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Assignment Four: Social Science Essay M5727

Social Science Essay

In this essay I aim to discuss the impact of socio-economic circumstances on the experiences of pregnancy, childbirth and childcare, with reference to my Family Study Mother, Nurul, and to broader societal context. By socio-economic circumstances, I mean particularly Social Class and Income, and I will relate them to: Diet and Nutrition during Pregnancy Birth Outcomes in Childbirth And Breastfeeding and Nutrition in Childcare My discussion would be comparing the above relationships in Nuruls scenario with Malaysian and United Kingdom(UK)s context. This is in attempt to appreciate how medical practice would differ in various cultures.

Social Class and Income

Social Class is stratifying people in a society based on the skills level of their occupations.[1] This closely intertwines with two other factors which are Income and Education. Though Education decides social class, social class decides Income, which affects lifestyle; and thus in our discussion affects pregnancy, childbirth and childcare. Income is defined as the earnings from employment, including investment profits and state benefits.[1] Every country has a unique system of Social Classification specific for the range of occupations housed by its industries. In Malaysia, the Malaysia Standard Classification of Occupations(MASCO)[2] has ten major divisions of occupations with relation to four main skill levels.(Figure 1)

Figure 1: MASCO Code(Linking Group 1(Managers) and 0(Armed Forces) to an education level would be irrelevant)


Assignment Four: Social Science Essay M5727

Nurul works as a Security Guard in a High School thus falls under the Major Group 5 with Skill Level 2 as she has completed Secondary Education. Her Monthly Household Income is about RM3000.

Percentage Distribution of Employment by Social Class

9:Elementary Occupations 13% 8:Plant and Machineoperators and Assemblers 12% 7:Craft and Related Trades Workers 11% 6:Skilled Agricultural, Forestry and Fishery Workers 9% 1:Managers 6% 2:Professionals 10% 3:Technicians and Associate Professionals 10% 4:Clerical Support Workers 9.1%

5:Service and Sales Workers 21%

Figure 2: Percentage Distribution of Employment by Social Class(2011)

The Major Group she belongs to is the largest employment sector in Malaysia(Figure 2) with a fifth of those employed[3]. However, Nuruls Monthly Household Income is much lower than the National Average of RM4025[4] and also the National Average for Bumiputra(Local Malays) of RM3624. Malaysia has a Gini Coefficient of 0.441[4] and by its income distribution(Figure 3)[4] her familys economic position lies within the bottom of the middle 40%.

Income Distribution
(Value shown is the highest income for that group)

20000 15000 10000 5000 0 Top 20% Middle 40% Bottom 40%


Percentage Population 11994 3338 2388

Figure 3: Income Distribution in Malaysia


Assignment Four: Social Science Essay M5727

In contrast, the Mean Monthly Income in UK is 1900(7726RM) with a Gini Coefficient of 0.369[5]. The average incomes in UK are thus higher with a fairer distribution amongst its people than Malaysia. There are no direct relationships between income and health such that health standards increase as income goes up but it has been proven that in societies with more equal distribution of income, people are healthier regardless of the money spends on healthcare.[1]

