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Women researchers working in the area of women's health face a number of problems in representing the views of the women who participate in their research. The most fundamental concerns for the researcher are to protect the interests of the group being studied, to ensure that its members are not harmed and to ensure that the findings are valid. The emphasis on medical treatment of this transition threatens to obscure analysis of the way in which women negotiate it. In the case of women in midlife, there has been little formal community organisation and there is the additional problem that women may not wish to identify themselves as menopausal because of negative cultural attitudes to menopause. Many midlife women turn to medical journals for their information about menopause, but the wider needs of the 'community' are likely to be best served by less formal means of communicating results.

The prevalence and intractability of preterm birth is known as is its association with reproductive history, but the relationship with sequence of pregnancies is not well studied. The data were from a population-based case-control study, conducted in Victoria, Australia. The study recruited women giving birth between April 2002 and April 2004 from 73 maternity hospitals. Detailed reproductive histories were collected by interview a few weeks after the birth. The cases were 603 women having a singleton birth between 20 and

In published studies of preterm birth, analyses have usually been centred on individual reproductive events and do not account for the joint distributions of these events. In particular, spontaneous and induced abortions have often been studied separately and have been variously reported as having no increased risk, increased risk or different risks for subsequent preterm birth. In order to address this inconsistency, we categorised women into mutually exclusive groups according to their reproductive history, and explored the range of risks associated with different reproductive histories and assessed similarities of risks between different pregnancy histories. The data were from a population-based case-control study, conducted in Victoria, Australia. The study recruited women giving birth between April 2002 and April 2004 from 73 maternity hospitals. Detailed reproductive histories were collected by interview a few weeks after the birth. The cases were 603 women who had had a singleton birth between 20 and less than 32 weeks gestation (very preterm births including terminations of pregnancy) and the controls were 796 randomly selected women from the population who had had a singleton birth of at least 37 completed weeks gestation. All birth outcomes were included. Unconditional logistic regression was used to assess the association of very preterm birth with type and number of prior abortions, prior preterm births and sociodemographic factors. Using the complex combinations of prior pregnancy experiences of women (including nulligravidity), we showed that a history of prior childbirth (at term) with no preterm births gave the lowest risk of very preterm birth. With this group as the reference category, odds ratios of more than two were associated with all other prior reproductive histories. There was no evidence of difference in risk between types of abortion (i.e. spontaneous or induced) although the risk increased if a prior preterm birth had also occurred. There was an increasing risk of very preterm birth associated with increasing numbers of abortions. This method of data analysis reveals consistent and similar risks for very preterm birth following spontaneous or induced abortions. The findings point to the need to explore commonalities rather than differences in regard to the impact of abortion on subsequent births.

The aims of this study were to document the extent of cigarette smoking and alcohol consumption by Victorian women during pregnancy and relate the use of cigarettes and alcohol to various measures of pregnancy outcome. The study found that 24 per cent of women smoked during pregnancy and smoking was more common amongst younger women; 99.5 per cent of women drank, on average, less than two standard drinks per day and older women were more likely to be drinkers than younger women; 3.6 per cent of women reported at least one episode of binge drinking during pregnancy. There was an increasing trend in the proportion of low birthweight (less than 2500 g) infants with increasing use of tobacco and a dose-dependent reduction in mean birthweight. Drinkers were less likely to have a pre-term or low birthweight infant than abstainers and babies born to drinkers had a higher mean birthweight than babies born to abstainers. The results of our study did not suggest that drinkers were at increased risk of delivering an infant with a congenital malformation, however heavy drinking was very uncommon in the studied population.

The aim of this study was to evaluate the association between the incidence of low birthweight and socioeconomic status, in particular whether the relationship was different for very low birthweight (less than 1500 g) and moderately low birthweight (1500 to 2499 g). The study population was births from 1982 to 1986 to women resident in Victoria (300,704). Data on socioeconomic status were derived from an indicator developed by the Australian Bureau of Statistics from the 1981 census and applied to postcodes. Using the rates of very low birthweight and moderately low birthweight in the highest socioeconomic status decile as the reference value we found that the relative risk for very low birthweight was significantly raised in only the lowest socioeconomic status decile (relative risk = 1.29, 95% confidence interval (CI) 1.17 to 1.42). The relative risk for moderately low birthweight was increased in the two lowest deciles: 1.19 (CI 1.12 to 1.26) and 1.09 (CI 1.01 to 1.17) respectively. Women not married at the time of the birth had a higher rate of low birthweight and were more likely to live in the lower socioeconomic status postcode areas. The relationships between very low birthweight, moderately low birthweight and socioeconomic status were attenuated but still significant when this factor was taken into account. Differences in low birthweight by socioeconomic status decile were not apparent for nonsmoking women. The relationship between smoking and low birthweight was different in the two lowest socioeconomic status deciles: the relative risk of low birthweight in smokers was 2.60 (CI 1.73 to 3.91) compared with a relative risk of 1.64 (CI 1.33 to 2.03) in deciles 3 to 10.

