more_vertThere are many uncertainties in global health. Major policy changes risk affecting women’s reproductive health, internal displacement and refugee crises are raging in many parts of the world, and weak public health systems are not readily responsive to emerging health threats. Many countries face fragility, conflict, and economic upheavals. But there is also inspiration and hope in the amazing resilience of communities, as seen in post-Ebola west African countries, and in the power of voice and collective action among informed citizens who are advocating for sexual and reproductive health and rights for all women.
Preference: Obstetrics and gynaecology and women's health
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[Editorial] Prospects for neonatal intensive care
In today’s Lancet we publish a clinical Series on neonatal intensive care in higher resource settings. The Series, led by Lex Doyle from The Royal Women’s Hospital in Melbourne, VIC, Australia, includes new approaches to the old nemesis of bronchopulmonary dysplasia (which still affects up to 50% of infants born before 28 weeks’ gestation), discusses the delicacy of fine-tuning interventions in response to evolving evidence, and explores the frontier of nutritional research by referring to preterm birth as a nutritional emergency.
Maternal vaccine highly effective against pertussis
A large US study is the first to provide strong evidence that vaccinating expecting mothers against pertussis protects their newborns.
Data from nearly 150,000 newborns born between 2010 to 2015 showed a 91% efficacy of a maternal vaccine during the first two months of life – a crucial period since babies are only vaccinated at two months.
In the study, of 17 cases of pertussis recorded in the first two months of life, only one involved a newborn whose mother had been vaccinated before birth.
Maternal vaccination continued to protect even after the newborn had been immunised, with a 69% efficacy over the entire first year of life.
The researchers from Kaiser Permanente in Oakland, California, found no evidence of interference between maternal and newborn vaccines.
“The strategy of immunising pregnant women to boost maternal antibody transfer appears to be more effective for protecting young infants against pertussis than are attempts at ‘cocooning’ in which mothers and other persons in close contact with newborns are vaccinated,” they write in the journal Pediatrics.
In Australia, which has one of the highest reported rates of pertussis in the world, the immunisation handbook was updated in 2015 to include a recommendation to vaccinate pregnant women in their third trimester, regardless of their vaccination history.
Although this recommendation, coupled with new funding, significantly boosted vaccination uptake, over a quarter of pregnant women in Australia are still not vaccinated during their pregnancy, report Melbourne researchers writing in the ANZ Journal of Obstetrics and Gynaecology.
The most common reasons for pregnant women not getting vaccinated are that their healthcare provider doesn’t offer it or that they are unaware of the recommendation, the researchers found.
Social media could play a role in boosting vaccination rates in pregnant women, they suggest.
You can read these two studies in the journals Pediatrics and the ANZ Journal of Obstetrics and Gynaecology.
[Editorial] Gynaecological care: delivering the real essentials
Nearly 50% of women with fibroids and endometriosis in the UK were not told about the short-term or long-term complications from their treatment according to a survey of 2600 women published in a new report on barriers to women’s health care. The report, published on March 28, 2017, by the UK’s All Party Parliamentary Working Group on Women’s Health, also describes how 42% of women surveyed who had fibroids and endometriosis felt that they were not treated with dignity and respect. The experiences of patients with these common gynaecological conditions could potentially affect millions of women in the UK.
Delays and confusion cloud roll-out of new cervical cancer screening program
Australia’s new national cervical cancer screening program has had a bad week.
The government announced it would delay the May 1 roll-out of its new program until Dec 1, 2017. And a petition opposing the new program swept social media.
But it’s not all bad news. The delay gives the Standing Committee on Screening, which is responsible for implementing the new program, the chance to engage with the public and communicate why the changes are being made and what they mean.
If the online petition is anything to go by, this is badly needed to counter the widespread misunderstanding of the new cervical screening program and the role of human papillomavirus (HPV) in causing cervical cancer.
How did we get here?
In 2014 the Medical Services Advisory Committee recommended the national cervical screening program be “renewed” to provide better protection against cervical cancer.
Key changes included raising the screening age to 25 and replacing Pap tests every two years with HPV tests every five years. The HPV test is more accurate than the existing Pap test, which looks for abnormal cells on the cervix rather than HPV, and its accuracy means it is safer for women to go longer between tests.
Another important change is setting up a national cancer screening register to record people’s cervical cancer screening histories.
But last week, Commonwealth Chief Medical Officer Brendan Murphy announced the Telstra Health-managed register would not be ready for May.
As a result, the new cervical screening test will not be made available on the Medicare Benefits Schedule from May 1; instead, the health department advised women continue to be screened using the existing Pap test.
