Women's health

To the Editor: Australia’s world-leading government-funded National Human Papillomavirus (HPV) Vaccination Program for women aged 12–26 years is made up of two components: an ongoing school-based program and a time-limited catch-up program delivered through schools, general practices and community vaccination services. The catch-up program started in April 2007 and was due to finish by July 2009, but has been extended to 31 December 2009 to allow women to complete the three-dose schedule. Assessing the coverage achieved by the National HPV Vaccination Program will be an important measure of the Program’s success, particularly in terms of ensuring equity in vaccine uptake — so that the current gap in cervical cancer incidence and mortality between Indigenous and non-Indigenous women is reduced, not widened.1 Vaccination coverage data are also needed to monitor vaccine effectiveness in preventing cervical lesions and cancer. Accordingly, an integral part of the Program was the establishment, enabled by legislation passed in August 2007, of Australia’s first national adult vaccine register — the National HPV Vaccination Program Register. The Register began collecting data in mid 2008 and is currently uploading notifications of the 5 million doses of HPV vaccine distributed in Australia to date. Initial coverage estimates from the Register will be published by the end of the year, with all notifications from the catch-up program due to be submitted to the Register by March 2010. General practitioner incentive payments of $6 per notification will be available until that time. Interim coverage data provided by various jurisdictions are encouraging; school-based program data for 2007 from New South Wales and Victoria estimate one-dose coverage of more than 80% and three-dose coverage of approximately 70%.2 Unfortunately, there are no routine systems in place to provisionally estimate coverage in women vaccinated outside of schools. In a small population-based telephone survey that was conducted by the Cancer Council Victoria 3 months after the Program commenced, 35 of 90 women aged 18–26 years (39%) had received HPV vaccine. Australian women are taking advantage of Australia’s most expensive vaccination program to date. We encourage vaccination providers to notify the Register3 of doses administered to ensure that this facet of Australian women’s health can be followed into the future. Although we anticipate complete notification of vaccinations given at schools, the accuracy and completeness of total coverage data will depend on GPs notifying the Register.

Julia M L Brotherton · Robyn M Mullins

To the Editor: Over a third of women seeking a termination of pregnancy (TOP) in Melbourne are aged 30 years or over.1 Between 1996 and 2006, there was a 29% increase in the number of women aged 30–50 years having a TOP.2 Possible reasons for this trend are not immediately apparent. We audited the files of 50 consecutive women aged 35 years and over attending a private termination service in metropolitan Melbourne in February 2007 to determine reasons for deciding on a TOP and the women’s prior and intended contraceptive use. Of the 50 women, 38 were working in paid employment, 28 had private health insurance, 39 had at least one child, 22 had had at least one previous TOP, and 43 were in an ongoing relationship. Sixteen separate reasons for TOP were elicited (Box), with nearly three-quarters of the women citing more than three reasons for terminating their pregnancy. Over a third of the women cited financial pressures, a focus on career or studies, having dependent children, or emotional unpreparedness for children as reasons for having a TOP. Contraceptive methods used by the 29 women who indicated their prior contraceptive practice were as follows: none (9), condoms (8), natural family planning (NFP) (4), the combined oral contraceptive pill (COCP) (4), withdrawal (3), and the mini pill (1). After the TOP, contraceptive methods chosen were the COCP (11), vasectomy (10), an intrauterine device (10), condoms (8), the mini pill (5), an etonogestrel implant (4) and NFP (1). Although ours was a small retrospective audit, the contraceptive findings and reasons given for TOP in our study were similar to those of other studies.1-4 However, some of the reasons given for TOP in this age group have not previously been described — for example, having ageing parents to care for, recent migration to Australia, and ambivalence towards parenting. Furthermore, although recent Australian studies have reported a high level of contraceptive use,2,5 women in our study often relied on less effective forms of contraception or no contraception at all. Further qualitative research is needed in women of this age group to explore their understanding of fertility and pregnancy risk, barriers to effective contraceptive use, and additional supports and interventions that could prevent unplanned pregnancy in these women. Reasons for termination of pregnancy among 50 women aged ≥ 35 years Reason Number citing reason Already have dependent children 17 Focus on career or studies 17 Emotionally unprepared for a child 16 Financial pressures 16 Completed family 15 Relationship factors 14 Too old to raise a child 10 Partner factors, including partner not wanting children 9 Physical or psychological health issues 8 Concerns about congenital anomalies 7 Does not want single parenthood 6 Bad timing (recent job change, move home, move to Australia) 4 Uncertain of wanting children or does not want children 4 Exposure to medications or agents that might harm fetus 1 Pregnancy from sexual assault 1 Other factors (other life plans, uncertain paternity, poor social supports, aged dependent parents) 9

