Women's health

Women’s health in general practice. 2nd edition. Danielle Mazza. Sydney: Elsevier, 2011 (ix+346 pp, $94.95). ISBN 9780729538718. DANIELLE MAZZA, an associate professor at the School of Primary Health Care, Monash University, is a general practitioner with broad experience in women’s health and evidence-based research. She was previously medical director of Family Planning Victoria and is currently a member of the Royal Australian College of General Practitioners National Standing Committee on Quality Care. Her credibility is reflected in this comprehensive text on women’s sexual and reproductive health issues, with particular relevance to Australian general practice. This second edition has been fully revised to include developments in the field, such as the latest guides to taking “the pill”, the contraceptive vaginal ring, human papillomavirus epidemiology and polycystic ovary syndrome. The chapter on contraception provides practical and definitive information on all methods in current use — a mandatory knowledge base for all GPs providing such advice. The inclusion of chapters on violence against women, unplanned pregnancy and sexual problems is to be commended. Mazza’s style of frank discussion of the issues, legalities and practicalities presents these difficult subjects in an informative, non-judgemental manner. Registrars starting in practice and studying for their exams ignore this text at their peril! The layout is educationally sound, with learning objectives, case studies and key points. The chapters are extensively referenced. Mazza also uses many tables, photographs and helpful diagrams (although some of these could be larger). Mazza is to be commended for strongly presenting the evidence, or lack thereof, for treatments. Mostly, the evidence is cleverly mixed with practical approaches for the clinician. At times, however, evidence overwhelms practicality, discouraging some harmless treatments (eg, for mastalgia and premenstrual syndrome) and leaving options of reassurance only, or active drugs. Purchase of the softcover book includes online access to the complete book. In summary, this is an authoritative and comprehensive reference for new GPs as well as experienced practitioners wanting to update or check the latest evidence.

Karen M Flegg

Screening plus equitable provision of vitamin D supplements could mitigate many adverse outcomes For nothing worthy proving can be proven, Nor yet disproven: wherefore thou be wise, Cleave ever to the sunnier side of doubt. Alfred, Lord Tennyson, The ancient sage Tennyson may not have been alluding to the need for high-level evidence from randomised controlled trials (RCTs) to alter clinical practice, but he would have been aware of children with rickets. Evidence has accumulated linking vitamin D deficiency to adverse outcomes in pregnancy, such as pre-eclampsia, hypertension, higher rates of caesarean section and preterm delivery. Lau and colleagues (→ Serum 25-hydroxyvitamin D and glycated haemoglobin levels in women with gestational diabetes mellitus) contribute to this evidence by demonstrating that, in women with gestational diabetes mellitus (GDM), a lower serum 25-hydroxyvitamin D (25[OH]D) concentration was independently associated with poorer glycaemic control.1 Of 147 women who were studied late in pregnancy (at a mean of 35 weeks’ gestation), about 40% had vitamin D insufficiency or deficiency (serum 25[OH]D concentrations ≤ 50 nmol/L). Most of the women in this study were not white, and ethnicity, occupational status and season, not surprisingly, all influenced 25(OH)D concentrations, while body mass index did not. Perhaps more surprisingly, however, 25(OH)D concentrations were inversely associated with fasting and 2-hour glucose levels measured during an oral glucose tolerance test and with the marker of glycaemic control, glycated haemoglobin. Most importantly, serum 25(OH)D was an independent predictor of glycaemic control. In adults, a number of large cross-sectional studies have shown a consistent, independent and positive relationship between serum 25(OH)D and insulin sensitivity, and an inverse relationship with risk of diabetes.2-5 Serum 25(OH)D levels have been shown to account for 42% of the variation in insulin sensitivity assessed by hyperglycaemic clamp.3 Consistent with Lau et al’s findings, fasting and 2-hour levels of glucose and insulin have been shown to be independently and inversely associated with serum 25(OH)D levels.3-5 In a United States study, the odds ratio for diabetes was 0.25 (95% CI, 0.11–0.60) for non-Hispanic white participants in the highest versus the lowest serum 25(OH)D quartile.2 The highest-level evidence to date comes from a large prospective study with a 17-year follow-up that showed people in the highest quartile of serum 25(OH)D had a 40% decreased risk of type 2 diabetes compared with those in the lowest quartile.6 Based on these data, RCTs of vitamin D supplementation in adults to improve insulin sensitivity and reduce diabetes risk are underway. GDM is becoming increasingly more common, affecting up to 10% of pregnancies. The presence of GDM is not trivial and has long-term implications for the health of mothers and their children. The former have an increased risk of developing type 2 diabetes, while their offspring have an increased risk of obesity and diabetes later in life. Vitamin D deficiency is also very common in pregnancy. The prevalence of inadequate levels of vitamin D in Lau et al’s study is comparable with rates of vitamin D insufficiency of 47.1% and 83.5% in white and black pregnant women, respectively, in the northern US (defined as 25[OH]D < 80 nmol/L)7 and 65.3% in pregnant women in rural Victoria (defined as 25[OH]D < 75 nmol/L).8 RCTs of vitamin D supplementation, initiated early in pregnancy, are now required to demonstrate whether vitamin D supplementation might reduce the incidence or severity of GDM. International debate is currently focused on the optimal level of serum 25(OH)D. Based on meta-analyses using musculoskeletal end points in older individuals, cut points of 60 nmol/L and 75 nmol/L seem appropriate to prevent falls and fractures, respectively.9 However, a recent Institute of Medicine report recommended at least 50 nmol/L,10 which appears overly conservative and does not take season into account. The public health implications of vitamin D deficiency in pregnancy are far broader than glycaemic control. In Australia, there has been a resurgence of rickets — partly owing to an increased refugee population comprising dark-skinned and veiled women with vitamin D deficiency, and also because of decreased exposure of babies to sunlight, lack of supplementation of infant feeds with vitamin D and weaning of infants onto non-milk liquids. Milder forms of bone disease may also occur with vitamin D deficiency. Recently, a study that used three-dimensional ultrasonography in pregnant women showed that vitamin D deficiency was associated with increased femur metaphyseal cross-sectional area and increased femur splaying (the ratio of femoral metaphyseal cross-sectional area to femoral length) at as early as 19 weeks’ gestation.11 In addition, it was previously shown that children born to mothers with vitamin D deficiency (< 50 nmol/L) during pregnancy exhibit deficits in total body bone mineral content as great as 11% at 9 years of age.12 This could lead to an increased risk of osteoporotic fracture later in adult life, but this is unlikely to be evaluated in long-term studies. In addition, maternal or early life vitamin D deficiency has been linked to an increased risk of several other disorders, including neonatal craniotabes, prematurity, type 1 diabetes mellitus, schizophrenia, and childhood respiratory infections and wheeze.13,14 Current evidence strongly supports routine screening for vitamin D deficiency early in pregnancy. Furthermore, vitamin D supplementation to correct deficiency should be initiated early in pregnancy as it might reduce the incidence or severity of GDM and because changes in skeletal morphology of the fetus associated with deficiency are seen as early as 19 weeks’ gestation. The most common recommended daily doses of cholecalciferol are 1000 IU–2000 IU, however, daily doses of up to 4000 IU have recently been shown to be safe in pregnancy (Bruce W Hollis, Professor, Department of Paediatrics, Medical University of South Carolina, USA, personal communication). What is problematic is the equitable provision of vitamin D supplements to pregnant Australian women with deficiency. Pregnant and breastfeeding women who are most at risk of vitamin D deficiency are often the least likely to be able to afford supplements. In the United Kingdom, vitamin D supplements are provided free of charge to such women through the Healthy Start program.15 There is evidence to support more widespread use of vitamin D supplements during pregnancy in Australia, although more research is required. One way to increase access might be to alter the scheduling of higher-dose, lower-cost vitamin D supplements.

Peter R Ebeling MB BS, MD, FRACP

Objective: To test the hypothesis that lower 25-hydroxyvitamin D (25[OH]D) levels in late pregnancy are associated with poorer glucose control in gestational diabetes mellitus (GDM).Design and setting: Retrospective cross-sectional study, in a GDM clinic at a tertiary referral centre.Patients: Women attending the GDM clinic at Westmead Hospital from 1 February 2007 to 1 February 2008, excluding those with prepregnancy glucose intolerance.Main outcome measures: Levels of glycated haemoglobin (HbA1c) and 25(OH)D measured during the third trimester; maternal age, ethnicity, body mass index (BMI) and occupational status; and results of oral glucose tolerance testing (OGTT).Results: 147 women with a mean gestational age of 35 ± 2 weeks were included, of whom 41% had insufficient or deficient levels of 25(OH)D (≤ 50 nmol/L). Ethnicity, occupational status and season significantly influenced 25(OH)D levels (P < 0.01 for all) but BMI did not. 25(OH)D levels were inversely associated with fasting and 2-hour blood glucose levels during OGTT (Spearman r = − 0.16; P = 0.05 for both) and with log[HbA1c] (Spearman r = − 0.32; P < 0.001). BMI and insulin doses were also associated with HbA1c levels. Multivariable analysis identified 25(OH)D and blood glucose levels during the OGTT as independent predictors of HbA1c levels.Conclusions: Lower 25(OH)D levels are independently associated with poorer glycaemic control. Future randomised trials are needed to determine whether vitamin D plays a role in glycaemic control in GDM. Regardless, maternal vitamin D insufficiency has adverse effects including neonatal hypocalcaemia and rickets. The 41% prevalence of inadequate 25(OH)D levels in the women in our study is unacceptably high. We propose routine 25(OH)D testing of all pregnant women at screening for GDM or earlier, and treatment of women who are found to be deficient.

