more_vertWhen Ellen Johnson Sirleaf retired last month after 12 years in office in Liberia, she signed an executive order banning female genital mutilation (FGM) in the country for girls younger than 18 years. Her profile as Africa’s first female president and a recipient of the Nobel Peace Prize for efforts to advance women’s rights and peace ensured her executive order got international media attention, thus shining needed light on a devastating practice. Globally, a staggering 200 million women and girls have undergone FGM, and UNICEF estimates that more than one in three girls between 15 and 19 years of age are currently affected.
Preference: Obstetrics and gynaecology and women's health
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Caesarean vs natural birth: an obstetrician examines a new review
Births by caesarean section are rising, worldwide. The latest figures (2016) show that 25% of births in Western Europe were by caesarean delivery; in North America it was 32%, and in South America 41%. Given these statistics, it’s not surprising that people are interested in new evidence that looks at the potential harms (and benefits) of this procedure. However, I read the latest review of the evidence with mixed feelings.
The review, published in PLOS Medicine, focused on three main outcomes: pelvic floor problems in the mother (such as urinary incontinence), asthma in the child, and death of the child in subsequent pregnancies (stillbirth or neonatal death). The headline findings were: compared with vaginal delivery, there is a decreased risk of urinary incontinence and vaginal prolapse with a caesarean delivery. There is an increased risk of asthma in children delivered by cesarean section, up to the age of 12. And pregnancy after caesarean delivery was associated with increased risk of miscarriage and stillbirth, but not of neonatal death.
As a scientist, I can appreciate the effort made in conducting a systematic review on the topic, but as an obstetrician I worry that the results can be over-interpreted by patients – not to mention obstetricians and midwives – and caesarean section “marketed” as a safe way to avoid pelvic floor problems.
The results of the study, conducted by the University of Edinburgh, are based on an analysis of the combined data (a “meta-analysis”) of one large randomised controlled trial and 79 observational studies, all from wealthy countries.
Overall, it is a well-conducted review. But there are weaknesses (which the authors acknowledge), such as not taking into account the type of caesarean section (emergency versus planned operations) and not taking into account the stage of labour when the operation was done. (Performing a caesarean section during the late stages of delivery is probably going to harm the pelvic floor in some ways.)
Driven by fears of urinary incontinence
As an obstetrician, I meet many women who are concerned about their coming delivery and have a strong wish for a safe caesarean section. They often think it is a good way to avoid the pelvic floor problems that can occur after a natural birth. The benefits of a caesarean section for preventing pelvic floor problems are widely debated on social media, and in parenthood and pregnancy magazines, which contributes to the increased demand for caesarean deliveries.
Women are well aware of the discomfort and embarrassment associated with urinary incontinence and have an understandable fear of sexual dysfunction. But despite the reported findings that suggest decreased risk with a caesarean delivery, these problems are manageable, treatable and, importantly, not life threatening.
There are, however, life-threatening risks associated with a caesarean delivery on subsequent pregnancies, including increased risk of miscarriage, stillbirth and problems with the placenta – such as placenta praevia (the placenta covering the birth canal), placenta accreta (when the placenta grows too deep into the wall of the uterus) and placental abruption (where the placenta partially or completely separates from the womb before the baby is born).
A caesarean section delivery can also affect children. The results from this latest review show that it increases the risk of childhood asthma (21% increased risk) and the risk of obesity (59%) in children up to the age of five, compared with children born by vaginal delivery.
thechatat/Shutterstock
All risks are not created equal
Clearly, it does not make sense to compare the risk of urinary incontinence, say, with the risk of a stillbirth. Obstetricians are aware of the various risks of caesarean versus vaginal delivery and should help to guide the patient in making a decision. In order to prevent any further increase in the caesarean section trend, obstetricians need to take responsibility for how this information is conveyed to patients, taking the patient’s full reproductive life into account, and also aiming to minimise the risks for any following pregnancies.
It is an educational and ethical challenge for doctors to balance the potential risk factors of current versus future pregnancies. While women are being given more choice, I don’t think that it is ethical or advisable to let the patient prioritise between different outcomes as the authors suggest. Rather, patients should be informed of all of the risks – at all life stages, for mother and child – and assess their options based on that.
Stefan Hansson, Professor in Obstetrics and Gynaecology, Lund University
This article was originally published on The Conversation. Read the original article.
