Women's health

Objective: To compare cervical screening policy, screening uptake, and changes in cervical cancer incidence and mortality between Australia and the United Kingdom.Design: Analysis of screening registry data and national cancer statistics.Setting: In Australia, organised cervical screening was initiated in 1991 for sexually active women aged 18–69 years, with a recommended 2-yearly interval. In the UK, organised screening began in 1988 for women aged 20–64 years, with a recommended 3-yearly interval in most regions.Results: Estimated lifetime screening participation rates in 2001 were similar in the two countries, at 88% in Australia and 90% in the UK. For women who were screened and had a negative result, the median time to the next screen was 27 months in Australia and 38 months in the UK. At 39 months, equivalent proportions (74%) had been re-screened in the two countries, and by 60 months the re-screened proportions were 81% in Australia and 94% in the UK. From 1991–1993 to 1998–2000, the incidence of cervical cancer in women aged 20–69 years fell by 33% in Australia and 33% in the UK, and mortality from cervical cancer fell by 36% in both countries.Conclusions: After the introduction of organised screening, similar reductions in cervical cancer incidence and mortality were achieved in Australia and the UK. Therefore, the 2-yearly screening policy in Australia and the predominantly 3-yearly screening policy in the UK appear to have been of broadly similar effectiveness.

Karen Canfell DPhil · Freddy Sitas MSc(Med), MSc(Epi), DPhil · Valerie Beral FRS

Perinatal care at the borderlines of viability demands a delicate balance between parents’ wishes and autonomy, biological feasibility, clinicians’ responsibilities and expectations, and the prospects of an acceptable long-term outcome — coupled with a tolerable margin of uncertainty. A multi-professional workshop with consumer involvement was held in February 2005 to agree on management of this issue in New South Wales and the Australian Capital Territory. Participants discussed and formulated consensus statements after an extensive consultation process. Consensus was reached that the “grey zone” is between 23 weeks’ and 25 weeks and 6 days’ gestation. While there is an increasing obligation to treat with increasing length of gestation, it is acceptable medical practice not to initiate intensive care during this period if parents so wish, after appropriate counselling. Poor condition at birth and the presence of serious congenital anomalies have an important influence on any decision not to initiate intensive care within the grey zone. Women at high risk of imminent delivery within the grey zone should receive appropriate and skilled counselling with the most relevant up-to-date outcome information. Management plans can thus be made before birth. Information should be simple, factual and consistent. The consensus statements developed will provide a framework to assist parents and clinicians in communication, decision making and managing these challenging situations.

Kei Lui MB BS, MD, FRACP · Barbara Bajuk MPH · Kirsty Foster MB ChB, DRCOG, MEd · Arnolda Gaston MPH · Alison Kent BM BS, FRACP · John Sinn MB BS, FRACP, MMed(Epi) · Kaye Spence RN, BEd(N), MN, FCN · Wendy Fischer BA(Hons), RN, CM · David Henderson-Smart MB BS, PhD, FRACP

Men’s health needs, health beliefs, and health-related behaviour are different to those of women Our current research examining young men aged 15–44 years presents worrying epidemiological evidence — a picture of men dying prematurely of conditions such as ischaemic heart disease and cancer, at a time when screening and treatment for many of these diseases has improved (Box).1 This evidence suggests that these men are either not following health advice or not using health services soon enough for effective remedial treatment. Here, we argue that there is a need for health professionals to rethink service provision for young men. What is “men’s health”?Men’s health may be defined as “. . . any issue, condition or determinant that affects the quality of life of men and/or for which different responses are required in order for men (and boys) to experience optimal social, emotional and physical health”.2 This definition highlights that men’s health is concerned with a broader range of issues than specific diseases of the male reproductive organs. In general, epidemiological evidence suggests that men and women have different health challenges through the lifespan, with men consistently having the higher mortality across all countries surveyed from conception onwards.3,4 For most disease states, men appear to have a higher rate of premature death and are more susceptible to the effect of worsening socioeconomic status.1,4 Men’s poorer social and emotional wellbeing is also reflected in higher suicide rates;1,4 for example, in Australia, men are four times more likely than women to commit suicide in the age range 15–44 years (1206 male deaths and 291 female deaths in 2001).1 Men are also more likely to die from drug and alcohol misuse.4 If the health challenges facing men and women are different, then you might expect that there should be visible recognition of this in the way services are configured and the way health policy is framed. Similarly, if men and women differ in the way that they use health services, having one service for all is likely to end up serving men or women (or both) inappropriately. What do we know about men’s help-seeking behaviour?As interest in men’s health has grown during the past 5–10 years, there has been a corresponding increase in research suggesting that men do differ from women in their help-seeking behaviour,5-8 with sporadic and infrequent use of services, lack of engagement with health material, and a tendency to delay when faced with health problems of key concern. These problems appear most pronounced in younger men. We suggest there may be three main reasons for these findings and offer suggestions as to how services might be reconfigured. Firstly, men are not invited to engage actively with health services in the same way that women are from puberty onwards for non-illness related reasons (eg, within formal screening programs, and for contraception and antenatal care). This leads to men failing to recognise the range of health service provision available and its link with preventive health practices. Secondly, it can be argued that most health service provision is female-orientated, with services predominantly provided during the day, when men are more likely to work full-time, have less opportunity for flexible working, and are often in precarious employment where taking time off for visits to doctors may be perceived as a sign of vulnerability, by the men themselves and by their peers and employers. Thirdly, beyond these structural constraints, there is another difference between men’s and women’s health behaviour that merits consideration. How men and women manage their health and wellbeing is, in part, predicated on their own health beliefs and how these beliefs affect their health behaviour — whether these beliefs differ between men and women is, therefore, germane. For example, patterns of premature mortality among young men suggest that risk-taking is a significant factor, and rates of premature death from disease processes also implicate aspects of men’s lifestyles.1,4 But this question goes deeper: we need to explore both the intrinsic drivers of men’s behaviour and how society moulds men’s values, attitudes, and behaviour. It is widely accepted that the expression of masculinity is socially constructed and there are multiple masculinities.9 In Western cultures, there is a restrictive conceptualisation of masculinity, which limits men’s choices and appears to have a negative influence on their health.10 For example, at the individual level, gender roles may partially explain a variety of risk-taking behaviours (such as unsafe sex, binge drinking, and steroid and other drug use).10,11 In addition, stigma and the fear of discrimination may work against men with mental or physical health difficulties. Together with the social pressures relating to full-time work and the current work environments for men, the so-called benefits, or patriarchal dividend, that men are said to enjoy can also be a powerful negative force for men experiencing problems.10 Where do we go from here?As the mortality data confirm, men’s health is not as good when compared with women’s, but such direct comparison with the way women manage their own health may be inappropriate, as we are not comparing like with like. Thus, the challenge that men face with regard to their help-seeking behaviour is a complex issue,12 which is not amenable to a “quick fix”. The common perception that men are being stubborn, or in denial, about their health is clearly simplistic and, if it is true, may be as much a product of socialisation and how services are structured as it is about individual choice. Nevertheless, we cannot maintain the status quo and wait for some sort of “new man” to emerge — the current and future threats to men’s health are too pressing. The increases in skin cancer, in young male obesity with its related health risks, and in substance use all suggest a pressing need to target the young man. There is already considerable recognition within Australia,13 as elsewhere, that men’s health requires specific attention and that health services and policy need to take this into account in making knowledge and services more accessible to men, for example, via specialist men’s health care clinics, and men’s health information nights held in men-friendly environments (such as pubs and sporting clubs) or the workplace.14 This work is already being taken forward through the ongoing activities of the Men’s Health Information & Resource Centre at the University of Western Sydney; the GPs4MeN group; the biannual National Men’s Health Conference; and, in 1997, the House of Representatives Standing Committee on Family and Community Affairs’ discussion of a National Men’s Health Policy.15 Nevertheless, as with many other countries, these initiatives have yet to permeate into mainstream action.16 The fact that a number of Australian organisations have begun implementing such innovations is to be celebrated; however, these approaches could be further developed. This includes tackling boys’ and men’s beliefs about their health from an early age through both formal education and more broad-based health promotion campaigns, with more focus on providing services and education through the workplace, as has been done successfully in Europe and the United States. For example, the Internet-based weight loss campaign run by the Men’s Health Forum in England with British Telecom workers saw 4000 men lose an average of 2.2 kg over the 6-week program. More fundamentally, there is a need for the public, the health care professions, and policymakers to recognise that men’s health needs, health beliefs, and health-related behaviour are different to those of women. The recognition of Men’s Health as a field of practice in its own right, to stimulate the development of research, debate, education and practice, would seem a prerequisite step. Patterns of mortality in young men and women Our study1 was the first international analysis of patterns of mortality in young men and women (aged 15–44 years). Data from 44 countries were considered using the World Health Organization Statistical Information Service Mortality Database. We found that men were at greater risk of premature death, with accidents and suicide being the key causes in the earlier years. Deaths as a result of disease processes became markedly more prominent in the 35–44 years age group.

