Social factors impacting pregnancy and infant development

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Introduction

The family which participated in my study is a nuclear family. Peter (38) and Jane (34) have a daughter Sally (8) and a newborn son James (3 months). They are both Chinese Malaysians. Both the pregnancy of their first child and the newborn were unplanned. Peter was working as a salesman in Singapore whereas Jane works as a promoter in her family business. Peter was educated to secondary level and Jane was at primary level. According to MASCO 2008, Peter is categorized to the fifth major group with second skill level while Jane is classified to fifth major group with first skill level. Jane and her family live in an urban area. They owned a double storey terrace house. This area is not well-developing but the essential amenities can be found and it was developing rapidly. Thus, Jane and her family are not having any trouble accessing the medical health care, food and entertainment. Moreover, Jane was receiving great support from her family as her parents often help offer their help with the newborn upbringing. Jane also meets up with her friends for advice when she is experiencing any emotional problems. Peter had hired a midwife to prepare nutritional meals for Jane daily. Therefore, Jane was not experiencing great difficulty during her pregnancy.

Both Peter and Jane have never smoked. Jane hardly drinks but Peter usually drinks moderately (5-8 cans per day). Jane used to jog daily but she stopped excising during her pregnancy. Besides that, Jane believed that she is having a healthy diet. She often takes her meals on time and eats plenty of veggie and fruits daily. Besides that, her GP advised Jane to take low-calorie foods as Jane was obese. Obesity may lead to adverse outcomes such as an increased risk of insulin resistance, gestational hypertension and gestational diabetes.

Locality

Jane and her family live in an urban area which is well-developed. Several evidences have shown that locality can affect a pregnancy and childbirth. Locality determines the accessibility and avaibility of medical healthcare services. Prenatal and postnatal care can significantly improve the maternal and fetal mortality rate. With easy medical care access, Jane was able to monitor her pregnancy development conveniently.

In Malaysia, urban area is usually equipped with a better healthcare facilities. Healthcare institutions in the city often possess better manpower and equipment as well. Jane was glad that there were several hospitals located nearby her housing area, giving her the choices to give birth in government hospital or private hospital. Table 1shows that less urbanized state such as Sabah have the lowest doctor-patient ratio (1:897) whereas more urbanized state like Kuala Lumpur have a high doctor-patient ratio (1:170).[1] As a result, pregnant women who stay in a less urbanized area tend to get neglected and have a lower probability to get healthcare service. Besides that, Table 1 shows that urban areas generally often packed with more doctors compared to rural area. This is probably due to more hospitals are usually found in the cities than in a rural areas.

Table 1: Distribution of Urban Centres and Access to Health Care by State

State

Area/km2

Status

Public Doctors3

Public Doctor:Patient4

Average Size5

Johor

18,986

Yes

1,295

1:662

949

Kedah

9,426

No

822

1:617

449

Kelantan

14,920

No

1,012

1:360

79

Melaka

1,651

Yes

465

1:425

275

Negeri Sembilan

6,643

No

710

1:366

511

Pahang

35,965

No

634

1:594

1,798

Trengganu

12,955

No

497

1:514

997

Perak

21,005

Yes

1,244

1:500

875

Perlis

795

No

147

1:472

398

Pulau Pinang

1,030

Yes

941

1:491

79

Selangor

7,955

Yes

2,079

1:672

362

Sarawak

124,449

No

797

1:790

2,963

Sabah+FT Labuan

73,712

No#

894

1:897

1,504

FT Kuala Lumpur

243

Yes#

2761

1:170

122

FT Putrajaya

49

Yes#

NA

NA

25

*Minimum number of population per gazzeted area of 10,000; +As listed in Telekom Malaysia Yellow Pages for 2007 only (official data not

available); 120-65 years (x1,000); 2hospitals and clinics; 3sector doctors; 4sector doctor to female patient (20-65 y) ratio; 5 size of public hospital catchment area (km2); FT=Federal Territory; #Due to its acreage

Medical affordability also plays an important role to the accessibility of healthcare services. Malaysia does not have a national public health insurance scheme to cover the citizens’ health expenditures.[2] Approximately 74% of funding in private Malaysian health sector is from consumers’ out-of-pocket money.[3] Therefore, the medicine affordability has become the major determination of access to healthcare services. Several studies also showed that innovator medicines sold in Malaysia were more expensive than the generics and hardly affordable for lowest income families.[4-6]

Locality also affects the social support to a pregnant woman. Various forms of emotional support may lead to more positive birth outcomes. Study shows that social support can be potentially effective strategy for preventing and intervening early for antenatal depression.[7] It is also found that lack of emotional support from partners significantly increased the risk for depression by more than twofold. Antenatal depression can negatively affect both maternal and fetal health. Research have showed that antenatal depression is often associated with maternal suicide, low birth weight and preterm delivery.[8, 9] Throughout the pregnancy, Jane stayed with her mother whose has great childbirth and childcare experience.

Locality also determines the exposure of the pollution to a pregnant woman. The level of pollution of an area depends on the ongoing activities in that area. Jane’s hosing area was located nearby an industrial area. A study showed that the exposure to urban air pollution may lead to a lower birth weight.[10] Another study suggested that pre-natal exposure to air pollution might negatively affect the early lung development, leading to a long-term respiratory morbidity.[11] Therefore, James (the baby) was susceptible to the adverse impacts brought upon by the environmental pollution.

Furthermore, the culture and its practices alter with locality. Jane was practising her one month confinement after her labour. During her confinement period, Jane was not allowed to go out, washed her hair and took cold drink. She was also asked to bath her body with herbal herb known as Fiddleleaf Aster. It is said that this can helps in lowering blood pressure and improve blood circulation. There are also evidence indicating confinement practices in Chinese culture may reduce postpartum depression.[12] Women in western countries usually do not follow this confinement. Therefore, this shows that geographical location might affect the practise adopted by the woman.

