Some aspects of social obstetricsVinodini P Desai, Vijaya R Bhalerao, DN Pai
Department of Preventive and Social Medicine, Seth G. S. Medical College, Parel, Bombay-400 012., India
The effects of environmental and social factors on reproductive performance were studied. 664 General hospital patients (Group A) were compared with 207' private hospital patients (Group B). The data was analysed statistically. Mean age of marriage in Group B was higher than in Group A. No difference was observed in the spacing between the last child and present delivery. Previous reproductive loss such as abortions, still-births, neo-natal death rate and child-mortality was higher in Group A.. In present deliveries, the percentage of low birth weight babies was higher in Group A than in Group B. The nuclear type of family, poor state of housing, less per capita space available and hard work increased the incidence of low birth weight babies and mortality in Group A. Higher percentage of mothers with medical complications was observed in Group A which adversely affected birthweight and mortality.
The recognition and scientific study of social obstetrics is a recent development pioneered by Sir Dugald Baird  after the World War II. In a series of papers, he and his colleagues and many other workers have reported upon a wide variety of those social factors which, we now know, can have profound effects on the outcome of pregnancy.
The need to explore the adverse effects of environmental and social factors in our country on reproductive efficiency is urgent.
In Bombay, institutional deliveries account nearly 92% of the total.  With the improvement in obstetric and surgical techniques, the medical causes of maternal morbidity have declined, but the social causes still continue to play their role in morbidity and mortality in obstetric practice.
The aim of this work was to study the effects of complex social factors on reproductive performance, as judged by birthweight, still-birth rate, neonatal death rate, maternal risk, maternal and foetal morbidity and mortality.
We have compared data obtained from C64 women admitted to a large free Municipal teaching hospital with that from 207 women admitted to two nearby private hospitals. All the data was submitted to statistical analysis.
One out of every three women admitted for delivery to the teaching hospital during an eight month period (January to August 1973) was included in this series, whereas, all women admitted to the two private hospitals were included because less number of women were admitted to the private hospitals during the same period.
All these women were categorised according to the socio-economic classification of Prasad.  The criteria for this classification were as follows:
Class I represented a group having per capita income per month of Rs. 300 or above; Class II with income varying between 150 and 299 rupees; Class III-Rs. 70-149; Class IV-Rs- 30-69 and Class V had per capita income of Rs. 30 or below.
These women were further studied for the following social variables: age distribution, their ages at marriage, spacing between the last child and present one. previous reproductive loss, type of family, type of dwelling, per capita space available, type of work done by the mother, mother's educational status, antenatal visits, medical illnesses during pregnancy, type of labour, awareness and attitude towards family planning and postnatal visits.
Among the hospital patients, 97 belonged to Class III, 415 to Class IV and 152 to Class V. In contrast among private patients 14 belonged to Class I, 156 to Class II and 37 to Class III. This showed an interesting observation that patients belonging to Class I & II never attended the general hospital whereas patients belonging to Class IV & V could not afford to attend private hospitals and had to come to the free general hospitals.
The husbands of majority of hospital patients were unskilled and semiskilled workers, commonly working in mills. The husbands of private patients by contrast, were white collared employees or ran a business.
Age of Mother
The mean age of mothers in both the groups was 25 years, the range being 16 years to 45 years.
Age at Marriage
The mean age at marriage in hospital patients was 17 years while it was 21 years in private patients. It varied directly with the per capita income and inversely with the socio-economic class. 100 of the hospital patients had been married before the age of 12 years. There was no similar instance of early marriage in the private patients.
Previous reproductive loss in terms of abortions, miscarriages and still-births increased from Class I to Class V [Table 1].
The difference between the two groups was found to be statistically significant.
Neonatal, postneonatal (1 month-1 year) and child mortality was 15.5% in hospital patients and 8.7% in private patients. The difference is statistically significant.
A study of the time interval in years between the last child and present delivery showed that there was no planning of pregnancies in either group of women [Table 2].
Place of Previous Deliveries
14% of hospital patients had had domiciliary deliveries in the past whereas in the case of private patients the figure was only 6%.
Low-birth weight, still-births and early neonatal deaths-(upto 5 days in hospital patients and 10 days in private patients) were studied in relation to social variables.
The percentage of low birth weight babies (less than 2000 gms. as
Type of Family
The incidence of low birth weight deliveries was 20% in nuclear families and 13.5% in joint families in the hospital patients whereas the corresponding figures were 12.6% and 12.2% in the private patients.
Among the hospital patients still-birthcum-neonatal mortality rate was higher in nuclear (12.3%) than in joint (9.7% ) families though this difference was not statistically significant. Still births cum neonatal mortality rate was similar in nuclear (2.7%) and joint (2.04%) families in the private patients.
Type of Housing
The type of housing appeared to bear significant influence on the weight of the baby [Table 3].
The incidence of low birth weight babies was significantly different between zopada dwellers and chawl dwellers, as well as, between chawl dwelers and flat dwellers in hospital patients. It was not significantly different when the flat dwellers and chawl dwellers among the private patients were compared.
Space Available per Capita
Population density and overcrowding are significantly associated with low birth weight and high mortality [Table 4].
There were only five deaths in Private patients. This number was too small for detailed breakdown.
Type of Work Done by the Mother
Mothers who worked till late in pregnancy especially those who engaged in heavy manual labour and those who had great physical strain, tended to have babies of low-birth weight, and the neonatal mortality was also higher [Table 5],[Table 6].