Alan White PhD, RN · Helen J Fawkner BSc, MSc, PhD · Mike Holmes PhD

To the Editor: The current rate of caesarean sections in Australia (29% of all live births) is higher than the rate in other similarly affluent countries.1 In addition, the rate is continuing to increase; for example, it was less than 20% in 1993.1 Some commentators have suggested that this increase is partly a result of caesarean sections undertaken for non-medical reasons, such as patient demand.2,3 We examined trends in the rates of caesarean section for low-risk women using population-based perinatal data for Queensland over 15 years between 1990 and 2004. Our aim was to assess whether caesarean sections were becoming more common among women with no obvious medical indication for the procedure. The increase in caesarean sections among low-risk women was most dramatic in the private health care sector, where the percentage increased from 10% to 19% (Box). This represents an average annual increase of 4.6% (95% CI, 4.3%–5.0%). In the public health care sector, the increase was less — from 6% to 8% — an average annual increase of 2.4% (95% CI, 2.0%–2.7%). The increase in the private sector in Queensland was similar to the increase reported in the United States.4 The appropriate use of caesarean section, as for any medical intervention, should be based on evidence about the benefits and harm, with doctors, women and their families choosing a method of delivery after considering balanced information on potential outcomes of each method. There is continuing debate about the feasibility of randomised trials to clarify the benefits and harm of caesarean deliveries among low-risk women.2 Opposition to such trials is based mainly on ethical concerns about inflicting a surgical procedure on healthy women based only on randomisation. Non-randomised studies have compared outcomes of caesarean section versus vaginal delivery. However, their results are inconclusive because of the difficulty of distinguishing the effects of factors that influence the selection of delivery method from the effects of the delivery method itself (confounding by indication).3,5 In the absence of randomised trials, non-randomised studies that remove this potential bias by restricting the sample to women who remain at low risk throughout the pregnancy and delivery, according to clearly defined criteria, may provide useful information. They would need to assess both short-term and long-term outcomes. Until such better evidence is available, it is impossible to judge whether or not the current increase in caesarean section rates among low-risk women is desirable. Caesarean section rates among low-risk* women in Queensland, 1990–2004 * Low-risk births were defined as singleton, full-term (37–40 weeks’ gestation), vertex delivery with no reported medical risk factors or complications of labour or delivery, based on a list compiled by Declercq and colleagues.4 Women who had a previous caesarean delivery were excluded from the low-risk group.

Trisha C Johnston · Michael D Coory

To the Editor: The 2005 Cochrane review Home-like versus conventional institutional settings for birth1 has been cited in the public media to claim that birth centres are less safe than labour wards as there was an increased risk of a baby dying during or immediately after childbirth.2 This “headline-grabbing” statement is false. Firstly, this finding from the systematic review did not reach statistical significance.1 Secondly, the outcomes reviewed were related to the allocated place of birth, not the care provided. This fact is critically important, as 48% of women who were booked to have their baby in a birth centre did not give birth there.1 This is a predictable effect of the intention-to-treat principle. However, such high rates of “treatment contamination” negatively affect confidence in the study results.3 Additionally, the vast majority of baby deaths examined in the Cochrane review happened before labour and thus had nothing to do with care during childbirth. One might wonder whether there was a real increased perinatal mortality rate resulting from delayed transfers from birth centres.1 The analysis found 41 deaths in total, but only six that occurred in normally formed babies who reached term (these are the only babies who are eligible to be born in a birth centre). Three of these deaths were associated with birth centre care, and three with standard labour care. The interpretation of this Cochrane review raises questions about the validity of the underlying randomised controlled trials. In this experimental design, researcher control should ensure that people receive the specific treatment that was planned for them (treatment fidelity).4 The Cochrane handbook gives no guidance as to how to evaluate either the quality of the researchers’ definition of the planned treatments, or the fidelity between the treatments provided and the researchers’ plan.3 Most of the trials that formed the basis of the Cochrane review did not adequately define their treatments, nor adequately control the treatments provided to either group. It is not clear how the birth centre trials could sensibly be considered to have been scientifically controlled. The reviewers attempted to deal with this critical point by claiming that they were looking only at the effect of the “setting”, but their question clearly states that they were examining the effect of “care within a setting”.1 We conclude that the Cochrane review of the setting for birth is unreliable because of the weaknesses of the underlying trials. Rather than using questionable research to attack birth centres, it would be more constructive to engage in rigorously designed research that could provide robust evidence on the safety of all forms of maternity care, including standard medical care.

Kathleen M Fahy · Sally Tracy

In reply: Fahy and Tracy highlight the lack of high-level evidence about the relative safety of different models of maternity care. But in criticising the Cochrane review, it is important not to “shoot the messenger”. There is no doubt that the Cochrane review is not ideal but, like it or not, it remains the best evidence we have. The review of 8677 women in six randomised trials found a relative risk (RR) of perinatal death of 1.83 (95% CI, 0.99–3.38) in birth centres versus conventional institutional settings. In the 3332 pregnancies assigned to continuity of care by midwives who did not also work in conventional delivery suites, the RR was 2.38 (95% CI, 1.05–5.41).1 It would be fair to say that such findings should lead to real concerns about lack of safety rather than reassure the unbiased observer. Other published evidence has raised similar concerns. A retrospective review of over 183 000 low-risk births in Stockholm, Sweden, found a statistically significant fourfold increase in intrapartum fetal mortality in women planning birth centre care compared with those planning standard care (three intrapartum deaths in 3256 babies of women planning birth centre care versus 36 deaths in 180 380 babies of those planning standard care).2 The increase in intrapartum mortality was almost sevenfold for primigravidae. These findings led to evidence-based changes in the organisation of the birth centre involved to minimise the identified risks. To paraphrase Fahy and Tracy, rather than criticising the best available evidence reviewing birth centre outcomes, it would be more constructive to engage in rigorously designed research to assess how risk might be minimised in all forms of maternity care.

Andrew F Pesce

Objective: To assess the potential for dose-reduction of prophylactic anti-D postpartum.Design: Retrospective audit of fetomaternal haemorrhage (FMH) quantitation by flow cytometry.Participants and setting: 5148 consecutive Rhesus D-negative women aged 15–45 years who had FMH estimation by flow cytometry at a central laboratory in Western Australia in the 65 months between 1 August 1999 and 31 January 2005.Main outcome measures: Quantitation of FMH volume for adequate prophylactic anti-D administration in a timely fashion.Results: 90.4% (4651/5148) of the women had an FMH volume of 1.0 mL or less of Rh D-positive red cells, and 98.5% (5072/5148) had a volume of less than 2.5 mL. Only 0.4% of cases had an FMH volume of 6.0 mL or greater (range, 6.0–92.4 mL).Conclusions: This large retrospective audit shows that a currently available dose of 250 IU (50 mg) of anti-D would have been sufficient for 98.5% of the 5148 Rh D-negative women. On the basis of this evidence, a reduction in the recommended routine postpartum dose of anti-D from 625 IU to 250 IU when flow cytometric quantitation for FMH is available should be considered. Adopting such a strategy would ensure the ongoing provision of a valuable human blood product currently in limited supply.

Bradley M Augustson FRACP, FRCPA · Elizabeth A Fong BappSc, PGradDip(MBiol), GradDip(BCom) · Dianne E Grey FAIMS, BAppSc · Janine I Davies BAppSc, PGradDip(MSc) · Wendy N Erber MD, FRCPA

Objectives: To determine whether pregnant women and their newborns show evidence of iodine deficiency, and to examine the correlation between maternal urine iodine concentration (UIC) and newborn thyroid-stimulating hormone (TSH) level.Design: A cross-sectional study.Setting: Hospital antenatal care services (March–May 2004) and private obstetrician clinics (June 2004) in the Central Coast area of New South Wales.Participants: 815 pregnant women (≥ 28 weeks’ gestation) and 824 newborns.Main outcome measures: World Health Organization/International Council for the Control of Iodine Deficiency Disorders criteria for assessing severity of iodine deficiency (recommended levels: < 20% of urine samples in a population with UIC < 50 μg/L; and < 3% of newborns with whole-blood TSH level > 5 mIU/L).Results: The median UIC for pregnant women was 85 μg/L, indicating mild iodine deficiency. Almost 17% of pregnant women had a UIC < 50 μg/L, and 18 newborns (2.2%) had TSH values > 5 mIU/L. There was no statistically significant linear correlation between neonatal whole-blood TSH level and maternal UIC (r = − 0.03; P = 0.4). Mothers with a UIC < 50 μg/L were 2.6 times (relative risk = 2.65; 95% CI, 1.49–4.73; P = 0.01) more likely to have a baby with a TSH level > 5 mIU/L.Conclusion: The pregnant women surveyed were mildly iodine deficient. TSH values for their newborns were mostly within acceptable limits. Ongoing surveillance of the iodine status of NSW communities to establish trends over time is recommended.

