Overpopulation in Asia

To determine the frequency of prematurity among the Javanese newborns it was necessary to compute the average birthweight of the newborns first, because the frequency of prematurity depends on this figure.
The determination of the average birthweight of the Javanese newborn infants in the D.I. Jogjakarta was possible because the archives of the midwife-school in Bethesda-hospital at Jogjakarta were at our disposal.
It was possible to examine the birthweight of all the newborn infants, who were born alive in the maternity-ward of the Bethesda hospital during the period January 1, 1946 – December 31, 1957.
From the total number of newborn infants, who were born alive during these twelve years in the maternity-ward of Bethesda-hospital, a number of 4,162 newborn infants (2,182 male and 1,980 female) were taken into consideration to compute the average birthweight. Only the newborn infants born alive with a birthweight of 1,000 grams and over of the Javanese race were taken into consideration. A small number of newborn infants of another race or whose data were not written in the records are left out of consideration. Also twins were included in this investigation.
The admission into the maternity-ward of Bethesda-hospital means an economic selection. This department is intended for poor and impecunious patients. The well-to-do patients are admitted in a special department of the same hospital or in some other maternity-clinics which exist in Jogjakarta.
The bill, which was paid by the patients of the Bethesda maternity-ward before the patients left the hospital varied according to the poverty of the patient concerned. It appeared that in the period 1954 – 1957:

• 22% of the patients paid nothing at all,
• 32% of the patients paid Rupiah 20 – 40,
• 32% of the patients paid Rupiah 70 – 100,
• 14% of the patients paid Rupiah 100 – 150, for assistance during delivery and nursing for seven days.

The real expense of the hospital was in this period Rupiah 17 per nursing-day, (exclusive of payment for assistance during delivery). This means that all the newborn infants in this delivery-ward belonged to the population-group with a low to very low income.
The place of residence of the patients admitted in the Bethesda maternity-ward appeared to be mainly the town of Jogjakarta and the kabupaten Sleman.
The proportional distribution of the patients according to their place of residence was as follows:

• In Jogjakarta lived 56%,
• in Sleman lived 30%
• in Bantul lived 8%,
• while 4% and 2% lived in Kulon Progo and Gunung Kidul respectively.

The newborn infants were weighed directly after birth in the delivery-room. The balance used was legally stamped and verified, accurate to 10 grams and under regular control of the Weights and Measures office at Jogjakarta. Besides this control the balance was also checked with the standard weights of the hospital chemist’s. The weighing was done by the pupil-midwives, who were supervised by the qualified midwife in charge of the education of these pupils.
Because there was reason to suppose that the average birthweight of the newborn infants could be influenced by the social status of the parents the investigation was not restricted to the newborn infants of the lower social class.
Besides the infants of the low-income group born in the maternity-ward of Bethesda-hospital we also tried to compute the average birth-weight of newborns of well-to-do mothers of the same race.
The data of the birthweight of the newborns of well-to-do mothers we collected from the archives of the “Lampujangan”-maternity-ward. This maternity-ward, also called “Nurse Prins-clinic”, is a subsidiary maternity-ward of the Bethesda-hospital but especially intended for well-to-do patients. In this ward only patients, who are able to pay the normal fixed rate, are admitted. This ward is also used for training pupil-midwives and every newborn infant is accurately weighed. In the period 1954-1958 a total number of 894 Javanese newborns were born alive in this maternity-ward. The average birthweight of the 498 male infants appeared to be 3,050 grams, while the average birth weight of 396 female infants was 2,988 grams. There proved to be an important difference that was statistically significant between the average birthweight of the infants of both social groups. The average birthweight of the male infants of the poor mothers was 186 grams below that of the well-to-do mothers. The average birthweight of the female infants of the poor mothers appeared to be 224 grams below that of the well-to-do mothers. This difference was further analysed. The compa-

Fig. 19. Frequency curves of male infants of well-to-do mothers
(I) and of poor mothers (II)

Fig. 20. Frequency curves of female infants of well-to-do mothers
(I) and of poor mothers (II)

rison between the average birthweight of infants of poor and well-to-do mothers was carried out between 894 newborn infants of the well-to-do mothers, born in the period 1954-1958 in the Lampujangan- or “Nurse Prins”-maternity clinic and with 1,618 newborn infants of poor mothers, born in the Bethesda maternity ward in this same period. In this way two groups of newborn infants of the same race, born in the same period, and of parents living in the same region, were compared. The birthweights of the male infants of both groups were mutually compared, just as was done with the birthweights of the female infants of both groups.
The number of infants in these groups was as follows:

• male infants of poor mothers : 836
• male infants of well-to-do mothers : 498
• female infants of poor mothers : 782
• female infants of well-to-do mothers : 396.

