Women's health

Objective: To identify factors associated with antenatal smoking and explore characteristics of smoking behaviour among pregnant Aboriginal and Torres Strait Islander women.Design and setting: Cross-sectional study using interviewer-administered questionnaires of 145 pregnant Aboriginal and Torres Strait Islander women attending a health service in Far North Queensland between November 2005 and December 2006.Main outcome measures: Prevalence of self-reported smoking; predictors and patterns of smoking in early pregnancy; and relationships between smoking and the prevalence of predisposing, enabling and reinforcing factors, including women’s knowledge about and attitudes towards smoking and the risks involved.Results: Of 145 women, 41% (n = 60) reported being daily or occasional smokers. Knowledge about harms of smoking was generally high. Women who were smokers had a significantly higher rate of smoking partners (n = 36) than women who were non-smokers (n = 31) (77% v 41%, P < 0.001). Level of daily stress was significantly higher among smokers than non-smokers (P = 0.001).Conclusion: Shifted population norms among Aboriginal and Torres Strait Islanders are accompanied by a shift in the factors that can effectively differentiate between smokers and non-smokers within this population. Rather than the traditional, mainstream predictors of antenatal smoking, interventions with Aboriginal and Torres Strait Islander women should focus on the social environment, and the influences of social networks and partners on the behaviour of individuals.

Conor Gilligan PhD · Robert W Sanson-Fisher PhD · Catherine D’Este PhD · Sandra Eades PhD · Mark Wenitong MD

Objective: To determine whether the current planned transfer of pregnant women from Cape York communities to Cairns at 36 weeks’ gestation for birthing is medically appropriate.Design and setting: Retrospective audit of travel details and demographic and obstetric outcome data on all women from Cape York communities who travelled to Cairns for late pregnancy care and birth at Cairns Base Hospital in 2006.Main outcome measures: Length of stay in Cairns; gestational age at birth.Results: In 2006, 172 women from 14 Cape communities travelled to Cairns to give birth. Of these, 76% identified as Aboriginal or Torres Strait Islander, 20% as Caucasian and 4% were from other ethnic groups. The mean time of stay in Cairns before birth (range) was 24 (0–86) days. Eleven women (6%) gave birth between 36 and 37 weeks of pregnancy; this point marked the beginning of a significant rise in births for increasing gestational ages.Conclusion: Aiming for 36 weeks’ gestation for transfer is medically appropriate, but results in long periods of separation of women from Cape communities from family and friends, with detrimental social, cultural and financial consequences. Reopening maternity units in towns serving the Cape communities could reduce the number of women from the region having to travel to Cairns for pregnancy care and birth.

Joanna L Arnold MB BS, FRANZCOG · Caroline M de Costa FRANZCOG, FRCOG, MPH · Paul W Howat MB BS, FRANZCOG

Challenging the assumption that higher rates of intervention provide no benefits for babies Hardly a week seems to pass in Australia without an article in national newspapers drawing attention to the differences in obstetric intervention rates between private patients cared for by obstetricians and public patients who receive various models of care.1 The reported assumption has consistently been that the higher intervention rates observed in private patients are of no benefit to women or their babies, and possibly cause harm. This opinion has inevitably led to suggestions that federal support for private obstetric care be scaled back and redirected to models of care with lower intervention rates.2 An article by Robson and colleagues in this issue of the Journal reporting the results of a review of births in Australia (Adverse outcomes of labour in public and private hospitals in Australia: a population-based descriptive study)3 thus achieves increased significance by being published at a time when the federal Health Minister has received and is preparing her response to the report of the Maternity Services Review.4 Robson and colleagues report a retrospective analysis of the 789 240 singleton births occurring between 37 and 41 weeks’ gestation in Australia during 2001–2004, excluding about 15% of pregnant women for methodological reasons.3 Outcomes reported in the National Perinatal Data Collection (NPDC) were adjusted for recorded risk factors. Their study confirms increased intervention rates in private patients. A previous study by Roberts and colleagues reporting higher instrumental delivery rates for low-risk private patients found a higher risk of low Apgar scores in babies of public patients,5 which might have implied a possibility of poorer outcomes for these babies, but perinatal mortality and morbidity data were otherwise lacking. Robson et al’s study demonstrated a twofold increase in risk of perinatal death for babies delivered in public hospitals, as well as significant increases in risk of low Apgar scores, need for high-level resuscitation, and admission to a special care or neonatal intensive care nursery. Of the two maternal outcomes available in the NPDC, only perineal trauma was reported, and, somewhat unexpectedly given the higher rate of instrumental deliveries in private patients, the rate of third- and fourth-degree lacerations was lower in private patients (also confirming the findings of Roberts et al’s study5). Unfortunately, incomplete data precluded reporting of maternal blood loss, and the NPDC does not report other maternal complications. This situation should hopefully be addressed in the future by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ planned maternal morbidity audit. So what can we learn from this study? It is always more difficult to rely on retrospective data, especially when gathered from populations with different sociodemographic factors, even when adjusting as far as possible for known risk factors. However, unless we are to conduct randomised controlled trials of private versus public models of maternity care (unlikely) or planned caesarean versus planned normal delivery (even more unlikely), the quality of these data is as good as any we are likely to obtain. It is worth noting that in restricting their analysis to women with singleton pregnancies delivered between 37 and 41 completed weeks’ gestation, Robson et al minimise the bias that follows from the fact that women with preterm deliveries, which are at highest risk of perinatal morbidity, are generally transferred when possible to tertiary referral centres in the public system. However, failure to similarly exclude outcomes for predictably high-risk pregnancies delivered at term at these centres (eg, babies with antenatally diagnosed major congenital abnormalities) introduces a numerically small but possibly significant bias towards a relatively higher risk of adverse outcomes in the public patient group. Adjusting for other known risk factors also minimises to the extent possible the differences in outcomes attributable to different prevalences of these risk factors in populations of differing socioeconomic background, but cannot eliminate them altogether. Notably, some of these socioeconomic differences would be expected to increase the risk for babies of private patients (higher proportions of primigravidae, maternal age of 40 years or older, and history of previous caesarean delivery). In addition, the exclusion of babies delivered after 41 completed weeks’ gestation is likely to reduce the rate of adverse outcomes in the public patient group, as allowing pregnancies past 41 weeks — when perinatal mortality is 70% higher than for babies delivered at 40 weeks6 — is virtually unknown in private patients, but does occur in the public system. This study has inevitably generated some media controversy7 because for the first time there are national data, albeit with methodological limitations, to suggest that private obstetric care and its associated higher rates of intervention might actually be benefiting babies, if not their mothers. The study is silent on major maternal problems other than severe perineal trauma, which might be associated with the increased obstetric intervention rates associated with private care and especially with caesarean delivery (haemorrhage, hysterectomy, wound complications and venous thromboembolism). Is it possible to extrapolate the findings of this study to conclude that private care provided by obstetricians, with its increased intervention rates, prevents perinatal mortality and morbidity in Australia? No, but it must make us at least consider the possibility, and challenge the tacit assumption that continuity of care with a private obstetrician and/or higher intervention rates do not prevent perinatal morbidity and mortality. Historically, it was always assumed that a decision in favour of intervention (especially caesarean delivery) presented a balance of risks — babies benefited, but this benefit was bought at the cost of increased maternal risk. More recently, some studies have been published which suggest that babies born by caesarean delivery are actually at higher risk of adverse outcomes, including perinatal death.8 Robson et al’s study supports a return to the previous understanding that, in choosing obstetric intervention, clinicians and their patients need to balance the potential benefits for the baby with the risks borne by the mother.