Cheryl A Travers BSc, MPH · Kamala Guttikonda MB BS, FRACP · Carol A Norton BHSc, GDMid, MMid · Peter R Lewis MB BS, MPH, FAFPHM · Lyndall J Mollart RN, RM, MMid Studies · Veronica Wiley PhD, FHGSA · Bridget Wilcken AM, MB ChB, FRACP · Creswell J Eastman AM, MD, FRCPA, FRACP · Steven C Boyages PhD, DDU, FRACP

To the Editor: We now know the outcome of the parliamentary vote on mifepristone (RU-486), which restored responsibility for its use to the Therapeutic Goods Association (TGA). Politicians from both houses used their conscience votes to support the scientific scrutiny of medical abortion. van Gend will now be worried about Australian women “demanding” abortions.1 However, abortion on demand in Australia does not exist. I refer van Gend to state laws which specify under what circumstances termination of pregnancy can take place. In no state can women “demand” an abortion whenever, wherever or however they wish. Regulations exist in all states and territories and, as a family doctor, van Gend must be aware of the multiple requirements. While there remains a lack of clarity about various state laws,2 the current position in Australia is that termination of pregnancy is available under certain conditions and in particular cases. The attempt by the Minister for Health Tony Abbott to influence women’s decisions about abortion by providing Medicare-funded, church-affiliated counselling for pregnant women3 has only further entrenched the view that the Minister is not able to speak for the majority of Australians. The previous situation whereby any Minister for Health, rather than the TGA, had the power to decide on the safety and efficacy of new medications before their entry into the pharmaceutical market place was ludicrous. Despite the endorsement of science over theology in health, and potential access to medical abortion, we still have the freedom of our own conscience. No one can force medical practitioners to prescribe mifepristone and no one can force women to accept medical (or surgical) abortions. Morals in Australia are a private matter and these decisions should be left to individuals and their families. Who would decide the authenticity of the medical grounds for abortion, mentioned by van Gend — doctors or priests, or academic ethicists, or feminists? van Gend is clearly not in favour of women deciding. I agree that more attention should be paid to the reasons for women stating they do not want to continue with a pregnancy, and, yes, we could do more to assist them. But I do not agree that excluding non-medical reasons is the answer — which, as van Gend points out, are financial hardship, relationship problems, single motherhood, and a completed family. To many, these appear convincing reasons to choose abortion. While this may not sit comfortably with van Gend’s medical paradigm, the “non-medical” reasons include the mental health of the woman (see the Menhennitt ruling which stipulates that an abortion is lawful if a doctor believes that the abortion is necessary to preserve her physical or mental health).4

Suzanne Belton

In reply: Belton is correct that “safety and efficacy of medications” is a matter for the Therapeutic Goods Association. The dispute was whether such limited criteria can meaningfully assess a drug designed to take life. The government needed to consider higher criteria for RU-486 — its ethical and medical justifiability. Doctors needed to advise the government on justifiable indications for RU-486, in contrast to the corrupt practice of abortion for non-medical reasons. That advice was withheld. The Australian Medical Association advised only on the ethically neutral question of “. . . who is best qualified to scientifically assess the safety and efficacy of a drug”.1 Such marginalisation of ethical concerns is consistent with the AMA’s earlier response in the context of late-term abortion: “There is no place for third parties — governments, over-zealous politicians and lawyers, hospital committees, or even the spectre of legal action”.2 This assertion of unchallengeable medical power over an unborn life is wrong. Belton’s notion that the morality of abortion is “a private matter” is wrong; neither parents nor doctors are above the moral and legal prohibition on intentional killing. “The law in this state has not abdicated its responsibility as guardian of the silent innocence of the unborn”,3 even if medical leaders have.

David van Gend

Objective: To assess obstetricians’ antenatal screening practice for blood-borne viruses (HIV, hepatitis B and C viruses [HBV and HCV]) and knowledge about management during labour and risk of transmission via breastfeeding for infected women after an educational intervention.Design: Cohort study, with surveys before and after an educational intervention.Setting and participants: Survey 1 was mailed in 2002–2003 to all 767 Fellows registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Survey 2 was mailed in 2004 to the 743 of these Fellows who were still practising.Intervention: Multifaceted intervention with mail-out of survey results and a summary of recommended management, publication of two review articles in the RANZCOG journal, and an oral presentation at the RANZCOG annual scientific meeting.Main outcome measures: Self-reported frequency of antenatal screening for blood-borne viruses, change in practice based on a woman’s infection status, and advice given about risk of virus transmission via breastfeeding in Survey 2, compared with Survey 1.Results: Survey 2 (response rate, 68%) found increases from the previous survey in the proportion of respondents reporting they always offered antenatal screening for HIV, from 51% to 59%, and for HCV, from 60% to 69% (P = 0.001 for both). For women with HIV infection, the proportion of respondents always recommending elective caesarean section increased from 37% to 49% (P = 0.001) and always avoiding rupture of membranes increased from 33% to 49% (P < 0.001). The proportion who reported advising (incorrectly) that breastfeeding is associated with increased risk of transmission to the infant decreased from 34% to 25% for HBV (P = 0.01) and from 47% to 39% for HCV (P = 0.03).Conclusion: The frequency of antenatal testing for HIV and HCV is increasing in Australia. Knowledge about interventions to reduce mother-to-child transmission of HIV and knowledge of the risk of HBV and HCV transmission via breastfeeding improved after a relatively simple educational intervention.

Michelle L Giles FRACP · Suzanne M Garland FRCPA, FACSHP, MD, FRANZCOG · Sonia R Grover FRANZCOG · Sharon M Lewin FRACP, PhD · Margaret E Hellard FRACP, PhD

