Dugald Baird

ENVIRONMENT AND REPRODUCTION

Using national perinatal death statistics extending back to the 19th century and more recent and detailed data from Scotland, it can be shown that death rates from central nervous system deformities and from other causes, generally associated with the mothers socio‐economic circumstances, are related to the period at which the mother herself was born and reared. For example, the increased death rate from anencephaly which occurred throughout the late 1940s and the 1950s can be attributed to cohorts of women who were all born during the great economic depression of 1926 to 1937. While advances in obstetric care will probably continue to reduce the perinatal mortality rate, it is unlikely that rates similar to those in Sweden can be achieved until a generation of women has been reared in an environment comparable to that in Sweden where social class differences in stature have disappeared.

Epidemiology of congenital malformations of the central nervous system in (a) Aberdeen and (b) Scotland

The incidence of anencephalus and other malformations of the central nervous system (CNS) is much higher in the United Kingdom than in other countries of Western Europe which were not industrialized to the same extent. In the UK the incidence is highest in the unskilled manual occupational group, especially in the large cities of the North of England, Scotland and Northern Ireland. Standards of living have been low in these areas for many years and deteriorated sharply at the time of the worldwide industrial depression from 1928 to 1934. The population tended to be stunted in stature and to show other signs of chronic malnutrition. The cohort of women born in these years had an unusually high stillbirth rate from anencephalus (and from all other CNS malformations) from about 1946 onwards. It was highest in the early 1960s when these women were at the peak of their reproductive activity. This suggests that the severe malnutrition to which they were subjected before and soon after birth resulted in severe damage, which reduced their reproductive efficiency as demonstrated by the unusually high perinatal death rate from all CNS malformations. Not surprisingly the death rate rose sooner, lasted longer and reached a higher level in social classes IV and V than in social classes I and II. Other evidence of damage was an increase in the incidence of low birth weight babies with a corresponding increase in the perinatal death rate from this cause. In Scotland the stillbirth rate from anencephalus was approximately 2·1 per 1000 in 1948–49, 3·4 at its highest point between 1961 and 1963 and 2·1 in 1968, by which time the women born in the years of the depression had completed their childbearing. A teratogen acting during a particular period of time could not provide a satisfactory explanation for this sequence of events.

The epidemiology of low birth weight; changes in incidence in Aberdeen, 1948-72.

n Changes in the incidence of low birth weight (defined as 2500 gm or less) in Aberdeen, Scotland are explored. The article also focuses on the perinatal mortality rate associated with unexplained low birth weight (LBW). Results, when analysed in terms of age, parity and social class of the mother, showed that in para 0 the incidence was highest in 1948-52. There was very little variation in incidence in each five year group in terms of para 1. The incidence of LBW was most strongly influenced by the socioeconomic climate at the time of the mothers birth. At least in Aberdeen the incidence of LBW in short women was twice that in tall women. The author concludes that the epidemiological characteristics of LBW is very closely associated with the changes in the socioeconomic conditions in Britain in the last decade which have affected health, nutrition and reproductive efficiency.n

Changing problems and priorities in obstetrics

Summary. National perinatal mortality data suggest that the root causes of many deaths may lie in the environmental circumstances in which the mother grew up. Aberdeen primigravidae under the age of 20 years who gave birth to a baby with a birthweight of <2500 g between 1968 and 1972 were divided into those where there was an associated obstetric complication and those where the cause of the low birthweight infant was ‘unexplained. The ‘unexplained’ group were more often smaller, underweight, cigarette smokers, and from relatively large families in the lower socioeconomic classes. Investigations of case records and by interview revealed that the mothers of these primigravidae were similarly disadvantaged and it is argued that further improvement in perinatal health and mortality will depend on the elimination of this continuity of social disadvantage.

PERINATAL MORTALITY IN HONG KONG AND IN ABERDEEN, SCOTLAND

BETWEEN 1951 and 1958 the official stillbirth rate in Hong Kong fell from 17 to 12 per 1,000 and during this time the rate in England and Wales remained fairly stationary at about 23 per 1,000. Taking into account the adverse social conditions in Hong Kong and the influx of about 1 million refugees from China since 1949 one might be justified in assuming that the official statistics were grossly inaccurate and misleadingly low. During a brief visit to the Colony in 1957 one of us (D.B.) found reason to believe that the explanation might be less simple. It was accordingly arranged, with financial support from the Colonial Office, for Dr. Thomson to visit Hong Kong for 6 weeks during October-November, 1959, to examine the situation more closely and to make any observations that might be feasible in that time. It became clear that a comparison of perinatal mortality in Hong Kong and Aberdeen would be very worth while, because conditions differed greatly in many respects, and the data made available by the Director of Medical Services and the University Teaching Hospital were so complete and carefully compiled that vital statistics could be estimated with a high degree of accuracy. In addition, since the standard of obstetric care given in the Tsan Yuk University Teaching Hospital was up to that found in teaching hospitals in Britain, any differences in perinatal mortality between the Aberdeen Maternity Hospital and the Tsan Yuk Hospital are unlikely to be due to differing standards of obstetric care.

