Women's health

To the Editor: In a recent article, de Costa and Robson1 suggest that Australia’s high rates of caesarean surgery — currently among the highest in the Western world — may be beneficial, and causally related to our low perinatal mortality rate. In support, they cite a single article that reports the outcomes from three large hospitals in Dublin between 1979 and 2000.2 In these hospitals, as in most of the Western world, caesarean rates increased and perinatal mortality rates declined over this 21-year period. The authors of the article ascribe a causal relationship, but admit that “. . . it was not possible to allow for the confounding effect of time”.2 The time factor also confounds the interpretation of Australian data. Furthermore, results from an earlier Dublin study “. . . do not support the contention that the expansion in cesarean birth rates has contributed significantly to reduced perinatal mortality in recent years,”3 and there are many other articles with similar conclusions.4 Moreover, de Costa and Robson do not acknowledge the significant morbidity associated with caesarean surgery, nor the risks to mother and baby in subsequent pregnancies. A recent large retrospective cohort study in Scotland found that women whose first baby had been born by caesarean section had twice the risk of unexplained stillbirth at term in the subsequent pregnancy.5 There are also well documented increased risks of placental pathology (placenta praevia, accreta and percreta) in this group. Such problems are likely to increase in Australia in proportion to the increase in caesarean rate. I note also that King et al, who discuss maternal mortality in the same issue of the Journal, specifically mention the contribution of previous caesarean surgery to severe obstetric haemorrhage and emergency hysterectomy.6 They report that maternal death from amniotic fluid embolism occurred in association with induction in five of seven cases. Australian rates of induction and augmentation are among the highest in the Western world. Finally, as regards onus of proof, I agree with the statements by Enkin et al7 that “. . . the only justification for practices that restrict a woman’s autonomy, her freedom of choice, and her access to her baby, would be clear evidence that these restrictive practices do more good than harm; and second, that any interference with the natural processes of pregnancy and childbirth should also be shown to do more good than harm”, and “. . . the onus of proof rests on those who advocate any intervention that interferes with either of these principles”.

Sarah J Buckley MB ChB, DipObst

In reply: Buckley makes some important points regarding caesarean section, but overlooks the fact that our brief was to explore childbirth options from the viewpoint of the baby, not the mother. The Irish study of Matthews (a paediatrician) and colleagues took as its outcome measure deaths during pregnancy or within one week of birth of normally formed infants weighing > 2.5 kg.1 This was done because two of the main contributors to crude perinatal mortality rates (in Australia and other developed countries) are lethal abnormalities and very low birthweight — neither of which is likely to be improved by increasing caesarean section rates. More than 400 000 births over 22 years were studied retrospectively. While the time factor is acknowledged, the authors clearly show that as caesarean section rates have risen mortality among these normally formed babies of normal weight has fallen. They state that “. . . the caesarean section rate is an important part of the overall package of care delivered”, a “package” that includes the advances in antenatal surveillance and neonatal care of the past 22 years, as well as wider indications for caesarean section. The authors invite other centres to publish “similar matching caesarean section and mortality rates . . . to see whether some hospitals are capable of delivering packages of care that include low caesarean section rates (? < 15%) and perinatal mortality rates of < 1.5/1000 for normally formed babies of normal birthweight”. To date, none have done so, but there have been reports from other large maternity hospitals of similar findings to those of Matthews et al. One of these adds that “[our] low incidence of intrapartum hypoxic ischaemic encephalopathy (1.3/1000 births) . . . suggests that a policy of more liberal caesarean section may benefit babies in ways other than simply avoiding death”.2,3 In other words, this very large and careful study, and others resulting from it, strongly support the view that current caesarean section rates are good for babies.

Caroline M de Costa FRANZCOG, FRCOG

To the Editor: The article by de Costa and Robson1 is a timely reminder that the ideology and politics surrounding maternity services could have an adverse impact on Australia’s excellent record as one of the safest countries in the world in which to be born.2 de Costa and Robson highlighted continuity of care as the attribute of antenatal supervision and birthing that women value most highly, and they quote evidence of the safe care provided by a midwife or general practitioner in a “low-tech” environment. This type of care is currently provided by a diminishing number of GP obstetricians and midwives in small obstetric units throughout rural Australia, where continuity of carer ensures the continuity of care that leads to maternal satisfaction and good health outcomes. Data show a lower rate of adverse events in small rural hospitals compared with urban hospitals. Studies in diverse environments suggest communication breakdowns and handovers between multiple carers are major risk factors.3,4 These points of vulnerability are minimised in the close environment of a small rural hospital. National and international data demonstrate the safety of small rural maternity services,5 and yet rural obstetric units continue to be closed at an alarming and accelerating rate. The proponents of “de-medicalising” birth and improving maternal satisfaction through continuity of care are focused on perceived problems in the delivery of obstetric care in large urban hospitals. The evidence presented by de Costa and Robson confirms that women are most satisfied with care by a midwife and GP in a “low-tech” environment. While this option may now be unavailable in many urban areas, it is generally the model that exists in rural areas. Unfortunately, the politics of change is resulting in the application of urban- and ideology-based processes to rural maternity units, where they are often inappropriate and can lead to reduced support for rural procedural obstetricians. This is likely to result in the eventual closure of the maternity units — a situation in which women, their babies, local healthcare professionals and their communities will all lose out in the end. For rural communities, the risk in local maternity services is not to the standard of care, but to the continued existence of their services. Transferring alternative urban models of maternity care to country hospitals may be superficially attractive to budget-focused health authorities or ideologues, but it is rural people and their babies who will have to live with the consequences.

Graham M Slaney · Susan M Stratigos

Re: “Postnatal evaluation of vitamin D and bone health in women who were vitamin D-deficient in pregnancy, and in their infants”, by Thomson K, Morley R, Grover SR and Zacharin MR in the 1 November 2004 issue of the Journal (Med J Aust 2004; 181: 486-488). The first author’s name was incorrectly given as “Katherine Thompson”. The correct name is “Katherine Thomson”. The html and pdf versions of the article published in the eMJA were corrected on 30 November 2004.