GPs can play an important role in helping women to realise their plans for a family You don’t think of a first-time, breastfeeding mum experiencing hot flushes, but that’s how my story begins. I was 40 years old when I conceived my daughter — and very easily, I might add. When Abby was about a year and a half old, my husband and I began trying to conceive a second child. Deceived by our luck the first time, we assumed we’d have no problem. Misguided by the prevailing advice, we persevered for 12 months before seeking professional help. When we finally did, my general practitioner advised that I discontinue breastfeeding even once a day, and, a month later, sent me to have my serum follicle-stimulating hormone (FSH) level tested. We might have reversed those steps because the results showed, at 98 IU/L, that I wasn’t conceiving, not because I had been breastfeeding, but because I was menopausal. The penny dropped — the sweatiness I’d been experiencing while still breastfeeding had been hot flushes. My doctor was as surprised as we were that menopause would follow so closely upon the heels of immediate conception and birth, but the results were confirmed. A fertility centre informed us that the only real option for conception was with donated eggs. And, fortunate as we were to have a friend to donate hers (Box 1), after three failed in-vitro fertilisation (IVF) cycles we have resigned ourselves to the reality that Abby will be our one and only child. That resignation is not without some resentment, however, that my GP, knowing that I was already 41 and trying to conceive, didn’t intervene with a fertility assessment well before a crucial year was lost. Given my age and very sporadic cycles (which naively I had attributed to my still once-daily breastfeeding), my chances of becoming pregnant were slim to remote1 and conception at that point called for a more aggressive strategy. At the age of 40, or even 35, a basic infertility evaluation has been recommended after 6 (rather than the usual 12) months of trying unsuccessfully to conceive,2 as has early referral to a fertility specialist.3 In fact, given my age, rather than prescribing birth control pills postpartum, as you might with a younger woman, a candid discussion about whether I intended to try for a second child, while perhaps awkward in those early days, could have been key to conserving my chances. Why wait?But isn’t it a woman’s own responsibility, and not her doctor’s, to begin a family while she’s still fertile? Perhaps, but what if she lacks accurate information about how long to expect to remain fertile? The current trend to delay childbearing is the result of many factors.4 Maybe I did take my mother’s admonition not to marry early a bit too far — but not by choice. I was eager to start a family and would have done so well before turning 40 if I had I found a suitable partner. And I was in very good company. A full 50% of women surveyed at Monash IVF reported that they had delayed childbearing because they lacked a partner.5 Another study found that many women delay childbearing in favour of establishing careers, relationships and financial security (often believing fertility treatments will be available as a “backup” if needed).2 And if we take into consideration the tendency of women to overestimate their window of fertility,6 or to be unaware of the relationship between age and fertility,5 we can only expect my experience to be repeated many times over. I am writing this article to give a wake-up call to GPs and family planning professionals and to urge them to proactively address a suite of problems related to the rapidly ageing population of women seeking to become mothers for the first time. I hope that, in this way, my experience may help to prevent similar “missed conceptions”. “Positive” family planningThe feminist movement that helped to shape me and my choices was itself shaped by women escaping the confines of the traditional roles of wife and mother. Largely because of this, an emphasis has been placed on “negative” family planning — helping women to prevent unwanted pregnancy or to control the number and timing of children. Contraception and the availability of affordable, legal abortion have meant that women have been free to develop other important dimensions of their lives, such as robust careers and relationships, before having children. But times have changed — again. Years down the track, major advances in women’s ability to break through professional “glass ceilings” and the perception that we can extend indefinitely our ability to become parents have contributed to a growing number of women reaching “biological ceilings” that are even more difficult to break through. It is therefore now time that “positive” family planning be promoted as well. Health practitioners, particularly GPs, now need to provide guidance about the waxing and waning of fertility, preconception care and protective fertility — conception as well as contraception.7 A partnership between government, GPs and their representative organisations, as well as the family planning community, could help to educate women to have a more realistic understanding of their reproductive lifespan, enabling them to make more informed choices. Because although there may be many women who would not be surprised to find themselves infertile at 42, there are others, some as publicly prominent as ABC Television’s Virginia Haussegger, who have been as surprised as I was.8 The “misconception” seems to prevail, consciously or unconsciously, that we can expect to be able to naturally conceive throughout our forties, or if we can’t, that we can expect IVF treatment to “fix it” for us.6 And the truth is, not only does fertility take a nose-dive at about 30 years of age, but the success of IVF, as astounding as its results can be, dives as well (Box 2).7,10 Knowing betterThe media are teeming with fertility information. Books with names like What, no baby?,11 Inconceivable12 and Hot flashes, warm bottles13 have been published in recent years describing women’s experiences of meeting the challenges of subfertility, of being older first-time mothers, and of dealing with the social problem of infertility. While one news article might bust the “you can have everything” myth and report on the challenges of age-related infertility, another may announce a “miraculous” birth at 60, perpetuating the evergreen fertility myth still further. In the absence of individualised guidance by GPs, patients (as in many areas of medicine) arm themselves with information obtained on the Internet.14 Fertility consumers seek advice from sites such as the “Over 40 high FSH” discussion group (www.network54.com/Forum/53068) and “Mothers via egg donation” (www.surrogacy.com/online_support/mved). Such sites are replete with research, anecdotes and coaching about endocrinology, variations in protocols and success rates, and offer moral support to women wanting to take on the expertise of their reproductive endocrinologists, together with advice on how to discern valid treatments from quackery. Such sites also bring to the surface a widespread fervour relating to the desire to conceive, with some women willing to try almost anything to have a child. As in other areas, less scrupulous operators prey on this desperation and confusion. In another, parallel universe, new fertility innovations and studies are continually being reported in scientific and medical research. And while we medical consumers may be able to sift through to the best information on our own, how much more likely are we to find what we are looking for if we have the help of a GP who knows us? What’s a doctor to do?Because of their ongoing interactions with so many women, their knowledge and the resources available to them, GPs are uniquely well suited to convey from the medical world the current and reliable information a woman will need to realise her plans for a family — whether or not to have one, its timing and its size. GPs can play a central and vital role in educating women patients about our fertility’s natural expected lifespan while there is still time to act on it.5 Perhaps this is more important than ever, given the federal government’s recent attempts to restrict Medicare-funded access to assisted reproductive technology — especially for older women.15 The first step involves a doctor’s willingness to broach the subject. And if most Australian doctors are not inviting patients to discuss their family plans, they would not be alone. In one German study, many of the GPs surveyed viewed infertility as a private matter.16 In a related study of GPs and their infertile patients, most GPs did not ask childless patients about their plans to have children, even though 25% of infertile women and 50% of infertile men said they would prefer their doctor to raise the issue.17 Beyond that, I offer some suggestions for what GPs and others can do (Box 3). ConclusionThe growing tendency of women to delay parenthood either by choice or circumstance has implications as we have discussed for the likelihood of successful conception, for the wellbeing of the mother compressing her fertility, and for the children.21 It has repercussions not only for the individuals involved, but on the overall fertility rate.22 Sadly, there is cause for concern that patients may now be bypassing GPs and going directly to fertility specialists.23 This would be an unfortunate trend likely to lead to more heartbreak, more unnecessary individual and public expense and less holistic and continuous care for the woman or couple involved. All of these factors provide compelling reasons for GPs to engage in “positive” family planning by helping younger women to grasp the biological imperative to start their families earlier and helping older women to salvage their residual fertility. Of course, “positive” family planning will not solve all fertility problems. It will not be a treatment for endometriosis, chlamydia or polycystic ovaries. It will not necessarily help women to choose suitable partners during their more fertile years (although it may sharpen their focus). And it will not, in itself, effect the industrial and societal changes required to relieve mothers of the burden of having to compromise their professional lives so much more than fathers do. What it will do, however, is give women the information and tools they need to plan and create families responsibly. 1 Donor’s superovulation ultrasound image 2 Live births per transfer for ART cycles using fresh embryos from own and donor eggs, by ART patient’s age, 2002* ART = assisted reproductive technology. * Reproduced with permission from the US Centers for Disease Control and Prevention.9 3 “Positive” family planning* What an individual general practitioner could do When a childless woman comes for a health check-up or for contraceptive advice or prescription, take the opportunity to refresh her understanding of her reproductive lifespan, discuss her plans for children and make contraceptive recommendations commensurate with those plans.18 Advise women over 35 of the technological advances available for helping to salvage residual fertility. For example: Ovarian reserve screening by transvaginal sonography to establish when a woman’s fertility window is likely to close19 and whether she is a candidate for in-vitro fertilisation (IVF);20 Ovulation tracking by blood testing; Cryopreservation of embryos (or eggs, when the technology to achieve that becomes readily available). What organisations could do Family Planning Australia and its local affiliates could draw from relevant courses they currently offer to doctors, nurses and others to address “positive” family planning, the growing problem of the postponement of parenthood and age-related infertility. With government support, the divisions of general practice could incorporate fertility into their women’s health priorities and assist with informational posters, brochures and other strategies. The Royal Australian College of General Practitioners’ Women’s Health Committee could incorporate fertility into their agenda and urge fertility updates in continuing education programs. In light of Australia’s declining fertility,4 rather than simply cutting off access to IVF at a given age, the government should launch an educational campaign that would help to prevent the need to spend such large sums on IVF. * Planning for conception rather than contraception.

