Thank you letters from recipients of the AMA Indigenous Medical Scholarship

It has made a huge difference

I am writing to you today to inform you that I have officially completed my studies at the University of Newcastle in the Bachelor of Medicine program as of the 7^th December 2018, and I would like to take this opportunity to say thank you to the Australian Medical Association for their support throughout my time at Newcastle University that made this endeavour possible with the Indigenous Peoples’ Medical Scholarship 2016.

I can still remember the day I received the phone call that I had been awarded the scholarship. I was studying in the library, trying to finish off that week’s ‘Working Problem’. I saw it was a Canberra phone number, and instantly became nervous. I can still remember saying to myself ‘is this real?’ as I never expected to be even considered for such an award, but nonetheless, it has made a huge difference to where I am today.

As a mature aged student with a family, the scholarship took the pressure off the financial strain of attending university, and allowed me to focus more on my studies at the time when it was needed the most. Previous to the scholarship, my usual routine was to attend university Monday to Friday, then work Friday and Saturday night shifts in as a Registered Nurse in the Intensive Care Unit at the Newcastle Mater Hospital. This left me with one day to spend time with my family, and catch up on any extra reading. The scholarship enabled me to scale back work, spend more time studying, but it also allowed me to spend extra time with my boys.

I was fortunate enough to secure a position as a Junior Medical Officer in the Hunter New England Local Health District, commencing on the 21^st January in 2019. This will keep me close to home at the present time, and I am looking forward to the challenge. Being an active member of the Wollotuka Institute at the University of Newcastle, I am also now looking forward to mentoring and tutoring Indigenous medical students in a new capacity so as to foster the next generation of Indigenous medical graduates.

Thank you once again to all the staff at the Australian Medical Association for making this dream possible.

Regards
Dr Darren Hartnett

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Continues to be the source of support that facilitates my passion to pursue medicine

This year was my first clinical year of medicine, where I was placed in Wagga-Wagga NSW. I have always been sure about pursuing rural and remote medicine – but being immersed in clinical medicine in rural NSW has only reaffirmed this more and made me more motivated!

Reading about the UNSW medicine program before I even gained entry, I was always very keen to be placed in Wagga. I placed it as my first preference and was lucky enough to get it [Wagga is becoming very popular among students!].

The relocation to Wagga from Wollongong was always going to be an expensive exercise; however, it was very comforting knowing that the transition would be supported by the AMA Indigenous medical scholarship. Throughout various placements this year, both within the hospital and the community, I have been exposed to the spectrum of health – and in particular health issues common in rural Australia such as Indigenous health and mental health.

An interest of mine has always been obstetrics, and I have made sure that this year I have had as much exposure as possible. As part of the UNSW medicine program, students are required to complete a 30-week independent learning project in their 4th year of study. I have been fortunate enough to have my proposal approved and will also be completing my research project in Wagga during 2019.

My research has an obstetric focus and will be assessing Indigenous foetal-maternal outcomes. I have not had much exposure to research however I am excited to learn more about rural obstetric medicine and am looking forward to the challenge next year! This year has also seen the budget allocate funding of a new medical school in Wagga-Wagga. I firmly believe this is a great opportunity to increase Indigenous medical student numbers as well as improving retention. As this has involved the current Wagga-Wagga rural clinical school I have been lucky enough to share my thoughts with the Dean of rural medicine.

This is something I have become quite passionate about as I truly believe that increasing the amount of Indigenous medical and allied health professionals will only aid in closing the gap between Indigenous and non-Indigenous health status. This is a passion which I will continue to lobby for. The AMA Indigenous scholarship has, and continues to be, the source of support that facilitates my passion to pursue medicine. Medicine is a challenging experience and sometimes a little daunting and overwhelming. Being a recipient of the AMA Indigenous Medical Scholarship is a constant source of motivation and an opportunity I am and will always be grateful for! Thank you again for your support and in assisting me throughout my medical studies and I look forward to 2019 as a proud recipient of the AMA Indigenous Scholarship.