Online petition shows women want to know more
The past week saw 70,000 people (so far) sign an online petition opposing the changes to the cervical screening program.
The letter accompanying the petition, since removed, unfortunately misrepresented the effectiveness of screening women under the age of 25, the role of HPV as the cause of cervical cancer and the rationale behind the new screening program.
The petition struck a chord and quickly gathered steam.
In an interview, the person behind the petition said she was motivated by “concern and worry”, because “[she] didn’t know about it and no one seemed to know about it”, and because “[she’d] love someone to be able to get down on our level and explain the testing”.
Responses to her petition indicated widespread concern about safety of the new starting age and the wider screening interval. In addition, women perceived the renewed program as a cutback – that less screening is being driven by cost-savings rather than the availability of a better test.
A response from Michael Gannon for the Australian Medical Association provided a large number of facts.
It also portrayed the petitioners as “well-intentioned […] but woefully misinformed and misguided”, but did not respond to the factors motivating the anger in many petition comments.
How to handle concerns?
Petitioners’ concerns should not be dismissed. If the public is “misinformed and misguided” about changes to cervical screening, it is the result of a failure to effectively communicate the changes and their rationale.
An implementation phase was to be undertaken that included engaging with the public to assess acceptability and educating clinicians and women about the changes. No public information has been released about this phase, so it is not clear what has been done or who may have been consulted.
Other countries that have introduced HPV testing to their cervical screening programs have noted the importance of responding to women’s concerns around screening changes, especially when and how they receive information about HPV. Research also
highlights some people’s reluctance to accept less-frequent screening.
How do we communicate change?
Screening programs generally change because the evidence about screening changes. It’s a good thing for screening programs to be responsive, to make adjustments when it becomes apparent harms may be occurring, or that benefits can be retained with less burden on participants and the health system.
Now, with the delay to the cancer screening register, there is an opportunity to take seriously the responsibilities of a screening program to communicate well with the population it serves.
The epidemiology that guides screening is complex, but its simple communication is a vital part of any public health program. Good communication and understanding what matters to stakeholders are as important as the scientific evidence that programs are based on.
In this case, a reasonable message to take from the petition opposing the renewal is that communication and consultation have not been sufficient or effective.
Unfortunately, this seems to have become a feature of Australian health policy. For instance, last year people were confused about pathology rebates and GP rebate freezes.
Meaningful public engagement and communication are neither easy nor cheap, but shying away from them is not an acceptable response.
Jane Williams, Researcher at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney and Sally Wortley, Research Fellow and PhD candidate School of Public Health, University of Sydney
This article was originally published on The Conversation. Read the original article.
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Women don’t always get what they want from labiaplasty
Labiaplasty is the most common form of female genital cosmetic surgery and involves surgical reduction of the labia minora or the inner lips of the vulva.
However we still don’t really know what impact the procedure has on the lives of women who choose to have it. This is not that surprising given female genitals are still considered taboo. The words “vulva” and “vagina” are difficult to say for most people, never mind an entire discussion on the topic!
But these questions can be addressed through research. Our latest study shows although women are pleased with how their genitals look after labiaplasty, their self-esteem and general sexual confidence do not improve. This sort of information is vital to help women weigh up whether labial surgery is the right option for them.
Rising rates of labiaplasty
Labiaplasty has become increasingly popular over the last 10-15 years in Western countries, including in Australia. From 2001 to 2013, the number of these procedures more than doubled from 640 to 1,605 in public patients across Australia. These numbers do not include women undergoing procedures in the private sector, for whom we have no national data.
In NSW specifically, numbers in both public and private hospitals rose from 256 in 2001 to 421 in 2013, representing a total increase of 64%.
Although there is a common misconception teenagers are the age group most interested in labiaplasty, women are most often aged between 25 and 34 when they undergo surgery.
Why do women have ‘the Barbie surgery’?
Although there are physical or functional reasons for having labiaplasty (discomfort participating in sports like cycling or during sexual intercourse), most women do it due to reported unhappiness with their genital appearance.
Women desire a smooth genital surface, with labia minora (the inner lips) that do not protrude beyond the labia majora (the outer lips). As a result, this surgery is sometimes nicknamed the “Barbie surgery” as these dolls have no obvious genital features.
The way women’s genitals are portrayed in the media – particularly in pornography and on the internet – may be promoting this “ideal”. And men appear to be picking up on this too, prompting some to criticise their partner’s genitals. As a result, an increasing number of women are becoming concerned their genitals are unacceptable and need to be surgically altered.
But what happens to women after undergoing labiaplasty – do they really get what they were hoping for?