Amy Bachrach BA

Delayed childbearing is not an issue to “keep mum” about For fertility specialists, there is no more difficult and depressing news to break to a woman seeking a baby than “Sadly, it’s too late. You’re menopausal.” In our experience, this situation is encountered with ever-increasing frequency as the age of first attempting to conceive increases. With 1% of the female population menopausal by 40 years and 5% by 43 years,1 and with many more perimenopausal, the rising number of disappointed older women is not surprising. Breaking the bad news requires compassion but realism. Pregnancies are extremely rare in “menopausal” women. Even for those still menstruating, a high follicle-stimulating hormone level in the early follicular phase sounds alarm bells. Pregnancy rates in such women are much less than 2% per cycle, even with “high-tech” approaches such as in-vitro fertilisation (IVF).2 How big is the problem of delayed childbearing?The average age of women bearing their first child in Australia has risen from less than 26 years in 1991 to nearly 30 years in 2003.3 First births in women over 35 years now account for 12% of all births, compared with 6% a decade ago — and those women are the lucky ones. The average age of women undergoing IVF treatment has risen from 31 years in 1993 to just over 35 years in 2003.3,4 The proportion of women commencing such treatment in their 40s has risen from 13% to almost 25% over the same period — that is, one in four women undergoing IVF treatment is at least 40 years of age. Why is childbearing delayed?Bachrach, in her Personal Perspective,5 raises the critical issues that lead to delayed childbearing — career goals, the perceived need for financial security, and/or delay in finding a long-term partner (either through distraction by the pursuit of personal development, or because of lack of interest from a man in forming such a relationship). While 20th century feminism carries significant responsibility for encouraging women to be more self-centred and independent, a changing male attitude to early childbearing also must be acknowledged.6,7 Life can be too much fun to be tied down by wife and children. What are the limits to what we can achieve?Belief in the ability of assisted reproductive technology (ART) to overcome the “biological clock” and achieve a pregnancy in most women and at almost any age is ill-founded. Despite great advances in ART (a woman at 40 years in 2006 now has the same chance of becoming pregnant with an IVF cycle as a 30-year-old woman in 1995),4 over 80% of women having ART treatment will not conceive in their first cycle. Even when a pregnancy occurs, older women have a substantially higher risk of miscarriage and fetal abnormality.4 One in six pregnancies miscarries in a 30-year-old, but by 40 years the risk is one in four. Down syndrome occurs in 1 : 1000 pregancies at 30 years of age but 1 : 100 pregancies at 40 years. The success of technology will always be limited and probably never be able to reverse the relentless deterioration in egg quality and number in the late reproductive years. What can the medical profession do?The general community certainly does not seem to sufficiently appreciate how age affects fertility. Our personal experience with referring general practitioners suggests that the concept of age affecting fertility is widely acknowledged but that the specific, current facts are not known, and there is some evidence to support this.8 Some GPs carry the message they learnt at medical school, that only after a year of trying is it appropriate to refer for help. This is fine for women younger than 35 years, but for older women, earlier referral should be the norm — even if only to confirm that there are no potential barriers to conception. As in Bachrach’s experience, blind reassurance for 12 months may be seen, in time, to have been a terrible mistake. We suggest that any GP, or appropriate other doctor, consulted by a woman over 30 years of age should initiate queries about any plans for parenthood. Doctors can educate women and their partners about the loss of fertility with increasing age and encourage early conception. Similarly, when a doctor sees a new couple over 35 years of age, the doctor should initiate a positive push to consider childbearing — if that is part of their life-plan — as a matter of some urgency.9 We need to reverse any view that raising this matter would be paternalistic or “not politically correct”.10 What can be done in the community at large?Increased public awareness of the risks of delaying childbearing is vital. Government concerns about the rising costs of ART could best be addressed by reversing the trend towards increasing age of first conception. We believe that a little money spent on education would be more than repaid by a reduction in the age-related demand for ART. In 2004, the Fertility Society of Australia initiated the concept of a national education campaign focusing on fertility preservation. As part of their presentation to the Abbott Committee on ART in October 2005, the Fertility Society of Australia and the IVF Directors’ Group urged the Committee to recommend the provision of federal government funding for the campaign. While it would cover many health issues that affect fertility (eg, smoking, obesity and sexually transmitted diseases), a major plank of the campaign could also be to encourage earlier childbearing. This would focus not only on women but also on men, who are often the procrastinating party.7 Barriers to the decision to seek pregnancy earlier need to be examined. For example, workplace reforms should encourage rather than discourage childbearing. Flexible hours and on-site, affordable childcare would bring women back into their jobs earlier and so assist in their desire to be successful on all fronts. But, ultimately, we need to spread the message that there are significant risks of long-term failure and disappointment if women delay attempts to conceive until they reach the age of 35 years or more. Early referral could potentially prevent the disappointment expressed in Bachrach’s Personal Perspective.5

Michael G Chapman FRANZCOG, MD, CREI · Geoffrey L Driscoll FRANZCOG, FRCOG, CREI · Bryony Jones MB BS, MRCOG

Carol Breeze,* Caroline M de Costa,† Mark Jagusch‡ * Senior Registrar, † Professor, Department of Obstetrics and Gynaecology, James Cook University School of Medicine; ‡ Director of Pathology, Cairns Base Hospital, PO Box 902, Cairns QLD 4870. caroline.decostaATjcu.edu.au To the Editor: The incidence of cervical cancer in Far North Queensland (FNQ) is 10 times the national average and the mortality rate five times greater.1,2 Of the Australian states, Queensland has the lowest average rate of regular cervical screening (57% of eligible women), and in some FNQ communities rates of less than 40% have been reported. Cairns Base Hospital (CBH) provides all public colposcopy services in Cairns and throughout Cape York for a population that is largely rural, remote and transient. In 2004, through the outpatients department of CBH, 12 new cases of invasive cancer were diagnosed (with additional advanced cases admitted directly to the surgical services). None of these women had undergone cervical screening in the previous 4 years. We conducted a three-part study at CBH: a 3-month retrospective study (Feb–Apr 2004) and a 3-month prospective study (Oct–Dec 2004) comparing cytological reports with histological results, and a further study (Oct–Dec 2004) of women who were referred for colposcopy but failed to attend. In the retrospective study, of 43 new patients with a cytology report of low-grade epithelial abnormality (LGEA) who had histology performed, 19 (44%) had a histological diagnosis of a high-grade epithelial abnormality (HGEA). (“Low-grade cytology” was defined in the 1994 National Health and Medical Research Council [NHMRC] guidelines3 as two consecutive “atypical” smears or one smear reported as cervical intraepithelial neoplasia [CIN 1], with or without the presence of human papilloma virus. CIN 2 or CIN 3 were defined as “high-grade” abnormalities.) In the prospective study, of 40 women with a cytology report of LGEA, 13 (33%) had HGEA on histopathology. Although our numbers were small, the incidence of histologically confirmed HGEA in patients presenting with LGEA on cytology appeared to be higher than the 24.5% reported by the Queensland Pap Smear Registry in 2000 for Queensland as a whole.4 Our colposcopy attendance study showed that, of 341 women referred for colposcopy over a 3-month period, 106 (31%) failed to attend scheduled appointments. Non-attenders included 27 Indigenous women, 10 women living only transiently in the area and 40 women living in remote areas. Thirty per cent of newly referred women and 32% of follow-up patients failed to attend, despite prolonged efforts by doctors, nurses and social workers to persuade them to do so (Box). (These proportions are substantially higher than those reported in clinics in large urban centres.5) Under previous NHMRC guidelines, women with reports of CIN 1 were immediately referred for colposcopy.3 However, under the recently adopted guidelines, such women are required to have at least one further smear 12 months later and demonstrate ongoing abnormality before referral.6 This policy assumes a stable, informed, compliant population with well motivated patients able to return for long-term follow-up. It also requires a reliable, non-labour-intensive system to track down non-attenders. In the FNQ region, with limited health care personnel, a population scattered over a huge area and patients often non-compliant (for many reasons, including social, financial, geographic and educational factors), we feel that the latest NHMRC policy is likely to be counterproductive, with the women most at risk possibly slipping through the net. We believe that in FNQ, and possibly in other rural areas where the incidence of cervical cancer is high, it may be appropriate to adapt the new national guidelines and continue with policies for managing LGEA that are more akin to the former guidelines. Breakdown of patients who failed to attend for colposcopy, by last-recorded cytology/histopathology results LGEA or less Possible HGEA HGEA Total number of non-attenders Newly referred patients (n = 157) 27 3 17 47 (30%) Follow-up patients (n = 184) 44 0 15 59 (32%) HGEA = high-grade epithelial abnormality. LGEA = low-grade epithelial abnormality.

Carol Breeze · Caroline M de Costa · Mark Jagusch

Multiple pregnancy, with its adverse outcomes, is a significant problem in assisted reproductive technology. Single embryo transfer (SET) is the only feasible solution for reducing the rate of multiple pregnancy. Many patients and some clinicians remain to be convinced that SET is a better clinical option. Adequate education, based on available evidence, is one important way to promote the use of SET.