In the first stage of the statistical analysis¹ for each of these four groups a frequency polygon was made in order to exhibit the relative frequencies of the continuous distribution of weights if the observations are grouped in intervals of 200 grams. The intervals are such that no observation coincides with a boundary point of an interval. Next frequency curves were constructed for the four groups of infants. A frequency curve may be viewed as the limiting form of the frequency polygon as the number of observations tends to become infinitely large and the class intervals indefinitely small, while the total area below the curve remains constant. The results of the analysis are demonstrated in the figures 19-22. In fig.19 is demonstrated the frequency curve of the birthweights of the two groups of male infants, while in fig. 20 the frequency curve of the female infants is demonstrated. The line marked I concerns the infants of the well-to-do mothers and the line marked II concerns the infants of the poor mothers. In fig. 21 and fig. 22 the weights are classified along the horizontal axis (abscissa), while along the vertical axis (ordinate) percentages are place.
Curve I in fig.21 is the estimated cumulative distribution-function of the birth-weight of the male infants of the well-to-do mothers. This curve is based on the data of a sample of 498 newborn infants.
Curve II is the estimated cumulative distribution-function of the male infants of the poor mothers. This curve is based on the data of a sample of 836 newborn infants.

Fig. 21. Cumulative frequency curves of male infants of well-to-do
mothers (I) and of poor mothers(II)

Fig. 22. Cumulative frequency curves of female infants of well-to-do
mothers (I) and of poor mothers(II)

