Women's health

Objective: To determine the association between smoking in pregnant teenagers and baby birthweight.Design, setting and participants: A retrospective population-based study of women aged < 20 years who gave birth to liveborn singletons in Australia between January 2001 and December 2004. Data were drawn from the National Perinatal Data Collection.Main outcome measures: Maternal smoking, birthweight, low birthweight (LBW).Results: The prevalence of LBW in babies born to teenage smokers was 9.9%, compared with 6.0% in babies born to teenage non-smokers (odds ratio [OR], 1.72 [95% CI, 1.57–1.90]). On average, babies born to teenage smokers were 179.8 g lower in birthweight than babies born to teenage non-smokers (95% CI, 165.5 –194.1 g; t = 24.6, P < 0.001). Smoking, Indigenous status, Socio-Economic Indexes for Areas category and parity were independently associated with LBW (all ORs > 1.3; P < 0.001) after adjusting for maternal age group. Teenagers smoking > 10 cigarettes a day had babies with lower birthweight that those who smoked ≤ 10 cigarettes a day, demonstrating a dose–response relationship. The babies of teenage smokers who stopped smoking before 20 weeks’ gestation had birthweights similar to those of babies born to teenage non-smokers. One in 15 teenage smokers stopped smoking during pregnancy.Conclusion: Babies whose mothers smoked during pregnancy were more likely to have LBW than babies whose mothers did not smoke. Mothers who continue to smoke in the second half of pregnancy increase their baby’s risk of LBW. There is significant scope to improve the quitting rate, and health professionals need to target smoking cessation at all contacts with pregnant women who continue to smoke.

Denise L Chan · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health)

After a decade of closures, a flexible approach is needed About one in three Australian women give birth outside metropolitan areas. Historically, most of these women have been cared for by general practitioner obstetricians and midwives in local hospitals. However, in recent years it has been difficult to recruit and retain midwives and doctors with the necessary skills to adequately staff many rural maternity units providing traditional models of care. Whenever any essential component of obstetric, anaesthetic, paediatric or midwife infrastructure has become unavailable, maternity units have been closed, and women in the area are required to travel to the nearest maternity centre instead. It is estimated that more than 130 Australian rural maternity units have closed since 1995.1 In this issue of the Journal, a description by Scherman and colleagues (→ The first year of a midwifery-led model of care in Far North Queensland) of the first year’s experience at Mareeba District Hospital’s midwifery-led maternity unit provides some interesting and valuable insights into the role of low-intervention birth units for low-risk women in rural areas.2 Women planning to give birth at Mareeba were screened for risk factors, and low-risk women were selected for maternity care provided by a midwife. Medical back-up was provided through regular case conferences with an obstetrician at the nearby Cairns Base Hospital, who also visited Mareeba once a month, and on-site back-up from local GPs, who were able to perform caesarean section delivery if necessary. Intrapartum transfer was rarely used and largely confined to primiparous women. The authors reported no significant preventable morbidity or mortality in mothers or their babies, and their findings would appear to support the feasibility of this model of care, especially for multiparous women — although they acknowledge that the number of births so far is too low to support any conclusions regarding safety. Intervention rates were significantly below state averages. In 2004, 207 women gave birth at Mareeba District Hospital under the previous model of care,3 and in the 12 months of this study (2005–2006), 147 low-risk women (plus 11 high-risk women) did so under the care of a midwife. Had the maternity unit been closed, these women would have had to travel over 60 km to Cairns Base Hospital for delivery, as did the 45 women who required transfer during pregnancy for pre-existing or emergent risk factors. Interestingly, the powerful sway of maternity care politics is evident. What other clinical discipline would employ three full-time and nine part-time staff in a dedicated unit with medical back-up to treat 203 patients a year, with an alternative facility 60 km away that ultimately treated almost a quarter of them anyway? The study by Scherman and colleagues raises several other significant issues. The low use of epidural anaesthesia (1%) — which required transfer to Cairns when requested — surely reflects the lack of access at Mareeba, rather than true patient preference. Although facilities for some caesarean deliveries are in place at Mareeba, it is not always possible to perform an emergency caesarean section on site. Recorded transfer times for unplanned deliveries at Cairns Base Hospital were 80–145 minutes, with transfer required either for epidural request or first-stage failure to progress. There is little evidence upon which to base recommendations for the optimum time interval between decision to transfer and emergency delivery, and perhaps transfer would be completed more urgently in a situation where delay could compromise the mother or baby, but most clinicians would agree that a shorter interval than those reported is desirable. A related issue is whether or not staff (both medical and midwifery) providing obstetric care at such units should also spend some time working in a higher-level unit, to maintain their skills in management of relatively rare complications. For example, the treatment of catastrophic life-threatening obstetric haemorrhage is rarely required — but will outcomes be optimal in units where this complication might only be seen by staff once every 5 or 6 years? A Cochrane review of outcomes at birth centres and medical-led units found a statistically significant higher perinatal mortality rate (relative risk, 2.38) in birth units staffed by midwives who did not also work in medically supervised hospital units.4 The search for models of maternity care best suited to women in rural areas will continue to challenge health service planners. A paradox haunts them: the more remote a maternity service is from a referral centre, the higher the perceived community value in keeping it open, but also the higher the risk in operating a low-intervention unit that can provide care for most low-risk women but which ultimately relies on emergency transfer of women with unexpected complications. It is noteworthy that 70% of women who develop pregnancy complications are classified as low risk on initial assessment.5 It seems likely that continuing provision of maternity services in rural areas will depend on optimum use of the local workforce and health facility infrastructure. Individual regional areas will need to come up with arrangements based on consultation with the local community and health workforce. This will require a flexible approach and should recognise that transfer of women may sometimes be required, because of temporary unavailability of a core of necessary staff. It is unlikely that a “one size fits all” approach will deliver solutions to all areas at all times. The key will be cooperation and consultation with the local medical and midwifery workforce, open disclosure to women of what services can and can’t be provided locally, and facilitation of transfer of pregnant women to referral centres if they so choose. Since the MJA’s acceptance of the review of the Mareeba Maternity Unit, reports of an intrapartum, apparently avoidable stillbirth have been published in the press. The incident is being investigated by the Health Quality Complaints Commission following an internal review.

Andrew F Pesce MB BS, FRANZCOG

Objective: To describe a midwifery-led model of care in Far North Queensland and the outcomes obtained in its first year of operation.Design, setting and participants: Prospective analysis of data for all women who were booked for antenatal care with the midwifery-led unit at Mareeba District Hospital (MDH) and who gave birth during its first year of operation, from 27 June 2005 to 30 June 2006.Main outcome measures: Number of women giving birth at MDH; antenatal, intrapartum and postpartum transfers to a higher-level referral centre (Cairns Base Hospital [CBH]); and labour and delivery outcomes.Results: Of the 203 women who were booked for antenatal care at MDH and gave birth in the 12-month period, 170 were categorised as low risk and suitable to give birth at MDH. Of these, 147 (86%) did give birth at MDH, while 17 women (10%) had their care transferred antenatally to CBH, and six (4%) were transferred intrapartum. Of the 33 women categorised as high risk, 22 (67%) gave birth at CBH as planned, seven (21%) had elective caesarean sections performed by a general practitioner at MDH, and four (12%) presented to MDH in labour and gave birth there with no complications. Of the 158 women who gave birth at MDH, 146 (92%) had a spontaneous vertex delivery.Conclusion: Outcomes for the first year of operation of the midwifery-led model of care are consistent with a viable maternity unit, with delivery outcomes and transfer rates that compare favourably with other similar units in Australia.