Sue Lynn Lau MB BS, FRACP · Jenny E Gunton MB BS, FRACP, PhD · Neil P Athayde MB BS(Hons), FRANZCOG, CMFM · Karen Byth PhD · N Wah Cheung MB BS, FRACP, PhD

Objective: The International Association of Diabetes and Pregnancy Study Groups (IADPSG) has proposed new criteria for the diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to compare the prevalence of GDM when IADPSG criteria were used with the prevalence when the current Australasian Diabetes in Pregnancy Society (ADIPS) criteria were used.Design, setting and participants: This was a prospective study over a 6-month period, examining the results of all glucose tolerance tests (GTTs) conducted for the diagnosis of GDM in Wollongong, a city using the public and private sectors.Main outcome measures: The prevalence of GDM using the existing (ADIPS) and the proposed (IADPSG) criteria.Results: There were 1275 evaluable GTTs (571 public and 704 private). Using the current ADIPS diagnostic criteria, the prevalence of GDM was 8.6% (public), 10.5% (private) and 9.6% (overall). Using the proposed IADPSG criteria, the prevalence of GDM was 9.1% (public), 16.2% (private) and 13.0% (overall).Conclusions: The proposed IADPSG criteria would increase the prevalence of GDM from 9.6% to 13.0% (P < 0.001). In our study in the Wollongong area, which has a population with a predominantly white background, this increase came mainly from older women attending a private pathology provider. Data from both the public and private sectors need to be included in any discussion on the change in prevalence of GDM.

Robert G Moses MD · Gary J Morris BAppSc · Peter Petocz PhD · Fernando San Gil PhD · Dinesh Garg MD

Kenneth Hugh Atkinson’s death late last year ended the career of one of Sydney’s most accomplished gynaecologists. Ken was born on 1 August 1939 in Moss Vale, New South Wales. He grew up in Armidale, where he attended The Armidale School and finished as dux of his year. He studied medicine at the University of Sydney, living at St Paul’s College and graduating with honours in 1963. He then worked at Royal Prince Alfred Hospital (RPAH) and, 2 years later, became a registrar at the associated King George V Memorial Hospital for Mothers and Babies (KGV). In his second year there, he sat the membership examination for the Royal College of Obstetricians and Gynaecologists (RCOG) and received the top mark in Australia. In 1968, he was appointed clinical superintendent at KGV. He single-handedly altered the whole ethos of the hospital — introducing formal resident training and running regular seminars incorporating interaction with other clinical specialities. In 1970, Ken was awarded a Joseph Foreman Fellowship. This took him to Massachusetts General Hospital in Boston, where he was surgical resident to Howard Ulfelder, one of the greatest gynaecological surgeons of the time. In 1971, he returned to Sydney and was appointed visiting medical officer in obstetrics and gynaecology at KGV and then, from 1974, at Ryde Hospital, Poplars Private Hospital and Sydney Adventist Hospital. After he gave up obstetrics in the mid 1990s, Ken concentrated on gynaecological cancer surgery. He handled most of the gynaecological cancer surgery on Sydney’s upper north shore, and was on call at RPAH for surgical emergencies. He never complained about being called in at any time of the day or night; he did it all with good humour and no one equalled him “when the chips were down”. In 1974, Ken became a member of the NSW state committee of the RCOG. In 1984, he served on the executive committee of the Australian Society for Colposcopy and Cervical Pathology and became chairman of the committee in 1994. In the same year, he was elected to the council of the NSW Medical Defence Union and, in 1995, he served on its executive committee. In 1996, he became a director of United Medical Protection and later deputy chairman. Ken’s interests included art, oriental snuff bottles and rugs, sport, good food and fine wine. He died on 25 November 2010 from complications after a myocardial infarction. He is survived by his wife Susan, and children Tracey, Josephine and Bill.

Andrew R Korda

To the Editor: The recent article by Lewis and colleagues highlights the important role of long-acting reversible contraceptives (LARCs) in reducing unintended pregnancy in Australian teenagers.1 LARCs are defined as contraceptives that are administered less than monthly and include hormonal implants and injections, and intrauterine devices (IUDs).2 The critical importance of improving access to LARC methods has been recognised in the United Kingdom by the National Institute of Health and Clinical Excellence, which produced guidelines for implementing this policy in 2005.2 The United States has recently followed this lead. In 2009, expanding access to intrauterine devices and other LARCs, particularly for younger women, was declared a national public health priority by the US Institute of Medicine.3 Our particular interest is to expand Australian women’s access to intrauterine contraception, including the copper devices and the levonorgestrel-releasing device (LNG-IUD). IUDs provide highly effective long-term contraception, and the LNG-IUD offers additional benefits for women with heavy menstrual bleeding.2 Although IUDs are the most widely used reversible contraceptives in the world, they are underused in Australia; the most recent available data suggest use by about 1.2% of women using contrceptives,4 compared with 17% in France and 21% in Sweden.5 The reasons for the low uptake of IUDs are undoubtedly complex, but appear to include lack of information, and misinformation in relation to infection risk and their unsuitability for younger women. There is now good evidence that modern devices present minimal risk of infection and no increased risk of subsequent infertility. There is increasing experience of their use in younger women, and nulliparity is not considered a contraindication.6 To investigate barriers to acquiring an IUD, we surveyed 334 of the 366 women who attended for IUD insertion over 3 months in 2009 at family planning clinics in New South Wales and Queensland. Excluding the 16 women (5%) for whom there were missing data, 16% of respondents (51 of 318) had not found it easy to obtain IUD-related information and almost a fifth (58; 18%) had been told it was not a suitable method for them by either a health professional or a friend or family member (or both), despite these women meeting appropriate medical eligibility criteria at the family planning clinic. Although family planning organisations are currently engaged nationally in developing and delivering IUD-insertion training for general practitioners, we suggest that increasing appropriate use of IUDs in line with other countries will only be achieved if the misperceptions of the risks relating to modern IUDs among consumers and health professionals are addressed. This is crucial to reducing the burden of unintended pregnancy, particularly in young women.

Deborah Bateson · Caroline Harvey · Julia Williams · Kirsten I Black

To the Editor: At budget estimates hearings of the Senate Community Affairs Committee in June 2010, answers were provided to questions on notice asked by Senator Guy Barnett to the Therapeutic Goods Administration (TGA) about the use of mifepristone for medical abortion in Australia since 2006.1 The answers are of interest as they include the number of practitioners who have become authorised prescribers of mifepristone in Australia since the “Harradine Amendment” was overturned in federal parliament in February 2006, as well as details of their practice. Nationally, 81 medical practitioners now have TGA authorised prescriber approval for mifepristone: 33 in New South Wales and 18 in Victoria (several large private clinics have gained approval in these states); 15 in South Australia, six in the Australian Capital Territory, five in Western Australia, and four in Queensland. There are none in Tasmania or the Northern Territory, so women in these two regions have no access to mifepristone abortion. There is very accurate documentation of all adverse effects of mifepristone–misoprostol medical abortion, which must be reported 6-monthly to the TGA. This information is then available to the general public through Senate estimates questioning. To 31 December 2009, 2926 medical abortions using mifepristone and misoprostol were performed in Australia by authorised prescribers. These include early and late procedures. The following adverse events were reported in that period: significant haemorrhage (7; 0.24%); retained products of conception requiring dilatation and curettage (D&C) or dilatation and extraction (84; 2.9%); ongoing pregnancy requiring surgical evacuation (14; 0.48%); and nausea and vomiting (10; 0.34%). These results are all well within the parameters expected from Australian and overseas studies of mifepristone–misoprostol use,2-5especially as a high proportion of the 2926 abortions would have been performed in the second trimester, as reported in a recent WA study.2 Large overseas studies on the use of mifepristone–misoprostol for early medical abortion (to 63 days of pregnancy) show a continuing pregnancy rate of around 1%, the need for D&C in 2%–3% of cases, and heavy vaginal bleeding requiring transfusion among 1 : 500 to 1 : 1000 women.3-5 These complications are more common in second-trimester procedures than in early medical abortions.2-5 Use of mifepristone in Australia is still restricted to authorised prescribers, and it is therefore not accessible to many women who might wish to use it. However, the number of cases performed in Australia is now large enough to conclude that mifepristone is safe and effective for the Australian women able to access it.