Diet and Nutrition in Pregnancy

Diet and nutrition are important behavioural aspects that greatly impact the experiences of pregnancy. They also extend to affect the outcomes of pregnancy, childbirth and care, which will be linked to in later sections. A households reach to good quality and quantity of nutrients largely depends on their disposable income.[6] However, it is also key to note that by the behavioural model, other determinants like cultural preferences work in hand with disposable income to form a relationship with nutrition level. Nurul, with an income lower than the average, could only afford about one serving of fruits and vegetables per person per day for herself and her family(Health and Social Influences Survey). However, a pregnant woman should at least consume five servings of fruits and vegetables a day[7]. Such under-consumption causes several Vitamin and Mineral Deficiencies which have been proven to increase the incidence of fetal abnormalities and Neutral Tube Defects(NTDs)[8]. Maternal malnutrition also decreases uterine tone, thus increases the risk of miscarriage.[9] This is shown in Nuruls case where she suffered from two miscarriages before. Since Nurul is from the lower middle 40% of the population in Income distribution, pregnant women from roughly 50% of the Malaysian population under Nurul could probably not be consuming enough nutrients through fruits and vegetables during their pregnancies too. This is supported by the idea that between social classes, there is a social gradient in diet quality decreasing as income levels decrease, leading to health inequalities.[10] The main dietary difference between various social classes is the source of nutrients as those with lower incomes tend to substitute fresh food with cheaper processed foods.[10] This idea can also be tallied with The Black Report which discussed the social gradient where descending down the social classes showed ascending trends of morbidity and mortality.[11] Mothers inability to consume and provide proper nutrition(for their families) broadens beyond medical effects to a psycho-socio-frame as well. The lack of energy due to Maternal Malnutrition can affect working-mothers usual commitment to both their occupations and family. Especially since the argument is that low Income is what causes Maternal Malnutrition, if reduced contribution to work leads to retrenchment, it would worsen the initial problem of undernourishment. This reverse correlation[12] would be a situation of poverty causes disease which causes poverty[13] which sets off a vicious cycle that adds on psychological stress[14] and low self-esteem for working mothers. It has also been proven that stress could aggravate the already ill-effects of poor maternal diet.[1] On the other end of the spectrum, higher Incomes tend to lead to over-nourishment, as with a greater access to quality diet comes a mentality of why not eat for two during pregnancy.[15] UK for instance has a significant pregnancy obesity rate at 4.99%[16]. This also has detrimental effects 3|Page

Assignment Four: Social Science Essay M5727

to pregnancy like Pregnancy-induced Hypertension or Gestational Diabetes. This situation would also apply to states within Malaysia itself, like Kuala Lumpur and Selangor which have the highest average incomes in the country. This shows that there would definitely be variations even within the same country and same culture.

Birth Outcome in Childbirth

Birth outcome is a direct factor reflecting the influence of diet and nutrition on pregnancy[17, 18]. Thus since we have matched a correlation between income levels and quality of nutrition, we can now extend the relationship to birth weight and outcomes too. By birth outcome, I mean to discuss if there are any deaths among Mother or baby during or shortly following childbirth. Nuruls son weighed 3300g upon birth however she had complications during delivery. Her poor diet during pregnancy as mentioned above reduced her uterine tone, and in this case caused weaker uterine contractions during labour.[9] This led to inadequate dilation of the cervix, resulting in a Caesarean-section delivery.[19] Poor diet may also cause many other problems that lead to intervention in delivery and perhaps this might account for the 19.1% of Caesarean cases in Malaysia (with 0% because of maternal request).[20] Income has proven to have direct correlation to birth outcomes too. It has been proven that lower incomes lead to increased stillbirths and infant mortality rates.[1] This is evident when we compare stillbirth rates between Johor and Kuala Lumpur, where the former has lower average incomes than the latter, the death rates are higher for Johor(4.4 per 1000 live births) than Kuala Lumpur(3.3 per 1000 live births).[21] Even within UK, those of the lower social class experience more perinatal deaths than those who are in higher classes.[8] Though diet could be a key contributor here too, other factors like availability and accessibility to proper antenatal care, which is also linked to income, could have contributed as well. Furthermore, statistics show that Johor(where Nurul stays) has the highest maternal mortality rate in the Nation which is 29 women per 1000 live births[21]. Thus, by following The Black Report model, Nurul and pregnant women with a lower household income than her in Johor have the highest risk rate in Malaysia to experience mortality during labour. This alerts us that again, even within the same country there is variation. This could be possibly because of various maternal mortality rates amongst different ethnicities(Figure 4) and the different composition of ethnicities in each state. The above mentioned risk of labour complications due to diet during pregnancy becomes relevant here too, as World Health Organisation(WHO) has identified obstructed delivery as one of the five main causes of maternal death.[8]


Assignment Four: Social Science Essay M5727

Figure 4: Maternal Mortality Ratio by Ethnicities

When we contrast this situation to UK which has a higher Income, UK has a maternal mortality rate of 8.2 per 1000 live births compared to 42.4 per 1000 live births in Malaysia which has a lower income.[22]

