Women's health

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

The pill and other forms of hormonal contraception. The facts. 7th ed. John Guillebaud, Anne MacGregor. Oxford: Oxford University Press, 2009 (xix + 193 pp). ISBN 9780199565764. Does life begin at fertilisation or implantation? At times, the sticky question about whether certain types of contraception are actually causing an abortion arises with patients or colleagues. This book helps by providing a discussion of some ethical aspects of contraception in one of the appendices, where the authors argue that one can write an equation for the definition of conception as follows: CONCEPTION = FERTILIZATION + IMPLANTATION (being with child) (crucial) (also crucial) This equation makes it possible to argue that methods of contraception which may block implantation are contraceptives, and not abortifacients. John Guillebaud is Emeritus Professor of Family Planning and Reproductive Health at University College London, and a guru in family planning. He first wrote this guidebook in 1980 as he is passionate about sharing his knowledge with women: “here are the facts, now you decide”. Anne MacGregor is an Instructing Doctor in Sexual and Reproductive Healthcare at the Royal College of Obstetricians and Gynaecologists, London. This “book about the Pill for a general readership” is a user-friendly explanation of the contraceptive pill and other hormonal contraceptive methods. There are plenty of diagrams, tables and flowcharts to assist the reader’s understanding of reproductive physiology, choice of pill and what to do about breakthrough bleeding and other management issues. Tables present the risks and side effects, but also the benefits of taking the Pill. Although many people regard the Pill as “unnatural”, one could argue that having regular menstrual cycles is an unnatural condition. Before contraception was available, women would have been pregnant or breastfeeding for most of their reproductive lives. Although the Pill is not suitable for all women, many women find that taking the Pill and being “a little bit pregnant” works well at one or more stages of their life, or “contraceptive ages” as this book puts it.

Lisa H Amir

Objective: To determine whether there is an excess risk of breast cancer among female employees of the Australian Broadcasting Corporation (ABC), especially outside Queensland, compared with women in the general populations of the states and territories.Design, setting and participants: We used an occupational cohort design. Information from ABC staff records was linked with data from state and territory cancer registries to identify female employees of the ABC with an incident, histologically confirmed breast cancer. Data linkage was complemented by a self-report method. We included a cohort of ABC female employees who had developed breast cancer at any time between 1994 and 2005, during their employment or after cessation of employment with the ABC. The standardised incidence ratio (SIR) was calculated as the number of women at the ABC observed with breast cancer divided by the expected number based on population rates in each state and territory. Tests for heterogeneity were performed to examine the variation of breast cancer risk between states and territories.Results: Out of 5969 women who were permanently employed either part-time or full-time at the ABC between 1994 and 2005, 48 eligible women with breast cancer were identified. An excess risk of breast cancer among ABC female employees in Queensland (identified in an earlier study) was reconfirmed. No excess risk of breast cancer was observed among ABC staff diagnosed in states outside Queensland (SIR, 1.01 [95% CI, 0.72–1.38]), or in Australia as a whole (including Queensland) (SIR, 1.12 [95% CI, 0.83–1.49]). There was no significant heterogeneity in breast cancer risk among states and territories once Queensland was excluded from the analysis (P = 0.39).Conclusion: No statistically significant excess risk of breast cancer in ABC female employees was found across the Australian states and territories as a whole compared with their respective population incidences. A statistically significant increased risk of breast cancer was found among ABC female employees in Queensland, consistent with the findings in an earlier report.

Freddy Sitas MSc(Med), MSc(Epidemiol), DPhil · Dianne L O’Connell BMaths(Hons), PhD · Cathelijne H van Kemenade MSc, MPH · Mark W Short BSc(Hons), PhD · Kun Zhao BEcon, BPsych(Hons)

