Discuss the implications of social inequality for midwifery practice.
Inequalities in health and the risks of premature death have been recorded since the 19th Century (Graham 1999). This is a continuing cause for concern in the 21st Century, especially when linked to midwifery practice and maternity care as a whole. For the purpose of this essay I will attempt to discuss social inequality, and the implications it has for midwives and the care they provide.
Social class remains an enduring theme in the sociology field. Class differentials have been constructed within a capitalist society according to an individual’s relationship to the labour market. Hence, in this respect the notion of class is derived from economic events and as such it is an economic category (Heptinstall 1997). The use of class as a social category has often been accepted uncritically and taken for granted as a natural category. For example, in a comparative study of kinship between working class and middle class families in East London in the 1950s (Willmott & Young 1957), the use of social class categorization is largely descriptive and the authors do not perceive class as problematic.
Oakley (1992) describes how social class can be regarded as a designation introduced by statisticians to describe occupational and social differences between people. Clearly, there are differences, but Oakley emphasizes, "What social class differences do not do is explain anything" (Oakley 1992).
The new science of "vital statistics" developed in the mid 19th Century (Heptinstall 1997). At this time there was concern amongst politicians and economists over civil unrest in both rural and urban areas. Civil servants collected information about individuals’ home ownership, occupation, marital status and other social distinctions. From this time onwards, successive government regulations on all areas of public provision have been informed by demographic data (Heptinstall 1997).
The categorization of individuals into social class according to occupation by the British Registrar General is a commonly used classification (see table 1 below).
I Professional and managerial, e.g. lawyers, doctors, accountants
II Managerial and semi-professional, e.g. teachers, midwives, nurses
IIIN Skilled non-manual, e.g. clerical workers, secretaries, shop workers
IIIM Skilled manual, e.g. builders, taxi drivers, electricians
IV Semi-skilled, e.g. agricultural workers, postal workers, telephone
V Unskilled, e.g. cleaners, labourers
VI Underclass, e.g. unemployed, students
Using official government categorizations, sociologists have conducted studies that have provided an array of descriptive data including lifestyle differences between occupational groups (Blaxter 1990). The rates of births and deaths are also delineated according to social class, as well as more specific information such as the rate of perinatal mortality.
Despite its inadequacies, the Registrar general’s classification did, to some extent, reflect the occupational structure of British society throughout most of the inter and post-war years (Symonds & Hunt 1996). This system has changed beyond recognition in the last ten to fifteen years. The growth in self-employment, part-time working, women’s employment, redundancy and ‘early’ retirement and unemployment, as well as the change in the type of jobs, with the decline in skilled manual jobs and the increase in the service and information industries, have rendered this model practically obsolete. This was officially recognised in 1995 when the Office of Population Censuses and Surveys (OPCS) commissioned a study to update the classification system. It was estimated by the Economic and Social Research Council in the subsequent report that as many as 40 per cent of the population was excluded from official classification and that this group probably included the most disadvantaged in society (Symonds & Hunt 1996). This meant that social and medical research as well as the allocation of government funding for a whole range of social welfare provision including housing grants and cash for health authorities, would be based upon a totally inaccurate identification of the population.
The inequalities in women’s health have been primarily obscured by the conventional view of determining women’s social class. A married woman is ascribed the same social class as her husband, and for other women, class is based upon their own current or last occupation (Heptinstall 1997). This is a poor measure of a woman’s material circumstances and therefore renders many women’s poverty invisible.
For midwives, one significance of social class categorization is that it has led to the development of class stereotypes of women using the maternity services (Cartwright 1979; Macintyre 1982; Kirkham 1989; Green et al 1990). In a study carried out by Margaret Arnold at three London teaching hospitals in 1984, it could be seen that women of social classes IV and V received less intensive antenatal care than women of social classes I, II and III. Social classes IV and V had a greater number of risk factors surrounding their pregnancy, and were admitted to hospital more often than any other social class.. The author found that the women of the higher social class were more likely to be seen by the most senior obstetrician.
"At one hospital, the consultant went through the notes selecting the women
he would see; at another, a system of gold stars was used. Guess which notes
received the gold star treatment?"
It was of course the notes of the wives of doctors, lawyers, accountants, or those of women who were professionals in their own right. The most junior doctors ended up seeing the women who had the most at risk pregnancies, the women from social classes IV and V. The midwife was seen as the "helpful" member of the team, testing urine, taking blood pressures, and directing women through the clinic. If perhaps the midwife was used to do the job she was trained to do, and see the women who had the least risk factors, this would leave the senior obstetricians free to see the women with more at risk pregnancies. According to Margaret Arnold,
" In order for this change to occur, obstetricians must want it; for it
is they who effectively control the policy making in hospitals.".