Samantha Scherman MB BS, FRANZCOG · Jan Smith RM · Megan Davidson RM

To the Editor: Dabadghao and colleagues have drawn attention to the high prevalence of diabetes mellitus and impaired glucose tolerance (IGT) among Australian women with polycystic ovary syndrome (PCOS).1 Quite rightly, both in this article and in the accompanying editorial by Teede and Stuckey,2 the authors have stressed the need to test women with PCOS for diabetes, and that long-term follow-up and lifestyle modification are important. However, it is important to note that many of these women were attending a reproductive endocrinology clinic for treatment of infertility. Therefore, two other points need to be highlighted. First, the high prevalence of glucose intolerance among this group is of immediate concern, as type 2 diabetes can pose a considerable risk to a pregnancy.3 The dangers include miscarriage, fetal malformation and perinatal mortality. Data from New Zealand indicate that perinatal mortality in pregnancies of women with type 2 diabetes was about triple that in pregnancies of women without diabetes; and, in women with type 2 diabetes which was not detected until after pregnancy was achieved, perinatal mortality was 4.5 times that of women without diabetes.4 Screening for diabetes therefore provides an opportunity to ensure that women with glucose intolerance are adequately prepared for pregnancy, thereby minimising the risks. Important measures include high-dose folate therapy and tight glycaemic control, in accordance with guidelines previously published in the Journal.5 Second, the risk of adverse pregnancy outcomes related to the women’s obesity (mean body mass index, 35.1 kg/m2) is also of concern. Therefore, stringent efforts should be made to take the opportunity presented to normalise the weight of women with PCOS before conception.6 The data presented by Dabadghao and colleagues also provide insights into the most appropriate means of screening for diabetes in this high-risk population. They have shown that screening by fasting glucose level alone will miss a third of cases of diabetes. Furthermore, at least 81% of IGT will also be missed! Glucose tolerance testing is therefore far superior to fasting glucose level for the detection of diabetes and IGT. This is a critical point, given the potential ramifications of undetected diabetes. Given these findings, we urge clinicians to routinely perform a glucose tolerance test for women with PCOS attending for fertility treatment, so that all cases of abnormal glucose tolerance are detected, and appropriately managed, before and after conception. It would be a tragedy for a woman to achieve a pregnancy through in-vitro fertilisation, only to develop complications from undiagnosed diabetes.

N Wah Cheung · Jeremy J N Oats

Christmas this year will be marked for us by the arrival of our first grandchild, so as a mother and obstetrician I am receiving a steady stream of questions from my daughter on pregnancy-related matters — not the least of which relate to the use of analgesia in labour. At her antenatal classes, the advice has been to draw up a birth plan: warm baths, movement, partner support, and later, possibly, reluctantly, epidural ... But if I do want an epidural, she asks, will it be available even at Christmas? Christmas is also the time for celebrating the birth of Christ — which led me to wonder about the obstetric details of this event. There is little precise information available to us. Luke 2:4-7, though the author was himself a physician, gives but a brief historical account: ... Joseph ... went up ... unto ... Bethlehem ... with Mary his espoused wife, being great with child ... while they were there, the days were accomplished that she should be delivered. And she brought forth her firstborn son, and wrapped him in swaddling clothes, and laid him in a manger ... (All Bible quotations given here are from the King James Version.) Although there was clearly a birth plan, this was heavenly and long-term, rather than a matter of maternal choices. Presumably the delivery was a spontaneous vaginal one, with a cephalic presentation and rapid labour — possibly initiated by the long donkey ride to Bethlehem. There would have been few facilities for intrapartum care in a stable, and, although angels were in evidence, we are not told of the presence of any human support other than Mary’s husband. The third stage of labour was probably uncomplicated — depictions in religious art always show the mother of Jesus as serene postpartum, with no hint of exhaustion or exsanguination. What can be said with certainty is that for the Madonna there was little in the way of pain relief in labour, and that this situation would continue for women in childbirth for nearly two thousand years. Not only was effective medication lacking, women also had to contend with the curse of Eve — a belief that the pain of labour was women’s lot following Eve’s succumbing to temptation and her subsequent banishment from the Garden of Eden. In Genesis 3:16, God declares sternly, “... in sorrow thou shalt bring forth children”. And so, for hundreds of years, women brought forth children with only the support of other women for relief from pain, and many men, particularly clergy, regarded pain in childbirth as evidence of God’s moving in mysterious ways that should not be questioned. The Nativity, by Petrus Christus, circa 1450. Fortunately, all this finally began to change in the middle of the 19th century, thanks largely to Queen Victoria and a remarkable medical practitioner named John Snow. Victoria, mother of nine, has often been depicted as disliking sex (“lie back and think of England!” is frequently attributed to her), but immediately after her marriage in February 1840 she wrote to her Uncle Leopold, King of the Belgians, that she was the “... happiest Being that ever existed”, and within days she conceived her first child, the Princess Royal, born in November that year.1 She was no wimp — despite “all the ennuies” of pregnancy, she worked until close to each birth — but she was not amused by the experience of labour.1 After her first delivery, she remonstrated with Leopold that “men never think ... what a hard task it is for us women to go through this very often”.1 Later, when her eldest daughter was herself married, Victoria wrote to her of the “heavy trials” and “cruel sufferings” that labour entailed,2,3 and commented that: ... the pride of giving life to an immortal soul is very fine ... but I own I cannot enter into that; I think much more of our being like a cow or a dog at such moments; when our poor nature becomes so very animal and unecstatic.2 Nevertheless, her letters show that she adored her “Angel” — her consort, Prince Albert — and was devoted to all her children.1 In London in 1847, Dr John Snow began to experiment with ether, which dentist William Morton had successfully demonstrated as an anaesthetic to an interested Boston audience the previous year.4 Born in 1813 to a poor Yorkshire family and apprenticed at age 14 to a surgeon, Snow later studied medicine at the Hunterian School of Medicine in London.5 He was a vegetarian, a teetotaller and, by his own admission, celibate all his life, devoting his energies entirely to his profession.6 Snow was one of the first to calculate appropriate dosages of ether; he devised his own apparatus for its administration and soon had “the busiest ether practice in London”.6 He was also interested in chloroform, introduced by James Simpson of Edinburgh in 1847 for obstetric and surgical anaesthesia, and he wrote about both drugs.7,8 Simpson, as well as taking a clinical interest in pain relief for childbirth, also confronted the Church’s objections, quoting from Genesis 2:21-22 the story of Eve’s creation from Adam’s rib: ... the Lord God caused a deep sleep to fall upon Adam ... and He took one of his ribs ... and the rib ... made he a woman. Thus, said Simpson to his opponents, did God condone the use of anaesthesia.9 Victoria and Albert initially expressed interest in chloroform for childbirth in 1848. However, the Royal physicians, Dr Charles Locock and Sir James Clark (a man described as “a walking medical calamity”), had grave concerns about the safety of the drug, so the birth in 1850 of Victoria’s seventh child, Prince Arthur, took place without anaesthesia.6 Over the next 3 years, Snow’s reputation as a safe anaesthetist grew, and, in early April 1853, with the arrival of another child imminent, Albert summoned him to Buckingham Palace for a private conversation. Three days later, the Queen commenced labour, and Snow was again called to the Palace. Subsequently he wrote: April 7, 1853 — Administered ... to the Queen in her confinement ... a little chloroform with each pain ... on a folded handkerchief .... Her Majesty expressed great relief from the application [and] appeared very cheerful and well, expressing herself much gratified with the effect ...6 The Queen indeed found chloroform “delightful beyond measure”, and the child, Prince Leopold, was born healthy. The editors of the Lancet, however, were not amused. “Intense astonishment ... has been excited throughout the profession by the rumour that her Majesty during her last labour was placed under the influence of chloroform, an agent which has unquestionably caused instantaneous death in a considerable number of cases”, they thundered.10 The British Medical Journal hit back at its rival, asserting that “when well controlled and supervised, the use of chloroform is safe”, and by the 1860s, using chloroform in both obstetrics and general surgery was standard practice.11 In 1857, at the birth of her last child, Princess Beatrice, the Queen again used chloroform, once more administered by Dr Snow. “Her Majesty is a model patient”, Snow declared, but very properly declined to comment further on his conduct of either case. The Royal approval much enhanced his professional reputation, and chloroform in childbirth became respectable, being referred to as anaesthesia à la reine. The notion of pain relief in labour was here to stay.12 Snow died in 1858, aged just 45, but left an enduring medical legacy not just confined to his contribution to anaesthesia. In 1854, he had investigated an outbreak of cholera in his London neighbourhood of Soho, becoming convinced — well before the germ theory of disease was accepted — that the source could be traced to water from a public pump in Broad Street. He persuaded a sceptical municipality to remove the pump’s handle — whereupon the epidemic abated. He thus made a significant contribution to epidemiology, as well as to the realisation that plagues and epidemics were not, in fact, the work of a wrathful God.6 Chloroform continued to be used in childbirth until the 1970s, joined by narcotics such as pethidine, nitrous oxide–oxygen mixtures, and other self-administered analgesics. Since the 1960s, increasingly sophisticated techniques of epidural analgesia have been developed.5,12 Currently, 90% of Australian women having their first child have some form of pharmacological pain relief in labour.13-15 However, with the growth since the 1980s of a movement critical of the medicalisation of childbirth, opinions on the acceptability of pain relief in labour have become polarised. Now, instead of the doctrine of the divine necessity of pain in labour, we have the view that experiencing pain is a woman’s right, and that accepting analgesia diminishes the experience of childbirth. “The easy availability of analgesia”, says one advocate of this viewpoint, “can reinforce the medical notion that women’s bodies are intrinsically defective”.16 Not so, respond some obstetric anaesthetists — epidurals are “the gold standard ... you can participate in the experience, you can push the baby out, and it takes the pain away”.17 Had it been possible, Queen Victoria would almost certainly have ordered one. So, what advice should I give my daughter? The same that I would give all women. There is no right or wrong way to have a baby, be it in a stable or a tertiary-level hospital — there is just the best way for you. Epidurals are effective and safe, and available even on Christmas Day. Be well informed, keep an open mind, make the decisions that seem right for you at the time, and do not be tempted to regret them later; the most important thing is a healthy baby and a healthy mother. We will welcome our Christmas arrival with joy.

