Women's health

To the Editor: We comment on practical aspects of the approach to maternal Indigenous smoking raised in the study by Eades and colleagues.1 Pregnant smokers face barriers to quitting; however, we believe some additional barriers are systemic,2 including excessive caution in prescribing nicotine replacement therapy (NRT). Guidelines for maternal smoking cessation recommend an unassisted attempt before considering NRT.3 There is no agreed definition of a “failed ...

Gillian S Gould · Andy McEwen

In reply: Although our trial1 did not decrease quit rates with an intensive intervention, health professionals should continue to deliver appropriate intensive smoking interventions to pregnant Indigenous women.2 Guidelines advise the exercise of caution with the use of nicotine replacement therapy (NRT) in pregnancy,3 given the lack of trial data supporting its use.4 A recent trial of NRT in pregnancy found similar rates of adverse ...

Sandra J Eades · Rob W Sanson-Fisher · Katie Panaretto

Objectives: To report on the prevalence and implications of overweight and obesity in a rural maternity cohort.Design, setting and participants: A retrospective 6-year cohort of 6138 pregnancies managed in a rural Victorian maternity service from 1 January 2005 to 31 December 2010.Main outcome measures: Maternal body mass index (BMI), prevalence of overweight and obesity, prevalence of pregnancy complications and their association with BMI ...

Chris E Cunningham MSc, BLit, BA · Glyn R Teale MRCP, MRCOG, FRANZCOG

David Healy was born in Melbourne on 30 September 1948. He studied at Monash University, graduating in medicine in 1973 and completing a PhD on human prolactin physiology in 1979. After commencing training in obstetrics and gynaecology at the Royal Women’s Hospital, Melbourne, David completed his training at the National Institutes of Health in the United States and the Simpson Memorial Maternity Pavilion in Edinburgh, Scotland. In 1985, ...

Luk J F Rombauts

A retrospective study of the extent and management of pelvic inflammatory disease in remote-living Aboriginal women reveals that it occurs frequently, but is underdiagnosed and poorly treated.

Bronwyn J Silver BNurs, GradDipMID, MPH · Janet Knox MMed(STD/HIV), DTM · Kirsty S Smith GDipCommNurs, GDipEd, MPH · James S Ward BA · Jacqueline Boyle FRANZCOG, MPH, PhD · Rebecca J Guy BAppSc, MAppEpid, PhD · John Kaldor PhD · Alice R Rumbold BSc(Hons), MPH, PhD

The risks to the future child of morbidity associated with birth outside a hospital setting — largely ignored to date — need to be better quantified and communicated.

Lachlan J de Crespigny · Susan P Walker · Julian Savulescu

Mifepristone, in conjunction with misoprostol, is extremely effective for medical abortion at any gestation and is now widely used throughout much of the world for this purpose. However, the history of the drug in Australia has been controversial. For 10 years from 1996, it was the object of federal legislation that allowed its use ...

Caroline M de Costa PhD, FRANZCOG, FRCOG · Michael Carrette MB BS, FRANZCOG

Cunningham’s perspective provides a timely review of the literature relating to the maternal psychological outcomes of holding stillborn babies, which remains controversial. It is unfortunate that some popular media sources reported it incorrectly as saying that seeing and holding stillborn babies may cause harm. The correct conclusion is that the literature is inconclusive. The Australian and New Zealand Stillbirth Alliance strongly supports Cunningham’s ...

Vicki J Flenady · Christine Carroll · Ros M Richardson

Australia has among the world’s lowest maternal and perinatal mortality rates, with the latter more than halving over the past 40 years. However, as in other high-income countries, a decline in neonatal rather than fetal deaths has mainly contributed to falling rates, leading to calls for more attention to preventing stillbirth. Identified maternal risk ...

Henry Drysdale MB BS · Sanjeeva Ranasinha MEpid, MSc(ApplStat) · Amanda Kendall BMid · Michelle Knight RM, LLB · Euan M Wallace MD, FRCOG, FRANZCOG

The antiprogesterone mifepristone combined with a prostaglandin analogue (misoprostol or gemeprost) is effective for terminating early pregnancy and has a favourable safety profile.

Philip Goldstone MB BS(Hons) · Jill Michelson RN, RM, MBA(HealthAdmin) · Eve Williamson BPharm, PDM

Bob Kenihan was born in Adelaide, South Australia, on 1 February 1923, the son of Raphael Kenihan, a family medical practitioner. He attended Rostrevor College for his secondary schooling, before entering the University of Adelaide Medical School, from which he graduated in 1946. During this time, he excelled at sport, gaining a university Blue in lacrosse, as well as being proficient in cricket, swimming and golf. After ...

John M Svigos

Struan Robertson was born in Sydney on 27 January 1925, to parents who were both medical practitioners. He was educated at Sydney Church of England Grammar School, North Sydney, where he rowed in the First VIII and was a Lieutenant in the Cadet Corps. In 1943, he joined the Royal Australian Air Force (RAAF) as a pilot and served in the New Guinea campaign in Bougainville ...

James B Roche

Objective: To identify a level of iodine supplementation to recommend for pregnant and breastfeeding women in Australia.Design, setting and participants: Dietary modelling indicated that mandatory fortification of bread with iodine by replacing salt with iodised salt would still leave a gap in iodine intakes in pregnant and breastfeeding women in Australia. Iodine shortfall was estimated by two separate methods: (i) analysis ...

Dorothy E M Mackerras MPH, PhD · Creswell J Eastman MD, FRACP, FRCPA

David Morton was born in Wauchope, New South Wales, on 9 May 1929, the son of a teacher. He achieved a maximum pass in the Leaving Certificate from Sydney Boys High School and commenced medicine at the University of Sydney in 1946. His older brother Max and sister Marion were both prosectors in anatomy there. David’s first year marks made him the family’s third prosector — ...