Wendy Lee · Danielle Mazza

To the Editor: Although many medicines transfer into breast milk, the amount received by the breastfed infant is usually low, with minimal risk to the infant.1 Because medicines are not tested on breastfeeding women, product information often states that the safety of use during lactation is unknown. This may lead to over-caution in prescribers, who may incorrectly advise women to stop breastfeeding during courses of medication.2 Even brief interruptions to breastfeeding can lead to complications, such as mastitis or breast refusal.1,2 Evidence-based assessments should be made for each mother–baby pair, depending on the baby’s age and the drug’s pharmacokinetics.2 Information about the safety of medicines during breastfeeding is available from books and websites,3 but doctors’ knowledge and use of these resources are not known. We carried out an observational study to describe general practitioners’ current and preferred sources of information about the safety of medicines during breastfeeding. We surveyed the 640 GPs who provided shared maternity care at Victoria’s largest maternity hospital, the Royal Women’s Hospital (RWH), Melbourne. A postal survey to be completed anonymously was sent in November 2007 with a reminder postcard 2 weeks later; a second copy of the survey was sent in February 2008. The study was approved by the human research ethics committees at La Trobe University, University of Melbourne and the RWH. Responses were received from 52% of GPs (335/640); most respondents were women (70%, 233/333), and most had personal experience of breastfeeding for longer than 6 months (68% of participants or their partners, 227/333). Over two-thirds (70%, 233/335) used the Internet during consultations. Eighty-two per cent (270/331) found the Internet helpful. Most participants (73%) obtained information about medicines and breastfeeding from their software program, or from dedicated books (61%; predominantly the RWH’s Drugs and breastfeeding4), and 51% used telephone advice (predominantly from the RWH pharmacy). When asked where they would prefer to access this information, most nominated their software prescribing program (68%) or a reliable Internet database (57%) in their top three preferences (Box). Although most participants (89%, 293/331) felt confident about prescribing for breastfeeding women, the majority were not aware that ibuprofen is considered safe for breastfeeding women; only 31% (102/330) agreed that “there is no problem taking this medicine while breastfeeding”. It appeared that some GPs erroneously believed that pregnancy drug ratings also apply to breastfeeding women. Ibuprofen has a category C pregnancy rating (drugs that have caused or may be suspected of causing harmful effects in the human fetus or neonate without causing malformations), yet the product information from Reckitt Benckiser (Slough, United Kingdom), the manufacturer of Nurofen, states that “no harmful effects are known in breastfed infants”.5 An additional problem is the contradictory advice given by different sources;6 another manufacturer, Abbott, does not recommend ibuprofen for breastfeeding mothers.5 As recommended by researchers in the United States, “We should replace the assumption ‘when in doubt, don’t breast-feed’ with the mandate ‘when in doubt, look it up in a reliable source’”.6 A central accessible source of up-to-date information about individual medications and lactation is urgently needed.7 Most GPs in our study would like this information available on the Internet. Sources of information used by general practitioners when prescribing for breastfeeding women No. of GPs (n = 332) Current sources* Preferred sources† Software prescribing program 242 (73%) 226 (68%) Reliable Internet database 33 (10%) 191 (57%) Dedicated books 203 (61%) 146 (44%) Australian medicines handbook 109 (33%) 125 (38%) Printed guidelines 0 112 (34%) Telephone advice 168 (51%) 106 (32%) Conference/seminars 2 (0.6%) 23 (7%) Journal articles 68 (20%) 19 (6%) One-on-one educational visiting (academic detailing) 0 10 (3%) Printed product information (eg, MIMS) 181 (55%) 3 (0.9%) Therapeutic guidelines 33 (10%) 3 (0.9%) Previous experience 202 (61%) 0 Pharmacist 71 (21%) 0 Colleagues 61 (18%) 0 Other books 3 (0.9%) 0 MIMS = monthly index of medical specialties. * More than one option permitted. † GPs were asked to number their top three preferences.