In Hospital patients 44.8c/% were illiterate, 23.78% had received only primary education, 25.9% secondary education and only 5.4% were matriculate. In private patients only 13.5% were illiterate and 79.6% were educated above matriculation.
All women irrespective of education and socio-economic status had registered in the hospitals in the 7 th month of pregnancy.
In hospital patients the late comers and the under-users of antenatal clinics were 21.3% as compared to only 1.92% in private patients.
3.4% of hospital patients paid very early visit (i.e. before 24th week) and more than five visits because they had medical problems, as compared to only 20% in private patients; this difference was significant.
In hospital patients, 23.4% of women paid only one antenatal visit, 24.8% of women paid more than five visits and 14.0% of women came as emergencies.
Other Associated Illnesses
Medical illnesses including anaemia, oedema, toxaemia, accidental haemorrhage, hypertension, diabetes, syphilis, tuberculosis were more frequent in hospital patients. (41.7%) whereas in private patients only 26.5% had these complications. This difference is statistically significant.
Anemia-In hospital patients 28.7% were anemic (hemoglobin below 10.5 gms%) whereas 7% of the private patients were anemic. The difference is statistically significant.
In hospital patients 20% of anemic mothers gave birth to low birth weight babies. In non-anemic mothers, 8.5% gave birth to low birth weight babies. The difference of 20% and 8.5% was statistically significant.
In private patients, 25% of anemic mothers and 10.7% of non-anemic mother; gave birth to low birth weight babies The difference was significant.
The difference of 18.1% and 9.8% was not statistically significant. The difference of 15.4% and 9.8% was of borderline significance. In hospital babies, foetal mortality was nearly equal in normal or sick women.
There were only two deaths in hospital patients and none in private patients.
Type of Labour
The incidence of prolonged labour, forceps and Caesarean Section was higher in private patients (11.1%) than in hospital patients (7.5%) though the difference was not significant.
Foetal morbidity and mortality in women having normal labour in hospital patients was 11.3% whereas in those with abnormal labour it was 32.2%.
Infections -The rate of infection in hospital patients was 4.0% in mothers and 4.5% in new born babies.
In private patients the rate was 1 % in mothers and the same in new born babies.
Family Planning-Awareness and knowledge of family planning was present in 57.3% of hospital patients and 88.8% in private patients. 42.0% of hospital patients and 77.8% of private patients said they were in favour of family planning.
Post-natal Surveillance: Of hospital patients only 22.0; came for follow-up. Out of these, 2% had come to the regular post-natal clinic, where their primary intention was to get their babies examined.
90% of private patients paid regular post-natal visits averaging to five.
Age at marriage varies directly with the Socio-economic class. Marriage below 12 years of age still occurred in hospital patients. Ogale  noted the mean age at marriage as 16.2 years in India.
Increased reproductive loss in terms of abortions, miscarriages and still births among hospital patients could be due to low nutritional status, anemia, repeated pregnancies, physical stress and infections.
44% of infant deaths occur in neonatal period due to poor viability of the infant arising from maternal malnutrition. 40%, of neonatal deaths are due to prematurity.  Infections, ,, malnutrition and accidents are responsible for deaths in infants and toddlers.
The frequency of domiciliary delivery is declining.
The mother is identified by the type of house in which she lives, her family structure, the available living space and type of work she does.
It appears that a nuclear family gives much more privacy but it lacks in the social security and protection provided by the joint family in times of illness, financial crisis; moreover, the poor overburdened mother suffers the most. 
The type of housing bears a significant association with the weight of the baby. Poor housing conditions and poverty reflected on the mother's constitution.
According to the recent survey by the Tata Institute of Social Sciences, four out of every five houses provide a living area of not more than 25 sq. ft. per head, which is the minimum recommended under the Bombay Municipal Act. Four out of every five families in Bombay live in one room tenements.  Population density and overcrowding were significantly associated with the low birth weight babies and foetal mortality. Similar results were obtained in a study of premature births and perinatal deaths in Indiana by Thompson. 
Women who work till late in pregnancy tended to have babies of low birth weight and also had increased foetal mortality.
No trends were observed between mother's work and birth weight by Pachauri and Marwah. 
It is a common practice to pay the first antenatal visit in the 7th month of pregnancy. In the hospital patients it has been made compulsory to register for delivery at least in the 7th month of pregnancy. The same trend was observed in all women irrespective of whether they were rich or poor,, literate or illiterate.
The awareness of utilisation of services did not depend on education. However in hospital patients, it depended on medical problems. Women with medical problems attended the antenatal clinics more often than those without medical problems.
Pregnancy wastage was significantly higher in hospital patients with medical problems than in private patients with medical problems. This implied that though mothers at risk are present in the private group the increase of pregnancy wastage among them was negligible. Women in private hospitals took full advantage of the skilled obstetric care and services.
In hospital patients, the foetal loss had been same whether mothers were normal or with the medical problems.
In hospital patients, foetal loss was less when the labour was normal than when it was abnormal; however, in both groups, it was significant.
As regards family planning, there was a high degree of awareness in these women except in those who were extremely uneducated. Attitude towards acceptance of family planning methods depended on many fac.ors lake number of living children, sex of the child, mother's illness and religious beliefs etc.
In urban areas only 14.6% of men and 13.1% of women said they had ever practiced family planning. 
Private patients were much more aware and regular towards post-natal care than hospital patients.
We are thankful to Dean, Seth G. S. M. College and K.E.M. Hospital, Bombay, for allowing us to use the hospital data and for publishing the work.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]