Katherine Thomson MB BS · Margaret R Zacharin MB BS, FRACP · Ruth Morley BA, MB BChir, FRCPCH · Sonia R Grover MB BS, FRACOG

Objective: To determine the postnatal vitamin D status and bone health of women identified as vitamin D-deficient in pregnancy, and of their infants.Design and participants: Retrospective audit conducted between 27 August and 5 November 2003. The study included women delivering between August and October 2002 at the Royal Women’s Hospital, Melbourne, who had had a 25-hydroxyvitamin D (25-[OH]D) level < 30 nmol/L in pregnancy, and their infants at age 4–10 months.Setting: The outpatient clinic at the Royal Children’s Hospital, Melbourne.Main outcome measures: Maternal and infant serum levels of vitamin D, total alkaline phosphatase (tALP), parathyroid hormone (PTH), calcium and phosphorus; x-ray results in children with clinical or laboratory findings suggestive of rickets.Results: Of 69 mother–infant pairs invited to participate, 47 (68%) attended. All 47 women had 25-(OH)D levels < 50 nmol/L, and 39 (83%) had levels < 30 nmol/L. Vitamin D supplements had been prescribed in pregnancy for 35 women (74%), and 19/35 reported having taken them as prescribed. None had continued to take supplements postnatally, but one had recently started taking them again. Among 45 infants from whom blood samples were successfully obtained, 18 (40%) had 25-(OH)D levels < 50 nmol/L, and 14 (31%) had levels < 30 nmol/L. Twelve of 16 breastfed infants had 25-(OH)D levels < 30 nmol/L, compared with 2/29 fed formula milk (P = 0.001).Conclusions: Most mothers who had been vitamin D-deficient in pregnancy were also deficient postnatally, indicating that treatment offered, counselling and/or treatment compliance were inadequate. Their infants, especially if breastfed, were at high risk of vitamin D deficiency and increased bone formation. Breastfed infants of mothers at high risk of vitamin D deficiency should receive vitamin D supplements.

Katherine Thomson MB BS · Margaret R Zacharin MB BS, FRACP · Ruth Morley BA, MB BChir, FRCPCH · Sonia R Grover MB BS, FRACOG

Many maternal deaths in Australia are still preventable The recently released report Maternal deaths in Australia 1997–1999 is the twelfth in a series of triennial reports, spanning over 35 years.1 The maternal mortality ratio (MMR) for this triennium was 8.2 per 100 000 confinements — one of the lowest national MMRs in the world. The MMR of a country reflects, in part, the overall health of women, the quality of the maternity services, and women’s access to those services. For comparison, the MMR per 100 000 confinements for the United Kingdom over this period was 11.4 and for the United States (for the year 2000), 17.0; Sweden had the lowest rate (2.0).2,3 There are huge differences in MMRs between developed and developing countries, with about 99% of global maternal mortality occurring in Africa, Asia and Latin America. The World Health Organization estimated that, in the year 2000, the MMR for Sierra Leone was 2000 per 100 000, or one death for every 50 confinements, compared with Australia’s one death for every 8500.3 While it is easy to see the magnitude and urgency of the problem of maternal mortality in developing countries, what, if anything, can be learned from analysing the rare maternal deaths in countries such as Australia? The answer lies in the fact that mortality represents the “tip of the iceberg” of severe morbidity; for every case of mortality directly or indirectly caused by pregnancy or its management, there are probably 50 women who experience a life-threatening complication but survive with varying degrees of short- and long-term sequelae. Improvements in obstetric care, which result from considering maternal mortality, can therefore be expected to apply to a broad population of childbearing women and their infants.4 Australia has witnessed a one-third reduction in the MMR over the past 30 years, from 12.7 per 100 000 confinements in 1973–1975 to 8.2 per 100 000 in 1997–1999. Higher rates of maternal mortality are seen for older women and for Indigenous women (Box). The highest risk of death was among women aged 40 years and older, who form an increasing proportion of the childbearing population, and who are more likely to use assisted reproduction techniques for conception, with higher multiple pregnancy rates. The inequity seen in all-cause mortality among Aboriginal and Torres Strait Islander women is reflected in the higher MMR for this population, who, in this triennium, represented about 3% of confinements, but 8% of deaths. There were no deaths in the triennium from terminations of pregnancy. If estimates are correct that over 80 000 termination procedures are performed in Australia annually, then these procedures carry exceptionally low risks of serious perioperative complications. Several conditions warrant special mention. Obstetric haemorrhage is still the major direct cause of maternal mortality (deaths directly caused by complications of pregnancy or its management). A recent report from Victoria supports the clinical impression of an increasing incidence of emergency hysterectomy for severe obstetric haemorrhage, possibly related to the increasing proportion of women embarking on pregnancy after one or more caesarean sections, with an increased risk of the more severe forms of abnormal placental implantation — placenta praevia, accreta and percreta.5 This is another change in the characteristics of the obstetric population which warrants close observation through systematic and comprehensive maternal mortality analysis. The Australian and UK reports encourage maternity institutions to rehearse the management of simulated cases of obstetric haemorrhage, which is happening in some, but not all, Australian institutions. Amniotic fluid embolism was responsible for seven deaths in Australia in the 1997–1999 triennium. Although small numbers are open to overinterpretation, it is noted that, in five of these cases, labour was induced. There is community and clinical concern about adverse consequences of induction of labour, especially when undertaken for non-clinical indications. We reiterate the need for maternity units (of all sizes) to have disaster plans for the immediate management of the rare and unpredictable cases of amniotic fluid embolism, which usually present with acute syncope and haemorrhage. Thromboembolism and severe hypertension continue to be major contributors to maternal mortality, with six deaths in each category. Some of these deaths were considered preventable, and, with the trend towards more obesity, higher caesarean rates and women delaying childbirth into their 40s, awareness of the indications for perioperative thromboprophylaxis is increasingly important. Adherence to clinical practice guidelines for severe hypertensive disorders, including earlier specialist referral, would have prevented at least some of the six deaths from hypertensive disorders. Deaths related to cardiac disease and psychiatric illness dominate the category of indirect maternal deaths (deaths in which the pregnancy was complicated by pre-existing disease). Eight deaths due to psychiatric causes mirrored what has been found in the UK, where increasing numbers of maternal deaths are reportedly due to psychiatric conditions. Clinicians and the community need to be reminded about not ignoring or dismissing symptoms of depression, especially suicidal intent, during and following pregnancy.2 There is an emerging group of women at risk of maternal death — those who have had surgery for major congenital heart disease as infants or children, and who are now attaining reproductive age. These women are at risk of severe cardiac complications during and after pregnancy, and require sophisticated and multidisciplinary management. Despite a very low risk of death associated with pregnancy, no-one should claim that, in a country like Australia, mere survival rates could serve as an indicator of the quality of maternity services. However, because of the implications for the broader population of women experiencing pregnancy and childbirth, maternal mortality warrants continuing systematic ascertainment, and high-level investigation and reporting, with reasonable timeliness, so that recommendations are relevant to current practice. Key findings of Maternal deaths in Australia 1997–19991 The 1997–1999 maternal mortality ratio (MMR) was 8.2 deaths per 100 000 confinements, compared with 9.1 per 100 000 in 1994–1996. There were 90 maternal deaths: 34 direct, 28 indirect, and 28 incidental deaths. The main causes of death were obstetric haemorrhage (8 deaths), psychiatric disease (8 deaths), amniotic fluid embolism (7 deaths), and cardiac disease (7 deaths). The highest risk of death was seen in women aged 40 years and older (MMR, 23.2 deaths per 100 000 confinements, compared with 4.0 deaths per 100 000 confinements for those aged 20–24 years). The MMR for Aboriginal and Torres Strait Islander women remains three times higher than the MMR for non-Indigenous women.

