Changing surgical trends for female stress urinary incontinence in England.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) surgery has significantly evolved with the introduction of synthetic midurethral slings (MUS). However, following reports from the US Food and Drug Administration and European Commission, the use of vaginal meshes in urogynaecology has been largely scrutinised. We analysed trends in female SUI surgery in England from 2000 to 2017. METHODS: The Hospital Episode Statistics database was retrieved from the Health and Social Care Information Centre website. Specific four-character codes of the evolving OPCS-4 coding system were used to quantify SUI operations. RESULTS: We analysed 180,773 admissions from 2000 to 2017. A steep rise in MUS use was noted until 2008-2009, followed by a consistent drop, with a nadir of 6383 procedures in 2016-2017. Removal of MUS has become increasingly popular, with a peak of 591 in 2012-2013. Numbers for traditional continence operations remained low. Colposuspensions markedly decreased to 189 in 2012-2013, with a slight positive trend only in the last few years, while autologous sling use costantly dropped from 262 to 124 throughout the study period. Admissions for urethral bulking agents increased from 650 to 1324 in the last 2 years. CONCLUSIONS: MUS represents the most commonly performed procedure for SUI, despite an obvious reduction in the last 8 years. Urethral bulking agents are becoming more popular, while the numbers of colposuspensions and autologous slings are still low. Training programmes should take into account current shifts in surgical practice.

Trends in prolapse surgery in England.

INTRODUCTION AND HYPOTHESIS: Women have a lifetime risk of undergoing pelvic organ prolapse (POP) surgery of 11-19%. Traditional native tissue repairs are associated with reoperation rates of approximately 11% after 20 years. Surgery with mesh augmentation was introduced to improve anatomic outcomes. However, the use of synthetic meshes in urogynaecological procedures has been scrutinised by the US Food and Drug Administration (FDA) and by the European Commission (SCENIHR). We aimed to review trends in pelvic organ prolapse (POP) surgery in England. METHODS: Data were collected from the national hospital episode statistics database. Procedure and interventions-4 character tables were used to quantify POP operations. Annual reports from 2005 to 2016 were considered. RESULTS: The total number of POP procedures increased from 2005, reaching a peak in 2014 (N = 29,228). With regard to vaginal prolapse, native tissue repairs represented more than 90% of the procedures, whereas surgical meshes were considered in a few selected cases. The number of sacrospinous ligament fixations (SSLFs) grew more than 3 times over the years, whereas sacrocolpopexy remained stable. To treat vault prolapse, transvaginal surgical meshes have been progressively abandoned. We also noted a steady increase in uterine-sparing, and obliterative procedures. CONCLUSIONS: Following FDA and SCENIHR warnings, a positive trend for meshes has only been seen in uterine-sparing surgery. Native tissue repairs constitute the vast majority of POP operations. SSLFs have been increasingly performed to achieve apical support. Urogynaecologists' training should take into account shifts in surgical practice.

Omega-3 fatty acid supply in pregnancy for risk reduction of preterm and early preterm birth: A position statement by the European Board and College of Obstetrics and Gynaecology (EBCOG).

Pre-term birth is associated with significant neonatal morbidity and mortality. Pre-term births are associated with significant health and neuro-developmental risks in childhood and adulthood. Women with multiple pregnancies are at much higher risks. Low levels of omega-3 long-chain polyunsaturated fatty acids (PUFAs), such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are associated with higher risk of pre-term labour and increased consumption of foods rich in omega-3 PUFA or supplements are associated with a 11 % and 42 % risk reduction of early and late preterm births, respectively.

The effects of climate change and environmental pollution on human reproduction: A scientific review commissioned by the European Board and College of Obstetrics and Gynaecology (EBCOG).

The European Board and College of Obstetrics and Gynaecology (EBCOG) and the European Network of Trainees in Obstetrics and Gynaecology (ENTOG) express their concerns on the effect of climate change and environmental pollution. This paper reviews the impact on reproductive health and the contribution to climate change by the field of obstetrics and gynaecology. It concludes that its contributors and the effects of climate change cause definite adverse consequences to fertility and adverse obstetric outcomes. Mankind, and obstetrics and gynaecology personnel as well, must be aware and responsible of its contribution to climate change and consider the impact of their actions and interventions.