Regards
James Chapman

indigenous-medical-scholarship-2019

#GoodDoctorsTeach Australian Medical Students’ National Teaching Awards

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

Every day, great doctors around Australia go above and beyond to teach students, and role model what medicine is all about. This year the Australian Medical Students’ Association (AMSA) celebrated those teachers in medical schools and hospitals with the National Awards for Teaching Excellence.

The AMSA National Awards are the highest honour bestowed on a teacher by medical students across the country. They are based on nominations from around the country, and represent students’ appreciation and recognition of teachers who have made an especially positive impact on their studies. There are a number of award categories including excellence in teaching, in rural education, teaching by a junior doctor, and as well as teaching by a member of an allied health profession.

Although it is such an important part of the doctor’s role, the teaching culture across different hospitals varies widely. Despite the recent focus and positive steps in the last few years, bullying, harassment, and teaching by humiliation are still too common an experience. These awards are part of AMSA’s #GoodDoctorsTeach campaign, acknowledging those who tackle this by actively creating a positive teaching culture within medicine.

AMSA received close to 100 nominations for the awards. Reading those nominations was heart-warming, as student after student shared stories of the teachers who have inspired, motivated and challenged them. It was a reminder of just how significant the impact of teaching is on the lives of students, and of how many exceptional teachers there are.

On behalf of Australian medical students, I’d like to thank all the doctors and allied health professionals who make it part of their daily work to make medicine a welcoming and exciting place for students and junior doctors, and nurturing their passion. Consultant or intern; metropolitan or remote; doctor, midwife or echocardiographer: the way you treat your students is making for better future doctors, and a better medical culture in Australia.

Excellence in Teaching winner: Dr Zafar Smith (James Cook University)

Quote from students: “Dr Smith has gone above and beyond teaching us Emergency Medicine in our 3rd year. He completely re-vamped the course making it much easier to learn and more enjoyable. Every single person I know has enjoyed his lectures, tutorial and approachability. He uses interactive methods of teaching which engage the class, such as gosoapbox and kahoot quizzes to test us, and has even created a deck of cards with Emergency medicine case studies that we were all able to get our hands on and use for our exams. As this is his first year of coordinating and lecturing this course, he has outdone himself and on behalf of Med 3 at James Cook University, we would like to recognise his efforts and generosity, and the fun spirit he has brought to sometimes difficult topics.”

Excellence in rural education winner: Dr Elizabeth Kennedy (University of Melbourne, Goulburn Valley Region)

Quote from student: “Dr Kennedy has provided me with outstanding mentorship over 2018, cementing my passion for rural medicine … She is consistently motivated to include students in the extracurriculars of the medical profession, including education events in the Goulburn Valley Region, attending Youth Forums regarding young women’s health, and promoting student engagement in the community. She constantly provides me with the mentorship and support to strive for more, and to be the kind of person and doctor that is needed in a rural area. She constantly gives her medical knowledge, emotional support and more to her patients and I learn from her each and every day.”

Excellence in teaching by a junior doctor winner: Dr Kenneth Cho (University of Sydney and University of Western Sydney, Nepean Hospital)

Quote from selection panel: “Kenneth’s work developing a JMO-led bedside tutorial program and a JMO-led Friday lecture series, run by Junior Medical Officers for medical students is an example of the way anyone, despite age or experience, can lead by example to create a culture of teaching where they work.”

Excellence in teaching by a member of an allied health profession winner: Mr David Law (Echocardiographer, University of New South Wales, Coffs Harbour Hospital)

Quote from student: “David- Coffs Harbour’s most prized sonographer- is probably the only teacher I’ve had who has been able to explain ECGs in a way that makes sense. But more important than that is how he has made the hospital such an inclusive place for medical students to be, welcoming us to catheterisation lab, and always taking the time to explain things to us.”

[Perspectives] Breaking the rules

Disobedience, the first novel by Naomi Alderman, author of The Power, which won the Baileys Women’s Prize for Fiction in 2017, has been made into a film directed by Sebastián Lelio, and co-written by Lelio and Rebecca Lenkiewicz. It is set in the orthodox Jewish community in north London, but its themes have a more universal resonance. Is community stronger than love? Are rules more important than individual expression? Who is allowed to express their true sexuality and what happens to those who do?