Objective to describe the structure and organisation of hospital postnatal care in Victoria, Australia. Design postal survey sent to all public hospitals in Victoria ( n = 71 ) and key-informant interviews with midwives and medical practitioners ( n = 38 ). Setting Victoria, Australia. Participants providers of postnatal care in Victorian public hospitals. Findings there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care. Key conclusions and implications for practice current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.

Background The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in “at risk” women have used a “psychoeducational” intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period. Method Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4. Results Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women “completing” the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 “completers” showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS > 12; N = 19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups. Limitations A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself. Conclusion While a modest reduction in depression scores was noted in study “completers”, both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention.

Objective This retrospective cohort study aimed to examine the long-term psychosocial outcomes for women assessed or treated during adolescence for tall stature. Method Women assessed or treated for tall stature identified from the records of Australian paediatricians were eligible to participate. Psychosocial outcomes were measured using the depression, mania and eating disorders modules of the Composite International Diagnostic Interview (CIDI), the SF-36, and an index of social support. Results There was no significant difference between treated and untreated women in the prevalence of 12 month or lifetime major depression, eating disorders, scores on the SF-36 mental health summary scale, or the index of social support. However, compared with the findings of population-based studies, the prevalence of major depression in both treated and untreated tall girls was high (12 month prevalence: untreated 10.7%, treated 11.2%; lifetime prevalence: untreated 29.4%, treated 26.6%). Factors significantly associated with lifetime major depression in this study were self-reported difficulties during adolescence being the reason for seeking a medical assessment of height (OR 2.25, 95% CI 1.4–3.6) and a negative experience of the assessment or treatment procedures (OR 2.04, 95% CI 1.4–3.0). Conclusion Long-term follow-up of a large cohort of tall girls showed that psychological outcomes among both treated and untreated women were poor and that the intended psychosocial benefit of treatment may not have been realized. The findings highlight the importance of attending to the mental health of adolescents presenting for management of conditions where self-concept and body image are a primary focus.

Treatment with synthetic oestrogens to reduce adult height has been available for tall girls since the 1950s. Treatment aims to reduce psychosocial problems associated with tall stature that might occur in adolescence or adulthood, but little is known about the long-term outcomes. This retrospective cohort study identified 1248 eligible women from the medical records of Australian paediatricians who assessed or treated tall girls between 1959 and 1993, and 184 women from self-referrals. They included girls who received oestrogen treatment (diethylstilbestrol or ethinyl estradiol) in adolescence (treated group) and those who had been assessed but did not receive treatment (untreated group). A total of 1243 (86.8%) women were traced and invited to participate in the study, and 67.9% of these women (396 treated and 448 untreated) agreed. This paper reports on women's satisfaction with the decision that was made to have treatment to reduce their adult height. In a postal questionnaire women were asked to comment on a range of issues including how they felt about their current height, the assessment and treatment procedures, and the decision whether or not to have treatment. While untreated women were almost unanimously glad they were not treated (99.1%), no matter how tall they became, 42.1% of the treated women expressed dissatisfaction with the decision that was made. There was no clear association between satisfaction with treatment and the women's final height. However, dissatisfaction was related to: (a) whether or not the girls had an active say in the decision-making; (b) to negative experiences of the assessment or treatment procedures; (c) to side effects experienced during the treatment period; and (d) to later side effects women believed were associated with the treatment. The study finds that qualitative analysis of comments made by treated women helps to explain their dissatisfaction with the decision to have treatment.

This paper describes initial partnership development in PRISM (Program of Resources, Information and Support for Mothers), a community‐randomised trial to improve maternal health in the first year after birth conducted in Victoria in the period 1998–2003. First, we discuss the principles underpinning community recruitment methods in PRISM that guided both our initial approaches to, and our continuing relationships with, communities. Second, we outline the strategies used to recruit communities and to establish the groundwork for ongoing partnerships over the projected six years of the study.