European Board and College of Obstetrics and Gynaecology (EBCOG) position statement on the use of laser vaginal devices for treatment of genitourinary syndrome of menopause, vaginal laxity, pelvic organ prolapse and stress urinary incontinence.

One in three women will experience pelvic floor disorders in her lifetime and nearly 60 percent of postmenopausal women are affected by vaginal dryness. Conservative management is recommended as first line treatment for pelvic organ prolapse and stress urinary incontinence. Also, vaginal estrogens are often prescribed for symptomatic vaginal atrophy. Lasers have been used in cosmetic industry for connective tissue remodeling and repair of skin. Their use in the last decade for treating genitourinary symptoms of menopause, pelvic organ prolapse and stress urinary incontinence has gained popularity but there is lack of robust evidence to support its use in routine practice. The European Board and College of Obstetrics and Gynaecology calls for high quality evidence with patient related outcome measures before adopting to routine clinical practice.

A national survey of UK practice for day-case vaginal prolapse surgery: Unrealistic expectations?

OBJECTIVE: The UK NHS Getting It Right First Time report (2021) recommended that a significant proportion of native tissue vaginal prolapse operations should be undertaken as day-case procedures (target: 80% anterior compartment, 70% posterior compartment, 60% combined anterior/posterior compartment). The evidence for perioperative care, options for anaesthesia and outcomes of day-case vaginal prolapse surgery is limited. This study aimed to establish current practice amongst UK gynaecologists and explore perceived barriers to implementing day-case surgery for pelvic organ prolapse. Study design A pre-tested 16-item survey was emailed to British Society of Urogynaecology members in July 2022. This survey recorded rates of day-case prolapse surgeries, barriers to implementation and practices for managing urethral catheters, vaginal packs, intraoperative anaesthetics and perioperative care. Responses to free-text questions were independently analysed by two of the authors and underwent thematic analysis. RESULTS: 121 eligible responses were received (28 % response-rate): 41 % never undertook day-case prolapse repair, 16 % undertook < 5 per year and 26 % undertook > 20 cases per year. There was no significant difference in training level or hospital setting between those groups. Reasons cited for not undertaking day-case prolapse surgery included concerns about vaginal packs and urinary catheters (92 %) postoperative complications (67 %), early discharge of elderly patients (60 %) and a lack of published evidence (39 %) or national guidance (35 %). For those currently undertaking day-case prolapse surgery; 67 % used general anaesthesia, 15 % spinal with short-acting local anaesthetic, 14 % spinal with long-acting local anaesthetic and 3 % local anaesthetic alone. Vaginal packs and self-retaining urethral catheters were used by 68 % and 70 % respectively. Concerns regarding the management of vaginal packs and urinary catheters were the most frequently cited barrier to implementing day-case surgery for pelvic organ prolapse amongst free-text responses. There were wide variations in managing catheters and packs, and in managing readmissions. CONCLUSIONS: There is significant variation in uptake and practice for day-case prolapse surgery in the UK, with legitimate clinical concerns a barrier to its implementation. Further evaluation and development of robust, evidence-based management pathways are required to make day-case prolapse surgery consistent, feasible and defensible in clinical practice.

European Board and College of Obstetrics and Gynaecology position statement on maternal mortality surveillance in Europe.

Maternal mortality data and review are important indicators of the effectiveness of maternity healthcare systems and an impetus for action. Recently, a rising incidence of maternal mortality in high income countries has been reported. Various publications have raised concern about data collection methods at country level, as this usually relies mainly on national vital statistics. It is therefore essential that the collected data are complete and accurate and conform to international definitions and disease classification. Accurate data and review can only be truly available when an Enhanced Obstetric Surveillance System is in place. EBCOG calls for action by national societies to work closely with their respective ministries of health to ensure that high quality surveillance systems are in place.

