Editor-In-Chief's Introduction to ANZJOG 65(3)

Abstract

Welcome to this issue of ANZJOG. This issue has several articles of public health importance in both obstetrics and gynaecology.

Dietz et al. contribute an opinion piece regarding birth trauma, with a particular reference to the 2024 NSW Upper House Select Committee Inquiry [1]. They rightly raise the issue of informed consent and shared decision-making in intrapartum care. This is a longstanding issue of clear medicolegal significance and an undoubted source of anxiety for those of us in active intrapartum obstetric practice. The authors suggest that ‘It should be apparent to everyone that the main problem is a lack of obstetrician involvement in antenatal care leading to poor patient preparedness and an absence of informed consent when intervention becomes necessary’ and they are critical of the recommendation for the ‘prioritisation of a midwifery-led model of care’. They are further critical of RANZCOG's contribution to the Birth Trauma Inquiry and its previous endorsement of an RCOG guideline on instrumental vaginal birth. This is an oversimplification of a much more nuanced topic.

I am mindful of the authors' substantial backgrounds in obstetric somatic trauma and informed consent for vaginal birth and I accept that their opinion piece is not intended to include an extensive review of the evidence basis for the prevention of birth trauma and informed consent around birth, nor of the impact of varying models of care upon them. However, despite their criticism of women who have suffered harm from obstetric intervention using the term ‘obstetric violence’ as ‘offensive, vexatious, and inflammatory’, their own language describing midwifery-led care as ‘the patient dying of poisoning’ is surely equally offensive to some. In particular, this appears to ignore the substantial body of evidence demonstrating the benefit of midwifery continuity of care models, not least a reduction in both caesarean section and instrumental vaginal birth [2], and the importance of outcomes other than ‘medical care, morbidity, and mortality’. Such attitudes and language contribute to disenfranchisement of an important proportion of midwives and pregnant women with obstetricians, driving an ‘us and them’ mentality which is counterproductive to the truly collaborative maternity care which can only be achieved when midwives and obstetricians work in a mutually respectful environment. It is only when we recognise that our two craft groups each rely upon the other to provide safe maternity care, optimising all relevant outcomes for mother, infant and their support networks, that we will be able to realise those outcomes. The authors call for better provision of information about birth outcomes to allow women to make informed decisions is entirely appropriate, but these must be made in the context of open and respectful dialogue.

Moore et al. present their study of the management of syphilis in pregnancy in South-East Queensland [3]. They report that mechanisms in place were effective in ensuring treatment administration and response assessment were completed in all women identified. This provides reassurance that once pregnant women with syphilis are identified, revised guidelines and dedicated surveillance ensure effective treatment is provided. Despite this, the rise in congenital syphilis remains incompletely abated, with the persistent challenge being identification of cases early enough in pregnancy for treatment to be effective, made particularly difficult by the disproportionate prevalence of active syphilis in socially disadvantaged women with additional barriers to accessing early pregnancy care and screening.

Pynaker et al. report their study of the opinions of Australian healthcare providers and consumers regarding public funding for non-invasive prenatal testing (NIPT) [4]. They identified very strong support among responding clinicians and consumers for public funding of NIPT given perceptions of financial cost representing a substantial barrier to equitable access to this screening. Respondents indicated equity, ethical, clinical and health economic justifications for public funding. The study identified important demographics differences between NIPT users and non-users, highlighting sociodemographic indicators, particularly those of disadvantage, as associated with lower NIPT use. The rapid and widespread uptake of NIPT as a primary aneuploidy screening shows women's preference for this methodology and the authors make a convincing case for public funding to remove financial barriers to equitable access.

Anderson et al. present their economic assessment of maternity and newborn care in New Zealand [5]. Their data show the large financial cost of the provision of this care overall, and the substantial additional burden of preterm and multiple births. Such studies demonstrate the value of preventive strategies to reduce preterm and multiple births, informing policy and healthcare decision-making around reproductive and neonatal technologies.

Rose et al. present their study of participants' experiences of an HPV detected result prior to the national rollout of primary HPV cervical cancer screening in Aotearoa New Zealand in 2023 [6]. Online survey respondents described anxiety on receiving an HPV detected result, with fear of a cancer diagnosis being commonly reported, indicating the need for clear information provision prior to screening and on receipt of an abnormal result. Participants were supportive of the provision of multiple screening techniques including self-collection, highlighting this as an important strategy to increase screening uptake. This study provides valuable information to guide the public education strategies around cervical cancer screening specific to the New Zealand setting.

This issue includes two studies of the COVID-19 pandemic response and maternal outcomes of infection during pregnancy. Forster et al. evaluated the changes to maternity care provision in Victoria during the pandemic [7]. They found considerable variation in changes to antenatal care provision, with different approaches between services to telehealth and face-to-face appointment schedules and to antenatal screening strategies such as blood pressure and fetal wellbeing assessments. There remains little consensus as to the optimal provision of maternity care in a pandemic setting, which is of significant concern given the important changes in perinatal outcomes observed over the pandemic period which may be directly related to the provision of antenatal care [8-10]. Strategies to the safe delivery of maternity care as part of a pandemic response are required in order to inform pandemic preparedness for the future.

Barnes et al. report the outcomes of pregnant and postpartum women admitted to Australian intensive care units with COVID-19 between March 2020 and June 2023 [11]. Peripartum women made up 23% of all women aged under 45 years positive admitted to ICU with COVID-19 in the study period, with 29% requiring mechanical ventilation. Vaccination rates were lower in peripartum women than non-pregnant women, but they were younger, had lower rates of comorbidities, and were more likely to receive tocilizumab therapy, with these protective factors likely explaining the significantly lower rate of mortality in peripartum women despite lower vaccination rates.

Munn et al. present their overview of the evidence surrounding the short- and long-term effects of prenatal cannabis exposure on fetal growth and development, neonatal conditions, later-life offspring outcomes and maternal outcomes [12]. The authors found a potentially harmful impact of prenatal cannabis exposure in all these domains, albeit with mixed evidence in some. Evidence was most consistent for an adverse impact on fetal outcomes. The authors conclude that cannabis use should be avoided in pregnancy due to the range of adverse outcomes.

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

Thank you for your continued support of ANZJOG.

The author declares no conflicts of interest.