The effectiveness of continuous positive airway pressure for treating obstructive sleep apnoea in pregnancy: A systematic review.

BACKGROUND: Obstructive sleep apnoea (OSA) occurs in 15-20% of pregnant women living with obesity. As global obesity prevalence increases, OSA in pregnancy is concurrently increasing, yet remains under-diagnosed. The effects of treating OSA in pregnancy are under-investigated. AIM: A systematic review was conducted to determine whether treating pregnant women with OSA using continuous positive airway pressure (CPAP) will improve maternal or fetal outcomes, compared with no treatment or delayed treatment. MATERIALS AND METHODS: Original studies in English published until May 2022 were included. Searches were conducted in Medline, PubMed, Scopus, the Cochrane Library and clinicaltrials.org. Maternal and neonatal outcome data were extracted, and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach (PROSPERO registration: CRD42019127754). RESULTS: Seven trials met inclusion criteria. Use of CPAP in pregnancy appears to be well tolerated with reasonable adherence. Use of CPAP in pregnancy may be associated with both a reduction in blood pressure and pre-eclampsia. Birthweight may be increased by maternal CPAP treatment, and preterm birth may be reduced by treatment with CPAP in pregnancy. CONCLUSION: Treatment of OSA with CPAP in pregnancy may reduce hypertension and, preterm birth, and may increase neonatal birthweight. However, more rigorous definitive trial evidence is required to adequately assess the indication, efficacy, and applications of CPAP treatment in pregnancy.

A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to?

BACKGROUND: Severe maternal morbidity or maternal near miss (MNM) events can have significant consequences for individuals, their families and society and the study of these events may inform practices to reduce future adverse pregnancy outcomes. AIMS: To review the scope of MNM studies undertaken in Australia, New Zealand, South-East Asia and the South Pacific region. MATERIALS AND METHODS: A systematic search of four online databases (MEDLINE, EMBASE, SCOPUS and CINAHL) and the World Health Organization Library was conducted to identify all relevant studies published between 1 January 2011 and 31 December 2020. The studies were reviewed and included if they assessed MNM using a composite outcome or a predefined set of indicators. RESULTS: The literature search yielded 143 articles of which 49 are included in this review. There were substantial differences in the monitoring approach to MNM in the Australasian region. Overall rates of MNM in the region ranged from two to 100/1000 births and the most common aetiologies identified were direct obstetric causes such as postpartum haemorrhage, pre-eclampsia and sepsis. Multidisciplinary review indicated a substantial number of MNM cases were preventable or amenable to improved management, mostly from a provider perspective. CONCLUSIONS: Assessment of MNM is an important part of the evaluation of maternity care provision. Reaching a consensus on indicators and how best to collect information will allow a more discerning assessment of MNM including longer-term health outcomes, aspects of preventability and financial implications for health services.

Views and practice of abortion among Queensland midwives and sexual health nurses.

BACKGROUND: A significant barrier to the access of safe abortion is the lack of trained abortion providers. Recent studies show that with appropriate education, nurses and midwives can provide abortions as safely as medical practitioners. AIMS: To examine the attitudes and practices of registered midwives (RMs) and sexual health nurses (SHNs) in Queensland toward abortion. MATERIALS AND METHODS: A cross-sectional mixed-methods questionnaire was distributed to RMs and SHNs from the Queensland Nursing and Midwifery Union. Data were described and analysed both quantitatively and qualitatively. RESULTS: There was a 20% response rate (n = 624) to the survey from the overall study population. There were 53.5% who reported they would support the provision of abortion in any situation at all; 7.4% held views based on religion or conscience that would make them completely opposed to abortion. There were 92.9% who felt that education surrounding abortion should be part of the core curriculum for midwifery and/or nursing students in Australia. The qualitative responses demonstrated a variety of views and suggestions regarding the practice of abortion. CONCLUSIONS: There was a wide variation in views toward induced abortion from RMs and SHNs in Queensland. While a proportion of respondents opposed abortion in most circumstances, a significant group was in support of abortion in any situation and felt involvement in initiating and/or performing abortion would be within the scope of RMs and SHNs.

Australian medical students' and junior doctors' perceptions of gender discrepancies in obstetrics and gynaecology.