Summary Background Treatment with oestrogen to reduce the adult height of tall girls has been available since the 1950s. We undertook a retrospective cohort study to assess the long-term effects of this treatment on fertility. Methods Eligible participants were identified from the records of Australian paediatric endocrinologists who assessed tall girls from 1959 to 1993, and from self-referrals. Individuals included girls who had received oestrogen treatment (diethylstilboestrol or ethinyl oestradiol) (treated group) and those who were assessed but not treated (untreated group). Information about reproductive history was sought by telephone interview. Findings 1432 eligible individuals were identified, of whom 1243 (87%) could be traced. Of these, 780 (63%) completed interviews: 651 were identified from endocrinologists' records, 129 were self-referred. Treated (n=371) and untreated (n=409) women were similar in socioeconomic and other characteristics. After adjustment for age, treated women were more likely to have ever tried for 12 months or more to become pregnant without success (relative risk [RR] 1·80, 95% CI 1·40–2·30); more likely to have seen a doctor because they were having difficulty becoming pregnant (RR 1·80, 1·39–2·32); and more likely to have ever taken fertility drugs (RR 2·05, 1·39–3·04). Time to first pregnancy analysis showed that the treated group was 40% less likely to conceive in any given menstrual cycle of unprotected intercourse (age-adjusted fecundability ratio 0·59, 95% CI 0·46–0·76). These associations persisted when self-referred women were excluded. Interpretation High-dose oestrogen treatment in adolescence seems to reduce female fertility in later life. This finding has implications for current treatment practices and for our understanding of reproductive biology.

This paper discusses some of the processes for establishing a large cluster-randomized trial of a community and primary care intervention in 16 local government areas in Victoria, Australia. The development of the trial in terms of design factors such as sample size estimates and the selection and randomization of communities to intervention or comparison is described. The intervention program to be implemented in Program of Resources, Information and Support for Mothers (PRISM) was conceived as a whole community approach to improving support for all mothers in the first 12 months after birth. A cluster-randomized trial was thus the design of choice from the outset. With a limited number of communities available, a matched-pair design with eight pairs was chosen. Sample size estimates, adjusting for the cluster randomization and the pair-matched design, showed that with eight pairs, on average, 800 women from each community would need to respond to provide sufficient power to determine a 3% reduction in the prevalence of maternal depression 6 months after birth-a reduction deemed to be a worthwhile impact of the intervention to be reliably detected at 80% power. The process of selecting suitable communities and matching them into pairs required careful collection of data on numbers of births, size of the local government areas (LGAs), and an assessment of the capacity of communities to implement the intervention. Ways of dealing with boundary issues associated with potential contamination are discussed. Methods for the selection of feasible configurations of sets of pairs and the ultimate allocation to intervention or comparison are provided in detail. Ultimately, all such studies are a balancing act between selecting the minimum number of communities to detect a meaningful outcome effect of an intervention and the maximum size budget and other resources allow.

To investigate in an Australian study of immigrant women conducted 6-9 months following childbirth (a) the associations of a range of demographic, obstetric, health and social context variables with maternal depression, and (b) women's views of contributing factors in their experiences of depression.Three hundred and eighteen Vietnamese, Turkish and Filipino women participated in personal interviews conducted by three bicultural interviewers in the language of the women's choice. Utilising three approaches to the assessment of maternal depression, the consistency of associations on the different measures is examined. Women's views of contributing factors are compared with previous research with largely English-speaking Australian-born women.Analysis of the associations of maternal depression revealed considerable consistency in associations among the three approaches to assessing depression. Significant associations with depression on at least two of the measures were seen for: mothers under 25 years, shorter residence in Australia, speaking little or no English, migrating for marriage, having no relatives in Melbourne, or no friends to confide in, physical health problems, or a baby with feeding problems. There were no consistent associations found with family income or maternal education, method of delivery and a range of other birth events, or women's views about maternity care. The issues most commonly identified by women in this study as contributing to depression are similar to those found previously for Australian-born women: isolation (in this study, including being homesick)--29%; lack of support and marital issues--25%; physical ill-health and exhaustion--23%; family problems--19%, and baby-related issues--17%. There were some differences in the importance of these among the three country-of-birth groups, but all except family issues were in the top four contributing factors mentioned by women in all groups.These findings support the evidence for quite marked cross-cultural similarity in the associations of maternal depression and in women's views about their experiences.

The midwifery profession is increasingly applying the results of evidence-based research findings. Several researchers were asked if they would answer questions regarding the essential research skills necessary for midwives, the relevance of applying valid evidence to practice, and concerns regarding evidence-based practice overall. The objectives were to share expert researchers’ responses that could be used by educators to help introductory midwifery students understand the importance of developing skills in assessing “the best evidence” and to stimulate interactive discussion in the classroom. Consideration of the expert opinions stimulated student thinking on the relation of evidence-based findings to practice in an exciting approach characterized by inquiry and debate, which got favorable responses and evaluations from the students.