Fig. 22 represents the same distribution-function for female infants.
Curve I concerns the data of 396 female infants of the well-to-do families and curve II concerns the data about 782 infants of poor families. Using these curves for every weight the corresponding percentage of the children with a birthweight the same as this weight or below can be read off for both milieus.
Curve I concerns the data of 396 female infants of the well-to-do families and curve II concerns the data about 782 infants of poor families. Using these curves for every weight the corresponding percentage of the children with a birthweight the same as this weight or below can be read off for both milieus.
A point of the curve of which the abscissa corresponds with any given weight between 1,000-5,000 grams demonstrated on the ordinate the percentage of the newborn infants of the sample with a bithweight the same as or smaller than the birthweight concerned.
In fig. 21 and also in fig. 22 it appears that at every weight the percentage of newborn infants of well-to-do parents in the sample with a birthweight smaller or the same as this weight, is smaller than the corresponding percentage of the newborn infants of poor parents.
This suggests the conclusion that the infants of the well-to-do parents have generally a higher birthweight. This conclusion has to be investigated statistically owing to the fact that all curves are based on samples with inherent sampling fluctuations. The two sample test of Kolmogorov-Smirnov, with level of significance 0, 05, tells us that the percentages, which can be read off from the curves I and II for every birthweight, should not differ more from one another than a fixed value. This value depends on the size of both samples. In figures 21 and 22 this value has been added to the percentages of curve I. In this way curve III is found. When the milieu has no influence at all on the birthweight, then, except for a probability 0, 05, curve II should be wholly below curve III, Since this is fa from being the case the hypothesis that the milieu has no influence on the birthweight must be rejected. It is therefore almost certain that the difference in birthweight of poor and well-to-do infants is not due to chance, and this leads us to the conclusion that the difference found is due to the milieu. The factor which in the milieu of the poor and well-to-do Javanese families in the D.I. Jogjakarta is of great importance concerning this matter, is according to our judgement the daily food. There is a marked difference between the daily food of the poor families and between the well-to-do families concerning the calories and especially concerning the percentage of protein in the daily diet.
This difference between the average birthweight of the infants of the poor and well-to-do mothers and also the striking difference in the frequency of premature babies is according to our opinion very probably due to the difference in daily diet of these two groups of the population.
In the Wonosar-hospital in the Gunung Kidul region the physician in charge of this hospital H.J. Nielen determined the average birthweight of two groups of infants born in this hospital during the period August 1, 1957 till September 1, 1959. The first group of infants given birth to by mothers who lived outside this principal-place of the kabupaten and had cassave-roots as a basic food.
The second group of infants were given birth to by mothers who lived in the village of Wonosari, whose basic food was rice. The results of his examination was as shown in table VIII-2.
The same phenomenon, viz. And important difference in average birthweight between these two groups of newborn infants was demonstrated. In the two groups of mothers admitted in the Wonosari-hospital an important difference is in basic food. The mothers living on cassave-diet (Manihot utillisima) get a diet with a very small amount of vegetable protein, while animal protein is not consumed at all. For further details about the cassave diet see chapter XI.
The mothers on rice diet have, because rice contains 7% protein and cassave-roots only 1½%, a diet which contains considerable more protein. The mothers on a rice diet are the wives of officials and merchants, who have a better income than the poor peasants, who are living outside this place and whose living conditions are described more detailed in chapter XI.
It is very probable that this difference between the average birth weight of the two groups of newborn infants is caused by this difference in diet. The fetus, who develops in a mother who takes rice as a basic food, has a relative better offer of proteins for his development than the fetus developing in a mother, who gets only a very small amount of protein in her daily diet. This we suppose, is an important factor in the explanation of this striking difference in a average birthweight of the Wonosari-infants.
Njo examined the birthweights of newborns of well nourished and insufficiently nourished mothers in Djakarta in 1951. The average birthweight of 181 Indonesian infants, borne by mothers who got a good diet was 3,136 grams  29.5 gr.
The average birthweight of 190 newborns of mothers, who had a qualitatively insufficient diet, was 3,011 gram  28.5 gram. Although this difference was 125  41 gram and appeared to be significant, there are some objections to these results. The difference between the average birthweight of the male and female infants was not taken into account, while also in the group Indonesian newborn infants a number of different racial groups are probably brought together. The difference between these two groups of newborns was in this way more complicated than by the factor of difference in quality of the daily diet of the mothers only, as racial factors and sex-factors were present. In the examination of Njo proper nourishment meant a daily diet, which contained a sufficient amount of animal and vegetable proteins, carbohydrates, fats and vitamins Inferior nourishment meant a daily diet of these mothers which did not contain one or more of these components in a sufficient quantity.
In these cases animal protein was nearly always lacking while vegetable protein was available in only very small amounts.
When compared with the other figures of the average birthweight of Indonesian infants which are published in the literature about this subject, the average birthweight of the Javanese infants at Jogjakarta is a rather low figure.
The data about the birthweight of the Indonesian infants are collected in table VIII-2.
De Geus made no annotation about the premature babies. It is therefore not known if these are in= or excluded in the average birthweight. De Haas and also Njo Tiong Tjiat left all the prematures with a birthweight less than 2,000 gram out of consideration. In this way they found an average birthweight somewhat higher than would be the case if all the premature babies were included in their examinations. These data are therefore not fully comparable with those about the Jogjakarta newborn infants.
Some figures about the birthweight in other Asian and African countries are the following: In Biak (Schouten islands) van der Hoeven (1956) mentions an average birthweight of the male Papuan infants in this region of 2,858 grams, while the average birthweight of the female newborn infants was 2,818 grams. Among the 117 Papuan newborn infants who were examined it appeared that 23% were premature babies. Underwood Ground mentioned an average birthweight of 200 infants, born in the Maseru-hospital in Basutoland, of 2,860 grams.
From the review that Millis wrote in 1953 about birthweight we take the following figures:

• Average birthweight of South African Bantus-infants : 3,100 gr.
• Sinhalese infants : 2,800 gr.
• South African Indian infants : 2,800 gr.
• Singapore Indian infants : 2,900 gr.

Table VIII – 2.
Summary of the data concerning the birthweights of Indonesian newborns.