BACKGROUND: There is currently a gender imbalance 85:15 female/male in the intake into specialist training for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). AIMS: To determine the views and perceptions of Australian medical students, and junior doctors in the first five years of practice, toward obstetrics and gynaecology (O&G) as a career, including whether there are any perceived barriers to the pursuit of such a career. MATERIALS AND METHODS: A semi-structured questionnaire was developed with members of the RANZCOG Gender Equity and Diversity Working Group There were two separate studies: the first involved telephone interviews of medical students across three campuses of a medical school in North Queensland. The second study surveyed junior doctors in Queensland who are members of the Australian Medical Association. Responses were analysed and compared using quantitative and qualitative methods. RESULTS: Both studies found that experiences with O&G as a medical student influenced the decision to pursue O&G as a career. Exclusion from clinical scenarios and difficulty establishing good relationship with midwives within busy birthing suites were some reasons deterring male students from O&G. In addition, students felt poorly informed about the specialty in their preclinical years, affecting their early decisions in choice of specialty. Post-rotation, more female than male students reported positive experiences and were considering O&G as a career. CONCLUSIONS: Both groups see medical student experience as critical in attitudes toward the specialty as a possible career. This experience plays a significant role in encouraging female students toward a career in O&G and discouraging male students. More exposure to the specialty in the preclinical years, and attention to improving clinical rotations for all students, is required.

Abortion education in Australian medical schools.

This aim of this study was to gain an updated perspective of the teaching and learning experiences of abortion care among Australian medical students. All 2020 Australian final-year medical students were invited to complete a 12-question cross-sectional electronic survey. While it appears that abortion care is taught in most Australian medical schools, in some it is not, and where the topic is presented, structured and standardised teaching is still lacking. Students' confidence around abortion care once they are in practice is low, and the majority of students showed a strong desire to have more direct abortion placement exposure. The current abortion curriculum in Australia needs revision and refinement.

Induced abortion in Papua-New Guinea: Experience and opinions of health professionals.

BACKGROUND: Papua-New Guinea (PNG) has one of the highest maternal mortality rates in the world; complications due to unsafe abortion are an important cause. Abortion laws are restrictive, and safe, induced abortions are unavailable to the majority of women, while unsafe abortions are known to be practised throughout the country. The topic of abortion is stigmatised, for women and health professionals. AIM: To conduct a study of PNG health professionals' experience of induced abortion and their views on the provision of safe, accessible abortion services for PNG women. MATERIALS AND METHODS: A questionnaire developed from similar surveys conducted in Australia and New Zealand was distributed in 2017 to doctors working in provincial hospitals of the public health system; in 2020, the questionnaire was distributed to doctors and nursing staff in Port Moresby General Hospital, and to medical, nursing and health sciences students in the University of Papua-New Guinea. RESULTS: Significant numbers of senior medical officers and nurses reported experience of women presenting following unsafe induced abortion. There was wide variation across all respondents with regard to accurate knowledge of PNG's abortion laws, and to views on the provision of safe accessible abortion services in the country's public health system. CONCLUSIONS: Abortion training for service providers and provision of primary care services are necessary to ensure that PNG women have equitable access to abortion care instead of seeking out untrained providers or attempting self-abortion. Innovative approaches also need to be adopted to complement family planning efforts in PNG.

Clinical experience of trainees of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists in insertion of long-acting reversible contraceptives.

BACKGROUND: Long-acting reversible contraceptives (LARCs) include both progestogen-containing implants and intrauterine devices releasing either a progestogen or copper, providing highly effective contraception. Increasing uptake of LARCs is advocated by governments and professional organisations as an important strategy to reduce unintended pregnancy; such uptake requires, among other measures, adequate training of doctors in the areas of obstetrics and gynaecology and women's health. AIMS: To assess The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees' (Fellowship, Diploma or Certificate of Women's Health) experience and training in insertion and removal of LARCs. MATERIALS AND METHODS: An invitation email to participate in an anonymous survey approved by the Continuing Professional Development Committee of RANZCOG was sent to all current RANZCOG trainees in the three categories. The responses were categorised and analysed. RESULTS: Of 1686 invited trainees, 294 (17.4%) responded: 250 in Australia and 44 in New Zealand; 127 were undertaking Fellowship training (8.3% of those invited) and 166 (100% of those invited) were undertaking training for the Diploma (either DRANZCOG and DRANZCOG Advanced) or the Certificate of Women's Health. Significant numbers of all categories of trainees had no or limited experience of insertion or removal of LARCs of all types and/or lacked self-confidence in LARC provision. CONCLUSION: RANZCOG needs to address this training deficiency to continue as the leader in Australia in the provision of women's reproductive healthcare.

