Women's health

To the Editor: We read the recent article by Pitts and colleagues1 with interest, given the rising trend of diagnosed chronic pelvic pain (CPP) in Australian women. The article identified three types of CPP, but did not differentiate pain into the two major categories of nociceptive (visceral and somatic) and neuropathic. In pain management settings it is considered essential, where possible, to make this differentiation, as it significantly alters management strategies, particularly in relation to medication. While the true incidence of neuropathic pain is unknown, it is believed to be underdiagnosed and inadequately treated. A 2008 French study based on a nationwide postal survey revealed a 6.9% prevalence of neuropathic pain in the general population, with 5.1% of respondents reporting pain levels as moderate to severe.2 Neuropathic pain results from damage to the nervous system. Specifically, this can be from damage to, or pathological changes in, the axons of peripheral nerves or from damage to the central nervous system, probably as a result of deafferentation. This is the process whereby neurones in the central nervous system lose their accustomed afferent input, either from a peripheral nerve or from an ascending sensory tract. Furthermore, neuropathic pain can and does cross neuroanatomical boundaries, often presenting viscerally as referred pain and eliciting pain descriptors such as burning, shooting, stabbing, and searing. For this reason, CPP is often wrongly assumed to be visceral in origin.3 In such cases, awareness that CPP may in fact be neuropathic may avoid inappropriate surgical interventions. Moreover, an association between CPP and neuropathy has been demonstrated in studies of sacral nerve and percutaneous tibial nerve stimulation in women presenting with CPP.4,5 Differential diagnosis of pain of neuropathic origin has been shown to be pertinent for the accurate implementation of pain management strategies.6 Therefore, we suggest that future studies on the epidemiology and/or prevalence of pain include tools to determine the proportion of pain of neuropathic, nociceptive and mixed origin. There are a number of tools available, including questionnaires such as painDETECT, DN4 (Douleur Neuropathique en 4), LANSS (Leeds Assessment of Neuropathic Symptoms and Signs) and NPS (Neuropathic Pain Scale). Some of these, such as the self-assessed LANSS (S-LANSS), do not require clinical examination and thus can be worked into population-based questionnaires. The ability to identify neuropathic pain should lead to individualised treatment, resulting in improved pain control for patients with CPP.

David Vivian · Adele Barnard

In reply: We are pleased to see our article about chronic pelvic pain in Australian women has provoked interest.1 Black’s suggestion that virtually every normal physiological event that occurs within a woman’s pelvis is associated with pain is surprising, and not supported by our evidence. Of the women in our sample, 23% were totally pain free, and most of the chronic pelvic pain reported was mild. A parallel study showed that men also suffered chronic pelvic pain — a smaller proportion than women, but still significant.2 We are not medicalising normal events; rather, we are alerting general practitioners to the normal range of pelvic pain experience to help them assess its clinical significance. A GP who says to a female patient “it’s normal, love, just grin and bear it” denies the psychosocial complexity of her experience. Vivian and Barnard suggest we might have differentiated between two major types of pain, nociceptive and neuropathic. It would not be practical to collect this information in a broad survey on sexual and reproductive health. Certainly, a study of the prevalence of neuropathic pain in the Australian population that mirrors recent studies overseas would be informative. However, our study concerned pelvic pain only. The pelvis is not a common site for neuropathic pain.3

Marian K Pitts · Jason A Ferris · Anthony M Smith · Julia M Shelley · Juliet Richters

A 53-year-old woman presented with a 2-day history of epigastric pain. She had mild tenderness over the right upper quadrant and epigastrium, with no peritonism. A chest x-ray revealed free gas under the diaphragm (Figure, A; arrows). A computed tomography scan confirmed a large pneumoperitoneum but no hollow-viscus perforation; the uterus was filled with gas (Figure, B; arrow). On further questioning, the patient recalled that the pain began after she sat on the gas outlet of a pneumatic spa. She was managed conservatively and discharged uneventfully. Air introduced through the gynaecological tract is a non-surgical cause of pneumoperitoneum. Distension of the uterus with gas on imaging can be a clue to diagnosis.

Yu Xuan Kitzing · Sam McCormack

Objectives: To ascertain changes in: women’s knowledge of the role of folic acid in the prevention of neural tube defects (NTDs); intake of folic acid among pregnant women; and prevalence of NTDs in South Australia.Design, setting and participants: Computer-assisted telephone interviews of South Australian households from 1994 to 2007 over a period encompassing a statewide folate promotion campaign (1994–1995), continuing folate promotion, as well as the introduction of voluntary folate fortification of foods (1996); ascertainment of the total prevalence of NTDs from births and terminations of pregnancy from 1966 to 2007.Main outcome measures: Changes in women’s knowledge of the role of folic acid in the prevention of NTDs; changes in the prevalence of NTDs.Results: From 1994 to 2006 and 2007, knowledge about the role of folic acid increased from 25% to 77% (P < 0.001) and knowledge that folic acid needs to be taken in the periconceptional period increased from 12% to 39% (P < 0.001). The proportion of pregnant women who increased their periconceptional intake of folate rose from 61% in 1998 to 81% in 2006 and 2007 (P < 0.001), with significant increases in the consumption of fortified cereals (from 15% to 29%) and folic acid tablets (from 37% to 64%). The total prevalence of NTDs fell from 2.06 per 1000 births in 1986–1990 to 1.23 per 1000 births in 2002–2007 (relative risk, 0.60; 95% CI, 0.48–0.74; P < 0.001).Conclusions: Folate promotion and voluntary fortification of certain foods with folic acid were associated with increased awareness of the role of periconceptional folic acid, increased folate consumption and a reduction in the prevalence of NTDs in South Australia by 40% (95% CI, 26%–52%).