The number of premature babies among the newborn infants, born in the Bethesda-hospital in the period 1946-1957 amounted to 25.8% of the total number. As a premature baby was considered every newborn weighing exactly 2,500 gram or less at birth. This is the international definition of prematurity recommended by the World Health Assembly 1,948 and the Expert group on Prematurity (W.H.O. 1950). The number of premature babies among the newborn infants of primiparae, of II- and III-parae, and of IV—X-parae differed. The results are collected in table VIII-3.
Also the figures about the prematurity among the newborn infants of the well-to-do mothers in Jogjakarta are presented in this table VIII-3.
In both groups of mothers the primiparae gave birth to the greatest number of premature babies, but the difference between the primiparae of the group of poor mothers and the well-to-do mothers is very striking, viz. 33% and 12% respectively.

Table VIII – 3.
Review of the percentages of premature babies among the newborns of poor parents (A) born in Bethesda hospital during 1946-1957 and among the newborns of well-to-do
parents (B) , divided according to parity.

In the last column the figures concerning the frequency of prematurity among Javanese newborns of well-to-do parents at Semarang are given for purposes of comparison.
Source: Bol (will be published).
The frequency of prematurity among the infants of the poor mothers was 25.8% and among the newborns of the well-to-do mothers it was 8.8%.
Especially the first figure means a very high frequency of premature babies among the newborn infants of the poor mothers. When this figure is compared with European figures where the frequency of prematurity is about 3.0 – 4.5% this means that the figure concerning the newborns of the poor mothers, is 6 times higher.
As for the premature babies among the group of newborn infants of the mothers of the low-income group, 289 out of the 1,075 premature babies, i.e. 27%, had a birthweight between 1,000 and 2,000 grams. In the group of premature babies of the well-to-do mothers 15 out of the 89 premature babies, i.e. 17%, had a birthweight between 1,000 and 2,000 grams.
Other recent figures about the occurrence of prematurity among Javanese newborn are collected by Bol at Semarang. Bol examined the birthweight of the Javanese infants of well-to-do mothers who were admitted in the maternity-ward “Panti Wilasa”, during the period 1953-1957. In this maternity-ward are admitted patients of the same welfare group as those of the Lampujangan maternity-ward in Jogjakarta. The mothers who were admitted in the maternity-ward “Panti Wilas” in Sema rang were all well-to-do and able to pay the bill of 200 – 500 rupiah on the day of discharge. The average birhtweight of the infants of these Javanese mothers was of the male newborn infants 3,084 gram and of the female infants 2,984 grams (see table VIII-2).

Table VIII – 4.
Average birthweight of newborns from some European countries
and the frequency of prematurity among live-borns.

1) quoted in the publication of v.Gelderen et al (1954)