Andrew F Pesce MB BS, FRANZCOG

Objective: Design, setting and participants: A population-based study of 789 240 term singleton births in public and private hospitals in 2001–2004, using data from the National Perinatal Data Collection.Main outcome measures: Third- and fourth-degree perineal injury, requirement for high level of neonatal resuscitation, Apgar score < 7 at 5 minutes, admission to neonatal intensive care unit or special care nursery, and perinatal death.Results: 31.4% of the term singleton births occurred in private hospitals. After adjusting for maternal age, Indigenous status, parity, smoking status, diabetes, hypertension, remoteness of usual residence, and method of birth, the rates of all adverse outcomes studied were higher for public hospital births. For women, the adjusted odds ratio (AOR) for third- or fourth-degree perineal injury was 2.28 (95% CI, 2.16–2.40). For babies, the odds of a high level of resuscitation (AOR, 2.37; 95% CI, 2.17–2.59), low Apgar score (AOR, 1.75; 95% CI, 1.65–1.84), intensive care requirement (AOR, 1.48; 95% CI, 1.45–1.51) and perinatal death (AOR, 2.02; 95% CI, 1.78–2.29) were all higher in public hospitals.Conclusion: For women delivering a single baby at term in Australia, the prevalence of adverse perinatal outcomes is higher in public hospitals than in private hospitals.

Stephen J Robson MPH, MD, FRANZCOG · Paula Laws BAppPsych(Hons) · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health)

Early detection of breast cancer has been shown to reduce breast cancer deaths in randomised controlled trials (RCTs) of mammography in women aged 50–69 years, with weaker evidence of benefit in those aged 40–49 or 70 years and older. Magnetic resonance imaging (MRI) and ultrasonography have been evaluated in breast cancer screening, relative to, or in addition to, mammography, in selected populations; neither test has been examined in an RCT, and thus evidence of associated screening benefit is uncertain. MRI is more sensitive than mammography in screening women with suspected or proven inherited mutations of the breast cancer genes. The addition of MRI in screening this population detects 8–24 additional cancers per 1000 screens, but also significantly increases a woman’s risk of being recalled for investigation or surgical biopsy for false-positive findings. In Australia, Medicare funding for MRI screening of women in specific risk groups was announced in February 2009. Ultrasonography can detect cancers not identified on mammography in asymptomatic women with dense breast tissue. Incremental ultrasound cancer detection is reported in 0.27%–0.46% of women with mammography-negative dense breasts; evidence varies on its association with false-positive findings. Computer-aided detection (CAD) is a complementary tool to mammography, prompting the reader to consider lesions on the mammogram that may represent cancer. Emerging evidence and improved CAD technology are likely to help define its role in breast screening.

Nehmat Houssami MB BS(Hons), FAFPHM, PhD · Sarah J Lord MB BS, MSc(Epi) · Stefano Ciatto MD, PhD

In June 2008, the ABC screened a television documentary involving a couple who decided to have an additional child in the hope of obtaining umbilical cord blood to treat their daughter who had leukaemia. The couple conceived naturally, meaning that there was a one in four chance that their child would be suitably matched. They seemed to be unaware of technologies that, if successful, could provide a near certainty that the next child would be a matched “saviour sibling”. This story raises questions about whether clinicians have an obligation to discuss emerging and morally contentious treatment options. Ignorance of technology, assumptions about availability, and medical assessment of burdens and benefits may affect attitudes towards treatment options, but they do not justify non-disclosure of information.

Kimberly A Strong BSc, GradDipGenCouns

To the Editor: We are concerned that conclusions drawn by Robson and colleagues1 regarding perinatal outcomes in private and public hospital settings perpetuate misinformation about safe birthing options. One of the major limitations of using routine datasets, which the authors acknowledge, is that analyses are only able to control for potential confounders held within those datasets.2 Because these datasets are not designed for research, they commonly do not contain information on all pertinent indicators. In this case, the inability to control for expected and potential pregnancy complications affecting poor perinatal outcomes means caution is warranted when drawing conclusions about the safety of public versus private intrapartum care. The public hospital system in Australia is designed to cater for women at risk of adverse events in pregnancy and labour, regardless of their health insurance status. Women with known risk factors may opt for public care in a tertiary hospital, where neonatal intensive care facilities are available. Accounting for only a few surrogate markers of social disadvantage is unlikely to control adequately for inequities in these two very different populations. As such, the extent to which the reported odds ratios are a result of differences in the type of care provided in public and private hospitals, or underlying differences in the populations that have not been adjusted for, is unknown. By attending to odds ratios only, Robson and colleagues have missed the opportunity to disseminate information about overall risk across both health sectors. Although statistical models used in their study indicate the risk of perinatal death is three times more likely in public than private hospitals (taking account of caveats already discussed), the population risk of such adverse perinatal outcomes is extremely small regardless of place of birth. When using data from secondary sources, the onus is on researchers to exercise caution in interpretation and dissemination of results, because we know the media won’t. “Babies die in public hospitals ...”3 is just one example of how the general public are fed conclusions based on insubstantial evidence. We cannot foresee any benefit in undermining trust in our public hospital system. There is, however, potential for harm if women perceive they are in a substandard system of care. It is a simplistic assertion by Robson and colleagues that women can use the information presented in their article to make choices about giving birth in either the public or private sector. For many women, there is no choice.