Caroline M de Costa MPH, FRCOG, FRANZCOG

Objective: To determine the live birth rate following surgical reversal of sterilisation in women aged 40 years and older.Design: Retrospective cohort study of pregnancy outcome following day surgery microsurgical reversal of sterilisation performed by two reproductive microsurgeons in the private sector.Setting and patients: 47 patients (aged 40 years or older) who had reversal of sterilisation performed between 1997 and 2005 in Adelaide, South Australia (n = 35), or the Infertility Centre of St Louis, Missouri, USA (n = 12).Main outcome measures: Independently audited live birth surviving the neonatal period.Results: Of the 47 patients on whom follow-up was obtainable from the two centres, 19 (40%) had a live birth, 7 had had only a first trimester miscarriage at the time of follow-up, and 21 (44%) had failed to conceive. Age at conception ranged between 40 and 47 years. Two women had two live births following surgery. The total direct costs (Australian dollars, adjusted to 2005) in Australia were $4850 per treatment, and $11 317 per live birth. The corresponding direct cost of a single cycle of in-vitro fertilisation (IVF) in Australia has been estimated at $6940, with a cost per live birth of $97 884 for women aged 40–42 years and $182 794 for older women.Conclusion: Previously sterilised women wanting further pregnancy should be offered tubal surgery as an alternative to IVF, as it offers them the opportunity to have an entirely natural pregnancy. In settings where IVF is financially supported by government agencies or insurance, tubal reversal is a highly cost-effective strategy for the previously fertile woman.

Oswald M Petrucco FRCOG, FRACOG, CREI · Sherman J Silber MD · Sarah L Chamberlain · Graham M Warnes PhD, BAgricSci(Hons) · Michael Davies BA(Hons), MPH, PhD

To the Editor: O’Leary and colleagues1 rightly point to the need for better evidence on whether low to moderate maternal alcohol intake affects the fetus. Evidence to date is weak and inconsistent, largely because alcohol consumption in pregnancy is generally poorly documented,2 and few studies have recorded data on factors that could potentially modify fetal exposure. Evidence could come from large pregnancy cohort studies, usually designed to address other issues, but there are no published guidelines on how to collect information relevant to fetal alcohol exposure during gestation. There is, therefore, a great need to define a core dataset for research studies, as well as one that is sufficiently simple to use in routine pregnancy care settings. We have identified a number of issues that need to be addressed. To stimulate discussion, the Box shows our suggested core dataset. Maternal alcohol intake: Alcohol questionnaires have largely been designed to identify women who are heavy drinkers, misuse alcohol or are alcohol-dependent.3 Questionnaires are needed that capture information on alcohol intake across the range, from minimal to heavy drinking, as well as information on drinking patterns and alcohol intake at different periods of gestation. Factors that may modify the relationship between maternal intake and fetal alcohol exposure: For a given maternal intake over a given period, maternal blood alcohol level and hence fetal alcohol exposure may vary according to maternal size and body composition. Other factors can affect maternal alcohol absorption and elimination, such as whether alcohol is taken with food,4 and possibly maternal genotype.5 This information is rarely reported in pregnancy studies. Factors that may modify effects of alcohol on the fetus: There is animal evidence that maternal micronutrient supplementation may protect the fetus against some of the adverse effects of gestational alcohol exposure.6 We need to consider recording supplement use and measures of maternal nutritional intake or status. In well resourced studies, fetal genotype could also be considered.6 Researchers with expertise in the field need to reach consensus and provide guidelines on the best way to assess fetal alcohol exposure, so that pregnancy researchers and clinicians with little experience of alcohol research do not need to create their own. Better data should provide better evidence on which to base advice to women who are (or may be) pregnant. Good studies may also provide explanations for the apparently variable link between maternal alcohol consumption and adverse sequelae in the offspring. Suggested core dataset for studies of maternal alcohol intake during gestation and outcome of offspring As a basis for discussion, we suggest the folllowing dataset: Baseline Weeks of gestation at pregnancy recognition, or expected date of delivery and date that pregnancy was recognised (to allow calculation) Height For specific periods of gestation (eg, from date of start of last menstrual period until pregnancy recognition; from pregnancy recognition to 12 weeks’ gestation; from 13 to 28 weeks; and from 28 weeks to term) Body weight (eg, at 12 and 28 weeks) Alcohol intake — we suggest: Average number of standard alcoholic drinks per week; Average number of days per week on which alcoholic drinks are taken; and Maximum number of drinks on one occasion. Whether alcohol is taken with or soon after food (never, sometimes, usually or always) Dietary intake of fruit and vegetables Use of nutritional supplements