Caroline M de Costa

The issue of whether medical practitioners should perform “ritual nicks” as a method of meeting demand for female genital mutilation (FGM) has recently been debated in the United States and Australia. Due to increasing numbers of people arriving and settling in Australia from African nations in which FGM is customary, demand for FGM in Australia is present and may be increasing. Australian law clearly prohibits performance of any type of FGM. FGM is also prohibited by the most recent policy of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). For legal, medical and social reasons, the RANZCOG policy is sound, and medical practitioners should not administer FGM in any form. Development of an evidence base regarding incidence of and attitudes towards FGM, and the need for post-FGM treatment, would help inform sound policy and practical responses. Strategies adopted in African nations to abolish FGM may assist in refining educational and supportive efforts.

Ben Mathews LLB, BA(Hons), PhD

Objective: To determine the impact that mandatory fortification with folic acid of wheat flour used in breadmaking has had on the blood folate levels of an Australian population since it was introduced in September 2009.Design, setting and patients: A retrospective analysis of serum and red blood cell (RBC) folate levels of 20 592 blood samples collected between April 2007 and April 2010 from a wide variety of inpatients and outpatients and analysed in a large public hospital diagnostic pathology laboratory.Main outcome measures: Prevalences of low levels of serum and RBC folate and monthly mean levels before and after introduction of mandatory fortification.Results: Between April 2009 and April 2010, there was a 77% reduction in the prevalence of low serum folate levels (from 9.3% to 2.1%) in all samples tested and an 85% reduction in the prevalence of low RBC folate levels (from 3.4% to 0.5%). In April 2010, the prevalence of low RBC folate levels for females of childbearing age was 0.16% for all samples. There was a 31% increase in mean serum folate level (from 17.7 nmol/L to 23.1 nmol/L; t = 9.3, P < 0.01), and a 22% increase in mean RBC folate level (from 881 nmol/L to 1071 nmol/L). The greatest increment in mean serum folate levels occurred in September 2009, the month that mandatory fortification was introduced, although there was evidence of a gradual change during the preceding months.Conclusion: The introduction of mandatory fortification with folic acid has significantly reduced the prevalence of folate deficiency in Australia, including in women of childbearing age.

Ross D Brown PhD, MBA, FAIMS · Mark R Langshaw BAppSci, GradDipIT · Elaine J Uhr MSc(BiolSc) · John N Gibson PhD, FRACP, FRCPA · Douglas E Joshua DPhil, FRACP, FRCPA

Never, ever, again . . . Why Australian abortion law needs reform. Caroline de Costa. Brisbane: Boolarong Press, 2010 (168 pp) ISBN 978 1 921555510. Caroline de Costa wrote her new book because of her belief that it is inappropriate to punish a woman for making the decision that she is unable to become a mother at this point in her life. The material has been carefully researched by the author, who is Professor of Obstetrics and Gynaecology at James Cook University, in Cairns, Queensland. It brings together into a single clear record the often confused history of abortion law and relevant court cases in both Queensland and elsewhere in Australia. The chapter on the long history of the family planning and abortion information service “Children by Choice” and its remarkable contribution to Queenslanders is enlightening. The book records gruesome personal stories of barbaric pre-1970 illegal abortions. They highlight the dangers to life and health to which Australian women, especially the poor and isolated, were exposed before court rulings that made some abortions lawful. The documentation of the history of the emergency contraceptive mifepristone (RU-486), which can be used for medical (non-surgical) abortion in early pregnancy or in the second trimester, is also valuable. The author knows the process well — she and her colleague were the first two doctors who were permitted by the Therapeutic Goods Administration to prescribe mifepristone in Australia. The book describes in detail the build-up to criminal action against Tegan Leach and her partner in Cairns, who were sent mifepristone from overseas. Leach appears to be the first Australian woman charged with procuring an abortion for herself. De Costa will publish an account of the court case on her website. De Costa’s book highlights the unclear and inconsistent abortion laws throughout Australia and the need for uniform and just laws as a first step in providing equitable access to abortion, including for mifepristone. This book documents how Australia continues to fail women who conceive but feel unable to raise a child at the time. I would strongly recommend this book to all obstetricians and gynaecologists, as well as others interested in women’s health. It adds to de Costa’s proud record as an advocate for women’s health.

Lachlan de Crespigny

Bob Barter, who contributed much to the establishment of gynaecological oncology and neonatal pathology services in Western Australia, died recently in Perth at the age of 85. Bob was born in Perth on 27 January 1925. He was educated at Scotch College, Perth, where he was dux of the school in his final year. As there was no medical school in WA at the time, he studied medicine at the University of Adelaide, completing his undergraduate degree in 1949 and a doctorate (on the pathology of lung disease in premature babies) in 1952. He was then awarded a Nuffield Fellowship to study at King’s College in London. Bob returned to Australia in 1954 and worked briefly as a Senior Lecturer at the University of Adelaide before taking an Assistant Pathologist position at the Royal Women’s Hospital in Melbourne in 1955. When a position as Senior Lecturer at the new Faculty of Medicine at the University of Western Australia became available in 1960, he returned with his family to Perth. He was subsequently appointed Associate Professor and Director of the newly established Pathology Department at King Edward Memorial Hospital for Women (KEMH). Apart from a sabbatical year spent as Visiting Professor at Ohio State University in Columbus, Ohio, in 1967, Bob remained at KEMH. During his time at KEMH, community cytological screening for cervical cancer was initiated in Australia. In its early days, it was viewed with considerable scepticism; indeed, the program in WA almost foundered due to lack of standardisation of laboratory cytological examination and reporting, but Bob took on the training and accreditation of scientific staff to a high standard and the crisis was averted. From 1970 to 1972, he was a consultant to the World Health Organization program that was establishing cytology services in Indonesia. From 1976, Bob played a crucial role in the newly established gynaecological oncology service at KEMH. He conducted weekly Tumour Board multidisciplinary meetings until his retirement, making a major contribution to the management of women with gynaecological cancer. He taught medical undergraduate and postgraduate students throughout his career, and had a long association with the Cancer Council Western Australia, serving as its president from 1974 to 1978. In 1990, he was made a Member of the Order of Australia in recognition of his services to medicine. After retirement in 1985, Bob turned his restless intellect and energy to other pursuits, including farming, travel, foreign languages and reading. The last 10 to 15 years of his life were dogged by failing health, which he faced with great fortitude. A series of strokes left him with increasingly severe dysphasia, and eventually resulted in his being unable to read. Despite his progressive incapacity, Bob remained interested in people and the world, and did not lose his sense of humour. This was in large measure made possible by the unfailing love and support of Lyle, his wife of 57 years. Bob died peacefully in hospital on 12 October 2010. He is survived by his wife Lyle, daughter Ann and son Graham, and predeceased by his older son Michael.