[Perspectives] Natalia Kanem: lifelong advocate for women’s health and rights
”My big disappointment is that women’s rights are still not at the centre”, says Natalia Kanem, echoing her lifelong “passion and hope” for women’s health and rights. Her interest in these issues started in 1975 when, as an undergraduate at Harvard University, she attended the first UN World Conference on Women. Appointed as the Executive Director of the United Nations Population Fund (UNFPA) in October, 2017, Kanem hopes she “can really affect the fate of some of the poorest and most vulnerable women and girls in the world”.
[This Year in Medicine] 2017: a year in review
2017 was not only a year marred by conflict-driven humanitarian crises and political quagmires but also a year for biomedical innovation and women’s empowerment. Farhat Yaqub looks back.
Rural health in retrospect
As the second Chair of AMACRD, I feel that despite being a relatively new group within the AMA, we have much to be proud of. So, as 2017 turns into 2018, I look at the circumstances that surrounded us, and am glad to note that we have worked hard, we have little victories we can take credit for.
So, Rural Doctors, I invite you to commemorate all our work in the year 2017, but also to note the challenges that lay ahead.
First off, I want to address the slow internet in the Outback. We are getting attention concerning this slowly (but steadily) and have advocated consistently for improvements.
- NBN Co attended an AMACRD meeting at the time of the rollout of Skymuster II and had a good opportunity to hear our stories. We advocated to end the data drought by increasing bandwidth, reducing the cost per gb to make our data needs more affordable. We know that NBNCo has now announced larger satellite data allowances and intends giving medical practice ‘public interest premises’ status, which should improve data allowances and speed even further.
- We made a submission to the Productivity Commission for the Telecommunications Universal Service Obligation, some of which we were pleased to see was included in their Final Report
- Council members appeared before the Joint Standing Committee on the NBN, making a case for improved access to superfast broadband by describing in vivid stories what internet is like for us. I am told the stories were received with amazement.
Workforce Distribution continues to be an issue. Despite the influx of new medical graduates, there are still unfilled workforce needs in rural Australia. The concept of maldistribution is on the minds of everyone who is trying to solve this problem.
- AMA has been invited to the Distribution Workforce Working Group. This group will meet frequently to advise the Minister of Health and the Rural Stakeholders Forum with recommendations.
- We have also updated the AMA Rural Workforce Initiatives Position Statement to reflect the current state of our workforce and to offer solutions: new wet behind the ears medical graduates, bewildered overworked International Medical Graduates (IMGs) feeling unappreciated, rural health still far behind but eager to catch up.
- The Government has provided funding of up to $93.8 million from 2015-16 to 2018-19 to implement three components to support the rural pipeline that included: Regional Hubs; Rural Junior Doctor Training Fund; and Specialist Training Programme.
Infrastructure is an area where we have had some wins, but we cannot afford to relax on this front. Hospital, clinics and toilets all need walls, doors and privacy.
- Following AMA advocacy, the Government, as part of the 2016/17 Federal Budget, announced a redesign of the Rural and Remote Teaching Infrastructure Grants (RRTIGP) to create a more streamlined Rural General Practice Grants Program (RGPGP) which intends to improve uptake. AMACRD provided input to inform the Department of Health revision of the RRTIGP. The AMA will push for continued infrastructure grant funding.
- Closure of services in hospitals, especially maternity services is the trend. However there are some “wins” in Queensland with their Rural Generalist program bolstering rural obstetrics.
In the past, Rural Health has been pushed into the background, but we are beginning to see it given some attention by the Government.
- Recently at an international rural medical conference I was eavesdropping on North American attendees. They were impressed with the focus that Australia has on rural health. To quote, “They think rural health is so important they have a Federal Minister for Rural Health!”
- Now we have even gone a bigger step forward. We have a National Rural Health Commissioner, Professor Paul Worley. That should impress the International Rural community. It took an act of parliament to create this arms-length Commissioner separate from the governing bodies and he is one of us. We will have an advocate, speaking on our behalf. He will be rolling out a national Rural Generalist program and the AMA is keen to work with him.
The vexed issue of Bonded Placements has yet to be resolved, but we are seeing some developments here.
- The Government is looking at potentially reforming Return of Service (RoS) obligations on doctors working in bonded placements. This issue will continue to be developed into the new year as well. AMA is in discussions concerning this.