Preterm birth is the major clinical problem associated with perinatal mortality, serious neonatal morbidity and moderate to severe childhood disability in prosperous countries. Its prevalence is affected by the way in which gestational age is assessed, by national differences in the registration of births, associated practices, such as burial costs, or maternity benefits, which encourage or discourage registration, and by the perceived viability of extremely preterm infants. Despite these uncertainties, there is reliable evidence that preterm births are increasing, especially births before 28 weeks gestation. Contributing factors include births following assisted reproductive therapy and ovulation induction, especially multiple births, and the increasing proportion of births among women >34 years. On the other hand, improvements in neonatal care have substantially increased the survival of preterm infants during the last 15 years. There is wider acceptance of the importance of infection as a factor in preterm birth, and increasing recognition that processes leading to preterm birth may be initiated in very early pregnancy (the initiation of pre-eclampsia, major birth defects, premature placental separation), or even prior to pregnancy (prior pregnancy losses). It is unclear whether the familiar clinical presentations of preterm labour and birth reflect different pathophysiological processes. The pathways which link those processes to the consistent pattern of social differences in the probability of preterm birth have prompted new research approaches but in 2002 ‘the stubborn challenge of preterm birth’ remains just that.

Objective: To describe the screening properties of the antenatal tools which have been developed to predict depression after birth and to summarize the implications of the findings for antenatal screening. Method: Systematic review and secondary analysis of published papers. Results: Sixteen studies including sufficient data for the calculation of screening properties were identified. The majority developed a study-specific screening instrument. Outcome assessments used the Edinburgh Postnatal Depression Scale or standardized diagnostic psychiatric interviews, or both. In the two largest population-based studies, the proportion of women screening as positive (‘at risk’ of postnatal depression) was 16 and 52%, respectively, and of these only 35 and 8% actually developed depression after birth. Conclusion: No screening instrument(s) met the criteria for routine application in the antenatal period. Factors that may have affected poor sensitivity and positive predictive values include the exclusion of key domains in predicting risk, particularly personality, a past history of abuse and postnatal events, the contribution of which may be being under-estimated in studies evaluating antenatal risk prediction tools.

Somatization of depression symptoms has been assumed to characterize particular cultural groups, yet evidence for this has often been anecdotal. The Mothers in a New Country (MINC) study aimed to explore cultural assumptions about somatization in three groups of immigrant women who had recently given birth in Melbourne, Australia. Physical health (SF-36 physical health dimensions and a symptom list) and depression (EPDS, SF-36 mental health dimension and self assessment) data from personal interviews with Vietnamese (n = 104), Turkish (n = 107) and Filipino (n = 107) women, conducted in women's language of choice, six to nine months after childbirth were analyzed. Comparisons with data from a statewide postal survey of Victorian women are also made. Contrary to the study hypothesis that Turkish and Vietnamese women in particular would exhibit a high degree of somatization (leading to low depression scores on the standard measures and greater reporting of somatic symptoms), Turkish women were in fact most likely of the three groups to be assessed as depressed on the two psychological measures and by self-assessment, to report high levels of somatic symptoms, and Vietnamese and Filipino women had a low prevalence of depression on all measures and relatively lower levels of somatic symptom reporting. The MINC study findings thus call into question some common cultural assumptions about depression and demonstrate the importance of designing studies which can put hypothesized cultural differences to the test.

Postnatal depression is a major public health problem affecting about one in seven women after childbirth. Depression is also common during pregnancy and throughout the perinatal period it is associated with symptoms of anxiety. Apart from the adverse consequences for women themselves becoming depressed when they are going through demanding physical and social changes, there are additional concerns. There is the possible negative impact of maternal depression on the relationship between mother and child and on the child's emotional, behavioural and cognitive development. Primary prevention and early intervention/secondary prevention strategies are potentially important in view of the frequent contact pregnant women, new mothers and infants have with health services, but the effectiveness of these strategies needs to be tested. In the past year there have been five new studies of antenatal screening for postnatal depression. These studies are consistent with nine earlier studies in showing that there is no evidence to support routine antenatal screening for postnatal depression. Seven new primary prevention/early intervention trials add evidence on a wide range of interventions ranging from practical support to individual interpersonal therapy, but without identifying significant differences in depression as an outcome. Two new trials of secondary prevention, one involving interpersonal therapy and the other including partners in a series of psychoeducational visits, show promise but neither is large enough to form a basis for practice change. Novel interventions, or promising findings, with a strong basis in theory need to be tested in trials which are appropriately sized and which comply with internationally accepted design and reporting guidelines.