James F King MPH, FRANZCOG, FRCSC · Emma K Slaytor MPH, BMedSci(Hons) · Elizabeth A Sullivan MPH, MMed, FAFPHM

Australia is now one of the safest countries in the world in which to be born. This is largely a result of the many advances in obstetric and neonatal medicine of the past 50 years. However, the “medicalisation” of birth has tended to diminish women’s satisfaction with their experience of childbirth. It has been shown that women are most satisfied by care from a single practitioner, and when they themselves have input into decision-making. Although maternal satisfaction is important, it should not be promoted at the expense of the health of mothers and babies. More realistic antenatal education and preparation should be available for all pregnant women so that both maternal satisfaction and good perinatal outcomes can be achieved.

Caroline M de Costa FRANZCOG, FRCOG · Stephen Robson MM, FRANZCOG, MRCOG

The National Diabetes in Pregnancy Advisory Committee (NDIPAC) is a multidisciplinary committee established in November 2000 by the Commonwealth Department of Health and Aged Care as part of the National Diabetes Strategy. On behalf of the NDIPAC, we present the first Australian consensus statement (endorsed by the Committee in February 2004) on diabetes control for women with type 1 or type 2 diabetes who are preparing for pregnancy: Women planning pregnancy should aim to achieve a target HbA1c value of < 7% (where the upper limit of the normal range for people without diabetes is < 6%) (If the normal range for people without diabetes is specified otherwise, the target HbA1c level should be < 1% above the upper limit of normal.) The following important qualifying statements apply: Women with diabetes should aim to achieve the best control of diabetes possible in preparation for pregnancy. This should include achieving blood glucose levels as close to the normal range as possible, while avoiding hypoglycaemia. Decisions about the precise glucose level targets to be achieved should be made on an individual basis, with collaboration between the woman and her healthcare team. Women who are able to achieve better control of their diabetes than the target value indicated above (eg, an HbA1c level of 6%) should be encouraged to maintain these levels in preparation for pregnancy. Other aspects of care are also important in preparation for pregnancy. These include healthy eating, taking folic acid supplements, and detection and treatment of other diabetes-related complications. It is recommended that tighter control of blood glucose levels (eg, HbA1c < 6% or within the upper limit of the normal range) be targeted once pregnancy is achieved to minimise the risk of pregnancy complications and long-term metabolic consequences for the child. These recommendations were made after reviewing and discussing the available data (the references listed here are a selection of the data sources considered the most relevant).1-15 The recommendations have now been endorsed by the Australasian Diabetes in Pregnancy Society, the Australian Diabetes Society, the National Diabetes Strategy Group and the Royal Australasian College of General Practitioners. The NDIPAC suggests that the recommendations be used to determine action strategies for improving outcomes in pregnancies complicated by diabetes. For example, they could be applied in: designing appropriate enhanced primary-care guidelines and target HbA1c levels for women in their child-bearing years; flagging pathology results (specifically, the HbA1c value in women of child-bearing potential) for action by treating clinicians; ongoing monitoring of pre-pregnancy glycaemic control using the framework of the National Diabetes in Pregnancy Audit Program (for more information, see the Australasian Diabetes in Pregnancy Society website, www.adips.org).

on behalf of the National Diabetes in Pregnancy Advisory Committee

Jeremy J N Oats,* H David McIntyre† (on behalf of the Australasian Diabetes in Pregnancy Society, in conjunction with the Women’s Health Committee of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists) * Clinical Director, Department of Women’s Services, Royal Women’s Hospital, Carlton, VIC; † Director, Department of Endocrinology, Mater Health Services, South Brisbane, QLD. jeremy.oatsATrwh.org.au To the Editor: Consensus guidelines for the management of gestational diabetes mellitus (GDM) were prepared by the Australasian Diabetes in Pregnancy Society in 1997–1998 and subsequently published in the Journal.1 Since that time, there have been two minor revisions to these guidelines. The first, in relation to the recommended frequency of follow-up testing of women identified as having GDM, was detailed in a letter to the Editor in 2002.2 The second concerns the timing of delivery of women with GDM. At the request of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the original recommendation that “continuation of the pregnancy in uncomplicated GDM to 10 days beyond term is acceptable provided that indications from fetal monitoring are reassuring” has been modified by replacing “10 days beyond term” with “full term” to bring this into line with current practice. The initial guidelines were arrived at by consensus of Australasian practitioners involved in the care of women with GDM. The Australasian Diabetes in Pregnancy Society recognised, both at the time and subsequently, that the level of evidence available to guide clinical decision-making fell well short of that necessary for a definitive statement on the timing of delivery. It is noteworthy that no international consensus exists concerning the optimal timing of delivery in pregnancies complicated by GDM. The American Diabetes Association, in its Clinical Practice Guidelines, recommends delivery “during the 38th week . . . unless obstetric considerations dictate otherwise”.3 The European Association of Perinatal Medicine does not make a recommendation, instead stating that “the optimal time of delivery and need to induce labour are still controversial.”4 There is currently a paucity of quality evidence on which to confidently base recommendations. We hope that current studies, such as the Australian Carbohydrate Intolerance in Pregnancy Study and the Hyperglycemia and Adverse Pregnancy Outcome Study,5 will provide this evidence.

Jeremy J N Oats · H David McIntyre

B E Christopher Nordin,* Allan G Need† * Physician, Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA; † Head, Division of Clinical Biochemistry, Institute of Medical and Veterinary Science, Adelaide, SA. christopher.nordinATimvs.sa.gov.au To the Editor: The article by Seeman and Eisman on treatment of osteoporosis1 not only neglects the pathogenesis and prevention of this condition, but also fails to appreciate the profound differences between the three main types of fragility fracture (peripheral non-hip, hip and spine). To say that adults lose bone with age because the “volume of bone resorbed is greater than the volume replaced” is a spectacular but common tautology which simply describes what would be expected from an external negative calcium balance. The common postmenopausal bone loss can generally be accounted for by the rise in calcium requirement due to a fall in calcium absorption and rise in obligatory calcium excretion.2-4 This can be corrected with hormones or compensated for with a calcium supplement, which is known to suppress bone resorption.5 In 20 trials of calcium therapy completed up to 1997, the loss of bone in 855 postmenopausal women treated with calcium was 0.3% per annum, compared with 1.0% per annum in 635 untreated control women (P < 0.001).6 In older women, this relative calcium deficiency is complicated by a decline in vitamin D status caused by reduced exposure to sunlight and progressive thinning of the skin. It has been known for 30 years that vitamin D deficiency is common in patients with hip fracture,7 for 20 years that this was also true in Australia,8 and for 12 years that vitamin D with calcium can reduce the hip fracture rate by 43% in 18 months in women in residential care.9 When it comes to established osteoporosis (the combination of low bone density with fracture), treatment needs to distinguish between the three main types of fracture referred to above. In hip fractures, surely the first priority must be to give adequate vitamin D and calcium. Most non-hip peripheral fractures occur in women with bone densities in the normal range,10 so the need for treatment is debatable unless bone turnover is very high. Vertebral fractures are a different matter. Unlike peripheral fractures, they do not “heal” in the usual sense — the deformity remains and often causes local pain and mechanical dysfunction. The recurrence rate is very high, because all the vertebrae have much the same bone density, and the osteoporotic collapse of one indicates that the others are ready to follow. This condition is notoriously difficult to manage and should almost be regarded as a medical emergency that requires full investigation — not least to exclude myeloma — and rapid, effective treatment. It is in the secondary prevention of these fractures that the remedies advocated by Seeman and Eisman probably have their main role and are most cost-effective. In fact, although the authors place great emphasis on prevalent fracture as a risk factor for further fracture, the reference they quote deals with prevalent vertebral fracture, not with prevalent non-hip peripheral fracture, where the evidence of benefit from bisphosphonates and raloxifene is very much weaker. We are arguing for much greater emphasis on the prevention of osteoporosis with adequate calcium after the menopause and adequate vitamin D in the elderly, and the use of appropriate investigation and selective treatment in the management of the condition when it is established.