Toby T Nichols · Ian Hammond

I was honoured to be asked by the Editor of the Journal to contribute to the Power of One series — then a little perturbed when I read through examples of previous contributors. They all had such steady career goals and progress. My own pathway seems to have been much more winding and more tempered by personal life experience. School of Medicine and Dentistry, James Cook University, Cairns, QLD. Caroline M de Costa BA, MPH, PhD, FRANZCOG, FRCOG, FRCS(Glas), Professor of Obstetrics and Gynaecology caroline.decostaATjcu.edu.au AntecedentsI grew up in Sydney’s west, at a time when that area consisted mostly of bush and market gardens. My father, John Downes, was a physicist who was not able to attend university because of the Depression; while working in a bank, he undertook an external degree in science from the University of London. This gave him an enormous appreciation of the value of education, which he passed on to me; he would have liked me to follow him into pure science, although medicine was “acceptable”. He also taught himself Russian so that he could read relevant scientific journals, and when I was 11 he took me, my mother and my two brothers on a wonderful 8-month, low-budget trek across Europe, including former Yugoslavia, which was definitely not a tourist destination in those days. My mother, Dorothy, was unusual among the mothers of my school friends as she had a full-time job, in what would now be called special education. With an arts degree and qualifications in occupational therapy, she developed numerous employment and physical education programs for young adults with intellectual disabilities. Without ever specifically mentioning it, she showed me it was possible to do all this, run a household and still make cakes for school fetes. Despite, or perhaps because of, this background, my time at high school was far from smooth and eventually I left the public education system by mutual agreement. I was fortunate, somewhat later, to be given a second chance by an inspiring educator, Betty Archdale, and I was accepted into the final year at Abbotsleigh School. There, I took the New South Wales Leaving Certificate, taught by dedicated teachers who provided the grounding for everything I have done since. I thought I would like to be a doctor without knowing much about what was involved. I enrolled in medicine at the University of Sydney in 1963 at the age of 16, and, although I completed the first year, I dropped out, uncertain about where I was heading. I decided to travel again, and worked in a variety of menial jobs in Sydney to raise my fare to Europe, the centre of the world for my generation. I then discovered the possibility of signing on to a ship of the Swedish merchant navy, who would actually pay me to travel. In this way, over several years, I got to see North and South America and the Mediterranean, leaving the boat in Athens. Now that I have children of my own, I look back at my parents’ agreement for my embarking on this journey and understand the trepidation they must have felt. On the Crystal Sea I worked as a mess girl, and quickly learnt the value of being organised and getting a job done properly the first time. The captain made a meticulous inspection of my area every Saturday; if a speck of dust was detected, the whole thing had to be redone on Sunday. The Irish yearsFrom Athens, travel through southern Europe and the Middle East brought me to Jerusalem (then part of Jordan) where, among other jobs, I taught English in a Palestinian refugee camp near Ramallah. My experiences there, added to what I had seen in South America, decided me to return to medical studies, with the idea of working in a developing country, and in 1967 I was accepted into the Royal College of Surgeons in Ireland undergraduate medical school in Dublin. “Surgeons” was then (and is now) a wonderful institution, multicultural 20 years before the word was invented, and preferring students to have some life experience before studying medicine. From the very beginning, I loved the classes, the prospect of being a doctor, the atmosphere of the College, and Dublin life. I also, in my first year, became pregnant. I had no ongoing relationship with the father of my child. Abortion was by then legal in England, but I decided to continue the pregnancy and, in 1968, my beautiful son was born. There was an enormous stigma attached to “unmarried motherhood” in Ireland at the time that I was largely able to avoid, as my family did not live in Ireland and I was not Catholic. I was also greatly helped by many of my fellow students to cope with the demands of a small child, medical studies and earning enough to support my son. Some of the latter I did by writing articles about the lack of support for women in my position and the need for Irish women to have access to effective family planning services; this was the beginning of my writing career. It was at this time too that I realised that control of our own reproductive health is essential for women if we are to have fulfilling lives and bring up our (wanted) children to do the same; I also saw the need for more women doctors to be working in this area. The second wind of feminism was blowing across Europe and North America in the 1970s, although at first it was only a gentle breeze in Ireland. I was involved in a variety of political activities throughout my student years. In May 1971, I, with about 60 others, took part in a well remembered event in the fight for contraception in Ireland: the “contraceptive train” (Box 1). This was a day trip from Dublin to Belfast, where condoms, illegal in the Republic, were bought in the North and then brought back openly to Customs in the Dublin railway station. A blushing and highly embarrassed Customs officer looked at his feet as he asked me, “Miss, have you got any of them fings?” Charges against us were later dropped. The Irish Family Planning Association (IFPA) was established in the early 1970s and I have huge admiration for the doctors who put themselves forward to provide services that were both illegal and condemned by the very powerful Irish Roman Catholic Church. As a student, I was privileged to attend some of those first IFPA clinics. Meanwhile, every day in Dublin hospitals I saw women crushed by the burden of poverty and too many pregnancies. I had my obstetrics term in the venerable Coombe Women’s Hospital and was hooked when I saw my first breech birth — a difficult but successfully managed vaginal delivery. I wanted to be able to do that. I couldn’t help noticing that all the consultants were men, and although they were competent and caring, their attitudes to women were often patronising and paternalistic. Surgeons was a traditionally run medical school and in the first 3 years, all 17 women in the class of 120 sat at the front during lectures. By fourth year, we were considered mature enough to be distributed alphabetically among our male peers. As a “D” I was placed next to Alan de Costa from Sri Lanka; we married in 1972, have since had six children and now live in Cairns where Alan is a surgeon. (Sitting behind us in the class in “M” and “S”, others took similar steps.) Specialist training in Papua New Guinea, Ireland, England and AustraliaAlan and I qualified in 1973 and headed to Papua New Guinea (PNG), where we undertook internships at Port Moresby General Hospital with the first graduates of the University of Papua New Guinea medical school. This was a fantastic clinical experience. As well as medicine and surgery, I was able to practise some obstetrics under the direction of the late Dr Geoff Bird, whose enthusiasm for what he did reinforced my determination to specialise.1 In 1974 in Sydney, I passed Part One of the Membership examination of the Royal College of Obstetricians and Gynaecologists — only to be told that Sydney hospitals “never” took on women trainees in obstetrics. So we went back to Dublin and spent 3 years there; Alan trained in surgery and I in obstetrics and gynaecology (O&G) (Box 2). I was the first woman to be appointed as Assistant Master at “the Coombe” (really a registrar post but quite sought after), and I must say that I had enormous support from my male colleagues in those years. I also worked at the IFPA clinics; they were gradually becoming more widely known, although there were still clashes with the government and the Church. I often travelled back from England with a dozen intrauterine devices discreetly concealed in my bags for IFPA doctors. More and more, I was realising the importance of choice for women in their reproductive health care. Those Irish years were followed by further training in Birmingham. We then returned to Port Moresby as senior registrars. Again, the work was interesting and demanding, but PNG had gained independence since we had been interns, there were more local graduates and life was becoming difficult for expatriates. After 18 months, we returned to Australia and worked in the Kimberley region of Western Australia before settling in Sydney. Involvement in the sociopolitical aspects of obstetrics and gynaecologyBoth our practices were in western Sydney. Alan and I were involved in setting up our respective departments in the new Mt Druitt Hospital, and I also worked at Auburn Hospital. In both these hospitals there was a large population of recently arrived immigrant women, mostly from Middle Eastern countries, whose cultural and social views and expectations of childbirth were very different from those of Australian-born Anglo-Celtic women. The maternity and gynaecology services, although physically adequate, were not readily accessible to many of these women. I became involved in efforts to provide clinics directed at specific cultural and ethnic groups