Objectives To increase a review's relevance to practitioners and service users and identify the implications for systematic review methodology. Methods A systematic review of the effects of smoking cessation programmes implemented during pregnancy integrated process indicators and the views of maternity service users and health promotion specialists. Additional qualitative data were extracted systematically from included randomised control trials (RCTs) to determine whether the design of interventions and conclusions arising from their evaluation related to the views of service users. On completing the review we reflected on the types of observational and qualitative research it drew on, where this research was incorporated into the review, and its added value. Results Incorporating process indicators into the review revealed: 1) problems with implementation and transplantation of some interventions and 2) studies with more stringent quality criteria and process evaluations demonstrated greater impact (weighted mean difference in smoking). Pregnant smokers were rarely involved in the design or evaluation of the interventions. Prior observational and qualitative studies and small scale consultations influenced the criteria by which the effectiveness of the interventions were judged, and revealed to what extent these criteria are adopted in practice. Conclusions Systematically abstracting data about the development and delivery of interventions revealed gaps that might be filled by the active involvement of service users.

Objective: To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction. Design: Randomised controlled trial. Setting: Large maternity teaching hospital in Melbourne, Australia. Participants: 1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64). Main outcome measures: Maternal depression (score ≥13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum. Results: 917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1.37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= −2.31, 95% confidence interval −10.48 to −0.84). Conclusions: Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.

Objectives: To map the provision of shared obstetric care in Victoria, and investigate the views of care providers about the ways in which current practice could be improved. Method: All Victorian public hospitals with

OBJECTIVE: To discuss a range of strategies to address the methodological and practical challenges in designing cross-cultural public health studies. METHOD: The Mothers in a New Country (MINC) Study was an interview study of 318 Vietnamese, Turkish and Filipino recent mothers exploring their views of maternity care and the early months of motherhood. It was carried out in Melbourne between 1994 and 1997. Sampling, recruitment, retention and representativeness all pose problems for studies involving non-English-speaking background immigrant populations, as do selection, training and support processes for bicultural interviewers. These issues are discussed with reference to the strategies undertaken to tackle them in the MINC Study. RESULTS: In the MINC Study, a systematic approach to sampling and recruitment, combined with a flexible and sensitive study protocol were largely successful both in achieving in adequate sample size and a largely representative study sample. Similarly, paying significant attention to the selection, training and ongoing support of the biocultural interviewers employed on the study contributed greatly to its successful completion and enhanced confidence in the study findings. IMPLICATIONS: Both researchers and funders need to take seriously the implications of the many methodological and practical issues involved in designing sound cross-cultural public health studies. In particular, there are major implications for study costs and timelines. However, the benefits to be gained are significant.

There are few population based studies which explore the views immigrant women have of the maternity care they receive in their new homelands. Three hundred and eighteen Vietnamese, Turkish and Filipino women who gave birth in three major city hospitals in Melbourne, Australia were interviewed about their experiences of maternity care. Outcomes and experiences for women with different levels of English fluency were studied, as were women's needs and preferences for assistance with interpreting. Observance of traditional cultural practices surrounding birth and the impact of not being able to observe such practices on women's experiences of care were also explored. Women in the study not fluent in English experienced problems in communicating with their caregivers and these were reflected in less positive experiences of care. Women were less concerned that caregivers knew little about their cultural practices than they were about care they experienced as unkind, rushed, and unsupportive. Maternity care for immigrant women is only likely to improve when barriers to effective communication are addressed and attention is paid to raising standards of care.

Preterm birth is associated with increased perinatal morbidity and mortality and an elevated risk of disability. Women with precancerous changes of the cervix who have had treatment such as conization or a loop electrosurgical excision procedure (LEEP) are believed to be at increased risk of preterm birth. However, because many of the known risk factors for preterm birth, such as sexually transmitted disease, smoking, or prior induced abortion, also are associated with an increased risk of precancerous changes in the uterine cervix, it has been difficult to determine the degree risk due solely to cervical treatment from the degree of risk due to the other risk factors for preterm birth. This retrospective study was intended to compare rates of preterm birth in women having precancerous cervical changes to those of the general age-standardized population, and to detect any effect of cervical treatment on the time of delivery. Preterm deliveries, defined as those taking place before 37 weeks' gestation, were analyzed in 5548 women referred to a single institution in the years 1982–2000 who had either an abnormal Pap smear or a cervix that appeared abnormal. Compared with the general population of parturients, women referred to the dysplasia clinic were significantly more likely to have a preterm birth, whether or not they were treated. The standardized prevalence ratio was 2.0 (95% confidence interval [CI], 1.8–2.3) for treated women and 1.5 (95% CI, 1.4–1.7) for those not treated. This finding was verified when analysis was limited to women referred with positive cytology who had a confirmed lesion. Of the women seen in the dysplasia clinic, the adjusted odds ratio (OR) for preterm birth in treated versus untreated women was 1.23 (95% CI, 1.01–1.51), a significant association. Other factors increasing the risk of preterm birth included past abortion (induced or spontaneous), illicit drug use while pregnant, and major maternal disease. Cone biopsy, loop electrosurgical excision, and diathermy all were associated with an increased risk of preterm birth but, after adjusting for these possible confounding factors, the only significant correlation was with diathermy (OR, 1.72; 95% CI, 1.36–2.17). Laser ablation did not increase the risk of preterm birth. It appears that women who present with precancerous cervical changes are likelier to have a preterm birth, whether or not they have had treatment, but those who have had treatment that destroyed or removed a substantial amount of cervical tissue are at highest risk. Using precise methods of cervical ablation may help to reduce this risk.