Ruth Morley · Jane L Halliday · Susan M Donath

To the Editor: I would like to put forward a consumer’s perspective in response to the recent article by O’Leary and colleagues.1 I am puzzled that they concluded that the National Health and Medical Research Council (NHMRC) guideline is in step with policies of the United Kingdom and Canada. My research of Canadian policy suggests that it is in direct contrast to current NHMRC guidelines. Health Canada states very clearly, “Whether you are trying to get pregnant or are pregnant already, stop drinking alcohol”,2 and “No amount or type of alcohol during pregnancy is considered safe”.3,4 The potential harm to the birth mother that results from an abstinence-based message was also raised by O’Leary and colleagues. Elizabeth Russell, the birth mother of two sons affected by prenatal exposure to alcohol, offers an alternative viewpoint: By not discussing alcohol and pregnancy through misplaced compassion, we are hurting one person for the sake of another. Very few mothers would want that but that is exactly what is happening — children are being sacrificed to ensure that the anxiety level of a mother is kept within acceptable limits — neither mother nor child will benefit from this methodology.5 Many pregnant women give up eating shellfish and processed meats and drinking coffee but still continue to consume alcohol, thinking it is safe because they have not been told otherwise. I would like to pose the following questions. What is the potential harm of not having an abstinence message? Might this prevent women who are alcohol-dependent from seeking help to alter their drinking behaviour when pregnant because they are not aware of the risks? Should further research to “elucidate the true association between low to moderate alcohol consumption and fetal harm” really be a priority? What are the benefits to the unborn child of trying to ascertain a safe level of consumption of a teratogen and neurotoxin that is known to disrupt fetal development, particularly the fetal brain, throughout the three trimesters of pregnancy?6 While I acknowledge the importance of scientifically sound research on the risks of prenatal exposure to alcohol, I am concerned that this argument is diverting attention and dollars away from the urgent need for diagnosis and management of fetal alcohol spectrum disorder (FASD) in Australia. The reality is that children, adolescents and adults with FASD are seldom recognised, seldom treated effectively, and seldom connected to service dollars. Addressing this situation needs to be the priority.

Sue Miers

In reply: Morley and colleagues and Miers raise a number of interesting discussion points. As we reported in our policy review, the Canadian, United Kingdom and Australian guidelines have similar intent but differ in emphasis.1 Health Canada’s policy position is that, although abstinence is the prudent choice, fetal risk is relative to the amount of alcohol consumed and is minimal with low levels of maternal alcohol intake. Australian policy addresses the same issues, with less emphasis on abstinence and more on avoiding intoxication and ensuring low-level alcohol consumption. Since our review was published, UK guidelines have been reframed to emphasise abstinence, but their message has not changed — they now place more weight on avoiding alcohol during pregnancy.2 We strongly agree with Morley and colleagues that screening for alcohol should be routine in all pregnant women, and that standardised items should be included in a core dataset.3 If this were implemented, Australia would be in a unique position to make a valuable contribution to alcohol and pregnancy research. Miers comments that research into the impact of low to moderate alcohol exposure during pregnancy should not be a priority, because it may direct “attention and dollars away from the urgent need for diagnosis and management of fetal alcohol spectrum disorder”. Although we agree that specialised clinical services are important — and lacking — in Australia, it is short-sighted to suggest that there is no need for further research to establish the true risks from low to moderate alcohol consumption. Rates of alcohol consumption in Australia are high: about 80% of women report alcohol consumption in the 3 months before pregnancy, 14% report binge drinking, while 47% report that pregnancy was unplanned.4 Many fetuses may thus be exposed to alcohol before women are aware they are pregnant. Unfortunately, many women are unable to stop drinking and may expose their babies to high alcohol levels. Health professionals need to have a true estimate of risk to the fetus and know what additional factors (eg, genetics and nutrition) may alter risk, and women deserve to be well informed. The need for research is well articulated by Morley et al. Research evidence in humans does not clearly indicate a risk to the fetus from low levels of alcohol consumption, and this has led to inconsistent policy.5,6 As we point out, the potential for harm from an abstinence message should be considered when Australian alcohol guidelines are reframed. Whatever the policy, it needs to be widely disseminated, in a “digestible” format, to health professionals and the community. Research being conducted at the Telethon Institute for Child Health Research is evaluating educational materials for health professionals about alcohol and pregnancy.