Research has shown that babies of women in disadvantaged groups are more likely to have reduced growth rates in utero. Babies with fathers in social classes IV and V have a birthweight that is on average 130 grams lower than that of babies with fathers in social classes I and II (Office for National Statistics 1997).
Birthweight also varies with the mother’s country of birth. Babies whose mother’s were born in the Indian sub-continent were on average 200 grams lighter than those of mothers born in the United Kingdom (Office for National Statistics 1997). This does have implications for maternity care. It could mean an increase in the demand for cots in the Special Care Baby Unit (SCBU), especially if these low birthweight babies are also born prematurely. This means that there will be an increased demand for midwifery staff to work in the SCBU, possibly leading to a shortage of staff in other areas.
Research published in 1998 found that people who had a low birthweight or who were thin and stunted at birth, are at an increased risk of cardiovascular disease and the disorders related to it in later life (Barker 1998). The implications this has for midwifery practice are wide ranging. It could mean that midwives end up caring for women who were born at a low birthweight, and as a consequence are suffering from cardiovascular problems later in life. It means that midwives will need cardiac care skills as well as midwifery skills.
Research conducted in 1995 suggested that mothers who are reliant on State benefits may not be able to afford a healthy diet (Dallison & Lobstein 1995; Lobstein 1991), and may go short of food in order to feed their children (Dobson et al 1995; Dowler & Calvert 1995). As far as implications for midwifery are concerned, if these mothers who are going short of food are also pregnant, there is the risk of a nutritionally compromised mother, and the added risk of a low birthweight baby, possibly placing a higher demand on SCBU cots. If the mother is not eating properly during pregnancy, there is the possibility she will become more anaemic than the pregnancy will already make her. This could lead to extra admissions to hospital perhaps due to collapse, again placing more strain on midwives who are already caring for women in labour and during the post delivery period. In the United States, guaranteeing a minimum income to pregnant women has been shown to increase birthweight (Kehrer & Wolin 1979), although the mechanism is unknown.
There is also the problem that many women in the lower social classes tend to be obese. According to some research conducted in 1996 (published 1998), there is a gradient of decreasing obesity with increasing social class. 25% of women in social class V are obese, compared to 14% in social class I (Prescott-Clarke & Primatesta 1998). The mother going short of healthy food in order to ensure her children are fed, and then filling herself up with cheap junk food may cause much of this.
It can therefore be seen that a child’s long term health is related to the nutrition of its’ mother, so it is important that families in the lower social classes have the means to ensure that as well as the children being fed, the parents and especially the pregnant mother are also eating nutritious meals.
According to some research done in 1997, babies of fathers from social class I are more likely to be breastfed at birth than those from social class V, but this has decreased during the period 1985-95. Continued breast-feeding is less common in the lower social classes (Foster et al 1997). This opens a huge debate over whether breast feeding is better for a baby, and what the child is missing out on by being artificially fed, in terms of bonding as well as nutritional factors.
There have been studies done of people born during the same week or month, called birth cohort studies. These have recorded how exposure to disadvantage in childhood ‘casts long shadows forward’ both over future socio-economic status and over future health. The 1958 Child Development Study has followed children born during one week in April 1958: they are now 42 years old, and analyses of their lives have been completed to the age of 33 (Power & Matthews 1997). The long shadows of disadvantage mean that children born into poorer circumstances ‘clock up’ more material, psycho-social and behavioural risks (Power & Matthews 1997). For example, girls and boys born into social class IV and V were much more likely than those in higher social classes to grow up in overcrowded homes, to experience such life changing events as their parents divorcing, and be exposed to behavioural risks like parental smoking (Power & Matthews 1997). This process of differential accumulation of risks does not end with childhood. By the age of 33 (in 1991), there were sharp socio-economic gradients by fathers’ social class in the proportions of men and women in rented housing and in receipt of means tested benefits. There were similar gradients in the proportion who had low levels of social support and who smoked cigarettes and had a poor diet.
Another study has described the long shadow that childhood disadvantage casts over health in later life. Socio-economic circumstances at each stage of childhood and early adolescence are related to health in adult life (Power et al 1991).
One of the greatest things to impact on midwifery care and pregnancy outcomes is that of poverty. According to the Department of Social Security (DSS 1994) a quarter of the British population is now living on les than half the national average income. In 1988 the number of pregnant women on means tested benefits was one in five, by 1994 it had risen to one in three (the Maternity Alliance 1995). Perinatal and infant mortality rates show a vast variation between countries and between regions (Symonds & Hunt 1996). In the United Kingdom, in 1994 the stillbirth rate for social class I was 4.2 per 1000 babies born, which was almost half that of social class V. The perinatal mortality rates for social class I was 6.3 per 1000 babies, whilst the rate for social class V was 8.9 per 1000 babies (OPCS 1994). 66% of babies born to mothers on benefits had a birth weight below the national average and were at greater risk of ill health (OPCS 1994, 1995).