The Upper Urinary Tract in Pregnancy and Puerperium with Special Reference to Pyelitis of Pregnancy. (Continued from Vol. 42, p. 794)

IV. PYELITIS OF PREGNANCY. Pyelitis is inflammation of the renal pelvis. When the renal parenchyma is affected, the condition is termed pyelonephritis. I have used the term pyelitis in this study to include both types, as it is often very difficult to decide whether the inflammation is limited to the renal pelvis or not. Many urologists consider simple pyelitis to be rare, and that most often the renal parenchyma is primarily infected, with secondary involvement of the renal pelvis. Wilson and Schloss (1929) found at autopsy in a series of cases of pyelo-nephritis in children, that the renal pelvis was seldom involved. In pregnancy, however, there is obstruction to the outflow of urine and consequent stasis in the upper urinary tract which makes the renal pelvis and ureter more liable to infection, without the parenchyma being necessarily involved.

A Study of Ureteral Tone During Pregnancy.

SINCE the problem of the activity of the uterus, which has been the main subject for discussion at this meeting, is probably closely associated with that of the ureters during pregnancy, I venture to bring before you this preliminary communication regarding a method of estimating ureteral tone. I t is now well known that dilatation and stasis occur in the ureters vcry frequently during pregnancy, believed by some to be due to an atony which is a normal accompaniment of pregnancy, by others to be due to pressure on the ureters by the pregnant uterus. I t is likely that both factors play a part in the production of the dilatation and stasis but it is difficult to estimate their relative importance. There is no doubt that the uterus does compress the ureters at the level of the pelvic brim, but this does not constitute the sole factor in the production of the dilatation for several reasons. First, the amount of dilatation and kinking is very much greater than that produced by tumours of similar size in nonpregnant women ; secondly, the dilatation reaches its maximum about the sixth month of pregnancy, and in many cases diminishes towards term, despite the increase in size of the uterus; and thirdly, it varies in different patients much more than one would expect. Some other factor must exist. From the evidence supplied by chromocystoscopy and intravenous pyelography it seems likely that atony of the urinary tract occurs early in pregnancy, and increases as the pregnancy advances, so that at the fourth month even the soft uterus pressing on the ureters at the pelvic brim is enough to cause dilatation and stasis above this point. Towards term the atony disappears so that although the pressure of the uterus is now greater, the stasis

The Changing Pattern of Human Reproduction in Scotland, 1928–72

Fifty years ago, in the early 1920s, Marie Stopes published her books on childbearing, contraception and sex, and immediately became famous. Indeed recently when an American jury was asked to select the 25 most influential books published in the previous 50 years, Marie Stopes was one of a list of twelve authors which included Marx, Lenin, Freud, Einstein, William James and Hitler. I was fortunate to read her books when I began my career as a practising obstetrician in Glasgow in 1928 and I propose to discuss the changes in human reproduction which have occurred in the last 50 years under the headings of three of Marie Stopes best known books: (1) Radiant Motherhood , (2) Planned Parenthood and (3) Married Love .

THE CONTRIBUTION OF OPERATIVE OBSTETRICS TO THE PREVENTION OF PERINATAL DEATH

WILLIAM SMELLIE began to practise as a doctor in his native town of Lanark in the year 1720 without a University degree or a licence from the Faculty of Physicians or Surgeons. No formal qualification was essential and Smellie probably entered the profession by apprenticeship. In any case there seems to have been little organized teaching of medicine at that time, although Edinburgh had Professors of Botany, Chemistry, Anatomy and Physics. Those who had the means to do so, went abroad to Leyden or Paris; those who had not, became apprenticed to a practitioner at home. The difficulties of midwifery practice must have been formidable. Homes were primitive and poverty and famine were widespread, so that many of the women that Smellie was called to see because of prolonged or obstructed labour were extremely debilitated. Sometimes the untrained midwife had made imprudent attempts to complete the delivery of a baby lying in an abnormal position by internal manipulations. Even in London the standard of living was very low. It is reported that only one in four children survived to the age of 5 and the exposure of unwanted children and even infanticide were commonplace. It was in these circumstances that Smellie emerged as an outstanding teacher and writer and an excellent practical obstetrician. He invented what became known as the English or Smellie Lock, and also the pelvic curve, the object of which was to enable the forceps to obtain a better grasp of the head when it was high in the pelvis and to enable this to be done without the perineum being damaged by any undue backward pressure of the handles. While there is no evidence that Smellie ever performed Caesarean section he gave a brief

Some impressions of childbearing in tropical areas Part 2: Pre-eclampsia and low birth weight.

A higher-than-average incidence of pre-eclampsia and lower-than-average incidence of prematurity has been found to occur in women who gain much weight during pregnancy in Aberdeen Scotland and West African and South East Asian populations. Women in villages in West Africa and in Borneo tend to be thin and to put on a small amount of weight during pregnancy. Low preeclampsia during pregnancy and high prematurity rates have been exhibited by these women. Regardless of their residence the Chinese populations studied have a low incidence of preeclampsia and prematurity. Factors favoring successful pregnancy in Chinese populations include low age group (20 to 24) slim build prior to and moderate weight gain during pregnancy.