Georgina A Sutherland · Deirdre Gartland · Jane S Yelland · Stephanie J Brown

To the Editor: In their recent article, Robson and colleagues conclude that women are at increased risk of adverse perinatal outcomes if they give birth in public rather than private hospitals.1 We are concerned that this interpretation is likely to be false, has caused the public unnecessary alarm, and may be used to support vested interests. There are several serious limitations in the data, the analyses and the implications. The authors report that 14.3% of women (about 134 000) giving birth in Australia during the study period were excluded from the analyses. We believe that this exclusion introduces significant bias. Outcomes and sensitivity analyses should have been presented for the excluded groups, enabling the reader to interpret the findings appropriately. Pre- and post-term births and multiple births were appropriately excluded from the analysis. However, perinatal deaths due to congenital anomalies should also have been excluded. In Victoria in 2004, 19% of perinatal deaths at term were caused by congenital anomalies.2 These almost always occur in public hospitals. The authors adjusted for a number of maternal demographic characteristics in their risk assessment. Other factors known to reflect sociodemographic status, such as education, occupation and income, and low birthweight, were not included; therefore the adjustment is unlikely to be adequate. The analysis should have been stratified by hospital level of care. Women at high risk of adverse outcomes should be (and are being) cared for in tertiary public hospitals — which, unlike private hospitals, are designed to provide high-level care — as a matter of need and not of choice. The lumping together of all public hospitals in the analysis and provision of summary outcomes necessarily skews the findings. By doing this, the authors are effectively comparing apples with oranges. The proper analysis of severe perineal laceration would exclude those women who had caesarean sections, because they are not at risk of perineal trauma. Stratification by type of vaginal birth is misleading when women attempting vaginal birth in private hospitals are much more likely to experience instrumental birth than those in public hospitals. In conclusion, differential exclusion of a significant proportion of the population, inadequate adjustment for confounding factors, lack of stratification by hospital type, and inappropriate analysis of perineal lacerations are likely to lead to faulty inference and cause unnecessary alarm. This is particularly unfortunate at the time of publication of the national Maternity Services Review.3

Lyndsey F Watson · Mary-Ann Davey · Mary A Biro · James F King

In reply: We thank Sutherland and colleagues for their comments and acknowledge that dissemination of our research findings1 by some in the Australian media has caused unnecessary alarm.2,3 The data presented in our article show that there appear to be different risk profiles for women giving birth in the public and private sectors in Australia. We agree with Sutherland et al that the “public hospital system in Australia is designed to cater for women at risk of adverse events in pregnancy and labour, regardless of their health insurance status” and/or risk profile. Watson and colleagues estimate that about 19% of all perinatal deaths among term births in Victoria are due to congenital anomalies.4 This is consistent with a reported national figure of 18.1% for 2004.5 This limitation should have been acknowledged in our article, even if the analysis was not possible. Congenital anomaly data are not currently included in the Perinatal National Minimum Data Set. This limitation highlights the need for integrated uniform national perinatal data on cause of perinatal death and diagnosis of congenital anomaly.

Stephen J Robson · Paula Laws · Elizabeth A Sullivan

To the Editor: Wills and Coory emphasise maternal smoking as a risk factor for preterm birth and low birthweight, with exaggerated effects apparent in Indigenous women.1 They suggest that governments have a responsibility to ensure that interventions are offered to help women quit. Unfortunately, there are adverse effects of smoking cessation that mitigate the gains of cessation and introduce a caveat to that otherwise laudable motive. It has been shown that young women who cease smoking almost always gain significant weight.2 The fall in smoking rates in women over the past 20 years appears to have been in inverse proportion to the rise in rates of obesity in pregnancy, suggesting a possible relationship. The adverse maternal and fetal effects of overweight and obesity in pregnancy have been confirmed in numerous studies,3-5 and equal or exceed those of smoking. Typical odds ratios (ORs) from the literature3-6 are shown below. Maternal overweight (body mass index [BMI], 25–30 kg/m2) and obesity (BMI, > 30 kg/m2) are associated with significant increases in pre-eclampsia (OR for overweight, 1.8; OR for obese, 3.0), gestational diabetes (1.8; 3.2), macrosomia (1.6; 2.4), shoulder dystocia (2.9 for obese), obstructed labour, caesarean delivery (1.5; 2.0), postpartum haemorrhage (1.2; 1.5), wound infection (1.3; 2.2), venous thromboembolism (1.3; 2.8) and maternal death. Further, overweight and obesity are also associated with increased rates of infertility, fetal abnormality (OR, 1.3–3.5), miscarriage (1.2–3.0), stillbirth (1.5; 2.0), admission to neonatal intensive care (1.2; 1.4) and neonatal death (1.6–2.7 for obese). In addition, the adverse effects of excessive weight gain during pregnancy are very similar to those detailed above.7 The long-term effects on the offspring of women who were obese in pregnancy (increased rates of obesity, diabetes and components of the metabolic syndrome) are well documented,8 and at least equal in severity to the consequences for the children of smokers. What then should we do? Should we condone smoking during pregnancy? No one would agree. Ideally, women should never start smoking, or they should give up without gaining weight, but these are elusive aims. At the very least, the conscientious practitioner must provide weight-control counselling, referral to a dietitian and an exercise program lest the gains of smoking cessation be overwhelmed by the losses accompanying excess maternal weight gain, overweight and obesity in pregnancy.

Barry N J Walters

Objective: To determine whether the proportion of babies born large for gestational age (LGA) in New South Wales has increased, and to identify possible reasons for any increase.Design and setting: Population-based study using data obtained from the NSW Midwives Data Collection, a legislated surveillance system of all births in NSW.Participants: All 1 273 924 live-born singletons delivered at term (≥ 37 complete weeks’ gestation) in NSW from 1990 to 2005.Main outcome measures: LGA, defined as > 90th centile for sex and gestational age using 1991–1994 Australian centile charts; maternal factors associated with LGA were assessed using logistic regression.Results: The proportion of babies born LGA increased from 9.2% to 10.8% (18% increase) for male infants and from 9.1% to 11.0% (21% increase) for female infants. The mean birthweight increased by 23 g for boys and 25 g for girls over the study period. Increasing maternal age, higher rates of gestational diabetes and a decline in smoking contributed significantly to these increases, but did not fully explain them.Conclusions: There is an increasing trend in the proportion of babies born LGA, which is only partly attributable to decreasing maternal smoking, increasing maternal age and increasing gestational diabetes.

Ruth M Hadfield BSc, GCBiostat, DPhil(Oxon) · Samantha J Lain BComm, BHlthSci(Hons), MPH · Judy M Simpson PhD, CStat · Jane B Ford BA(Hons), PhD · Camille H Raynes-Greenow BA, MPH, PhD · Jonathan M Morris MM, FRANZCOG, PhD · Christine L Roberts MB BS, DipObs(RACOG), DrPH

Recently, two major epidemiological studies found that hormone replacement therapy (HRT) in postmenopausal women increased the risk of breast cancer. One of the studies also found that HRT increased the risk of cardiovascular disease and thrombosis. As a consequence, women were advised to cease this therapy. However, detailed analysis of these studies suggests that the conclusions may be erroneous. Other studies suggest that the timing of initiation of HRT for healthy women is critical to achieving a beneficial outcome. When begun within 5 years of menopause in healthy women, oestrogen-based HRT results in far greater benefits than adverse outcomes. There is substantial objective evidence that the benefits of HRT include: Reduced distressing symptoms of menopause. Reduced risk of osteoporotic fractures, dementia and colorectal cancer. Improved wellbeing, quality of life; improved vaginal epithelium, sexual enjoyment and bladder capacity. Improved cardiovascular system, with reduced myocardial ischaemia and cardiovascular-related death. Increased longevity. The adverse effects of HRT include: Oral HRT doubles the risk of thromboembolism. HRT promotes growth of pre-existing breast cancer.