Annabelle C Chan DPH, DCCH, FAFPHM · Phillipa van Essen BHSc, MPH · Heather Scott · Eric A Haan BMedSc, MB BS(Hons), FRACP · Leonie Sage RN, RM · Joan Scott RN, RM · Tiffany K Gill MAppSc, CertHealthEc, PostGradDipHlthSc · Anh-Minh T Nguyen BSc(Hons)

Objective: To describe the prevalence of neural tube defects (NTDs) in Victoria, and to evaluate women’s knowledge and awareness of the importance of folate after the introduction of voluntary food fortification.Design and setting: Descriptive study, set in Victoria, Australia, based on routinely collected data from the Victorian Birth Defects Register (VBDR) for 1998–2006, and responses by women aged 18–50 years to five questions relating to folate on the 2005 and 2006 Victorian Population Health Surveys (2314 and 2488 women, respectively). Main outcome measures: Prevalence of NTDs, and extent of women’s knowledge of the importance of folate in NTD prevention, comparing the period before and since voluntary food fortification and a folate awareness campaign.Results: The total prevalence of pregnancies affected by NTDs declined from approximately 17 to 14 per 10 000 births from 1997 to 1999 (coinciding with the period when voluntary food fortification was introduced, and a 1-year folate awareness campaign was held). It has since remained static. Over the 9-year study period, the termination of pregnancy rate was 79%, resulting in three NTD-affected babies per 10 000 livebirths. Compared with women aged 30–34 years (the reference group), those aged 20–24 years had the greatest likelihood of having a baby with an NTD (adjusted odds ratio, 1.70; 95% CI, 1.33–2.18; P < 0.001). Women aged 18–24 years had the lowest rate of folate supplement use (15.9% in 2006), while women aged 30–34 years had the highest rate (30.3% in 2006).Conclusions: There has been no further reduction in prevalence of NTDs in Victoria since 1999, and this prevalence remains well above that achievable through adequate folate intake. Accurate knowledge of folate consumption, population-based NTD prevalence data and folate awareness data are essential in monitoring the effectiveness of the mandatory fortification program to be implemented in Australia in the next 2 years.

Louise du Plessis BSc(Hons), MB ChB, FRACP · Rod W Hunt BM BS, MMed, PhD · Ashley S Fletcher BSc, MEpi · Merilyn M Riley BApplSc, GradDipEpi, Biostat · Jane L Halliday BSc, PhD

Objective: To estimate the percentage of preterm (< 37 weeks) and full-term low-birthweight (37–41 weeks, < 2500 g) babies born to mothers who smoke, stratified by Indigenous status and statistically adjusted for the potential confounding effects of social and demographic factors, medical conditions and pregnancy complications.Design, setting and participants: Population-based study of singleton babies born to mothers resident in Queensland who gave birth in Queensland from 1 July 2005 to 31 December 2006.Main outcome measures: Adjusted percentages of preterm birth and full-term low birthweight for babies born to Indigenous and non-Indigenous mothers.Results: Of the 79 803 babies studied, 4228 (5.3%) were born to Indigenous mothers and 16 395 (20.5%) were born to mothers who smoked during pregnancy. The percentage of Indigenous mothers who smoked (54%) was almost triple that for non-Indigenous mothers (risk ratio, 2.90; 95% CI, 2.81–2.99). The adjusted outcomes for babies born to Indigenous non-smokers were similar to those for non-Indigenous non-smokers (preterm, 7.1% v 6.1%; full-term low birthweight, 1.6% v 1.1%). The adjusted percentages for smokers were high regardless of Indigenous status (preterm, Indigenous v non-Indigenous, 8.3% v 7.8%; full-term low birthweight, Indigenous v non-Indigenous, 5.3% v 3.7%).Conclusions: Antenatal smoking remains an important cause of poor health among both Indigenous and non-Indigenous newborn babies. Most pregnant smokers receive their antenatal care in the public sector. State and federal governments, who directly fund this sector, have a particular responsibility to ensure that interventions are offered to all pregnant smokers to help them quit smoking.

Rachael-Anne Wills BAppSc(Hons) · Michael D Coory PhD, FAFPHM, AStat

Objectives: To explore the role of socioeconomic status and Aboriginality on birthweight at an urban hospital.Design, participants and setting: Extraction of data on the demographic characteristics (socioeconomic status, mothers’ single-parent status, age and smoking status) and infants’ birthweight from a clinical record system. Infants delivered at an outer urban hospital to mothers residing in the local government area during 2002 were included. Infants were identified and results interpreted in consultation with Indigenous health workers.Main outcome measure: Infant birthweight.Results: Indigenous infants had a lower mean birthweight than non-Indigenous infants (difference, 127 g), and were more likely to weigh < 2500 g. Mothers of Indigenous infants were more likely to be single, aged < 20 years and to smoke during pregnancy. Lower birthweight was associated with lower socioeconomic status for Indigenous and non-Indigenous infants. Indigenous infants in the most socioeconomically disadvantaged quintile in this study were at higher risk and had a mean birthweight 204 g less than non-Indigenous infants in the same quintile. In multivariate analysis, differences in birthweight were associated with socioeconomic status and smoking during pregnancy.Conclusions: For both Indigenous and non-Indigenous infants, birthweights were associated with socioeconomic status. Differences between Indigenous and non-Indigenous infants were largely explained by low socioeconomic status and smoking during pregnancy.

Angela T Titmuss BSci(Med)(Hons), MB BS, MPH · Elizabeth Harris BA, DipSocWork, MPH · Elizabeth J Comino BVSc, MPH, PhD

