Thirty years of the World Health Organization's target caesarean section rate: time to move on.

It has been 30 years since the World Health Organization first recommended a "maximum" caesarean section (CS) rate of 15%. There are demographic differences across the 194 WHO member countries; recent analyses suggest the optimal global CS rate is almost 20%. Attempts to reduce CS rates in developed countries have not worked. The strongest predictor of caesarean delivery for the first birth of "low risk" women appears to be maternal age; a factor that continues to increase. Most women whose first baby is born by caesarean delivery will have all subsequent children by caesarean delivery. Outcomes that informed the WHO recommendation primarily relate to maternal and perinatal mortality, which are easy to measure. Longer term outcomes, such as pelvic organ prolapse and urinary incontinence, are closely related to mode of birth, and up to 20% of women will undergo surgery for these conditions. Pelvic floor surgery is typically undertaken for older women who are less fit for surgery. Serious complications such as placenta accreta occur with repeat caesarean deliveries, but the odds only reach statistical significance at the third or subsequent caesarean delivery. However, in Australia, parity is falling, and only 20% of women will have more than two births. We should aim to provide CS to women in need and to continue including women in the conversation about the benefits and disadvantages, both short and long term, of birth by caesarean delivery.

Integrating parental leave into specialist training: experience of trainees and recently graduated RANZCOG Fellows.

OBJECTIVES: To ascertain the views of trainees and recently graduated Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on their experiences of taking parental leave during specialist training. DESIGN: An anonymous online survey, conducted over a 1-month period from 16 August 2012 to 14 September 2012, of participants' experiences of taking parental leave and of the effects of parental leave taken by trainee colleagues on participants' own training. SETTING AND PARTICIPANTS: All trainees undertaking training for the Fellowship of the College, and all Fellows who had graduated in the past 6 years were invited to take part. Of the total 1051 invitees, 261 responded to the survey. MAIN OUTCOME MEASURES: Ease with which parental leave was granted, ability to return to a training post after taking leave, and participants' experiences of views expressed about parental leave in the work environment. RESULTS: Most participants requesting parental leave were able to access it and return to a training post; however, a small proportion experienced difficulties. Among female respondents who had taken parental leave, 28 (26.2%) reported being asked about their intentions for future pregnancy during the training application process, and 45 (42.1%) reported receiving negative comments about this in the work environment. CONCLUSIONS: While in most instances parental leave is accessible automatically, a small but significant number of trainees reported encountering difficulties. These matters are being addressed within our own College, and our results are likely to be relevant to all bodies involved in postgraduate medical training, particularly given the increasing feminisation of the medical workforce.

Pregnancy characteristics of women giving birth to children with fetal alcohol syndrome in Far North Queensland.

BACKGROUND: Fetal alcohol syndrome (FAS) has been identified as a major cause of impairment to normal physical and intellectual development among Indigenous children in Far North Queensland; however, little is known of the pregnancy characteristics of mothers of those children diagnosed with FAS or of interventions that might assist in lowering the prevalence of the syndrome. AIM: To review the pregnancy records of women whose infants were subsequently diagnosed with FAS by the Paediatric Outreach Service (POS) of the Cairns Base Hospital, and to determine how such women might be identified prospectively in pregnancy and offered intervention to reduce alcohol consumption. METHODS: A retrospective case-control study involving all children diagnosed with FAS by the POS between 1994 and 2006; maternal pregnancy records were accessed and details obtained. RESULTS: Mothers of cases were older, of higher parity, smoked more cigarettes, attended fewer antenatal visits and experienced more antenatal and delivery complications than mothers of controls. The average gestational age at booking was not statistically significant between the two groups. There was a significant difference between the two groups in self-reported alcohol consumption both before and during pregnancy and in numbers of women who decreased alcohol consumption once the diagnosis of pregnancy was known to them. CONCLUSIONS: There is the potential to identify prospectively women presenting for antenatal care who are heavy drinkers and risk FAS in their infants, using the self-reported information about alcohol intake already being collected by our service; such women may then be offered specific interventions to try to reduce alcohol consumption in pregnancy.