Lisa H Amir · Marie V Pirotta

Could a technique using fetal DNA from the maternal circulation mean the end of invasive prenatal testing? Since the first application of ultrasound to it 50 years ago, the “black box” that is the pregnant uterus has gradually yielded to efforts to gain increasingly precise information about the condition of the fetus. Technological advances in ultrasound and, more recently, magnetic resonance imaging have seen the production of high-resolution displays of fetal anatomy and physiology. Specific information about the fetal genome, however, has until now only been available through the application of invasive techniques. Amniocentesis and chorionic villus sampling have been used to diagnose fetal aneuploidy (such as Down syndrome) and an ever-increasing range of genetic conditions. But these invasive procedures come at a cost — an associated 1% risk of pregnancy loss1 limits their application and causes significant stress for women thinking of undertaking such testing. Screening tests such as ultrasound and maternal serum screening to assess aneuploidy risk have been developed to allow more judicious application of invasive procedures, but of themselves cannot accurately diagnose the fetal condition, and false negatives and positives both occur. Now, the era of non-invasive prenatal diagnosis beckons — offering the ability to obtain specific and accurate genetic information from the fetus without the need for an invasive procedure and its associated risks. The article by Hyland and colleagues in this issue of the Journal reports on the first potential clinical application of non-invasive prenatal diagnosis in an Australian population — the determination of fetal RHD status in Rhesus (Rh) D-negative women.2 About 17% of Australian women are RhD-negative.3 These women are at risk of isoimmunisation, caused by the passage of RhD-positive fetal red blood cells across the placenta during pregnancy and childbirth. The resultant antibodies produced by the mother can cross the placenta and cause fetal anaemia due to haemolysis of fetal red blood cells. Women who are isoimmunised require intensive fetal surveillance, and are at risk for fetal death and neonatal brain injury if timely intervention is not performed. The incidence of isoimmunisation has been dramatically reduced since the introduction of preventive strategies, but these rely on administration of plasma-derived RhD immunoglobulin to all RhD-negative women. The technique employed by Hyland et al involves detecting cell-free fetal DNA (ffDNA) in maternal plasma by real-time polymerase chain reaction (PCR).2 ffDNA constitutes about 4%–6% of all cell-free DNA in the maternal circulation and can be reliably detected as early as 7 weeks after conception.4 The use of ffDNA to detect the RHD gene in RhD-negative pregnant women was first described by Lo and colleagues in 1998.5 Others have since applied the technique, and a recent meta-analysis demonstrated 96.1% sensitivity and 96.5% specificity for correctly determining fetal RHD status.6 To minimise false-negative results, internal controls are used to confirm the presence of fetal DNA. The SRY gene was initially used for this purpose, but as this only detects male fetuses, Hyland and colleagues have also utilised the RASSF1A gene to confirm the presence of fetal DNA from female fetuses.2 Where they were able to determine the fetal RHD status, their predictions showed 100% accuracy when compared with the infants’ serotype determined from cord blood after delivery. In a small number of cases, determination of fetal status could not be achieved. This technique requires further evaluation in larger studies to clarify the true performance characteristics of the test, and to allow algorithms to be developed for dealing with indeterminate results and the RHD gene variants seen in some ethnic groups. However, if these issues can be satisfactorily addressed, the potential applications are significant. In the small group of women with isoimmunised pregnancies, it will allow the determination of fetal RHD status without resorting to invasive tests. In addition to the risk of pregnancy loss, invasive procedures also have the potential to cause further sensitisation and worsen the natural history of the condition. More broadly, this testing has the potential to reduce unnecessary exposure of pregnant women to RhD immunoglobulin. Currently, RhD immunoglobulin is administered for antenatal prophylaxis, potential sensitising events, and postnatally for RhD-positive infants. This regime has been very effective, reducing the incidence of sensitisation during pregnancy by more than 90%.7 However, up to 40% of RhD-negative women receive treatment unnecessarily, as they will be carrying an RhD-negative fetus from a heterozygous partner.8 Routine introduction of non-invasive fetal DNA testing would therefore be likely to have cost implications for delivery of this preventive treatment. Non-invasive detection of fetal RHD status is already being incorporated into clinical practice in Europe, and the feasibility of using this approach to make decisions about prophylaxis has been demonstrated.9 The use of ffDNA can also be applied more broadly than determination of fetal RHD status. Already, reports exist of the non-invasive prenatal diagnosis of Huntington disease,10 cystic fibrosis11 and other conditions. Detection of the SRY gene allows determination of fetal sex in women at risk of carrying a fetus with an X-linked condition.12 The non-invasive diagnosis of Down syndrome and other aneuploidies remains challenging, but newer techniques such as methylation-dependent PCR and digital PCR hold promise.13 As with many technological advances involving reproductive choices, there are ethical concerns associated with this test. Sex determination for social rather than health reasons, for example, could result from unregulated use of such technologies. There is a pressing need for vigorous discussion of these issues. Non-invasive diagnosis of specific fetal gene status using fetal DNA from the maternal circulation without any risk to the pregnancy may be the “holy grail” of prenatal diagnosis. The determination of fetal RHD status is nearing availability as a clinical tool, and is likely to be the first of many applications of non-invasive prenatal testing over the coming decade. Is a future without amniocentesis and chorionic villus sampling dawning? Not quite yet, but at least there is some light on the horizon.