B E Christopher Nordin · Allan G Need

Ego Seeman,* John A Eisman† * Professor of Medicine and Endocrinologist, Austin Hospital, Studley Road, Heidelberg, VIC 3084. † Professor of Medicine, and Director, Bone and Mineral Research Program, Garvan Institute of Medical Research, St Vincent's Hospital, Sydney, NSW. egosATunimelb.edu.au In reply: Our article concerned a discussion of evidence-based treatment for the prevention of osteoporotic fractures. Prevention of osteoporosis per se is important, but the approaches chosen must be evidence- based. Calcium supplementation may diminish, but not abolish, bone loss by reducing remodelling rate.1 Any association of a lifelong diet high in calcium appears to be with peak bone mass, not rates of bone loss,2 and may be attributable to differences in protein intake or physical activity. Despite opinion, meta-analysis of prospective, randomised, double-blind, placebo-controlled studies does not support a role for calcium supplementation in reducing fractures.3 Later rather than earlier intervention avoids needless exposure to treatment for large numbers of individuals at low absolute risk of fracture (ie, those who are unlikely to sustain a fracture even without treatment).4 Vitamin D is of course indicated in vitamin D deficiency. However, there is no evidence for anti-fracture efficacy of vitamin D in ambulant community dwellers.5

Ego Seeman · John A Eisman

Jessica H Ford,* Annette J Dobson† * Research Assistant, † Professor of Biostatistics, School of Population Health, University of Queensland, Herston Road, Herston, QLD 4006. A. DobsonATsph.uq.edu.au To the Editor: Helping pregnant women to stop smoking and not to resume after their baby is born is a key target for smoking prevention. Pregnancy (or trying to become pregnant) is a time when women are motivated to stop smoking for the sake of the baby and they are in contact with healthcare professionals who can help them do so. We have calculated the impact of smoking during pregnancy in terms of deaths, hospital separations and costs to the healthcare system, and estimated the extent to which these effects could be reduced through interventions initiated by healthcare professionals as part of routine clinical contact. We considered the following conditions: pre-eclampsia (which is less common among smokers), low birthweight (including hospital costs for the mother and the baby, and infant deaths), premature rupture of membrane, spontaneous abortion, ectopic pregnancy, placenta praevia (including infant death), and sudden infant death syndrome (SIDS). We used estimates of relative risks (RRs) for these conditions for women who smoke during pregnancy (or, for ectopic pregnancy, for women who might become pregnant) from meta-analyses.1-3 We obtained data on deaths,4 hospital separations,5 and costs to the healthcare system6 for 2001–02. The prevalence of smoking among pregnant women of all ages in New South Wales since 1994 has been in the range 17% to 22%.7 The prevalence of smoking among all women of child-bearing age in 2001 was about 28%.8 From these data, we calculated attributable fractions1,2,9 for average values (using point estimates for RRs and 20% for prevalence of smoking in pregnancy) and extreme values (using the 95% confidence limits for RRs and 17% and 22% for smoking prevalence). In summary, the average number of adverse events attributable to smoking each year in Australia are: infant deaths, 78 (extreme values, 66–87); hospital separations, 6890 (extreme values, 4130–9450); costs to the healthcare system, $23 million (extreme values, $16–$29 million). A Cochrane review of behavioural (not pharmacological) interventions for stopping smoking in pregnancy showed an absolute reduction of 6% (95% CI, 4%–8%).10 Thus, if the prevalence of smoking during pregnancy were reduced from 20% to 14%, we calculate that there would be 20 fewer infant deaths, 1600 fewer hospital separations, and a saving of $5 million to the Australian healthcare system per year. (Details of the calculations can be obtained from the authors.) These gains could be realised by increasing community awareness of the risks of smoking in pregnancy and helping health professionals to use smoking prevention strategies in their routine encounters with pregnant women.

Jessica H Ford · Annette J Dobson

Australian criminal law is a matter for states and territories. In relation to abortion, many laws are unclear and outdated, and are inconsistent between states and territories. Doctors practise under time constraints and on a case-by-case basis. Most current laws have grey areas that leave doctors vulnerable to accusations, negative publicity and career damage, especially in the case of late abortions. All jurisdictions should follow the Australian Capital Territory’s lead in allowing women to access abortion without fear of criminal prosecution. Federal, state and territory governments should introduce a single clear national law on abortion, both in early and late pregnancy.