Objectives To assess usage of birth plans, and examine differences in social and obstetric characteristics, and intrapartum experiences of women who did and did not use a birth plan. Design Population-based survey distributed by hospitals and home birth practitioners, 6–7 months post-natally. Setting and participants Women who gave birth in Victoria, Australia over a 2-week period in September, 1993, excluding those who had a stillbirth or neonatal death. Main outcome measures Use of a written birth plan; perceived helpfulness, advantages and disadvantages of birth plans; relationship between use of birth plans and overall rating of intrapartum care, and involvement in decision-making. Results Twenty per cent of women (270/1336) had prepared a written birth plan and discussed it with caregivers. Women who made use of a birth plan were more likely to be satisfied with pain relief (OR = 1.74[1.3–2.3]), but did not differ from women not completing a birth plan in terms of their overall rating of intrapartum care, or involvement in making decisions about their care. Conclusions The lack of association between use of a written birth plan and variables assessing women's views of intrapartum care suggest there are insufficient grounds for continuing to advocate a policy of encouraging pregnant women to complete written birth plans, unless it is within the context of a well-designed randomized trial able to provide further evidence regarding their effectiveness.

Objective: To provide an overview of the characteristics of Victorian infants born between 1983 and 1995 who are affected by one or more of 27 sentinel birth defects. Methodology: Using data on congenital malformations supplied to the Victorian Perinatal Data Collection Unit from multiple sources between 1983 and 1995, information was summarised for 25 231 infants (born at 20 weeks or more) and 1566 terminations of pregnancy before 20 weeks' gestation. Results: During the 13-year study period in Victoria, 3.2% of babies had at least one malformation. Congenital dislocation of the hip was the most common defect with a prevalence of 28.9 per 10 000 pregnancies or 1/346. Increase in birth prevalence between 1983 and 1995 is greatest in obstructive defects of the renal pelvis, hypospadias and the trisomies 21,13 and 18. Nearly 50% of pregnancies affected by anencephaly were terminated before 20 weeks compared to 26% affected by spina bifida. The perinatal mortality of infants born at 20 weeks or more with congenital malformations is more than 10 times greater than that of infants without any malformations. Males are more at risk of being born with a malformation than females. Congenital malformations are more common in infants of multiple pregnancies and those of low birthweight. Conclusion: This large data collection is a valuable source of information for perinatal epidemiologists, for providers of prenatal diagnostic services and for the care of the disabled. In addition, the continued reporting and monitoring of birth defects will allow for targeted research that may lead to a better understanding of their aetiology.

OBJECTIVES To compare the views of women from non-English-speaking backgrounds who received antenatal care at a public hospital clinic with those whose care was shared between a public hospital clinic and a general practitioner. DESIGN Structured interviews in the language of the woman's choice. SETTING Women were recruited from the postnatal wards of three maternity teaching hospitals in Melbourne between July 1994 and November 1995, and interviewed six to nine months later. PARTICIPANTS Women born in Vietnam, Turkey and the Philippines who gave birth to a live healthy baby (over 1500 g) were eligible. Of 435 women recruited, 318 (Vietnamese [32.7%], Filipino [33.6%] and Turkish [33.6%]) completed the study. MAIN OUTCOME MEASURES Women's ratings of their antenatal care overall and views on specific aspects of their antenatal care. RESULTS Women in shared care (n = 151) were not more likely than women in public clinic care (n = 143) to rate their care as "very good" (odds ratio [OR], 1.38; 95% confidence interval [95% CI], 0.72-2.63). Satisfaction with particular aspects of care (waiting times, opportunity to ask questions, whether caregivers were rushed, whether concerns were taken seriously) did not differ significantly between those in shared care and those in public clinic care. Women in shared care were not happier with their medical care than women in public clinic care (OR, 0.83; 95% CI, 0.35-1.96), but were more likely to see a caregiver who spoke their language (OR, 17.69; 95% CI, 6.15-69.06), although two-thirds still saw a GP who spoke only English. CONCLUSION Shared antenatal care is not more satisfying than public clinic care for women from non-English-speaking backgrounds. Further evaluation of shared care is clearly needed.