In the examination of Bol also infants with a birthweight more than 1,000 gram were taken into consideration. He found that 132 out of the total number of 1,639 newborn infants of these well-to-do mothers were premature babies. The occurrence of premature babies among the newborn infants of primiparae, II- and III-parae, IV- and higher-parae are collected in table VIII-3. The frequency of prematurity among these newborn infants of the well-to-do mothers was nearly the same as was found among the newborn infants of the Jogjakarta well-to-do mothers.
The connection between birthweight and duration of pregnancy could not be examined, because the pregnant women who were admitted in Bethesda-hospital and in the Lampujangan maternity-ward were mostly not able to inform us of the first day of the last menstruation. The question whether the duration of pregnancy of these Javanese women was of importance as a factor to make clear the high frequency of prematurity among the newborns could not be answered.
The observations that the average birhtweight of children of poor and well-to-do mothers differs significantly and that the frequency of prematurity among these two groups of newborn infants differs also very much with the hightest frequency among the newborns of the poor mothers, we like to explain as symptoms of the different social status. The most important difference between the poor and the well-to-do Javanese inhabitants of this region is the quality of the food. The proteinrich foodstuffs (e.g. Meat, eggs, fish, soyabean products, soyabean curd, soyabean cake, peas and beans) are for the poor people in this region nearly unobtainable.
These foodstuffs, which are the most important sources of protein for the population are expensive and therefore mostly purchased by well-to-do people. Even the basic food rice is in the daily meals of many families partly superseded by the cheap but nearly proteinless cassave root. The difference in average birthweight between newborns of the poor and those of the well-to-do mothers is, we assume chiefly due to the quality of the food which is consumed by the mother before and during pregnancy.
The occurrence of chronic since several generations existing deficient feeding conditions of the Javanese women and men finds its expression among other things in the hemoglobin level of the pregnant women. Before delivery this is examined of every pregnant women who is admitted in the delivery ward or is examined on the consultation bureau for pregnant women. A level of hemoglobin of 60% Sahli, is under these local circumstances accepted a s ”normal”
These women are living near the minimum of existence.
In Javanese society, which is to a great extent man-dominated, the greater part of manual labour is done by women. The Javanese women are busy day and night carrying heavy loads to the market in the neighbouring village or to the town. It is not a rare thing for a woman to be the “rice”-winner of the family. During pregnancy there is no generally accepted reason for a Javanese woman to lessen her activities or change her diet. It is a normal thing that she carries on with her daily activities and often she starts again within a week after delivery. The daily diet consisting of rice and some vegetables twice or three times a day remains unchanged during pregnancy.
Straub who worked as a physician of the Deli-Company on the east-coast of Sumatera, wrote his thesis about child-mortality in these regions in 1927. He supposed that the newborn infants of the Javanese labourers and their wives, working on the plantations in these regions, were born with a bodily inferiority or a congenital bodily debility. The observations which supported this supposition were the following:

1. The surplus of male newborn infants compared with the number of female newborn infants.
   The proportion of the male and female newborn infants was at the plantations of the Deli-Company 107.8 boys per 100 girls.
   of the H.A.P.-company during the period 1918-1921: 111 boys per 100 girls.
   and during the period 1923-1927: 150 boys per 100 girls.
2. The high mortality in the first days of life.
3. The high mortality in the first year of life, especially in the first three months of life.
4. The unstable equilibrium of fluid and electrolytes in the body of the infants. This circumstance facilitated the occurrence of dehydration in the infants.
5. The liability to may kinds of infections.
6. The quick disappearance of the congenital immunity from respiratory diseases, so that these diseases occurred already in the first month of life.
7. The low birthweight of the infants.
8. The connection that appeared to exist between the low birthweight and the high mortality in the first three months of life. A higher birthweight appeared to be linked up with a lower death-rate in the first three months of life.

During the investigation we made concerning child-mortality of the Javanese children in the D.I. Jogjakarta all these observations of Straub, which were made more than 30 years ago, could be confirmed.

ad 1: The proportion between the male and female newborn infants, who were born in the Bethesda-hospital during 1946-1957 was 110 boys per 100 girls.
The proportion between the male and female newborn infants, born in the
Lampujangan-delivery-ward during 1954-1958 was 118 boys per 100 girls.
From these figures it appears that the sex-ratio of the Jogjakarta newborn
infants is higher than that observed in European countries. Von Pflaunder
(1947) mentions a sex-ratio from German literature of 105-106. Van Loghem
(1956) mentions a sex-ratio in the Netherlands of 104-107.
Drogendijk (1935) mentions in a special study about supply of obstetric
assistance for the population of the town of Dordrecht a sex-ratio of 106
during the period 1920-1929.
The sex-ratio of the Jogjakarta newborn infants appeared to be higher when
compared with these figures. The real explanation of this phenomenon
observed in Sumatera snd in Jogjakarta is, however, not yet clear.

ad 2 The high-mortality in the first days of life, in the first three months of life

ad 3: in the first year of life is discussed in chapter VI.

ad 4: The unstable equilibrium of the balance of fluid and electrolytes which is so
easily disturbed by infections, will be mentioned in the section about enteritis
in the first year of life.

ad 5: The susceptibility to all kinds of infections o.a. impetigo, otitis, bronchitis,
furunculosis, appears from the experiences gained in the out-patients clinic.

ad 6: Also among the Javanese infants in Jogjakarta the respiratory diseases
appeared to be a more important cause of death in the second than in the first
three months of life. The respiratory diseases were responsible for 12.2% and
3.8% of the deaths in these periods of life, Cf table VII-9.

ad 7: The very low birthweight of the Javanese newborn is discussed above.

ad 8: To examine the connection between the birthweight and mortality in the first
three months of life was impossible for us at Jogjakarta.