Lachlan J de Crespigny MD, FRANZCOG, COGU · Julian Savulescu MB BS, BMedSci

A small number of Australian babies continue to acquire HIV infection unnecessarily The World Health Organization estimates that each year worldwide about 700 000 children are infected with HIV.1 Most of these infections occur through mother-to-child transmission in resource-poor settings, predominantly in Africa and Asia. Mother-to-child transmission rates of 30% continue to occur, despite the fact that this form of transmission is almost entirely preventable with antiretroviral therapy and formula feeding. The barriers to implementation of prevention strategies include restricted access to antenatal testing, cost and limited availability of antiretroviral therapy, poor workforce resources, and political obstacles, such as have occurred in South Africa.2 . . . the concerns about cost-effectiveness have largely been resolved . . . The outlook for babies born to HIV-positive mothers in high-income settings has improved dramatically. Most pregnant women with HIV infection in Western Europe or North America can expect an infection risk for their infant of less than 2%.3,4 This ability to interrupt perinatal transmission of HIV is, of course, only possible if the mother’s status is known. From 1998 to 2002, 103 pregnant Australian women were aware of their HIV-positive status. None of their infants was infected. During the same period, HIV was diagnosed in eight of the 15 infants born to mothers who became aware of their status only after giving birth.5 Overall, almost half the women in Australia with HIV infection known to have completed a pregnancy were unaware of their status before the birth of their baby.6 With this ignorance, no interventions can be offered. Despite the ready availability of prevention strategies, it appears that a small number of Australian babies continue to acquire HIV infection unnecessarily. The solution to this calamity is to prevent HIV infection in women and, when it does occur, to identify it before or during pregnancy. Unfortunately, national policies on antenatal screening are flawed. The Australian National Council on AIDS and Related Diseases recommends that “[pregnant] women found to be at higher risk of HIV . . . should be encouraged to undergo HIV antibody screening”, but does not explain the term “higher”.7 HIV antibody testing is now recommended for all pregnant women in the Northern Territory, New South Wales and Queensland, but the national guidelines continue to be followed in South Australia, Western Australia and Victoria. However, the facts show that existing practice fails to identify a number of preventable cases of mother-to-child transmission.8 The policy of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists is that HIV testing of pregnant women is the standard of care.9 Between 1995 and 1999, surveys indicated that rates of antenatal testing in Australia increased from 20%10 to 33%,11 and a recent survey suggests that the rate continues to increase slowly.12 Routine testing has been opposed on several grounds. There are quite reasonable concerns that routine testing might result in a degree of coercion and the conduct of testing without proper pre- and post-test counselling. Clearly, any recommendation to offer testing to all pregnant women would need to be accompanied by systematic strengthening of counselling and consent procedures. However, the strongest argument against routine antenatal testing has been that, given the low prevalence of diagnosed HIV infection in women, it is unlikely to be cost-effective. Our recent report challenges this position.13 We evaluated the cost-effectiveness of universal antenatal testing. We assumed that society would pay $39 000 per life-year gained, about twice the national average per-capita income. This value has been shown to result in efficient resource allocation.14 This is less than the cost per life-year gained for other screening programs currently under way in Australia, and is the valuation of a life-year gain used implicitly by the Australian Pharmaceutical Benefits Advisory Committee.15 The costs of universal testing — about $1.8 million — are offset by economic benefits for a prevalence of undiagnosed HIV of 0.0044%, or 1 in 23 000. The true prevalence is unknown, but available data suggest it is of this order. The major costs taken into account in our model were the training and time required for counselling about testing, and the pathology costs. The major benefit is that a young life might be extended by 60 or 70 healthy years. Many women in Australia with HIV infection were born overseas and are less likely to have comprehensive health insurance than those born here. Their access to antenatal care is thus limited. It is possible that women with undiagnosed HIV infection are currently over-represented among those missing the testing currently being done. If there were to be a uniform national approach to HIV testing, then education of the public, providers and clinic populations could be expected to improve the consent process. In the United States and Europe, anonymous HIV serological surveys among women giving birth in the 1980s gave way to recommendations for routine testing. Such surveillance of women giving birth has been seen as politically difficult in Australia.16 Given that concerns about cost-effectiveness have largely been resolved, the time has now come for public health and political courage to make it national policy that HIV testing be recommended for all women receiving antenatal care.

John B Ziegler FRACP, MD · Nicholas Graves PhD

Sharon J Gardiner,* Evan J Begg,† Carl M J Kirkpatrick,‡ Robert B Buckham¶ * Drug Information Pharmacist, † Professor of Medicine, Christchurch School of Medicine and Health Sciences, Private Bag 4345, Christchurch, NZ; ‡ Lecturer, School of Pharmacy, University of Queensland, Brisbane; ¶ Drug Information Pharmacist, Christchurch Hospital, NZ sharon.gardinerATcdhb.govt.nz To the Editor: We wish to commend the Australasian Diabetes in Pregnancy Society (ADIPS) ad hoc working party for providing an update on the safety of metformin in pregnancy.1 However, we would like to comment on the information they provided on the safety of this drug in breastfeeding. Metformin can be regarded as a well studied drug with respect to its distribution into human breastmilk;2,3 most drugs are not as well served in this regard. As Simmons et al indicated,1 the infant “dose” in breastmilk is small at less than 0.4% of the maternal dose, corrected for body weight. This is substantially lower than the arbitrary cut-off of 10% used to guide drug use during lactation and thus implies safety.4 Further evidence for the safety of this drug in breastfeeding arises from failure to detect metformin in blood sampled from four of six infants exposed via breastmilk (limit of detection, 5–10 μg/L) and lack of adverse effects noted in nine exposed infants.2,3 Simmons et al stated that infant exposure to metformin could be reduced by breastfeeding immediately before maternal dose ingestion and then avoiding feeding for at least 2–3 hours after the dose. For drugs with a short elimination half-life, this recommendation — avoiding feeding at peak drug concentrations in the milk — may reduce infant exposure. However, this is not the case for metformin. Two studies investigating metformin in breastfeeding have shown that the metformin peak plasma concentration occurs about 2–4 hours after the dose, while milk concentrations are “flat” across the entire dosing interval. This is distinctly different from most drugs, in which the drug concentrations in milk mimic the rise and fall of plasma concentrations, consistent with passive diffusion.2,3 The flat profile observed with metformin raises the possibility that the distribution of metformin into or out of breastmilk may involve an active process such as organic cation transporter(s), in addition to passive diffusion Given this unusual concentration profile in breastmilk, infant exposure (albeit small) will not be reduced by the practice of avoiding breastfeeding for a few hours after maternal dose ingestion, as suggested by Simmons et al. In other words, mothers may feed their infants at any time during the dosing interval and this will not affect infant exposure to metformin. We believe that there is sufficient evidence for metformin to be considered a safe therapeutic option in the treatment of diabetes or polycystic ovary syndrome in breastfeeding mothers, with the usual caveat of weighing up the risk–benefit ratio in each case.

Sharon J Gardiner · Evan J Begg · Carl M J Kirkpatrick · Robert B Buckham

David Simmons,* Barry N J Walters,† Janet A Rowan,‡ H David McIntyre§ * Professor of Medicine, Waikato Clinical School, Waikato Hospital, Hamilton, NZ; † Clinical Associate Professor, Department of Women’s and Children’s Health, King Edward Memorial Hospital, Subiaco, WA; ‡ Physician, Department of Obstetrics, National Women's Hospital, Auckland, NZ; § Director of Endocrinology, Mater Hospital, Brisbane, QLD. simmonsdATwaikatodhb.govt.nz In reply: We thank Gardiner et al for their commendation and support for our update on the safety of metformin in pregnancy.1 We agree with their analysis regarding the timing of the use of metformin during lactation. Nevertheless, we would like to highlight that the safety of metformin can not be assumed from the studies they quote, as these included very few subjects. Such studies, helpful as they may be, provide no imprimatur for the long-term safety for the growing infant and subsequent adult. While no babies had side effects reported during these studies, this may not be the case for other babies. Should a woman decide against the use of insulin to control hyperglycaemia postnatally, then the risk of potential known and unanticipated side effects of metformin should be discussed while obtaining informed consent for metformin use. However, during this discussion, it would also be prudent to weigh-up metformin use against breastfeeding with continued hyperglycaemia, an activity associated with greater obesity and impaired glucose tolerance in the offspring.2