Jim Wang PhD · Michelle Lane PhD · Robert J Norman MD

David van Gend Queensland Secretary, World Federation of Doctors who Respect Human Life, Mackenzie House Medical Centre, 116 Russell Street, Toowoomba, QLD 4350. vangendATmachousemedical.com.au To the Editor: As politicians prepare to debate the Therapeutic Goods Amendment (Repeal of Ministerial responsibility for approval of RU486) Bill 2005,1 one question is central: why should mifepristone require special approval from the Minister of Health and Ageing, when all other drugs are simply assessed by the Therapeutic Goods Administration (TGA)? The answer is that abortifacients such as mifepristone are unique in that they are the only drugs designed to end a human life, and therefore their use demands a unique level of ethical assessment and accountability, beyond the scope of the TGA. The TGA has the vital but limited role “to ensure the quality, safety and efficacy of medicines”. These criteria are adequate for assessing most medications, but inadequate for a drug designed to extinguish life. The TGA in its approval process does not consider ethical criteria.2 However, without broader ethical considerations, such as what medical conditions might justify the use of mifepristone, or the moral status of the life to be extinguished, no meaningful assessment of an abortifacient can be made. Abortion “on demand” (ie, without medical justification) is readily available in Australia, even where, as Judge Fred McGuire stated in a Queensland case: “There is no legal justification for abortion on demand”.3 Evidence for the predominantly non-medical justification for abortion was documented in a 1995 survey of women seeking termination of pregnancy in New South Wales.4 The most frequently listed contributing factor, given by 60% of the 2249 respondents, was “financial concerns”. Younger women were more likely to cite youth, career, single parenthood and changes to lifestyle, while women aged over 30 were more likely to cite completed family and problems in their relationship with their partner. Because abortion law is under state jurisdiction, the federal government has no stated position on abortion “on demand”. Now that it is being asked to authorise a drug for abortion, the government has the opportunity and responsibility to defend basic standards of law and ethics by limiting mifepristone use to medically essential terminations of pregnancy, excluding abortion for non-medical reasons. The government should establish, in consultation with medical authorities, valid medical indications for mifepristone, including certain cancers, hormonal diseases, and medically essential termination of pregnancy, and approve the drug for those uses. The criteria could be specified using the existing authority prescription mechanism. This would exclude abortions for which there is no medical indication; for this category, the compelling task for government and the profession is to address the underlying social stresses for which abortion is seen as a solution, reconstructing social supports for women distressed by unplanned pregnancy. Certainly, setting ethical parameters for the use of mifepristone will not affect the availability “on demand” of surgical abortion, which operates without effective ethical or legal restraint. Yet, even largely symbolic acts can be important. If it is right ethically and medically to set limits on the use of abortifacients such as mifepristone, these limits should be set. The medical profession should use the debate on mifepristone to reaffirm ethical limits on abortion, upholding our duty of care to both mother and unborn baby. Disappointingly, in the debate so far, leaders of organised medicine have limited discussion of mifepristone to sterile technical matters of safety and efficacy, as if ethical concerns have no bearing on public policy or medical practice.5 Much expert advice would be needed concerning authentic medical grounds for the use of mifepristone, and even then the authority prescription system could still be abused. But at least the attempt will have been made to establish valid medical indications for this gravest of medical acts, and the profession will be seen to distance itself from abortion “on demand”.

David van Gend

Further complications of the “obesity epidemic” The potential health burden to our community of escalating overweight and obesity is well documented and publicised. Attention has focused on the association with chronic diseases such as hypertension, diabetes, cardiovascular disease and all-cause mortality. The effects of obesity on reproductive function and outcomes have received less attention. The ability to conceive spontaneously is reduced by obesity. While many overweight women can conceive easily, they are over-represented among subfertile groups and those presenting with menstrual disorders.1 Overweight women, both with and without polycystic ovary syndrome, present with menstrual irregularity and anovulation more frequently than women with normal body mass index (BMI). The US Women’s Health Study concluded that even a slightly elevated BMI at age 18 was a risk factor for subsequent anovulatory infertility.2 Several studies have confirmed the association between obesity and reduced fertility.1,3 Elevated BMI is also associated with poorer outcomes from assisted reproduction.3 Obesity also affects pregnancy outcomes. The article in this issue by Callaway et al4 is an important and timely reminder of the high prevalence of obesity in women of reproductive age and the serious adverse effects of overweight during pregnancy. Risks are increased for both mother and baby. Maternal problems can result from pre-existing obesity-related illnesses such as hypertension and type 2 diabetes. The increased pregnancy-related risks of obesity include increased rates of miscarriage,1 gestational diabetes, pregnancy-induced hypertension, pre-eclampsia, thromboembolism, haemorrhage, caesarean section, sleep apnoea, wound infection and anaesthetic complications.5,6 These risks persist, even when adjusted for pre-existing illness. The offspring of overweight and obese women are more likely to require admission to neonatal intensive care and to have congenital abnormalities such as neural tube and cardiac defects. Birth-related injuries and fetal death in utero are also higher in this group, and babies are more likely to be macrosomic, placing them at risk of birth trauma and possible subsequent childhood (and, indeed, lifelong) obesity.5,7 What are the effects of weight loss on fertility and pregnancy outcomes? Weight loss alone often leads to improvement in conception rates. Clark et al,1 evaluating a 6-month diet and exercise program in overweight anovulatory women, found that participants in the program tended to lose weight and resume ovulation. Pregnancy rates, self-esteem and endocrine parameters improved, while rates of miscarriage fell. Seventy-eight per cent of the women conceived, with 67% achieving a live birth. Weight loss of dramatic proportions was not required — a relatively small weight loss (6–10 kg) could lead to resumption of spontaneous ovulation. The effects of weight loss on pregnancy outcomes have recently been reported by Dixon et al.8 Their prospective study sought to examine the effects of laparoscopic adjustable gastric banding (LAGB) in severe obesity. They concluded that “pregnancy outcomes after LAGB are consistent with general community outcomes rather than outcomes from severely obese women”. Callaway et al4 comment on the implications for health care delivery costs of obesity-related increases in maternal and neonatal morbidity. This problem will only worsen. The AusDiab study9 reported that the prevalence of obesity in 2003 was 2.5 times higher than in 1980. Moreover, obesity is occurring at a younger age, the problem increases with time, and women are becoming pregnant later in life.10 Solutions to such a complex problem will inevitably be multifaceted and costly. Callaway and colleagues recommend that maternal BMI should be recorded at the booking visit for all pregnancies. While this will assist in documenting the problem, any meaningful intervention must occur before presentation with an established pregnancy. Given the potential for adverse health outcomes for both mother and baby, and the potential lifelong effects of neonatal macrosomia, there is a pressing need for action well before conception. As part of general public health efforts to combat obesity, we strongly recommend pre-pregnancy counselling for all women, with every effort being made to intervene in the case of women who are overweight or obese. The majority of women are highly motivated to strive to have healthy babies, and the power of this commitment could well be used to achieve behavioural change that could have short-term (and potentially lifelong) benefits for both mothers and children.

Alison J Nankervis MB BS, MD, FRACP · Jennifer J Conn MB BS, MClinEd, FRACP · Rachael L Knight MB BS, MD, FRANZCOG

Objective: To assess the prevalence and impact of overweight and obesity in an Australian obstetric population.Design, setting and participants: The Mater Mother’s Hospital (MMH), South Brisbane, is an urban tertiary referral maternity hospital. We reviewed data for the 18 401 women who were booked for antenatal care at the MMH, delivered between January 1998 and December 2002, and had a singleton pregnancy. Of those women, 14 230 had an estimated pre-pregnancy body mass index (BMI) noted in their record; 2978 women with BMI ≤ 20 kg/m2 were excluded from further study; the remaining 11 252 women were divided into four categories: “normal” (BMI 20.01–25 kg/m2), “overweight” (BMI 25.01–30 kg/m2), “obese” (BMI 30.01–40 kg/m2) and “morbidly obese” (BMI > 40 kg/m2).Main outcome measures: Prevalence of overweight and obesity in an obstetric population; maternal, peripartum and neonatal outcomes associated with raised BMI.Results: Of the 14 230 women, 6443 (45%) were of normal weight, and 4809 (34%) were overweight, obese or morbidly obese. Overweight, obese and morbidly obese women were at increased risk of adverse outcomes (figures represent adjusted odds ratio [AOR] [95% CI]): hypertensive disorders of pregnancy (overweight 1.74 [1.45–2.15], obese 3.00 [2.40–3.74], morbidly obese 4.87 [3.27–7.24]); gestational diabetes (overweight 1.78 [1.25–2.52], obese 2.95 [2.05–4.25], morbidly obese 7.44 [4.42–12.54]); hospital admission longer than 5 days (overweight 1.36 [1.13–1.63], obese 1.49 [1.21–1.86], morbidly obese 3.18 [2.19–4.61]); and caesarean section (overweight 1.50 [1.36–1.66], obese 2.02 [1.79–2.29], morbidly obese 2.54 [1.94–3.32]). Neonates born to obese and morbidly obese women had an increased risk of birth defects (obese 1.58 [1.02–2.46], morbidly obese 3.41 [1.67–6.94]); and hypoglycaemia (obese 2.57 [1.39–4.78], morbidly obese 7.14 [3.04–16.74]). Neonates born to morbidly obese women were at increased risk of admission to intensive care (2.77 [1.81–4.25]); premature delivery (< 34 weeks’ gestation) (2.13 [1.13–4.01]); and jaundice (1.44 [1.09–1.89]).Conclusions: Overweight and obesity are common in pregnant women. Increasing BMI is associated with maternal and neonatal outcomes that may increase the costs of obstetric care. To assist in planning health service delivery, we believe that BMI should be routinely recorded on perinatal data collection sheets.