with female interpreters more readily available; I also carried out research into the views and beliefs around childbirth of ethnic women in western Sydney.2-5 In the early 1980s, there were several hundred male O&G specialists in Sydney and about seven women, most of whom were close to retiring age as they had been “allowed” to train when men went off to the war; after 1945, no more women were admitted to training. I found myself being recruited onto dozens of government committees as the token woman. It was also clear that if we were to have more women training as specialists, it was necessary to be involved with the Royal Australian College of Obstetricians and Gynaecologists (now the Royal Australian and New Zealand College of Obstetricians and Gynaecologists). I first became a member of the NSW state committee in 1984, spent 6 years on the Council (Box 3) and now, over 25 years later, still seem to be on several committees. There was plenty of support from the blokes though, and we now have a large intake of talented and enthusiastic young women (and men) every year into all branches of our discipline. Midwives — we can’t live without themOne of the most effective and interesting bits of committee work was the “Shearman Committee”, run under the benign dictatorship of the late Professor Rodney Shearman, which revolutionised the way maternity services were viewed and provided in NSW — and set an example for other states to follow. Consumers and midwives were shown by the “Shearman Report” to be important in the provision of high-quality pregnancy and intrapartum care — almost as important as medical practitioners!6,7 The concept of choice in childbirth began to be acknowledged as valid. I have always had great respect for the midwives I have worked with, have learnt a great deal from them and valued their judgement. It is disappointing to me that there are still turf wars between our two professions, when we should be seamlessly complementing each other in our work: midwives caring for women experiencing normal pregnancy and birth (the majority), and obstetricians dealing with emergencies and more complex cases. I am glad to say that in Cairns, possibly because much of our work is in remote areas and requires more responsibility in decision making, our relationships are generally excellent. The move to the tropical northPractice in Sydney, both public and private, was rewarding but Alan and I both hankered for a return to the tropical lifestyle and professional satisfaction we had experienced in PNG. In 1994, I undertook a locum for Professor Michael Humphrey in Cairns (after he told me “women won’t ever work in the country!”). I was tremendously impressed by the service Michael was setting up, including FROGS (Far North Regional Obstetric and Gynaecological Service), which sent specialists out to rural and remote communities and was particularly directed at caring for Indigenous women.8 I had already established a specialist gynaecological service at the Aboriginal Medical Service in Redfern, where I held clinics twice a week, so I was well aware of the multiple health problems facing Indigenous women.9 Locums in Cairns continued over the next 5 years while we maintained our practices in Sydney (Box 4), then in 1999 we made the permanent move north. I was employed by James Cook University (JCU), first as a senior lecturer; in 2004, I became the first female professor of O&G in Australia. That was the year we first had JCU clinical students in Cairns Base Hospital, which has become the second teaching hospital for JCU and has now produced five cohorts of young graduates, many of whom have stayed on to work in Cairns or elsewhere in rural Queensland. I am delighted that already several of my students have gone on to further training in O&G. As well as working at JCU, until 2008, I worked as an O&G specialist at Cairns Base Hospital and was actively involved in the outreach program, which has made a huge contribution to improving the health of women in a region the size of Victoria. I have also worked and taught in several countries in the region, including Nauru and Vietnam, and have returned to PNG as an external examiner.10 Although I still do some clinical work, I am now mostly involved in teaching, research and administration (Box 5). Empowering women — with accurate informationI have always felt that for women to be able to make informed choices about their reproductive health, they need good information. In 1989, I published my first book of heath care information for women, about sterilisation. Since I moved from private to public practice and my children grew up and left home, I have found more time to write, and the stable has grown to 12 books of information for women and several textbooks, including a manual for doctors performing caesarean sections.11 Through the internet I made contact again with a fellow Surgeons’ graduate, now back in the United States, Dr Michele Moore, and together we have published books in the US on caesarean section, hysterectomy, parenting after the age of 35 and other topics in women’s health, drawing on our professional knowledge but also on our personal experience, a combination that seems to ring true with many women readers. Abortion — law reform and improved servicesIn practice in Sydney I had not given much thought to abortion, as excellent clinics such as the Preterm Foundation offered good early abortion services, and late abortion using prostaglandins was becoming available as our methods for diagnosing severe fetal abnormality improved. I was aware that in 1996 the “Harradine Amendment” had made mifepristone unavailable to Australian women, but I hadn’t seen that as a particular problem in my own practice. However, in Cairns I realised that accessing safe abortion was much more difficult for women in rural and remote regions. In 2005, I attended the annual conference of the American College of Obstetricians and Gynecologists in San Francisco and began to understand the advantages that making mifepristone available in Australia held for all women. Since my own experience of unplanned pregnancy, I have always been pro-choice, even though I had not personally chosen abortion. I read widely about mifepristone use and the politics involved in its banning in Australia and came to the conclusion that action was necessary. In October 2005, the Journal published my article advocating the introduction of mifepristone into Australia.12 Immediately I found a large number of doctors, politicians and pro-choice advocates (mostly women but also many men) contacting me to agree with my recommendation. Late 2005 saw the rapid formation of a movement with great public support that in February 2006 led to a private members’ bill, sponsored cross-party by four women senators, and the overturning of the Harradine Amendment. Overturning the Amendment did not immediately bring about the introduction of mifepristone to Australia, as an application has to be made to the Therapeutic Goods Administration (TGA) for this, and the drug was controversial — more so here than anywhere else in the world owing to Harradine’s political manoeuvring. No drug company has yet been willing to make such an application. There exists a pathway for individual doctors to be approved to use in their own practices drugs that are available overseas but not available here — this is the Authorised Prescriber (AP) legislation. My colleague Dr Mike Carrette and I made such an application to use mifepristone in Cairns — it took time and the paper from many trees, but the TGA were extremely professional in their handling of what became a matter of considerable public interest. In April 2006 we received approval, and in July that year began to use the drug (initially with some apprehension in the face of such publicity). We have since demonstrated that it is a very useful addition to abortion practice and now more than 80 Australian doctors have AP approval. I look forward to the day when a drug company applies to market mifepristone nationally. There is still great variation between states in women’s access to abortion services, and this is an area I will continue to work in. Abortion must become part of mainstream Australian medicine; only then can we look at ways to lower what we know is a very high national abortion rate.13,14 ConclusionWhen I began my specialist training, there was no laparoscopy, no ultrasound, computed tomography or magnetic resonance imaging, limited fetal monitoring, no synthetic prostaglandins . . . the list could go on. There were also few women in the specialist workforce and there was a very hierarchical structure. I am pleased to have been involved in putting into practice many of the new developments in our specialty (Box 6). However, I am even more pleased to have been part of changes in attitudes among colleagues, midwives, nurses, administrators and women themselves that have brought about better reproductive health and greater input by women into decisions about their own health. Having control of their reproductive health is essential if women are to develop their full human potential. 1 Return of the “contraceptive train” from Belfast —Dublin railway station, May 1971 Caroline de Costa (then Downes) and Jerome, aged 3 years, with Customs officials of the Irish Republic. 2 Staff of Rotunda Hospital, Dublin, June 1975 Caroline de Costa: middle row, far right. 3 Royal Australian and New Zealand College of Obstetricians and Gynaecologists Council, 1992 Caroline de Costa: middle row, second from left. 4 In the operating theatre, Sydney, 1996 Caroline (second from left) and Alan de Costa operating in collaboration. 5 Cairns, 2006 6 Australian Medical Association National Conference, May 2010 — awarded the President’s Medal