To the Editor: It’s all very difficult isn’t it? Teasing out the issues around impartiality, weighing evidence and competing interests? Wain wrote a recent editorial for the Journal, and included a list of his “competing interests”: Chair of the CSL Gardasil Advisory Board; speaker fees, travel assistance and consultancy fees from CSL Biotherapies and from Merck and its affiliates in relation to Gardasil; and shares in CSL Limited.1 He helpfully advises that Gardasil (Merck) “is available at no cost to Australian girls and women between the ages of 12 and 26 as part of the National Immunisation Program. The bivalent vaccine, Cervarix (GlaxoSmithKline), has to date not been included in the program, having initially been rejected by the Pharmaceutical Benefits Advisory Committee (PBAC) on the basis of uncertain cost-effectiveness, but subsequently recommended for inclusion.”1 This is disingenuous at best. Initially, the PBAC also “rejected the application for [Gardasil] . . . based on unacceptable and uncertain cost-effectiveness at the price requested.”2 At the request of the then Health Minister, the PBAC reviewed its decision after the company made some small changes to its submission, including a change in pricing. At about the time Wain’s editorial was published, a hard copy of the previous Medical Journal of Australia article on human papillomavirus (HPV) arrived on my desk,3 courtesy of GlaxoSmithKline. That article on HPV vaccination listed the “competing interests” at the end. Clearly, all the authors have received some sort of funding through GlaxoSmithKline, CSL and/or Merck. I am not impressed by authors who receive funding from pharmaceutical companies that market the drugs they are discussing. It seems to me that the problem lies with interests not competing, or at least not competing with the author’s intent. Perhaps a little healthy competition would bring out some more thoughtful, articulate articles, unaffected by any commercial pressures. “A plague o’ both your houses.” Let’s consider where we could best spend our money without the help of the competing interests of various pharmaceutical marketing mechanisms. “HPV vaccination will not prevent all cases of cervical cancer, therefore vaccinated women should continue to have two yearly Pap smears.”4 Given that HPV vaccination (in this country) will not change the rate of cervical screening required in the near future, perhaps the money would be better spent on ensuring that all Australian women are screened in a timely manner. That is, ensuring that poor women, Indigenous women, rural women, and immigrant women are part of “Cervical screening in Australia . . . one of the great public health success stories, as witnessed by a continuing dramatic fall in the incidence of carcinoma of the cervix and mortality from this disease since the introduction of the National Cervical Screening Program (NCSP).”5

Lilon G Bandler

To the Editor: We would like to express our disappointment with the Journal’s decision to publish an editorial on human papillomavirus (HPV) vaccines that demonstrated significant bias.1 It seems that simply documenting an author’s conflicts of interest exonerates the author and relieves the Journal of the responsibility of considering whether or not the article is biased. In his article, Wain states that the bivalent vaccine, Cervarix (GlaxoSmithKline), has not been included in the National Immunisation Program, having initially been rejected by the Pharmaceutical Benefits Advisory Committee (PBAC) on the grounds of uncertain cost-effectiveness. He omits to mention that Gardasil (Merck), was initially also rejected, and only funded after political intervention, an emergency meeting of the PBAC and further price negotiations with CSL.2 Wain claims that Cervarix is being promoted to older women despite the absence of efficacy data and the uncertain population benefits in this age group. Surely a balanced argument would include the fact that Gardasil is licensed for boys aged from 9–15 years based on immunogenicity data only, and that efficacy has not been established in this population. Why does the author consider this to be acceptable, but that licensing the vaccine for older women where the indication is to prevent cervical cancer is unacceptable? Many vaccines are licensed on the basis of immunogenicity data provided these have been shown to predict efficacy. While the efficacy of HPV vaccines in older women is being established, there are good data to show that an immune response to HPV vaccine is predictive of efficacy.3 Women aged over 26 years produce a robust immune response to HPV vaccines, similar to levels achieved in women aged 15–25 years, for whom efficacy has already been demonstrated. The Therapeutic Goods Administration has licensed Cervarix for women aged 26–45 years, before efficacy data became available, based on the assumption that efficacy will be demonstrated in seronegative older women. Women of all ages have shown interest in benefiting from a vaccine to protect against cervical cancer.4 Women of any age have the right to be informed, and to have the opportunity to discuss with their treating physician the relative benefits and risks of receiving the HPV vaccine for prevention of cervical cancer. Many vaccines are initially available only if purchased by individuals and, although this may result in inequity, ultimately, this is a decision of priority (individual financial and public health funding priorities) and not a reason to withhold licensing a vaccine with proven benefit.

Helen S Marshall · David Isaacs

To the Editor: Wain’s criticism of the Australian Therapeutic Goods Administration (TGA) approval of the bivalent vaccine, Cervarix (GlaxoSmithKline), suggesting it did not adhere to World Health Organization guidelines,1 should not detract from the potential benefits of human papillomavirus (HPV) vaccination in women over 26 years of age. An immunogenicity study showed all women up to the age of 55 years seroconverted to both HPV types and, while mean antibody concentrations at Month 7 were lower than in the younger age group, they were still three to four times higher than those observed in 15–25-year-old women in the long-term follow-up study (up to 4.5 years after vaccination), where continued efficacy was demonstrated.2 HPV infection is most prevalent in younger age groups, with one study showing a prevalence of 44.8% in women aged 20–24 years.3 As indicated by Wain, the vaccine has diminished efficacy in populations with high rates of previous exposure. Thus, 20–24-year-olds would benefit least, and if we extrapolate his argument, should not be included in any catch-up vaccination program. The United Kingdom has, in fact, recommended a catch-up campaign for girls aged up to 18 years only. The prevalence of HPV infection decreases after 26 years of age, and these “older” women should benefit from vaccination as supported by preliminary efficacy data of the quadrivalent vaccine Gardasil (Merck) in an older population.4 This vaccine may also be protective for women who have been previously exposed to the same subtypes of HPV as the vaccines, as shown by 100% efficacy against cervical intraepithelial neoplasia (CIN) grade 2/3 or adenocarcinoma in situ (AIS) among people who are seropositive but HPV-DNA-negative to the relevant HPV type.5 The Pharmaceutical Benefits Advisory Committee initially did not recommend funding for Gardasil on the basis of cost-effectiveness until after an extraordinary meeting to consider a revised submission, following an “unusual” request from the Health Minister.6,7 CSL agreed to reduce the price, undertook to make a substantial contribution to any booster program if it became necessary in the next 20 years, and also to the costs of setting up a national register to link vaccination data to later cervical screening records. It is obvious that the efficacy of HPV vaccines will inevitably be lower after commencement of sexual activity, but we believe that it is the medical practitioner’s responsibility to offer women aged over 26 years the current, albeit incomplete, information on vaccine efficacy, and allow women to make the choice.