The Javanese mothers do not consider prematurity as an urgent reason for special care for these vulnerable babies. The mothers are accustomed to small newborn infants and consider in many causes premature babies as normal. At home a baby is never weighed, so that the know ledge about the weight of a bay is not within the interest of these mothers. The premature babies born in hospital are as a rule taken home by the parents one week after birth. According to our experience it is not the financial aspects of the matter, which leads to this decision. Also in cases that nursing for some weeks was offered on moderate terms of without any payment at all this offer was refused. The mothers like to go home and see no reason to prolong their stay in hospital because the baby has such a low birthweight. The mother makes a more favourable prognosis for her small baby than the doctor.
Only in rare cases a premature baby is taken to hospital by mothers who ask for special care. During the period July 1, 1954 till July 1, 1958 45 premature babies were admitted in the Bethesda children’s ward, but only in 10 out of these cases the mother requested admission because the baby was premature and unable to drink. During the period May 1, 1955 – July 1, 1958 in the University.’s children’s ward 39 premature babies were admitted but only in 22 cases because the mother asked for special care. In the other cases there was another reason: the mother died during delivery and the father took the baby to hospital because it could not be fed at home. Other reasons were mental disturbance of the mother or the mother was admitted in hospital. Sometimes premature babies were sent to hospital by the Mother and Child Welfare workers.
When we suppose that in the year 1955 the total number of inhabitants in the town of Jogjakarta and the kabupatens Sleman and Bantul was 1.2 million and the birth-rate was 40%, the total number of newborn infants in this region in 1955 was 48,000. Because well-to-do Javanese people are rather scanty, we take as the frequency of prematurity 25% of all the newborns. In this year the total number of premature babies was 12,000. Out of the premature babies about 17% are supposed to have a birthweight of less than 2,000 gram. This means that more than 2,000 premature babies were in need of special care while only some ten people asked for it. All these small premature babies stayed at home and the mother took care of them under unfavourable and unhygienic conditions.
It is very probable that there is a high mortality among these premature babies. From our figures collected in the hospital this is not so clear because premature babies are not taken to hospital.
Among the premature babies who were admitted in the hospital there was a high mortality. Out of the 84 premature babies admitted in the two children’s ward 46 i.e. 57% died. A small number of the prematures, born in Bethesda-hospital were nursed for a longer period than one week in the hospital and 20 of them died.
When we pay attention to the age at the moment of decease it appears that the greater part of these premature babies died in the first month of life, viz. 53 out of 66. Only 13 premature babies died in the 2 – 5 month of life. This delay is caused by the circumstance that these babies were nursed in a hospital where incubator, proteinmilk, buttermilk and small bloodtransfusions were available, so that these lives were prolonged. For many weeks these babies kept their weight before pining away notwithstanding all the care they were given. The experience with artificial feeding was not satisfying in these premature babies, while mothers’ milk was not available. Javanese mothers, who have an abundant milk production are never willing to give some to babies of other mothers. There is a rule in Javanese adat (customs) which resists this.
The idea is that when a mother gives her surplus of breast milk to a child of another mother, this will result in suffering of her own child. The Javanese mother prefers this milk to be thrown away rather than to be given to other babies.
Summarizing we suppose that the low average birthweight of the Javanese newborns of mothers belonging to the low-income group and the high frequency of premature babies among these Javanese newborns is very probably due to the unfavourable nutritional condition of the poor and greater part of the population.
The great number of premature babies has a considerable influence on the infant-mortality in the first week and month of life, which is not so striking in the data collected in the hospital, because the premature babies are as a rule not sent to the hospital for special care in this region.
The low average birthweight and the high frequency of prematurity among the newborn-infants are to be understood as features of the unsatisfying social-economic conditions under which the population of the D.I. Jogjakarta lives.

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1. The statistical analysis, discussed in this section, was carried out by the Statistical Department of the Mathematical Centre in Amsterdam (contract number 1960-89). [↩]