Editor-in-Chief's introduction to ANZJOG 64 (3)

Welcome to the June issue of the Australian and New Zealand Journal of Obstetrics and Gynaecology.

This issue begins with a thought-provoking editorial by Boothroyd et al¹ which explores the declining fertility rate in the Australian population and its implications for society. Australia is not alone among similar countries in this situation, it being a common challenge faced by virtually all high-income countries. While we have been able to maintain population growth due to net immigration, this is unlikely to remain the case in the longer term, and at some point we are likely to find ourselves in the situation where supporting the growing elderly population is reliant upon a shrinking working age population. This is clearly economically unsustainable. The authors identify contributors such as higher levels of female education and employment and extended educational and career development pathways coinciding with peak fertility ages. In suggesting areas for public policy changes which could address the fertility decline, the authors make a call for this to become part of the political agenda.

The issue continues with a wide-ranging selection of papers from across our specialty.

Endometriosis continues to be topical. Fang et al² present a systematic review of multidisciplinary teams for the care of people with endometriosis. They find the models studied varied in professional composition, with little clear evidence to demonstrate which is the superior model in terms of clinical and important non-clinical outcomes. They speculate that multidisciplinary teams are likely to be valuable but that further research is required to show which models are most effective. Frayne et al³ present a mixed methods study of the acceptability of using the Raising Awareness Tool for Endometriosis (RATE) in a general practice setting. They found that general practitioners found RATE valuable, particularly in facilitating discussion about symptoms and their management, but identified uncertainty about the identification and management of people with chronic pain syndromes. Pelvic pain was highly prevalent, with a significant impact on quality of life in a substantial proportion of those participants. Paterson et al⁴ present the first published data on endometriosis surgery in Aotearoa New Zealand. This retrospective review of over 400 surgeries performed for known or suspected endometriosis found pain to be the most common indication for surgery, with 68% of surgeries confirming this condition. These findings are broadly comparable to international data, but the authors call for further research into endometriosis in a New Zealand-specific context.

McGinn et al⁵ present their study of sexual and reproductive health services in New Zealand. They report that these services are fragmented without an overarching strategic framework, limiting their capacity to deliver on the Women's Health Strategy, and conclude that a suite of community-based programs should be developed and evaluated, with consumer co-design being a fundamental component of such work. Also in the sexual health sphere, Nyakio et al⁶ present their study of sexual violence in the Democratic Republic of Congo. They found that victims of sexual violence were more likely to be from poorer socioeconomic backgrounds, to be younger, and to have had younger age at menarche and first sexual intercourse. They propose that targeted interventions are required to reduce the high prevalence of sexual violence in these communities, including educational and reproductive health resources, incorporated in both public health and societal contexts.

Hohmann-Marriott et al⁷ present their survey of consumers and healthcare providers regarding the role of menstrual cycle tracking apps in fertility and infertility. Both groups reported beliefs in a role for such apps, but with discordant values placed on the different functions by consumers and by health professionals. Sakas et al.⁸ present their study on the use of testicular fine needle aspiration (TEFNA) for absolute non-obstructive azoospermia in terms of successful mature sperm retrieval and fertilisation and pregnancy outcomes. They conclude the TEFNA is a simple and safe technique, effective in sperm retrieval and that the fertilisation outcomes were proportional to the number of sperm retrieved. Mitchell and Bennett's⁹ opinion piece addresses infertility in Pacific Island nations. They argue that infertility is underacknowledged as a public health issue in these countries despite its relatively high prevalence and being of particular cultural importance. They advocate for further context-specific research into locally appropriate reproductive health service provision and education and identify potential areas for synergistic public and reproductive health messaging. They call for infertility to be recognised as a public health and social rights issue to be considered in national and regional policy planning.

Foster et al¹⁰ present their single-institution review of the use of intraperitoneal chemotherapy as adjuvant treatment for advanced epithelial ovarian cancer. They found that outcomes were comparable to published international data in terms of completion rate and survival, and that ten-year survival was greater than for those who received intravenous chemotherapy. Also in gynaecological oncology, McInerny et al¹¹ present their retrospective review of low-risk gestational trophoblastic neoplasia cases from a prospectively maintained registry. They found good rates of response to methotrexate monotherapy in participants with low World Health Organisation scores but lower rates of success in those with higher scores or higher baseline human chorionic gonadotropin levels. They conclude that methotrexate monotherapy is an excellent treatment for low-risk disease and that further investigation is required to determine optimal therapy for higher-risk cases.

Cron et al¹² present their systematic review of clinical practice guidelines for medication use in pregnancy. They found significant variation in quality and recommendations between 39 clinical guidelines regarding medication use for specific conditions in pregnancy across Australian jurisdictions. Using antibiotics for premature rupture of membranes (PROM) at term, metformin for gestational diabetes mellitus, and antidepressants for depression and anxiety as specific examples, they conclude that such variation in clinical guidance may explain observed variation in clinical practice around medication use in maternity care. Jardine Cameron et al¹³ also evaluated variation in clinical practice in their study of the management of PROM over a 14-year period. They observed an increase in elective caesarean section and induction of labour compared to expectant management in women with preterm PROM across the course of the study, concluding that research is needed to determine the drivers of this increase in intervention.

Han et al¹⁴ present a retrospective review of their single-centre experience of pregnancy outcomes in women with prior kidney transplantation. They found high rates of pre-existing hypertension and subsequent pre-eclampsia and gestational hypertension. Preterm birth was common, occurring in 60%, including very preterm birth at or prior to 32 weeks in around one-quarter of cases. Neonatal intensive care admission occurred in half of the neonates. Obstetric intervention was also very common, with 62% of cases undergoing caesarean section. These outcomes highlight the high rate of obstetric and neonatal complications in such pregnancies, requiring multidisciplinary management in experienced centres to optimise outcomes.

Zheng et al¹⁵ present their case–control study of obesity and birth outcomes. They found a 43% increase in unplanned caesarean section in women with body mass index (BMI) above 40 kg/m² compared to those of BMI below 25 kg/m², and higher rates of intrapartum interventions including fetal scalp electrode, intrauterine pressure monitoring, epidural analgesia, and fetal blood sampling. Facchetti et al present their study of vaginal birth after caesarean (VBAC) in relation to model of maternity care. Continuity of care models were associated with the rate of attempting VBAC and the rate of vaginal birth, with midwifery models having higher rates and private obstetrician models having lower rates. The authors conclude that continuity of care can improve rates of attempted VBAC and vaginal birth, possibly mediated through increased counselling and provision of birth choices. However, it is less clear to what extent women choose various models of care due to predetermined plans for VBAC or planned repeat caesarean section.

I trust that you will find these and the remaining articles in this issue interesting. Thank you for your ongoing interest in and support of ANZJOG.

The author reports no conflicts of interest.