Labiaplasty won’t fix your sex life
In our most recent research published in Plastic and Reconstructive Surgery, we applied a forward-looking study design to examine psychological outcomes of labiaplasty. We found women experienced significant improvements in satisfaction with their genital appearance from pre- to post-surgery. But we found no significant improvements in any other psychological domains, such as self-esteem and sexual confidence.
Labiaplasty is often advertised online as a way for women to restore self-confidence and esteem, and improve their sexual relationships: our results suggest this is not necessarily the case. Instead, it appears although labiaplasty allows women to stop worrying about their genital appearance, it does not radically change how they view themselves and their intimate relationships.
Our research was the first to examine preoperative characteristics of women who are likely to be dissatisfied with their surgical outcomes. We found women who were more psychologically distressed – showing depression and anxiety symptoms in particular – or were currently involved in an intimate relationship were more likely to be dissatisfied after labiaplasty.
Although further investigation is required, we reasoned these women may have had unrealistic expectations for how labiaplasty might improve their psychological well-being or their relationship with their partner, and when this did not happen, they were dissatisfied.
It’s important for doctors to be able to identify these women before they undergo labiaplasty so they can be guided into another form of treatment that may be more beneficial, such as psychological therapy.
Avoiding disappointment after surgery
It looks like most women are getting what they want out of labiaplasty in terms of becoming more comfortable with their genital appearance.
But when women have unrealistic expectations for improvements in other areas of their lives such as their self-esteem and sexual relationships, they are more likely to be disappointed. For this reason, we recommend doctors thoroughly explore their patients’ motivations and expectations for labiaplasty so women can get treatment that will best address worries about their genital appearance.
Now we’ve started to identify some of the issues related to women’s dissatisfaction with labiaplasty, we hope our findings might assist doctors when they’re considering a patient’s suitability for cosmetic genital surgery.
Gemma Sharp, PhD candidate (submitted), Flinders University and Julie Mattiske, Senior Lecturer , Flinders University
This article was originally published on The Conversation. Read the original article.
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Five traps to be aware of when reading success rates on IVF clinic website
A recent review of in-vitro fertilisation treatment (IVF) clinics in Australia, conducted by the Australian Competition and Consumer Commission (ACCC), identified some misleading ways they present people’s chances of a having a baby on their websites.
Clinics provide IVF success rates in often confusing ways because there is no agreed format on how this information should be presented.
This article was originally published on The Conversation. Read the original article.
Our recent audit, presented at a recent conference of the Fertility Society of Australia, reviewed the success rates published on the websites of IVF clinics in Australia and New Zealand. It identified some common traps in the way these figures are presented. Below are five things consumers should be aware of when visiting IVF clinic websites.
But first, a bit about IVF.
IVF treatment involves several steps: fertility drugs to develop a number of eggs, retrieving the eggs, adding sperm to the eggs for embryos to develop and finally, an embryo transfer (ET). The ET involves an embryo being placed in the uterus, where it hopefully implants and grows into a baby.
Unfortunately, things can go wrong in each of these steps. The woman might not respond to the fertility drugs, eggs may not be recovered and embryos may not develop or implant. And even if the embryo does implant and what is known as a clinical pregnancy is established, there is still a risk of miscarriage.
1. How do clinics define ‘success’?
One clinic can look much more successful than another because of the way they measure success. It is important to know whether a clinic’s success is defined as a clinical pregnancy or a live birth. And whether the success rate figures are per started treatment cycle or per embryo transfer.
As an example, let’s say 100 women start a treatment cycle. 75 of them have an embryo transfer, 25 have a clinical pregnancy and 20 give birth. The rate of the pregnancy per embryo transfer then is 33%. But the live birth per started treatment cycle is only 20%.
Regardless how success is reported, the outcome is the same: of the 100 women who started a treatment cycle, 20 had a baby.
Our recent audit found most clinics quote pregnancy per embryo transfer rates. This does not account for women who don’t get eggs or embryos, or the 20% of women who get pregnant but miscarry.
2. Is there information about the impact of age?
The most important factor in IVF success is the age of the woman undergoing treatment. For women in their early 30s, the chance of having a baby per started treatment cycle is about 25%, but it drops to only 6% after age 40.
Most clinics mention that a woman’s age affects the chance of success but our audit found one in five clinics didn’t.
3. Does the website say your health matters?
There is clear evidence parental obesity, smoking and other health behaviours affect the chance of conceiving spontaneously, as well as the health of the baby at birth and in the future. But people may not be aware these factors also affect the chance of having a baby with IVF.
We were concerned to find only one in ten websites mentioned the impact of potentially modifiable lifestyle factors on the chance of IVF success. This may be a missed opportunity. People who consider IVF are highly motivated to have a baby and knowing early there are things they can do to improve their chances could be an incentive to improve their health before treatment.