Colleen M O’Leary · Louise M Heuzenroeder · Elizabeth J Elliott · Carol I Bower

We describe three women who developed endometrial cancer after taking “bioidentical” hormone replacement therapy (HRT) to relieve menopausal symptoms. Although pharmaceutical HRT is a well established and tested therapy, little is known about the quality control, safety and efficacy of bioidentical HRT. Women should be advised to avoid bioidentical HRT, and those who continue to use it should receive regular endometrial surveillance. Clinical recordsPatient 1A 71-year-old non-diabetic woman had been on some form of hormone replacement therapy (HRT) since the age of 49 years. She took oral oestrone sulfate 1.25 mg daily and medroxyprogesterone acetate 10 mg for at least 10 days a month for 8 years. For the next 2 years, she used a 3.2% compounded topical progesterone cream (at a daily dose of “one level spoonful”). In December 1997, she had some irregular vaginal bleeding, which was investigated by diagnostic hysteroscopy and curettage. The tissue diagnosis was atrophic endometritis. Between June 1998 and July 2002, she used “bioidentical” HRT as troches. Each troche contained: oestradiol, 1.75 mg; progesterone, 300 mg; testosterone, 4.5 mg; and dehydroepiandrosterone (DHEA), 5 mg. The initial dose was half a troche per day, dissolved in the mouth. Between July 2002 and December 2004, she used one-eighth of a troche in the morning and one-quarter in the evening. Each troche contained: trieste (oestrone, oestradiol, oestriol), 3.0 mg; progesterone, 400 mg; testosterone, 1.5 mg; and DHEA, 5 mg. Early in 2004, she presented with several episodes of vaginal bleeding, and an ultrasonic scan revealed a thickened endometrial lining (combined thickness, 18 mm; normal for a postmenopausal woman is < 5 mm). Hysteroscopy confirmed a grossly abnormal endometrium with abnormal vascularisation. Curettage revealed a grade 2 endometrioid carcinoma. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The final diagnosis was stage IA, grade 2 endometrial cancer. Patient 2A 59-year-old non-diabetic woman, who had been menopausal from age 51 years, used “bioidentical” HRT as troches containing oestradiol, progesterone, testosterone and DHEA (doses unknown) from November 2001. From May 2003, she had noted continuous vaginal bleeding. An ultrasonic scan showed that the endometrial thickness was 19 mm. Diagnostic curettage in July 2003 confirmed a diagnosis of complex endometrial hyperplasia with atypia. She was referred to the Gynaecological Cancer Centre at the Royal Hospital for Women in September 2003, and underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. The final diagnosis was stage IB, grade 2 endometrial cancer. Patient 3A 54-year-old non-diabetic woman presented with irregular vaginal bleeding. She had been using troches made by a compounding chemist for several years (precise time unknown). This treatment had been commenced while she was still menstruating. The troches had contained varying doses of DHEA, oestrone, oestradiol, oestriol and progesterone (doses unknown). The troches were posted to her by mail and she was monitored by telephone conversations with a nurse. A pelvic ultrasound revealed a thickened endometrium; hysteroscopy and curettage showed a polypoid lesion at the fundus. Histopathology revealed grade 2 endometrial cancer. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, and the final diagnosis was stage IA, grade 2 endometrial cancer. DiscussionPharmaceutical HRT is a well established and tested therapy for the relief of menopausal symptoms such as hot flushes.1 The risks, benefits and adverse effects of pharmaceutical HRT have been established in large randomised controlled trials such as the Women’s Health Initiative study.2 For example, unopposed oestrogen is known to be associated with an increased risk of endometrial carcinoma,3 so a progestin is added to prevent this complication. Pharmaceutical progestins, when used appropriately, are very effective in preventing endometrial carcinoma.3 Pharmaceutical medications undergo rigorous quality control, safety and efficacy testing. In Australia, pharmaceutical medicines are regulated by the Therapeutic Goods Administration. In contrast to this, compounding chemists can “hand make” pharmaceuticals in novel delivery systems. Currently, these compounds are not directly regulated by the Therapeutic Goods Administration. Thus, little is known about the quality control, pharmacokinetics, safety and efficacy of these treatments. Compounded hormone replacement therapy is often termed “bioidentical” HRT. Typically, bioidentical HRT contains three oestrogens (oestrone, oestradiol and oestriol), progesterone, and androgens such as testosterone and DHEA, and is usually given either as cream rubbed onto the skin or as troches. Often, bioidentical HRT is monitored using blood or salivary levels of sex hormones. If the dose of progesterone is insufficient to prevent oestrogen-induced endometrial hyperplasia, then these treatments might cause endometrial carcinoma. When testing new HRT regimens, endometrial assessment is one of the most important safety endpoints. The usual method used for evaluating the endometrium in HRT trials is endometrial biopsy (usually performed every 6–12 months). In its guidelines to the pharmaceutical industry, the United States Food and Drug Administration recommends endometrial biopsies at the beginning and end of an HRT trial.4 Sometimes ultrasound can give additional useful information (endometrial thickness, polyps, fibroids etc). The current “gold standard” test for endometrial assessment is hysteroscopy and curettage. The three cases reported here raise the possibility that the oestrogen component of the troche was significantly absorbed but the dose of progesterone was inadequate, thereby causing endometrial hyperplasia. The North American Menopause Society has produced a useful discussion paper on bioidentical HRT,5 and it should be noted that the Australasian Menopause Society does not recommend the use of bioidentical HRT.6,7 Until this therapy has been properly tested, it may be prudent not to advocate bioidentical HRT and to perform endometrial surveillance (eg, annual transvaginal ultrasound and endometrial biopsies) on women who, despite counselling, continue to use bioidentical HRT.

John A Eden FRANZCOG, FRCOG, CREI · Neville F Hacker FACOG, FACS, CGO · Michael Fortune MB BChir, FRCOG, FRANZCOG

Mifepristone (RU486), which is used for early medical abortion, can only be obtained in Australia under the Authorised Prescriber legislation (Section 19[5] of the Therapeutic Goods Act 1989 [Cwlth]); two of the authors have permission to obtain, prescribe and administer this drug in Cairns, Queensland. From July 2006 to April 2007, 10 women who fulfilled the Therapeutic Goods Administration (TGA) criteria of “life-threatening or otherwise serious” indications underwent medical abortion with mifepristone/misoprostol, and 12 women conforming with abortion requirements of Queensland law, but not TGA legislation for mifepristone administration, had medical abortions with the less preferable methotrexate/misoprostol combination. Although it is now more than a year since the cross-party vote in federal Parliament in February 2006 confirmed wide support for the right of Australian women to a medical abortion, we believe we are at present the only medical practitioners in Australia with permission to use mifepristone. Obtaining Authorised Prescriber status from the TGA is of necessity a complex and protracted process, involving ethics committee approval and auditing, and regular reporting to the TGA. Because of the current restrictions, we believe that women seeking medical abortion in Australia face barriers not experienced by women in other comparable countries, and that drug manufacturing and distributing companies may be discouraged from seeking to market mifepristone in Australia.

Caroline M de Costa FRANZCOG, FRCOG, MPH · Darren B Russell FRACGP, DipVen, FAChSHM · Naomi R de Costa LLB(Hons), GradDipLegalPrac · Michael Carrette MB BCh, FRANZCOG · Heather M McNamee MB ChB, FRACGP

Is it me or my hormones? Understanding midlife change. 2nd ed. Margaret Smith, Patricia Michalka. Sydney: Finch Publishing, 2006 (278 pp). ISBN 187645174 2. We’ve all seen them in our practices: anxious women, bewildered or even frightened by the signs of the menopause transition. Perhaps they’re carrying the burden of family folklore; perhaps they’ve somehow managed to insulate themselves — even through pregnancy and childbirth — from a proper understanding of their own bodies; perhaps they’re shocked by these intimations of mortality. Hot flushes, night sweats and mood swings may have taken them by surprise. The loss of sexual desire or the experience of discomfort during intercourse may be evoking confused responses, ranging from self-doubt (“Am I still an attractive woman?”), to worry about the state of the relationship with their partner. For some women, patient listening and an assessment of their physical state (including, in appropriate cases, hormone therapy) may provide all the reassurance they need. For others, though, something more comprehensive is called for. For women who need detailed information — physical, emotional, sexual, social and even spiritual — about the menopause transition, this book is a godsend. Margaret Smith, a gynaecologist specialising in the menopause, and Patricia Michalka, a psychotherapist, have distilled their combined wisdom into a book that addresses one of the most fundamental questions raised by menopausal women: “Is it me or my hormones?” In a genuinely holistic approach, the authors explore the many symptoms and issues that sometimes confuse menopausal women to the point of despair. The case-study approach is handled warmly and with compassion: worried women will find it easy to identify with the stories in this book. We all know that the “one size fits all” approach flies in the face of common sense and our experience of the uniqueness of each patient’s situation. Is it me or my hormones? emphasises the need to take an individual approach, and to recognise that symptoms are rarely a sign of only one thing.

Sheila O’Neill

In 2002, when results of the Women's Health Initiative (WHI) randomised controlled trial of hormone replacement therapy (HRT) showed an increased occurrence of breast cancer and thromboembolism, up to two-thirds of women taking HRT stopped the therapy, often without medical consultation. Recent analyses of the WHI data and other randomised controlled trials suggest that, although there are potential side effects and risks involved in taking HRT, these may be reduced by: using lower HRT doses; minimising or eliminating systemic progestogens; using non-oral routes in some women; and initiating HRT in symptomatic women near menopause. When HRT is initiated near menopause for symptom control, there may be additional benefits (reduced fracture and cardiovascular risk) that outweigh the risks (which are not significantly raised in women under age 60 years). Older women with continuing symptoms should not be denied HRT if their therapy and risks are assessed on an individual basis and each patient is aware of the risks.

