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It has been 30 years since the World Health Organization first recommended a "maximum" caesarean section (CS) rate of 15%. There are demographic differences across the 194 WHO member countries; recent analyses suggest the optimal global CS rate is almost 20%. Attempts to reduce CS rates in developed countries have not worked. The strongest predictor of caesarean delivery for the first birth of "low risk" women appears to be maternal age; a factor that continues to increase. Most women whose first baby is born by caesarean delivery will have all subsequent children by caesarean delivery. Outcomes that informed the WHO recommendation primarily relate to maternal and perinatal mortality, which are easy to measure. Longer term outcomes, such as pelvic organ prolapse and urinary incontinence, are closely related to mode of birth, and up to 20% of women will undergo surgery for these conditions. Pelvic floor surgery is typically undertaken for older women who are less fit for surgery. Serious complications such as placenta accreta occur with repeat caesarean deliveries, but the odds only reach statistical significance at the third or subsequent caesarean delivery. However, in Australia, parity is falling, and only 20% of women will have more than two births. We should aim to provide CS to women in need and to continue including women in the conversation about the benefits and disadvantages, both short and long term, of birth by caesarean delivery.

Objectives: To ascertain the views of trainees and recently graduated Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on their experiences of taking parental leave during specialist training., Design: An anonymous online survey, conducted over a 1-month period from 16 August 2012 to 14 September 2012, of participants' experiences of taking parental leave and of the effects of parental leave taken by trainee colleagues on participants' own training., Setting and Participants: All trainees undertaking training for the Fellowship of the College, and all Fellows who had graduated in the past 6 years were invited to take part. Of the total 1051 invitees, 261 responded to the survey., Main Outcome Measures: Ease with which parental leave was granted, ability to return to a training post after taking leave, and participants' experiences of views expressed about parental leave in the work environment., Results: Most participants requesting parental leave were able to access it and return to a training post; however, a small proportion experienced difficulties. Among female respondents who had taken parental leave, 28 (26.2%) reported being asked about their intentions for future pregnancy during the training application process, and 45 (42.1%) reported receiving negative comments about this in the work environment., Conclusions: While in most instances parental leave is accessible automatically, a small but significant number of trainees reported encountering difficulties. These matters are being addressed within our own College, and our results are likely to be relevant to all bodies involved in postgraduate medical training, particularly given the increasing feminisation of the medical workforce.

Objective: To determine the opinions and current practice of obstetricians and gynaecologists and trainees in the specialty with regard to induced abortion., Design, Setting and Participants: A voluntary, anonymous survey of Australian Fellows and specialist trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted between 23 June and 31 July 2009 using an email invitation to proceed to an online questionnaire., Main Outcome Measures: Attitudes to abortion; self-reported usual practice of induced abortion., Results: Of 1498 Fellows and trainees invited to complete the questionnaire, 740 (49%) did so. Of these respondents, 632 (85%) stated that they did not hold religious or conscientious views that would make them totally opposed to abortion; 463 of these (73%) reported performing abortion as part of their personal practice, with 204 (44%) doing so only for severe fetal abnormality or serious maternal medical conditions. 108 respondents reported holding views that made them totally opposed to abortion - 60 (56%) opposed it in any situation at all and 48 (44%) opposed it with limited exceptions. Of those opposed, 34 (32%) added comment that they perform abortion for severe fetal abnormality or serious maternal medical conditions, and a further 17 (16%) commented that they refer women requesting abortion in these circumstances to colleagues. Of the respondents not opposed to abortion, 89% supported the availability of induced abortion within the public health system, and half felt that national availability of mifepristone would modify their practice of induced abortion., Conclusions: There was broad support among responding specialist obstetricians and gynaecologists and trainees for the availability of induced abortion in Australia. This study highlights the difficulties of accurately reporting a wide range of views on a contentious issue.

The case that established the lawfulness of terminating pregnancy to preserve women's health.

Objective: To determine whether the current planned transfer of pregnant women from Cape York communities to Cairns at 36 weeks' gestation for birthing is medically appropriate., Design and Setting: Retrospective audit of travel details and demographic and obstetric outcome data on all women from Cape York communities who travelled to Cairns for late pregnancy care and birth at Cairns Base Hospital in 2006., Main Outcome Measures: Length of stay in Cairns; gestational age at birth., Results: In 2006, 172 women from 14 Cape communities travelled to Cairns to give birth. Of these, 76% identified as Aboriginal or Torres Strait Islander, 20% as Caucasian and 4% were from other ethnic groups. The mean time of stay in Cairns before birth (range) was 24 (0-86) days. Eleven women (6%) gave birth between 36 and 37 weeks of pregnancy; this point marked the beginning of a significant rise in births for increasing gestational ages., Conclusion: Aiming for 36 weeks' gestation for transfer is medically appropriate, but results in long periods of separation of women from Cape communities from family and friends, with detrimental social, cultural and financial consequences. Reopening maternity units in towns serving the Cape communities could reduce the number of women from the region having to travel to Cairns for pregnancy care and birth.