Barry G Wren MD, FRANZCOG, FRCOG

Should intrusions by political bodies into personal reproductive decisions be an Australian fact of life? Babies are generally very good news for Australian families, and nationally there is acclaim that our previously declining birth rate has been on a clear rise since 2004 (Box).1 In part, this rise has been a result of welcome government intervention, and several articles and letters in this issue of the Journal relate to reproduction and government subsidy.1-7 Lain and colleagues assessed the effect on New South Wales birth rates of the Howard Government’s cash bonus of $3000 for the birth of a child, introduced on 1 July 2004;1 the then Treasurer, Peter Costello, quipped that a third child could be “for the country”. The Baby Bonus was increased to $5000 on 1 July 2008. Between 1997 and 2006, the proportion of first births in NSW (among a declining total number of births) increased steadily until 2004, after which the proportion of second births, and especially of third and subsequent births, began to rise.1 The timing of the turnaround and the strength of any causal link between the bonus and additional births invites further analysis, using data from the National Perinatal Statistics Unit (Box).8 The $3000 bonus payment to about 272 000 women giving birth nationally during 2005, and 282 000 in 2006, cost about $1.7 billion. We know that in these 2 years over 16 000 of the babies were conceived by in-vitro fertilisation (IVF), and that having an IVF baby most likely indicates reproductive intentions independent of the bonus. If the previous birth-rate trend for non-IVF babies had continued in 2005 and 2006, just over 250 000 babies would have been born in each of these years. This means that about 37 000 of the extra babies born in 2005 and 2006 were attributable to the bonus. The Baby Bonus thus represented a government investment of just over $45 000 for each extra baby. Comparing this figure with the total of $295 million paid out in IVF-related Medicare rebates in the same 2-year period for assisted conception of more than 16 000 IVF babies (an average of less than $20 000 for each baby), it is obvious that, as an ongoing government investment, Medicare funding of IVF is more than twice as productive as the bonus. The Rudd Government has now restricted the bonus to the more disadvantaged in the community by means-testing families. Acknowledging the need to “start in the womb” if we are to close the gap in life expectancy between Indigenous and non-Indigenous Australians,2 de Costa and Wenitong compare Australia’s Baby Bonus with a well established endowment scheme for babies in France that operates with some important differences. An extra payment is recommended for women who commence medically supervised antenatal care before 14 weeks’ gestation; and, instead of a lump sum after the birth, payments are made in instalments linked to positive health practices by the new mothers. The authors make a case for changing the way baby bonuses are delivered in Australia to assist all disadvantaged women to have healthy babies with better life prospects.2 IVF practices, meanwhile, have not stood still.3 When Medicare rebates were introduced for IVF services in 1989, a limit of six treatment cycles was set.9 As IVF practices and outcomes improved during the 1990s,10 including better methods for cryostoring excess early embryos for later transfers, the frequency of multiple pregnancies, with their attendant higher medical and social costs, increased disproportionately.3,10 Since 2000, improved pregnancy rates, the withdrawal of the six-cycle limit for Medicare rebates, and the introduction of the Medicare Safety Net (which decreases out-of-pocket expenses) have worked together to facilitate a fast-increasing practice in Australia of transferring just one IVF embryo at a time. This practice, known as elective single embryo transfer, or eSET, is now the benchmark for best practice. Its effect has been a sharp fall in multiple deliveries after IVF, from a peak of over 22% of confinements in 20008 to now single figures, and better pregnancy outcomes, as Wang et al report3. Improved storage techniques for immature sperm and unfertilised eggs are also pushing the frontiers of what’s possible, biologically and socially. Two such developments are reported in this issue of the Journal.4,5 When a young man is found to be terminally ill or dies suddenly, immature sperm can be collected from a testis before or after death, cryostored, and potentially be available for conceiving a child using IVF — but, if the legal constraint advocated by Middleton and Buist prevails, this will be allowed in Victoria and some other states only if the man has given proven written consent, irrespective of other evidence that this was his wish for his family.4 For women facing sterility from radiotherapy or chemotherapy and who are still to form a permanent relationship, the opportunity to store usable unfertilised eggs has also become technically practicable. Using vitrification, an ultra-rapid freezing method, retrieved mature eggs can be cryostored and, if they survive thawing, can resume a fertilisable physiological state. Given the rise in median maternal age at the birth of a first baby in Australia11 and the increasing physiological sterility of women from their mid 30s,12 this technique can also be used by healthy women to provide what Molloy et al refer to as “reproductive insurance”.5 This is not a development that should disrupt community social order. But governments tend to over-react,13 and can incite indignation. One man has written to the Journal in relation to a statutory limit in Victoria of 10 years for the storage of sperm (in his case his own, for his own use, having survived cancer treatment),6 beyond which each application for continued storage must have the individual approval of Victoria’s Infertility Treatment Authority.7 It seems some parliaments in our country would still subscribe to a 1993 report from Canada’s National Reproductive Technologies Commission, which claimed as paramount the need for “peace, order and good government power”13 and which unintentionally paraphrased Aldous Huxley’s “Community, identity, stability”, the world government’s ruling imperative in Brave new world.14 As Victoria’s statutes stand, a woman seeking “reproductive insurance”5 will likewise need, at a statutorily determined period and presumably regularly thereafter, to justify her decision to store her eggs to an appointed group of people of differing personal views, and she will also need their assent should she wish to take her eggs to another jurisdiction. The power of legislation to destroy individuals’ reproductive futures was demonstrated in the United Kingdom on 1 August 1996.15 Many infertile couples, not able to be contacted over a 3-month period, found out after the event that all UK IVF clinics, to avoid prosecution,16 had been forced by the UK’s Human Fertilisation and Embryology Authority to throw out more than 3000 embryos reaching their 5-year statutory storage limit without a properly formulated request for longer storage. Australia, like most countries, has a long history of government intervention in fertility issues. In 1983, it was the first country to adopt national ethical guidelines for the clinical conduct of IVF. For the safe development of IVF practices, it was considered necessary to do research involving human eggs and sperm (with consent of the providers).17 But (to cut a long story short), a conservative political reaction prevented such research in most states other than NSW until the federal parliament’s passage of the Research Involving Human Embryos Act 2002 (Cwlth). This conservative thinking still finds expression today, with the Australian Health Ethics Committee (a principal committee of the otherwise firmly evidence-based National Health and Medical Research Council [NHMRC]) arguing against research involving human embryos by resting on “an enduring ethical tradition of thought and belief” that has limited community support,18,19 at the expense of outcomes-based ethical principles.13,20 States that legislated to regulate IVF practices in the early 1980s, as Victoria did with its Infertility (Medical Procedures) Act 1984, faced what was then considered radical technology with uncertain social consequences, by applying similar, conservative, non-evidence-based principles. So rapidly were perspectives changing, however, that some parts of this Act were not proclaimed, some parts were later repealed, and, despite a 1996 overhaul of the Act, other parts have come into conflict with Commonwealth legislation.21 The Research Involving Human Embryos Act, which has been mirrored by most state legislatures, legalised embryo research across Australia through special and specific licences administered by the NHMRC. The community clearly recognises and supports the contribution that modern IVF practices make to responsible formation of families in Australia,22 but in Victoria a government authority established under the 1984 Act continues to be responsible for individual, personal decisions affecting all families who have or intend to have their sperm, eggs or embryos exposed in labs. In December 2008, the Assisted Reproductive Treatment Bill 2008, the second rewrite of the legislation in 24 years, and intended to broaden access to assisted reproductive technologies, was passed by the Victorian parliament. Cabinet has apparently over-ridden the advice of the state’s Law Reform Commission and imposed a fitness-to-parent code — compulsory police and child-protection checks — before infertile or childless people can attempt to form families with technological help. The Act also provides for a Patient Review Panel appointed by the Health Minister, with a “primary role” in determining applications for IVF and medically assisted conception.23 For couples with the disability of infertility who need medical help to have children, “the bedroom” is, alas, now a nostalgic metaphor for lost privacy. Intrusions by politically appointed committees into people’s lives and their personal reproductive decisions in Victoria and some other states are real and set to increase. With governments at the bedroom door determined to be part of the detail, too often it’s still two steps in and just a rare step out. Annual IVF and non-IVF births in Australia, 1991–2006 IVF = in-vitro fertilisation. Non-IVF births in 2005 and 2006 above the preceding 4 years’ average (dotted line) are potentially attributable to the Baby Bonus. Data source: Australian Institute of Health and Welfare National Perinatal Statistics Unit.