Background: This study assessed women's views of care in pregnancy, contrasting the experiences and satisfaction of women using different models of care in Victoria, Australia. Methods: A statewide postal survey of women who gave birth during a 2-week period in 1993 was carried out 6 to 7 months after birth. Results: Of 1336 women, 62.5 percent responded, and of these, 62.4 percent rated their antenatal care as very good, 27.7 percent as good, 8.2 percent as mixed, and 1.8 percent as poor or very poor. Although social factors, obstetric factors, and model of care had significant associations with satisfaction in univariate analyses, only model of care, mother's country of birth, and medical risk remained significant in a multivariate analysis using logistic regression. Women were most likely to be satisfied when antenatal care was provided by an obstetrician in private practice or a birth center. When comparisons were restricted to options available to women without private health insurance, using public hospital clinics as the baseline in a multivariate analysis, women were significantly more likely to be satisfied with birth center care, and significantly less likely to be satisfied with shared care. Contributing factors were waiting times, staff seeming rushed, and lack of continuity of caregiver. Conclusion: The expansion of shared antenatal care has not succeeded in improving satisfaction with antenatal care for women in the public health care sector. (BIRTH 24:2, June 1997)

This paper draws on tape-recorded interviews with 90 women who gave birth in Victoria, Australia in 1989, followed-up when their infants were around 2 years. Half of the sample had been assessed as depressed 8–9 months post-partum using the Edinburgh Postnatal Depression Scale (case/depressed group), the other half had low scores indicating they were unlikely to have been depressed at the time of the original survey (control). Fifteen of the women in the case/depressed group and two women in the control group had scores of 13 or higher on the EPDS at the time of follow-up at 2 years. The interviews explored a broad range of topics related to the experience of motherhood in the first 2 years after giving birth. The paper focuses on a section of the interviews in which women were asked to describe their conception of a ‘good mother’. Women who had been depressed at 8–9 months post-partum compared with women not scoring as depressed at this time, and those depressed at follow-up compared with women ...

After the December issue was published, this Journal received some negative comment on a paper by Steele et al on children in immigration detention centres. The most serious accusation was that the authors were over-sympathetic to their research participants, so that the children’s mental illness was exaggerated. Thus the scientific credibility of the paper is called into question. At a more personal level, a book on evidence-based medicine, by one of us (JD),1 has aroused negative comment for failing to represent fairly the contribution of women researchers. Underlying both criticisms is the problem of how to assess credible research. How should we reconcile different points of view about what should be addressed in research? How do we ensure balanced representation in the research published in the Journal? Evidence-based medicine has taught the clear lesson that there is unlikely to be a definitive study in health research, no matter how carefully it is designed and executed. The most rigorous trial will be subjected to review in the light of subsequent research and the conclusions may be revised or even rejected. This is even more likely when research addresses a context where there are numerous interacting factors operating, such as in a communitybased study. Here it would be almost impossible to conduct a single definitive study. Instead, researchers focus on the major factors relevant to their research question. The issue then is to be clear about, and to justify, the choices that were made, providing details on what was excluded, so that subsequent researchers can replicate the research or review the conclusions. It is not just a matter of making evident the choices made. When researchers ignore an issue that is central to the research question, the conclusions must lose credibility. For example, there is much concern at present about weight gain in primary schoolchildren and programs have been devised to encourage children to walk or cycle to school. If the research has not taken account of the physical and social environment that may make walking and cycling impractical or unsafe, then its value is undermined. While editors make their own judgments, the peer review process helps identify those contextual factors that must enter into an account if a paper is to count as a substantial contribution to knowledge. Our commitment is to select reviewers from a diversity of relevant backgrounds to ensure that different views on the topic are considered. Researchers know that there are inequities in health and many are aware that we often fail to see the needs of those disadvantaged by class, race, gender, age or disability, as well as other factors operating in specific contexts. There is the expectation in public health that researchers should at least be conscious of not further increasing disadvantage. Some sociologists go further and see it as incumbent on the researcher to ‘represent the underdog’. This is easier said than done. When social or community groups are excluded and disadvantaged, the most common way in which this is effected is by silencing them. That complicates the task of the researcher. In the study conducted by Steel et al, we have a clear example of the difficulties of doing research under constrained circumstances. There is concern about the situation of people in the detention centres that house newly arrived refugees and people judged to be illegal immigrants; a particular concern has been the mental health of the children detained. It has been very difficult to gain research access to these children. Under such circumstances, data collection is necessarily compromised. What then is the test that is applied to assess the credibility of research? The first requirement is that the study must be done as well as it could be, given the circumstances. The second is that the study’s limitations should be fully disclosed. Those who question the results can then replicate the study, perhaps with the advantage of better access to study participants. The article by Steele et al met these requirements. Should we have required that the views of the authorities in the detention centre or government depar tments be represented as well? That, we believe, is a task for other researchers than those already facing substantial research challenges. The book on the rise of evidence-based medicine addresses a completely different situation and one more familiar to researchers using qualitative methods. Here balanced representation is complicated by a long history; there are extensive data sources, a growing literature and a large number of highly articulate potential research participants. There must be exclusions and only a fraction of the relevant material can be addressed in any one study. The troublesome question remains whether some less vocal contributors are unfairly overlooked in the book or, indeed, in evidence-based medicine itself, and whether this is linked to class, race or gender or even age or disability. It is certainly possible to write an account of evidence-based medicine that is focused on those groups whose views are overshadowed in the public discourse. Understanding the situation in which disadvantage manifests is an important research topic in its own right. On the other hand, it also seems justif iable to concentrate on a critical analysis of the rise of evidence-based medicine, concentrating on its public face, identifying disadvantage where it occurs without making that disadvantage the focus of analysis. As in the case of children in detention, this is a substantial task and, in time, there will be other complementary representations. In both these cases, the requirement is that the authors be alert to issues that compromise the scientif ic credibility of their studies and be clear about the practical and conceptual limitations of their research. Our task, as editors, is to ensure that competing, well justified representations also see the light of day.