Variations in sexual and reproductive health services for the provision of comprehensive contraceptive and abortion services across Europe: A questionnaire-based study commissioned by the European Board and College of Obstetrics & Gynaecology (EBCOG) and European Society of Contraception (ESC).

A questionnaire-based study was jointly organised by European Board and College of Obstetrics and Gynaecology and European Society of Contraception to evaluate the current status as regards access and quality of care regarding contraception, abortion care, and pre-conceptional counselling and care among the 26 European countries. There are considerable variations among these countries as regards the provision of contraceptive services and abortion care. There is ample room for improvement through European training and education programs. However, the most important difference is the absence of a comprehensive network of healthcare providers in various countries to deliver these services at different points of access. There is notable absence of educational programs and instructional materials tailored specifically for nurses and midwives in several countries. This deficiency impedes the professional development and skills enhancement of these healthcare professionals, potentially compromising the quality of healthcare services provided to women in these countries.

EBCOG position statement on Inequalities in screening for cervical and breast cancer.

Gynaecological cancers, namely breast and cervical cancer represent a high burden in women's health. It is well established that cervical and breast cancer screening programmes are effective in reducing morbidity and mortality. It is of the most importance to define strategies to provide a universal access to screening. In European countries, significant progress has been made over the past years concerning screening strategies, namely the choice of screening test, its frequency as well as the age to start and stop the screening. Introduction of Human Papillomavirus vaccination programmes is also making a measurable impact to reduce cervical cancer prevalence and mortality. Our survey has shown a variation among European countries in delivery of cervical and breast cancer screening programmes. These variations can be due to organizational, economic or cultural reasons. The European Board and College of Obstetrics and Gynaecology calls for an implementation of a unified policy of prevention, screening and early detection of cervical and breast cancer across Europe to optimize clinical outcomes and reduce variations.

Provision of screening services for cervical and breast cancer - A scientific study commissioned by the European Board & College of Obstetrics and Gynaecology (EBCOG).

OBJECTIVE: Cancer screening can play an important role in early detection, improving treatment outcomes and reducing morbidity and mortality. Breast and cervical cancers belong to the most common gynaecological cancers group. Countries provide different screening programmes on its eligible population basis centred on different health care policies. This scientific study aims to assess and understand the health inequalities in the member countries of the European Board & College of Obstetrics and Gynaecology (EBCOG) as regards screening programmes of gynaecological cancer, with a special focus on breast and cervical cancers' screening strategies. STUDY DESIGN: A descriptive questionnaire-based study was conducted, addressed to EBCOG member countries. RESULTS: Ninety-one percent of the countries have an organized national or regional screening programme for cervical cancer. Of these, 45% of countries use both cytology and testing for Human Papilloma Virus (HPV) as screening test, 31% use cytology exclusively and 17% only perform HPV testing. Considerable differences were found regarding the interval of screening test: there are countries performing HPV detection triennially, while others perform only conventional cytology every 5 years. Sixty-nine percent of countries included in this study begin screening for cervical cancer in women aged 25 to 29 years, four of them using HPV detection as the screening test. Six countries begin cervical cancer screening before the age of 25. As regards vaccination against HPV, almost all countries have implemented national HPV vaccination programme, except in Poland and Turkey. The 9-valent HPV vaccine is the most frequently offered (77% of countries) and the majority vaccination programmes include both girls and boys. As regards breast cancer screening, all thirty-two countries have an implemented screening programme. All countries perform mammography as the screening test, 62.5% of them begin in women aged 50 to 54, with a 2-yearly interval in the majority. In five countries, screening programmes are performed biennially, starting between 45 and 49 years old. Seven countries start in women aged 41 to 44. CONCLUSIONS: There are discrepancies around gynaecological cancer screenings provision among EBCOG member countries. It is important to establish European recommendations about screening for gynaecological cancers, in order to standardize the access to equitable better health care in gynaecological cancers within Europe.

Can we predict shoulder dystocia?