Fertility techniques linked to intellectual disability

New research has revealed a link between intellectual disability and some forms of Assisted Reproductive Technology (ART), highlighting an urgent need for the long-term monitoring of children conceived via these techniques.

The study by the Telethon Kids Institute, published in Pediatrics, linked intellectual disability and ART data from population-based registers in Western Australia. The cohort included 210 627 live births from 1994 to 2002, with at least 8 years of follow-up.

The researchers found that 1 in 48 ART children were diagnosed with intellectual disability, compared to 1 in 59 for non-ART children. Children conceived through intracytoplasmic sperm injection (ICSI) showed a higher risk of intellectual disability at 1 in 32.

The risk of intellectual disability in very preterm births was much greater regardless of the method of conception – but within preterm singleton births, the risk was doubled for those that were ART-conceived. The researchers showed that 1 in 8 ART singletons vs 1 in 14 non-ART singletons born before 32 weeks were diagnosed with intellectual disability.

The findings are significant – but practices have changed since the study period

Lead researcher Dr Michele Hansen from the Telethon Kids Institute said that while the results are significant, it is important to note these findings relate to births from 1994 to 2002 and there have been major shifts in ART clinical practice in Australia since that time.

“During the study period, the transfer of multiple embryos in a single treatment cycle was the norm in Australia. This practice led to high rates of multiple pregnancies and preterm birth – which are both known to increase the risk of intellectual disability,” Dr Hansen said.

“However, this practice has changed dramatically in Australia over time. As of 2016, 88 per cent of treatment cycles saw only a single embryo transferred, resulting in much lower proportions of multiple and preterm births.”

Concerns over intracytoplasmic sperm injection technique

Dr Hansen said the research reinforces concerns about ICSI, which is now being used more broadly.

“Genetic abnormalities occur more frequently in men who are infertile, so ICSI – which bypasses natural selection barriers by injecting a sperm directly into an egg – may allow for the transmission of anomalies to the offspring,” Dr Hansen said.

ICSI use has increased over time in Australia since the study period and is currently used in 63 per cent of treatment cycles.

An urgent need for long-term monitoring of outcomes in ART children

Dr Hansen said that “our findings show an urgent need for more recent data to establish whether the increased risks of intellectual disability seen in children conceived using ICSI are solely related to severe male subfertility and older paternal age, or if there are other risks associated with the technique itself.”

Dr Genia Rozen, obstetrician and gynaecologist from Melbourne IVF, said this latest research was in agreement with similar studies showing a higher rate (though absolute risk is still low) of intellectual disability in the ART population, even when comparing similar groups such as singleton births.

“As fertility specialists this is something we must be counselling our patients about.”

Dr Rozen said that given the much higher rates of ICSI now observed in parts of the world, “to uphold ‘primum non nocere’ – first do no harm – studies, such as this one, are imperative.”

Straight fish oil recommended in pregnancy to reduce pre-term births

Pregnant women are being urged to double-check their intake of omega-3 and not rely on multivitamins after a review found strong evidence additional intake reduces the risk of preterm labour.

An updated Cochrane review this month concluded that omega-3 long chain fatty acid addition during pregnancy – usually by supplementation – reduced the risk of preterm birth (<37 weeks) by 11% (95% CI 0.81-0.97).

The intervention was even more effective at preventing early preterm birth (<34 weeks), with a 42% risk reduction (95% CI 0.44 to 0.77). It was also found to reduce the risk of having a low birth weight baby by 10% (95% CI 0.82 to 0.99).

Review lead author, Professor Maria Makrides of the Healthy Mothers, Babies and Children research program at the South Australian Health and Medical Research Institute, said the findings were “extremely promising”.

“We now have strong evidence that omega-3 supplements are a simple and cost-effective intervention to prevent premature birth,” she said.

Professor Makrides urged women to take straight fish oil or algal oil capsules to get the required dose of omega-3 to prevent preterm births.