Caroline M de Costa

“Child deaths are falling, but not quickly enough to reach the target.” “Most maternal deaths could be avoided.” The Millennium Development Goals Report, 20101 “Where we are now in terms of health service delivery should be measured against where we have come from and not where we ideally should be. A lot of progress has been made.” Mary L Nannono, Permanent Secretary at Uganda’s Ministry of Health, 20082 The Millennium Development Goals (MDGs) report published in June 20101 shows that the targets to reduce maternal and child deaths will not be met, particularly in sub-Saharan Africa. Uganda is an east African country committed to achieving MDG 4 (the goal to improve child survival) and MDG 5 (the goal to improve maternal health). In recent years, there has been much work to improve Ugandan antenatal and neonatal care, scaling up emergency obstetric care services and child health policies. However, progress remains slow and, at current standards, Uganda is unlikely to attain the MDG 4 and 5 objectives (Box).3 Why has there been insufficient progress? What happens when mothers and children come to hospital? I am an Australian doctor training in paediatrics under the Royal Australasian College of Physicians. I also intend to train in anaesthesia. I decided to take a year-long break from the training scheme to do humanitarian aid work in a developing country, and I am now coming to the end of a 6-month sabbatical in Uganda. This personal perspective on paediatric and obstetric care provision in Uganda aims to illustrate some of the stumbling blocks in practice that are limiting progress towards the MDGs in maternal and child health. My time in Uganda was divided between the obstetric operating theatre of the National Referral Hospital in Kampala, and responsibility for a paediatric ward in rural Uganda at a not-for-profit mission hospital, run jointly by the local Catholic diocese and an international non-government organisation. Every morning on arrival at the obstetric theatre I was greeted by women waiting, lining up in the entrance hall or lying on plastic sheets on the floor of the ward, contracting in pain. All needed emergency caesarean sections. However, each woman waited in turn for her operation or spontaneous delivery, whichever came first. When her turn came, the patient would walk into theatre and struggle onto the operating table with minimal assistance, pausing only for a grunt or grimace during a contraction. My first day at the Kampala hospital theatre was particularly disappointing — six emergency caesarean sections resulted in two fresh stillbirths, one macerated stillbirth and two admissions to the special-care baby unit. We hand-ventilated one baby for an hour because there was no mechanical ventilator. Later that afternoon, the baby stabilised on continuous positive airway pressure, but died overnight. My colleagues and I decided to undertake a 1-month audit to review maternal and neonatal outcomes: were there avoidable delays for emergency caesarean sections, and could anything be done about them? The maternal mortality rate in my sample of 435 was 1%, the stillbirth rate was close to 7% (equivalent to the hospital’s 1968 rates14) and mothers waited on average for 5 hours for the emergency procedure. Reasons for delays included staff unavailability, a lack of running water, a non-functional autoclave (and hence no sterile drapes and gowns), and no spinal needles or drugs for spinal anaesthesia. As a result of the audit, the hospital expedited the building of two new obstetric and gynaecological operating theatres and undertook to ensure that highly qualified and experienced staff ran them. Mothers are advised to bring a delivery pack when they come to hospital — not a dressing gown, slippers and baby clothes, but their own cannulae, sterile swabs, suture materials and 10 packets of sterile gloves, in case the hospital supply runs out. During my second week, a woman in her seventh pregnancy joined the section queue. Her indication for surgery was obstructed labour at 38 weeks gestation, with a “poor obstetric history” that translated as six previous stillbirths. She waited patiently in line but when it was her turn there were no gloves in stock and she had brought only one packet. She waited while women with gloves had their procedures. Her blank emotionless expression when the surgeons told her over the drapes that her baby was stillborn will remain with me forever. How can this hospital function as a comprehensive emergency obstetric care provider when caesarean section priority relates to the number of gloves the patient can supply rather than the underlying urgency of surgery? My responsibility for a 23-bed children’s ward (often with two to three patients per bed) in rural Uganda also brought me many challenges. At this hospital, one difficult day started with a mother in obstructed labour who delivered her baby with shoulder dystocia. During our attempt to resuscitate the baby, there was a power failure and, as there was no fuel for the back-up generator, the oxygen concentrator did not work. The oxygen cylinders were empty, so there was no oxygen in the hospital. Sadly, we were unable to save the baby. The same day, a 4-day-old twin died of jaundice because our phototherapy machine was broken and the parents could not afford to travel to another hospital. Then the mother decided to discharge herself from hospital with her surviving twin, also jaundiced and on intravenous antibiotics, and consult a traditional healer. I remember a 3-year-old patient referred from a larger regional centre to our rural hospital for a blood transfusion because there was “no blood available”. The child’s haemoglobin level was 2 g/dL and she was in severe respiratory distress. I was confused by the cross-match form and unit number noted in her case notes, yet the clearly documented reason for transfer was “no blood available”. The mother reported that, while she and her daughter were at the regional centre, another child, as sick as her own, had arrived whose need for the blood, already crossed-matched for our patient, was decided to be the more urgent because his or her mother could contribute money. As health care practitioners, we make decisions that are generally evidence based and (hopefully) in the patient’s best interests. A premature neonate, with a gestational age of 27 weeks, had been labelled a “fighter” after surviving 3 days on only a whiff of oxygen. This was going to be a success story for Africa — the survival of a premature baby. One night, a 6-month-old boy presented in severe respiratory distress when the oxygen concentrator was away being repaired and the only oxygen cylinder that wasn’t empty (it was one-quarter full) was with the fighter, who hadn’t tolerated a trial on room air. Reluctant to take oxygen away from her, I told the mother of the boy that I had done all I could. He died 3 hours later and I could hear the mother wailing from my room. The next day, the condition of the fighter on oxygen therapy suddenly deteriorated and I was unable to revive her. Had I made the wrong decision? Hindsight is a torment for one’s conscience. However, the oxygen dilemma prompted us to adapt the oxygen tubing so that two children could receive low-flow oxygen at the same time. When I received my first Ugandan arrest call, I ran to the bedside. Almost 5 minutes after I arrived, the suction and some monitoring equipment appeared. Oxygen was not available until later and we also had to wait for resuscitation drugs. The outcome was poor, both for the patient and my confidence. After my third resuscitation call, I didn’t run any more. I walked “mpola mpola” (slowly, slowly) with the rest of the team — arrests are difficult to manage without basic equipment, and usually fatal because of delayed treatment. So far I have painted a somewhat bleak picture, but there were good days and successes. A 6-week-old girl was brought in severely malnourished, weighing 2 kg with sepsis and malaria. The good Samaritan who had picked her up as a newborn from the roadside after the mother abandoned her was feeding her cow’s milk. After antibiotics, antimalarials and commencing our formula feeding program, the child gained weight and even started to smile. Also heartening, and something that has constantly amazed me, is the resilience and good humour of the staff, who do their best with what is available. However, when I read in the local newspaper that the World Health Organization’s Making Pregnancy Safer program is to be extended, and more mothers will be encouraged to give birth in hospital, I remember all the critical events that I have witnessed. Surely this advice will not lead to improved outcomes while there is such a disparity between demand and supply, between concept and reality. Reliable running water and electricity; hospital supplies like basic disposables, oxygen, and blood for transfusion; and adequate staffing and staff training are essential requirements for emergency obstetric and paediatric care. My story highlights that if basic hospital facilities were improved and some systemic delivery deficiencies overcome, more progress towards the MDGs 4 and 5 in Uganda and all of sub-Saharan Africa would be made. Ensuring that 90 per cent of African mothers and newborns have access to the essential interventions already written into policy would cost a very affordable US$1.39 per capita.15 What are the Millennium Development Goals for maternal and child health and where does Uganda stand in achieving them? Millennium Development Goal (MDG) 4 aspires to a global target of a two-third reduction by 2015 in the mortality rate of children aged under 5 years. For Uganda, this means a decrease to below 56 deaths per 1000 live births; however, the rate only declined from 186 to 135 deaths per 1000 live births during the period 1990 to 2008.4 Globally, neonatal mortality accounts for 38 per cent of deaths in children aged under 5 years; hence, a substantial reduction in neonatal deaths is necessary if this goal is to be attained.5 A 2006 Ugandan survey reported a perinatal mortality rate (comprising the stillbirth rate and early neonatal mortality rate) of 36.3 per 1000 pregnancies.6 This amounts to 44 500 newborns dying and 45 100 stillborn babies each year.7 Childbirth is the time of greatest lifetime risk of mortality for a mother and her baby. Intrapartum complications account for an estimated 42% of the world’s 358 000 annual maternal mortality rate (MMR). Sub-Saharan Africa contributes 57% to the world’s annual MMR.8 The first target of MDG 5 is to reduce the MMR by three-quarters before 2015, equivalent to a reduction to 131 deaths per 100 000 live births in Uganda — the estimated MMR is currently 435 deaths per 100 000 live births.9 A 2005 study estimated the MMR at 645 deaths per 100 000 live births at the National Referral Hospital, my workplace.10 Many obstetric and newborn complications can be prevented or successfully managed with prompt interventions. The Lancet Newborn Survival Series demonstrated that skilled clinical care could effect a reduction in neonatal mortality rates of up to 72 per cent.11 Timely identification and management of childbirth complications is paramount, and while more mothers and newborns die during this period than at any other, coverage and quality of care often remains inadequate in resource-limited settings.12 It is also important to note that with gross under-reporting (deaths at home or en route to hospital are often not recorded), the true figures are undoubtedly substantially higher. However, Uganda’s slow progress towards MDGs 4 and 5 has put the spotlight firmly on maternal and child health delivery. The government has responded by developing a national roadmap to accelerate the reduction of maternal and child mortality and morbidity. It has been placed high on the political agenda and, with the country’s upcoming elections in February 2011, all major political parties in the country are promising to make maternal and child health a priority. In addition, the World Bank in May 2010 released a new 5-year action plan to help poor countries reduce their maternal and child deaths. Uganda is one of the sub-Saharan African countries targeted. There is hope that, with time, Uganda will achieve the aim of the United Nations 2009 global consensus on maternal, newborn and child health: to have “every pregnancy wanted, every birth safe and every newborn and child healthy”.13 “All needed an emergency caesarean section. However, each woman waited in turn for her operation or spontaneous delivery, whichever came first.” “My responsibility for a 23-bed children’s ward (often with two to three patients per bed) in rural Uganda also brought me many challenges.” Communication, Ugandan style!

Katie M Moynihan MB BS, DCH

Objective: Design, setting and participants: Cross-sectional study of consecutive patients attending the Joondalup Health Campus public antenatal clinics in WA in January 2010.Intervention: Audit of uptake of the H1N1-specific vaccine.Main outcome measures: Rate of H1N1-specific vaccination, and reasons for not being the vaccinated.Results: 479 of 541 women who attended the clinics (88.5%) were included in the audit. Three women had been infected with pandemic influenza in the preceding influenza season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476 women, only 33 (6.9%) had been vaccinated. Of the remaining 443 women who were eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered vaccination despite multiple visits to their general practitioners during pregnancy, 19.6% had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that they would decline vaccination if offered because of safety concerns.Conclusions: Uptake of H1N1-specific influenza vaccine in pregnant women was poor. Reasons for this relate both to vaccination not being offered to or actively sought by the women, as well as concerns — of both the women and their GPs — about vaccine safety in pregnancy. Uptake in this setting may improve if vaccination is offered through public antenatal clinics with concurrent safety education for obstetricians and vaccination providers.

Scott W White MB BS · Rodney W Petersen MB BS, MBA, FRANZCOG · Julie A Quinlivan MB BS, PhD, FRANZCOG

To the Editor: I refer to the article by Gallego and colleagues in the 19 April 2010 issue of the Journal,1 which stated that (as at the time of writing, in July 2009) Australia had no formal policies for iodine supplementation in pregnant and lactating women. In January 2010, the National Health and Medical Research Council (NHMRC) released a public statement, Iodine supplementation for pregnant and breastfeeding women.2 The NHMRC recommends that women who are pregnant, breastfeeding or considering pregnancy take an iodine supplement of 150 μg each day; and women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement. The public statement also provides information on the increased need for iodine during pre-pregnancy, pregnancy and breastfeeding, the risks of not having enough iodine and the types of supplement that should and should not be used. The statement was developed in consultation with an expert reference group and was based on a review of recent international scientific literature for the efficacy of iodine supplementation in increasing iodine levels in pregnant and breastfeeding women to levels that mitigate the risks associated with iodine deficiency.3 The public statement and supporting literature review can be found on the NHMRC website.2,3