To the Editor: Treatment of critically ill pregnant women is challenging, and information on medication use during pregnancy is scant. We describe the case of a pregnant woman who required extracorporeal membrane oxygenation (ECMO), prolonged sedation and paralysis to treat acute respiratory distress syndrome secondary to pandemic (H1N1) 2009 influenza. A 34-year-old pregnant woman (G2P1) at 21 weeks’ gestation presented to a metropolitan hospital with level 1 intensive care unit facilities. She had known Grade 2 placenta praevia, a 5-day history of influenza-like symptoms, and no history of asthma, chronic disease or recent travel. On examination, she was severely hypoxic (PaO2, 27 mmHg on 15 L/min O2), conscious, tachypnoeic and speaking in single words. A chest x-ray showed extensive bilateral infiltrates (Box). She needed urgent endotracheal intubation but remained hypoxic despite maximal intensive mechanical ventilation. The patient was transferred to St Vincent’s Hospital, Sydney, where venovenous ECMO was commenced on arrival. Her oxygenation status improved and remained satisfactory. Mechanical ventilation was reduced (tidal volume, < 6 mL/kg; peak pressure, < 30 cm H2O) to avoid ventilator-induced lung injury. The patient required very high doses of morphine, fentanyl, midazolam, propofol, dexmedetomidine, cisatracurium and heparin during ventilation and ECMO. In addition, empirical treatment with oseltamivir (150 mg twice a day, Days 1–8), azithromycin and ceftriaxone was started on admission, before a bronchoalveolar lavage specimen tested positive for influenza A and pandemic influenza. Furthermore, a multiresistant Escherichia coli caused ventilator-associated pneumonia, which was treated with meropenem (1 g three times a day, Days 17–30). ECMO was discontinued on Day 19, when lung function had improved. No other organ failure developed. On Day 21, a tracheostomy was performed for severe weakness and weaning failure. The patient was weaned from the ventilator on Day 35 and was discharged home 2 weeks later, after making a full recovery. She gave birth by caesarean section at 35 weeks’ gestation. The baby was in good health and the patient recovered well — both left hospital 3 days after the birth. Information on the use of medication in pregnant women who require intensive care is limited, especially the use of neuraminidase inhibitors.1 We found little evidence on the safety of long-term use of neuromuscular blockers and sedation in pregnancy, with or without ECMO.2 Most literature on this topic describes short-term use of neuromuscular blockers and sedation. Dexmedetomidine has a short postmarketing history, and has therefore had limited use. Data from Australia and New Zealand indicate that 9% of patients admitted to an intensive care unit with pandemic influenza are pregnant. An estimated inhospital mortality rate of more than 16% in this population indicates the severity of the infection.3,4 Single-organ lung failure is a common feature of complicated pandemic influenza, and venovenous ECMO should be considered in these circumstances.2,4,5 Our case demonstrates that ECMO and the drugs necessary for its use can be used during pregnancy in a patient with influenza-associated acute respiratory distress syndrome, and that survival of the patient and fetus is possible. Chest x-ray of a pregnant woman with influenza-associated acute respiratory distress syndrome showing extensive bilateral infiltrates

