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[Comment] Chasing 60% of maternal deaths in the post-fact era

In September, 2016, at the UN General Assembly, the Independent Accountability Panel (IAP) of the UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health presented their first report. The IAP report states that 60% of maternal deaths today take place in humanitarian settings, specified as “conflict, displacement and natural disaster”.1 The “60%” has been trending in development aid advocacy ever since late 2015 when UNFPA stated that 60% of maternal deaths happen in “humanitarian situations like refugee camps”.

[Department of Error] Department of Error

Unfinished business: women’s health inequality in the USA. Lancet 2016; 388: 842—In this Editorial, the name of the organisation responsible for the report into women’s health-care cover should be the “National Women’s Law Center (NWLC)”. This correction has been made to the online version as of Sept 1, 2016.

[Perspectives] Ellen Wiebe: pro-choice doctor providing peaceful deaths

Ellen Wiebe is not what you would expect from a physician who has spent her career ensuring women’s right to choose abortion and now, in her renaissance, providing medical assistance for people who are dying. Having faced down death threats, endured claims that she is a murderer, and provided 40 years of service to Canadian family medicine and research, you would think she would call herself a fighter, an activist, certainly a trailblazer. But, no. Wiebe rejects those labels and instead describes herself as just doing what is best for her patients.

[Editorial] Unfinished business: women’s health inequality in the USA

Not so long ago, women in the USA faced overt institutional sex discrimination in access to health care. “Gender rating” meant some women could be charged up to 50% more for health-care insurance than men, while many services that women required—such as sexual, reproductive, and maternity services—were often excluded from insurance plans. One of the key aims of the Patient Protection and Affordable Care Act (ACA), introduced in 2010, was to address women’s unequal access to affordable health care.

[Comment] Learning from every stillbirth and neonatal death

The period around childbirth carries the highest risk of death for a mother and her baby. Approximately half of all stillbirths and neonatal deaths are preventable with the provision of high quality, evidence-based, and timely interventions.1 Such interventions can be implemented before and during pregnancy, during labour and childbirth, and in the hours after birth.1 Three Lancet Series, Every Newborn (2014),2 Stillbirths (2011),3 and Ending Preventable Stillbirths (2016),4 highlighted interventions to reach the ambitious but achievable targets set out by the UN Sustainable Development Goals, and the WHO Global Strategy for Women’s, Children’s and Adolescent’s Health 2016–2030, to reduce preventable stillbirths and neonatal deaths worldwide.

Doctors criticise Australia’s oldest mum as ‘irresponsible’, ‘wrong’

News that a 62-year-old woman has become Australia’s oldest mum after giving birth to a daughter following IVF treatment has been criticised by some of Australia’s leading doctors.

The Tasmanian woman, who hasn’t been named, was implanted with a donor embryo in an overseas facility after undergoing several years of failed IVF procedures.

According to the Seven Network, the woman and her 78-year-old partner welcomed the arrival of the baby at Frances Perry House Private Hospital in Melbourne on Monday. It was previously reported that the woman was 63.

The baby was born at 34 weeks via a caesarean and is understood to be progressing well.

AMA President Dr Michael Gannon, an obstetrician and gynaecologist, condemned the birth on Twitter.

“This is a rights issue. Consider rights of the child, society, taxpayer. Madness. Not designed to have kids in 60s’,” he wrote in reference to a News Corp article about the topic.

Related: Don’t dismiss conflict-of-interest concerns in IVF, they have a basis

He followed up in another tweet: “63yo woman has baby. Greater priorities in . Child starts life in NICU. Anyone thought ahead to its teens? Selfish, wrong.”

Doctors criticise Australia's oldest mum as 'selfish, wrong' - Featured Image

The move was also criticised by IVF expert Gab Kovacs in News Corp newspapers.

“I think getting people of that age pregnant is irresponsible,” he said. “Our bodies weren’t designed to have children in our 60s. I don’t think any responsible IVF unit in Australia would treat someone of that age, and it’s not a standard of medicine I would condone.”

Most IVF clinics refused treatment once a woman turned 53, which is the “end of natural pregnancy”.

The previous record was held by a woman who had her first child at 60 in 2010. The oldest mother in the world was a 66 Romanian woman who gave birth in 2005.

Latest news:

[Viewpoint] Virginity testing in professional obstetric and gynaecological ethics

Doctors around the world might be asked to provide virginity testing. The ethical framework for the assessment of the physician’s role in virginity testing is based on the professional responsibility model of ethics in obstetrics and gynaecology and its three core ethical principles: beneficence, respect for autonomy, and justice. Beneficence-based objections are that virginity testing has no clinical indications and has substantial biopsychosocial risks. Autonomy-based objections are that virginity testing might be the result of social and cultural pressures that result in non-voluntary requests and, by being undertaken mainly for the benefit of others and not the female patient, impermissibly violates the patient’s human right to privacy.

[Editorial] Dear Mr Ban Ki-moon

We have greatly admired your leadership as Secretary-General of the UN. Over your 10 years heading the world’s most important international organisation, you have played an exemplary part in strengthening the global health agenda—championing awareness of women’s and children’s health, global warming, and humanitarianism. But there is one issue that concerns us deeply.