Robert P S Jansen MD, FRACP, FRANZCOG · Sandra K Dill AM, BComm, MLS

Objective: To compare the perinatal outcomes of babies conceived by single embryo transfer (SET) with those conceived by double embryo transfer (DET).Design, setting and participants: A retrospective population-based study of embryo transfer cycles in Australia and New Zealand between 2002 and 2006, using data from the Australia and New Zealand Assisted Reproduction Database.Main outcome measures: Proportion of SET procedures; comparison of SET and DET procedures with respect to multiple births, low birthweight (LBW), preterm birth and fetal death.Results: The proportion of SET procedures has increased from 28.4% in 2002 to 32.0% in 2003, 40.5% in 2004, 48.2% in 2005 and 56.9% in 2006. The multiple birth rate for all babies conceived by SET (4.0%) was 10 times lower than for those conceived by DET (39.1%) (P < 0.01). The average birthweight for all liveborn babies conceived by SET (3290 g) was higher than for those conceived by DET (2934 g) (P < 0.01). The preterm birth rate of all DET-conceived babies (30.3%) was higher than for SET-conceived babies (12.3%) (adjusted odds ratio [AOR], 3.19 [95% CI, 3.01–3.38]). All babies conceived by DET were more likely to be stillborn than those conceived by SET (AOR, 1.49 [95% CI, 1.21–1.82]). Singletons conceived by DET were more likely to be born preterm than singletons conceived by SET (AOR, 1.13 [95% CI, 1.05–1.22]). Liveborn singletons conceived by DET were 15% more likely to have LBW than liveborn singletons conceived by SET (AOR, 1.15 [95% CI, 1.05–1.26]). There was no significant difference in fetal death rate between DET- and SET-conceived singletons.Conclusion: The increase in proportion of SET procedures has resulted in a lower rate of multiple births and in better perinatal outcomes in Australian and New Zealand assisted reproduction programs.

Yueping A Wang MPH · Elizabeth A Sullivan MPH, MMed(SexHlth), FAFPHM · David L Healy FRACOG, CREI, PhD · Deborah A Black BSc, MStat, PhD

Objective: To assess the change in birth rates, both overall and in age, parity, socioeconomic and geographical subgroups of the population, after the introduction of the Baby Bonus payment in Australia on 1 July 2004.Design and setting: Population-based study using New South Wales birth records and Australian Bureau of Statistics population estimates for the period 1 January 1997 – 31 December 2006.Participants: All 853 606 women aged 15–44 years with a pregnancy resulting in a birth at ≥ 20 weeks’ gestation or a baby ≥ 400 g birthweight.Main outcome measure: Change in birth rate in 2005 and 2006 compared with the trend in birth rates before the introduction of the Baby Bonus.Results: The crude annual birth rate showed a downward trend from 1997 to 2004; after 2004 this trend reversed with a sharp increase in 2005 and a further increase in 2006. All age-specific birth rates increased after 2004, with the greatest increase in birth rate, relative to the trend before the Baby Bonus, being seen in teenagers. Rates of first births were not significantly affected by the bonus; however, rates of third or subsequent births increased across all age, socioeconomic and geographical subgroups.Conclusions: In the first 2 years after the introduction of the Baby Bonus, birth rates increased, especially among women having a third or subsequent birth. This could represent an increase in family size and/or a change in the timing of births.

Samantha J Lain BComm, BHlthSci(Hons), MPH · Jane B Ford BA(Hons), PhD · Camille H Raynes-Greenow BA, MPH, PhD · Ruth M Hadfield BSc, DPhil(Oxon), GCBiostat · Judy M Simpson BSc, PhD · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, MPH, DrPH

Closing the gap in life expectancy between Indigenous and non-Indigenous Australians needs to start in the womb. Rates of perinatal mortality, preterm birth and low birthweight are two to three times greater among the babies of Indigenous women than among those of non-Indigenous women; low birthweight predisposes infants to greater risks of chronic illness in later life. Indigenous women in Australia tend to present for antenatal care later in pregnancy than do non-Indigenous women. There are many barriers for Indigenous women seeking to access antenatal care — geographical, social, cultural, financial and in some cases a lack of service provision. Many of these problems are being addressed within the public health system and by Indigenous community-controlled health services. However, more needs to be done. While antenatal care cannot solve all medical and social problems, commencing such care as early as possible in pregnancy has the potential to improve maternal health and hence pregnancy outcomes. Changes in the way the government Baby Bonus is paid to new mothers could act as an incentive not only to service providers but also to women themselves to initiate antenatal care in the first trimester of pregnancy. Such a system has been well established for many years in France. Any changes to the Baby Bonus scheme should provide incentives and not be punitive in nature.