- We need to care for our young, as they are the next generation of doctors. If they are treated like prisoners they will rarely return voluntarily to their former jail cells.
Regarding 2018, AMACRD has additional areas it will be vigilant on including (but certainly not limited to) the following:
- Support for IMGs and doctors who are struggling with Australian Medical Council and Fellowship exams
- Monitor the development of the National Rural Generalist Pathway
- Provide input to Health care Homes, Practice Incentives Program redesign, and Medicare Benefits Schedule Reforms
- Invigilate the application of the Modified Monash Model for Rural Workforce Incentive programs
- Support our new Rural Health Commissioner
- Rural Aged Care
- Foster team work amongst Rural health care providers both medical and allied health
- Monitor the new Rural Junior Doctor Innovation Fund (a tweak on the former Prevocational GP Placement Program (PGPPP)) to see 60 Full time equivalents by 2019.
Although some of these discussions may be uncomfortable, it is essential that we keep rural health in the spotlight. I look forward to continuing to make advancements and am optimistic about AMACRD achieving more victories in 2018.
[Comment] Women in science, medicine, and global health: call for papers
Women are rising. Recent reports of sexual harassment and assault of women by men in powerful positions have regalvanised solidarity around women’s rights, and remind us that disadvantage, discrimination, and sexism are a regular part of the lived experience of many women. These reflect broader and unjustified inequalities between men and women that have persisted across time, culture, and geography. That disadvantages exist for women in science, medicine, and global health is thus unsurprising—and yet wholly unacceptable.
EU driving e-health
Estonia, which is coming to the end of its presidency of the Council of the European Union, has recently sought to bring together EU countries that would be willing to launch a project concerning the cross-border movement of healthcare data.
The Digital Health Society, initiated by the Estonian Presidency of the Council of the European Union and ECHAlliance, have assembled an e-Health Declaration that includes more than 100 European organisations’ proposals for developing e-health in Europe.
The Declaration describes the bottlenecks that hamper the development of e-health, such as the lack of people’s trust in e-services in Europe, the lack of interoperability between different information systems, the lack of a clear legal framework, inadequate training of health-care professionals. Proposing solutions for overcoming these obstacles, the document emphasizes the need for unified approaches to the development of data exchange infrastructure, raising people’s awareness of the use of e-health solutions and implementing the European Union Data Protection Regulation in a way that it does not create unnecessary obstacles to the free flow of data between member states.
At the recent e-health conference held in Estonia, European Commissioner for Health and Food Safety Vytenis Andriukaitis called for a strong partnership within the EU to move towards simplified public e-services and formalities.
This would make interactions between citizens and public administrations easier.
“Let us all work together with governments, health professionals, businesses, and researchers, but above all with the patients to make digital health in Europe a reality,” he said.
Central to the EU’s agenda on digital innovation in healthcare is: the right of citizens to access, manage and control their health data electronically in a convenient and secure manner; to better use health data, in particular for research and innovation purpose; and the better use of health data, in particular for research and innovation purposes.
Clemens Martin Auer, Director General of the Austrian Federal Ministry of Health and Women’s Affairs, said that using the opportunities of information technology in healthcare, or e-health, is one of the most important innovative drivers in the healthcare sector: “Especially for organizing the continuous care in the fragmented world of healthcare services.”
The EU acknowledges that at that level, although health competence remains the responsibility of each member state, there is a goal for a common understanding to be formed into an agreement that fixes common components and common infrastructure that enables the free flow of health data.
A number of European member states have already designed their healthcare system in order to digitalise data. The remaining member states should implement strategies and policies for the creation of electronic health records across their country in order to stimulate the innovation for health and exchanges data with other EU countries.
MEREDITH HORNE
[Comment] Where is the accountability to adolescents?
Accountability is a loaded concept. For many, the term itself has negative and punitive connotations. When it comes to accountability to adolescents—who number 1·2 billion today1—discourse is rare. Adolescents are the central promise for accelerated, lasting progress on the Global Strategy for Women’s, Children’s and Adolescents’ Health2 and the Sustainable Development Goals (SDGs). But for adolescents, who lack power, vote, and influential voice, the notion of accountability to their health, development, and rights is fragile.
