Women's health

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

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

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

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

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

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

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

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

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

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

To the Editor: So a large proportion of women experience pelvic pain, often over years. What’s new? Of course they do. Pitts and colleagues1 fail to mention that virtually every normal, physiological event that occurs within a woman’s pelvis is associated with pain. Clearly, such pains vary in duration and intensity and are associated with events such as ovulation, menstruation, pregnancy, labour and childbirth. We men have it easy by comparison. But to conclude by saying that “only about a third of women who experience chronic pelvic pain seek advice from a health professional” gives the impression the authors are trying to medicalise yet another essentially normal event. One can get into long, philosophical discussions as to why such normal events should be so painful, but it remains a fact. I have spent my career urging general practitioners and fellow specialists to avoid surgery and “silver bullets” in most cases of pelvic pain and follow a conservative approach.2 It would have been more helpful if the authors had gone on to discuss what type of pain is suffered by what type of woman and who is treated by what type of doctor. This truly would have assisted in determining who would benefit from the attention of a health professional and who would not.

Jules S Black

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