Editor-In-Chief's Introduction to ANZJOG 65(2)

Abstract

Welcome to this issue of ANZJOG. This issue contains a diverse array of articles covering many aspects of our specialty.

One of my aims for ANZJOG is to publish articles which are of direct use to clinicians in their practice. The Australian Sickle Cell Disease Working Group position statement on the management of pregnancy in sickle cell disease (SCD) by Yue et al. is a fine example of such an article [1]. This guideline provides clear and practical guidance for maternity care providers for the management of this relatively rare condition in Australia and New Zealand. SCD has significant implications for preconception, prenatal, intrapartum, and postnatal care for the mother and inheritance potential for the fetus and neonate which warrant specific consideration in order to minimise the risk of potentially serious complications. As migration patterns change the demographic of the pregnant population, we are likely to see an increase in pregnancies in women with SCD and this statement will be of benefit particularly to clinicians unfamiliar with its management before, during, and after pregnancy.

Jenkinson et al. present their evaluation of the implementation of a suite of resources for ‘partnering with the woman who declines recommended maternity care’ [2]. This paper describes the rigorous development and refinement of clinical guidance for managing this difficult clinical situation. The situation where a woman declines recommended care presents her carers with a conflict between providing what they consider as optimal care for the clinical scenario and maintain respect for the woman's autonomy. The difficulty of these situations varies enormously, influenced by a variety of factors such as the chance of an adverse outcome, the severity of such an outcome, whether the risk is primarily to the mother, the fetus, or both, the existing relationship, or lack thereof, between the woman and the carer, the urgency of the clinical situation, and the numerous psychosociocultural factors that impact clinical communication. A defined and systematic approach such as that presented allows clinicians to navigate this space more effectively, aiming to maintain a therapeutic relationship such that a woman's rights are respected and that clinical outcomes can be optimised. Clinical Excellence Queensland have made this suite of resources freely publicly available, including for adaptation for other maternity services to fit their local needs.

Aboud et al. present a single-centre review of haemorrhagic and thromboembolic complications of pregnancies to women with mechanical heart valves [3]. As long as Australia continues to struggle to reduce rheumatic heart disease in marginalised populations such as remote First Nations communities, and for decades following, we will continue to be faced with the challenge of peripartum anticoagulation management in this high-thromboembolic-risk situation. Although this study is limited by small numbers over a long study period, including 23 pregnancies to 18 women over 22 years, the data show a very high rate of haemorrhagic complications mostly secondary to anticoagulation. There was one case of valvular thromboembolism highlighting the real risk of this potentially fatal complication and the need for careful haematological management. Studies such as this provide valuable insight into the management and complications of rare pregnancy-associated conditions and should be pooled into larger databases to guide evidence-based clinical care in such cases.

Further on the topic of evidence-based practice in maternity care, Quattrini et al. present their study of Australian women's willingness to participate in medication trials in pregnancy [4]. Exclusion of pregnant women from clinical trials contributes to the existing gender gap in clinical trials and therefore health outcomes [5, 6], delays or prevents the uptake of new therapies in pregnant women, and potentially exposes women and their foetuses to risk when drugs are used without a thorough evidence basis for safety or withheld due to a lack of safety data. The authors found that women have a positive attitude toward research participation in pregnancy, typically expressing a higher tolerance for risk to the mother than to the fetus. Awareness of such attitudes is useful in the design and recruitment of pregnant women into clinical trials.

Lee et al. present their study of miscarriage care in an Australian private maternity care setting [7]. Using a mixed-methods approach, the authors found a reassuringly high level of satisfaction with the emotional support provided. They identified key themes of supportive miscarriage care, including sensitive, respectful, and acknowledging interactions, consistent and multimodal information provision, inclusion of partners, and provision of follow up and external supports as contributing to high-quality miscarriage care. These findings conflict with the existing body of literature demonstrating higher levels of dissatisfaction with miscarriage care. This is likely explained by the specific setting of this study where care was provided within a specialist maternity service. Although the quantitative findings may not be generalisable to all settings such as primary care and non-maternity hospital settings, they demonstrate the high level of care that can be achieved with appropriate service design, and the qualitative findings identify the key contributors to success that can be applied in other settings. Miscarriage is a common life experience with often underappreciated short- and long-term psychological impacts and it is important that we design services to provide emotionally sensitive and supportive care around it.

McNamara et al. present their study of postpartum contraception provision among women with substance use disorders (SUD) [8]. Women with SUD are known to use less contraception and to have more unintended pregnancies that women without SUD. The peripartum period provides an opportunity where barriers to access healthcare access that women with SUD face are temporarily reduced. The authors found evidence that this opportunity was being used to provide effective contraception, with significantly higher rates of pre-discharge contraception initiation in women with SUD compared to those without. Less ideally, still half of women with SUD were discharged without a plan for contraception, likely in many cases an opportunity missed. The authors call for postpartum contraception provision to be embedded within maternity care in order to improve access for all women, including those with access barriers such as those with SUD.

Pittman et al. describe their study of the baseline psychological wellbeing of women with uterine factor infertility [9]. Common to other people experiencing infertility, there were high rates of depression/anxiety and decreased fertility-related quality of life measures in women with uterine factor infertility, with important differences between women with congenital vs. acquired infertility. In particular, women with acquired uterine factor infertility appear to have greater impacts on quality of life than the general infertility population. These findings suggest a particularly vulnerable group of infertility patients who may benefit from enhanced psychological support.

I trust that you will find these and the remaining articles in this issue interesting.

Thank you for your ongoing support of ANZJOG.

The author declares no conflicts of interest.