Alan D Hewson

Despite nearly 70% of Australian women of reproductive age using a contraceptive method, estimates are that over 50% of Australian women have had an unplanned pregnancy. This rate, similar to that in the United Kingdom (30%) and United States (49%), may in part be explained by the fact that the combined oral contraceptive pill (COCP) remains the preferred method of contraception in Australia as it is in the UK ...

Danielle Mazza MD, FRACGP · Christopher Harrison BPsych(Hons), MSocHlth · Angela Taft BA, MPH, PhD · Bianca Brijnath BA(Hons), PhD · Helena Britt BA, PhD · Melissa Hobbs RN, MPH · Kay Stewart BPharm(Hons), PhD · Safeera Hussainy BPharm(Hons), PhD

Objective: To determine the effectiveness of an intensive quit-smoking intervention on smoking rates at 36 weeks’ gestation among pregnant Aboriginal and Torres Strait Islander women.Design: Randomised controlled trial.Setting and participants: Pregnant Aboriginal and Torres Strait Islander women (n = 263) attending their first antenatal visit at one of three Aboriginal community-controlled health services between June 2005 and December 2009.Intervention: A general ...

Sandra J Eades BMed, PhD · Rob W Sanson-Fisher PhD, ClinMPsych · Mark Wenitong BMed · Katie Panaretto MB BS · Catherine D’Este BMath, PhD · Conor Gilligan BBiomedSc, PhD · Jessica Stewart BA/LLB, MPP

Information from clinical trials informs our treatment of breast cancer, as it does that of many other common diseases. The trials establish “ideal” management, but the relevance of this information to any individual patient varies because the strict inclusion criteria used for trials exclude many important groups in the community. In breast cancer trials, the old, the poor and the rural-dwelling are often underrepresented. So, ...

Annette Katelaris MB BS, MPH, FRACGP

Objectives: To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer.Design, setting and participants: A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital.Main outcome measures: 5-year cumulative incidence ...

Sarah J Lord MB BS, MS, FRACGP · M Luke Marinovich BA, MPH · Jillian A Patterson BSc, MBiostats · Nicholas Wilcken MB BS, PhD, FRACP · Belinda E Kiely MB BS, FRACP · Val Gebski BA, MStats, FRANZCR(Hons) · Sally Crossing AM, BEc · David M Roder AM, MPH, DDSc · Melina Gattellari PhD, MPH, BSc(Psychol) · Nehmat Houssami MB BS, PhD, FAFPHM

It is now less clear how parents should be advisedIn Australia, stillbirth is defined as the loss of a fetus of at least 20 weeks’ gestation, or 400 g birth weight if gestational age is unknown. Every year in Australia there are 1750 stillbirths.1 Several studies have reported that stillbirth, regardless of how it is managed, can have ...

Kelly A Cunningham BSc, PhD

In Australia, regionalised maternity care aims to ensure provision of the appropriate level of care to all women, through assessment of risk, referral and transfer. An important element of this care is providing high-quality, safe and accessible services to women and babies in rural and remote areas. For women who experience pregnancy complications, this means their needs may not necessarily be met by their local hospital. They may be admitted ...

Tim Badgery-Parker BSc(Hons), MBiostat · Jane B Ford BA(Hons), PhD · Mary G Jenkins RN, CM, MScM · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, FAFPHM, DrPH

To the Editor: As an author, researcher and lecturer on the safety of drugs used in the obstetric setting for over 30 years — during which I participated in successive Medicines in Pregnancy Working Parties of the Australian Drug Evaluation Committee and Therapeutic Goods Administration (TGA) — I share Kennedy’s concerns about the alphabetical drug categorisation system currently used in Australia.1 I am also concerned that, since the demise in 2008 of the Prescribing Medicines in Pregnancy TGA Advisory Group (which provided ongoing external clinical expertise to the TGA), there has been a complete lack of action, preparation and consultation with external sources of expertise and experience by the TGA with regard to the safety of drugs used in pregnancy. Expert consultation would be invaluable in preparing for the overseas “game-changing” developments in labelling relating to safety of drugs used during pregnancy, as identified by Kennedy. These changes in labelling are primarily being driven in the United States, with the aim of providing definitive, well substantiated advice to patients and health professionals — advice that reflects the consensus of expert opinion in a way that the alphabetical system, by its inherent structural and functional limitations, is unable to do.

Ronald P Batagol

To the Editor: Kennedy highlights a major source of frustration for mothers and health professionals — the accuracy of information regarding the safety of medications in pregnancy.1 The current categorisation system is inaccurate and outdated. Labetalol, used safely throughout pregnancy to treat hypertension for more than 30 years, has a Category C label because atenolol was associated with intrauterine growth retardation in one study.2,3 Proton pump inhibitors remain in Category C despite large studies demonstrating their safety in pregnancy.4 Hydroxychloroquine is in Category D despite extensive use in pregnancy without any adverse effect.5 The present A to X system could be simplified to three categories — safe, uncertain and definite risk, with a brief description of the information available, together with the references on which the evaluation is made. This could be freely available online and regularly updated as new information is published. In addition, more rapid accumulation of evidence regarding the safety of newer medications in pregnancy and lactation is needed. At present, we rely on the publication of case reports and case series by single institutions. It would be valuable if a national or international database of de-identified information could be kept on mothers and babies who are exposed to drugs for which the safety is uncertain, so that outcomes may be followed, to better guide future parents and their health professionals regarding the safety of these medications in pregnancy and lactation.

Adam P Morton