Objective: To assess the impact on mothers' knowledge and anxiety of the 1991-92 health promotion campaign on Sudden Infant Death Syndrome (SIDS) risk factors. Methodology: A telephone survey of a population based sample of 339 mothers in Victoria, Australia, conducted 1992-94. Results: Recall by mothers of the risk factors for SIDS was as follows: not breast-feeding. 15%; smoking, 46%; overheating, 48%; and prone sleeping, 84%. Recall rate increased as the campaign progressed. Receiving the campaign pamphlet was associated with an increased recall of all risk factors. Discussion of the pamphlet with a health professional was rare (9%). One-third of all mothers reported being very worried about cot death when caring for their babies. Self-reported worry was significantly more common among mothers whose babies were born at the time of the campaign introduction. Conclusions: The campaign pamphlets were effective in increasing knowledge of the risk factors. The limited discussion with health professionals suggests that future campaigns need increased professional involvement to address problems, including anxiety among new mothers.

The ethical principles of beneficence (doing the best for one's patients and clients), nonmaleficence (doing no harm), autonomy, justice, and equity, are positively associated with the quality of a trial rather than being opposed to it. Ethical considerations involve such important questions as appropriate design and documentation, participation rates, withdrawals or losses to follow-up, careful monitoring of safety and efficacy, timely completion, generalizability, and publication and dissemination of findings. When conflicts between ethical considerations and the trial's scientific quality do occur, the ethical considerations must be paramount.

Monitoring perinatal services is a complex and multifaceted matter. Case by case review has an immediate appeal because of the potential to identify simple clinical messages for practitioners, but interpretation is less straightforward than it might seem. Other non-experimental evaluations of perinatal care need to find ways of taking into account differences between hospitals, other than quality of care, which significantly influence outcome. These evaluations can be combined with the provision of information back to hospitals themselves from central health agencies. In addition to approaches using vital statistics and routinely collected data intermittent surveys of satisfaction with maternity care and preferences for care provide complementary information. The combination of several methods of monitoring perinatal services should enable hospitals and health planning agencies to work more effectively towards their shared goals.

Objective To determine the outcome to five years of age of liveborn children born at 24-26 weeks' gestation. Design Regional cohort study of preterm children. Subjects Consecutive children liveborn at 24-26 weeks' gestation in Victoria from 1 January 1985 to 31 December 1987. Main outcome measures Survival rates and rates of sensorineural impairment and disability at five years of age. Results 95 of 316 (30.1%) children survived to five years; survival rates increased with gestational age. 94 children (99%) were assessed at five or more years of age, corrected for prematurity. Twelve children had some form of cerebral palsy, causing a severe disability in only one. Two children required hearing aids for sensorineural deafness, five had bilateral blindness, and four were too disabled for intelligence quotient measurement. Overall, sensorineural disability was severe in seven (7.4%), moderate in seven (7.4%), mild in 23 (24.5%), and nil in 57 (60.6%) of children assessed. There was no trend to increasing disability with lower gestational age. Conclusions The sensorineural outcome for this cohort is mostly favourable, and is better than that reported from some contemporaneous regional cohorts born in other parts of the world. The rates of sensorineural impairments, such as blindness and cerebral palsy, are higher than in non-preterm children but are not inordinately high, and most have no sensorineural impairment or disability.