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1
Social Origins
To include epistemological questions concerning the validity of sociological knowledge in the sociology of knowledge is somewhat like trying to push a bus in which one is riding. (Berger and Luckman 1971: 85)
The main problem with retrospective interpretations is that subsequent experience can play the trick of laying new meanings on old events. In part this is because the need to make a coherent, seemingly planned story of oneâs life constantly overwhelms the more honest ambition of describing it as it was. As it was is usually a series of false starts and premature stops, a mix of ill-assorted and conflicting ideas, and of feelings and intellectual insights all jumbled together in an unholy melting-pot. Memory is unfortunately but endearingly opaque, leading us to dissemble instead of revealing.
Bearing this qualification in mind, it seems to me now that the Social Support and Pregnancy Outcome (SSPO) study, as it was ultimately called, had its origins in six sets of observations about social relations. These were that:
1. Science, including medical science, may be regarded as a âsocialâ product â its content and practice reflect the social backgrounds and motives of its practitioners, rather than existing in some pure, uncontaminated, ahistorical mode.
2. The professional ideologies, status and organization of the medical profession militate against recognition of the universe and impact of the âsocialâ in health care.
3. The survival and health of mothers and babies are consistently worse in socially disadvantaged as compared with socially advantaged groups.
4. Differences in social position and experience, especially as mediated by stress, are linked with different fates of mothers and babies.
5. Social support is good for health.
6. Being researched may in this sense be health-promoting.
The rest of this chapter expands these six observations as a prelude to describing the background and beginnings of the study.
âKnit your own incubatorâ
For twenty years from 1965 to 1985 I worked as a contract researcher, for the last five years of this twenty-year period with other such researchers in the National Perinatal Epidemiology Unit (NPEU) in Oxford. The NPEU was a new unit set up in 1978 through a joint initiative of the Royal College of Obstetricians and Gynaecologists and the British Paediatric Association, and funded by the Department of Health to carry out epidemiological research âwith a view to providing information which can promote effective use of resources in the perinatal health servicesâ (Hansard, 5 July 1978). A major reason for the unitâs establishment was to consider whether or not a fourth national survey of perinatal mortality should be carried out. Since the earlier ones had been undertaken in 1946, 1958 and 1970, 1982 was looming as the next twelve-year interval for the fourth in the series. One of my first tasks as the Unitâs advisory social scientist was to comment on the desirability of a fourth survey from a social science point of view. My conclusion was that the evidence was insufficiently strong to justify the effort: the problem was not that we needed more data to understand patterns of reproductive health and illness, but that we needed to make better use of the data we already had (Oakley 1979b).1
The next major project on which I worked was funded by the Wellcome Trust and concerned the development of antenatal care in Britain. The notion of medical care as an important influence on the social process of becoming a mother had emerged in work I had previously carried out on first childbirth (Oakley 1979a; Oakley 1980). At the NPEU I was exposed to a complementary debate â one about the extent to which medical care could itself confidently be said to influence the physical processes of reproduction. Which obstetric procedures had been shown to be effective and safe, and which had not? An alarming number had not (see Chalmers et al. 1989a). As the NPEU set out on its path to becoming an internationally renowned repository of wisdom about evaluation in perinatal care â and in particular a proponent of the use of randomized controlled trials â government reports and pressure groups were vociferously making some rather simplistic claims about the state of Britainâs perinatal health services, and about the therapeutic power of modern medicine. Britainâs record of baby deaths was described as a âholocaustâ (Court Report 1976), and âguestimatesâ cited 10,000 British babies as dying or being handicapped every year as a result of shortfalls in the maternity services (Social Services Committee 1980). Many of the recommendations put forward in the Social Services Committeeâs report on Perinatal and Neonatal Mortality to correct this state of affairs pushed for more, and especially more centralized, high-technology, medical care, despite lack of evidence that this would be an appropriate or effective solution, and on the shaky assumption that medical care could compensate for or override the health-damaging effects of material disadvantage.
Interventions in human life designed to benefit may also harm. Until the 1980s, there was virtually no information on the frequency of handicapping disorders in children that might have their origin in the perinatal period (Chalmers 1981; Chalmers et al. 1980). The accelerating trend in many countries in the increasing âsalvageâ of small sick babies led to suggestions that more expenditure on specialist neonatal care â the âknit an incubatorâ campaign of pressure groups such as the Spastics Society â would automatically reduce deaths and illness among babies. The acronym BLISS of one such group, Baby Life Support Systems, identified the technological support of the special care baby unit â the first resting place of 1 in 20 British babies in 1964 but of 1 in 5 in 1977 (Richards 1980) â as a primary target of maternity services policy. Scepticism among researchers and epidemiologists regarding these claims â technology could not solve all the problems some babies were born with â equalled the missionary enthusiasm of the maternity pressure groups, and the battle cries of (some) neonatal paediatricians. The leap from the laudable goal of preventing baby deaths to the dubious recommendation of increasing expenditure on mechanized birth and postbirth care exposed the mendacious logic of the Cartesian medical model itself: the silly idea that death is the only suffering worth avoiding, and the nonsense of arguing that the health of babies placed in jeopardy by hazardous social conditions may easily be restored by expensive hospital machines (see Hack and Fanaroff 1986; Heinonen et al. 1988, for discussions).
