When you visit a quite mysterious country for the first time, your first impressions remain deeply imprinted. I cannot forget the start of my first visit to China, in 1977. While on the way to our hotel in the centre of Beijing, in late afternoon, I could observe at leisure the hundreds of cyclists who were surrounding our bus. The driver had to go slowly and to sound his horn continuously, in order to clear the way. My very first feeling was that, in spite of their dull Mao-style uniform, all these people looked happy, relaxed and free from anxiety. What their body and facial expressions were saying contrasted with what I was familiar with when observing commuters in western cities such as Paris.
I was there among a group of French health professionals belonging to the “French- Chinese Friendship Association”. Everywhere we were warmly welcomed by our Chinese friends. I had less positive emotions when I started visiting maternity units. Our colleagues were fascinated by high technology applied to obstetrics. They wanted to learn from us about the latest advances in electronic fetal monitoring and ultra-sound scans. The acupuncturists of our group were disappointed. They could not learn anything else than the best techniques of acupuncture for anesthesia during C-sections. Although it was difficult to obtain precise statistics, it was obvious that the rate of C-sections was already high. In the various hospitals I visited I could watch this operation without any restriction, because there was always at least one in progress in any maternity unit. Even in remote rural areas, childbirth was highly medicalised. In a village I visited, where the average number of deliveries a year was 13, women had to give birth in a ‘maternity unit’. This was in fact a room with a delivery table equipped with stirrups. Two bare-foot doctors were in charge of these births. The midwives were already forgotten.
I had a shock the first time I visited a nursery for newborn babies. Dozens of babies were arranged side by side, all of them wrapped in swaddling. Regularly, at a precise time, a nurse wearing a mask was conscientiously picking up one of the little parcels: it was feeding time. I could not help thinking of the future of all these human beings. As soon as they were born they were learning to be hopeless. They were obviously in danger. They were already losing that impulse which makes us struggle, struggle for life.
I went back to China 25 years later. This was in 2002. The pessimistic anticipations inspired by my first visit were undoubtedly grounded. The cyclists were replaced by car-drivers coping with traffic jams. In general, commuters who were still on a bike and those on the sidewalks looked serious, thoughtful, preoccupied, even worried. I could not look at them without thinking of the statistics I was carrying in my bag. Today China accounts for 44% of all suicides and for 56% of all female suicides in the world (1, 2, 3, 4). This rate translates to over a quarter of a million suicide deaths per year in China (according to the most optimistic evaluations). The important point is that the toll is particularly high among teenagers and young adults: suicide is the leading cause of deaths in individuals 15-34 years of age, accounting for 19% of all deaths.
At the very time when the Lancet was publishing its authoritative statistical study about suicide deaths in China (4), a more specialized medical journal was providing important information about depression and suicide ideation in Chinese adolescents (5). A survey using self-completion questionnaires was carried out in six middle schools (predominant age range 13-17 years) in an urban and a rural setting in Zhejiang Province in eastern China. The results are frightening. One-third of the students had suffered symptoms of severe depression, with 16% admitting to suicide ideation and 9% to actually having attempted suicide.
The suicide of adolescents is highly topical. We focused on China as a country where the rates are still higher than elsewhere, and also because some of the particularities of this huge country can help us interpret an increasing phenomenon of modern age.
If we refer to the work of anthropologists and historians (6,7) it appears that young suicide was almost unknown in other cultures. This is confirmed by reviews of the western literature. There are many references to suicide in texts written by such authors as Montesquieu, Shakespeare (8) and Rousseau (9), for example. It seems that the suicide of students started to arouse public concern at the beginning of the twentieth century. As early as 1910, the psychoanalysis association of Vienna held a meeting, under the chairmanship of Alfred Adler and in the presence of Sigmund Freud, to exchange views on constantly rising suicide rates among students.