PURPOSE: To analyse the significance of risk factors and the possibility of prediction of shoulder dystocia. METHODS: This was a retrospective cohort study. There were 9,767 vaginal deliveries at 37 and more weeks of gestation analysed during 2005-2007. Studied population included 234 deliveries complicated by shoulder dystocia. Shoulder dystocia was defined as a delivery that required additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed. First, a univariate analysis was done to identify the factors that had a significant association with shoulder dystocia. Parity, age, gestation, induction of labour, epidural analgesia, birth weight, duration of second stage of labour and mode of delivery were studied factors. All factors were then combined in a multivariate logistic regression analysis. Adjusted odds ratios (Adj. OR) with 95% confidence intervals (CI) were calculated. RESULTS: The incidence of shoulder dystocia was 2.4% (234/9,767). Only mode of delivery and birth weight were independent risk factors for shoulder dystocia. Parity, age, gestation, induction of labour, epidural analgesia and duration of second stage of labour were not independent risk factors. Ventouse delivery increases the risk of shoulder dystocia almost 3 times, forceps delivery comparing to the ventouse delivery increases risk almost 3.4 times. Risk of shoulder dystocia is minimal with the birth weight of 3,000 g or less. CONCLUSION: It is difficult to foretell the exact birth weight and the mode of delivery, therefore occurrence of shoulder dystocia is highly unpredictable. Regular drills for shoulder dystocia and awareness of increased incidence with instrumental deliveries are important to reduce fetal and maternal morbidity and mortality.

Healthcare inequalities in antenatal care in the European Region: EBCOG Scientific review.

It is now well recognized that unacceptable inequalities in maternity care that exist due to a woman's ethnicity, socio-economic deprivation, age, residential social status within a country can have adverse effects on the outcomes of their pregnancies. Perceived attitudes can lead to dismissal of concerns, breakdown of trust and can affect interactions with maternity services. Women from black and Asian ethnicity are at 2-4 times higher risk of maternal mortality. Similarly women with underlying mental health issues and those with undocumented status are also at higher risk of adverse outcomes during pregnancy and within the first postnatal year. There is need for research, to understand why these different practices exist and how we can more effectively understand and overcome the barriers and factors which can lead to inequality in access to uniform standard of care. Covid-19 pandemic created challenges for the provision of maternity services. Each country responded by their own creative and pragmatic solutions. It is important that individualized care based on a woman's individual social and medical needs must remain a priority to improve maternity care. It is proposed that EU funding should be made available to set up large scale European wide research to inform future policies.

EBCOG position statement inequalities in antenatal care provision in Europe: In the wake of an EBCOG survey.

Health inequalities adversely affect the health outcomes generally but more so for those who are socially deprived, immigrants of unknown status and low socioeconomic status. The inequitable access to care during pregnancy can lead to long term adverse inter-generational effects. Current economic crisis within Europe will have deepening effect on the health of the vulnerable families. The European Board and College of Obstetrics and Gynaecology calls for action by the European Union.

The United States Supreme Court ruling and women's reproductive rights - A position statement issued by The European Board and College of Obstetrics and Gynaecology (EBCOG).

The judicial review by the Supreme Court of the United States on Roe v. Wade has fundamentally limited the ability of women to exercise choice and control of their sexual and reproductive rights in the United States. The global organisations are concerned that there remains a risk that women's rights will be diminished globally in future.

The consequences of armed conflict on the health of women and newborn and sexual reproductive health - A position statement by the European Board and College of Obstetrics and Gynaecology (EBCOG).

Armed conflict brings about significant health-related consequences to the non-combatant population especially the elderly, women, and children. The consequences for women extend further than battle-related deaths. One important consequence of conflict is the population displacement resulting from individuals and families seeking safety in non-conflict zones. This forced migration places women at risk of gender-based violence during their journey and for this reason the host countries should ensure that the migrants are given access to reproductive health services, including providing emergency contraception and abortion. In the conflict zone, the collapse of all social support, including healthcare services, contribute towards a marked deterioration in the level of care provided to ensure reproductive health and safe motherhood. In addition, the community living the conflict zone is at an increased risk of community infectious disease and poor management of chronic illness. Women and children are almost always innocent victims of war. The international community must act effectively to primarily avoid conflict by sound diplomatic intervention and, when diplomacy fails, reduce the consequences of conflict.