4. Is it obvious you may need several treatment cycles?
While clinics advertise success rate figures in more or less transparent ways, the reality is that most IVF cycles fail. People often need several treatment cycles to have a reasonable chance of having a baby.
For most people, the ultimate chance of having a baby increases for each additional cycle, (up until five cycles).
So it’s helpful to have a series of treatments in mind rather than expecting immediate success when embarking on IVF. That way expectations may be more realistic and people may be more likely to try again if treatment fails.
5. Are there lots of baby images?
Many clinics use images of cute babies on the pages where chance of success is described. Linking success rate figures to such images can make people susceptible to overestimating the potential of having a baby from treatment.
People who need IVF to have a family are particularly vulnerable, as they are staring down the barrel of physically, emotionally and financially demanding treatment to have what most of us expect to achieve in the privacy of our bedroom. Ensuring they receive the most accurate and realistic information of what is possible with IVF should be every clinic’s goal.
This article was co-authored by Louise Johnson, CEO of the Victorian Assisted Reproductive Treatment Authority (VARTA). VARTA provides independent information and support to those looking into the use of assisted reproductive technologies, such as IVF. More information about how to interpret clinic success rates can be found here.
Karin Hammarberg, Senior Research Fellow, Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash University.
This article was originally published on The Conversation. Read the original article.
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News briefs
Can assisted reproduction lower birth defects for older mothers?
Research from the University of Adelaide suggests that babies born to women aged 40 and over from assisted reproduction have fewer birth defects compared with those from women who conceive naturally at the same age. Published in BJOG: An International Journal of Obstetrics and Gynaecology (doi: 10.1111/1471-0528.14365) the research, led by Professor Michael Davies from the Robinson Research Institute, was based on data of all live births recorded in South Australia from 1986-2002, including more than 301 000 naturally conceived births, as well as 2200 births from in vitro fertilisation (IVF) and almost 1400 from intracytoplasmic sperm injection (ICSI). The average prevalence of a birth defect was 5.7% among naturally conceived births, 7.1% for the IVF births, and 9.9% for the ICSI births, across all age groups. In births from assisted reproduction, the prevalence of birth defects ranged from 11.3% at its highest for women less than age 30 using ICSI, down to 3.6% for women aged 40 and older using IVF. For natural conceptions, the corresponding prevalence across age groups was 5.6% in young women, increasing to 8.2% in women aged over 40 years. “There is some aspect of IVF treatment in particular that could be helping older women to redress the maternal age issues we see among natural conception, where we observe a transition at around the age of 35 years toward a steadily increasing risk of birth defects,” Professor Davies said. “We don’t know what that is quite yet – it could be an aspect of hormonal stimulation that helps to reverse the age-related decline in control of ovulation. More research is desperately needed in this area to understand why this is occurring, and whether it could be adapted to both fertile and infertile women in future to prevent birth defects, which continue to be a major cause of death and disability in the first year of life globally.”
Growing association between obesity and cancer
A new literature review by the International Agency for Research on Cancer published in the New England Journal of Medicine (doi: 10.1056/NEJMsr1606602) has concluded that “having lower overall body fat lowers the risk of developing eight tumor types: cancers of the gastric cardia, liver, gallbladder, pancreas, ovaries, and thyroid, in addition to multiple myeloma and meningioma”, according to a commentary published in the Journal of the National Cancer Institute (doi: 10.1093/jnci/djw243). The review brings the list to 13 following the IARC’s 2002 report which found evidence that the risk of being diagnosed with colorectal cancer, adenocarcinoma of the oesophagus, renal cell carcinoma, postmenopausal breast cancer, and uterine cancer was lower among non-overweight people. “The association between obesity and cancer is still not common knowledge. When people think of obesity, they think of diseases such as diabetes and cardiovascular issues,” said one of the IARC authors.
[Comment] Quality, equity, and dignity for women and babies
This Lancet Series on maternal health1–6 comes just 1 year after countries committed to the Sustainable Development Goals (SDGs). The SDGs call on all stakeholders to leave no one behind in addressing the unfinished agenda for maternal and child health. The Global Strategy for Women’s, Children’s and Adolescents’ Health (Global Strategy)7 calls for integrated solutions to prevent maternal, newborn, and child deaths and stillbirths and to realise a world where women and children thrive and transform their communities and nations.
[Department of Error] Department of Error
Chen D, Cui S, Liu C, Qi H, Zhong N. Stillbirth in China. Lancet 2016; 387: 1995–96—The affiliation of Caixia Liu should read “Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University”. This correction has been made to the online version as of Oct 13, 2016.