A number of different studies starting in the 1970s began to suggest that one result of the increasing survival of low-birthweight babies through the use of high-technology medical care was that rates of cerebral palsy were increasing (Hagberg et al. 1984; Powell et al. 1986; Stanley and Atkinson 1981; Stanley and Watson 1992). Another possible consequence was a transfer of death from the immediate period after birth to later in infancy (Heinonen et al. 1988). In other words, paediatricians were keeping more small babies alive for longer, but some of these merely died later, while others survived with mental and physical impairment. In societal terms, as various commentators have pointed out, this may seem far from an advance. To the families involved, it represents a multilayered trauma, in which the agony of watching a tiny baby subjected to a series of intensive âtherapeuticâ manipulations, only eventually to die or grow up disabled, is mixed with the impertinence of a medical system which allows no parental input to medical decision-making, and stereotypes mothers2 as uncaring, and psychiatrically abnormal if they dare to suggest a peaceful death as preferable to a suffering life â for the child as well as the family (see Guillemin and Holmstrom 1986; Levin 1990).
Quantifying the biological and the social
Perinatal mortality, birthweight and social class are the three key concepts linking the social to the medical in this debate about appropriate strategies for promoting the health of mothers and babies. Figure 1.1 gives the definitions. Table 1.1 shows the most recent available figures for social class, low birthweight and perinatal mortality in England and Wales in 1989. The low-birthweight rate goes from 4.9 in social class I to 8.0 in social class V, a rise which is paralleled by a near-doubling of the perinatal mortality rate from 5.8 to 10.2. The pattern underlying the figures shown in Table 1.1 is that, for the same birthweight, babies in working-class households are twice as likely to die as their middle-class counterparts. Though the figures in 1980 were slightly different from those shown in Table 1.1, the general pattern was the same. The trend is for perinatal mortality to fall over time, but for the social class differences to be maintained (Social Services Committee 1988). There is no similar trend towards a falling incidence for low birthweight, nor any suggestion of a disappearing social class differential. The conjunction of a stable low-birthweight rate with a falling perinatal mortality rate is, of course, evidence of the trend already mentioned towards increasing survival for small babies.
Figure 1.1: Definitions of perinatal mortality, birthweight and social class, England and Wales
Table 1.1: Social class, low birthweight and perinatal mortality, England and Wales, 1989
While use of these terms âsocial classâ, âbirthweightâ and âperinatal mortalityâ can yield information which is useful to the debate about how health is produced, it is equally important to understand how history has produced the terms themselves. Social class, for example, is a designation introduced by nineteenth-century statisticians and intended to describe cultural as well as occupational differences between individuals. The concern was to find a way of differentiating people by social class which would, in the aggregate, produce a picture of the different social classes having the greatest mortality differentials possible (Macfarlane and Mugford 1984). Given this, it is hardly surprising that occupationally based class does differentiate. What social class differences do not do is to explain anything. The âreificationâ of the analytical construct of class into something substantive-in-itself diverts attention from the ways in which the social and material circumstances of individuals provide different constellations of risk. Furthermore, the debate about why the designation âsocial classâ is so predictive of life chances was, and is, largely a debate about the lives of men. In the most widely used measures of social class, including that of the British Registrar-General, men are assigned a social class directly on the basis of their occupation, but women and children are only assigned an occupationally based class because of their membership of a family âheadedâ by a man. Thus, as Hilary Graham has pointed out:
when we talk of âworking-class menâ, âworking-class womenâ and âworking-class childrenâ, we are not using categories that are equivalent. Working-class men are men in manual occupations: working-class women are women fathered by, married to or living with men in manual occupations. Working-class children, similarly, are children living with a man with a manual job. Only when the woman lives alone is the ascription âworking-classâ likely to describe her occupational status. (Graham 1986: 42)
The narrowness of current âsocial classâ definitions was recognized by the Office of Population Censuses and Surveys (OPCS) in 1989 in the form of a recommendation that social class be renamed âoccupational skill groupsâ, a strategy which would, of course, leave untouched the conceptual and practical problems inherent in tying social location to employment status.