David Simmons · Barry N J Walters · Janet A Rowan · H David McIntyre

Risks to the fetus make it imperative that revised guidelines for fish consumption are clear and reach those most likely to be affected Headlines such as “Mercury warning for children, pregnant women” and “Danger of too much fish” appeared in March throughout Australian newspapers. The media blitz was triggered by the release of revised advice from Food Standards Australia New Zealand (FSANZ) on health risks associated with consuming fish with high methylmercury (MeHg) content (Box).1 The warnings come after a Food and Agriculture Organisation of the United Nations/World Health Organization Expert Committee halved the “provisional tolerable weekly intake” of MeHg in pregnancy from 3.3 µg to 1.6 µg per kilogram bodyweight to protect fetal development.2 Fetal neurotoxicity of MeHg was discovered in the 1960s in Japan. It was named “fetal Minamata disease” after 25 cases of cerebral palsy were found in newborns whose mothers had high levels of MeHg exposure from eating fish contaminated by industrial pollution,3 while the expected number of cases in that population was less than one. Subsequent cohort studies following children from birth to 14 years in New Zealand4 and in the Faeroe Islands5 reported associations between maternal MeHg exposure from fish consumed during pregnancy and deficits in psychological performance or in neurophysiological testing. One prospective study in the Seychelles did not find such effects.6 The Minamata case and subsequent studies indicate that there may be a shift to the left in IQ distribution as a result of excessive MeHg exposure from fish, even at levels too low to produce overt mental retardation. However, a robust debate is continuing about the toxic level of exposure and the “safety margin” required to protect the fetus. The potential risk to children in Australia needs to be carefully considered. The new advice from FSANZ is welcome, as some commonly consumed ocean fish (such as shark) often have natural MeHg concentrations sufficient to cause high weekly exposures. Interestingly, no recommendation was made for tuna. Although canned tuna is usually sourced from smaller, younger fish and is relatively low in mercury, some tuna (albacore, bluefin) has higher concentrations. The United States Environmental Protection Agency advises vulnerable groups against consuming any fish with high mercury content.7 Fish is well established as a “healthy” food. Evidence for cardiovascular benefits from regular fish consumption emerged in the 1990s, as low rates of cardiovascular disease were found in populations with high levels of fish consumption. A number of studies indicate that omega-3 fatty acids reduce cardiovascular risk by improving lipid profiles, inhibiting atherosclerotic plaque, improving arrhythmia, improving vascular function, and reducing damage from ischaemia.8 Curiously, one study reported that high levels of MeHg exposure from fish increased the incidence of myocardial infarction.9 We are therefore faced with the difficult public health challenge of avoiding the health risks from MeHg intake in fish in vulnerable groups while taking advantage of the health benefits of fish consumption. The National Heart Foundation recommends fish be consumed at least twice a week, consistent with advice from FSANZ for most kinds of fish, but this is two to four times the latest recommendations for consumption of fish containing high levels of mercury. While some species of fish have high levels of MeHg, others, such as salmon and hake, have relatively low levels. Expecting consumers to change their understanding that “fish is good” to “some fish are good, sometimes”, and “some fish are not so good, sometimes” introduces a level of complexity into consumer health education that has rarely been seen. Parallels might be drawn with fats and oils, with important shifts in understandings from “all fats are bad” to “some fats are good”, or with alcohol consumption, where some patterns of moderate drinking might be more beneficial to health than abstinence.10 Patterns of fish consumption are highly variable, so ensuring advice reaches those most at risk is essential. For example, shark is frequently unintentional “by-catch”, often used in cheaper meals such as fish and chips and fishcakes, which are consumed fairly regularly by some groups. People more likely to rely on these products may also be less aware of, and less able to respond to, the health advice from FSANZ. While some relatively expensive fish are also high in mercury (swordfish, orange roughy), these are perhaps less likely to form a regular part of the diet. Mercury has a half-life of about 9 weeks, so that women who stop all consumption of fish on becoming pregnant may still be exposing their fetuses to high levels of mercury well into pregnancy. Therefore, we suggest that all healthcare professionals make women of child-bearing age aware of the revised FSANZ recommendations and the potential risks to the developing fetus associated with even moderate consumption of some types of fish during pregnancy. Standards of fish nomenclature should also be developed and enforced to reduce confusion and to ensure consumers are getting what they expect. Further, epidemiological research on actual levels of exposure and the efficacy of the FSANZ health advice is much needed. Revised Australian recommendations for fish consumption* One serve per week (no other fish that week)* One serve per fortnight (no other fish that fortnight)* Two or three serves per week Pregnant women, women intending to become pregnant, and children (up to 6 years) Orange roughy (sea perch), catfish OR Shark (flake), billfish (swordfish, broadbill, marlin) OR Any fish or seafood not listed to the left Rest of population Shark (flake), billfish (swordfish, broadbill, marlin) OR OR Any fish or seafood not listed to the left * Serving size = 150 g for adults and older children, 75 g for children aged up to 6 years.1

Hilary J Bambrick PhD · Tord E Kjellström MEng (Stockholm), MedDr (Stockholm)

The contraceptive implant Implanon (Organon) was introduced in Australia in May 2001, and in the next 18 months was associated with an unprecedented number of adverse incident reports to medical indemnity insurers, including almost 100 unintended pregnancies. The medical indemnity insurer, MDA National, responded to this by applying the Australian and New Zealand Standard for Risk Management (AS/NZS 4360: 1999) in two stages. The first stage was to contain potential costs by moving the treatment into the general practice procedural category, resulting in a one-year moratorium on its use for most general practitioner members (prudential risk management). The second stage was to manage the clinical risk by developing strategies to reduce identified risks associated with the procedure. The Royal Australian College of General Practitioners (RACGP) was enlisted to develop guidelines for use of Implanon, with a consent form and checklists for doctors and patients, enabling MDA National to reinstate the treatment to the general practice non-procedural category. This case demonstrates the need for early risk assessment and development of risk-management tools for new treatments and devices, a role that is appropriate for the RACGP.

Beres C A Wenck MBBS, FAMA · Penelope J Johnston

Donald M Clark Obstetrician, PO Box 503, Mount Lawley, WA 6929. To the Editor: Giles et al1 have “poisoned the well” for future research by attacking the obstetricians who took the trouble to help them with their study on management of hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV. Many of the discrepancies noted between current practice and the recommendations/guidelines are easy to explain: Failure to screen. Many obstetricians were told that it is discriminatory to screen for HIV and HCV without extensive pretest counselling. The advice is obsolete, but old habits die slowly. Failure to recommend caesarean section for women with HIV. Many obstetricians have never seen a case of HIV and would most certainly phone for advice if the situation arose. Failure to promote breastfeeding. Many obstetricians leave advice on breastfeeding to the midwives and paediatricians. However, the article does concede that mother-to-baby transmission is a theoretical risk, so patients are entitled to be informed. Failure to adhere to guidelines. Many obstetricians regard guidelines issued by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) as just that — guidelines, not gospel.