Closing the gap in life expectancy between Indigenous and non-Indigenous Australians needs to start in the womb. Rates of perinatal mortality, preterm birth and low birthweight are two to three times greater among the babies of Indigenous women than among those of non-Indigenous women; low birthweight predisposes infants to greater risks of chronic illness in later life. Indigenous women in Australia tend to present for antenatal care later in pregnancy than do non-Indigenous women. There are many barriers for Indigenous women seeking to access antenatal care - geographical, social, cultural, financial and in some cases a lack of service provision. Many of these problems are being addressed within the public health system and by Indigenous community-controlled health services. However, more needs to be done. While antenatal care cannot solve all medical and social problems, commencing such care as early as possible in pregnancy has the potential to improve maternal health and hence pregnancy outcomes. Changes in the way the government Baby Bonus is paid to new mothers could act as an incentive not only to service providers but also to women themselves to initiate antenatal care in the first trimester of pregnancy. Such a system has been well established for many years in France. Any changes to the Baby Bonus scheme should provide incentives and not be punitive in nature.

Recent changes to Federal Therapeutic Goods Administration legislation have seen the limited introduction of the drug mifepristone to Australia for the purpose of early medical abortion. At the same time it has become evident that both methotrexate and misoprostol, licenced and available for other indications, are being used safely and appropriately for early abortion by Australian medical practitioners. Early medical abortion is widely practiced overseas where its safety and effectiveness are well supported by current evidence. However, abortion law in many states is still contained within the Criminal Codes and does not reflect current evidence-based abortion practice. In other states and territories restrictions on where abortions may be performed pose potential barriers to the introduction of mifepristone for medical abortion. There is an urgent need for abortion law to be clarified and made uniform across the country so that the best possible services can be provided to Australian women.

Mifepristone (RU486), which is used for early medical abortion, can only be obtained in Australia under the Authorised Prescriber legislation (Section 19[5] of the Therapeutic Goods Act 1989 [Cwlth]); two of the authors have permission to obtain, prescribe and administer this drug in Cairns, Queensland. From July 2006 to April 2007, 10 women who fulfilled the Therapeutic Goods Administration (TGA) criteria of "life-threatening or otherwise serious" indications underwent medical abortion with mifepristone/misoprostol, and 12 women conforming with abortion requirements of Queensland law, but not TGA legislation for mifepristone administration, had medical abortions with the less preferable methotrexate/misoprostol combination. Although it is now more than a year since the cross-party vote in federal Parliament in February 2006 confirmed wide support for the right of Australian women to a medical abortion, we believe we are at present the only medical practitioners in Australia with permission to use mifepristone. Obtaining Authorised Prescriber status from the TGA is of necessity a complex and protracted process, involving ethics committee approval and auditing, and regular reporting to the TGA. Because of the current restrictions, we believe that women seeking medical abortion in Australia face barriers not experienced by women in other comparable countries, and that drug manufacturing and distributing companies may be discouraged from seeking to market mifepristone in Australia.

Medical termination of pregnancy with mifepristone, a progesterone antagonist, is available to women in North America, the United Kingdom, much of Western Europe, Russia, China, Israel, New Zealand, Turkey and Tunisia, but not Australia. Experience of mifepristone use in around two million abortions has shown that it is safe, effective, cheap to produce, and highly acceptable to women. Mifepristone is usually used in combination with a prostaglandin analogue, such as misoprostol; these drugs have been added to the World Health Organization's list of essential medicines for developing countries. Availability of this drug in Australia might largely overcome many of the inequities of access to abortion, and is critical for many women in rural areas and women in some ethnic groups whose access to surgical abortion is limited.

Australia is now one of the safest countries in the world in which to be born. This is largely a result of the many advances in obstetric and neonatal medicine of the past 50 years. However, the "medicalisation" of birth has tended to diminish women's satisfaction with their experience of childbirth. It has been shown that women are most satisfied by care from a single practitioner, and when they themselves have input into decision-making. Although maternal satisfaction is important, it should not be promoted at the expense of the health of mothers and babies. More realistic antenatal education and preparation should be available for all pregnant women so that both maternal satisfaction and good perinatal outcomes can be achieved.

At the beginning of the twenty-first century, consanguineous marriage is practiced widely in many parts of the world. More than 2 billion people, of various religious and ethnic backgrounds, live in countries where a large proportion of marriages are contracted between blood relatives. The practice is seen as promoting family stability and having significant social and economic advantages. Consanguineous marriage is important genetically-the children of consanguineous unions are more often homozygous for particular alleles than are the offspring of unrelated parents, and therefore, autosomal recessive disorders, which may be lethal or debilitating, are more common in such children. Health-care providers working with communities where consanguineous marriage is common, in particular obstetricians, family physicians, and pediatricians, need to be aware of the possible impact of such marriages on pregnancy outcomes, so the best possible genetic and antenatal care can be provided, sympathetically and nonjudgmentally, and the best possible results obtained.