Scleroderma in Cairns: an epidemiological study.

BACKGROUND: Systemic sclerosis (SSc) refers to an autoimmune fibrosing disorder with high disease burden and mortality. The prevalence of 23/100 000 in South Australia (SA) is among the highest documented, but anecdotally it is higher still in Cairns. AIMS: To ascertain the prevalence of SSc in Cairns and surrounding regions, and to compare the demographic and clinical characteristics of patients with SSc in Cairns with those in SA. METHODS: Patients with SSc in Cairns were ascertained through hospital records and by referrals from specialist physicians in the region. These patients were interviewed and completed a structured questionnaire. Their physical findings and autoantibodies were recorded. These patients were compared with the SA patients enrolled in the Australian Scleroderma Cohort Study. RESULTS: A total of 81 patients was identified in Cairns, giving an estimated cross-sectional prevalence of 33.7/100 000. Among 65 patients interviewed in Cairns, 23 were born in Cairns, 16 had migrated to Cairns to ameliorate their Raynaud phenomenon and 26 for other reasons. The clinical features in both cohorts were similar, although Cairns had a lower prevalence of digital ulcers (30.8% vs 46.6%; odds ratio (OR) = 0.5035, 95% confidence interval (CI): 0.2839-0.8929, P = 0.0271) and higher prevalence of calcinosis (29.2% vs 17.0%; OR = 2.005, 95% CI: 1.055-3.382). CONCLUSIONS: The higher prevalence of SSc in Cairns is partly, but not completely, due to migration. Differences in clinical features are not entirely explained by the warmer climate. There is a need for greater rheumatologic services in the Cairns region.

Views and practices of induced abortion among Australian Fellows and trainees of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists: A second study.

OBJECTIVES: Knowledge of current practices of abortion is important for planning of health services in Australia and for future training. AIMS: To conduct an online survey of the Fellows and specialist trainees of RANZCOG regarding their views and practices of induced abortion and compare these with results of a similar study from 2010. METHODS AND MATERIALS: A questionnaire was distributed to Australian Fellows and specialist trainees. Data collected were descriptively analysed and thematic analysis used for free comments. RESULTS: Approximately 25% of those emailed responded (632 of 2542); 13.7% reported total opposition to abortion on religious or conscientious grounds; the remainder did not. 83.5% believed that abortion should be part of general obstetric and gynaecological practice; 90% believed that education about abortion should be part of the curriculum for RANZCOG trainees. 92% supported public hospital provision of abortion services. A range of views was explored using thematic analysis. DISCUSSION: While a majority of Fellows and trainees do not hold religious or conscientious objections to abortion a significant minority do; this has changed little since 2010. Many respondents distinguish between 'medical' and 'social' indications for abortion although definitions of 'social' appear variable. There was strong support for the inclusion of abortion in the Fellowship training curriculum. CONCLUSION: Although the response rate was lower than for the 2010 survey participants expressed strong support for the provision of abortion services in the public sector in Australia, and for incorporation of information about abortion in the training curriculum for Fellowship of RANZCOG.

Characteristics and preventability of obstetric intensive care unit admissions in Far North Queensland.

BACKGROUND: The rarity of maternal deaths in developed countries has increased interest in auditing cases of severe maternal morbidity or maternal 'near miss'. The assessment and preventability of cases of maternal 'near misses' are important in improving the provision of maternity care. AIMS: To describe the epidemiology and determine aspects of preventability in care among women admitted to an obstetric intensive care unit (ICU) in Far North Queensland. MATERIALS AND METHODS: A retrospective observational study of pregnant and postpartum patients admitted to the Cairns Hospital ICU between 1 January 2013 and 31 December 2017 was undertaken. Cases of severe maternal morbidity were identified using the World Health Organization (WHO) 'near miss' criteria and reviewed to determine reasons for admission to ICU and ascertain aspects of preventability in the care provided. RESULTS: Sixty-nine out of 12 081 (0.6%) women admitted for obstetric care were transferred to the ICU with 31 cases fulfilling WHO 'near miss' criteria. The most common direct obstetric-related diagnosis for ICU admission was hypertensive disease of pregnancy and obstetric haemorrhage. Indirect obstetric causes contributed to approximately 40% of ICU admissions. Among the 31 cases of WHO 'near miss', ten cases were deemed preventable with the most common reason for preventability related to lack of recognition of high-risk clinical status. CONCLUSION: Maternal 'near miss' and rates of obstetric admission to the ICU at Cairns Hospital are reassuringly low. Nevertheless, one-third of women with 'near miss' required improvements in the provision of care, emphasising the need for continued audit and improvement of clinical practice.