Jeffrey H J Tan · Michael A Quinn

To the Editor: Buruli ulcer, caused by the bacterium Mycobacterium ulcerans, leads to the destruction of skin and sometimes bone. It has been reported in many tropical countries in Africa and in some temperate regions of Australia, Japan and China.1 In 2004, the World Health Organization recommended treatment with the combination of oral rifampicin and intramuscular streptomycin (or amikacin) for 8 weeks.2,3 In-vitro studies and new data from mouse models suggest that combinations of rifampicin with clarithromycin, rifampicin with moxifloxacin, or clarithromycin with moxifloxacin may be as effective as rifampicin and streptomycin.4,5 In June 2007, a woman who was 6-months pregnant with her first child and had a 7-month history of Buruli ulcer on her right upper limb (Box 1, A) was admitted to the Buruli ulcer treatment centre in Allada, Benin. She was otherwise in good health, and the fetal heart beat was normal. Routine laboratory examinations, including HIV serology tests, found no abnormalities. Swabs from the ulcer were positive for acid-fast bacilli by Ziehl–Neelsen stain, and for IS 2404 (DNA sequence specific for Mycobacterium ulcerans) by polymerase chain reaction testing, but no growth of M. ulcerans was obtained on culture. Histopathological analysis of punch biopsy specimens showed typical features of Buruli ulcer. As streptomycin is contraindicated in pregnancy, we treated the patient with a combination of oral rifampicin (600 mg daily) and oral clarithromycin (500 mg twice daily) for 56 days, beginning 2 weeks after presentation. The treatment was well tolerated. We monitored the clinical response through serial photographs (Box 1) and measurements of the circumference of the affected and unaffected limbs at defined points (Box 2). The patient gave birth to a healthy boy weighing 2.25 kg in September 2007, 2 weeks after completing antibiotic treatment. She underwent skin grafting a month later. The lesion healed without functional limitation (Box 1, D), and the patient was discharged in December 2007. At that time, the surface area affected by the lesion was reduced by 55%. To our knowledge, this is the first report of successful treatment of Buruli ulcer using fully oral treament with rifampicin and clarithromycin alone. We hope our experience will contribute to future discussion and studies to find an oral treatment for this devastating disease. 1 Serial views of Buruli ulcer in a woman treated with rifampicin and clarithromycin A: At presentation. B: After 4 weeks' antibiotic treatment. C: On completion of antibiotic treatment (8 weeks). D: At hospital discharge after skin grafting, showing full movement of the elbow joint (23 weeks). 2 Clinical response to treatment Week after treatment start 0 4 8 23 Limb circumference (cm) At wrist Affected limb 21 17.5 16.5 15 Unaffected limb 14 14 14 14 % difference 50% 25% 18% 7% At mid-arm Affected limb 36 33 30 25 Unaffected limb 22 22 22 22 % difference 64% 50% 36% 14% At elbow Affected limb 34 21 21 21 Unaffected limb 23 23 23 23 % difference 48% − 9% − 9% − 9% Lesion dimensions Diameter (cm)* 30.3 23.8 22.5 20.3 Area Estimate (cm2) 722 446 397 325 % reduction — 38% 45% 55% * Median diameter.

Ange D Dossou · Ghislain E Sopoh · Christian R Johnson · Yves T Barogui · Dissou Affolabi · Sévérin Y Anagonou · Théophile Zohoun · Françoise Portaels · Kingsley Asiedu

Clinical cases in obstetrics, gynaecology and women’s health. Caroline M de Costa, Paul Howat. Sydney: McGraw-Hill, 2007 (xv + 256 pp). ISBN 978 0 07 471640 3. Clinical cases in obstetrics, gynaecology and women’s health is the kind of book I would have liked to have had when I was a medical student or junior resident. Well written and in a conversational tone, de Costa and Howat outline an approach to those common questions that arise in clinical practice. The book extends the type of cases presented to medical students as part of problem-based learning to a higher level of complexity, and pleasingly incorporates the emotional, social and psychological aspects of care that are often absent from standard obstetric and gynaecology textbooks. Each case provides an up-to-date overview of the topic area and concludes with references which, while not cited in the text, are accompanied by useful suggestions for further reading. Readers are kept engaged with highlighted boxes and clinical pearls, and for those undertaking a diploma in obstetrics and gynaecology, the multiple choice questions at the end of the book are a useful way to test your knowledge. Targeted at the level of medical student and junior doctor, general practitioners very experienced in women’s health may find the content a little simplistic, and there are some omissions, such as preconception care and counselling regarding an unplanned pregnancy. However, for those who want to know what current practice is or should be in clinical scenarios that arise in day-to-day practice, Clinical cases in obstetrics, gynaecology and women’s health will be very useful.

Danielle Mazza

Objective: To investigate whether the relationship between socioeconomic status and breastfeeding initiation and duration changed in Australia between 1995 and 2004.Design and setting: Secondary analysis of data from national health surveys (NHSs) conducted by the Australian Bureau of Statistics in 1995, 2001 and 2004–05. The Socio-Economic Indexes for Areas (SEIFA) classification was used as a measure of socioeconomic status.Main outcome measures: Rates of initiation of breastfeeding; rates of breastfeeding at 3, 6 and 12 months.Results: Between the 1995 and 2004–05 NHSs, there was little change in overall rates of breastfeeding initiation and duration. In 2004–05, breastfeeding initiation was 87.8%, and the proportions of infants breastfeeding at 3, 6 and 12 months were 64.4%, 50.4% and 23.3%, respectively. In 1995, the odds ratio (OR) of breastfeeding at 6 months increased by an average of 13% (OR, 1.13 [95% CI, 1.07–1.19]) for each increase in SEIFA quintile; in 2001, the comparative increase was 21% (OR, 1.21 [95% CI, 1.12–1.30]); while in 2004–05, the comparative increase was 26% (OR, 1.26 [95% CI, 1.17–1.36]). Breastfeeding at 3 months and 1 year showed similar changes in ORs. There was little change in the ORs for breastfeeding initiation.Conclusion: Although overall duration of breastfeeding remained fairly constant in Australia between 1995 and 2004–05, the gap between the most disadvantaged and least disadvantaged families has widened considerably over this period.