Donald M Clark

Objective: To ascertain patients’ attitudes to embryo donation for research purposes.Design: Anonymous questionnaire survey.Participants and setting: 235 couples who had embryos in storage at Concept Fertility Centre on 30 March 2003 that had been cryopreserved between 1 January 2000 and 30 June 2002.Main outcome measures: Participants’ choices with regard to donating embryos to another couple, to research to improve in-vitro fertilisation (IVF) techniques or to stem-cell research, and the likelihood of couples choosing to use a range of sources to help them with their decision.Results: The response rate was 57%. Twenty-nine per cent of respondents (36/126) reported they would donate their embryos to research that would improve IVF techniques and 27% (34/126) reported they would donate their embryos to stem-cell research. Fifteen per cent (19/126) would donate their embryos to another infertile couple. Willingness to donate to research was not influenced by whether the couple had previous children, or age. Women and men with moderate to strong religious beliefs were less likely to donate to research. Over 90% of respondents indicated they would seek outside help to decide the fate of their embryos.Conclusion: This study suggests that about 30% of couples would donate their embryos to research, and highlights the need to provide support and information to help couples through their decision-making process.

Peter J Burton PGDip(Sci), PhD · Katherine Sanders BSc(Hons), PhD

No adverse pregnancy outcomes with metformin use have been reported, except in one unmatched study. Otherwise, the studies are small and non-randomised, with the exception of one prospective, randomised controlled trial, currently under way, comparing metformin with insulin in women with gestational diabetes mellitus (the MiG trial). No long-term follow-up data for offspring of mothers receiving metformin have been published. Any woman with diabetes should be as close to euglycaemia as possible before pregnancy. In some circumstances (eg, severe insulin resistance), metformin therapy during pregnancy may be warranted. When metformin treatment is being considered, the individual risks and benefits need to be discussed with the patient so that an appropriate decision can be reached.

David Simmons FRACP, MD · Barry N J Walters FRACP · Janet A Rowan FRACP · H David McIntyre FRACP

QuestionDoes high-impact exercise in the prepubertal period have an osteogenic effect in females? Trial details Design: Randomised, partially blinded clinical trial. Participants: 21 monozygotic twin pairs of prepubertal girls aged 7–10 years; 15 pairs recruited through a twin registry and 6 pairs recruited from local schools. Twin pairs were randomly allocated, one to the intervention group and one to the control group. Intervention: The twin in the intervention group engaged in 10 minutes of impact exercise on three occasions each week for 9 months, supervised by a teacher at school. The twin in the control group received no extra contact with teachers or researchers. Main outcome measures: Adipose tissue measured by skinfold measurements; body weight, lean tissue mass, relative fat mass (%fat) and bone mineral content (BMC) measured by dual-energy x-ray absorptiometry. Main results: At 9 months, girls in the impact exercise group had reduced adipose tissue compared with those in the control group (5.6% reduction v 0.6% increase in skinfold measurements [P < 0.05] and a 3.7% reduction v 1.5% reduction in %fat [P < 0.05]), but no difference in body weight or lean tissue mass. In a post-hoc analysis of 12 pairs of twins who were not undertaking impact activities outside the intervention program, there was a higher proximal femur BMC in the intervention v control group (11.9% v 9.4% increase [P < 0.001]). Conclusion: The authors conclude that a high-impact exercise intervention results in an additive osteogenic bone response in prepubertal girls not undertaking other impact activity, but has no effect on bone status in girls already involved in high-impact sports. CommentaryRationale for the trialTo prevent osteoporosis, it is important to maximise bone mineral accrual in early life and minimise bone loss in later life. It is thought that high-impact exercise in premenarchal years may influence the accrual component of this process, although the most effective exercise regimen remains unknown. Trial methodsMonozygotic twins were selected to assure inherent control of genetic confounders, such as prepubertal status, rate of maturation and body dimension and, to some extent, environmental confounders, such as diet. Twins were not selected on any basis of perceived need, such as low bone mass or low involvement in impact activities. The trial’s methods of randomising twin-pairs to intervention and control groups and group allocation concealment from the radiographer are not described, but would be needed for inclusion of this trial’s findings in a systematic review. Major outcome measurements were based on dual-energy x-ray absorptiometry, a non-invasive, objective test for measuring bone and body composition which was read by a radiographer blinded to group status. The primary outcome was bone mineral content (BMC), a mass measurement that can be estimated with more precision than bone mineral density (BMD). It is unclear whether those measuring physical characteristics or analysing the data were blinded. No measurement of dietary intake was reported, and physical activity was not monitored objectively before or during the study. One girl from each twin-pair was randomly assigned to an impact exercise program, while the other received no intervention. The effect of confounders, which has been problematic in many non-randomised studies of bone health in childhood, was minimised to some extent, but bias may have resulted from parents’, teachers’ and participants’ awareness of group status. Chances for contamination between groups were high, with twins cohabiting and attending the same school. The trial design could have been strengthened by the control group receiving a low-impact exercise program or a placebo intervention such as health education. The success of the intervention would have depended on sustainability of program goals and intensity and motivation provided by teachers, and any differences in teachers’ ability to provide these would influence the nature of the intervention. Effects often overlooked are that more efficient skill execution over time reduces workload and that well trained muscles can attenuate bone load. Load is difficult to measure, but would be an essential component of future trials of physical activity in children. A commentary on compliance from the participants’ perspective would also have been useful to inform future studies. The conclusion that the intervention was more effective in girls not undertaking impact activity outside the intervention is not reflected in the summary statistics. In the 21 girls in the high-impact exercise group, BMC increased by 11.96%, compared with 11.90% in the subgroup of 12 girls inactive outside the intervention. Without further information, it is difficult to understand the large difference in t values between the two analyses (t = 0.78 for the whole group v t = 2.97 for the otherwise inactive subgroup) and why a small effect size was significant in 12 twin-pairs. A mean-versus-differences plot would have shown if the effect was greater in girls with low BMC, and additional statistics, such as 95% confidence intervals and number needed to treat (say, to improve BMC by 5%), would help to clarify the clinical importance of the results. New informationResults of musculoskeletal gains should be interpreted cautiously, as groups improved their bone mass equally, and so the role of exercise in the acquisition and maintenance of peak bone mass remains unclear. Further studies are needed, because many public health recommendations are being made even though there is little evidence supporting them. Implications for clinical practiceIntervention activities were developmentally appropriate and the simplicity of the program, with only 10 minutes of exercise on three occasions each week, could be attractive for public health interventions and inclusion in planning and policy documents. However, it is important to ascertain if certain subgroups, such as inactive children or those with low bone mass, benefit most. Family-based activities to target such groups may be more efficient than wider school-based activities that involve many children who may not benefit. To reliably measure the effects of impact exercise on early bone health, larger studies with a more generalisable population will be needed, with stratified random allocation to groups for greater control of potential confounders, and with more attention paid to issues of quality program delivery. Although large trials are a challenge to conduct, they are essential for increasing confidence in their clinical implications. Risk versus benefit must also be considered. In programs for prepubertal children, it is essential that teachers and parents have the expertise to ensure safe landings from jumps and safe increases in workload.