Caroline M de Costa FRANZCOG, FRCOG, MPH · Mark Wenitong BMed

Cryopreservation of unfertilised oocytes for later use in initiating pregnancy is now a viable technology, with acceptable pregnancy rates (over 20% per thaw cycle). Oocyte cryopreservation used as a form of insurance against “social” (age-related) infertility can improve the lifetime chance of pregnancy in women who defer pregnancy into their late 30s or early 40s. We report two pregnancies using oocytes that were frozen for social rather than medical reasons, as part of a larger series of nine pregnancies using cryopreserved oocytes. Use of oocytes harvested and frozen from women aged under 35 years may more than double the chance of pregnancy for a 41-year-old woman. The disadvantages of oocyte freezing for social infertility reasons include cost, the usual risks associated with in-vitro fertilisation, and the lack of a guarantee of eventual pregnancy.

David Molloy MB BS, FRANZCOG · Barbara A Hall MB BS, FRANZCOG · Marianne Ilbery MB BS, FRANZCOG · Jacqui Irving BSc(Hons), MSc · Keith L Harrison BSc, MSc

Alan Ferrier was born in Lismore, New South Wales, on 23 July 1954. As a child he suffered from severe asthma, and on medical advice his family moved to Sydney for a better climate. He attended Knox Grammar School, where he achieved distinction academically and at cricket. After graduating from the University of Sydney in 1978, Alan undertook specialist training in obstetrics and gynaecology at the Royal North Shore Hospital in Sydney. From 1986, he spent several years in North America training in gynaecological oncology at institutions such as the Memorial Sloan–Kettering Cancer Center in New York and the University of Toronto in Canada. Returning to Sydney in 1991, Alan was appointed Senior Lecturer in Obstetrics and Gynaecology at the University of Sydney. He was largely responsible for establishing the gynaecological oncology service for the Northern Metropolitan Region of Sydney. Alan soon earned a reputation as a cancer surgeon of exceptional ability. Despite an extraordinarily heavy surgical workload, he continued to enjoy practising obstetrics, which he felt brought a happy balance to his professional life. He mastered new laparoscopic techniques and was one of the first surgeons in Australia to apply them in oncology. He became an expert at radical trachelectomy with laparoscopic lymphadenectomy. Many of his specialist colleagues benefited from his advice and help with difficult cases. This assistance was given without hesitation and was often life-saving. Alan loved to teach and shared his knowledge and techniques generously. He had numerous research articles, book chapters and other publications to his credit and was involved in a broad range of research projects at the time of his death. He was an examiner for many years, a convenor of several postgraduate courses, and a member of various committees, including Chairman of the NSW Committee of the Royal Australian College of Obstetricians and Gynaecologists. Alan was absolutely devoted to his family. He strove to achieve excellence in all that he did personally and professionally. He was renowned for his urbane demeanour and sartorial elegance. Because of his asthma, he was also committed to keeping fit. Despite this, he died in his sleep of a cardiac arrhythmia on 23 December 2007, aged 53 years. Alan is farewelled as one who honoured his family and practised medicine with enormous skill and compassion. He is survived by his wife Sarah and daughters Katherine and Charlotte.

Robert M Ford · Keith G Hartman · Jonathan R Stretch

Objective: To develop national birthweight percentiles by gestational age for male and female singleton infants born in Australia, and to compare the birthweight percentiles of Indigenous and non-Indigenous infants. Design and setting: Cross-sectional study of singleton live births to Australian-born mothers from 1991 to 1994. Main outcome measures: Birthweight percentiles by gestational age. Results: During 1991–1994 Australian-born women gave birth to 769 077 live singleton infants. Of these, 28 230 (3.7%) were reported as births to Aboriginal or Torres Strait Islander women. Birthweight was missing for 581 (0.1%) births and gestational age was missing for 3014 (0.4%). An additional 3283 (0.4%) births were excluded because the recorded birthweights were extreme outliers for their recorded gestational ages. Indigenous women were more likely to be recorded as giving birth preterm (< 37 weeks’ gestation) than non-Indigenous women (11.6% v. 5.4%) and were more likely to give birth to small-for-gestational-age infants at term. After 34 weeks’ gestation, the median birthweights of Indigenous infants were consistently lower than those of non-Indigenous infants. At 40 weeks’ gestation the difference in the median birthweights between these two groups was 160 g for males and 130 g for females. Conclusions: We present recent birthweight percentiles by gestational age based on national data in Australia. These percentiles provide current Australian norms for clinicians and researchers, and can provide a baseline for monitoring Indigenous perinatal outcomes.

Christine L Roberts · Paul A L Lancaster

To the Editor: We read with interest Giles and colleagues’ recent article, which examined the adoption of strategies to reduce perinatal transmission of HIV infection in Australia.1 They found that uptake of strategies to reduce perinatal HIV transmission had increased, with widespread use of antiretroviral therapy (ART) and breastfeeding avoidance. The authors also noted that caesarean birth was a strategy less commonly utilised by women with HIV infection. They made particular comment about the caesarean delivery rate for women known to have HIV infection in Western Australia. It was disappointing that the authors did not refer to our recent publication describing the low rate of perinatal HIV transmission in WA using an individualised delivery modality policy.2 In our consecutive series of 56 pregnancies between 1991 and 2005, 48 (86%) were managed by a multidisciplinary team, with 98% (47/48) of women receiving ART (one woman actively declined this intervention). Only one baby in the group who received care through the multidisciplinary team acquired perinatal HIV. This pregnancy occurred in 1991 in a woman with advanced disease who received zidovudine monotherapy, a situation not applicable today. Elective caesarean delivery was based on either obstetric indications or a high HIV RNA level; 75% of women in our series had a vaginal delivery. The findings of our study were of particular note because 39% of mothers were Aboriginal, and predominantly from rural and remote regions of WA. Although the patient numbers in our study were small, the current international evidence does not support mandatory caesarean delivery for women receiving ART with undetectable plasma HIV RNA.3 The risk of vertical transmission in this circumstance is low, and caesarean birth is associated with short- and long-term morbidity (most notably, placenta accreta). Recent series have shown a trend of increasing vaginal birth rates among women with well controlled HIV infection.4,5 When infection is well controlled, we believe that the mode of delivery should be individualised, and vaginal birth should be an option for women who desire this delivery method. It is disappointing that Giles and colleagues appear to imply that the low caesarean delivery rate in WA is a reflection of suboptimal HIV care processes, rather than evidence-based practice.