Lisa H Amir MB BS, MMed, IBCLC · Susan M Donath BSc, MA

To the Editor: We concur with Chan and Sullivan regarding the importance of targeting modifiable risk factors, such as smoking during pregnancy, to improve perinatal outcomes.1 Alcohol consumption during pregnancy is another important modifiable risk factor. Alcohol exposure in utero is associated with growth retardation, birth defects, and impaired development and neurological function. Individuals exposed to alcohol in utero may have lifelong medical and psychosocial problems.2 In our national survey of 1103 Australian women aged 18–45 years conducted in 2006, 34.2% of women reported that they had consumed alcohol during their most recent pregnancy and 16.2% had smoked. When asked whether they would consume alcohol or smoke if they were to become pregnant in the future, 23.7% said they would consume alcohol and 4.0% said they would smoke. Intention to smoke during a future pregnancy was significantly associated with intention to consume alcohol (odds ratio, 5.1 [95% CI, 2.7–9.4]; P < 0.001).3 This strong association suggests that strategies aimed at reducing smoking and alcohol consumption during pregnancy should target both behaviours. Chan and Sullivan also note the need for uniform national data on smoking during pregnancy. Although alcohol consumption is more common than smoking during pregnancy, fewer data have been collected and reported on alcohol consumption during pregnancy than on smoking. Five Australian states and territories collect data on maternal smoking status,1 and the data are published by the Australian Institute of Health and Welfare in their annual Australia’s mothers and babies report.4 In contrast, data on alcohol consumption during pregnancy are routinely collected by only three states and territories (Tasmania, the Australian Capital Territory and the Northern Territory). These data are minimal and inadequate for monitoring trends or evaluating the effectiveness of public health interventions. Smoking and alcohol can both cause preventable harm to the unborn child. Public health strategies, national uniform data collection and community education are required to address these issues in order to promote healthy pregnancies and healthy babies.

Elizabeth M Peadon · Carol I Bower · Elizabeth J Elliott

What is a reasonable approach to management of women with pelvic pain? Pelvic pain in women is as common as the common cold, it seems. Certainly that is the impression one is left with after reading the article by Pitts et al on the prevalence and correlates of pelvic pain in Australian women. Pitts and colleagues found that 72% of women experienced dysmenorrhoea and only one in four women did not report any kind of pelvic pain.1 A systematic review of international studies reported a similar prevalence of dysmenorrhoea and pelvic pain.2 Is the experience of pelvic pain, particularly dysmenorrhoea, just a normal part of life? If this is the case, then we need to ask how clinicians should most appropriately respond to the many women presenting for assistance with chronic pelvic pain. What proportion of women with pelvic pain will have underlying pathology? Most studies of women with dysmenorrhoea suggest that endometriosis is present in 30%–40% of cases.3 But the pain felt by women during menstruation may be no less severe than the pain experienced by women with pathology. Period pain can lead to lost days from school or the workplace and may have a considerable impact on daily living. Which women with pelvic pain should be referred for further investigation with laparoscopy? Common sense suggests that women who warrant further investigation are those for whom empirical approaches (such as suppression of the menstrual cycle) have failed and those who have symptoms at the severe end of the spectrum. The guidelines of the Royal College of Obstetrics and Gynaecology in the United Kingdom and the consensus statement of the American College of Obstetrics and Gynecology support the use of an empirical approach before laparoscopy.4-6 Such an approach has been justified on the basis of the risks of the procedure and the possibility that pain will not be relieved even if surgery is undertaken, and that ongoing medical therapy will be necessary.7 Additionally, there would be the potential for harm if even 20% of adolescents with dysmenorrhoea were to undergo laparoscopy. A laparoscopy is an invasive procedure that may have unexpected consequences: performing extensive biopsies or peritoneal stripping could potentially lead to adhesion formation and impaired fertility. Further considerations concern patients and doctors alike. Women have stated that they find diagnostic laparoscopy reassuring because is either confirms or rules out endometriosis.8 Surveys of women with established endometriosis have reported delays of up to 12 years between the onset of pain symptoms and the surgical diagnosis of endometriosis.9 Some women are frustrated about these delays, and there have been calls for such delays to be avoided through greater education of health professionals, changes in guidelines and increased access to diagnostic laparoscopic services.7,10 The assumption underlying these women’s frustration is the possibility that when they first experienced pain they already had pathology that was not diagnosed. However, there is no evidence for this, as there are few longitudinal studies of pelvic pain and it is not possible to perform laparoscopy on all women with pelvic pain symptoms. Then there is the concern that the delay in diagnosis of endometriosis may have an impact on future fertility. But it is possible that the experience of pain as an adolescent is unrelated to a later diagnosis of endometriosis. So, on the one hand, clinicians are increasingly being asked to investigate women with pelvic pain, yet, on the other hand, the likelihood of pathology is less than 50%, especially in the adolescent age group. Furthermore, treatment of dysmenorrhoea can be initiated without a firm diagnosis. Decision making is thus a trade-off between missing a pathological condition and overinvestigation. In the light of current evidence, what is a reasonable management approach to women who present with pelvic pain? In adolescents with dysmenorrhoea, the first-line strategy should be to prescribe non-steroidal anti-inflammatory drugs (NSAIDs) with the oral contraceptive pill. Both of these have been found to reduce the experience of pain and reduce days of absenteeism.11,12 Avoiding menstruation by skipping the non-hormonal pills and allowing bleeding only 3–4 times a year is another useful strategy, although some women will experience breakthrough bleeding. Reassurance should be given that the experience of dysmenorrhoea is normal and that serious pathology such as advanced endometriosis is unlikely to arise during the adolescent years. Women who fail to respond to first-line approaches may need to consult a gynaecologist for consideration of a laparoscopy. For women in their 30s and 40s with pelvic pain, doctors should be aware of the increasing likelihood of underlying pathology. New or worsening symptoms can initially be managed with simple strategies such as the use of NSAIDs and oral contraceptives, but women who fail to respond to these should be referred to a gynaecologist earlier rather than later, especially if they wish to conceive in the future. Finally, there is a small group of women with chronic pelvic pain who have had repeated surgery and may suffer from a form of neuropathic pain. Such patients generally require the help of a multidisciplinary team that should include gynaecologists, psychologists, pain specialists and physiotherapists.

