used as a useful indicator of socioeconomic development. Most importantly, Baird’s paper, written in an age when the medical field began relying increasingly on biology and technology, reminds us that it has much to gain from paying attention to social factors that have a crucial impact on health.
Sara Gorman is a PhD candidate at Harvard University. She has written extensively about HIV, TB, and women’s and children’s health for a variety of public health organizations, including Save a Mother and Boston Center for Refugee Health and Human Rights. She most recently worked in the policy division at the HIV Law Project.