Truth and transparency in reproductive health

Although Australian perinatal mortality rates have more than halved over the past 40 years, the fetal component — the rate of stillbirth — has not changed much. Stillbirth is an emotive issue, and rightly so. In his book A grief observed (London: Faber & Faber, 1961), C S Lewis explored the unique nature of the grief of late pregnancy loss: “Never, in any place or time, will she have her son on her knees, or bathe him, or tell him a story, or plan for his future, or see her grandchild”.

In recent years, stillbirth has come “out of the shadows” in terms of the subjective, human experience, but we still lack data on many of the medical, socioeconomic and other contributors to stillbirth, and how it might be prevented. A study by Drysdale and colleagues (doi: 10.5694/mja12.10125) brings a small slice of “truth” to this problem. The authors examined the connections between ethnicity and stillbirth in a metropolitan maternity service in Melbourne. About one in seven women in their large sample was born in South Asia (India, Sri Lanka, Bangladesh or Pakistan), and these women were 2.4 times more likely to have a late-pregnancy antepartum stillbirth (3.55 per 1000 births) than women born in Australia.

According to Flenady and Ellwood (doi: 10.5694/mja12.11139), the drivers of this disparity will remain unclear until we have better investigation of the causes of individual stillbirths, and accurate, standardised reporting of perinatal statistics. A recent report card finds we have improved in this regard, but could do better (http://www.aihw.gov.au/publication-detail/?id=10737422546).

Fertility treatment is mostly a “good news” issue, but a South Australian study published earlier this year, showing an excess of birth defects in babies born after fertility treatment (N Engl J Med 2012; 366: 1803-1813), caused widespread concern. In this issue, Davies and Haan (doi: 10.5694/mja12.10865), two of the study’s authors, discuss how having good data on the small but significantly increased risk associated with some patients and procedures will help clinicians make decisions about individual patients. Bringing transparency into our evaluation of established techniques in this way can only enhance their safety and efficacy.

Medical abortion with mifepristone and misoprostol has had a controversial history in Australia, as outlined by de Costa and Carrette (doi: 10.5694/mja12.10877). Although available to individual doctors who apply to import and administer it, and endorsed for medical abortion by the Royal College of Obstetricians and Gynaecologists, mifepristone has no commercial sponsor in Australia, and no official Therapeutic Goods Administration approval. Goldstone and colleagues (doi: 10.5694/mja12.10297) describe the outcomes of medical abortion for more than 13 000 women at Marie Stopes International Australia clinics over a 2-year period. This is an important study for those weighing up the safety and efficacy of medical abortion, and underscores the importance of having consistent best-practice protocols, full follow-up and accurate data for the large group of women who choose this option.

Stillbirth, fertility, abortion. What more emotive and controversial topics could the Journal choose to explore? We would argue that, aside from ethical issues and the profound psychological impact of these events, providing data and informed commentary in these areas reflects the core business of a medical journal — to bring truth and transparency to matters that affect our lives and our health.