Stephen A Cole MB BS, FRANZCOG, CMFM · Helen F Savoia MB BS, FRCPA

Objective: To evaluate a non-invasive molecular test using free circulating fetal DNA in maternal plasma to predict the fetal RHD type.Design: A prospective cohort study.Participants and setting: Venous blood samples were collected from 140 Rhesus (Rh) D-negative women booked for antenatal care in two tertiary maternity hospitals in Sydney and Brisbane between November 2006 and April 2008. Cell-free DNA, including free maternal and fetal DNA, was extracted from maternal plasma in the tertiary Australian Red Cross Blood Service laboratory, and three exon regions of the RHD gene were amplified.Main outcome measures: Comparison of the predicted fetal RHD status and the infant’s RhD serotype. Secondary analysis involved using SRY and RASSF1A assays as internal controls to confirm the presence of fetal DNA in RHD-negative samples.Results: Of 140 samples tested, results for RHD status were assigned for 135, and all 135 predictions were correct. A result was not assigned in five cases: three did not meet strict threshold criteria for classification, and two were due to RHD variants. Fetal SRY status was correctly predicted in 137 of 140 cases. In 16 samples typed both RHD- and SRY-negative, a positive RASSF1A result verified the presence of fetal DNA.Conclusions: Non-invasive testing of multiple exons provides a robust method of assessing fetal RHD status, and provides a safer alternative to amniocentesis for the management of RhD-negative pregnant women who are isoimmunised.

Catherine A Hyland PhD, MSc · Glenn J Gardener MB BS, DipRACOG, FRANZCOG · Helen Davies BSc, GDPH · Minna Ahvenainen BSc · Robert L Flower PhD, MSc · Darryl Irwin PhD, MIndProp, BAppSc · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christopher M Ward MB ChB, PhD, FRACP · Jonathan A Hyett MB BS, MRCOG, FRANZCOG

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