Today the issue of suicide of young people is familiar to Primal Health Research. We might even suggest that Primal Health Research is holding the keys for interpreting this global phenomenon. Explore our data bank and type the key word “suicide”. You’ll be directed towards entries 0009, 0010, 0017, 0253 and 0338. An overview of these studies suggests that there are risk factors during the primal period in general and the perinatal period in particular. The study by Lee Salk (0019) is specifically about the suicide of adolescents in relation to what the birth was like. The studies by Bertil Jacobson (0009, 0253) look at the methods used to commit suicide in relation to the sort of birth complications they might have experienced. An overview of our data bank is still more fruitful if it includes all sorts of highly topical self-destructive behaviors, such as drug addiction (entries 0005, 0006, 0007, 0008, 0032, 0295) and anorexia nervosa (entry 0260).
Although the high incidence of self-destructive behaviors among young people is a characteristic of our societies, the number of relevant entries in the Primal Health Research Data Bank is comparatively small. Furthermore the medical articles I mentioned are rarely referenced afterwards in the medical literature. It seems that looking at any sort of “impaired capacity to love oneself” in relation to obstetrical practices is not politically correct. The authors of this sort of research must overcome terrible bureaucratic problems. I took such studies as examples when publishing my definition of “cul-de-sac epidemiology” (10), which is the opposite of “circular epidemiologiy”: epidemiologists usually have a regrettable tendency to constantly repeat the same studies, even when the results are known in advance.
For many reasons the case of China is appropriate to start international comparisons. First because more than a billion people are involved. Also because the suicide rates are exceptionally high. Furthermore – for those who keep in mind data provided by Primal Health Research – it is noticeable that this is a part of the world where childbirth became abruptly and recently highly medicalised: today the rates of C-sections are in the region of 40% in most Chinese hospitals. Another important point is that almost all the inhabitants of China live less than 45 degrees north from the equator. Yet latitude is the best-documented factor influencing the rate of suicides in a given population. Life below the 45th parallel is usually associated with low rates. Life above the 60th parallel (in the Northern Hemisphere) is associated with increased risks. This is the case of Finland, Norway, Northern Russia and Alaska. These are countries where there is no sunlight during the winter weeks and where seasonal depression is an important preoccupation. The issue of latitude can therefore be eliminated when trying to interpret the rates of suicides in China.
In the discussion that followed the publication of the Lancet article (11,12,13), it appeared that the current family planning policies do not provide direct explanations for such high rates of suicides, particularly among young women. To address this question, the authors included items about pregnancy, sterilisation, fines for exceeding the birth quota and birth of a female child in the life-event scale they have developed as part of their continuing national psychological autopsy study of accidental deaths. They could conclude that the social and psychological effects of the Chinese family planning policy are not an important determinant.
This aspect of the discussion was to a great extent induced by the fact that in China the rates of suicides in women are 25% higher than in men, while in Western countries the male-to-female ratio of completed suicide if often in the region of 3:1. Such data can easily be interpreted from a primal health research perspective. In a society where the birth of a girl is often seen as a catastrophe, the primal period of a human being is highly dependent on his or her sex. So far as the rates of suicides are still higher in the rural areas than in the cities, this leads to underline first that the medicalisation of childbirth spread out quickly to the whole China. It also leads to underline that, if there are risks factors in the period surrounding birth, it is not a reason to underestimate the importance of other possible risk factors. Furthermore, from the discussion that followed the Lancet article, it appeared that substantial proportions of victims of attempted and successful suicide had no known characterized mental illness.
In fact, what we must remember is that none of those who participated in this discussion ever suggested a possible link with how babies are born…an opportunity to refer again to the reality of “cul-de-sac epidemiology”.
What about the rest of the world? Everywhere the main preoccupation is the suicide of adolescents and young adults. An analysis of European statistics strongly supports data provided by the Primal Health Research perspective. The World Health Organization has published an evaluation of the number of suicides in the age group 15 to 24 in the main European countries (14). The rates are expressed as the number of suicides per 100 000 inhabitants. It is therefore possible to look at the number of young suicides in populations that have comparable standards of living and that live between the 45th and the 60th parallels. This leads to exclude Finland and Norway on the one hand, and Greece, Portugal, Italy and Spain on the other hand.