One of the most relevant studies considering the effect of poverty is by Oakley et al (1990 publ.1994). This study considers the effects of poverty and also attempts to measure in a systematic way, the benefits of midwifery care (Symonds & Hunt 1996). In this research, 509 women who had already had a low birthweight baby were randomised either to receive standard antenatal care or care from a research midwife. The study population was socially disadvantaged:
77% of the women were working class
18% had unemployed partners
41% smoked at booking.
The research midwives offered additional ‘social support’. This included listening to women, discussing their problems, obtaining advice about benefits, filling in forms, going with women to support groups and pursuing detailed medical questions raised by the women (Oakley 1994). This trial was conducted in four centres in England. Pregnancy outcomes were measured using information in the case notes and postal questionnaires. The results were far reaching, extensive and of great interest to midwives (Symonds & Hunt 1996). Babies in the social support group were heavier and there were less low birthweight babies. The women in this group were less likely to have their labour induced or to have epidural anaesthesia. There were more spontaneous births. The babies that required resuscitation were similar in both groups but those in the supported group required less invasive methods and less neonatal care (Oakley et al 1994). While the authors conclude that the effects of social support can never compensate for the cumulative effects of social disadvantage, there were clear benefits when midwives listened to women. They concluded:
"Although the policy implications of our findings must be in the
direction of promoting continuity of care and a less impersonal
and more sensitive antenatal service, it is important to remember
that social policy changes are also needed to improve the health
denying conditions in which many mothers and babies live."
(Oakley et al 1994)
Another important study is the ‘Newcastle Community Midwifery Care Project’ (Davies & Evans 1991), which was set up to provide enhanced support by midwives to childbearing women in their own home, in an area of the city defined as having a concentration of high risk factors, and to measure the effects of this intervention. The interventions included more personal, individual contact, better advice on smoking, diet, access to services and benefits, parent craft classes. The results were extensive and conclusive. Women were more likely to be satisfied with their care seeing it as more appropriate to their needs and they valued the close relationship they established with the midwife. The intervention of the midwives in the project had no effect on perinatal mortality nor on the incidence of abnormalities in the baby, but there was important evidence of a reduced incidence of low birthweight babies. The number of women in the survey was small, so the results should be treated with caution (Symonds & Hunt 1996). There was a small reduction in the numbers of pre-term deliveries. The women also used less pain relief in labour.
It is evident from the research that has been done, that although the major medical causes of mortality and morbidity have largely been eliminated, poverty and deprivation still continue to claim the lives of disadvantaged women and their babies.
In 1997, the Secretary of State for Health commissioned Sir Donald Acheson to review and summarise inequality in health in England and to identify and prioritise areas for development of policies to reduce them. His report, "Independent Inquiry into Inequalities in Health", was published in 1998. His report recommended wide ranging changes in the way that health policies are made. In particular his committee recommended policies which reduce poverty in families with children, by promoting material support for parents – removing barriers to work for those parents who wish to combine work with parenting, and by enabling those who wish to devote full time to parenting to do so. Specifically they recommended and integrated policy for the provision of affordable high quality day care and pre school education with extra resources for disadvantaged communities.
In conclusion, it is quite clear that women from the lower socio-economic groups are disadvantaged. They are more likely to be living in poverty, or relative poverty. They are more likely to be unemployed, or their partner may be out of work. They may live in cramped conditions, dependent on state benefits. They are more likely to be nutritionally compromised, either under or overweight, both of which have implications for midwifery care. When pregnant, they are more likely to be admitted to hospital, likely to default antenatal care appointments, and less likely to see a consultant obstetrician than a woman from social class I or II. These are the woman who have high risk pregnancies, and are more likely to deliver a preterm, low birthweight baby, who may well need resuscitation and neonatal intensive care in a special care baby unit. These women are more likely to smoke, which is more likely to produce a low birthweight baby (Brooke et al 1989), again possibly requiring incubation after birth.
The increasing shortage of midwives in the United Kingdom makes it more and more difficult to care properly for these socially disadvantaged women. When admitted to hospital antenatally they are likely to be admitted to a busy antenatal ward that possibly caters for an overspill of postnatal women. They are unlikely to be closely monitored, maybe only checked on four hourly in a busy unit. This is not the fault of the midwives, but the fault of the system that keeps these women living in abject poverty, while there are not enough health care professionals to look after them. The only was to change this situation is through legislation that pulls these women up from the lower social classes by giving them a decent amount of money to live on, and the chance to work if they want to by providing them with cheap, safe day care for their children, or the chance to return to education to train for a career that may well see them promoted to the ‘higher echelons’ of the social class scale.