Warwick P Anderson

To the Editor: We disagree with the opinion expressed by Gallego and colleagues that Australian “women planning a pregnancy and pregnant and lactating women should be advised to take an iodine supplement”,1 and offer two reasons to support our view. First, the data suggesting mild iodine deficiency in Australian women were collected from opportunistic samples of women not representative of the population at large and were obtained before the introduction of mandatory iodine fortification of bread in October 2009. We believe that recommending iodine supplementation in pregnancy without evaluating the effect of mandatory iodine fortification on iodine intake and status of pregnant women in Australia is premature.2 This is supported by a recent report, developed by the Dietitians Association of Australia on behalf of the National Health and Medical Research Council (NHMRC).3 The report clearly shows that the recommended iodine intake for pregnant women (recommended dietary allowance, 220 μg/day) is achievable from foods alone, together with iodine fortification of bread. Second, there are no randomised controlled trials (RCTs) that have examined the effect of iodine supplementation of pregnant women from regions of mild iodine deficiency (as in Australia) on neurodevelopment of the offspring or any other clinical outcomes. Gallego et al state that “iodine-containing supplements consistently benefit the iodine and thyroid status of both mother and newborn”, citing a review of iodine supplementation of pregnant women from populations with mild-to-moderate iodine deficiency.4 In fact, none of the six RCTs included in that review showed a clear effect of supplementation on maternal and newborn thyroid hormone concentrations, which suggests that the maternal thyroid is able to adapt to meet the increased thyroid hormone requirements of pregnancy in areas of mild-to-moderate iodine deficiency.5 Furthermore, Gallego et al cite no evidence to support their statement “Even subclinical hypothyroidism in the mother, occurring as a consequence of iodine deficiency, can cause irreversible brain damage in the fetus . . .”. In our view, major public health recommendations advising routine iodine supplementation for women planning a pregnancy, as well as pregnant and lactating women, should await the results of current RCTs6-8 examining the effect of maternal iodine supplementation on longer-term maternal health and neurodevelopmental outcome of children in regions with mild-to-moderate iodine deficiency, including Australia and New Zealand.

Shao J Zhou · Sheila A Skeaff · Philip Ryan · Maria Makrides

In reply: While Zhou and colleagues disagree with our viewpoint that Australian “women planning a pregnancy and pregnant and lactating women should be advised to take an iodine supplement”,1 we note that they suggest any such recommendation should await the results of their planned randomised controlled trial (RCT) examining the effects of maternal iodine supplementation on maternal health and neurodevelopmental outcome of the offspring. They neglect to mention that the National Health and Medical Research Council (NHMRC) issued a public statement in January this year, with supporting evidence attached, stating that: “The NHMRC recommends that all women who are pregnant, breastfeeding or considering pregnancy take an iodine supplement of 150 μg each day”.2 Similar recommendations, based upon available scientific evidence, have been issued by the World Health Organization, International Council for Control of Iodine Deficiency Disorders, American Thyroid Association and American Endocrine Society. We agree that there is a paucity of RCT evidence examining the effect of iodine supplementation of pregnant women living in mildly iodine-deficient areas, and this is regrettable. Given the overwhelming animal and human evidence that maternal iodine deficiency causes brain damage in the offspring of deficient mothers, we consider there are major ethical issues in conducting such trials where pregnant women would be deprived of iodine and their babies put at risk of brain damage. Zhou and colleagues imply that mild-to-moderate iodine deficiency is not widely prevalent in Australia. This statement ignores the evidence from several clinical studies of pregnant women in New South Wales, Victoria and Tasmania, all showing that mild-to-moderate iodine deficiency is widespread in the majority of the Australian population. Analysis of the data in some of these studies shows between 20% and 40% of women tested are moderately to severely iodine deficient.3 Furthermore, food modelling studies by Food Standards Australia New Zealand (FSANZ) predict between 45% and 75% of Australian women will continue to be iodine deficient after the mandatory use of iodised salt in bread that commenced in October 2009.4 Finally, we disagree with their assertion that the recommended iodine intake for pregnant women can be achieved by the majority of women from foods alone, together with iodine fortification of bread. A trial of bread fortification in Tasmania showed this was not achievable.5 If this were achievable, it is questionable why Zhou and colleagues would even consider conducting an RCT of maternal iodine supplementation in pregnant women in Australia and NZ.

Gisselle Gallego · Stephen Goodall · Creswell J Eastman

Objective: To investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations.Design, setting and participants: An anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008.Main outcome measures: Attitudes to abortion, particularly after 24 weeks’ gestation.Results: Our study showed a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks’ gestation.Conclusions: Our data show that a majority of Australians support laws which enable women to access abortion services after 24 weeks’ gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

Lachlan J de Crespigny MD BS, FROCG, COGU · Dominic J Wilkinson MB BS, MBioeth, FRACP · Thomas Douglas BMedSc, MB ChB, BA(Hons) · Mark Textor BEc · Julian Savulescu MB BS, BMedSci, PhD

Objective: To determine the opinions and current practice of obstetricians and gynaecologists and trainees in the specialty with regard to induced abortion.Design, setting and participants: A voluntary, anonymous survey of Australian Fellows and specialist trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted between 23 June and 31 July 2009 using an email invitation to proceed to an online questionnaire.Main outcome measures: Attitudes to abortion; self-reported usual practice of induced abortion.Results: Of 1498 Fellows and trainees invited to complete the questionnaire, 740 (49%) did so. Of these respondents, 632 (85%) stated that they did not hold religious or conscientious views that would make them totally opposed to abortion; 463 of these (73%) reported performing abortion as part of their personal practice, with 204 (44%) doing so only for severe fetal abnormality or serious maternal medical conditions. 108 respondents reported holding views that made them totally opposed to abortion — 60 (56%) opposed it in any situation at all and 48 (44%) opposed it with limited exceptions. Of those opposed, 34 (32%) added comment that they perform abortion for severe fetal abnormality or serious maternal medical conditions, and a further 17 (16%) commented that they refer women requesting abortion in these circumstances to colleagues. Of the respondents not opposed to abortion, 89% supported the availability of induced abortion within the public health system, and half felt that national availability of mifepristone would modify their practice of induced abortion.Conclusions: There was broad support among responding specialist obstetricians and gynaecologists and trainees for the availability of induced abortion in Australia. This study highlights the difficulties of accurately reporting a wide range of views on a contentious issue.

Caroline M de Costa PhD, FRANZCOG, FRCOG · Darren B Russell FRACGP, DipVen, FAChSHM · Michael Carrette MB BCh, FRANZCOG

Mifepristone is a safe, effective and relatively cheap drug that plays an important role in women’s health care and is widely used for early medical abortion in many countries. The Therapeutic Goods Administration (TGA) can authorise mifepristone to be imported into and marketed in Australia. To date, no pharmaceutical company has applied to register mifepristone in Australia. The TGA can also permit medical practitioners to prescribe medicine that is not approved for marketing in Australia under the Authorised Prescribers scheme. The number of approvals for mifepristone has gradually increased, in spite of a complicated and protracted application process. Approval under the Authorised Prescribers scheme requires medical practitioners to comply with state or territory legislation. Abortion laws in Australia vary between jurisdictions, and in some states the law is unclear and confusing. The decriminalisation of abortion in all Australian jurisdictions would protect medical practitioners from criminal liability, promote the health interests of Australian women, and discourage the illegal importation of abortifacients that are being used without quality controls or medical supervision. The Victorian Abortion Law Reform Act 2008 is one legislative model for this.

Kerry A Petersen LLB, LLM, PhD

Riwayat. Sanjay Patole, Ajay Rane, producers. Horizon Films, 2010. http://www.riwayatmovie.com. It’s not often that the Journal publishes film reviews. It’s not often, however, that two busy Australian clinicians get together to produce a full-length Bollywood extravaganza, complete with swooning love scenes and beautifully crafted song sequences. While the essential ingredients of love, death, family feuding and a happy ending are all present, Riwayat is no ordinary Bollywood set piece. Instead, Indian-born Townsville urogynaecologist Ajay Rane and Perth neonatologist Sanjay Patole have taken on the serious medical and social topic of “the missing millions” of Indian women — those female infants who, over the past few decades, were conceived and sometimes born but either aborted or killed at birth simply because they were female. “Riwayat” means “tradition” in Hindi — and, traditionally, many female infants in India have been killed at birth, mainly in poor communities. More recently, ultrasound has been misused, by those who can afford it, to detect female fetuses for the purpose of abortion. The film is in Hindi, with English subtitles, and will be screened in India as well as overseas. Riwayat is the story of three generations of the upper-class Desai family, whose two sons and their wives are expected to follow the dictates of its autocratic patriarch. This has already led to two abortions and the consequent psychological distress of the elder son’s wife. (Conveniently, the Desais include a private hospital and ultrasound facility in their substantial property portfolio.) The wife of the younger son, who had a love match rather than the traditional arranged marriage, is made of sterner stuff. Having also conceived a female child, she leaves the family home when ordered to abort and returns to the village where she has been working for a non-government organisation (NGO) — an opportunity for the filmmakers to display the beautiful Indian countryside, take a few digs at the doubtful benefits of NGOs to poverty-stricken Indian citizens, and demonstrate the weight of traditional customs at village level. Her Portia-like intervention in the court case of a villager who kills his daughter at birth is designed to show Hindi-speaking viewers the urgent need to cast off this dreadful aspect of their “tradition”, disastrous for those girls and women denied life, but also for society as a whole. Riwayat is both an enjoyable romp and an important piece of social commentary. Hopefully, it will be widely shown in Australia.