Don’t dismiss conflict-of-interest concerns in IVF, they have a basis

It’s estimated over 5 million children have been born worldwide as a result of assisted reproductive technology treatments. Assisted reproductive technology, an umbrella term that includes in vitro fertilisation (IVF), is a highly profitable global industry, and fertility clinics are increasingly regarded as an attractive investment option.

In 2014, two major IVF clinics – Virtus and Monash IVF — floated on the stock exchange. Excited financial analysts observed at the time that:

people will pay almost anything to have a baby.

Over the past 12 months, there have been numerous critical media analyses of the IVF industry in Australia, including Monday night’s ABC Four Corners program, The Baby Business. The episode suggested IVF doctors are recommending treatments that are expensive, unsafe and likely to be futile.

The following morning the Fertility Society of Australia rejected these assertions, saying:

Four Corners presented no evidence to support these claims.

One of the claims made in the program was that IVF doctors have a financial incentive to treat women with the more invasive practice of IVF. The program suggested this financial incentive conflicts with the doctor’s duty of care towards the patient.

Four Corners highlighted the conflicted nature of commercialised IVF, where some IVF doctors are more concerned about their own interests (making money for themselves or their clinics) than they are about their patients.

Not surprisingly, the Fertility Society of Australia strongly denied such conflicts of interest exist. It argued that the profession is both highly ethical and highly regulated.

Why might doctors be conflicted?

While it is certainly a big call to claim some IVF doctors may not be sufficiently committed to their patients, the possibility that practice is being shaped — at least in part — by conflict of interest cannot simply be dismissed. There are three key reasons individuals working in the IVF industry, and the industry more broadly, may be perceived to be conflicted.

First, every time a doctor advises patients to consider IVF treatment, he or she profits financially from the recommendation. While all Australian doctors receive fees for their services, many IVF doctors also own shares in assisted reproductive technology companies, so they receive passive income that reflects the amount of assisted reproductive technology the company sells.

It is also worth noting that, as employees of publicly listed companies, doctors at clinics such as Monash IVF, according to their code of conduct, must:

recognise that (their) primary responsibility is to the Company and its shareholders as a whole.

It is therefore not unreasonable for people to be concerned some clinicians may be motivated (perhaps unconsciously) by financial conflicts of interest to make decisions that may not be in the best interests of their patients.

Don't dismiss conflict-of-interest concerns in IVF, they have a basis - Featured Image

Second, there appears to be a lack of transparency about IVF success rates. Success, as measured by a live birth, is very dependent on age and the reason for seeking assistance.

In the youngest age bracket in Australia and New Zealand in 2013, the live birth per cycle rate was 27%. In the oldest it was between 1% and 5%, depending on whether a fresh or frozen egg was used. It is more likely that a cycle will result in failure than not, and some argue there is a lack of transparency about the likelihood of a live birth.

A striking example of this was seen on Four Corners when Dr Gab Kovacs, ex-medical director of Monash IVF, claimed:

I know that if you hang in there you get pregnant, because one of my patients got pregnant after 37 cycles. And, ah, so I encourage people to stay on.

While it is quite possible this woman made a fully informed decision to undergo this number of cycles, Dr Kovacs’ subsequent claim that he couldn’t say “no” and had no choice but to continue to offer the woman what she wanted inevitably makes one wonder what she knew about her real chances of success.

A third reason for concern about conflicts of interest, and one that might distinguish conflicts of interest in IVF from those in other medical settings, is the potential for exploitation of strong personal and social values associated with reproduction.

A strong discourse of hope runs through the IVF industry, and people seeking assisted reproductive technology are often very vulnerable. The profit motive of these companies has the potential to exploit these cultural norms and social pressures for ends that are not necessarily in the best interest of patients.

There are now two positions being taken: by those who consider some IVF practices are exploitative and unethical, and by those who consider that conflicts of interest are inherent in medical practice and are sufficiently well managed.

Rather than simply dismissing concerns about conflicts of interest, as the Fertility Society of Australia has just done, IVF specialists, ethicists and other stakeholders need to create a forum in which these concerns can be discussed openly and constructively.

The Conversation

Jane Williams, Doctoral student at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney; Brette Blakely, Post-Doctoral Research Fellow; Christopher Mayes, Post-Doctoral Fellow in Bioethics, University of Sydney, and Wendy Lipworth, Senior Research Fellow, Bioethics, University of Sydney

This article was originally published on The Conversation. Read the original article.

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[Comment] Tocolysis and preterm labour

With 15 million premature babies born worldwide every year, premature birth is the biggest problem in obstetrics.1 It is not only the most common reason that newborn babies die,1 but is also an important cause of long-term brain, bowel, lung, and eye damage. Antenatal steroids reduce the risk of lung disease, intracranial bleeding, and death2 and magnesium sulphate reduces cerebral palsy.3 Obstetricians often also prescribe uterine relaxant, or tocolytic, drugs to delay birth, albeit without much evidence to support this practice.