“The best available evidence from the randomized controlled trials in the review suggest that the minimum effective dose is 500 to 1000 mg per day of DHA and EPA (eicosapentaenoic acid), with at least 500mg coming from DHA,” she told doctorportal.

Professor Makrides cautioned that women were unlikely to achieve the recommended dose by dietary means – equivalent to two or three 150g servings of salmon weekly.

She also warned that popular pregnancy multivitamins usually did not contain enough omega 3 fatty acids – in particular, docosahexaenoic acid (DHA) – to be protective. Typical formulations only provided women with 250mg of DHA daily.

“Although many women take a pregnancy multivitamin, most of the evidence would suggest that there is no need for most of them,” she said. “Aside from this recommendation regarding fish oil, the only other evidence-based supplement routinely recommended in pregnancy is folic acid between peri-conception and 12 weeks to prevent neural tube defects”.

The latest review was the second update of the original 2006 review. It considered 70 randomised controlled trials assessing the impact of omega-3 on a range of maternal, neonatal and birth outcomes in women of varying risk profiles.

Professor Makrides said it was unclear from the evidence whether the dosage to prevent preterm births should vary by baseline omega-3 status or for multiple pregnancies.

‘Dampening down’ the birth trigger

Interest in omega-3 fatty acid supplementation in pregnancy began in the 1980s, after Danish researchers observed longer pregnancies among Faroe Islanders – who consume a diet high in fish – than in the mainland Danish population.

Cochrane review co-author Associate Professor Philippa Middleton told doctor portal: “Omega-3 fatty acids, and particularly DHA, are thought to reduce or dampen down the potency of prostaglandins that may otherwise have triggered early birth.”

The potential adverse consequence of this effect – going overdue – was evident in the latest review. Prolonged gestation >42 weeks was “probably increased from 1.6% to 2.6%” in women taking omega-3 supplements compared with those who did not, the review found (RR 1.61 95% CI 1.11 to 2.33).

However, the review found there was insufficient evidence to determine the effects of omega-3 on induction post-term.

Professor Middleton commented: “Overdue labour was a previous concern, but practice has now changed and very few women reach 42 weeks now without being induced.”

She added: “Women could stop taking the supplement at 37 weeks if they wished but it’s probably just easier to advise taking until birth.”

Overall, Professor Middleton said there did not appear to be any risks with omega-3 supplements in pregnancy.

Cognitive benefits not clear

In the past decade, observational studies have fueled claims that fish oil may improve children’s cognition and reduce the risk of maternal depression when taken in pregnancy.

However, the authors of latest Cochrane review update downgraded their assessment of the quality of evidence for this association.

One of the major studies to challenge the suggested cognitive benefits of fish oil in pregnancy was led by Professor Makrides in 2010. The five-year randomised controlled trial of 2400 pregnant Australian women found no evidence that fish oil reduced the risk of post-natal depression. The study also found no evidence that the supplement improved child cognition or language development at 18 months of age.

The Cochrane team concluded that further follow-up of completed trials was needed to assess longer-term outcomes for mother and child.

MBS Review – Chance for your say

BY ASSOCIATE PROFESSOR ANDREW C MILLER, CHAIR, AMA MEDICAL PRACTICE COMMITTEE

The AMA support for a review of the MBS has always been contingent on it being clinician-led, with a strong focus on supporting quality patient care. This includes having the right mix of practising clinicians on each committee, with genuine input into a process of transparent decision making.

The AMA, of course, would like to see a review process that delivers a schedule that reflects modern medical practice, by identifying outdated items and replacing them with new items that describe the medical services that are provided today. In doing so, it is crucial that any savings from the MBS review be reinvested into the MBS, and that the review is not simply a savings exercise.

The MBS Review is by no means a small feat, undertaking to review 5,700 items, some which have not been reviewed in 30 years. Obviously, the outcomes of this herculean review not only impact on Government operations and budgets, but significantly affect the entire health system—the always difficult balancing act between the public and private health sectors, the vast number and range of medical practitioners, specialties and medical services, and of course the public.

It was noted by the AMA that the Senate estimates transcripts (30 May 2018) indicated about $600 million in Government savings from the MBS reviews over the 2017 and 2018 budgets, with only $36 million reinvested into new items.