Marisa T Gilles · Martyn A French · Jan E Dickinson

In reply: We were interested in Gilles and colleagues’ response to our analysis of the uptake of interventions to prevent perinatal HIV transmission in Australia. As Gilles et al state, the reported rates of perinatal HIV transmission are low in Western Australia, where the choice of delivery modality is individualised. We agree that the additional benefit of elective caesarean section in women being treated with highly active antiretroviral therapy with an undetectable viral load is not known. We also agree that elective caesarean section is associated with potential risks, and women should have a choice regarding mode of delivery. This choice should be informed by other obstetric factors, maternal viral load, and the clinical setting in which delivery takes place. Geographic variation in such factors is likely, and will certainly contribute to differences across states in the uptake of preventive interventions. Ongoing national surveillance will help ensure that women with HIV infection and their children benefit as much as possible from evidence-based obstetric practices.

Michelle L Giles · Ann M McDonald · Elizabeth J Elliott · John B Ziegler · Margaret E Hellard · Sharon R Lewin · John M Kaldor

To the Editor: We question the conclusions drawn by Canfell and colleagues1 from their analysis of trends in hormone replacement therapy (HRT) prevalence and breast cancer incidence for Australian women aged 50 years or older. Their ecological analysis lacks individual-level information on HRT use and information on tumour oestrogen receptor (ER) status, and captures only 2 years following the decline in HRT prevalence. This is an inadequate design within which to judge issues of causality; it is at best an hypothesis-generating exercise.2 The examination of only 2 years of breast cancer incidence after the decline in HRT use is unsound because of substantial unexplained annual variability in national breast cancer incidence. This is evidenced, for example, by the graph in Canfell et al’s Box 2, which identifies a fall in 1998–1999 that was not ascribed to changes in HRT prevalence. The lack of data on tumour ER status is another weakness. HRT use increases the risk of ER+ tumours, so any decline in HRT prevalence would be expected specifically to reduce ER+ tumour incidence. We analysed Victorian Cancer Registry data for women aged 50 years or older for the period 2001–2005 — 2 years past the cut-off in Canfell et al’s analysis. Tumour ER status was available for 87% of breast cancer cases in 2001, rising to 90% in 2005. The demographic characteristics of the women for whom these data were available did not change between 2001 and 2005. Over this period, the proportion of all breast cancers that were ER+ increased from 65% to 71%, and the proportion of tumours with known ER status that were ER+ increased from 74% to 79%. Poisson regression analysis of the age-specific incidence rates for both total and ER+ breast cancer for women aged 50 years or older estimated an average annual decline of 1.7% in the total incidence rate (P = 0.0009) and an annual increase of 0.2% in the ER+ incidence rate (P = 0.7). Our findings are illustrated in the Box. Although there was an apparent small decline in total breast cancer incidence in 2001–2003, this trend was reversed in 2004–2005. More importantly, the trend in ER+ tumour incidence was stable across the entire period. Age-standardised incidence* of invasive breast cancer in women in Victoria aged ≥ 50 years, 2000–2005 Vertical bars represent 95% confidence intervals. ER+ = oestrogen receptor-positive. * Standardised to World Standard Population. These Victorian trends, covering a longer time period and including information on the tumour type most likely to be affected by changes in HRT use, provide no support for the hypothesis of Canfell and colleagues.

Graham G Giles · Richard Bell · Helen Farrugia · Vicky Thursfield

In reply: In saying that our work on the effect of hormone replacement therapy (HRT) on the development of breast cancer is “at best an hypothesis-generating exercise”, Giles and colleagues ignore both the preceding literature and the fact that our analysis of Australian data explicitly tested the hypothesis raised by an analysis of United States data. Both the US and Australian analyses showed falling breast cancer incidence from 2001 in women aged ≥ 50 years, but not in younger women, following large reductions in HRT use.1,2 The logic, methodology and statistics presented by Giles et al are unsound. They present data on incident breast cancers for women in Victoria only, a subset of the national data included in our analysis. Not only is it invalid to use a subset of data to retest a hypothesis previously tested on the larger dataset (unless complex statistics are applied3-5), but Giles et al misrepresent Victorian trends. It is clear that in Victorian women aged ≥ 50 years, breast cancer incidence rates fell substantially and significantly by 11.5% between 2001 and 2003 (95% CI, 6.0%–16.6%; P < 0.0001), with no significant change among women aged 20–49 years (P = 0.3) (Box). Giles et al present no data on HRT use. The largest drop in HRT use in Australia occurred between 2001 and 2003, and thereafter use began to plateau.6 It is therefore statistically inappropriate to calculate an “average annual decline” in breast cancer incidence from 2001 to 2005 because changes in HRT use over this time were not linear. In addition, their claim that the “trend was reversed in 2004–2005” is not supported by statistical testing, which shows no significant change in breast cancer incidence in women aged ≥ 50 years in Victoria from 2003 to 2005 (P = 0.4). US data showed that the fall in breast cancer incidence following the drop in HRT use was seen particularly in oestrogen receptor-positive (ER+) tumours.1 As we pointed out,2 the lack of reliable Australian data on ER status means that no conclusions can be drawn about Australian trends in ER+ tumours. Giles et al acknowledge that the Victorian ER data are incomplete and that the completeness has increased over time. This, together with the possibility of differential ascertainment of ER status in women who used HRT over the period of interest, render the trends they present on ER+ breast cancers uninterpretable. Overall, trends in breast cancer incidence in the subgroup of Victorian women cannot be said to differ materially from the national trends. A recent editorial in the Lancet draws attention to the fact that trends in HRT use and breast cancer incidence similar to those we reported have now been observed in many countries.7 The Australian findings add to the accumulating worldwide evidence that, in settings where HRT use was common and breast cancer screening rates relatively stable, a rapid decline in HRT use after 2001 was followed by a fall in breast cancer incidence. Age-standardised incidence* of invasive breast cancer in women in Victoria, 1996–2005 Vertical bars represent 95% confidence intervals. Vertical dotted line indicates commencement of the period over which there was a hypothesised decrease in breast cancer incidence in women aged ≥ 50 years but not in women aged < 50 years. * Standardised to the Australian 2001 population.

Karen Canfell · Emily Banks · Mark Clements · Yoon J Kang · Valerie Beral

Objective: To characterise the demographic and psychosocial circumstances of women contacting Victoria’s largest public pregnancy advisory service (PAS).Design and setting: Audit of PAS electronic records for the 12 months from 1 October 2006 to 30 September 2007. De-identified data were extracted from a comprehensive electronic database used for recording consultations.Main outcome measures: Summary statistics and measures of association.Results: During the 12 months, 5462 women contacted PAS; records were created for 3827 women, and data were available in more than 80% of records for 77% (13/17) of items. Over half of the women receiving pregnancy support from PAS (60%) were 18–29 years old; 12% lived outside the metropolitan area; 51% held a health care card, and smaller percentages faced housing, financial, or drug and alcohol problems; 16% reported violence, but 71% described partners as involved and supportive. Most (79%) made contact within 2 weeks of discovering pregnancy, and 72% were referred by a general practitioner. Later gestation at contact was associated with younger age (P < 0.001), having a health care card (P < 0.001), and living outside the metropolitan area (P < 0.001). The most common reasons for seeking abortion were the desire to delay pregnancy (23%) and family completion (18%); 42% already had at least one child. Twenty-three women reported that the pregnancy was the result of rape. Ten per cent had mental health problems, and smaller numbers faced access barriers and had special needs.Conclusions: This PAS responds to demand from women with diverse social and personal circumstances. Findings provide evidence for policy, prevention and service development.