Leonie K Callaway MB BS(Hons), FRACP · Allan M Chang PhD, FRANZCOG · H David McIntyre MB BS(Hons), FRACP · Johannes B Prins PhD, FRACP

Objective: To estimate the risks of maternal and perinatal morbidity and mortality in a second pregnancy, attributable to caesarean section in a first pregnancy.Design and setting: Cross-sectional analytic study of hospital births in New South Wales, based on linked population databases.Participants: 136 101 women with one previous birth who gave birth to a singleton infant in NSW in 1998–2002.Main outcome measures: Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for maternal and perinatal morbidity and mortality.Results: 19% of mothers had a caesarean section in their first pregnancy. Compared with mothers who had had primary vaginal births, mothers who had had primary caesarean section and undewent labour in the second birth were at increased risk of uterine rupture (aOR, 12.3; 95% CI, 5.0–30.1; P < 0.0001), hysterectomy (3.5; 1.5–8.4; P < 0.01), postpartum haemorrhage (PPH) following vaginal delivery (1.6; 1.4–1.7; P < 0.0001), manual removal of placenta (1.3; 1.1–1.6; P < 0.01), infection (6.2; 4.7–8.2; P < 0.0001) and intensive care unit (ICU) admission (3.1; 2.1–4.7; P < 0.0001); among mothers who did not undergo labour (ie, had an elective caesarean section), there was a lower risk of PPH (0.6; 0.5–0.7; P < 0.0001) and ICU admission (0.4; 0.3–0.5; P < 0.0001). For infants there was increased risk of preterm delivery (1.2; 1.1–1.3; P < 0.0001) and neonatal intensive care unit admission following labour (1.6; 1.4–1.9; P < 0.0001) in the birth after primary caesarean section. The occurrence of stillbirth was not modified by labour.Conclusions: Caesarean section in a first pregnancy confers additional risks on the second pregnancy, primarily associated with labour. These should be considered at the time caesarean section in the first pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.

Lee K Taylor DRANZCOG, FAFPHM · Judy M Simpson PhD, CStat · Christine L Roberts DrPH, FAFPHM · Emily C Olive FRANZCOG, DDU · David J Henderson-Smart FRACP, PhD

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

S Rachel Skinner PhD, FRACP · Cindy Ng MB BS(Hons), DCH · Ann McDonald MPaed, FRANZCP · Tamara Walters FRANZCOG

The scientific benefit is clear, but translating this into practice requires advocacy Fourteen years ago, randomised controlled studies in the United Kingdom1 confirmed observational studies from Australia,2 the United States,3 and elsewhere, showing that an adequate intake of folic acid by women at around conception prevents most neural tube defects in their babies.4 These three countries now (i) have government-sponsored public health campaigns which encourage women of childbearing age to increase their daily intake of folic acid; (ii) have food standards permitting the food industry to voluntarily add folic acid to cereal and other foods; and (iii) have health benefit claims related to the prevention of birth defects. In 1996, the US (along with Canada) introduced mandatory fortification of virtually all wheat flour products. Despite recommendations by the National Health and Medical Research Council in Australia and other scientific bodies and scientists in the UK, mandatory fortification has yet to be introduced in these countries. Why should this be? After mandatory wheat flour fortification in the US, median serum folate levels in non-pregnant women of reproductive age more than doubled.3 Mandatory fortification has resulted in a 30% reduction of neural tube defects, or 1000 fewer cases every year.2 Each case of spina bifida prevented saves an estimated US$500 000 in lifetime costs.5 Even so, more could be achieved in the US compared with other countries where mandatory fortification requires higher amounts of folic acid to be added to flour than in the US.6 Examples include Canada7 (50% reduction in neural tube defects) and Chile8 (70% reduction). It is well past the time that the Australian and the UK governments should have drafted food standards with sufficient folic acid to provide 400 μg of synthetic folic acid a day to women of child-bearing age. In Australia, while the number of preventable cases (about 500 a year) has been reduced by voluntary fortification,2 this has not occurred across all of society, with resulting inequities.9,10 The reduction of cases of lifelong disability from neural tube defects has largely resulted from antenatal detection, with pregnancies being terminated (now the leading cause for late-stage termination of pregnancy in Australia and the UK). Preventing 500 neural tube defect cases each year in Australia would relieve the huge time commitment, financial cost and emotional burden from not only the affected individual, but his or her network of family, friends, work colleagues and other associates and caregivers. In the 10 years since we have known how to prevent neural tube defects, this would have meant 50 000 highly affected people in Australia alone. Folic acid fortification of flour is cheap — less than 0.1% the cost of flour (ie, less than 20 cents Australian per ton of flour). As thiamine is already a required additive, the costs of preparation and of administering quality control of the process, as well as of changing the labels on some foods, are small. Some millers and grocery companies in Australia do not favour mandatory flour fortification because they fear loss of market share for already fortified foods. However, a number of the largest milling companies, including Allied Mills and the Manildra Group, have publicly stated their support for mandatory flour fortification. The mandatory fortification of flour in the US not only prevents neural tube defects, but has also brought a wider benefit to the population, especially to older people beset with chronic and degenerative diseases. The exact degree of this benefit is still being defined, but current evidence indicates the increase in serum folate concentrations in the population is sufficient to prevent almost all folate deficiency anaemia.7 The association between lower risks for heart attack and stroke with lower homocysteine concentrations has been established.7 Since mandatory flour fortification with folic acid in the US, there have been about 17 000 fewer heart attacks and 31 000 fewer strokes.7 In addition, several recent scientific articles have credited folic acid supplementation with protection against loss of cognitive function in the elderly and Alzheimer’s disease,11 and against several cancers (including neuroblastomas). The benefits described above are clear and significant, but what are the perceived risks? One is the possibility of masking pernicious anaemia (the result of vitamin B12 deficiency) in the elderly and evolution of its neurological manifestations. Mild forms of dietary vitamin B12 deficiency in the elderly do occur, but there is no relationship between folate and vitamin B12 deficiencies. A second perceived risk is an increased risk of certain cancers, such as colon and breast cancer; however, there is mounting evidence that the overall risk of cancer is reduced, as the genome is less stable and at higher risk of mutagenesis when people are deficient in certain micronutrients, including folic acid.12 Since the US first demonstrated the benefits of flour fortification, more than 40 countries around the world have made it mandatory.13 Recently, leaders from over 50 key organisations formed The Flour Fortification Initiative, a United Nations-registered public, private, and civic alliance in support of the UN Millennium goals. With Australians in the forefront of this global movement, it is time that Australians at home also gain the benefit of this substantial public health measure. If there were a toxin (such as lead and mercury) or an infectious agent (such as the mad cow product) in the nation’s food supply, action would be swift and decisive. The ethical issue here is not what harm the mandatory fortification of flour with folic acid would do; rather, it is the harm inflicted each day that fortification is delayed by those who know how to prevent the damage from folic acid deficiency. In 2005, The National Institute of Clinical Studies Evidence-Practice Gaps Report14 identified mandatory folate fortification of flour as a key issue, and the Australian, New Zealand and UK governments will decide for or against this measure during the next 6 months. If the medical community will not rally and become advocates for this public health issue, who will? And at whose expense?

Glen F Maberly BSc(Med), MD, FRACP · Fiona J Stanley AC, FAFPHM, FRACP, FRANZCOG

Strict control of blood glucose levels should be pursued before conception and maintained throughout the pregnancy (glycohaemoglobin [HbA1c] level as close as possible to the reference range). Before conception: high-dose (5 mg daily) folate supplementation should be commenced; oral hypoglycaemic agents should be ceased; and diabetes complications screening should take place. Management should be by a multidisciplinary team experienced in the management of diabetes in pregnancy. Blood glucose monitoring is mandatory during pregnancy, and targets are: fasting 4.0–5.5 mmol/L; postprandial < 8.0 mmol/L at 1 hour; < 7 mmol/L at 2 hours. A first trimester nuchal translucency (possibly with first trimester biochemical screening with pregnancy-associated plasma protein A and β-human chorionic gonadotropin) should be offered. Ultrasound should be performed for fetal morphology at 18–20 weeks, if required, for cardiac views at 24 weeks and for fetal growth at 28–30 and 34–36 weeks. Induction of labour or operative delivery should be based on obstetric and/or fetal indications. Level 3 neonatal nursing facilities may be required and should be anticipated when birth occurs before 36 weeks, or if there has been poor glycaemic control. Insulin requirements fall rapidly during labour and in the puerperium. At this time, close monitoring and adjustment of insulin therapy is necessary.

