Promoting women's health in a complex world

Is the world improving? Many would reply with a “no” and point to wars, violence, crime, greed, financial disasters, trafficking, exploitation, the downside of globalization, overpopulation, food shortages, the real or threatening environmental changes. The North pole ice diminishing. Many of those adversities are not new, but have been part of the only species that kills its own members, Homo sapiens (is it “sapiens”?), throughout history. Others might see the positive sides of technology, medical advances, global helpfulness through international organizations, education and the benefits of technology to enhance understanding among people's of the world. We can from the specialty of obstetrics and gynecology point to falling maternal and neonatal/infant mortality in most parts of the world, better access to population control in some continents, efforts towards using health resources in a rational way. Few would though doubt that the rapid increase of people on the surface of our planet is the major problem that all life there faces. Do we need more people, more jobs, more resources, more fighting over limited resources? Is it not a priority to contain and reduce populations? Man might be said to be the major threat to the globe. Obstetricians and gynecologists understand this better than many and certainly better than politicians and religious leaders who try to tell us “truths”. October sees the FIGO world congress in Rome, where many positive developments will no doubt be reported from different corners of the world. Hopefully the messages of the congress on women's need for freedom from excessive and uncontrolled fertility might even reach the papal state. Please, Monsignore Benedict, robed co-workers and other religious leaders of different denominations: Listen and respond, help contain the human spermatozoa! October provides a varied issue, starting with a guest editorial from one of the leading European centers for prenatal diagnosis and treatment, the Eurofetus project in Leuven, Belgium (http://www.eurofetus.org). Liesbeth Lewi and colleagues consider two Nordic articles, first on pp. 1196–1200 by Sverker Ek and co-workers in Stockholm, Sweden, and then by Karin Sundberg and collaborators in Copenhagen, Denmark (pp. 1201–1205), both of which give data for the treatment of twin-twin transfusion syndromes. Both studies show that there is potential for improved services. The question that begs to be asked is how many centers of this type do we need for the 28+ million inhabitants of the Nordic countries? Should there be one or even more for each country or should the rarity of this serious complication warrant one center only or perhaps two or three closely collaborating centers? Is this a matter of misplaced national pride or of rational thought with efforts to concentrate management of rare conditions? The Nordic Council of Ministers is poised to consider such issues and we might just use our Nordic good spirit and NFOG as an umbrella organization to promote sensible service provision for our culturally and health service-wise quite homogenous populations. In the last issue of AOGS such efforts were called for in relation to ovarian cancer (1). The consideration there had another spectrum, but is still basically the same. Europe needs more collaboration and coherence to be a better place. We might start here “at home”. We have this month two excellent reviews, one from the expert group for collating evidence in Toronto, Canada, from where Prakesh Shah and colleagues (pp. 1134–1146) write on biracial couples’ birth outcome and find that this is not quite as good as when both parents are white, but if both parents are black then outcome is worse. The mothers’ ethnicity matters more than that of the father. For the mixed ethnic strata of present day northern European populations such information may of course matter. The other review deals with an issue of growing interest, how to get the population at large to exercise more. Karina Kasawara and collagues from Campinas in Brazil, have dealt with this in a comprehensive way in relation to preeclampsia on pp. 1147–1157, and find as others have indicated before that more exercise is good. Not a surprise really, but how do we get people to change their ways? To eat better food in smaller portions? Again obstetricians are in a key position to boost population health. The front cover photograph reinforces the point. Jenny Chen and co-workers in Taipei, Taiwan, discuss on pp. 1158–1166 cervical adenosquamous carcinoma and come to conclusion on the debated point of how this should be classified, namely as one type of adenocarcinoma. There follow two articles on PCOS, first on the role of obesity as a predictor of glucose intolerance among these women (So-Jung Liang and coworkers, Taipei, Taiwan, pp. 1167–1172), and then on the fortunately relative rarity of endometrial hyperplasia and cancer among these women (Nina Lillegaard Holm and colleagues, Odense, Denmark, pp. 1173–1176). Defining and selecting the study population may not be straightforward (2) as illustrated in the first article. In some parts of the world the Hannah report in 2000 (3) all but stopped vaginal breech delivery. To mount a new randomized study on that is a huge undertaking, and may not be feasible. Meanwhile cohort studies such as the one from Elli Toivonen and colleagues in Tampere, Finland (pp. 1177–1183), can provide reassurance about what we know of old in the Nordic countries, i.e. that when women are carefully selected for a trial of vaginal breech delivery, then this can be conducted safely for mother and child. Obstetricians should go carefully through this article. Skills for conducting vaginal breech delivery must be maintained. Compensation in cases with substandard care affect practice in many countries in a serious way, causing huge costs to society through the complex health care required for individuals who suffer damage and by litigation and settlement payments. Human tragedy ensues, but human error is often at the root and that should be reduced as possible. In the Nordic countries health services are organized in such a way as to reduce claims and insurance premiums, but the problems are still there and have to be dealt with. Stine Andreasen and colleagues in Bergen, Oslo, Trondheim and Tromsø, Norway (pp. 1191–1195) have summarized claims in the Norwegian system and find that most such instances involve some form of substandard care. Reading their conclusions and recommendations is a must. A three-dimensional formula to estimate fetal weight in cases of suspected macrosomy is optimal (pp. 1217–1225). Parasitic leiomyoma seedlings after laparoscopy with morcellation may occur as a rarity, but perhaps more frequently now (pp. 1233–1236). A novel meeting coming up and not to be missed is the 1st Nordic Congress on Obesity in Gynaecology and Obstetrics, NOCOGO, in Billund, Denmark on 22.–24. October 2012. Look at http://www.NOCOGO.dk for information. For 2013 start to prepare for the 4th Nordic Endometriosis congress in Turku, Finland on 23.–25. May (http://www.NCE2013.fi) and the ISSHP (International Society for the Study of Hypertension in Pregnancy) European Congress in Tromsö, Norway, 12.–14. June(http://www.isshp.org). Note the short-cut to AOGS on the NFOG website or at Wiley-Online Library to establish YOUR personal on-line access to AOGS at home and at work.

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