Heather J Rowe BSc(Hons), PhD, MPHAA · Maggie Kirkman BA(Hons), PhD, MAPS · E Annarella Hardiman BSA, MSW, MAASW(acc) · Shelley Mallett BAppSci, BASoc, PhD · Doreen A Rosenthal BA(Hons), PhD

Updated guidelines widen the definition of pre-eclampsia and highlight that hypertension in pregnancy has become a lifelong disorder The “political” enthusiasm for women to have more babies will not come without a downside. Complications such as pre-eclampsia — a major cause of premature delivery — are likely to become more prevalent as increasing numbers of women become pregnant when they are older or obese, and may affect up to 5% of these women. The reason why pre-eclampsia develops is an enigma. Although there have been no recent major advances in the clinical treatment of this diverse disorder, maternal and fetal outcomes in Australia and New Zealand are good.1 The big risk now is that obstetricians, physicians, general practitioners and midwives will become complacent about the management of these high-risk pregnancies. The institution of standardised surveillance guidelines for Canadian women with pre-eclampsia has been associated with a reduction in adverse maternal outcomes (from 5.1% to 0.7%), but not perinatal outcomes.2 For this reason, the updated Australian and New Zealand Guidelines for the management of hypertensive disorders of pregnancy,3 assuming they are adopted, should improve outcomes for women with hypertension in pregnancy. These guidelines, which were produced in 2008 by the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ), highlight key aspects of these complex disorders. First, the traditional definition of pre-eclampsia — as only hypertension with proteinuria — fails to identify women who are at high risk by having other organ involvement (eg, hepatic, haematological or cerebral disease) without proteinuria.4 Second, a spot urine protein : creatinine ratio can be used to detect significant proteinuria, and 24-hourly urine collections are no longer necessary in routine clinical management.5 Third, although all women with pre-eclampsia should initially be admitted to hospital, many hospitals now have a day assessment unit where some patients with pre-eclampsia can be managed as outpatients — providing their initial assessment was as an inpatient. The treatment of these disorders is “supportive”, and does not ameliorate placental abnormalities or alter the pathophysiological sequelae of pre-eclampsia. Treatment of hypertension in pregnancy does not cure pre-eclampsia; it is intended to prevent cerebral haemorrhage and eclampsia (seizures), and may delay proteinuria.6 SOMANZ recommends antihypertensive treatment be commenced promptly in all pregnant women with a systolic blood pressure of 170 mmHg or higher, or a diastolic blood pressure of 110 mmHg or higher. Several rapidly acting agents are suitable for controlling severe hypertension, including oral nifedipine, intravenous labetalol and intravenous hydralazine.7 Treatment of mild to moderate hypertension in the systolic blood pressure range of 140–160 mmHg or diastolic blood pressure range of 90–100 mmHg is more controversial; however, most hospitals in Australia and New Zealand do implement treatment at these levels. At higher levels, treatment is mandatory, and several drug treatments are safe and efficacious: methyldopa, labetalol and oxprenolol are first-line options, and hydralazine, nifedipine and prazosin are second-line options. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy. The drug of choice for the prevention and treatment of eclampsia is intravenous magnesium sulfate. However, eclampsia complicates only one in 200–300 cases of pre-eclampsia in Australia, and the case for its routine administration in women with pre-eclampsia in countries with low maternal and perinatal mortality rates is not compelling. SOMANZ recommends magnesium prophylaxis only for women considered at high risk of seizures. Some preterm cases are managed expectantly in units that treat patients at high risk, but delivery remains the definitive management. Many women with pre-eclampsia deteriorate for a few days after delivery, and they require close monitoring during this phase. When there is intense pressure to discharge patients quickly, this is an important point to remember. Women want to know their risk of developing recurrent pre-eclampsia or gestational hypertension, which is about 15% for each after pre-eclampsia in the index pregnancy.8 These rates are probably higher after early-onset pre-eclampsia. Low-dose aspirin and calcium supplementation have both been shown to reduce the risk of pre-eclampsia, and should be used in women at high risk of pre-eclampsia, such as those with a history of early-onset pre-eclampsia. It is apparent that women with either pre-eclampsia or gestational hypertension are at increased risk of cardiovascular morbidity in subsequent years, including hypertension, stroke, coronary heart disease, venous thromboembolism and overall mortality.9 These associations could reflect a common cause for pre-eclampsia and cardiovascular disease, or an effect of pre-eclampsia on vascular disease development, or both. A similar risk for later end-stage renal failure has been reported recently, however only 0.08% of women were affected.10 From a practical point of view, it is reasonable to counsel patients who develop hypertension in pregnancy that they will benefit from avoiding smoking, maintaining a healthy bodyweight, exercising regularly and eating a healthy diet. It is recommended that all women with previous pre-eclampsia or hypertension in pregnancy have an annual blood pressure check and regular (at least 5-yearly) assessment of other cardiovascular risk factors, including serum lipids and blood glucose. In other words, hypertension in pregnancy has become a lifelong disorder. Risks and practice recommendations for women with hypertensive disorders of pregnancy are summarised in the Box. Pre-eclampsia and other hypertensive disorders of pregnancy: risks and recommendations Hypertensive disorders of pregnancy are a leading cause of perinatal and maternal morbidity and mortality, even in developed countries. Management according to systematic guidelines3 improves outcomes. Proteinuria is not mandatory for the clinical diagnosis of pre-eclampsia; renal, cerebral, clotting and hepatic dysfunction also indicate severe disease. Prompt treatment of severe hypertension (systolic blood pressure of 170 mmHg or higher, or a diastolic blood pressure of 110 mmHg or higher) or seizures is mandatory; however, debate persists regarding treatment of mild to moderate hypertension in pregnancy and the selection of patients for magnesium sulfate prophylaxis. Several risk factors for pre-eclampsia are recognised, but accurate prediction of women at risk of pre-eclampsia is still developing. Pre-eclampsia is associated with increased risk of recurrence in the next pregnancy and future risk of cardiovascular and renal morbidity. Women who experience hypertension in pregnancy should adopt a healthy lifestyle, even more so than women who have normotensive pregnancies.

Mark A Brown MB BS, FRACP, MD · Sandra A Lowe MB BS, FRACP, MD