Among this group of well-defined European countries, the lowest rate of young suicides is found in…Holland (6.4 per 100 000). It is 7.3 in the UK, 7.8 in Denmark, 8.0 in Germany, 8.3 in Sweden, 9.1 in France, 9.6 in Poland, 10.3 in the Czech Republic, 11.8 in Ireland, 12.3 in Hungary, 13.8 in Austria and 14.9 in Switzerland. Everybody knows that Holland is unique where childbirth is concerned. In Holland 82% of the midwives are independent. When a Dutch woman discovers that she is pregnant, her reflex is usually to visit a midwife. The midwife will decide – during the pregnancy and during labour – if the advice of a doctor is needed. The effect of the Dutch system is that about 30% of the births occur at home, while many hospital-births are attended by a midwife who is not answerable to any doctor. The rates of C-sections are around 10% and the rates of epidural anesthesia remain below 10%. Let us add that, among this group of European countries, Holland also has the lowest overall (i.e. all ages) rates of suicides (Hungary has the highest one).
These European statistics might inspire many other comments. Let us underline, for example, that the rate of young suicides is higher in France (although a part of the population lives below the 45th parallel) than in Sweden (although a part of the population lives above the 60th parallel). The degree of medicalisation and the rates of obstetrical intervention are much higher in France than in Sweden. We might also underline that the rates of young suicides are higher in Ireland – the realm of “active management of labour”- than in the UK…
The WHO statistics make comparisons possible with Japan, which is an Asian country, like China. The rates of young suicides (6.2) are pretty similar to the Dutch rates…so are the rates of C-sections (around 10%) and the rates of epidural anesthesia (below 10%). Obstetrics in Japan is characterised by the small average size of maternity units and by the great number of midwives. Let us mention that the rates of young suicides are 12.9 in the USA. American statistics are difficult to interpret, as they mix data from states as far apart as Alaska and Florida.
We should not conclude too quickly that the future of China is gloomy. In such a country the concept of “cultural revolution” does not belong to the imaginary island of Utopia. The only fact that “Midwifery Today” conferences could be held last June in Guangzhou and Shanghai is a reason for optimism. At these conferences most participants were obstetricians, for the simple reason that midwives have disappeared. But many of them were young women who feel – still vaguely - that there is something wrong in their current practices. We must realize that these doctors are at the ascending phase of their fascination for high technology. This was illustrated, for example, by the fact that none of the Chinese speakers could imagine a presentation without a power-point, while most Western speakers were using more rudimentary means of communication. I look forward to participate in the next Midwifery Today conference in China in 2004…will it be the beginning of the ‘descending phase’?
China is now influenced more than ever by Western countries. We cannot dissociate this huge country from the rest of the world. The rising rates of self-destructive behaviour among young people is a global phenomenon. It should prevail upon any other preoccupation. Studying the future of suicidal behaviour is trying to anticipate the future of Humanity. The conclusions of two trips to China, combined with the Primal Health Research perspective and with international comparisons leads us to ask a simple question: can humanity survive obstetrics…?
We propose a vocabulary adapted to the scientific context (15).
Primal - first in time and first in importance.
Primal period - the time which included fetal life, perinatal period and early infancy. It is during the primal period that the adaptive systems involved in what we commonly call health reach maturity. It is the time of close dependence on the mother. One can anticipate that any kind of event happening during this period can have irreversible effects.
Primal adaptive system - the subcortical nervous system, the endocrine system and the immune system should no longer be separated and should be understood as a whole (e.g. the brain is a gland, insulin is a neuromediator, lymphocytes can release endorphins, etc.). We call this network the ‘primal adaptive system’. Phrases used in the medical literature, such as ‘psychoneuroimmuno endocrinological system’, ‘psychoneuro immunology’, immuno endocrinology’, etc., should be expressed in simpler terms. A recent review-article in the New England Journal of Medicine gave a perfect updated description of what we call the ‘primal adaptive system’. (16)
Health - is how well the primal adaptive system works (it is not the absence of disease).
Primal health - at the end the primal period we are in a basic state of health called primal health. The objective of primal health research is to explore correlations between the Primal period and what will happen later on.