Alastair H MacLennan MD, FRCOG, FRACOG

To the Editor: A further reason for the differences in antenatal Down syndrome screening rates between urban and rural women, reported by Coory and colleagues,1 is likely to be the relative difficulties many Queensland women face in accessing abortion services. We are aware of several Queensland public hospitals that provide excellent antenatal screening services — testing for chromosomal abnormalities as well as providing the 18–20-week ultrasound scan for structural abnormalities. However, these hospitals do not offer subsequent counselling or abortion for women who make the difficult decision to terminate a pregnancy at this gestation, instead directing them to the private system. Some of these women are undoubtedly among the many Queensland women who travel interstate for abortions each year.2-5 First-trimester abortion is difficult to access for women in rural areas throughout Queensland. This is probably an important factor in women making the decision not to have early screening and/or chorionic villus biopsy, and possibly also a factor in doctors not offering it. Having to travel several hundred kilometres for the test, with the possibility of a further journey for an abortion, is beyond the resources of many rural women. We are in agreement with Coory et al that a majority of the population would support equity of access to services and equal choices for all women in the matter of antenatal screening for fetal abnormality. In fact, amniocentesis for chromosomal abnormalities has been available, with little controversy, for more than 30 years. If early antenatal screening is made available to all women, then it is reasonable to expect that appropriate counselling and access to safe, affordable abortion is also provided.

Caroline M De Costa · Cait Calcutt

To the Editor: Women of the remote Indian Ocean Territories (Christmas Island and the Cocos Islands [see map]) regularly question why their comprehensive obstetric service, allowing deliveries on the Islands, ceased in 1998. A study in 20051 aimed to provide answers for these women. There is one general practitioner on the Cocos Islands and two on Christmas Island. Previously, procedural GPs attended to most deliveries. Now, pregnant women must leave the Islands 4 weeks before their expected delivery. The financial, physical, emotional, and cultural costs of this are substantial. Reports published in 20022 and 20043 identified community concerns, but resisted recommendations to resume on-Island birthing, because of perceived low birth numbers and difficulty sustaining the skills of clinicians. Both studies relied on external birthing data, as the Indian Ocean Territories Health Service (IOTHS; administered by the Department of Transport and Regional Services) had not documented numbers of deliveries. The Alberton Report,3 extrapolating from Australian Bureau of Statistics (ABS) data, assumed that the population of children aged less than 1 year in a census year equalled the number of deliveries the year before. The ABS has a system to protect the confidentiality of small isolated populations and purposely does not report these numbers. The Bath Report2 relied on data from the Western Australian Midwife Notification System (MNS). The MNS reported 136 births to Island women from 1995 to 2004, while our study (Western Australian Centre for Remote and Rural Medicine)1 recorded 326 births. Thus, the MNS attributed only 41% of known births to Island women during 1995–2004, and only 23% during the period considered by the Bath Report. We believe that the MNS data shortfall occurred for two reasons. Firstly, women frequently provide their temporary mainland address on the MNS form for practical reasons. Secondly, one in seven women leaving the Islands to deliver their babies choose to give birth in a state other than Western Australia to be closer to family, and these births are not attributed to women from the Islands. The methods used by the Alberton Report, the MNS and the Bath Report result in underestimations of the number of confinements for Island women by up to 77%. It is regrettable that this situation has not been previously recognised or acknowledged, and that recommendations for the resumption of obstetric services by the IOTHS have repeatedly been based on incomplete data. If records of the numbers of births for Island women had been collected and considered by the IOTHS, Island families might again enjoy a comprehensive on-Island delivery service for low-risk pregnancies.

Susan Downes · Sally M Roach

Re: “Medicines and breastfeeding: information is available on safe use”, by Lisa H Amir, in the 7 May issue of the Journal (Med J Aust 2007; 186: 485). In the editing process, the last two sentences of the letter were altered, including removal of the author’s original emphasis on several words. The sentences should read “Medicines used during pregnancy are given safety ratings and the information is available online.5 Australian clinicians need similar guidance in relation to safe prescribing for breastfeeding women.” The author’s position at La Trobe University was also incorrectly given as “Lactation Consultant” rather than “Health Professional Research Fellow”. Her other positions (not included in the original letter) are General Practitioner at the Women’s Clinic on Richmond Hill, Melbourne, and Medical Officer at Breastfeeding Education and Support Services, Royal Women’s Hospital, Melbourne. The html and pdf versions of this letter have been corrected.

Lisa H Amir

Objective: To determine whether remoteness category of residence of Indigenous women affects the perinatal outcomes of their newborn infants.Design and participants: A population-based study of 35 240 mothers identified as Indigenous and their 35 658 babies included in the National Perinatal Data Collection in 2001–2004.Main outcome measures: Australian Standard Geographical Classification remoteness category, birthweight, Apgar score at 5 minutes, stillbirth, gestational age and a constructed measure of perinatal outcomes of babies called “healthy baby” (live birth, singleton, 37–41 completed weeks’ gestation, 2500–4499 g birthweight, and an Apgar score at 5 minutes ≥ 7).Results: The proportion of healthy babies in remote, regional and city areas was 74.9%, 77.7% and 77.6%, respectively. After adjusting for age, parity, smoking and diabetes or hypertension, babies born to mothers in remote areas were less likely to satisfy the study criteria of being a healthy baby (adjusted odds ratio [AOR], 0.87; 95% CI, 0.81–0.93) compared with those born in cities. Babies born to mothers living in remote areas had higher odds of being of low birthweight (AOR, 1.09; 95% CI, 1.01–1.19) and being born with an Apgar score < 7 at 5 minutes (AOR, 1.63; 95% CI, 1.39–1.92).Conclusions: Only three in four babies born to Indigenous mothers fell into the “healthy baby” category, and those born in more remote areas were particularly disadvantaged. These findings demonstrate the continuing need for urgent and concerted action to address the persistent perinatal inequity in the Indigenous population.

Simon Graham BIS · Lisa R Jackson Pulver PhD, MPH, GradDipAppEpi · Yueping Alex Wang MB BS; MPH · Paul M Kelly DTM · Paula J Laws BA(Hons) · Narelle Grayson BA(Hons) · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health)

It is well accepted that heavy alcohol consumption during pregnancy is a risk factor for fetal alcohol spectrum disorder, but research findings for exposure to low to moderate alcohol levels during pregnancy are equivocal, allowing a range of interpretations. The 2001 guideline from the National Health and Medical Research Council (NHMRC) for low-risk drinking for “women who are pregnant or might soon become pregnant” recommends fewer than seven standard drinks per week, and no more than two standard drinks on any one day. This position has polarised health professional and consumer opinion in Australia. The NHMRC guidelines on alcohol are scheduled for review in 2007. We surveyed the alcohol and pregnancy policies and clinical practice guidelines of Australia and six other English-speaking countries to identify current policy. Documents were obtained through Internet searches and direct contact with the relevant organisations. The policies and guidelines varied both across and within countries, and the NHMRC guideline, while not universally supported in Australia, is in step with the policies of the United Kingdom and Canada. Research is needed to elucidate the true association between low to moderate alcohol consumption and fetal harm, the impact of different policies on rates of maternal alcohol consumption during pregnancy, and any untoward outcomes of an abstinence message, to inform and underpin future policy development in Australia.