With so much at stake the AMA, specialty colleges, associations and societies must all work individually, and together to hold the MBS Review clinical committees, Taskforce and Government to account on their considerations and recommendations. They cannot be based on anecdotal evidence and narrow perspectives, rather than on data, scientific or robust evidence, or extensive and lived perspectives.

In that vein, I thought it timely to provide a sample of some of the AMA work in this space.

MBS Review clinical committee reports – consultation timeframes

Within the last two months, the Department of Health has requested feedback from AMA on 25 MBS Review clinical committee reports. The reports included around 2,000 MBS items and more than 2,000 pages. The number of items reviewed in these reports are almost 40 per cent of the total number of items in the entire Medicare schedule.

The MBS Review Taskforce has provided the AMA, colleges, associations and societies with only a few months to respond, whilst the Taskforce has deliberated on the review over the last three years. Furthermore, the reports are not publicly available – rather they are sent in a targeted fashion to certain stakeholders. The AMA has pushed back on this and called for them to be posted publicly online.

Obviously, this expediated consultation timeframe presents risks for having the ability to interrogate the clinical appropriateness of proposed changes for the profession, and increases potential for unintended consequences to go unremarked. The AMA has raised these issues with the Minister’s office and the Department to call for timeframes to be pushed out, as is reasonably practical, to ensure the profession are appropriately and adequately consulted on the recommendations.

Surgical assistants

In September, the AMA worked extensively behind the scenes with the Medical Surgical Assistants Society of Australia (MSASA), the Royal Australasian College Of Surgeons (RACS), individual surgical assistants (AMA members and non-members) and AMA Council members to tease out the key issues and lodge a submission strongly opposing the MBS Review Taskforce’s proposed changes to remuneration arrangements for surgical assistants. The AMA was also responsible for ensuring other groups were aware of the submission process.

A number of AMA communications and medical media was generated around the proposed changes and AMA’s response. This included AMA ‘Rounds’ and GP Network News, and in the medical press and social media.

The following key issues formed the basis of the AMA submission:

that surgical assistants are independent practitioners and they should remain so;
negative impact on surgical training;
risk of de-skilling GPs in rural and remote areas;
proposed derived fee – baseless assumptions;
Private Health Insurance and Out of Pockets Reforms already underway;
there are alternative mechanisms to address Taskforce’s concerns; and
no data provided on the problem.

MBS Review Clinical Committee reports – Gynaecology, Breast Imaging, Nuclear Medicine

The AMA has also lodged a submission to the Department of Health on the MBS Reviews on gynaecology, breast imaging and nuclear medicine.

The main issues raised in the submission related to the gynaecology review and the following were discussed:

Inadequate profession engagement;
Time based item descriptors – perverse incentive and unintended consequences;
Additional auditing provisions – onerous and unnecessary;
Item restructure – simplification and streamlining are required; and
Recommendation 19, Item Number 35750 – disagree with recommendations.

In this submission, the AMA also provided broad observations on the MBS Review including concerns regarding operation of committees, as well as inadequate communication and consultation and the removal of the reports from the public website.

MBS Review Clinical Committee reports – Anaesthesia and maximum 3 item rule for surgical items

The AMA recently wrote to the Chair of the MBS Review Taskforce (Prof Bruce Robinson) supporting the Australian Society of Anaesthetists (ASA) opposition to the majority of the MBS Review anaesthesia clinical committee (ACC) recommendations. In the same letter the AMA also raised concerns regarding the maximum three item rule for Group T8 surgical items.

The AMA urged the MBS Taskforce and Government to work with the ASA to come to mutually agreeable changes to the anaesthesia items in the MBS that align with contemporary clinical evidence and practice and improve health outcomes for patients.

The AMA also communicated to Prof Robinson that it is deeply concerned that whilst on the one hand the PRC deferred its decision regarding the three-item rule, due to consultation feedback, but on the other hand this recommendation is taken forward and applied in a specialty clinical committee report (eg urology) without reference to any previous profession feedback on the recommendation.