Cynthia M Farquhar MB ChB, MD, FRANZCOG

Objective: To identify the prevalence and correlates of three types of pelvic pain (dysmenorrhoea, dyspareunia, and other chronic pelvic pain [CPP]) in a nationally representative sample of Australian women.Design and setting: The CPP survey was part of a broader national study of health and relationships. Computer-assisted telephone interviews were administered to a random sample of 8656 Australian households; 4366 women aged between 16 and 64 years were interviewed in 2004 and 2005. Eighteen of the more than 200 potential survey questions related to pelvic pain.Main outcome measures: Self-reports of dysmenorrhoea, dyspareunia, and any other CPP not associated with sexual intercourse or menstruation.Results: Data on 1983 women aged 16–49 years who were still menstruating and sexually active were analysed. Prevalences were 71.7% for dysmenorrhoea, 14.1% for dyspareunia and 21.5% for other CPP; 23.3% of women reported no pelvic pain of any kind. Severe pain was reported by 15.0% (95% CI, 13.0%–17.1%) of women with dysmenorrhoea, 7.8% (95% CI, 5.0%–11.9%) of women with dyspareunia and 20.0% (95% CI, 16.1%–24.6%) of women with other CPP. Just over a third (34.2%) of women who reported any pain had sought advice from a health professional. Women reporting CPP were also likely to report other health conditions, most notably depression and anxiety. There were clear associations between CPP and sexual difficulties, pregnancy and pregnancy outcomes.Conclusions: Rates of pelvic pain in Australian women are high. General practitioners need to be ready to discuss these issues with patients, particularly in relation to underlying anxiety and depression.

Marian K Pitts BA(Hons), PhD, MAPS · Jason A Ferris BPsych(Hons), MBiostat, GStat · Anthony M A Smith BSc(Hons), PhD · Julia M Shelley BA(Hons), MPH, PhD · Juliet Richters BA, MPH, PhD

Girl stuff. Your full-on guide to the teen years. Kaz Cooke. Melbourne: Penguin, 2007 (554 pp). ISBN 978 0 670 02887 0. Kaz Cooke seems to have explored every nook and cranny in a teenage girl’s mind in this colourful, accessible tome. Divided into four parts: body, head, heart and “info to go,” she covers a vast range of issues from puberty, friends, and stress, to money matters and job hunting. Girl stuff understands where adolescents are coming from — useful for those of us working with them! The minutiae of pubertal development (vaginal secretions, nipple colour, tampon traumas ...) may never come to our attention in the consulting room, but can cause hours of angst for many a young woman. How to negotiate relationships is more important to the sexually experimenting adolescent than the risk of invisible sexually transmissible infections. Cooke learned about the concerns of teenage girls via a web-based survey that received over 4000 responses, and hundreds of these quotes appear throughout. The more medical issues (puberty, acne, eating disorders, and depression, just to name a few) have been well researched, and there is an impressive list of adolescent health experts among the acknowledgements. The book is heavily sprinkled with Kaz Cooke’s delightful humour as well as her great cartoon illustrations. I would have liked more integration of cross-cultural issues. In the otherwise excellent chapter on families, there is no mention of the cultural differences that shape families. An overt statement about how beliefs about sex and gender may be culturally determined and that not everyone will be part of the dominant culture would be preferable to the passing reference to how religion and culture influence people’s beliefs about sex. Adolescent substages progress rapidly, and by the time most adolescent girls are faced with sexual decision making, they may have worked out puberty. Conversely, the chapters on sex and drugs may not seem appropriate for a very young adolescent preoccupied with buying her first bra. It has been handy having three adolescent girls at home, one in each substage, to test this out. The book is so full of common sense and practical information including statements such as “don’t read this chapter if you’re not ready”, that I had no qualms myself. I wish it had been around when I was a teenager.

Melissa S L Kang

To the Editor: The recent article by de Crespigny and Savulescu1 is nominally about the medical care of pregnant women, but its ramifications extend more widely into power relations, law and ethics, and matters of life and death. The article is entirely adult-centred: its authors never hint that a doctor who is treating a pregnant woman has not one but two patients. There is never the faintest suggestion that the fetus is a separate human being with his or her own medical interests. The “research” reported is a survey of 20 obstetricians, who all agree with the authors on abortion for fetal abnormality. Unsurprisingly, most said they would prefer fewer constraints on such abortions. Which abnormalities are grounds for termination? The authors never say, although terminations are performed in Victoria for conditions as readily treatable as cleft lip.2 The authors cite an estimate that where Down syndrome is identified in Victoria, 95% of pregnancies are terminated. Yet people with Down syndrome do not appear to find their lives intolerable: is the misery we want to put Down syndrome children out of their misery, or their parents’? The authors insist that in Victoria, “uncertain laws compromise good prenatal care”. The prenatal care they seem to have in mind can hardly be called care of the child: can it be called care of the mother? In one of the cases cited, a woman at Melbourne’s Royal Women’s Hospital was threatening suicide unless her pregnancy was terminated after a diagnosis of dwarfism at 31 weeks.1 Instead of providing her with urgent psychiatric care (had they never encountered a suicidal patient before?), the doctors terminated her pregnancy. If she had demanded the amputation of her left arm, would they have called in the surgeons? The surgical mutilation of an adult patient would not have been considered for a moment, but the surgical killing of a fetal patient was an available and practised routine. This woman was already not well, and the “prenatal care” she received put her further at risk. This case illustrates how true prenatal care is compromised, not by the few remaining legal limits on child destruction and abortion, but by their ready availability. Readers of the literature on post-abortion syndrome will have encountered many other illustrations of what should be obvious: that you are not likely to help a woman by destroying her child. Experienced and attentive general practitioners and psychiatrists will be able to give their own examples. Doctors need to pay close attention to the short paragraph on conscientious objection.1 The authors declare that “a doctor’s conscience should not be allowed to interfere with medical care” and that if “some individuals or institutions have moral objections ... those objections cannot compromise patient care”. If that does not mean that the authors want to exclude anyone who disagrees with them about what constitutes “medical care” from medical practice, what does it mean? There could hardly be a plainer threat to doctors’ personal professional judgement.