Colleen M O'Leary BSc, MPH · Louise Heuzenroeder BN, MBA, MPH, MHlthSc · Elizabeth J Elliott MD, FRACP, FRCP, FRCPCH · Carol Bower PhD, FAFPHM, DLSHTM

To the Editor: In his review of drug information for thyroid-related medications, Stockigt noted the “outdated advice that antithyroid drugs are not compatible with breastfeeding.”1 However, outdated product information is not unique to antithyroid drugs. Product information rarely states that the drug is safe or advisable for breastfeeding women. Many women receive medicines in the postpartum period: a UK study found that 54% of women were given a drug in hospital and 55% were given a prescription by their general practitioner.2 Yet many breastfeeding women who need medicines are being given incorrect advice, as illustrated by the experience of my podiatrist, Janet. Breastfeeding was going well when, at 4 months postpartum, Janet fell down a flight of stairs. Neither the ambulance officers nor the metropolitan emergency department registrar were willing to administer any pain relief except paracetamol (“unless you are prepared to wean”) — although Janet was in excruciating pain with a fractured 12th rib. At 7 months postpartum, Janet was hypertensive despite treatment. Regardless of her strong desire to continue breastfeeding, her GP and specialist informed her that she needed to change medication and therefore would have to stop breastfeeding. Janet’s case illustrates two issues: firstly, a breastfeeding woman was denied necessary medication because she was breastfeeding, and secondly, her infant was denied continued breastfeeding because of maternal medication. Apparently none of the health professionals sought expert help with decision making surrounding medicines and breastfeeding. Janet encouraged me to use her story to educate other health professionals. For the vast majority of maternal medications, the amount of medication an infant would receive through breastfeeding is less than 1% of an infant dose. In general, if the medication is safe to use in infants, it will be safe for the breastfeeding mother. Only a small number of medications are contraindicated during breastfeeding: these include antineoplastic agents, ergotamine, methotrexate, cyclosporin, and radiopharmaceuticals.3 Information is available about safe use of medicines while breastfeeding (Box). The sources listed in the Box have reviewed the available evidence on individual drugs and given recommendations on whether they are safe to use during lactation. In general terms, they have followed the recommendations for evaluating appropriateness of off-label medicines as suggested by a recent New South Wales working party.4 Medicines used during pregnancy are given safety ratings and the information is available online.5 Australian clinicians need to access such guidance in relation to safe prescribing for breastfeeding women. Sources of information on medicines for breastfeeding women Reference books Pharmacy Department, Royal Women’s Hospital, Melbourne. Drugs and breastfeeding. Melbourne: RWH, 2004 (available for sale: tel: 03 9344 2484) Hale TW. Medications and mothers’ milk. 12th ed. Amarillo, Tex: Pharmasoft Medical Publishing, 2006 (available for sale at: http://neonatal.ttuhsc.edu/lact) Websites Drugs and lactation database (LactMed), a new searchable website set up by the US National Library of Medicine (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT) World Health Organization. Breastfeeding and maternal medication (http://www.who.int/ child-adolescent-health/New_Publications/NUTRITION/BF_Maternal_Medication.pdf) Telephone advice Pharmacy departments of tertiary maternity hospitals Drug Information Centre, Pharmacy Department, Royal Women’s Hospital, Melbourne (tel: 03 9344 2277)

Lisa H Amir

To the Editor: Cryopreservation has been an integral tool in the development of modern assisted reproductive technologies, beginning with sperm cryopreservation in 1953 and extending to embryo cryopreservation in 1983, with the evolution of in-vitro fertilisation (IVF) and embryo transfer as a major tool in the treatment of infertility.1 Until recent times, however, there has been a lack of reliable cryopreservation methods for human oocytes. The world’s first recorded pregnancy arising from frozen oocytes occurred in Australia in 1984,2 and although occasional live births following oocyte cryopreservation were subsequently announced,3 it was another 11 years before more reliable protocols were developed4 — hundreds of live births have since been reported.5 The most common protocol follows that of embryo cryopreservation, using slow freezing with propanediol as the cryoprotectant, although rapid vitrification methods are also being developed. Reliable oocyte cryopreservation protocols are important for patients for whom embryo cryopreservation is unacceptable under some national laws or religions, and in whom there may be sperm collection problems or unexplained azoospermia during IVF procedures. We report four live births, one ongoing pregnancy, and an ectopic pregnancy following oocyte cryopreservation. Three of these cases involved religious opposition to embryo freezing. In each case, only two oocytes were fertilised fresh and the remainder frozen. No pregnancies resulted from the fresh embryo transfers, and the frozen oocytes were subsequently thawed, fertilised, and transferred, to produce the pregnancies. Two cases involved idiopathic azoospermia on the day of IVF, while in another, no sperm could be obtained from testicular aspiration on the day. Oocytes from these men’s partners were frozen until the sperm supply problems were resolved. As these cases demonstrate, oocyte cryopreservation can serve as a valuable adjunct to assisted reproduction programs, by providing a solution to the occasional logistical problems caused by unavailable spermatozoa. It also provides another option for patients with ethical or religious objections to the cryopreservation of embryos, and for fertility preservation in women with cancer facing chemotherapy or for women who may wish to insure against age-related fertility decline. The six pregnancies described here arose from embryo transfers in 13 women who had oocytes cryopreserved. The results, combined with others achieved worldwide, suggest that oocyte cryopreservation may at last be coming of age.

Keith L Harrison · Michelle T Lane · Jeremy C Osborn · Christine A Kirby · Regan Jeffrey · John H Esler · David Molloy

To the Editor: My father, a retired general practitioner now 86 years old, continues to lament the fact that Latin terms have fallen out of use in medical practice. Even today, he can still recite the conjugation of Latin verbs without a mistake, and he likes to tell the story of how Latin helped a young teacher in the 1950s. Although World War II had made it acceptable for single and widowed women to work (but not for equal pay with men!), women who continued to work after getting married were considered to be “stealing jobs” from men who needed to support their families. Today, a pregnancy without a marriage certificate does not even cause a raised eyebrow, but, back then, it condemned a girl to a lifetime of discrimination and gossip. Single pregnant girls went to stay with distant relatives or went to religious homes for “wayward girls”. One day, a GP colleague of my father telephoned seeking advice. He had a young, single, very distressed teacher in his surgery and he had just confirmed her pregnancy. She had told an all too common story about being “unofficially engaged” to her university-student boyfriend and not having the money to get married. Apparently, on finding out about the suspected pregnancy, the boyfriend had decided that this was the time to end their unofficial engagement. The young teacher was still unsure whether to have the baby adopted, try to find a supportive relative, or bring up the child herself. The patient, being a full-time teacher with the Department of Education, was one of the few “lucky women” for whom society considered it acceptable to work and earn a living while married or with children. It was therefore very important that she keep her job. The medical certificate for her employer was to be a very important piece of paper. My father advised his colleague to put the following words on the patient’s medical certificate: “The patient is suffering from non-pseudocyesis and will be unfit for work for 3 months”. The colleague was delighted with this diagnosis. The teacher came to see her GP a short time later and reported that departmental leave had been approved and that her teaching colleagues had wished her well in her recovery. My father’s colleague continued to chuckle about the diagnosis and enjoyed providing the additional leave certificates until full-term delivery, when the non-pseudocyesis miraculously disappeared.