Susan A Welch · Leone N Snowden · Hergen Buscher

To the Editor: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes.1 Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcomes associated with a quality improvement approach.2 Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention.3 Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously.4 Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods.5 Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required. Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of non-Indigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor. Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/hygiene was recorded for only 4%–5% of all women. The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services. This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia. Documented pregnancy care across regions Characteristic NT Top End NT Central Australia Far West NSW Western Australia North Queensland Total Number of health centres | number of client records audited 13 | 136 2 | 45 6 | 103 9 | 193 4 | 58 34 | 535 Proportion of women with estimated gestational age < 12 weeks at first antenatal visit 49% 44% 35% 42% 34% 42% Mean number of antenatal visits 9 10 5 6 7 7* Proportion of women with folate prescribed before 20 weeks 29% 49% 3% 33% 24% 27%* Any use of: Cigarettes 41% 40% 39% 42% 55% 43% Alcohol 12% 27% 19% 25% 31% 22%* Illicit drugs 7% 2% 17% 8% 7% 9% Brief interventions or counselling Smoking cessation† 48% 67% 35% 49% 41% 46% Antenatal education 51% 93% 51% 46% 47% 52%* Nutrition 53% 76% 18% 32% 59% 41%* Breastfeeding 21% 51% 17% 25% 19% 24% Alcohol and other substance abuse 37% 56% 12% 39% 34% 34%* Investigations at first antenatal assessment Blood group/Rh 96% 100% 65% 77% 79% 82%* Antibodies 93% 100% 66% 70% 78% 79%* Midstream urine (MSU) 91% 96% 40% 67% 76% 71%* Full blood examination (FBE) 95% 100% 64% 73% 79% 80%* Rubella 92% 100% 61% 70% 78% 77%* Hepatitis B surface antigen 91% 100% 56% 75% 79% 78%* Syphilis serology 94% 100% 58% 55% 81% 72%* HIV 80% 89% 14% 72% 59% 63%* Offered anomaly screening 6% 33% 17% 20% 0% 15%* Other investigations Ultrasound before 16 weeks 32% 49% 38% 39% 24% 36% Ultrasound at 16–20 weeks 47% 69% 31% 41% 34% 42% 50g or 75g glucose challenge test (GCT) or glucose tolerance test (GTT) 78% 49% 33% 38% 66% 51%* FBE (20–28 weeks) 82% 69% 24% 46% 60% 54%* Low vaginal swab for group B streptococcus (34–37 weeks) 49% 62% 31% 29% 10% 35%* Follow-up of abnormal findings Record of abnormal standard GCT 17% (23/136) 22% (10/45) 10% (10/103) 4% (7/193) 17% (10/58) 11% (60/535)* GTT undertaken 87% (20/23) 90% (9/10) 80% (8/10) 43% (3/7) 60% (6/10) 77% (46/60) Anaemia (Hb < 100 g/L) 14% (19/136) 22% (10/45) 11% (11/103) 12% (24/193) 3% (2/58) 12% (66/535)* Iron prescribed 84% (16/19) 100% (10/10) 91% (10/11) 75% (18/24) 50% (1/2) 83% (55/66) Follow-up FBE or Hb test done 42% (8/19) 90% (9/10) 36% (4/11) 46% (11/24) 50% (1/2) 50% (33/66) Nitrites detected by dipstick 21% (28/136) 33% (15/45) 5% (5/103) 24% (46/193) 10% (6/58) 19% (100/535)* Urine sent for culture and sensitivity 96% (27/28) 100% (15/15) 100% (5/5) 93% (43/46) 100% (6/6) 96% (96/100) Oral antibiotic prescribed 93% (26/28) 60% (9/15) 80% (4/5) 37% (17/46) 83% (5/6) 61% (61/100)* Record of a normal follow-up MSU 46% (13/28) 100% (15/15) 40% (2/5) 26% (12/46) 83% (5/6) 47% (47/100)* Rubella antibodies negative or low-titre 35% (47/136) 7% (3/45) 15% (15/103) 15% (28/193) 7% (4/58) 18% (97/535)* Rubella vaccination given postnatally 36% (17/47) 67% (2/3) 13% (2/15) 32% (9/28) 0 (0/4) 31% (30/97) GTT = glucose tolerance test. Hb = haemoglobin. NSW = New South Wales. NT = Northern Territory. * P < 0.05 for comparisons between regions. † Among those who used cigarettes: NT Top End (n = 56), NT Central Australia (n = 18), Far West NSW (n = 40), WA (n = 82), North Queensland (n = 32); total N = 228.

Alice R Rumbold · Ross S Bailie · Damin Si · Michelle C Dowden · Catherine M Kennedy · Rhonda J Cox · Lynette O’Donoghue · Helen E Liddle · Ru K Kwedza · Sandra C Thompson · Hugh P Burke · Alex D Brown · Tarun Weeramanthri · Christine M Connors

Recent research has confirmed that Australian children and pregnant women are mildly iodine deficient. A considerable proportion of the pregnant population is moderately to severely iodine deficient. Even subclinical hypothyroidism in the mother, occurring as a consequence of iodine deficiency, can cause irreversible brain damage in the fetus, making it essential to avoid iodine deficiency in pregnancy. The proposal of Food Standards Australia and New Zealand (FSANZ) — Mandatory Iodine Fortification for Australia (P1003) — has been implemented. FSANZ openly admits P1003 is inadequate for covering the needs of pregnant women. Therefore, health professionals and the public must be properly informed about the limitations of this proposal. Views differ about the most effective measures to prevent iodine deficiency in Australia. We propose that women planning a pregnancy, and pregnant and lactating women should be advised to take an iodine supplement. Women with pre-existing thyroid disease should exercise caution and seek medical advice before taking a supplement.

Gisselle Gallego BPharm, PhD · Stephen Goodall BSc, MSc(Health Econ), PhD · Creswell J Eastman MD, FRACP, FAFPHM