Edward D Watt

To the Editor: Superficially, de Crespigny and Savulescu make a compelling case for clarifying late-term abortion law.1 However, at a deeper level, it is disappointing that alternative points of view were not discussed in their article. The only solution offered in the case of a potentially imperfect child is to abort the pregnancy and try again. Unfortunately, this ignores several important issues. First, the consequences of abortion for the mother, both physical and psychological, are neglected.2 Our experience, as general practitioners, is that late-term abortions only lead to heartache and regret, even depression and anxiety, as the mother tries to deal with what has happened to her. Every time she sees either a “normal” or an “abnormal” child, her loss is re-lived. A patient of one of us (S B G) has developed Asherman syndrome as a result of a late-term abortion; she is now infertile. Second, without a definition of “child”, any discussion regarding abortion law is, at best, futile; at worst, it is emotionally charged and reliant on anecdotes. If a fetus is defined as a child, then that child has a right to live, whatever the disability. If not, then any disability up to the defined age could potentially justify “abortion” (ie, destruction). Third, the references given to support the assertion that women might “refuse to consider motherhood” without genetic testing described women who carry germline monogenic abnormalities (eg, thalassaemias, Huntington genotypes). These women would be eligible for earlier antenatal screening, such as pre-implantation genetic diagnosis, amniocentesis and chorionic villus sampling — all of which are available well before the current legal time frames in question. Fourth, de Crespigny and Savulescu’s premise for allowing late-term abortion is that there is a life-threatening fetal abnormality and the mother wishes to have children. However, a consequence of liberalising the law for the benefit of these women would be that women with non-life-threatening fetal abnormalities, and also those who simply did not want a child, could also access late-term abortion more easily. This is obviously a major concern. Finally, use of the term “child destruction” in the law is important when considering these situations. A helpful definition of the purpose of the law is to prevent injustice.3 As seen by the ability for women to access “legal” abortion before 20 weeks’ gestation, any law that protects children needs to stand. The pregnant woman clearly has a voice; unfortunately, the unborn child does not have the same ability to state his or her case before an ethics committee.

Simon B Gerber · John T Wenham

In reply: Watt seems to wish to return to the days of no prenatal testing; we believe today’s women reject this paternalistic view. However, Watt is correct in saying our article is “adult-centred” — it is not self-evident that the fetus is a patient, nor is this view consistent with those of most liberal legal jurisdictions. It has been found that 81% of Australians,1 including a majority in all major Australian religious groups,2 agree with a woman’s right to choose an abortion. Only 4% of Australians consider abortion wrong.3 We echo Amnesty International’s call for abortion to be decriminalised globally.4 Abortion laws should no longer discriminate against pregnant women with fetal abnormalities. Contrary to Watt’s claims, it is well documented that an experienced psychiatrist was central in managing the pregnant woman who had an abortion at 32 weeks at the Royal Women’s Hospital. In addition, we do not believe abortion has been demonstrated to cause psychiatric “post-abortion syndrome”,5,6 nor that abortion is analogous to amputating a healthy limb. We do not challenge doctors’ personal judgements. All individuals must be free to make their own value judgements for their own lives, including doctors. However, doctors have a duty to inform patients of all appropriate treatments. When a patient requests abortion and the doctor has a moral objection to providing it, the doctor must refer the patient to another practitioner.5 Contrary to Gerber and Wenham’s claims, we did not suggest that “to abort the pregnancy and try again” is the only option for fetal abnormality. Abortion — or continuing the pregnancy — must be the woman’s decision. One of us (L J d C) has 30 years’ experience of prenatal testing, including treating many women after terminations for fetal abnormality. Such women are sad about the diagnosis and outcome, extremely worried during subsequent pregnancies, and regret having had to make an awful decision. However, none have said that they made the wrong decision. Regarding Gerber and Wenham’s comments about the definition of “child”, our position is that (before birth) the fetus does not have the rights of a child.7 The data we cited show that prenatal testing for Huntington disease “allows” at-risk women, who might otherwise choose not to conceive, to have children. Personal experience (of L J d C) shows that women with a past history of other serious fetal disorders are no different. We did not suggest that late abortion should be available only in cases of life-threatening fetal abnormality. Indeed, our article clearly related to “pregnant women with fetal abnormalities” (not necessarily life-threatening). The claim that women would request late abortion simply because they don’t want a child demeans women’s integrity. We need clear abortion laws so that pregnant women and their doctors can know when abortion is lawful. Developing clear laws necessitates removing the crime of child destruction.8

Lachlan J de Crespigny · Julian Savulescu

To the Editor: The Rural Doctors Association (RDA) of New South Wales, of which I am President, has been involved in desperately trying to keep maternity units close to people’s homes. The conclusion formed by Ford and colleagues in their recent report,1 that women with a previous postpartum haemorrhage should only deliver in units with a blood transfusion service, appears extraordinary and contradictory to their own findings. The authors based this conclusion on their finding that 5.8% of women had a postpartum haemorrhage in their first pregnancy, even though their definition of this was remarkably subjective and largely unscientific. They recognised in their study that the incidence of postpartum haemorrhage requiring transfusion is only 0.7%. Therefore, 88% of women defined as having a postpartum haemorrhage do not require a blood transfusion. I am bemused why the authors think 88% of women who did not require a blood transfusion but had a “postpartum haemorrhage” should only deliver in a unit with blood transfusion services. I doubt any of my colleagues would wish to deliver women who required a blood transfusion for a previous postpartum haemorrhage in a small unit. I refer Ford and colleagues, and readers, to a study by Tracy et al reported in January 2006.2 This was a much larger study of 750 491 women giving birth during 1999–2001. This study concluded that “In Australia lower hospital volume is not associated with increased adverse outcomes for low risk women”. In the past 10 years, we have seen the loss of 50% of our maternity units in NSW, and the rest are under severe stress due to the lack of staffing. I doubt that the sort of extraordinary conclusion made by Ford and colleagues will help us maintain services in rural NSW.