Jennifer K Peat PhD · Geraldine A Naughton PhD

On 15 January 2004, Jack Elliott died peacefully of cardiac failure after a long and productive life during which he made enormous contributions to the discipline of obstetrics and gynaecology — primarily in Newcastle and the Hunter Valley, but also at a national level. Jack was born in Nowra, NSW, on 12 February 1912. He did his Leaving Certificate in Nowra, but needed to attend Fort Street High School (in Sydney) for a year to matriculate to the University of Sydney. He graduated in pharmacy, science and finally medicine in 1940. He supported himself in those student years by working part-time or full-time, supplemented by playing professional rugby league. He also played district cricket and was awarded a university blue in rugby union. Jack was commissioned as a captain in the Royal Australian Army Medical Corps and served throughout most of World War II, including service in Papua New Guinea. After the war, he resumed his medical career at the Royal Newcastle Hospital, where he embarked on a lifetime involvement in obstetrics and gynaecology. He set up the first specialist unit in the Hunter Valley at the Royal, training generations of residents and registrars, and became the trusted consultant for general practitioners throughout the region, holding appointments at most of the region’s hospitals. Beginning in the 1950s, he implemented a remarkable series of new initiatives in obstetrics and gynaecology, including a dramatically increased role for midwives and rooming-in and demand-feeding for mothers. He embraced the principles of natural childbirth, encouraged fathers to attend antenatal classes — and eventually the labour ward (an idea considered very radical at the time!). He pioneered the use in Australia of magnesium sulfate to treat severe pre-eclampsia, advocated the increased use of caesarean section, and was one of the first to promote the use of vaginal hysterectomy rather than the older Manchester-type repair operation. In the 1960s, Jack was one of the first consultants to develop country hospital clinics and operating sessions. He obtained his membership of the Royal College of Obstetricians and Gynaecologists in 1953 and became heavily involved in the College, serving on the NSW committee and subsequently the Regional Council. He was a member of the inaugural Council of the Royal Australian College of Obstetricians and Gynaecologists in 1979. Jack was an extremely modest man and, sadly, recorded little of his knowledge and wisdom in the literature. But his enduring legacy is the gratitude of thousands of mothers and the babies he delivered and the adoption by his trainees and colleagues of many of the initiatives that he began 50 years ago. Alan D Hewson

Alan D Hewson

Michael A Quinn Director, Oncology and Dysplasia Unit, Royal Women's Hospital, 5th Floor, 132 Grattan Street, Carlton, VIC 3053. michael.quinnATmaynegroup.com To the Editor: A recent article by Zorbas et al1 highlights some of the many difficulties experienced by Australian women in accessing multidisciplinary care after they have been diagnosed with breast cancer. A multidisciplinary approach to women with gynaecological cancer has been the cornerstone of care since the establishment of gynaecologic oncology units in Australia in the early 1980s. Over 20 years’ experience has reinforced the value of this approach. By and large, however, the success of this model has very much depended not only on the skills of the multidisciplinary team but also on the readiness of referring doctors — in this case, specialist gynaecologists — to refer patients for management that is often surgical and could easily be done by themselves. Reinforcing the concept that care of the patient is holistic and that surgery plays an important (but not definitive) role in overall care has led to increased referrals, but there are still many to convince. For instance, a survey published in the Journal in 20022 showed that in the late 1990s more than half the women with ovarian cancer in Victoria were still being operated on outside established gynaecologic oncology units or by a non-gynaecological oncologist. It is to be hoped that new National Health and Medical Research Council guidelines on the management of ovarian cancer (soon to be released) will reduce this deficit and thereby improve outcomes for women with ovarian cancer. Much of the development of this benchmark care has come from patients, who, thankfully, are becoming increasingly articulate in their expectations of optimal clinical outcomes. The question of rural patients is an extremely important one. In Victoria, over a period of more than 10 years, the three major metropolitan gynaecologic oncology centres have established satellite clinics in country towns to facilitate patient follow-up, often involving local specialists and family doctors. This system seems to have worked well and is worthy of assessment as a model that might be transferable to other specialties. In conclusion, it is all very well setting up multidisciplinary teams, but the key to their success has to be the recognition of professional equality. If teams are based on a hierarchical setup they are likely to fail in their major aim, which is to provide the best care available based on input from a broad range of professionals and from patients themselves.

Michael A Quinn

Susan C Pendlebury,* Katherine J Clark,† Martin H N Tattersall‡ * Radiation Oncologist, † Palliative Care Physician, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050; ‡ Professor of Cancer Medicine, University of Sydney, Sydney, NSW. spendlebATemail.cs.nsw.gov.au To the Editor: Zorbas et al1 have highlighted both the complexities and resource intensiveness of multidisciplinary care for women with early-stage breast cancer. The same arguments exist in advanced disease, where input from many disciplines is the norm. However, there is no evidence that such a process improves outcomes in the Australian setting. The references the authors draw upon relate to regions in which breast cancer outcomes have historically been poor. Evidence from Australian studies suggests higher standards of care and appropriate changes over time. 2,3,4 The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of early breast cancer5 provide an evidence-based strategy for managing the disease. Enshrined within them is the concept that many different treatment approaches are equivalent and that patient preferences are important. Patient input into multidisciplinary case conferences is frequently minimal. Case conferences can be confusing for patients, and it may not be clear to them who is their doctor. Many clinics include a breast nurse, who commonly acts as a patient advocate. Zorbas and colleagues note the different models of multidisciplinary care, but the minimum approach required to achieve good outcomes has not been established. It is not surprising that 34% of rural surgeons find it difficult to implement a service in which all women have access to a full range of treatment options in a multidisciplinary setting. There is no evidence, however, that their patients are more unhappy or that management outcomes are inferior. Similarly, the guidelines correctly promote the importance of psychosocial support for patients, but the suggestion that this can be better achieved by a psychologist via teleconferencing rather than by the patient’s general practitioner is purely speculative. None of the multidisciplinary models suggested by Zorbas et al addresses the management of patients at relapse, and yet data and clinical experience indicate this is the time of greatest stress for patients, 6 a time when input from a number of specialties — medical care, radiation oncology, palliative care — is the norm. Multidisciplinary care appears to be beneficial regardless of the stage of disease. However, the execution of some of the models is resource-intensive. We need to evaluate not only whether the objectives of the NHMRC guidelines are met, but whether patient satisfaction and participation are enhanced, survival outcomes are improved and care through all stages of the disease is optimal. Currently, by such measures, multidisciplinary care has not been shown to be superior to a small number of well-directed, evidence-based selective consultations.

Susan C Pendlebury · Katherine J Clark · Martin H N Tattersall