Provision of antenatal care in Europe-A scientific study commissioned by European Board and College of Obstetrics and Gynaecology (EBCOG).

Differences in the way health care delivery across countries may have important impacts on health outcomes and can result in inequalities. A questionnaire survey of members of national societies through EBCOG and EAPM was carried out in 2021. A total of 53 responses were received from 26 countries. Most countries reported that routine antenatal care is primarily delivered by medical staff, involving obstetric specialists or family doctors mostly in government-run facilities. Women from minority groups are able to access antenatal care easily in most countries. Less than 10% of women did not attend antenatal care throughout the pregnancy. Most booking for antenatal care takes place in the first trimester and the number of visits range from 6 to 10 depending on parity. Most countries provide routine ultrasound with 2-3 reported scans performed by specifically trained health care professionals. Facilities for prenatal screening/diagnosis of malformations in both low- and high-risk cases varied across Europe. While antenatal care is relatively standardized throughout Europe, important differences still exist in care delivery and accessibility to care. Antenatal preventive strategies appear to be variably available throughout Europe.

European board and college of obstetrics and gynaecology position statement to mark "World Patient safety day - Safe maternal and newborn care" on 17th September 2021.

Maternal morbidity and mortality remain stubborn highly in many parts of the world. Similarly Neonatal morbidity, mortality and five years survival in most of the under-resourced countries has not declined significantly over the past decades. Furthermore sexual reproductive health services provision has not met the needs of the women and there remains a huge unmet need for reliable contraception globally. This is the time for a global action plan and for all agencies to work together to achieve meaningful outcomes to improve health of women and their babies. Covid 19 pandemic has led to increase in gender based violence as well which is deplorable. European Board and College of Obstetrics and Gynaecology welcome this initiative and commits to work with all the stakeholders to improve safety and quality of care for women and the newborn.

What happens to female sexual function during pregnancy?

INTRODUCTION: Female sexual function remains an under-investigated and neglected topic in medical research. Studies have found a strong association between female sexual dysfunction (FSD) and decreased physical, emotional and overall life satisfaction [1]. Although FSD and the impact it has on quality of life is becoming increasingly recognised, the effect of pregnancy on FSD is relatively under-researched. METHODS: Based on a significance level of 5% and a study power of 80 % a power calculation was performed using an assumed 20 % loss to follow up rate. 85 primiparous women with singleton pregnancies were recruited at their dating scan and asked to complete the Female Sexual Function Index (FSFI) questionnaire in each trimester. The total score and the six domains (pain, satisfaction, orgasm, desire, lubrication and desire) were compared with Friedman's ANOVA. The validated cut-off score of 26.55 was used to diagnose FSD. RESULTS: There was an overall decrease in total FSFI scores across the three trimesters, from a median full-scale score of 27.5 in the first trimester, to 24.7 in the second and 21.4 in the third trimester. There was a very significant decrease in all scores (the full scale score and the six domains- desire, lubrication, arousal, orgasm, satisfaction and pain), from the first trimester to the third trimester with each outcome (p < 0.0001). There were 30 women with FDS in the first trimester, 50 in the second and 68 in the third (p < 0.05). CONCLUSIONS: For primiparous women pregnancy appears to have a negative impact on sexual function with 86.1 % of women being classified as suffering from FSD in the third trimester. The importance of sexual function in overall quality life is well known and so it is important that the changes experienced by women and their partners are discussed by doctors with their patients.

EBCOG position statement: Inequality in fertility treatment in people of colour.

Despite advances in promoting sexual and reproductive rights by the United Nations, WHO and UNFPA, inequities in the provision of health care for women exist and are influenced by the socioeconomic status and the ethnicity and the migrant status. Of late, Human Fertility and Embryology Authority (HFEA) of the United Kingdom has identified that inequities exists in quality, accessibility and outcomes of fertility services for people of colour in the UK. EBCOG calls upon the EU Commission to set up a monitoring system akin to HFEA to ensure that all citizens of Europe not only enjoy equitable access to fertility treatments but also the outcomes of interventions meet the highest standards of care.