Breastfeeding and Nutrition in Childcare

Nutrition during early years of childcare has a significant impact on the health in later years of life is a concept that was proposed and discussed for over 78 years[23]. When discussing about nutrition in early childcare, breastfeeding is usually recommended as it fulfills most infant nutritional needs naturally. Breastfeeding ensures good infant and adult physical and mental health by paving a wellnourished and immune-protected foundation with forming emotional-bonds with mother.[24] In relation to income levels, nutrition during childcare can be seen from two different perspectives. Firstly, we can carry forward the argument of low income levels causing a poor maternal diet. Though by Barkers Hypothesis[25] maternal malnutrition also extends to increase risks for chronic illnesses when the child grows up, those of lower incomes, especially in Malaysia, are more likely to breastfeed[26] and this alleviates the situation. For example, Nurul, made sure she breastfed all her children to her best because of cultural beliefs as well as the fact that breastmilk is free. This correlation was further strengthened in a study[27] conducted in Klang(capital of Selangor, Malaysia, which has the highest average income[4]). It was found that those of lower incomes chose bed sharing1 which had a positive relationship to breastfeeding. There are benefits of breastfeeding especially in poor environments, for example: sources of milk other than breastmilk may contain pathogens or maybe diluted thus increasing risks of mortality or undernutrition. Thus the prevalence of breastfeeding among those of lower incomes at least forms a steady foundation of health for infants. However, there are other problems like discarding the

Mothers allowing their newborns to sleep on their beds a common non-Western practice. Source:


Assignment Four: Social Science Essay M5727

Colostrum2 during breastfeeding due to traditional advice[28] as those of lower income are usually from lower social classes who have low education to be aware of the benefits of Colostrum. WHOs recommends 6 months of exclusive breastfeeding[28] and NHS is promoting it largely in the UK.[29] While Malaysia has a national breastfeeding rate(at 5 months) of 29%UKs is only 3%.[30] This difference could be explained by the cultural differences, where generally Asians show more importance to breastfeeding. Education could also play a role as with more educated females in UK (99%) than Malaysia (85%)[31], working women might have convenience over formula feed than breastmilk. Moreover, in UK, with the possible higher influence of the media convincing audience that formula feed could compensate the benefits of breastmilk, the rates may be lower.

Figure 5: Trends in Breastfeeding rates with Education and Ethnicity as determinants

However, from Figure 5[32] plotted from Malaysian Family Life Surveys, I noted that within Malaysian Malays, education did not play a role over their preference of breastfeeding. This reflects their strong belief towards the necessity of breastfeeding.

Thfh Whitehall study

Colostrum is the first fluid secreted from the breasts and it is rich in proteins and in particular immuneglobulins which are critical in guarding and building the infants immune system. Source: Essential Obstetrics and Gynaecology(which Reference),


Assignment Four: Social Science Essay M5727 References

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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

21. 22.

23. 24.

Assignment Four: Social Science Essay M5727

and semi-urban communities in Kemaman, Terengganu. Mal J nutr, 1995(1): p. 51-61. 25. Barker, D.J., Maternal and fetal origins of coronary heart disease. Journal of the Royal College of Physicians, 1004(28): p. 544-551. 26. Fatimah S, et al., Breastfeeding in Malaysia: Results of the Third National Health and Morbidity Survey (NHMS III) 2006. Mal J Nutr, 2006. 16(2): p. 195-206. 27. K L Tan, M., M. S N Ghani, and P. F M Moy, The Prevalence and Characteristics Associated with Mother-Infant Bed-Sharing in Klang District, Malaysia. Med J Malaysia, 2009. 64(4). 28. Patil Sapna S, et al., Prevalence Of Exclusive Breast Feeding And Its Correlates In An Urban Slum In Western India. leJSME, 2009. 3(2): p. 14-18. 29. Choices, N. Health benefits for your baby. [cited 2012 23rd March 2012]; Available from: 30. Unicef. Infant and young child feeding (2000-2007). 2009 Jan 2009 [cited 2012 25th March]; Available from: 31. Agency, C.I. CIA World Factbook. 2012 March 16, 2012 [cited 2012 25th March]; Available from: 32. Julie DaVanzo, et al., Reversal of the Decline in Breastfeeding in Peninsular Malaysia? Ethnic and Educational Differentials and Data Quality Issues 1993. Rmb the flow of your essay! All parts shd be linked Rmb all that you say must crtically analyse and not just state facts! YOU MUST DISCUSS! So take out irrelv crap later which you feel doesnt ans the qn of exp of PCB in terms of social context in wide world!