A clinical audit of combined first trimester screening and non-invasive prenatal testing offered to pregnant women in a regional Australian hospital.

The records of women attending a large Australian regional hospital for antenatal care were retrospectively analysed to determine what proportion had undergone or been offered first trimester screening for fetal abnormalities; only 609 (54%) of 1114 women had undergone or been offered screening. Younger women, multiparous women and women living in rural Australia were less likely to be offered screening. Barriers to screening and solutions for overcoming these need to be identified to improve access and equality in antenatal screening for all women.

Natural fertility, infertility and the role of medically assisted reproduction: The knowledge amongst women of reproductive age in North Queensland.

BACKGROUND: The demand for medically assisted reproduction continues to increase, with more women encountering challenges with fertility. Due to misconceptions and gaps in knowledge, women are often unaware of the risks related to delayed childbearing. Lack of understanding of natural fertility, infertility and the role of medically assisted reproduction can lead to emotional suffering and changes in family plans. AIMS: To assess the understanding and knowledge that women of reproductive age in North Queensland have regarding natural fertility, infertility and the role of medically assisted reproduction. MATERIALS AND METHODS: Data were collected from 120 women (30 nurses, 30 teachers, 30 university students and 30 Technical and Further Education students) via the distribution of a structured questionnaire. Participants were surveyed in person about their personal plans and opinions, knowledge about natural fertility, infertility and medically assisted reproduction, and their preferred source of information. RESULTS: Participants demonstrated suboptimal knowledge levels throughout all sections of the questionnaire, in particular when asked about medically assisted reproduction. When asked to identify their main source of information, 'friends and family' was the most popular choice. CONCLUSIONS: Results from this North Queensland study add to the existing international literature, highlighting the widespread nature of the problem. Without adequate understanding of natural fertility, the risks of infertility, and the role and limitations of medically assisted reproduction, women make uninformed decisions. Development of local reproductive health education programs need to be instigated in response.

Medical students and midwives - How do they view each other?

Medical students from James Cook University who had completed their rotation in obstetrics, and midwives working in Cairns Hospital who had undertaken supervision of medical students in the birth suite, were invited to complete anonymous questionnaires on their views of their respective roles in the birth suite. Several issues were identified including increased medical and midwifery student numbers, and lack of communication between midwives and medical students. Increased cooperation and communication between medical and midwifery education providers is urgently needed to improve both student groups' learning experiences.

Maternal-choice caesarean section versus planned vaginal birth in low-risk primigravid women.

Rising rates of caesarean section (CS) have been attributed, in part, to maternal-choice CS (MCCS). There are few published data regarding maternal and perinatal risks comparing MCCS with planned vaginal birth (VB) in uncomplicated first pregnancies to inform choice. We report the results of a pragmatic patient-preference cohort study of private patients in Australia: 64 women planning MCCS and 113 women planning VB. There were few differences in outcome between the two groups. The study highlighted the well-recognised difficulties in undertaking prospective research into MCCS.

A randomised controlled trial of consumption of dark chocolate in pregnancy to reduce pre-eclampsia: Difficulties in recruitment, allocation and adherence.

In 2013-2014 we undertook a randomised controlled trial (RCT) to determine whether the daily ingestion of dark chocolate during pregnancy could reduce the incidence of pre-eclampsia in primigravidae. However, after two years we had not succeeded in recruiting more than 3.5% of the number of participants required to answer the research question, and the trial was halted. We also reviewed the literature on this topic and found it to be limited. We report here our findings and discuss the difficulties facing researchers in this area.

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.