The AMA sought Prof Robinson’s assurances that the three-item rule is open for further discussions and that the MBS Taskforce will coordinate with the affected Colleges, Associations, and Societies to come to mutually agreeable changes; that is consistent, as much as is reasonable, across the specialties; that align with contemporary clinical evidence and practice and improve health outcomes for patients.

AMA MBS Review Webpage

Finally, the AMA ‘s own MBS Review webpage is now live and provides AMA members (and the public) with a one-stop bulletin board on AMA’s engagement and advocacy with the MBS Reviews. I encourage you to visit the website for further information and future updates on AMA’s advocacy work on MBS Reviews. There you will also find all of the AMA’s submissions to date to the MBS Reviews, and advice on what we are currently working on. Furthermore, it provides the contact details so that those members who are interested in helping the AMA formulate its response to reviews can have their voices heard.

Only by members being engaged can the AMA hope to have a positive influence the direction, and outcomes, of the MBS Reviews.

Let’s be clear eyed while moving forward on private health insurance

BY ASSOCIATE PROFESSOR JULIAN RAIT, CHAIR, COUNCIL OF PRIVATE SPECIALIST PRACTICE

On October 11, Health Minister Greg Hunt announced the final rules that support the new private health insurance clinical categories and the Gold, Silver, Bronze and Basic classification system.

CPSP and the AMA have called on these reforms to deliver simplified, better value private health insurance products for consumers. A system that offers more comprehensive coverage, with clear definitions, and less caveats and carve outs. Will the new system deliver total clarity and transparency? Not quite, but it is going to be a lot simpler for consumers than trying to navigate through the current 70,000 policy offerings.

The AMA has always supported, two key aspects of these reforms:

Clarity about what medical conditions are covered in each tier of benefits; and
The use of standard clinical categories across all private health policies.

The new classification system categorises existing policies into easier to understand tiers. These tiers, in combination with new Private Health Information Statement (which includes mandatory information about what each policy covers), should make it easier for people to compare policies, to shop around and actually see what they are covered for.

This should enable consumers to know that when they book in for a procedure they are covered now and not have to wait an additional 12 months or try the public system.

The tiers outline minimum requirements, but they still allow insurers to add additional cover. The legislation clarifies that insurers can move people onto new products, closing old products, but introduces new protections about warning and information for consumers. Additionally, the Minister is on the record stating that “importantly consumers will not be forced to change their policy cover if they are happy with it”.

There are also some more hidden benefits that will come in with the new system.

That the system provides full mandatory cover for the medical conditions in each tier; partial cover is not permitted (except in Basic cover and for Psychiatry, Rehabilitation, and Palliative Care – except in Gold cover where there are no exclusions allowed at all);
The inclusion of gynaecology, breast surgery, cancer treatment, and breast reconstruction in bronze tier products;
That a clinical category covers the entire episode of hospital care for the investigation or treatment;
That an episode of hospital treatment covers the miscellaneous services allied to the primary service; and
Patients with limited cover for psychiatric care can upgrade their cover (once) to access higher benefits for in-hospital treatment without serving a waiting period.

While these look obvious, they haven’t always been included in policies. From next year they will be.

The Minister has called for an April 1, 2019 commencement to coincide with the annual announcement of new premiums. However, as with most major changes, not all groups can adapt as quickly as others. So, while the reforms start next year, insurers have a further 12 months to ensure that each of their products is compliant and to move people onto new products if required. This is not ideal, but the transition for the smaller insurers is likely to be very resource intensive. The Minister has stated that his expectation is that the great majority of policies will be ready to go by April 1 next year. He has also stated that these reforms will have an overall neutral to -0.3 per cent impact on premiums compared with current policy settings.

But we also need to be clear eyed here. This will not solve the wider issue of how to bridge the ongoing premium increases in the 4-5 per cent range, and wages growth at 2 per cent range. That fundamental paradox to a long-term, sustainable private health insurance system remains. These reforms will not address the concerns around private health insurer behavior, nor will they address the variation in rebates. These reforms are about making life a little easier for our patients, and our practices. But the AMA will need the support of all our members going forward – for clearly, the bigger problem is yet to be addressed.