Caroline M De Costa

Objective: To assess women’s compliance with different Australian guidelines on alcohol intake during pregnancy and examine factors that might influence compliance.Design, setting and participants: We analysed prospective, population-based data on women aged 22–33 years who were pregnant before October 2001, when guidelines recommended zero alcohol (n = 419), or were first pregnant after October 2001, when guidelines recommended low alcohol intake (n = 829). Data were obtained from surveys conducted in 1996, 2000, 2003 and 2006 as part of the Australian Longitudinal Study on Women’s Health.Main outcome measures: Relative risks (RRs) for zero alcohol intake, low alcohol intake and compliance with alcohol guidelines, estimated by a modified Poisson regression model with robust error variance.Results: About 80% of women consumed alcohol during pregnancy under zero and low alcohol guidelines. Compliance with zero alcohol guidelines or low alcohol guidelines (up to two drinks per day and less than seven drinks per week) was the same for women who were pregnant before October 2001 and women who were first pregnant after October 2001 (20% v 17% for compliance with zero alcohol guidelines, P > 0.01; 75% v 80% for compliance with low alcohol guidelines, P > 0.01). Over 90% of women drank alcohol before pregnancy and prior alcohol intake had a strong effect on alcohol intake during pregnancy, even at low levels (RR for zero alcohol, 0.21 [95% CI, 0.16–0.28]; RR for low alcohol, 0.91 [95% CI, 0.86–0.96]). RR for compliance with guidelines was 3.54 (95% CI, 2.85–4.40) for women who were pregnant while low alcohol intake was recommended, compared with those who were pregnant while zero alcohol guidelines were in place.Conclusion: The October 2001 change in alcohol guidelines does not appear to have changed behaviour. Risks associated with different levels of alcohol intake during pregnancy need to be clearly established and communicated.

Jennifer R Powers BSc, MMedStat · Deborah J Loxton BPsych(Hons), PhD · Lucy A Burns MPH, PhD, GradCertHlthPol · Anthony Shakeshaft BA, MA, PhD · Elizabeth J Elliott MD, MPhil, FRACP · Adrian J Dunlop MB BS, PhD, FAChAM

To the Editor: The aim of the study by Kennare and colleagues1 was to establish data on home and hospital birth outcomes for the period 1991–2006, before the Policy for Planned Birth at Home in South Australia was introduced in 2007.2 One significant shortcoming of the study was the lack of data regarding the type of birth attendant, the degree of cooperation with the local hospital and the quality of transfer arrangements. Currently, there are virtually no home birth policies in Australia governing women’s access to qualified midwives with hospital visiting rights that enable appropriate transfer. Women who intend to have a home birth are forced to rely on the charity of midwives who provide care without professional indemnity insurance. Failing this, women are known to give birth without a midwife. Kennare et al1 suggested that the Bachelor of Midwifery program will increase the number of midwives planning to offer home birth. However, their study did not examine whether women were attended by registered midwives, non-registered midwives, doulas, untrained birth helpers or a professional of any capacity, and assumed that planned home birth equates to home birth under the care of a qualified registered midwife. This has been a weakness of previous Australian studies.3 Overseas studies which identify the status of the midwives have shown that, for low-risk pregnancies, births at home attended by competent registered midwives in a networked system have outcomes that are comparable to hospital births.4,5 We have previously detailed other limitations of the study, including the inclusion of women who planned a home birth at booking but subsequently developed risk factors and gave birth in hospital, as well as the difficulty of examining the rare outcome of intrapartum death or intrapartum asphyxia in such a sample, as the wide confidence intervals show.6 Kennare and colleagues1 provide useful recommendations about risk assessment, transfer to hospital and fetal monitoring, and rightly highlight that the system must be so terrible for some women that they choose to give birth outside of it, even with risk factors. Despite a malfunctioning system in Australia — where midwives are uninsured and have no visiting rights, and home birth is unfunded and often hard to access — the perinatal mortality rate was no different for home births compared with hospital births. Risk assessment, transfer to hospital and fetal monitoring will be improved when midwives are no longer excluded from mainstream services.

Hannah G Dahlen · Caroline S E Homer · Sally K Tracy · Andrew M Bisits

To the Editor: Kennare and colleagues are to be congratulated.1 Careful, systematic collection and analysis of data on planned home births and planned hospital births creates evidence that women need to make intelligent and safe choices about perinatal care. A central medical cause of concern in the article1 and accompanying editorial2 is a high relative risk of death caused by intrapartum asphyxia in the planned home birth group. But, on closer examination, the underlying cause appears more likely to be a lack of proper integration of home birth midwives into the health care system. Of the nine infant deaths in the study, five were, by definition, unrelated to the place of birth — three were antenatal deaths that occurred after transfer to hospital (all unrelated to type of antenatal care) and two occurred in cases where the baby was born at home but had a fatal congenital anomaly. Three of the other four deaths (two of them due to intrapartum asphyxia) occurred after the parents persisted in their home birth choice despite advice against it, resulting in delayed transfer to hospital, or declined intervention after transfer to hospital — factors thought to have contributed to the deaths. Thus, an underlying contributing cause of the higher risk of intrapartum asphyxia appears to be some parents’ perception that care in hospital was not best for them or their baby. This perception is not entirely baseless, given that the caesarean section rate for planned hospital births in South Australia was 27.1%, 3.7 times the risk associated with planned home births after factoring in differences in maternal characteristics and obstetric conditions between the two groups (adjusted odds ratio, 0.27; 95% CI, 0.22–0.34)1 and about double to triple the 10%–15% rates recommended by the World Health Organization.3 Furthermore, women had seven times the risk of episiotomy for planned hospital births compared with planned home births, and three times the risk of instrumental delivery.1 Recent large, high-quality studies of home birth in Canada4,5 and the Netherlands6 demonstrated that — when home birth midwives are an integral, accepted, insured and funded part of the health care system — home birth is safe and refusal of midwife-recommended care by patients does not appear to be an issue. We suggest that an evidence-based solution to the underlying causes of excess asphyxia and perinatal mortality highlighted in Kennare et al’s study would be to follow the lead of countries such as the Netherlands and Canada — provide state funding for independent home birth midwifery practice, provide professional indemnity insurance and provide home birth midwives with access to hospital privileges as autonomous caregivers. When women can depend on continuity of care during transport, they are less likely to refuse or delay necessary care or transfer to hospital.

Kenneth C Johnson · Betty-Anne Daviss

In reply: Dahlen and colleagues overlooked that we excluded births without professional antenatal care (n = 1217), ensuring that all 1141 planned home births in our study were cared for by registered midwives.1 Nonetheless, we appreciate their acknowledgement that our article contains useful recommendations. Yet, they failed to endorse these recommendations in their letter and in the earlier critique to which they refer. They instead draw attention to a lack of difference in total mortality, but dismiss large differences in intrapartum and asphyxia-attributed mortality through their misinterpretation of confidence intervals. Rare outcomes, such as these, inevitably have wide confidence intervals. However, it is wrong and misleading to use the lack of precision in how much more frequent they are as an argument to dismiss their significantly much higher frequency. We tend to agree with the above correspondents, though, that proper integration of home birth care in maternity services might prevent some avoidable deaths that are a recurrent feature in Australian home birth studies.1-3 Indeed, we postulated this too.1 However, it is fallacious to assume that differences in outcome between Australia and other countries, to which the correspondents refer, are merely an issue of funding and access to hospital privileges for autonomous practitioners. The Netherlands,4 for example, has more than 40 000 home births a year, but only three midwifery academies, with a 4-year curriculum. Australia has less than 1000 home births a year, fewer than it has midwifery students, most of whom learn both nursing and midwifery within 4 years. Midwives in the Netherlands are medical professionals and carefully select only low-risk pregnancies for home birth.4 In Australia, on the contrary, many independent midwives accept home birth for pregnancies that are not low risk.1,2 Adherence to approved policies for planned home birth5 and collaboration with hospital services must be a prerequisite to their integration into maternity services. Unless leaders and teachers of the midwifery profession in Australia unequivocally condemn home birth for women with substantial risks, such as twin pregnancy or previous caesarean section, babies will continue to die needlessly, irrespective of any funding models.

Marc J N C Keirse · Robyn M Kennare · Graeme R Tucker · Annabelle C Chan