As concepts, both âsocial classâ and birthweightâ were important landmarks in the epistemological terrain supporting the foundations of the SSPO study. While social class is a social category, birthweight is seen as a distinctively biological one. In the pre-industrial era, and in small-scale rural societies today, babies are not greeted by being subject to quantification. The reasons why they began to be so are explored in Chapter 9, which takes a closer look at the social construction of birthweight today as âobjective factâ. But the same point holds for birthweight as for social class: once babies begin routinely to be weighed, birthweight becomes an explanatory variable in its own right, a thing which explains other things. People begin to speak as though a babyâs physical weight, its quantity, contributes an important and predictive item of knowledge about it, just as the âfactâ that someone is working- or middle-class is considered informative and explanatory, without anything else being said. Sub-categories of birthweight are subject to the same reification process as the principal category itself. The initiative of dividing babies into two weight classes â ânormalâ and âlowâ â was taken by a Finnish doctor working in Germany in the 1920s who observed that the effect of being born too small was somewhat different from that of being born too early, and that 2500 g might be a convenient point of division between the two groups (see Chapter 9). This observation about the importance of low birthweight (LBW) led to the near-universal designation of biological features of populations in these terms. In 1980, the World Health Organization (WHO) attempted a world view of the incidence of low birthweight. The figures updated a few years later showed the world LBW rate3 as 16.0 per cent â that is, 16 out of a 100 babies were quantified at birth as weighing less than 2500g. Asia was the region with the highest percentage â 19.7 per cent, three times the lowest, 6.5 per cent for Europe (WHO 1984; see Puffer and Serrano 1987). As a matter of fact, there remains a difference of opinion about what the exact dividing line between normal and low birthweight ought to be; it was a matter of continual irritation in our study that we had to remember the disagreement that obtains in the UK at the present time between the Department of Health and the Office of Population Censuses and Surveys â while the former defines LBW as 2500 g or less, OPCS defines it as less than 2500 g.
The amount a baby weighs is often taken in conjunction with the length of its gestation in arriving at estimates of what birthweight âmeansâ. Pregnancy, too, has been subdivided within the technical language of medicine into ânormalâ and âabnormalâ â here into âtermâ and âpretermâ. Preterm babies are defined as babies born before 37 completed weeks of pregnancy. A small baby born early is considered more normal than a small baby born at the end of pregnancy; that is, its reduced size is attributed to (explained in the light of) its premature exit from the womb. A small baby born at the end of pregnancy may be designated âsmall for gestational ageâ (SGA) or suffering from âintrauterine growth retardation (IUGR). Of the four groups produced by combining the two criteria of gestation and birthweight â preterm and LBW, preterm and normal birthweight, term and LBW, term and normal birthweight â babies who are born at term but are of LBW have the poorest chances of survival.
Two significant âfactsâ about birthweight are shown in Table 1.1: being born at less than ânormalâ birthweight is more likely if you come from a working-class family, and is associated with a greater risk of death around the time of birth. But the stigma of low birthweight follows one through life: LBW babies who survive are more likely than normal-birthweight survivors to suffer from neurological abnormalities, mental retardation, âlowâ intellectual and educational achievement/subnormality, to be ill as children, have later onset of puberty and âpoorâ physical development generally (Illsley and Mitchell 1984). In 1989 a group of Swedish doctors tracking the blood pressures of male army conscripts found the risk of high blood pressure to be significantly raised in men who had been low-birthweight babies, and especially in those who had been defined as growth-retarded at birth (Gennser et al. 1988). In Britain, researchers following the health of babies born in the 1946 and 1970 birth cohorts found a similar inverse relationship between systolic blood pressure and birthweight. This was present at age 10 but had strengthened by age 36 (Barker et al. 1989).
Like birthweight, perinatal mortality has become a universal descriptor of life and death events. The first-identified use of the term was in the 1940s, when it was argued that deaths during the first week of life lay on a continuum with those before birth (Peller 1947-8). Some of the causes of both were the same. Thus, it would make sense to link them analytically â âmake senseâ, that is, to the emergent profession of obstetrics, which was during this period demarcating an area of physical existence over which it wished to claim unique expertise.
The concepts of social class, birthweight and perinatal mortality all, then, arise at particular historical moments, as part of the armamentarium developed by power Ă©lites (politicians and health professionals) claiming control over the quality and quantity of populations by being able more precisely to measure their component parts.
The focus on low birthweight
The condition of LBW symbolizes much of the debate about the present, future and meaning of the perinatal health services in the 1970s and 1980s. Arbitrarily divided from their ânormalâ peers by the finer points of hospital scales and official statisticiansâ calculations, LBW babies appear ideologically both as exemplar and proof of biologyâs operation in determining ...