Leslie A Woollard

In reply: Safety and appropriateness are important principles underlying the provision of health care. Maternity care in Australia requires that women are offered care in an environment that is appropriate to their level of risk. Such a risk-management approach requires accurate data to inform the process, including accurate identification of women who may access local services as well as those who may benefit from higher levels of care. The aim of our study was to present risk estimates of recurrent postpartum haemorrhage (PPH) to better inform decision making by both clinicians and women about subsequent pregnancies. While we are aware of the struggles faced by rural maternity units, we estimated that only 0.2% of women giving birth in New South Wales would be affected by our suggestion that women with a history of PPH consider delivering at a hospital with onsite cross-match facilities. The definition of PPH that we used is consistent with that of the International classification of diseases1 and the NSW Department of Health’s PPH policy;2 this policy resulted from a review of hospital PPH policies sparked by a coronial inquest into a maternal death.3 In contrast to Tracy et al’s study, which only considered low-risk women and had no maternal morbidity outcomes,4 our study calculated risk among all women. Women with a PPH are at increased risk of transfusion, intensive care unit admission, unplanned procedure in the operating theatre, hysterectomy and major maternal morbidity.3 Where we have information about an increased risk of a potentially life-threatening event, surely we should communicate and act on this knowledge to achieve the best possible outcome for women and babies. In Canada, which has similar geographical challenges to those in Australia, it is recommended that where risk factors for PPH are identified, additional precautions such as intravenous access, coagulation studies, and availability of anaesthesia should also be considered.5 The key to successful regionalised maternity care is ensuring that women give birth in risk-appropriate settings.

Jane B Ford · Christine L Roberts · Jane C Bell · Charles S Algert · Jonathan M Morris

To the Editor: Pesce’s criticism of midwifery practice at Mareeba District Hospital1 requires rebuttal. His implication that the service is inefficient or pandering to “the powerful sway of maternity care politics” is incorrect and insults those who struggle to provide woman-centred care in a system focused on doctors. A private obstetrician in Sydney cannot understand midwifery workloads in a rural hospital without knowing the local environment and other impacts on the way clinicians work. The small group of midwives in Mareeba provide a highly valued service in their community, with few of the ancillary services taken for granted in metropolitan areas. In routine antenatal care, Dr Pesce presumably orders blood tests and then reviews the results filed in the chart or placed on his desk. A Mareeba midwife providing the same service will also perform the venepuncture, prepare a slide and spin the blood, arrange transport to the laboratory, make the next appointment, and file the results in the chart. A Mareeba midwife’s workload includes, among other things: Comprehensive perinatal care of inpatient midwifery clients; Postnatal and neonatal transfers from Cairns Base Hospital (CBH) (eg, to establish breastfeeding for low birthweight babies); 35–40 paediatric admissions per month; Emergency stabilisation and transfer of high-risk presentations (eg, a woman planning delivery with a private obstetrician in Cairns will nevertheless present to Mareeba when in labour at 32 weeks); Follow-up of high-risk or disadvantaged women who should attend CBH, but won’t for various social reasons; Lactation and parenting support for Mareeba women, regardless of where their deliveries occur; Pap smears and vaccinations; and Indirect care, including policy development, data collection, compilation of reports, professional development, inservice training and education. Pesce also criticised the low level of epidural use at Mareeba, which he says reflects a lack of access. However, models that provide one-to-one care in labour and promote continuity of care have been shown to decrease all interventions and increase maternal satisfaction.2,3 Perhaps the high use of epidurals and other interventions in modern tertiary units reflects a lack of access to such beneficial, woman-centred models of care.

L Gay Hawksworth

In reply: I am surprised that Hawksworth feels my editorial1 was critical of the Mareeba birth unit. There is no criticism of midwifery practice at Mareeba contained in the editorial. Several midwives have commended me for my support of the need for rural maternity units to evolve sustainable models of care based on the local workforce and infrastructure. Conversely, I received a few snide remarks from some obstetricians who felt that I had been too supportive. I have usually felt that when one is criticised by both sides in a controversial debate, one’s view is likely to be reasonable. I stand by my comments that the resourcing of the unit, based on staff–patient ratios and the availability of a nearby alternative service, would be the envy of many rural medical, surgical or community health teams. I also stand by my comments that a 1% rate of epidural use is more likely to reflect lack of access to an epidural service, rather than true patient preference. Reviews by a well known midwife of birth centre care and continuity of care confirm that these models of care decrease the use of epidural anaesthesia but are still associated with a 15% epidural rate.2,3 I am certain that if an epidural service were available, at least some of the Mareeba women would be grateful to have access to it.

Andrew F Pesce

Objective: To describe the pattern of stillbirths by cause and gestation period in New South Wales since the introduction of the Perinatal Society of Australia and New Zealand perinatal death classification (PSANZ-PDC); and to assess the agreement between classifications on cause of death between local hospital committees and the Perinatal Outcomes Working Party (POWP — a subgroup of the NSW Department of Health Ministerial Maternal and Perinatal Committee).Design, participants and setting: Population-based retrospective cohort study of all 258 045 births in NSW and all 1264 stillbirths classified by the POWP in 2002–2004, based on linked data on perinatal deaths from the NSW Midwives Data Collection and the NSW Ministerial Maternal and Perinatal Committee.Main outcome measures: Pattern of stillbirths by cause and gestation period; and interobserver agreement on classification of cause of death (according to the PSANZ-PDC) between local hospital review committees and the POWP.Results: The most common classification was unexplained antepartum death, comprising 41.5% of the cohort and 60% of stillbirths of ≥ 37 weeks’ gestation. These unexplained stillbirths were more likely to have had an autopsy performed than the explained stillbirths (45% v 36%; χ2 = 10.1; df = 1; P = 0.001). Agreement on cause of death differed by cause of death classification, with an overall κ statistic of 0.638.Conclusion: Unexplained antepartum death is the most common classification of stillbirths near term, and these stillbirths are more likely to have had an autopsy. Although reported interobserver agreement is high for PSANZ-PDC, in practice it is relatively low between hospital mortality review committees and the POWP.

Adrienne Gordon FRACP, MPH(Hons) · Heather E Jeffery FRACP, MPH, PhD