Katherine A Haley

Objective: To assess the evidence of an association between periconceptional folic acid (FA) supplementation or fortification of foods with FA and the risk of twinning, using the Food Standards Australia New Zealand (FSANZ) framework for assessing evidence when substantiating nutrition, health and related claims on foods.Data sources: The Cochrane Library Database, MEDLINE, MEDLINE in Process, EMBASE, PubMed National Library of Medicine, and CINAHL were searched to identify systematic reviews and primary intervention and observational studies published from 1 July 1994 to 7 July 2006.Study selection: One prospective and five retrospective cohort studies that assessed the rate of twinning in populations exposed to FA through supplementation, and six retrospective registry-based cohort studies examining twinning rates after fortification of foods with FA.Data extraction: Two reviewers appraised eligible studies and evaluated data independently.Data synthesis: The best maximal risk estimates of twinning after FA supplementation were an adjusted odds ratio (adjOR) of 1.26 (95% CI, 0.91–1.73) for preconceptional supplementation and dizygotic twinning and an adjOR of 1.02 (95% CI, 0.85–1.24) for overall twinning. Data from four FA fortification studies in the United States that allowed for calculation of an annual percentage increase showed a maximal annual increase in twinning rates of 4.6%.Conclusions: Overall, under the FSANZ framework, there is possible evidence for a relationship between periconceptional FA intake and increased twinning. To support this tentative relationship, more well designed, long-term follow-up studies are needed in places where fortification with FA has been introduced, focusing on dose–response and obtaining accurate data on infertility treatments.

Evelyne E Muggli MPH · Jane L Halliday PhD

New national guidelines recommend that women who choose to drink alcohol during pregnancy “should have less than seven standard drinks” in any week and “no more than two standard drinks” on any one day, and that they should never become intoxicated. Exposure to alcohol at these recommended levels has been shown to affect brain development and certain behaviours in animals. Some longitudinal studies in human children have detected detrimental affects from exposure to low levels of alcohol. Normal public health standards for exposure to environmental toxins should be applied for the unborn baby. We do not know what level of alcohol exposure is safe and pregnant women can only be advised to abstain.

John S Whitehall FRACP, MRCP, DCH

Major changes to the screening environment dictate a review of this successful program Internationally, cervical cancer prevention programs based on cytological surveillance have been among the most successful public health achievements in modern history. Almost all developed health jurisdictions have tackled the world’s second commonest cancer among women, and implemented successful screening programs. The achievements within each country have been variable, and Australia now has the lowest mortality and second lowest incidence in the developed world1,2 (see Box). However, Australia’s achievements did not come without considerable effort across the community. In the 1980s, many observers noted that ad-hoc screening in Australia was not achieving its potential in cancer prevention. This concern led the Australian Health Ministers’ Advisory Council (AHMAC) to establish a consultative committee, which in turn issued a critical, insightful and comprehensive review of cervical screening and made substantial recommendations to improve the program.1 The report was accepted by AHMAC, and a long process of substantial change began. The AHMAC recommendations involved the historic adoption of a national screening policy in 1991, active recruitment of women for screening, the development and implementation of quality measures across the screening pathway, the establishment of cervical cytology registers in all states and territories, and the endorsement of clinical practice guidelines for the management of screen-detected abnormalities. The success of these changes relied on broad consensus, collaboration and cooperation across the public and private sectors and state, territory and national jurisdictions, and also on the commitment of a broad range of stakeholders. In this issue of the Journal, Canfell and colleagues show that these achievements have been mirrored in the United Kingdom, where similar proportional reductions in incidence and mortality have been noted.3 Nevertheless, absolute incidence and mortality rates in the UK remain substantially higher than those in Australia (Box).1 Since the progressive implementation of the Organised Approach to Preventing Cancer of the Cervix (as the program was titled) began in 1992, both the incidence and mortality of cervical cancer in Australia have been halved.4 Although calculations show that this translates to 1200 women each year whose squamous cancers are being prevented,5 success has come at a cost. Each year, two million women are screened, about 100 000 receive a report of an abnormal smear, and about 15 000 (mostly young) women undergo treatment for a high-grade lesion. Since the 1980s, much about cervical cancer prevention has changed. The appreciation that human papillomavirus (HPV) is the necessary cause of cervical cancer, and increased understanding of the epidemiology of genital HPV infection, the role of acute HPV infection as the cause of most low-grade cervical abnormalities, and the natural history of cervical cancer precursors have all demanded a change in our approach to this disease. Most significantly, a vaccine that successfully prevents the most significant HPV infections, most cervical abnormalities and most cervical cancers is now available through private prescription. An application for public funding of this vaccine is currently before the Australian Government. Despite the dramatic achievements described above, the recent history of introducing change has not been one of consensus and collaboration. An attempt to incorporate HPV natural history into clinical management algorithms through review of the National Health and Medical Research Council (NHMRC) guidelines6 led to widespread controversy in the clinical community.7 A universal mass vaccination program with the HPV vaccine is a cost-effective primary prevention strategy. Markov modelling shows that this will further reduce cervical cancer incidence and mortality, with accompanying substantial reductions in the morbidity associated with our current approach.8 Failure to implement a mass vaccination program will further exacerbate the inequities of access that have been historically associated with cervical cancer prevention in most jurisdictions, such as the lower participation rate for Indigenous women in the Northern Territory that is documented by Binns and Condon in this issue of the Journal.9 Notwithstanding this opportunity, substantial questions remain regarding implementation of the vaccine program. For example, how will the substantial cost of this vaccine be met, even if it is cost-effective? Should the existing cervical screening program be obliged to find savings to cover its cost? Can the current intensive screening program still be justified in a population of young vaccinated women, when the rate of abnormalities will be significantly lower, and the risks of screening will almost certainly exceed the benefits? How will Australia monitor the effectiveness of its vaccination investment? How will the state-based cytology registers incorporate vaccination status into their management recommendations? There are no current plans to establish or incorporate HPV vaccination into any existing register system. Unfortunately, little capacity is evident within current health infrastructure to address any of these issues. The current cervical screening program also has many issues to resolve. There are major questions about the capacity of the cytology workforce to continue servicing a cytology-based program.10 HPV testing offers potential for an efficient reorganisation of the current approach. The registers could contribute to a more organised approach by switching to a recall system where women would be individually recalled for their test when it was due rather than their current reminder system which acts as a safety net for women who are overdue in having the test. However, these changes require substantial cross-sector consultation and consensus. The Australian Screening Advisory Committee was disbanded in May 2006 following an AHMAC review of population health advisory structures. This leaves no national structures available to consider, promote or implement any change within the screening program. Canfell and colleagues seem to be suggesting that the national screening policy in Australia should be modified.3 When the environment of screening is so altered, broader changes are needed than a simple variation to policy on screening interval. Clinicians and consumers do not appear willing to accept any potential increase in cancer rates; they will quickly mobilise to resist such a change. Cervical screening survives on a complex interaction of emotional, professional and commercial interests which are intertwined and sometimes in conflict. Australia needs to undertake a comprehensive review of cervical screening and to carefully consider potential modifications to this outstandingly successful program. Perhaps it’s time in Australia for a “Reorganised Approach to Preventing Cancer of the Cervix”. International variation in incidence and mortality from cervical cancer for selected countries, 2002 Country Incidence per 100 000 women (ASR) Mortality per 100 000 women (ASR) New Zealand 10.0 3.2 United Kingdom 8.3 3.1 Sweden 8.2 3.1 United States 7.7 2.3 Canada 7.7 2.5 Australia 6.9 1.7 Finland 4.3 1.8 ASR = age-standardised rate (World Standard Population). Source: GLOBOCAN.2

Gerard V Wain FRANZCOG, CGO