Encouraging news for prognosis of extremely premature babies

Parents of extremely preterm infants may gain reassurance from a new study showing dramatic day-by-day improvements in long-term prognosis for those receiving intensive care.

The study in The Lancet Child and Adolescent Health followed up 715 children born at less than 28 weeks gestation who were offered intensive care in Victorian hospitals during three distinct periods (1991-92, 1997 and 2005).

Almost three-quarters of the children (73%) offered intensive care survived to age 8 years, and 83% of the survivors were free of major disabilities (moderate-to-severe cerebral palsy, blindness, deafness, or profound cognitive disability).

Encouraging news

A major finding of the study was that an extremely premature baby’s risk of death and major disability rapidly declined in the first few days after birth, such that by the time of their discharge home their risk of death was similar to healthy full-term babies’.

Lead study author, Associate Professor Jeanie Cheong from the Royal Women’s Hospital in Melbourne commented: “This is very encouraging news for parents who are often very frightened when taking their newborn baby home from hospital.”

The study also confirmed four sentinel events in the postnatal period that strongly increased the likelihood of major disability: grade 3 or 4 intraventricular haemorrhage or cystic periventricular leukomalacia (both indicating brain damage), postnatal corticosteroid use to treat or prevent lung injury and surgery in the newborn period.

Almost one-half (48%) of the extremely preterm babies avoided all of these complications, and of those that did avoid these events, 93% survived without major disability.

Parents deserve regular updates

The study authors said the rapid changes in prognosis in the first few days after birth should be acknowledged by clinicians and conveyed to families.

“As survival prospects change rapidly immediately after birth, ongoing counselling should be provided… If one of the four major events arises, advice should be updated,” they wrote.

Professor Cheong said the study’s findings demonstrated how each baby’s individual risk changed significantly over the course of their intensive care treatment.

“Parents may be taking home their baby fearing that they are at a much higher risk of death or long-term disability than is the reality,” she said. “Now we can tailor the risk information to bring much-needed reassurance to parents.”

Preventing preterm births

The mean gestational age at birth in the study was 25.6 weeks and mean birth weight was 835g. Three survivors died between discharge and 2 years of age, but no additional deaths occurred between 2 years and 8 years of age.

Mortality by age 8 years was lower in infants who were given antenatal corticosteroids than in those who were not (OR 0.61, SD 1.2 and CI 0.39-0.97, p=0.37) and decreased with increasing gestational age at birth (0.58 for every 1 week increase). For babies born at 23 weeks, the chance of survival was around 45% for those offered intensive care.

Only seven (8%) of live births at 22 weeks gestation were offered intensive care, and only two of these children survived.

There was little difference in survival with major disability between birth eras.

Professor Cheong told doctorportal: “The ultimate goal would of course be to prevent preterm birth, and there are a lot of efforts happening in that space.”

“The reality is, however, that extremely preterm babies will continue to be born and we have the responsibility to parents and the children themselves, to inform them of the risks associated with death and major disability.”

[Correspondence] Essential need for quality in surgical health-care systems

We congratulate Donald Berwick and colleagues (July 21, p 194)1 for highlighting the need for health systems to achieve safe, effective, universal health-care coverage in the Era of Sustainable Development. The need is most apparent in surgery, obstetrics, and anaesthesia, in which adverse health-care events can have devastating consequences. Surgery can be deemed a reliable stress test for health-care facilities and indicative of overall quality as it requires the successful integration of multiple systems.

[Perspectives] Yvonne Sylvain: women’s health pioneer in Haiti

In the mid-20th century, a remarkable woman used her medical prowess and social prestige to address inequalities in Haitian society and raise the profile of public health. Born in Port-au-Prince in 1907, Yvonne Sylvain was the sixth of seven children of the poet, diplomat, and lawyer Georges Sylvain and his wife Eugénie. Both parents were part of a progressive intellectual elite that campaigned against the US occupation of Haiti, which lasted from 1915 to 1934. With a staunch feminist for a mother, the four Sylvain sisters all pursued either PhDs or medical training and furthered the cause of women’s rights.