Editor’s Choice

The emancipation and education of women is known to be associated with many social benefits, including a reduction in maternal and perinatal mortality, improvements in child health, a reduction in domestic violence and higher literacy rates in the population generally. Together with these benefits goes a reduction in population growth, as women acquire control over their own fertility, and the average family size decreases. Programmes to make contraception readily available to women have been very successful in improving population health. However, not all women find contraception easy to use, or it fails; yet, they are desperate to avoid having another hungry mouth to feed. In such circumstances, termination of pregnancy is the last resort. For many women, reliance on ‘back street abortion’ has ended in emotional and physical damage and even death. The introduction of misoprostol for early termination of pregnancy (less than 8 weeks of gestation) has brought an alternative to the crochet hooks of the back street abortionist or the societal control inherent in the technology needed for safe surgical evacuation of the uterus. Its availability has stirred strong emotions, but the ability to use it in the home represents a step forward in respecting the autonomy of women. On page 621, Shannon et al. describe a randomised controlled trial of varying doses and routes of administration of misoprostol following priming with mifepristone in 956 women in three Canadian cities. The results are impressive. The overall success rate (termination of the pregnancy without any need for surgical intervention) was 94%, and over 90% of the women described themselves as satisfied with the process. In the two lower dose groups, 85% of women said that the pain induced by the abortion process was acceptable (although this means that 15% thought that it was not). The complication rate was low, and most complications were minor, but one woman died. The decision to terminate a pregnancy is never trivial. As a man, it has been a surprise to me that women will choose a method of termination that inevitably involves substantial pain, when surgical aspiration is quicker and (relatively) pain free. The probable reason that so many women choose the medical procedure is that they have control over the proceedings, and they can avoid a clinical process involving anaesthesia that many women find daunting. On page 688, Bekker et al. report their study of a decision aid to help women in Leeds (UK) choose the method of termination that they considered most suitable to their personal circumstances. Even in the setting of a developed country with good medical facilities, over one-third of women chose medical termination. The decision aid did not affect the choice of method or anxiety about the procedure, but it did improve women’s understanding both of the options open to them and the likelihood of complications. Once they choose to continue with their pregnancy, women’s choice of mode of delivery is influenced by many factors, which we have yet fully to understand or even be aware of. I have written before in this journal of the evolutionary conflict between the fetus and its mother brought about by adaptation of the pelvis to the erect position, and the subsequent development by Homo sapiens of a large brain, leading to prolonged and obstructed labour in many women. Most labours are not only intensely painful but often have life threatening complications and thus fear of childbirth is a rational response to pregnancy. In Sweden, this has been recognised to the extent that ‘Aurora’ clinics have been set up at most maternity centres, where specially trained midwives, obstetricians and psychologists can counsel women whose fear of labour (tokophobia) becomes a major problem. On page 638, Waldenström et al. report a nationwide study of tokophobia in Sweden, and 67% of all eligible women filled in a questionnaire on the topic. About 3.6% of them declared that they had ‘very negative feelings’ about childbirth, of whom about half chose to have antenatal counselling. In addition, another 7.2% of the total chose to have counselling despite having less negative feelings. Thus, more than one in ten women either expressed or demonstrated concern about the impending birth process and 9% sought professional counselling. The highest rate of elective caesarean section—30%—was in the women with negative feelings who chose counselling, compared with less than 5% in women with similarly negative feelings who did not choose counselling. Thus, it appears that counselling facilitated a choice to avoid labour, rather than encouraging women to go through with it. What do obstetricians think about women who choose caesarean section rather than a trial of vaginal delivery with its inherent risk of needing an emergency caesarean? On page 647, Habiba et al. report that 79% of obstetricians questioned in the UK are willing to go along with maternal choice for caesarean section and this agrees with previous reports in this journal. Perhaps more surprising is that in Sweden, home of the Aurora clinics, the proportion was only 49%. Only in Germany (75%) was the proportion similar to that in the UK, and in the Netherlands, France and Spain it was only 22, 19 and 15%, respectively. However, many of these obstetricians changed their mind when presented with a quasi-medical justification, even when this was not evidence based. The author’s conclusion is that the difference between the views of obstetricians in the UK and Germany, and the other European countries, is the value placed on the right of the woman to choose. An important development in this discussion has been the consensus conference on maternal choice for elective caesarean section held by the National Institutes of Health in the USA, and in March this year they published their draft statement (http://consensus.nih.gov/2006/2006CesareanSOS027html.htm). A key comment was that ‘based on indirect evidence, there appear to be relatively similar degrees of risk from both pathways in women intending to limit their childbearing to one or two children …each woman deserves individual counselling’. On page 729, Michael Turner et al. come to a similar conclusion regarding the mode of delivery after a previous caesarean section. In a study of 5320 women with a single previous caesarean section, there were 4021 trials of vaginal delivery and 3129 vaginal births. There were only nine ruptures of a lower segment uterine scar and in none of these cases did the mother or baby suffered major morbidity. Although generally in favour of attempting vaginal delivery, they concluded that ‘the best option is …for obstetricians to continue to practice the art of obstetrics based on good clinical practice, taking into account individual patient circumstances’. Which presumably includes the preference of the mother herself. Ultrasound scanning to screen for fetal anomalies has been used for many years now; yet, the questions about when and how still provide fertile ground for study. Saltvedt et al. on page 664, compared anomaly screening at 12 weeks and 18 weeks and found no significant difference in anomaly detection rates. This favours scanning at 12 weeks, when termination of pregnancy is technically easier. However, the detection rate of moderate or lethal severity was 25% at 18 weeks, compared with 20% at 12 weeks, a trend which although not statistically significant favours the 18-week scan. The same group of investigators (Westin et al. page 675) also examined their success in detecting cardiac lesions and came to similar conclusions. Their (perhaps not surprising) conclusion was that if resources permit, scans should be offered at both gestations. This is in fact the current usual practice in most UK maternity services. Earlier this year, we published a commentary by Alan Farthing on fertility-sparing surgery for malignant disease in gynaecology. This month we publish an article by John Shepherd et al. on page 719 that reports 123 cases of radical trachelectomy for cancer of the cervix. Sixty-three of these women subsequently tried to conceive and 26 were successful. However, only 19 of them succeeded in having a child. Of 28 live births, all were born by caesarean section (classical in all but two). Twenty were preterm, with four being born at 24–26 weeks. So fertility-sparing surgery can result in a woman having children, but less than one-third of those who want them will be successful and less than one-third of them will have a baby delivered at term. Almost one in six pregnancies will end with a baby being born at borderline viability with the accompanying risk of long-term handicap if it survives. These are sobering data that women opting for such surgery need to be fully informed about. We have received many compliments about the new 2006 layout of the journal, which is gratifying. Many have commented that they find the colour coding of the various sections (general obstetrics, urogynaecology, etc.) helpful. However, this can lead to some inflexibility in determining the running order of the articles. For example, you may wonder why the two papers on the use of misoprostol for termination of pregnancy are in different sections, one in general obstetrics and one in fertility control. The answer is that the designation is chosen by the submitting authors, who sometimes differ in their perceptions of the section that is most appropriate for their work. So I do recommend that you run your eyes over the whole contents list each month—even if you are a subspecialist, you may find something of interest in almost any section.

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