Table 2: Prevalence of smoking among Malaysian males by socio-demographic variables

Adjusted odds ratio

95% CI

Residential Area

Urban

1

Rural

1.12

1.03–1.22

Education level

None

2.09

1.67–2.60

Primary

1.95

1.65–2.30

Secondary

1.88

1.63–2.11

Tertiary

1

Ethnicity

Malay

2.29

1.98–2.66

Chinese

1.23

1.05–1.45

Indian

1

Other indigenous

1.75

1.46–2.10

Other

1.48

1.15–1.91

Locality also determine the exposure of smoking to the pregnant woman. Table 2 shows lower prevalence of smoking among Malaysian in urban area as compared to rural area. A study done by WHO indicates that maternal smoking is associated with increased risks for ectopic pregnancy, miscarriage, stillbirth, preterm birth and low birth weight.[13] Furthermore, the study also suggests that maternal exposure to second-hand smoking during pregnancy may increase the risk of low birth weight. Jane and her partner have never smoked but she was still at a risk of exposure to second-hand smoke during her pregnancy. Jane lived in an urban area, so she has a lower risk to the second-hand smoke adverse effect.

Education level

According to the family study summary report, 3 out of 70 mothers was educated until primary level. Jane was one of them but she was aware of the important of breastfeeding and she intended to breastfeed exclusively. The finding in a study suggested that education level is not significantly associated with exclusive breastfeeding.[14] This might be due to prenatal breastfeeding skill education for pregnant women are often provided by hospitals. Jane was provided breastfeeding support in a government hospital during her postnatal care. Furthermore, another study also showed no significant difference in the association between smoking and education level.[15] This suggests that smoking is more likely to associate with other social factors such as media influence, peer pressure or stress.

High education level often lead to a high socioeconomic status. Several studies indicated that low socioeconomic may negatively affect a pregnancy. It was found that low socioeconomic could lead to depressive symptoms in late pregnancy and this might affect the maternal-infant bonding and interrupt the fetal cognitive development.[16] Besides that, another study also indicated pregnant women with low socioeconomic status often are overweight and have low weight gain during pregnancy.[17] This could lead to adverse pregnancy outcomes such as reduced birth weight and increased preterm labour risk.

Conclusion

Social factors such as locality and education could affect the pregnancy outcome, birth and early infant development. With ideal environment and good education, the outcome of a pregnancy would most likely be positive.

References

1.Othman, N.H. and M. Rebolj, Challenges to cervical screening in a developing country: The case of Malaysia. Asian Pac J Cancer Prev, 2009. 10(5): p. 747-52.

2.World Health Organization. The World Health Report 2000. Health system: improving performance. Geneva: World Health Organization; 2000.

3.World Health Organization. Country Health Information Profile: Malaysia, http://www.wpro.who.int/NR/rdonlyres/DB90A4E5-0963-4E00-B56C-E09C2AE01ECC/0/19Malaysia07.pdf; 2007.

4.Shafie AA, Hassali MA. Price comparison between innovator and generic medicines sold by community pharmacies in the state of Penang, Malaysia. Journal of Generic Medicines 2008;6(1): 35-42.

5.Chong CP, Bahari MB, Hassali MA. A pilot study on generic medicine substitution practices among community pharmacists in the State of Penang, Malaysia. Pharmacoepidemiology and Drug Safety 2008;17(1):82-9.

6.Babar ZUD, Ibrahim MIM, Singh H, Bukahri NI, Creese A. Evaluating drug prices, availability, affordability, and price components: implications for access to drugs in Malaysia. PLoS Medicine 2007;4(3):0466-475.

7.Negron, R., et al., Social support during the postpartum period: mothers' views on needs, expectations, and mobilization of support. Maternal & Child Health Journal, 2013. 17(4): p. 616-23.

8.Bonari, L., et al., Perinatal risks of untreated depression during pregnancy. Can J Psychiatry, 2004. 49(11): p. 726-35.

9.Grote, N.K., et al., A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry, 2010. 67(10): p. 1012-24.

10.Aguilera, I., et al., Association between GIS-based exposure to urban air pollution during pregnancy and birth weight in the INMA Sabadell Cohort. Environ Health Perspect, 2009. 117(8): p. 1322-7.

11.Latzin, P., et al., Air pollution during pregnancy and lung function in newborns: a birth cohort study. Eur Respir J, 2009. 33(3): p. 594-603.

12.Wong, J. and J. Fisher, The role of traditional confinement practices in determining postpartum depression in women in Chinese cultures: A systematic review of the English language evidence. Journal of Affective Disorders, 2009. 116(3): p. 161-169.

13.Organization., W.H., Tobacco use and second-hand smoke exposure in pregnancy. 2013: p. 104.

14.Colodro-Conde, L., et al., Relationship between level of education and breastfeeding duration depends on social context: breastfeeding trends over a 40-year period in Spain. J Hum Lact, 2011. 27(3): p. 272-8.

15.Charafeddine, R., H. Van Oyen, and S. Demarest, Does the association between smoking and mortality differ by educational level? Soc Sci Med, 2012. 74(9): p. 1402-6.

16.Goyal, D., C. Gay, and K.A. Lee, How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? Womens Health Issues, 2010. 20(2): p. 96-104.

17.Park, J.H., et al., Association between pre-pregnancy body mass index and socioeconomic status and impact on pregnancy outcomes in Korea. J Obstet Gynaecol Res, 2011. 37(2): p. 138-45.

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