Aidan McElduff MB BS, PhD, FRACP · N Wah Cheung MB BS, FRACP, PhD · H David McIntyre MB BS, FRACP · Janet A Lagström BSc, RM, GradCertDiabetesEd · Barry N J Walters FRACP, FRANZCOG · Jeremy J N Oats MB BS, DM, FRANZCOG · Peter Wein MB BS, FRANZCOG · Glynis P Ross MB BS(Hons), FRACP · David Simmons MD, FRACP

Medical termination of pregnancy with mifepristone, a progesterone antagonist, is available to women in North America, the United Kingdom, much of Western Europe, Russia, China, Israel, New Zealand, Turkey and Tunisia, but not Australia. Experience of mifepristone use in around two million abortions has shown that it is safe, effective, cheap to produce, and highly acceptable to women. Mifepristone is usually used in combination with a prostaglandin analogue, such as misoprostol; these drugs have been added to the World Health Organization’s list of essential medicines for developing countries. Availability of this drug in Australia might largely overcome many of the inequities of access to abortion, and is critical for many women in rural areas and women in some ethnic groups whose access to surgical abortion is limited.

Caroline M De Costa FRANZCOG, FRCOG

Results of a recent Australian trial suggest it is time to stop equivocating about screening and treatment The 1998 consensus guidelines on the management of gestational diabetes mellitus from the Australasian Diabetes in Pregnancy Society emphasised that, “due to a lack of good quality randomised controlled clinical trials in the area of [gestational diabetes mellitus], these guidelines are based on what is a reasonable consensus of informed opinion in Australasia”.1 The clear benefits of treating women with gestational diabetes according to these guidelines have now been demonstrated by the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS).2 This study randomised 1000 women with gestational diabetes to either routine antenatal care or to an intervention that comprised home glucose monitoring, review by a diabetes educator, dietitian and physician, and insulin therapy if glycaemic targets were not met. Serious adverse perinatal outcomes occurred in 1% of the intervention group versus 4% of the routine-care group (adjusted relative risk, 0.33 [95% CI, 0.14–0.75]). The percentage of infants who were large for gestational age was lower in the intervention group (13% v 22%), with no increase in those who were small for gestational age. Although induction of labour was more common in the intervention group (39% v 29%), rates of caesarean delivery were similar (around 31%). Measures of maternal quality of life were more favourable in the intervention group. To prevent one serious perinatal outcome, 34 women needed to be treated. The 1998 guidelines were equivocal in regard to screening for gestational diabetes, allowing either for universal screening or for selective screening based on clinical risk factors in relatively low-risk populations. In the light of the findings of ACHOIS, we believe that universal screening should now be accepted and implemented. There are multiple arguments in favour of this approach: Most women with gestational diabetes have no symptoms, and many have none of the classic risk factors associated with gestational diabetes.3 Screening based on risk factors adds an extra complexity to busy routine clinical practice and may lead to some women failing to undergo appropriate testing. Furthermore, ACHOIS patients were relatively “low risk”, being predominantly of European background, with a mean age of around 30 years, and a mean body mass index of around 26 kg/m2. Many would not have been tested based on risk factors. Nonetheless, the benefits of treatment were impressive. The precise level of hyperglycaemia that carries increased pregnancy risk remains to be defined. ACHOIS used as its inclusion criterion a 2-hour venous plasma glucose level on oral glucose tolerance testing ≥ 7.8 mmol/L but < 11.0 mmol/L. The women included in the study had a median fasting glucose level of 4.8 mmol/L and a median 2-hour glucose level of 8.6 mmol/L. The current Australian criteria suggest fasting and 2-hour cut-offs of ≥ 5.5 mmol/L and/or ≥ 8.0 mmol/L, respectively, for the diagnosis of gestational diabetes.4 To avoid the confusion which could occur if multiple sets of criteria were promulgated, we suggest that the diagnostic thresholds for gestational diabetes should not be revised until the blinded prospective international epidemiological study HAPO (Hyperglycemia and Adverse Pregnancy Outcome) reports its results, which are expected by mid-2007.5 Screening for gestational diabetes also offers benefits from a public health viewpoint, at a time of increasing prevalence of obesity and type 2 diabetes.6 Screening allows identification of women with undiagnosed type 2 diabetes and those at increased risk of developing this condition in the future. Detection of gestational diabetes has the potential to benefit not only the women involved, but also their children, through intervention.7 Preventing progression from gestational diabetes to type 2 diabetes is already considered cost-effective.8 Introduction of routine screening for gestational diabetes clearly carries cost and resource implications. The number of women diagnosed with gestational diabetes will increase, and appropriate provision must be made for their care. In ACHOIS, the intervention group received care from a multidisciplinary team, which generally comprised a dietitian, diabetes educator and physician, in addition to the obstetrician and midwives. This level of care is congruent with the 1998 Australasian guidelines, but may be difficult to implement on a large scale across Australia. Other models of care may be required, with increasing involvement of midwives, general practitioners and other health care providers. There is some evidence to support the efficacy of such treatment protocols.9 However, the ACHOIS data2 suggest that something more than “routine antenatal care” is required for optimal outcomes in this patient group. Therefore, less intensive models of care should be rigorously evaluated rather than promoted ad hoc on the basis of potential cost savings. The extra costs involved in providing optimal care for women with gestational diabetes are likely to be far outweighed by savings due to reduction in adverse perinatal outcomes. Evidence and recommendations on gestational diabetes Treatment for gestational diabetes substantially reduces adverse perinatal outcomes and improves maternal quality of life. Optimal proven treatment for gestational diabetes includes review by a diabetes educator, dietitian and physician, with insulin used if glycaemic targets are not achieved. Screening for gestational diabetes should be offered to all pregnant women. Maternity service providers should ensure that adequate resources are devoted to the detection and treatment of gestational diabetes.

H David McIntyre FRACP · N Wah Cheung PhD, FRACP · Jeremy J N Oats DM, FRCOG, FRANZCOG · David Simmons MD, FRACP

To the Editor: One of the great privileges in practising obstetric medicine is to support a couple through a successful confinement when they have previously been advised against attempting pregnancy because of pre-existing maternal disease. However, in some cases, pregnancy carries a substantial risk of morbidity and mortality to both the mother and infant. Indeed, many maternal deaths in Australia are still preventable,1 and underlying cardiac disease is an important cause.2 Recently, I was consulted for preconception counselling by a young woman with dilated cardiomyopathy. Based on the limited evidence in the literature, her risk of dying as a result of pregnancy would be greater than 25%.3 Similarly, I was recently involved in the care of a young woman with Eisenmenger syndrome who elected to terminate her pregnancy due to the 50% mortality associated with pregnancy with this condition.4 Pregnancy in young women with moderate renal failure carries a significant risk of permanent decline in renal function, along with a high risk of intrauterine growth retardation and prematurity for the baby.5 Organ transplantation offers the best hope for women in this situation, as pregnancy outcomes are excellent after solid organ transplantation (with the exception of lung transplantation). However, many women have organ dysfunction severe enough to compromise pregnancy outcome, but not to warrant transplantation.6 Pregnancy in the presence of maternal disease may also pose a substantial cost to the community. A 2001 study in the United Kingdom estimated the mean cost of pregnancy care for five mothers with severe cardiac disease to be £23 000, not including the cost of neonatal care.7 One mother and one baby died. Options for couples with pre-existing maternal disease are limited. In Queensland, they are excluded from adopting a child because they are not infertile and because of the mother’s medical condition. Altruistic surrogacy would allow them to have a child that is genetically their own without risking the mother’s and infant’s health. However, legislation on surrogacy varies significantly between Australian jurisdictions (Box),8 and, in Queensland, all surrogacy arrangements — both commercial and altruistic — are illegal. Thus, my patient with dilated cardiomyopathy faces prosecution if she were to attempt surrogacy anywhere in Australia while a Queensland resident, whereas it would be freely available to her if she moved 80 km south and became a New South Wales resident. I believe altruistic surrogacy should be available for women in whom underlying medical conditions result in a significant risk of morbidity or mortality associated with pregnancy. Legislation on surrogacy arrangements in Australia* Queensland: The Surrogate Parenthood Act 1988 (Qld) makes all arrangements relating to surrogacy illegal in Queensland, imposing criminal penalties on all parties involved in both altruistic and commercial surrogacy arrangements. Tasmania: The Surrogacy Contracts Act 1993 (Tas) makes it an offence to make or receive a payment or to publish any advertisement in relation to a surrogacy contract. All surrogacy contracts are void and unenforceable. South Australia: The Family Relationships Act 1975 (SA) makes it an offence to enter into a surrogacy contract for valuable consideration, and contracts are illegal and void. Australian Capital Territory: The Parentage Act 2004 (ACT) does not prohibit non-commercial surrogacy, provided no advertising or intermediaries are involved, and payments to cover expenses are allowed. Victoria: The Infertility Treatment Act 1995 (Vic) prohibits commercial surrogacy, and has complex criteria regarding eligibility of surrogate mothers. * New South Wales, Western Australia and the Northern Territory do not have surrogacy legislation.

Adam P Morton