My gender and my degree
BY DR DANIKA THIEMT
The first documented English-speaking female doctor was Dr James Miranda Barry, a medical officer of the British Army between 1813 and 1865. Dr Barry devoted her life to the British Army, earning the highest medical rank available: Inspector General of military hospitals. In an era when academic professions were the sole privilege of male members of society, it was necessary for Dr Barry to conceal her gender, living and practising medicine as a man. Her sad reality was exposed only posthumously where examination revealed her secret. Even in death, she was denied her right to her true identity; her gender kept secret for a further 100 years.
In Australia, medical training was opened to women in the late 1800s, and our first female graduate was registered to practice in 1891. Female medical trainees are now thriving, with female medical graduates in Australia outnumbering men since the mid-1990s. Women currently make up more than two-fifths of vocational trainees, focused largely in obstetrics and gynaecology (74.5 per cent), paediatrics (72.8 per cent) and general practice (63.1 per cent). Contrast this to the figures from oral and maxillofacial surgery, intensive care and surgery and female trainees make up less than a third of trainees. How, when we see women making up half or more of medical graduates and provisional trainees, are we still seeing unequally representation in the ongoing workforce? What is happening along the way? How and why does a speciality that starts out gender-neutral result in a specialist workforce that is predominantly male?
Fixing gender inequity in medicine requires supporting women in leadership. Diversity in the boardroom enhances corporate performance and, to advance as a profession, we need to attract and retain female leaders. Female specialists, on average, earn 16.6 per cent less than their male counterparts. Although differences in average hours worked account for some discrepancies, other contributory factors include a lack of women in senior positions and a lack of part-time or flexible senior roles. There are already inspiring and engaged female leaders within our profession, leading the world in clinical practice, medical research and education. We should be harnessing their talent to inspire the next generation.
The changing demographic of our workforce could, in part, be to blame. Trainees are graduating from medical school later and spending more time in vocational training. This leads to greater family and social pressures on trainees and possibly an increase in the need for breaks or flexible training options. Evidence shows that access to flexible training helps to retain female trainees and is desired by both female and male trainees regardless of parental status. We need to dispel the belief that trainees must choose between career and family and instead focus on how we enable trainees to have both.
Gender inequity extends beyond medical workforce.Many of my female colleagues report being mistaken for nursing or allied health staff, a rare occurrence among my male colleagues. Similarly, senior female doctors are often overlooked by patients who prefer to talk to the male junior by her side. How do women thrive in medicine and become leaders when public perception seems to favour male doctors? I watch senior medical staff respond to “Miss” in conversation rather than the respectful “Dr”. Although this seems petty in the scheme of everyday practice, it is easy for female doctors to believe that our degrees come second to our gender. Although the actions of some do not make a rule, it is time that we stand together as a profession to advance women in medicine. It is time to advocate for female leadership not only in the eyes of the profession but also in the eyes of the public.
Equity isn’t about creating a false forced equality. We aren’t all equal and that should be celebrated. It certainly shouldn’t hold us back. Opportunities to become leaders won’t be taken by all of our trainees, but they should be provided to all, regardless of gender.
(A version of this article first appeared in Emergency Medicine Australasia in 2016.)
AMA being heard over the medical indemnity concerns
AMA President Dr Michael Gannon used his National Press Club address to assure doctors and patients alike that he was keeping the issue of medical indemnity at the forefront of his discussions with political leaders.
He said medical indemnity was an area of great concern to the medical profession that has recently re-emerged.
“Some of you may remember the indemnity crisis more than a decade ago. The reforms and protections put in place by then Health Minister Tony Abbott are showing signs of stress,” Dr Gannon said.
“While back in the UK recently, I saw what could happen here again without intelligent policy.
“Medical indemnity in the UK is becoming unstable. The two major providers have pulled out of private obstetrics. There is talk of pulling out of coverage in other high risk areas.”
Dr Gannon noted that more than a decade ago, the AMA advocated tirelessly and brought together the profession to work with the Government in designing a series of schemes that have been a resounding policy success.
Those schemes have promoted stability. They provide affordable insurance, which flows through to affordable care.
That has been the AMA’s strong message heading into the current review of indemnity insurance.
“Thankfully, the Government has been receptive to our advice, and I am grateful to Health Minister Greg Hunt for listening,” he said.
“He was surprised to hear that annual premiums got as high as $126,000 a few years ago. And that’s after the support schemes’ contributions are taken into account.
“We now have a review that is focussed on improving and building on the current policy success. It is not a savings exercise.
“It removes a threat to a stable medical workforce.”
CHRIS JOHNSON